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Sample records for academic chronic care

  1. Integrating Systematic Chronic Care for Diabetes into an Academic General Internal Medicine Resident-Faculty Practice

    PubMed Central

    Dorr, David A.; Kelso, Christine; Bowen, Judith L.

    2008-01-01

    Background The quality of care for diabetes continues to fall short of recommended guidelines and results. Models for improving the care of chronic illnesses advocate a multidisciplinary team approach. Yet little is known about the effectiveness of such models in an academic setting with a diverse patient population and resident physicians participating in clinical care. Objective To implement a chronic illness management (CIM) practice within an academic setting with part-time providers, and evaluate its impact on the completion of diabetes-specific care processes and on the achievement of recommended outcomes for patients with diabetes mellitus. Design Retrospective cohort study Subjects Patients with the diagnosis of diabetes mellitus who receive their primary care in an academic general internal medicine resident-faculty practice. Measurements Process and outcomes measures in patients exposed to the CIM practice were compared with non-exposed patients receiving usual care. Main Results Five hundred and sixty-five patients met inclusion criteria. Patients in the CIM practice experienced a significant increase in completion of care processes compared to control patients for measurement of annual low-density lipoprotein (LDL) cholesterol (OR 3.1, 95% CI 1.7–5.7), urine microalbumin (OR 3.3, 95% CI 2.1–5.5), blood pressure (OR 1.8, 95% CI 1.1–2.8), retinal examination (OR 1.9, 95% CI 1.3–2.7), foot monofilament examination (OR 4.2, 95% CI 3.0–6.1) and administration of pneumococcal vaccination (OR 5.2, 95% CI 3.0–9.3). CIM-exposed patients were also more likely to achieve improvements in clinical outcomes of glycemic and blood pressure control reflected by hemoglobin A1c less than 7.0% (OR 1.7, 95% CI 1.02–3) and blood pressure less than 130/80 (OR 2.8, 95% CI 2.1–4.5) compared to controls. Conclusions A systematic chronic care model can be successfully integrated into an academic general internal medicine practice and may result in improved

  2. A Collaborative Approach to a Chronic Care Problem: An Academic Mentor's Point of View.

    PubMed

    Vallis, Michael

    2016-01-01

    The Atlantic Healthcare Collaboration for Innovation and Improvement in Chronic Disease (AHC) represents a social experiment of sorts. The AHC provided a platform to integrate regions, health issues, healthcare systems, providers and individuals/families living with chronic disease. As such, the scope of the AHC was very broad, providing a rich learning environment but also risking biting off more than it could chew. I participated in this experiment as an academic mentor to three of the improvement projects (IPs) with Health PEI, Central Health and Western Health and also was a member of the IP extended team at Nova Scotia Health Authority (formerly Capital Health) in Nova Scotia. My professional contribution was from the perspective of health behaviour change - change at the level of the patient and family living with chronic disease, at the level of the healthcare provider working within an expert-based, siloed system, and at the level of the healthcare system - the managers and decision-makers.

  3. A Collaborative Approach to a Chronic Care Problem: An Academic Mentor's Point of View.

    PubMed

    Vallis, Michael

    2016-01-01

    The Atlantic Healthcare Collaboration for Innovation and Improvement in Chronic Disease (AHC) represents a social experiment of sorts. The AHC provided a platform to integrate regions, health issues, healthcare systems, providers and individuals/families living with chronic disease. As such, the scope of the AHC was very broad, providing a rich learning environment but also risking biting off more than it could chew. I participated in this experiment as an academic mentor to three of the improvement projects (IPs) with Health PEI, Central Health and Western Health and also was a member of the IP extended team at Nova Scotia Health Authority (formerly Capital Health) in Nova Scotia. My professional contribution was from the perspective of health behaviour change - change at the level of the patient and family living with chronic disease, at the level of the healthcare provider working within an expert-based, siloed system, and at the level of the healthcare system - the managers and decision-makers. PMID:27009642

  4. Chronic care coordination.

    PubMed

    Peters, Steve G; Bunkers, Kari S

    2015-10-01

    Chronic care management describes the services provided to patients with two or more chronic conditions that pose risks of exacerbation, clinical deterioration, or death. These services extend beyond the typical face-to-face office visit and require coordination and oversight by a physician or other qualified health-care professional to maintain and modify as necessary a comprehensive and multidisciplinary plan of care. New codes for 2015 describe chronic care management services per calendar month. While the new services acknowledge the role and importance of coordination by primary care providers, they are also appropriate for specialists who oversee the management of all of the chronic conditions of a patient and provide access, education, care coordination, communication, and health information exchange with other providers.

  5. Perspective: transforming chronic care for older persons.

    PubMed

    Boult, Chad; Christmas, Colleen; Durso, Samuel C; Leff, Bruce; Boult, Lisa B; Fried, Linda P

    2008-07-01

    The size and impending morbidity of the aging baby boom generation could soon overwhelm the U.S. health care system. Transforming chronic care for older persons to avert this calamity will require rapid increases in the number of physicians who are skilled in providing chronic care and prompt adoption of new models for providing high-quality, cost-effective chronic care. The authors propose a new approach for attaining these objectives, recommending that today's leaders of academic medicine help transform geriatrics into a collaborative discipline of clinicians with advanced skills in leading educational, organizational, and research-related initiatives; that they support the collaboration of geriatrics with primary care and specialty disciplines in preparing physicians to practice effectively in new models of chronic care for older persons; and that they energetically promote rigorous training in chronic care at all levels of medical education. Implementing this strategy would require firm commitment by the Association of American Medical Colleges, specialty boards, accrediting organizations, academic institutions, the Centers for Medicare and Medicaid Services, legislators, and business leaders. Although garnering such support would be challenging and controversial, this approach could leverage the expertise of geriatric educator-leaders to help transform chronic care in the United States and to make high-quality, cost-effective chronic care accessible to most chronically ill Americans within 20 years.

  6. Academia, Chronic Care, and the Future of Primary Care

    PubMed Central

    2010-01-01

    Most proposals to reform health care delivery center on a robust, well-designed primary care sector capable of reducing the health and cost consequences of major chronic illnesses. Ironically, the intensified policy interest in primary care coincides with a steep decline in the proportion of medical students choosing primary care careers. Negativity stemming from the experience of trying to care for chronically ill patients with complex conditions in poorly designed, chaotic primary care teaching settings may be influencing trainees to choose other career paths. Redesigning teaching clinics so that they routinely provide high quality, well-organized chronic care would appear to be a critical early step in addressing the looming primary care workforce crisis. The Chronic Care Model provides a proven framework for such a redesign, and has been, with organizational support and effort, successfully implemented in academic settings. PMID:20737241

  7. Caring for academic ophthalmology in Croatia.

    PubMed

    Mandić, Zdravko; Vatavuk, Zoran

    2004-06-01

    Like any other area of academic medicine in Croatia, academic ophthalmology has always been limited by or has depended on the factors outside the profession itself: during the communist regime, it was mostly political and ideological correctness of academic ophthalmologists, and today during the social and economic transition, it is the lack of finances, planning, and sophisticated technology. The four university eye clinics, which are the pillars of academic ophthalmology in Croatia, provide health care to most difficult cases, educate students, residents, and specialists, and do research. On the other hand, they lack equipment, room, and financial recognition. This ever growing imbalance between requirements imposed on academic ophthalmology today and its possibilities make it less and less attractive, especially in comparison with private practice. The possible solution lies in increasing the independence of ophthalmology from pharmaceutical industry and politics, especially in research and financial aspects.

  8. Spiritual care and chronically ill clients.

    PubMed

    Sterling-Fisher, C E

    1998-04-01

    Today's high-technology, fast-paced healthcare system has left many providers and consumers feeling a void in the care provided. Home care nurses play pivotal roles in the delivery of spiritual care for chronically ill clients, who are usually confined to their homes. This article provides the nurse with interventions and techniques to integrate spiritual care into daily practice. PMID:9592425

  9. Medicare Pays for Chronic Care Management.

    PubMed

    Sorrel, Amy Lynn

    2015-09-01

    As of January, the Centers for Medicare & Medicaid Services began paying for chronic care management of patients with two or more conditions under its Chronic Care Management program. The payment applies to patients in traditional fee-for-service and noncapitated Medicare Advantage plan arrangements. Texas Medical Association leaders caution the program has some hefty requirements. PMID:26360339

  10. Medicare Pays for Chronic Care Management.

    PubMed

    Sorrel, Amy Lynn

    2015-09-01

    As of January, the Centers for Medicare & Medicaid Services began paying for chronic care management of patients with two or more conditions under its Chronic Care Management program. The payment applies to patients in traditional fee-for-service and noncapitated Medicare Advantage plan arrangements. Texas Medical Association leaders caution the program has some hefty requirements.

  11. Chronic Illness and the Academic Career

    ERIC Educational Resources Information Center

    Goodwin, Stephanie A.; Morgan, Susanne

    2012-01-01

    In this article, the authors discuss the hidden epidemic in higher education. They describe the stigma of chronic illness and argue that the invisibility of chronic illness may elicit particularly problematic responses from others, especially when faculty work in a context where people are expected to be highly productive and have unlimited…

  12. Chronic and integrated care in Catalonia

    PubMed Central

    Contel, Juan Carlos; Ledesma, Albert; Blay, Carles; Mestre, Assumpció González; Cabezas, Carmen; Puigdollers, Montse; Zara, Corine; Amil, Paloma; Sarquella, Ester; Constante, Carles

    2015-01-01

    Introduction The Chronicity Prevention and Care Programme set up by the Health Plan for Catalonia 2011–2015 has been an outstanding and excellent opportunity to create a new integrated care model in Catalonia. People with chronic conditions require major changes and transformation within the current health and social system. The new and gradual context of ageing, increase in the number of chronic diseases and the current fragmented system requires this transformation to be implemented. Method The Chronicity Prevention and Care Programme aims to implement actions which drive the current system towards a new scenario where organisations and professionals must work collaboratively. New tools should facilitate this new context- or work-like integrated health information systems, an integrative financing and commissioning scheme and provide a new approach to virtual care by substituting traditional face-to-face care with transfer and shared responsibilities between patients, citizens and health care professionals. Results It has been observed some impact reducing the rate of emergency admissions and readmission related to chronic conditions and better outcome related to better chronic disease control. Some initiative like the Catalan Expert Patient Program has obtained good results and an appropriate service utilization. Discussion The implementation of a Chronic Care Program show good results but it is expected that the new integrated health and social care agenda could provoke a real change and transformation. Some of the results related to better health outcomes and a decrease in avoidable hospital admissions related to chronic conditions confirm we are on the right track to make our health and social system more sustainable for the decades to come. PMID:26150763

  13. Chronic care management coding for neurologists

    PubMed Central

    2015-01-01

    Abstract Chronic care management provides a way for neurologists to code for time spent by clinical office staff who coordinate services for patients with major chronic illnesses. Medicare allows payment for one such code; some third party payers accept 2 additional codes. When using these codes, the physician develops a Care Plan that organizes the patient's medical and psychosocial needs. Clinical office staff communicates among the patient's physicians, therapists, community services, the patient, family, and caregiver. The patient chooses only one physician whose office provides these coordination services. Rules include 24/7 access for urgent phone contact and use of an electronic health record system. PMID:26526602

  14. Care of Adult Refugees with Chronic Conditions.

    PubMed

    Terasaki, Genji; Ahrenholz, Nicole Chow; Haider, Mahri Z

    2015-09-01

    Refugees share a common experience of displacement from their country of origin, migration, and resettlement in an unfamiliar country. More than 17 million people have fled their home countries due to war, generalized violence, and persecution. US primary care physicians must care for their immediate and long-term medical needs. Challenges include (1) language and cultural barriers, (2) high rates of mental health disorders, (3) higher prevalence of latent infections, and (4) different explanatory models for chronic diseases. This article discusses management strategies for common challenges that arise in the primary care of refugees. PMID:26320045

  15. Care of Adult Refugees with Chronic Conditions.

    PubMed

    Terasaki, Genji; Ahrenholz, Nicole Chow; Haider, Mahri Z

    2015-09-01

    Refugees share a common experience of displacement from their country of origin, migration, and resettlement in an unfamiliar country. More than 17 million people have fled their home countries due to war, generalized violence, and persecution. US primary care physicians must care for their immediate and long-term medical needs. Challenges include (1) language and cultural barriers, (2) high rates of mental health disorders, (3) higher prevalence of latent infections, and (4) different explanatory models for chronic diseases. This article discusses management strategies for common challenges that arise in the primary care of refugees.

  16. [The quality of chronic care in Germany].

    PubMed

    Fullerton, Birgit; Nolte, Ellen; Erler, Antje

    2011-01-01

    Over the last ten years changes in the legal framework of the German health care system have promoted the development of new health service models to improve chronic care. Recent innovations include the nation-wide introduction of disease management programmes (DMPs), integrated care contracts, community nurse programmes, the introduction of General Practitioner (GP)-centred care contracts, and new opportunities to offer interdisciplinary outpatient care in polyclinics. The aim of this article is to describe the recent developments regarding both the implementation of new health care models by statutory health insurance companies and their evaluation. As part of a European project on the development and validation of disease management evaluation methods (DISMEVAL), we carried out a selective literature search to identify relevant models and evaluation studies. However, on the basis of the currently available evaluation and study results it is difficult to judge whether these developments have actually led to an improvement in the quality of chronic care in Germany. Only for DMPs, evaluation is legally mandatory; its methods are inappropriate, though, for studying the effectiveness of DMPs. Further study results on the effectiveness of DMPs mostly focus on the DMP Diabetes mellitus type II and show consistent improvements regarding process parameters such as regular routine examinations, adherence to treatment guidelines, and quality of life. More research will be needed to determine whether DMPs can also help reduce the incidence of secondary disease and mortality in the long term. PMID:22142877

  17. Interdisciplinary care clinics in chronic kidney disease.

    PubMed

    Johns, Tanya S; Yee, Jerry; Smith-Jules, Terrian; Campbell, Ruth C; Bauer, Carolyn

    2015-01-01

    The burden of chronic kidney disease (CKD) is substantial, and is associated with high hospitalization rates, premature deaths, and considerable health care costs. These factors provide strong rationale for quality improvement initiatives in CKD care. The interdisciplinary care clinic (IDC) has emerged as one solution to improving CKD care. The IDC team may include other physicians, advanced practice providers, nurses, dietitians, pharmacists, and social workers--all working together to provide effective care to patients with chronic kidney disease. Studies suggest that IDCs may improve patient education and preparedness prior to kidney failure, both of which have been associated with improved health outcomes. Interdisciplinary care may also delay the progression to end-stage renal disease and reduce mortality. While most studies suggest that IDC services are likely cost-effective, financing IDCs is challenging and many insurance providers do not pay for all of the services. There are also no robust long-term studies demonstrating the cost-effectiveness of IDCs. This review discusses IDC models and its potential impact on CKD care as well as some of the challenges that may be associated with implementing these clinics. PMID:26458811

  18. Secondary Care Clinic for Chronic Disease: Protocol

    PubMed Central

    St-Pierre, Michèle; Juneau, Lucille; Legault-Mercier, Samuel; Bernardino, Elizabeth

    2015-01-01

    Background The complexity of chronic disease management activities and the associated financial burden have prompted the development of organizational models, based on the integration of care and services, which rely on primary care services. However, since the institutions providing these services are continually undergoing reorganization, the Centre hospitalier affilié universitaire de Québec wanted to innovate by adapting the Chronic Care Model to create a clinic for the integrated follow-up of chronic disease that relies on hospital-based specialty care. Objective The aim of the study is to follow the project in order to contribute to knowledge about the way in which professional and management practices are organized to ensure better care coordination and the successful integration of the various follow-ups implemented. Methods The research strategy adopted is based on the longitudinal comparative case study with embedded units of analysis. The case study uses a mixed research method. Results We are currently in the analysis phase of the project. The results will be available in 2015. Conclusions The project’s originality lies in its consideration of the macro, meso, and micro contexts structuring the creation of the clinic in order to ensure the integration process is successful and to allow a theoretical generalization of the reorganization of practices to be developed. PMID:25689840

  19. [Chronic pruritus : Care in daily practice].

    PubMed

    Ständer, S; Ständer, H F; Steinke, S; Bruland, P; Dugas, M; Augustin, M

    2016-08-01

    Chronic pruritus is a highly prevalent, multifactorial symptom requiring extensive diagnostics, treatment and consideration of accompanying symptoms (reduced quality of life, sleep disorders, psychic factors). Patient care is thus complex and requires consideration of individual treatment goals. Patients indicate their wish for a symptom-free life an explanation of the causes and a trustful physician-patient relationship. The targeted use of questionnaires is thus advisable in order to structurally survey the history, pruritus intensity, quality of life and treatment progression. Nevertheless, there are many administrative and economical hurdles in the health care system to overcome in order to provide patients with chronic pruritus the best possible care, also per the recommended guidelines. The development of specialized centers and training courses for medical practitioners is thus urgently needed. PMID:27316924

  20. [Chronic pruritus : Care in daily practice].

    PubMed

    Ständer, S; Ständer, H F; Steinke, S; Bruland, P; Dugas, M; Augustin, M

    2016-08-01

    Chronic pruritus is a highly prevalent, multifactorial symptom requiring extensive diagnostics, treatment and consideration of accompanying symptoms (reduced quality of life, sleep disorders, psychic factors). Patient care is thus complex and requires consideration of individual treatment goals. Patients indicate their wish for a symptom-free life an explanation of the causes and a trustful physician-patient relationship. The targeted use of questionnaires is thus advisable in order to structurally survey the history, pruritus intensity, quality of life and treatment progression. Nevertheless, there are many administrative and economical hurdles in the health care system to overcome in order to provide patients with chronic pruritus the best possible care, also per the recommended guidelines. The development of specialized centers and training courses for medical practitioners is thus urgently needed.

  1. [Chronic pain care : Reality and entitlement].

    PubMed

    Kieselbach, K; Schiltenwolf, M; Bozzaro, C

    2016-08-01

    From the point of view of healthcare policies, improvement in pain care has been required for years; however, there is a great discrepancy between the current need for pain care and the actual provision by healthcare services. This article seeks to demonstrate that while healthcare policies are one of the critical factors involved, a variety of conceptual, diagnostic and therapeutic causes should also be taken into account. Firstly, considering that pain care is primarily concerned with the suffering of pain by patients, the focus lies with their conscious experience in order to define the patients' understanding of pain. Additionally, in this article current biomedical and psychosocial comprehension concerning chronic pain will be illustrated and why it is necessary to broaden our horizons in order to do justice to patients with chronic pain. PMID:27402265

  2. Disruptive innovation in academic medical centers: balancing accountable and academic care.

    PubMed

    Stein, Daniel; Chen, Christopher; Ackerly, D Clay

    2015-05-01

    Numerous academic medicine leaders have argued that academic referral centers must prepare for the growing importance of accountability-driven payment models by adopting population health initiatives. Although this shift has merit, execution of this strategy will prove significantly more problematic than most observers have appreciated. The authors describe how successful implementation of an accountable care health strategy within a referral academic medical center (AMC) requires navigating a critical tension: The academic referral business model, driven by tertiary-level care, is fundamentally in conflict with population health. Referral AMCs that create successful value-driven population health systems within their organizations will in effect disrupt their own existing tertiary care businesses. The theory of disruptive innovation suggests that balancing the push and pull of academic and accountable care within a single organization is achievable. However, it will require significant shifts in resource allocation and changes in management structure to enable AMCs to make the inherent difficult choices and trade-offs that will ensue. On the basis of the theories of disruptive innovation, the authors present recommendations for how academic health systems can successfully navigate these issues as they transition toward accountability-driven care. PMID:25517702

  3. Disruptive innovation in academic medical centers: balancing accountable and academic care.

    PubMed

    Stein, Daniel; Chen, Christopher; Ackerly, D Clay

    2015-05-01

    Numerous academic medicine leaders have argued that academic referral centers must prepare for the growing importance of accountability-driven payment models by adopting population health initiatives. Although this shift has merit, execution of this strategy will prove significantly more problematic than most observers have appreciated. The authors describe how successful implementation of an accountable care health strategy within a referral academic medical center (AMC) requires navigating a critical tension: The academic referral business model, driven by tertiary-level care, is fundamentally in conflict with population health. Referral AMCs that create successful value-driven population health systems within their organizations will in effect disrupt their own existing tertiary care businesses. The theory of disruptive innovation suggests that balancing the push and pull of academic and accountable care within a single organization is achievable. However, it will require significant shifts in resource allocation and changes in management structure to enable AMCs to make the inherent difficult choices and trade-offs that will ensue. On the basis of the theories of disruptive innovation, the authors present recommendations for how academic health systems can successfully navigate these issues as they transition toward accountability-driven care.

  4. [Palliative care needs in advanced chronic illness].

    PubMed

    Tripodoro, Vilma A; Rynkiewicz, María C; Llanos, Victoria; Padova, Susana; De Lellis, Silvina; De Simone, Gustavo

    2016-01-01

    About 75% of population will die from one or more chronic progressive diseases. From this projection WHO urged countries to devise strategies for strengthening palliative treatment as part of comprehensive care. In Catalonia, Spain, direct measurement of the prevalence of these patients with NECPAL CCOMS-ICO© tool was 1.5% of the population. This tool is an indicative, not dichotomous, quali-quantitative multifactorial evaluation to be completed by the treating physician. In Argentina there is no information on these patients. Our goal was to explore and characterize the proportion of chronically ill patients in palliative care needs, by NECPAL CCOMS-ICO© tool, in an accessible population of the City of Buenos Aires. General hospitals of the Health Region 2 (Piñero, álvarez and Santojanni) and its program areas were surveyed. In Health Region 1, we surveyed the Udaondo gastroenterology hospital. A total of 53 physicians (704 patients) were interviewed. It was identified that 29.5% of these patients were affected by advanced chronic diseases; 72.1% of them were NECPAL positive, younger (median 64) than in others studies, and more than 98% presented high levels of comorbidity. Palliative care demand (31.4%) and needs (52.7%) were recorded. Specific indicators of fragility, progression, severity and kind of chronic disease were described. The main finding was to identify, with an instrument not based on mortality that, in Buenos Aires City, 1 in 3 patients with chronic diseases could die in the next year and had palliative care needs. PMID:27295702

  5. Care and Feeding of the Chief Academic Officer

    ERIC Educational Resources Information Center

    Holyer, Robert

    2010-01-01

    There is an adage common among deans and provosts: The board is concerned with the care and feeding of the president; the faculty is concerned with the care and feeding of the faculty. The implication--and why it brings a knowing smile to any chief academic officer's face--is that no one seems concerned with the care and feeding of the CAO. Small…

  6. Chronic disease management: the primary care perspective.

    PubMed

    Bragaglia, Pauline; O'Brien, Lewis

    2007-01-01

    This response to the essay is a "view from the trenches" by two doctors who have worked over 23 years at the Group Health Centre in Sault Ste. Marie, Ontario. We would agree wholeheartedly that reducing wait times for selected procedures will not transform our health system, although they are a start that does provide improved quality of life for a relatively small number of people. We have struggled with the care gap between known best practices and the reality of care provided, from the perspectives of both prevention and chronic disease management. This has resulted in an acute awareness of the need for an across-the-system, "bottom-up" approach to the prevention of disease and management of healthcare. Limited resources must be carefully leveraged in innovative ways if we are to eliminate this care gap, decrease morbidity and minimize expensive "rescue" procedures that make our system increasingly unaffordable.

  7. Preventive Care in Chronic Liver Disease

    PubMed Central

    Riley, Thomas R; Smith, Jill P

    1999-01-01

    OBJECTIVE To identify preventive care measures that are appropriate for and specific to patients with chronic liver disease and to provide recommendations and information that can be shared with patients. MEASUREMENTS A review of the literature was undertaken using medlinefrom 1970 to present. Priority was given to randomized controlled studies, but case reports, case-control studies, and reviews were included. MAIN RESULTS Evidence for the avoidance of alcohol and other toxic substances, immunizations, and dietary modifications for chronic liver disease is summarized. In addition, measures that are effective in the mitigation of the complications of cirrhosis are reviewed. CONCLUSIONS Preventive care can play an important role in patients with chronic liver diseases. Based on the existing data, the preventive strategies of alcohol avoidance, hepatitis vaccination, avoidance of NSAIDs nonsteroidal anti-inflammatory drugs, iron supplementation when appropriate, and a low-fat diet are prudent in patients with chronic liver disease. Once cirrhosis develops, screening for hepatocellular cancer with α-fetoprotein testing and ultrasound, and screening for varices by endoscopy are justified. PMID:10571719

  8. Palliative care in chronic obstructive pulmonary disease.

    PubMed

    Lilly, Evan J; Senderovich, Helen

    2016-10-01

    Chronic obstructive pulmonary disease (COPD) is the only major worldwide cause of mortality that is currently increasing in prevalence. Furthermore, COPD is incurable, and the only therapy that has been shown to increase survival is oxygen therapy in selected patients. Compared to patients with cancer, patients with COPD experience similar levels of pain, breathlessness, fatigue, depression, and anxiety and have a worse quality of life but have comparatively little access to palliative care. When these patients do receive palliative care, they tend to be referred later than patients with cancer. Many disease, patient-, and provider-related factors contribute to this phenomenon, including COPD's unpredictable course, misperceptions of palliative care among patients and physicians, and lack of advance care planning discussions outside of crisis situations. A new paradigm for palliative care would introduce palliative treatments alongside, rather than at the exclusion of disease-modifying interventions. This integrated approach would circumvent the issue of difficult prognostication in COPD, as any patient would receive individualized palliative interventions from the time of diagnosis. These points will be covered in this review, which discusses the challenges in providing palliative care to COPD patients, the strategies to mitigate the challenges, management of common symptoms, and the evidence for integrated palliative care models as well as some suggestions for future development.

  9. Palliative care in chronic obstructive pulmonary disease.

    PubMed

    Lilly, Evan J; Senderovich, Helen

    2016-10-01

    Chronic obstructive pulmonary disease (COPD) is the only major worldwide cause of mortality that is currently increasing in prevalence. Furthermore, COPD is incurable, and the only therapy that has been shown to increase survival is oxygen therapy in selected patients. Compared to patients with cancer, patients with COPD experience similar levels of pain, breathlessness, fatigue, depression, and anxiety and have a worse quality of life but have comparatively little access to palliative care. When these patients do receive palliative care, they tend to be referred later than patients with cancer. Many disease, patient-, and provider-related factors contribute to this phenomenon, including COPD's unpredictable course, misperceptions of palliative care among patients and physicians, and lack of advance care planning discussions outside of crisis situations. A new paradigm for palliative care would introduce palliative treatments alongside, rather than at the exclusion of disease-modifying interventions. This integrated approach would circumvent the issue of difficult prognostication in COPD, as any patient would receive individualized palliative interventions from the time of diagnosis. These points will be covered in this review, which discusses the challenges in providing palliative care to COPD patients, the strategies to mitigate the challenges, management of common symptoms, and the evidence for integrated palliative care models as well as some suggestions for future development. PMID:27481751

  10. Structured career pathways in academic primary care.

    PubMed

    Foy, Robbie; Eccles, Martin

    2008-02-01

    Research in primary care has much to offer researchers and ultimately efforts to improve population health and health care. There is a need for capacity building and efforts to improve the science of research in this field. This article outlines a relatively structured career pathway for primary care researchers and offers advice on opportunities and commonly encountered pitfalls. It is largely based upon the authors' experiences and personal reflections as medically trained researchers but many of the implications and lessons are relevant to other clinical and research disciplines.

  11. A Caring Attitude and Academic Advising.

    ERIC Educational Resources Information Center

    Ford, Jerry; Ford, Sheila Stoma

    1989-01-01

    A discussion of the value of a caring attitude in the advisor-advisee relationship is supported by a review of literature in the field. A list of 30 reminders for effective advising and an inventory for students to fill out concerning their perceptions of their advisor are appended. (MSE)

  12. Academic health center management of chronic diseases through knowledge networks: Project ECHO.

    PubMed

    Arora, Sanjeev; Geppert, Cynthia M A; Kalishman, Summers; Dion, Denise; Pullara, Frank; Bjeletich, Barbara; Simpson, Gary; Alverson, Dale C; Moore, Lori B; Kuhl, Dave; Scaletti, Joseph V

    2007-02-01

    The authors describe an innovative academic health center (AHC)-led program of health care delivery and clinical education for the management of complex, common, and chronic diseases in underserved areas, using hepatitis C virus (HCV) as a model. The program, based at the University of New Mexico School of Medicine, represents a paradigm shift in thinking and funding for the threefold mission of AHCs, moving from traditional fee-for-service models to public health funding of knowledge networks. This program, Project Extension for Community Health care Outcomes (ECHO), involves a partnership of academic medicine, public health offices, corrections departments, and rural community clinics dedicated to providing best practices and protocol-driven health care in rural areas. Telemedicine and Internet connections enable specialists in the program to comanage patients with complex diseases, using case-based knowledge networks and learning loops. Project ECHO partners (nurse practitioners, primary care physicians, physician assistants, and pharmacists) present HCV-positive patients during weekly two-hour telemedicine clinics using a standardized, case-based format that includes discussion of history, physical examination, test results, treatment complications, and psychiatric, medical, and substance abuse issues. In these case-based learning clinics, partners rapidly gain deep domain expertise in HCV as they collaborate with university specialists in hepatology, infectious disease, psychiatry, and substance abuse in comanaging their patients. Systematic monitoring of treatment outcomes is an integral aspect of the project. The authors believe this methodology will be generalizable to other complex and chronic conditions in a wide variety of underserved areas to improve disease outcomes, and it offers an opportunity for AHCs to enhance and expand their traditional mission of teaching, patient care, and research.

  13. Alberta's systems approach to chronic disease management and prevention utilizing the expanded chronic care model.

    PubMed

    Delon, Sandra; Mackinnon, Blair

    2009-01-01

    Alberta's integrated approach to chronic disease management programming embraces client-centred care, supports self-management and facilitates care across the continuum. This paper presents strategies implemented through collaboration with primary care to improve care of individuals with chronic conditions, evaluation evidence supporting success and lessons learned from the Alberta perspective.

  14. School Nurse Case Management for Children with Chronic Illness: Health, Academic, and Quality of Life Outcomes

    ERIC Educational Resources Information Center

    Engelke, Martha Keehner; Guttu, Martha; Warren, Michelle B.; Swanson, Melvin

    2008-01-01

    More children with chronic illnesses are attending school, and some of them struggle academically because of issues related to their health. School-based case management has been suggested as one strategy to improve the academic success of these children. This study tracked the academic, health, and quality of life outcomes for 114 children with…

  15. [Chronic wounds--perspective for integrated care].

    PubMed

    Karl, T; Gussmann, A; Storck, M

    2007-06-01

    In Germany more than 4.5 million people are treated for chronic wounds per year with resulting costs for the public health system up to five billion Euro. Within the next 30 years, the demographic development will result in a doubling of these numbers of patients. On the other hand, the social security systems have decreasing resources and are confronted with rising costs of modern medicine. New legislation was designed to limit costs and to enable new ways of cooperation between hospitals and practioners ("Intergrierte Versorgung" = IV) aside of fixed budgets. According to German legislation, the contract is made between practitioners, hospitals, rehabilitation units and homecare companies on the one hand and public health insurance companies on the other hand. When designing special contracts for IV, the strategic interests and expectations of the partners have to be analysed. In these complex models, financial as well as bureaucratic and others aspects of health care are to be considered including quality assessment. In the case of chronic wounds, specific in- and exclusion criteria, duration of the treatment period and clear end-points (treatment success or failure) have to be defined. Optimizing clinical pathways as well as improved process management should be possible with IV. Low-volume contracts with limited duration and well defined clinical features are probably the best way to establish IV for chronic wounds. PMID:17610196

  16. 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. PMID:9125960

  17. 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.

  18. Academic medicine amenities unit: developing a model to integrate academic medical care with luxury hotel services.

    PubMed

    Kennedy, David W; Kagan, Sarah H; Abramson, Kelly Brennen; Boberick, Cheryl; Kaiser, Larry R

    2009-02-01

    The interface between established values of academic medicine and the trend toward inpatient amenities units requires close examination. Opinions of such units can be polarized, reflecting traditional reservations about the ethical dilemma of offering exclusive services only to an elite patient group. An amenities unit was developed at the University of Pennsylvania Health System in 2007, using an approach that integrated academic medicine values with the benefits of philanthropy and service excellence to make amenities unit services available to all patients. Given inherent internal political concerns, a broadly based steering committee of academic and hospital leadership was developed. An academically appropriate model was conceived, anchored by four principles: (1) integration of academic values, (2) interdisciplinary senior leadership, (3) service excellence, and (4) recalibrated occupancy expectations based on multiple revenue streams. Foremost is ensuring the same health care is afforded all patients throughout the hospital, thereby overcoming ethical challenges and optimizing teaching experiences. Service excellence frames the service ethic for all staff, and this, in addition to luxury hotel-style amenities, differentiates the style and feel of the unit from others in the hospital. Recalibrated occupancy creates program viability given revenue streams redefined to encompass gifts and patient revenue, including both reimbursement and self-pay. The medical-surgical amenities patient-care unit has enjoyed a successful first year and a growing stream of returning patients and admitting physicians. Implications for other academic medical centers include opportunities to extrapolate service excellence throughout the hospital and to cultivate philanthropy to benefit services throughout the medical center. PMID:19174661

  19. Academic medicine amenities unit: developing a model to integrate academic medical care with luxury hotel services.

    PubMed

    Kennedy, David W; Kagan, Sarah H; Abramson, Kelly Brennen; Boberick, Cheryl; Kaiser, Larry R

    2009-02-01

    The interface between established values of academic medicine and the trend toward inpatient amenities units requires close examination. Opinions of such units can be polarized, reflecting traditional reservations about the ethical dilemma of offering exclusive services only to an elite patient group. An amenities unit was developed at the University of Pennsylvania Health System in 2007, using an approach that integrated academic medicine values with the benefits of philanthropy and service excellence to make amenities unit services available to all patients. Given inherent internal political concerns, a broadly based steering committee of academic and hospital leadership was developed. An academically appropriate model was conceived, anchored by four principles: (1) integration of academic values, (2) interdisciplinary senior leadership, (3) service excellence, and (4) recalibrated occupancy expectations based on multiple revenue streams. Foremost is ensuring the same health care is afforded all patients throughout the hospital, thereby overcoming ethical challenges and optimizing teaching experiences. Service excellence frames the service ethic for all staff, and this, in addition to luxury hotel-style amenities, differentiates the style and feel of the unit from others in the hospital. Recalibrated occupancy creates program viability given revenue streams redefined to encompass gifts and patient revenue, including both reimbursement and self-pay. The medical-surgical amenities patient-care unit has enjoyed a successful first year and a growing stream of returning patients and admitting physicians. Implications for other academic medical centers include opportunities to extrapolate service excellence throughout the hospital and to cultivate philanthropy to benefit services throughout the medical center.

  20. Parental Involvement of Mothers with Chronic Illness and Children's Academic Achievement

    ERIC Educational Resources Information Center

    Chen, Yung-Chi; Fish, Marian C.

    2013-01-01

    This study examined how maternal chronic illnesses may affect children's academic achievement through parental involvement. A total of 189 mothers diagnosed with chronic illnesses, such as multiple sclerosis, diabetes, cancer, HIV/AIDS, chronic pain, asthma, myelodysplasic syndrome, and fibromyalgia, and with a child in middle school or high…

  1. Paying the piper: the crisis in chronic care.

    PubMed

    Goforth, L

    2000-01-01

    The current article reviews the broad outlines of the crisis in chronic care with emphasis on Southern California, a region where the powerful forces buffeting health and long term care have reached gale force intensity. The article argues that a partial solution to the crisis lies in flexible local partnerships among patients, families, providers, and payers focused on helping the chronically ill cope with the tasks of daily life. Such partnerships would emphasize supportive care, prevention, family preservation, assistive devices, and family income supplementation through facilitation of productive work, aspects of chronic care neglected by current financing and service delivery practices. A case example, the Southern California-based Partners in Care Foundation's Family Care Network, illustrates these essential components of a revitalized, responsive chronic care system. PMID:11211318

  2. Accountable care organization readiness and academic medical centers.

    PubMed

    Berkowitz, Scott A; Pahira, Jennifer J

    2014-09-01

    As academic medical centers (AMCs) consider becoming accountable care organizations (ACOs) under Medicare, they must assess their readiness for this transition. Of the 253 Medicare ACOs prior to 2014, 51 (20%) are AMCs. Three critical components of ACO readiness are institutional and ACO structure, leadership, and governance; robust information technology and analytic systems; and care coordination and management to improve care delivery and health at the population level. All of these must be viewed through the lens of unique AMC mission-driven goals.There is clear benefit to developing and maintaining a centralized internal leadership when it comes to driving change within an ACO, yet there is also the need for broad stakeholder involvement. Other important structural features are an extensive primary care foundation; concomitant operation of a managed care plan or risk-bearing entity; or maintaining a close relationship with post-acute-care or skilled nursing facilities, which provide valuable expertise in coordinating care across the continuum. ACOs also require comprehensive and integrated data and analytic systems that provide meaningful population data to inform care teams in real time, promote quality improvement, and monitor spending trends. AMCs will require proven care coordination and management strategies within a population health framework and deployment of an innovative workforce.AMC core functions of providing high-quality subspecialty and primary care, generating new knowledge, and training future health care leaders can be well aligned with a transition to an ACO model. Further study of results from Medicare-related ACO programs and commercial ACOs will help define best practices.

  3. Accountable care organization readiness and academic medical centers.

    PubMed

    Berkowitz, Scott A; Pahira, Jennifer J

    2014-09-01

    As academic medical centers (AMCs) consider becoming accountable care organizations (ACOs) under Medicare, they must assess their readiness for this transition. Of the 253 Medicare ACOs prior to 2014, 51 (20%) are AMCs. Three critical components of ACO readiness are institutional and ACO structure, leadership, and governance; robust information technology and analytic systems; and care coordination and management to improve care delivery and health at the population level. All of these must be viewed through the lens of unique AMC mission-driven goals.There is clear benefit to developing and maintaining a centralized internal leadership when it comes to driving change within an ACO, yet there is also the need for broad stakeholder involvement. Other important structural features are an extensive primary care foundation; concomitant operation of a managed care plan or risk-bearing entity; or maintaining a close relationship with post-acute-care or skilled nursing facilities, which provide valuable expertise in coordinating care across the continuum. ACOs also require comprehensive and integrated data and analytic systems that provide meaningful population data to inform care teams in real time, promote quality improvement, and monitor spending trends. AMCs will require proven care coordination and management strategies within a population health framework and deployment of an innovative workforce.AMC core functions of providing high-quality subspecialty and primary care, generating new knowledge, and training future health care leaders can be well aligned with a transition to an ACO model. Further study of results from Medicare-related ACO programs and commercial ACOs will help define best practices. PMID:24979282

  4. Health Care Hassles of Caregivers to the Chronically Ill

    ERIC Educational Resources Information Center

    Keith, Pat M.

    2009-01-01

    This research investigated variables that influenced hassles with the health care system among 320 informal caregivers of the chronically ill. Caregivers of the chronically ill usually have considerable contact with the health care system. The research shifted the focus from strain in the caregiver-recipient dyad to hassles with the health care…

  5. Academic Care, Classroom Pedagogy and the House Group Teacher: "Making Hope Practical" in Uncertain Times

    ERIC Educational Resources Information Center

    Addison, Bruce Vincent

    2012-01-01

    The development of an ethos of academic care is about creating the structures, both formal and informal, that cater for the developmental learning needs of students. Such an approach celebrates individual difference in the belief that academic care will not only underpin improved academic performance but will also build confidence in the ability…

  6. Case management and the chronic care model: a multidisciplinary role.

    PubMed

    Schaefer, Judith; Davis, Connie

    2004-01-01

    The core functions of case management, assessment, planning, linking, monitoring, advocacy, and outreach assume a new perspective in the context of systems that have adopted the Chronic Care Model. This article considers case management through the experience of three systems that have implemented the Chronic Care Model. A movement toward condition neutral case management, focused on care that is more wholly patient centric, is also examined.

  7. 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.

  8. Academic and Behavioral Characteristics of Young Adolescents in Self-Care

    ERIC Educational Resources Information Center

    Shumow, Lee; Smith, Thomas J.; Smith, M. Cecil

    2009-01-01

    This study examines characteristics of young adolescents who experience self-care, associations between self-care and academic achievement, and whether associations of self-care with academic adjustment vary by child, family, or community characteristics. Using data from the nationally representative 1999 National Household Education Survey,…

  9. Interprofessional primary care in academic family medicine clinics

    PubMed Central

    Drummond, Neil; Abbott, Karen; Williamson, Tyler; Somji, Behnaz

    2012-01-01

    Abstract Objective To explore the status and processes of interprofessional work environments and the implications for interprofessional education in a sample of family medicine teaching clinics. Design Focus group interviews using a purposive sampling procedure. Setting Four academic family medicine clinics in Alberta. Participants Seven family physicians, 9 registered nurses, 5 licensed practical nurses, 2 residents, 1 psychologist, 1 informatics specialist, 1 pharmacist, 1 dietitian, 1 nurse practitioner, 1 receptionist, and 1 respiratory therapist. Methods Assessment of clinic status and performance in relation to established principles of interprofessional work and education was explored using semistructured focus group interviews. Main findings Our data supported the D’Amour and Oandasan model of successful interprofessional collaborative practice in terms of the model’s main “factors” (ie, shared goals and vision, sense of belonging, governance, and the structuring of clinical care) and their constituent “elements.” It is reasonable to conclude that the extent to which these factors and elements are both present and positively oriented in academic clinic settings is an important contributory factor to the establishment of interprofessional collaborative practice in primary care. Using this model, 2 of the 4 clinics were rated as expressing substantial progress in relation to interprofessional work, while the other 2 clinics were rated as less successful on that dimension. None of the clinics was identified as having a clear and explicit focus on providing interprofessional education. Conclusion The key factor in relation to the implementation of interprofessional work in primary care appears to be the existence of clear and explicit leadership in that direction. Substantial scope exists for improvement in the organization, conduct, and promotion of interprofessional education for Canadian primary care. PMID:22893347

  10. Improving outpatient access and patient experiences in academic ambulatory care.

    PubMed

    O'Neill, Sarah; Calderon, Sherry; Casella, Joanne; Wood, Elizabeth; Carvelli-Sheehan, Jayne; Zeidel, Mark L

    2012-02-01

    Effective scheduling of and ready access to doctor appointments affect ambulatory patient care quality, but these are often sacrificed by patients seeking care from physicians at academic medical centers. At one center, Beth Israel Deaconess Medical Center, the authors developed interventions to improve the scheduling of appointments and to reduce the access time between telephone call and first offered appointment. Improvements to scheduling included no redirection to voicemail, prompt telephone pickup, courteous service, complete registration, and effective scheduling. Reduced access time meant being offered an appointment with a physician in the appropriate specialty within three working days of the telephone call. Scheduling and access were assessed using monthly "mystery shopper" calls. Mystery shoppers collected data using standardized forms, rated the quality of service, and transcribed their interactions with schedulers. Monthly results were tabulated and discussed with clinical leaders; leaders and frontline staff then developed solutions to detected problems. Eighteen months after the beginning of the intervention (in June 2007), which is ongoing, schedulers had gone from using 60% of their registration skills to over 90%, customer service scores had risen from 2.6 to 4.9 (on a 5-point scale), and average access time had fallen from 12 days to 6 days. The program costs $50,000 per year and has been associated with a 35% increase in ambulatory volume across three years. The authors conclude that academic medical centers can markedly improve the scheduling process and access to care and that these improvements may result in increased ambulatory care volume. PMID:22193182

  11. Collaborative Chronic Care Networks (C3Ns) to transform chronic illness care.

    PubMed

    Margolis, Peter A; Peterson, Laura E; Seid, Michael

    2013-06-01

    Despite significant gains by pediatric collaborative improvement networks, the overall US system of chronic illness care does not work well. A new paradigm is needed: a Collaborative Chronic Care Network (C3N). A C3N is a network-based production system that harnesses the collective intelligence of patients, clinicians, and researchers and distributes the production of knowledge, information, and know-how over large groups of people, dramatically accelerating the discovery process. A C3N is a platform of "operating systems" on which interconnected processes and interventions are designed, tested, and implemented. The social operating system is facilitated by community building, engaging all stakeholders and their expertise, and providing multiple ways to participate. Standard progress measures and a robust information technology infrastructure enable the technical operating system to reduce unwanted variation and adopt advances more rapidly. A structured approach to innovation design provides a scientific operating system or "laboratory" for what works and how to make it work. Data support testing and research on multiple levels: comparative effectiveness research for populations, evaluating care delivery processes at the care center level, and N-of-1 trials and other methods to select the best treatment of individual patient circumstances. Methods to reduce transactional costs to participate include a Federated IRB Model in which centers rely on a protocol approved at 1 central institutional review board and a "commons framework" for organizational copyright and intellectual property concerns. A fully realized C3N represents a discontinuous leap to a self-developing learning health system capable of producing a qualitatively different approach to improving health. PMID:23729764

  12. Pathology Sections: The Four Chronic Diseases of Academic Corruption

    ERIC Educational Resources Information Center

    Chinese Education and Society, 2007

    2007-01-01

    One might say that people bitterly detest "academic corruption" and call it immoral and dishonest academic conduct, and that the deliberate falsification, covert plagiarism, and empty rhetoric employed by certain scholars when expounding their theories and the various means they use when attempting to get their works published and awarded prizes…

  13. Health Care Autonomy in Children with Chronic Conditions: Implications for Self Care and Family Management

    PubMed Central

    Beacham, Barbara L.; Deatrick, Janet A.

    2013-01-01

    Synopsis Health care autonomy typically occurs during late adolescence but health care providers and families often expect children with chronic health conditions to master self-care earlier. Few studies have examined the development of health care autonomy as it pertains to self-care and family management. This review will link the three concepts and discuss implications for families and health care providers. Case studies are provided as exemplars to highlight areas where intervention and research is needed. PMID:23659815

  14. An academic center's delivery of care after the Haitian earthquake.

    PubMed

    Jaffer, Amir K; Campo, Rafael E; Gaski, Greg; Reyes, Mario; Gebhard, Ralf; Ginzburg, Enrique; Kolber, Michael A; Macdonald, John; Falcone, Steven; Green, Barth A; Barreras-Pagan, Lazara; O'Neill, William W

    2010-08-17

    The Miller School of Medicine of the University of Miami and Project Medishare, an affiliated not-for-profit organization, provided a large-scale relief effort in Haiti after the earthquake of 12 January 2010. Their experience demonstrates that academic medical centers in proximity to natural disasters can help deliver effective medical care through a coordinated process involving mobilization of their own resources, establishment of focused management teams at home and on the ground with formal organizational oversight, and partnership with governmental and nongovernmental relief agencies. Proximity to the disaster area allows for prompt arrival of medical personnel and equipment. The recruitment and organized deployment of large numbers of local and national volunteers are indispensable parts of this effort. Multidisciplinary teams on short rotations can form the core of the medical response.

  15. Chronic Pain: The Impact on Academic, Social, and Emotional Functioning

    ERIC Educational Resources Information Center

    Parkins, Jason M.; Gfroerer, Susan D.

    2009-01-01

    Chronic pain is persistent and recurrent pain that tends to fluctuate in severity, quality, regularity, and predictability. It can occur in a single or multiple body regions or organ systems. Some of the most frequently reported types of chronic pain include headaches, recurrent abdominal pain (RAP), and musculoskeletal pain. In contrast to acute…

  16. Development of a Chronic Care Ostomy Self Management Program

    PubMed Central

    Grant, Marcia; McCorkle, Ruth; Hornbrook, Mark C.; Wendel, Christopher S.; Krouse, Robert

    2012-01-01

    Each year a percentage of the 1.2 million men and women in the United States with a new diagnosis of colorectal cancer join the 700,000 people who have an ostomy. Education targeting the long term, chronic care of this population is lacking. This report describes the development of a Chronic Care Ostomy Self Management Program, which was informed by (1) evidence on published quality of life changes for cancer patients with ostomies, (2) educational suggestions from patients with ostomies, and (3) examination of the usual care of new ostomates to illustrate areas for continued educational emphases and areas for needed education and support. Using these materials, the Chronic Care Ostomy Self Management Program was developed by a team of multi-disciplinary researchers accompanied by experienced ostomy nurses. Testing of the program is in process. Pilot study participants reported high satisfaction with the program syllabus, ostomy nurse leaders, and ostomate peer buddies. PMID:23104143

  17. Development of a chronic care ostomy self-management program.

    PubMed

    Grant, Marcia; McCorkle, Ruth; Hornbrook, Mark C; Wendel, Christopher S; Krouse, Robert

    2013-03-01

    Each year a percentage of the 1.2 million men and women in the United States with a new diagnosis of colorectal cancer join the 700,000 people who have an ostomy. Education targeting the long-term, chronic care of this population is lacking. This report describes the development of a Chronic Care Ostomy Self-Management Program, which was informed by (1) evidence on published quality-of-life changes for cancer patients with ostomies, (2) educational suggestions from patients with ostomies, and (3) examination of the usual care of new ostomates to illustrate areas for continued educational emphases and areas for needed education and support. Using these materials, the Chronic Care Ostomy Self-Management Program was developed by a team of multi-disciplinary researchers accompanied by experienced ostomy nurses. Testing of the program is in process. Pilot study participants reported high satisfaction with the program syllabus, ostomy nurse leaders, and ostomate peer buddies.

  18. Health care 2020: reengineering health care delivery to combat chronic disease.

    PubMed

    Milani, Richard V; Lavie, Carl J

    2015-04-01

    Chronic disease has become the great epidemic of our times, responsible for 75% of total health care costs and the majority of deaths in the US. Our current delivery model is poorly constructed to manage chronic disease, as evidenced by low adherence to quality indicators and poor control of treatable conditions. New technologies have emerged that can engage patients and offer additional modalities in the treatment of chronic disease. Modifying our delivery model to include team-based care in concert with patient-centered technologies offers great promise in managing the chronic disease epidemic.

  19. Health care 2020: reengineering health care delivery to combat chronic disease.

    PubMed

    Milani, Richard V; Lavie, Carl J

    2015-04-01

    Chronic disease has become the great epidemic of our times, responsible for 75% of total health care costs and the majority of deaths in the US. Our current delivery model is poorly constructed to manage chronic disease, as evidenced by low adherence to quality indicators and poor control of treatable conditions. New technologies have emerged that can engage patients and offer additional modalities in the treatment of chronic disease. Modifying our delivery model to include team-based care in concert with patient-centered technologies offers great promise in managing the chronic disease epidemic. PMID:25460529

  20. Care of the patient with chronic pain: Part I.

    PubMed

    Wells-Federman, C L

    1999-07-01

    Chronic nonmalignant pain is estimated to affect over 50 million Americans. It frequently results in significant physical, behavioral, psychological, social, and spiritual problems for patients and their families. In spite of its prevalence and consequences, chronic pain is often misunderstood and inadequately managed by healthcare professionals. Advanced practice nurses who are knowledgeable about chronic pain and the complex biopsychosocial-spiritual needs of this patient population serve an important role in recognizing these patients and intervening appropriately in their care. The purpose of this two-part article is to provide that information. Part I outlines the pathophysiology, assessment, biopsychosocial-spiritual aspects, and pharmacological treatment of chronic pain. Part II addresses a variety of nonpharmacologic and self-management interventions one can use in the primary care setting to treat these difficult health problems. PMID:10711057

  1. Evidence On The Chronic Care Model In The New Millennium

    PubMed Central

    Coleman, Katie; Austin, Brian T.; Brach, Cindy; Wagner, Edward H.

    2016-01-01

    Developed more than a decade ago, the Chronic Care Model (CCM) is a widely adopted approach to improving ambulatory care that has guided clinical quality initiatives in the United States and around the world. We examine the evidence of the CCM’s effectiveness by reviewing articles published since 2000 that used one of five key CCM papers as a reference. Accumulated evidence appears to support the CCM as an integrated framework to guide practice redesign. Although work remains to be done in areas such as cost-effectiveness, these studies suggest that redesigning care using the CCM leads to improved patient care and better health outcomes. PMID:19124857

  2. Tracking emergency department overcrowding in a tertiary care academic institution.

    PubMed

    Bullard, Michael J; Villa-Roel, Cristina; Bond, Kenneth; Vester, Michael; Holroyd, Brian R; Rowe, Brian H

    2009-01-01

    Despite the release of a national report describing key markers of emergency department (ED) overcrowding, limited linear data using these markers have been published. We sought to report the degree and trends of ED overcrowding in a typical academic hospital and to highlight some of the key markers of ED patient flow and care. We conducted a prospective study in a large Canadian urban tertiary care teaching hospital that receives approximately 55,000 annual adult ED visits. A database captured demographic and real-time process of care data for each patient from 2000 to 2007. Descriptive data are reported using Canadian Triage and Acuity Scale (CTAS) scores. Over the study period, the ED patient visit volume and presentation times remained predictable. Emergent cases (CTAS levels 1-2) doubled from 8 to 16.6%, and urgent cases (CTAS level 3) increased from 40.2 to 50.3%. Moreover, semi-urgent presentations (CTAS level 4) decreased from 42.4 to 28.8%, and non-urgent cases (CTAS level 5) dropped from 9.4 to 4.3%. The median wait time from triage to bed location increased from two minutes (inter-quartile range [IQR] 1, 46) in 2000 to 27 minutes (IQR 2, 110) in 2007, while the median time from bed location to physician remained constant (29 minutes in 2001 versus 28 minutes in 2007). Overall, admissions increased from 20.4 to 23%. Semi-urgent and non-urgent admissions dropped from 11.5 to 7.4% and 3.2 to 1.8%, respectively. Admitted patients "boarding" in the ED increased from 70,955 hours in 2002 to 118,741 hours in 2007, while the number of emergent and urgent patients leaving without being seen increased by more than 400%. ED overcrowding in a tertiary care hospital is primarily a result of access block due to boarding admitted patients, a situation that poses serious risks to the majority of patients who have emergent or urgent conditions that cannot be managed appropriately in the waiting room. PMID:19553772

  3. [Skillful care for chronic vascular wounds].

    PubMed

    Goullet de Rugy, C; Lazareth, I; You, C; Stansal, A; Priollet, P

    2016-09-01

    In vascular medicine, wound care requires pluridisciplinary expertise and nursing skill. Care must be perfectly adapted to each individual patient, the specificities of each particular wound, and the underlying vascular disease. The goal is to achieve wound healing. Inappropriate care can retard healing or even aggravate the wound. The skin should be cleaned with water a non-allergic detergent and should concern the entire limb in addition to the wound itself. Fibrin or necrosis detersion is an important step that can be painful. Different tools are available. The skin around the wound should be hydrated and protected, focusing on fragile areas, such as the tibial crest and heals, in order to prevent the development of new wounds. Other more complex interventions include tenosynovectomy, bone gouging and reduction of the necrotic toe that when properly performed can prevent a new passage in the operating room. If the ischemia becomes critical, the foot should be held warm with a carded cotton, taking care to separate the toes with dry dressings in order to preserve the healthy tissue and avoid induced wounds. Finally, compression bands are indispensable in cases with edema or venous hyperpressure. A skillful banding technique is essential, especially for legs with complex morphology. PMID:27594570

  4. School nurse case management for children with chronic illness: health, academic, and quality of life outcomes.

    PubMed

    Keehner Engelke, Martha; Guttu, Martha; Warren, Michelle B; Swanson, Melvin

    2008-08-01

    More children with chronic illnesses are attending school, and some of them struggle academically because of issues related to their health. School-based case management has been suggested as one strategy to improve the academic success of these children. This study tracked the academic, health, and quality of life outcomes for 114 children with asthma, diabetes, severe allergies, seizures, or sickle-cell anemia in 5 different school districts who were provided case management by school nurses. The children ranged in age from 5 to 19 years. At the end of the school year, children experienced an improvement in quality of life and gained skills and knowledge to manage their illness more effectively. Classroom participation, grades, and participation in extracurricular activities also increased for many children. The study provides evidence of the positive impact school nurses have on children with chronic illness and suggests ways they can measure the outcomes of their interventions. PMID:18757353

  5. Rethinking chronic pain in a primary care setting.

    PubMed

    Stanos, Steven; Brodsky, Marina; Argoff, Charles; Clauw, Daniel J; D'Arcy, Yvonne; Donevan, Sean; Gebke, Kevin B; Jensen, Mark P; Lewis Clark, Evelyn; McCarberg, Bill; Park, Peter W; Turk, Dennis C; Watt, Stephen

    2016-06-01

    Chronic pain substantially impacts patient function and quality of life and is a burden to society at large in terms of increased health care utilization and loss of productivity. As a result, there is an increasing recognition of chronic pain as a public health crisis. However, there remains wide variability in clinical practices related to the prevention, assessment, and treatment of chronic pain. Certain fundamental aspects of chronic pain are often neglected including the contribution of the psychological, social, and contextual factors associated with chronic pain. Also commonly overlooked is the importance of understanding the likely neurobiological mechanism(s) of the presenting pain and how they can guide treatment selection. Finally, physicians may not recognize the value of using electronic medical records to systematically capture data on pain and its impact on mood, function, and sleep. Such data can be used to monitor onset and maintenance of treatments effects at the patient level and evaluate costs at the systems level. In this review we explain how these factors play a critical role in the development of a coordinated, evidence-based treatment approach tailored to meet specific needs of the patient. We also discuss some practical approaches and techniques that can be implemented by clinicians in order to enhance the assessment and management of individuals with chronic pain in primary care settings.

  6. Rethinking chronic pain in a primary care setting.

    PubMed

    Stanos, Steven; Brodsky, Marina; Argoff, Charles; Clauw, Daniel J; D'Arcy, Yvonne; Donevan, Sean; Gebke, Kevin B; Jensen, Mark P; Lewis Clark, Evelyn; McCarberg, Bill; Park, Peter W; Turk, Dennis C; Watt, Stephen

    2016-06-01

    Chronic pain substantially impacts patient function and quality of life and is a burden to society at large in terms of increased health care utilization and loss of productivity. As a result, there is an increasing recognition of chronic pain as a public health crisis. However, there remains wide variability in clinical practices related to the prevention, assessment, and treatment of chronic pain. Certain fundamental aspects of chronic pain are often neglected including the contribution of the psychological, social, and contextual factors associated with chronic pain. Also commonly overlooked is the importance of understanding the likely neurobiological mechanism(s) of the presenting pain and how they can guide treatment selection. Finally, physicians may not recognize the value of using electronic medical records to systematically capture data on pain and its impact on mood, function, and sleep. Such data can be used to monitor onset and maintenance of treatments effects at the patient level and evaluate costs at the systems level. In this review we explain how these factors play a critical role in the development of a coordinated, evidence-based treatment approach tailored to meet specific needs of the patient. We also discuss some practical approaches and techniques that can be implemented by clinicians in order to enhance the assessment and management of individuals with chronic pain in primary care settings. PMID:27166559

  7. The Role of Technology in Chronic Disease Care.

    PubMed

    Milani, Richard V; Bober, Robert M; Lavie, Carl J

    2016-01-01

    Chronic disease represents the epidemic of our time, present in half the adult population and responsible for 86% of United States (US) healthcare costs and 70% of deaths. The major chronic diseases are primarily due to health risk behaviors that are widely communicable across populations. As a nation, the US has performed poorly in managing chronic disease, in large part because of a failed delivery model of care. New opportunities exist as a result of recent advances in home-based wireless devices, apps and wearables, enabling health delivery systems to monitor disease metrics in near real time. These technologies provide a framework for patient engagement and a new model of care delivery utilizing integrated practice units, both of which are needed to navigate the healthcare needs of the 21st century.

  8. Care of the patient with chronic pain: part II.

    PubMed

    Wells-Federman, C L

    2000-01-01

    Chronic nonmalignant pain frequently results in significant physical, behavioral, psychological, social, and spiritual issues for patients and their families. It is often misunderstood and unsuccessfully managed. Advanced practice nurses who are knowledgeable about chronic pain and the complex biopsychosocial-spiritual needs of this patient population serve an important role in recognizing these patients and intervening appropriately in their care. The purpose of this two-part article is to provide that information. Part I [Clinical Excellence for Nurse Practitioners, 3 (4), 192-204] outlined the pathophysiology, assessment, biopsychosocial-spiritual aspects, and pharmacologic treatment of chronic pain. In Part II, a variety of nonpharmacologic and self-management interventions one can use in the primary care setting to treat these difficult health problems are introduced. PMID:11858295

  9. Chronic heart failure: a review for the primary care physician.

    PubMed

    Rodríguez-Escudero, José A; Zayas-Torres, Carlos; Banchs-Pieretti, Hector

    2003-01-01

    Heart failure is a complex clinical syndrome. The pharmacological therapy for chronic heart failure has been changing in the past decade with acquired knowledge of the pathophysiology of this medical condition. Primary care physicians currently treat a significant number of patients. This article summarizes core topics of heart failure including epidemiological information, etiology, pathophysiology, clinical features and diagnostic tools. Also, we review some of the most relevant research studies that have led to the current recommendations for the pharmacological therapeutic strategies in the management of chronic heart failure. We make reference to the latest guidelines in the management of chronic heart failure submitted by the American College of Cardiology and the American Heart Association (ACC/AHA). New technological advances, such as the biventricular-pacing devices, are an important adjuvant to the established pharmacological therapies for chronic heart failure.

  10. Caring or Collusion? Academic Dishonesty in a School of Nursing

    ERIC Educational Resources Information Center

    Wideman, Maureen

    2011-01-01

    Academic dishonesty is an issue that post-secondary institutions are having difficulty resolving. More than 100 studies have been conducted over the past 30 years, yet these studies have not provided data necessary to effectively address this problem. Indeed, research indicates that academic dishonesty is increasing. The purpose of this study was…

  11. Multidisciplinary Care of the Patient with Chronic Obstructive Pulmonary Disease

    PubMed Central

    Kuzma, Anne Marie; Meli, Yvonne; Meldrum, Catherine; Jellen, Patricia; Butler-Lebair, Marianne; Koczen-Doyle, Debra; Rising, Peter; Stavrolakes, Kim; Brogan, Frances

    2008-01-01

    The National Emphysema Treatment Trial used a multidisciplinary team approach to implement the maximum medical care protocol, including adjustment of medications and outpatient pulmonary rehabilitation for all patients and nutritional and psychological counseling as needed. This article discusses the benefits of such an approach in the care of the patient with chronic obstructive pulmonary disease. Team member roles complement each other and contribute to the goal of providing the highest-quality medical care. The primary focus of the team is to reinforce the medical plan and to provide patient education and support. This article reviews the elements of the initial patient assessment and the functional and nutritional assessment. Patient education focuses on medication use, recognition and management of chronic obstructive pulmonary disease exacerbation symptoms, smoking cessation, advance directives, and travel. PMID:18453373

  12. Quality of life for chronic psychiatric illnesses and home care

    PubMed Central

    Molu, Nesibe Gunay; Ozkan, Birgul; Icel, Sema

    2016-01-01

    Nowadays, mental illnesses are gradually increasing and so does chronic psychiatric patients. As a result of this increase, chronic psychiatric disorders lead the burden of patients and their families. To reduce the burden of mental illnesses on individuals and their families, treatment and care are given including psychosocial, physiological and medical support and social services. To begin with, home care enables both the patient and his or her family to stay at their own houses and not to be bothered with residents or long-term, institutional-based nursing homes. In addition, the home care providers deliver services to the patient’s at their own house. The other advantages of taking care at home is that it eases financial issues in terms of reducing the cost, reduces the patient’s symptoms and improve the individual’s quality of life (QoL). In addition to these, home care also minimizes the burden on outpatient services and provides help for the patient and the family in order to solve their problems and give support. Home care services help patients to get their freedom back and enhance the quality of their lives. Thus, it is necessary to procure and implement these services and supply both the patient and his or her family a high-quality life. Sources of data/ study selection: Literature review was done by using the keywords “home care, patient with chronic mental illness, quality of life, home care nursing” from the sources including PsychINFO, PsychARTICLES, MEDLINE, PubMED, EBSCOHOST and The COCHRANE LIBRARY in the time period of 2005- 2015. PMID:27182272

  13. [Home care for the chronically ill: a self-care health system].

    PubMed

    Silva, Leticia Robles

    2004-01-01

    This article focuses on home care for chronically ill adults and seniors. According to our thesis, home care should be understood as a self-care system, and its aim is to guarantee the individual's social and bodily survival. Home care consists of three areas, related to illness, the home, and to life history. Caregiving, usually under women's responsibility, is present throughout the history of the illness and the health-seeking process. The article analyzes these issues in light of the ageing process, the epidemiological changes occurring worldwide, and the urgency to incorporate this analysis into the heath care research agenda. PMID:15073644

  14. 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

    2007-01-01

    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.

  15. [Complex chronic care situations and socio-health coordination].

    PubMed

    Morilla Herrera, Juan Carlos; Morales Asencio, José Miguel; Kaknani, Shakira; García Mayor, Silvia

    2016-01-01

    Patient-centered healthcare is currently one of the most pursued goals in health services. It is necessary to ensure a sufficient level of cooperative and coordinated work between different providers and settings, including family and social and community resources. Clinical integration occurs when the care provided by health professionals and providers is integrated into a single coherent process through different professions using shared guidelines and protocols. Such coordination can be developed at three levels: macro, which involves the integration of one or more of the three basic elements that support health care (the health plan, primary care and specialty care), with the aim of reducing fragmentation of care; meso, where health and social services are coordinated to provide comprehensive care to elderly and chronic patients; and micro, aimed to improve coordination in individual patients and caregivers. The implementation of new roles, such as Advanced Practice Nursing, along with improvements in family physicians' problem-solving capacity in certain processes, or modifying the place of provision of certain services are key to ensure services adapted to the requirements of chronic patients.

  16. Implementation of a collaborative care management program with buprenorphine in primary care: A comparison between opioid-dependent patients and chronic pain patients using opioids non-medically

    PubMed Central

    Suzuki, Joji; Matthews, Michele L.; Brick, David; Nguyen, Minh-Thuy; Jamison, Robert N.; Ellner, Andrew L.; Tishler, Lori W.; Weiss, Roger D.

    2014-01-01

    Objective To implement a collaborative care management program with buprenorphine in a primary care clinic. Design Prospective observational study. Setting A busy urban academic primary care clinic affiliated with a tertiary care hospital. Participants Opioid dependent patients or chronic pain patients using opioids non-medically were recruited for the study. A total of 45 participants enrolled. Interventions Patients were treated with buprenorphine and managed by a supervising psychiatrist, pharmacist care manager and health coaches. The care manager conducted buprenorphine inductions and all follow-ups visits. Health coaches offered telephonic support. The psychiatrist supervised both the care manager and health coaches. Main outcome measures Primary outcomes were treatment retention at 6 months, and change in the proportion of aberrant toxicology results and opioid craving scores from baseline to 6 months. After data collection, clinical outcomes were compared between opioid dependent patients and chronic pain patients using opioids non-medically. Overall, 55.0% (25/45) of participants remained in treatment at 6 months. PCPs’ attitudes about opioid dependence treatment were surveyed at baseline and at 18-months. Results Forty-three patients (95.6%) accepted treatment and 25 (55.0%) remained in treatment at 6 months. The proportion of aberrant urine toxicology results decreased significantly from baseline to 6 months (p<0.01). Craving scores significantly decreased from baseline to 6 months (p<0.01). Opioid dependent patients, as opposed to chronic pain patients using opioids non-medically, were significantly more likely to complete 6 months of treatment (p<0.05). PCPs’ confidence in treating opioid dependence in primary care increased significantly from baseline to 18-months post-implementation (p<0.01). Conclusion Collaborative care management for opioid dependence with buprenorphine may be feasible in a primary care clinic. More research is needed to

  17. Chronic pain management as a barrier to pediatric palliative care.

    PubMed

    Thompson, Lindsay A; Meinert, Elizabeth; Baker, Kimberly; Knapp, Caprice

    2013-12-01

    Pain is common as a presenting complaint to outpatient and emergency departments for children, yet pain management represents one of the children's largest unmet needs. A child may present with acute pain for an intermittent issue or may have acute or chronic pain in the setting of chronic illness. The mainstay of treatment for pain uses a stepwise approach for pain management, such as set up by the World Health Organization. For children with life-limiting illnesses, the Institute of Medicine guidelines recommends referral upon diagnosis for palliative care, meaning that the child receives comprehensive services that include pain control in coordination with curative therapies; yet barriers remain. From the provider perspective, pain can be better addressed through a careful assessment of one's own knowledge, skills, and attitudes. The key components of pain management in children are multimodal, regardless of the cause of the pain. PMID:23329083

  18. Chronic pain management as a barrier to pediatric palliative care.

    PubMed

    Thompson, Lindsay A; Meinert, Elizabeth; Baker, Kimberly; Knapp, Caprice

    2013-12-01

    Pain is common as a presenting complaint to outpatient and emergency departments for children, yet pain management represents one of the children's largest unmet needs. A child may present with acute pain for an intermittent issue or may have acute or chronic pain in the setting of chronic illness. The mainstay of treatment for pain uses a stepwise approach for pain management, such as set up by the World Health Organization. For children with life-limiting illnesses, the Institute of Medicine guidelines recommends referral upon diagnosis for palliative care, meaning that the child receives comprehensive services that include pain control in coordination with curative therapies; yet barriers remain. From the provider perspective, pain can be better addressed through a careful assessment of one's own knowledge, skills, and attitudes. The key components of pain management in children are multimodal, regardless of the cause of the pain.

  19. Providing holistic care for women with chronic pelvic pain.

    PubMed

    Abercrombie, Priscilla D; Learman, Lee A

    2012-01-01

    Chronic pelvic pain (CPP) is one of the most common pain conditions affecting women and can have a significant impact on quality of life. Assessment of women with CPP is best approached in a comprehensive, systematic manner that includes exploration of physiological and psychological causes. A range of treatment options that draw from conventional medicine and complementary and alternative modalities should be offered. The women's health nurse plays a pivotal role in all aspects of care.

  20. Effects of the Growth of Managed Care on Academic Medical Centers and Graduate Medical Education.

    ERIC Educational Resources Information Center

    Gold, Marsha R.

    1996-01-01

    Ways in which the proliferation of competitive health care financing and service delivery systems based on managed care affects the financial support available to academic medical centers (AMCs), especially graduate medical education programs, are discussed. Analysis is based on case studies of AMCs. Trends, potential conflicts, and areas for…

  1. Do telemonitoring projects of heart failure fit the Chronic Care Model?

    PubMed Central

    Willemse, Evi; Adriaenssens, Jef; Dilles, Tinne; Remmen, Roy

    2014-01-01

    This study describes the characteristics of extramural and transmural telemonitoring projects on chronic heart failure in Belgium. It describes to what extent these telemonitoring projects coincide with the Chronic Care Model of Wagner. Background The Chronic Care Model describes essential components for high-quality health care. Telemonitoring can be used to optimise home care for chronic heart failure. It provides a potential prospective to change the current care organisation. Methods This qualitative study describes seven non-invasive home-care telemonitoring projects in patients with heart failure in Belgium. A qualitative design, including interviews and literature review, was used to describe the correspondence of these home-care telemonitoring projects with the dimensions of the Chronic Care Model. Results The projects were situated in primary and secondary health care. Their primary goal was to reduce the number of readmissions for chronic heart failure. None of these projects succeeded in a final implementation of telemonitoring in home care after the pilot phase. Not all the projects were initiated to accomplish all of the dimensions of the Chronic Care Model. A central role for the patient was sparse. Conclusion Limited financial resources hampered continuation after the pilot phase. Cooperation and coordination in telemonitoring appears to be major barriers but are, within primary care as well as between the lines of care, important links in follow-up. This discrepancy can be prohibitive for deployment of good chronic care. Chronic Care Model is recommended as basis for future. PMID:25114664

  2. Care for chronic illness in Australian general practice – focus groups of chronic disease self-help groups over 10 years: implications for chronic care systems reforms

    PubMed Central

    Martin, Carmel M; Peterson, Chris; Robinson, Rowena; Sturmberg, Joachim P

    2009-01-01

    Background Chronic disease is a major global challenge. However, chronic illness and its care, when intruding into everyday life, has received less attention in Asia Pacific countries, including Australia, who are in the process of transitioning to chronic disease orientated health systems. Aim The study aims to examine experiences of chronic illness before and after the introduction of Australian Medicare incentives for longer consultations and structured health assessments in general practice. Methods Self-help groups around the conditions of diabetes, epilepsy, asthma and cancer identified key informants to participate in 4 disease specific focus groups. Audio taped transcripts of the focus groups were coded using grounded theory methodology. Key themes and lesser themes identified using a process of saturation until the study questions on needs and experiences of care were addressed. Thematic comparisons were made across the 2002/3 and 1992/3 focus groups. Findings At times of chronic illness, there was need to find and then ensure access to 'the right GP'. The 'right GP or specialist' committed to an in-depth relationship of trust, personal rapport and understanding together with clinical and therapeutic competence. The 'right GP', the main specialist, the community nurse and the pharmacist were key providers, whose success depended on interprofessional communication. The need to trust and rely on care providers was balanced by the need for self-efficacy 'to be in control of disease and treatment' and 'to be your own case manager'. Changes in Medicare appeared to have little penetration into everyday perceptions of chronic illness burden or time and quality of GP care. Inequity of health system support for different disease groupings emerged. Diabetes, asthma and certain cancers, like breast cancer, had greater support, despite common experiences of disease burden, and a need for research and support programs. Conclusion Core themes around chronic illness

  3. Academic physicians' assessment of the effects of computers on health care.

    PubMed

    Detmer, W M; Friedman, C P

    1994-01-01

    We assessed the attitudes of academic physicians towards computers in health care at two academic medical centers that are in the early stages of clinical information-system deployment. We distributed a 4-page questionnaire to 470 subjects, and a total of 272 physicians (58%) responded. Our results show that respondents use computers frequently, primarily to perform academic-oriented tasks as opposed to clinical tasks. Overall, respondents viewed computers as being slightly beneficial to health care. They perceive self-education and access to up-to-date information as the most beneficial aspects of computers and are most concerned about privacy issues and the effect of computers on the doctor-patient relationship. Physicians with prior computer training and greater knowledge of informatics concepts had more favorable attitudes towards computers in health care. We suggest that negative attitudes towards computers can be addressed by careful system design as well as targeted educational activities.

  4. Novel Telemedicine Technologies in Geriatric Chronic Non-Cancer Pain: Primary Care Providers’ Perspectives

    PubMed Central

    Levine, Mimi; Richardson, Joshua E.; Granieri, Evelyn; Reid, M. Cary

    2015-01-01

    Objective We sought to identify primary care providers’ interest in, as well as perceived barriers and facilitators to, using novel telemedicine technologies (e.g., smartphones) for managing chronic non-cancer pain (CNCP) in older adults. Design Six focus groups were conducted with 25 primary care providers. Setting Two academically affiliated primary care practices serving older adults with CNCP in New York City. Methods The investigators used content analysis to analyze transcribed focus group data and identify specific themes. Results While most providers reported limited use of telemedicine, they expressed substantial interest in trying devices such as smartphones in the management of older patients with CNCP. Perceived barriers to implementation of telemedicine tools included information overload, lack of mobile device usability among patients and clinicians, liability issues, and cost. To overcome these barriers, participants suggested implementing electronic or human-based pre-analysis of data (e.g., a computer or a person that triages patient data), creating a low-cost and user-friendly mobile device design, and targeting appropriate user populations. Conclusions Primary care providers are interested in applying telemedicine when caring for older adults with CNCP. Although they perceived multiple barriers to device implementation, they offered innovative solutions to address these barriers. Providers felt that novel telemedicine technologies may improve the management of CNCP but wanted evidence that the devices were both cost- and time-efficient, and led to improved patient outcomes before adopting their use in practice. PMID:24341423

  5. Academic Detailing in Diabetes: Using Outreach Education to Improve the Quality of Care.

    PubMed

    Fischer, Michael A

    2016-10-01

    Most diabetes care is provided in primary care settings, but typical primary care clinicians struggle to keep up with the latest evidence on diabetes screening, pharmacotherapy, and monitoring. Accordingly, many patients with diabetes are not receiving optimal guideline-based therapy. Relying on front-line clinicians on their own to assess the huge volume of new literature and incorporate it into their practice is unrealistic, and conventional continuing medical education has not proven adequate to address gaps in care. Academic detailing, direct educational outreach to clinicians that uses social marketing techniques to provide specific evidence-based recommendations, has been proven in clinical trials to improve the quality of care for a range of conditions. By directly engaging with clinicians to assess their needs, identify areas for change in practice, and provide them with specific tools to implement these changes, academic detailing can serve as a tool to improve care processes and outcomes for patients with diabetes. PMID:27586191

  6. Palliative Care, Hospice, and Advance Care Planning: Views of People Living with HIV and Other Chronic Conditions.

    PubMed

    Slomka, Jacquelyn; Prince-Paul, Maryjo; Webel, Allison; Daly, Barbara J

    2016-01-01

    People living with HIV (PLWH) who survive to older adulthood risk developing multiple chronic medical conditions. Health policymakers recognize the role of early palliative care and advance care planning in improving health quality for at-risk populations, but misperceptions about palliative care, hospice, and advance care planning are common. Before testing a program of early palliative care for PLWH and other chronic conditions, we conducted focus groups to elicit perceptions of palliative care, hospice, and advance care planning in our target population. Overall, participants were unfamiliar with the term palliative care, confused concepts of palliative care and hospice, and/or associated hospice care with dying. Participants misunderstood advance care planning, but valued communication about health care preferences. Accepting palliative care was contingent on distinguishing it from hospice and historical memories of HIV and dying. Provision of high-quality, comprehensive care will require changing public perceptions and individuals' views in this high-risk population.

  7. Early chronic kidney disease: diagnosis, management and models of care.

    PubMed

    Wouters, Olivier J; O'Donoghue, Donal J; Ritchie, James; Kanavos, Panos G; Narva, Andrew S

    2015-08-01

    Chronic kidney disease (CKD) is prevalent in many countries, and the costs associated with the care of patients with end-stage renal disease (ESRD) are estimated to exceed US$1 trillion globally. The clinical and economic rationale for the design of timely and appropriate health system responses to limit the progression of CKD to ESRD is clear. Clinical care might improve if early-stage CKD with risk of progression to ESRD is differentiated from early-stage CKD that is unlikely to advance. The diagnostic tests that are currently used for CKD exhibit key limitations; therefore, additional research is required to increase awareness of the risk factors for CKD progression. Systems modelling can be used to evaluate the impact of different care models on CKD outcomes and costs. The US Indian Health Service has demonstrated that an integrated, system-wide approach can produce notable benefits on cardiovascular and renal health outcomes. Economic and clinical improvements might, therefore, be possible if CKD is reconceptualized as a part of primary care. This Review discusses which early CKD interventions are appropriate, the optimum time to provide clinical care, and the most suitable model of care to adopt.

  8. Experience in Strategic Networking to Promote Palliative Care in a Clinical Academic Setting in India

    PubMed Central

    Nair, Shoba; Tarey, SD; Barathi, B; Mary, Thiophin Regina; Mathew, Lovely; Daniel, Sudha Pauline

    2016-01-01

    Background: Palliative care in low and middle-income countries is a new discipline, responding to a greater patient need, than in high-income countries. By its very nature, palliative as a specialty has to network with other specialties to provide quality care to patients. For any medical discipline to grow as a specialty, it should be well established in the teaching medical institutions of that country. Data show that palliative care is more likely to establish and grow in an academic health care institution. It is a necessity that multiple networking strategies are adopted to reach this goal. Objectives: (1) To describe a strategic approach to palliative care service development and integration into clinical academic setting. (2) To present the change in metrics to evaluate progress. Design and Setting: This is a descriptive study wherein, the different strategies that are adopted by the Department of Palliative Medicine for networking in an academic health care institution and outside the institution are scrutinized. Measurement: The impact of this networking was assessed, one, at the level of academics and the other, at the level of service. The number of people who attended various training programs conducted by the department and the number of patients who availed palliative care service over the years were assessed. Results: Ten different strategies were identified that helped with networking of palliative care in the institution. During this time, the referrals to the department increased both for malignant diseases (52–395) and nonmalignant diseases (5–353) from 2000 to 2013. The academic sessions conducted by the department for undergraduates also saw an increase in the number of hours from 6 to 12, apart from the increase in a number of courses conducted by the department for doctors and nurses. Conclusion: Networking is an essential strategy for the establishment of a relatively new medical discipline like palliative care in a developing and

  9. The role of team climate in improving the quality of chronic care delivery: a longitudinal study among professionals working with chronically ill adolescents in transitional care programmes

    PubMed Central

    Cramm, Jane M; Strating, Mathilde M H; Nieboer, Anna P

    2014-01-01

    Objectives This study aimed to (1) evaluate the effectiveness of implementing transition programmes in improving the quality of chronic care delivery and (2) identify the predictive role of (changes in) team climate on the quality of chronic care delivery over time. Settings This longitudinal study was undertaken with professionals working in hospitals and rehabilitation units that participated in the transition programme ‘On Your Own Feet Ahead!’ in the Netherlands. Participantss A total of 145/180 respondents (80.6%) filled in the questionnaire at the beginning of the programme (T1), and 101/173 respondents (58.4%) did so 1 year later at the end of the programme (T2). A total of 90 (52%) respondents filled in the questionnaire at both time points. Two-tailed, paired t tests were used to investigate improvements over time and multilevel analyses to investigate the predictive role of (changes in) team climate on the quality of chronic care delivery. Interventions Transition programme. Primary outcome measures Quality of chronic care delivery measured with the Assessment of Chronic Illness Care Short version (ACIC-S). Results The overall ACIC-S score at T1 was 5.90, indicating basic or intermediate support for chronic care delivery. The mean ACIC-S score at T2 significantly improved to 6.70, indicating advanced support for chronic care. After adjusting for the quality of chronic care delivery at T1 and significant respondents’ characteristics, multilevel regression analyses showed that team climate at T1 (p<0.01) and changes in team climate (p<0.001) predicted the quality of chronic care delivery at T2. Conclusions The implementation of transition programmes requires a supportive and stimulating team climate to enhance the quality of chronic care delivery to chronically ill adolescents. PMID:24852302

  10. Impact of financial agreements in European chronic care on health care expenditure growth.

    PubMed

    Tsiachristas, Apostolos; Dikkers, Carolien; Boland, Melinde R S; Rutten-van Mölken, Maureen P M H

    2016-04-01

    Various types of financial agreements have been implemented in Europe to reduce health care expenditure by stimulating integrated chronic care. This study used difference-in-differences (DID) models to estimate differences in health care expenditure trends before and after the introduction of a financial agreement between 9 intervention countries and 16 control countries. Intervention countries included countries with pay-for-coordination (PFC), pay-for-performance (PFP), and/or all inclusive agreements (bundled and global payment) for integrated chronic care. OECD and WHO data from 1996 to 2013 was used. The results from the main DID models showed that the annual growth of outpatient expenditure was decreased in countries with PFC (by 21.28 US$ per capita) and in countries with all-inclusive agreements (by 216.60 US$ per capita). The growth of hospital and administrative expenditure was decreased in countries with PFP by 64.50 US$ per capita and 5.74 US$ per capita, respectively. When modelling impact as a non-linear function of time during the total 4-year period after implementation, PFP decreased the growth of hospital and administrative expenditure and all-inclusive agreements reduced the growth of outpatient expenditure. Financial agreements are potentially powerful tools to stimulate integrated care and influence health care expenditure growth. A blended payment scheme that combines elements of PFC, PFP, and all-inclusive payments is likely to provide the strongest financial incentives to control health care expenditure growth. PMID:26971018

  11. Seamless health care for chronic diseases in a dual health care system: managed care and the role of family physicians.

    PubMed

    Lee, A

    1998-01-01

    Neither private nor state run health care systems are perfect. Although there is increasing evidence that Health Maintenance Organizations (HMOs) provide comparable care at lower cost, HMOs tend to select healthy patients. The dual health care system in Hong Kong spends about 3.9 per cent of GDP, with health indices among the best in the world. Hong Kong still faces the problem of escalating health care expenditure. One should take advantage of the dual health care system to evolve a new paradigm for a primary-led seamless health care service. The Diabetes Centre of a university teaching hospital together with the University of Community and Family Medicine has started a structured shared care programme in diabetes mellitus, involving general practitioners in both the private and public sectors integrating the primary and secondary care, and the private and public sectors. This programme starts to develop an infrastructure for providing quality care at an affordable cost for a large pool of patients with chronic disease. Unlike other "managed care schemes", this one is not run by profit-oriented companies, but by health professionals with an interest in providing best possible care at an affordable cost. The "disease management" approach needs a care delivery system without traditional boundaries; and a continuous improvement process which develops and refines the knowledge base, guidelines and delivery system. PMID:10351265

  12. Palliative care for patients with advance chronic kidney disease.

    PubMed

    Douglas, C A

    2014-01-01

    Over the past three decades there has been a dramatic rise in the number of patients with advanced chronic kidney disease. The fastest expanding group receiving dialysis has been the elderly. However, for those patients who are very elderly with co-morbidity, dialysis may not offer a survival advantage. Therefore, active conservative management is a growing service offered by many renal units in the UK and focuses on non-dialytic correction of fluid and electrolyes, management of renal anaemia, and assessment and management of symptoms. The five-year survival of a patient over 75 years of age starting dialysis is 20% and if a patient is over 75 years, has co-morbidity, or a poor performance status, dialysis may not offer any survival advantage. Whether a patient is managed by dialysis or by conservative management the symptom burden suffered is high. These symptoms are under-recognised and often managed poorly because of increased drug toxicity in renal failure. This complex group of patients require close working between renal, palliative care, medicine for the elderly, and community teams, to allow best quality of life and end of life care. This review describes some of the challenges in providing Advanced Care Planning for dialysis and conservatively managed patients, highlights the symptom burden of patients with advanced chronic kidney disease, and offers guidance in how to manage the symptoms effectively.

  13. Chronic disease management: improving care for people with osteoarthritis.

    PubMed

    Brand, Caroline A; Ackerman, Ilana N; Tropea, Joanne

    2014-02-01

    Chronic disease management (CDM) service models are being developed for many conditions; however, there is limited evidence to support their effectiveness in osteoarthritis (OA). A systematic review was undertaken to examine effectiveness, cost effectiveness and barriers to the use of osteoarthritis-chronic disease management (OA-CDM) service models. Thirteen eligible studies (eight randomised controlled trial (RCTs)) were identified. The majority focussed on delivery system design (n = 9) and/or providing self-management support (SMS) (n = 8). Overall, reported model effectiveness varied, and where positive impacts on process or health outcomes were observed, they were of small to moderate effect. There was no information about cost effectiveness. There is some evidence to support the use of collaborative care/multidisciplinary case management models in primary and community care and evidence-based pathways/standardisation of care in hospital settings. Multiple barriers were identified. Future research should focus on identifying the effective components of multi-faceted interventions and evaluating cost-effectiveness to support clinical and policy decision-making.

  14. Academic retainer medicine: an innovative business model for cross-subsidizing primary care.

    PubMed

    Lucier, David J; Frisch, Nicholas B; Cohen, Brian J; Wagner, Michael; Salem, Deeb; Fairchild, David G

    2010-06-01

    Retainer-medicine primary care practices, commonly referred to as "luxury" or "concierge" practices, provide enhanced services to patients beyond those available in traditional practices for a yearly retainer fee. Adoption of retainer practices has been largely absent in academic health centers (AHCs). Reasons for this trend stem primarily from ethical concerns, such as the potential for patient abandonment when physicians downsize from larger, traditional practices to smaller, retainer-medicine practices.In 2004, the Department of Medicine at Tufts Medical Center developed an academic retainer-medicine primary care practice within the Division of General Medicine that not only generates financial support for the division but also incorporates a clinical and business model that is aligned with the mission and ethics of an academic institution.In contrast to private retainer-medicine practices, this unique business model addresses several of the ethical issues associated with traditional retainer practices-it does not restrict net access to care and it neutralizes concerns about patient abandonment. Addressing the growing primary care shortage, the model also presents the opportunity for a retainer practice to cross-subsidize the expansion of general medicine in an academic medical setting. The authors elucidate the benefits, as well as the inherent challenges, of embedding an academic retainer-medicine practice within an AHC.

  15. From "retailers" to health care providers: Transforming the role of community pharmacists in chronic disease management.

    PubMed

    Mossialos, Elias; Courtin, Emilie; Naci, Huseyin; Benrimoj, Shalom; Bouvy, Marcel; Farris, Karen; Noyce, Peter; Sketris, Ingrid

    2015-05-01

    Community pharmacists are the third largest healthcare professional group in the world after physicians and nurses. Despite their considerable training, community pharmacists are the only health professionals who are not primarily rewarded for delivering health care and hence are under-utilized as public health professionals. An emerging consensus among academics, professional organizations, and policymakers is that community pharmacists, who work outside of hospital settings, should adopt an expanded role in order to contribute to the safe, effective, and efficient use of drugs-particularly when caring for people with multiple chronic conditions. Community pharmacists could help to improve health by reducing drug-related adverse events and promoting better medication adherence, which in turn may help in reducing unnecessary provider visits, hospitalizations, and readmissions while strengthening integrated primary care delivery across the health system. This paper reviews recent strategies to expand the role of community pharmacists in Australia, Canada, England, the Netherlands, Scotland, and the United States. The developments achieved or under way in these countries carry lessons for policymakers world-wide, where progress thus far in expanding the role of community pharmacists has been more limited. Future policies should focus on effectively integrating community pharmacists into primary care; developing a shared vision for different levels of pharmacist services; and devising new incentive mechanisms for improving quality and outcomes.

  16. Auditing chronic disease care: Does it make a difference?

    PubMed Central

    van Vuuren, Unita; De Sa, Angela; Govender, Srini; Murie, Katie; Schlemmer, Arina; Gunst, Colette; Namane, Mosedi; Boulle, Andrew; de Vries, Elma

    2015-01-01

    Background An integrated audit tool was developed for five chronic diseases, namely diabetes, hypertension, asthma, chronic obstructive pulmonary disease and epilepsy. Annual audits have been done in the Western Cape Metro district since 2009. The year 2012 was the first year that all six districts in South Africa's Western Cape Province participated in the audit process. Aim To determine whether clinical audits improve chronic disease care in health districts over time. Setting Western Cape Province, South Africa. Methods Internal audits were conducted of primary healthcare facility processes and equipment availability as well as a folder review of 10 folders per chronic condition per facility. Random systematic sampling was used to select the 10 folders for the folder review. Combined data for all facilities gave a provincial overview and allowed for comparison between districts. Analysis was done comparing districts that have been participating in the audit process from 2009 to 2010 (‘2012 old’) to districts that started auditing recently (‘2012 new’). Results The number of facilities audited has steadily increased from 29 in 2009 to 129 in 2012. Improvements between different years have been modest, and the overall provincial average seemed worse in 2012 compared to 2011. However, there was an improvement in the ‘2012 old’ districts compared to the ‘2012 new’ districts for both the facility audit and the folder review, including for eight clinical indicators, with ‘2012 new’ districts being less likely to record clinical processes (OR 0.25, 95% CI 0.21–0.31). Conclusion These findings are an indication of the value of audits to improve care processes over the long term. It is hoped that this improvement will lead to improved patient outcomes. PMID:26245615

  17. Wound healing and treating wounds: Chronic wound care and management.

    PubMed

    Powers, Jennifer G; Higham, Catherine; Broussard, Karen; Phillips, Tania J

    2016-04-01

    In the United States, chronic ulcers--including decubitus, vascular, inflammatory, and rheumatologic subtypes--affect >6 million people, with increasing numbers anticipated in our growing elderly and diabetic populations. These wounds cause significant morbidity and mortality and lead to significant medical costs. Preventative and treatment measures include disease-specific approaches and the use of moisture retentive dressings and adjunctive topical therapies to promote healing. In this article, we discuss recent advances in wound care technology and current management guidelines for the treatment of wounds and ulcers.

  18. Project ECHO: a model for complex, chronic care in the Pacific Northwest region of the United States.

    PubMed

    Scott, John D; Unruh, Kent T; Catlin, Mary C; Merrill, Joseph O; Tauben, David J; Rosenblatt, Roger; Buchwald, Dedra; Doorenbos, Ardith; Towle, Cara; Ramers, Christian B; Spacha, David H

    2012-12-01

    The Pacific Northwest of the US is a large, sparsely populated region. A telehealth programme called Project ECHO (Extension for Community Health Outcomes) was tested in this region in 2009. Weekly videoconferences were held in the areas of hepatitis C, chronic pain, integrated addictions and psychiatry, and HIV/AIDS. Rural clinicians presented cases to a panel of experts at an academic medical centre and received management advice and access to best practices. During the trial, more than 900 clinicians participated, and more than 700 patient cases were presented. At the end of June 2012, a total of 23 videoconference clinics for hepatitis C had been held, 16 clinics in addiction and psychiatry, 97 in chronic pain and 13 in HIV/AIDS. The Project ECHO model improves access to health care. It may provide a way to bring specialist care to rural areas in developing countries.

  19. Self-care and yoga-academic-practice collaboration for occupational health.

    PubMed

    Alexander, Gina

    2013-12-01

    High rates of stress and burnout among nurses and other health care providers justify the exploration of innovative interventions designed to reduce stress and promote self-care among this population. A growing body of evidence supports the physical and psychosocial benefits of yoga and suggests the potential for yoga to support self-care and reduce stress among health care providers. This article describes the formation of an academic-practice collaboration to use yoga as a model for occupational health and wellness among nurses employed at a tax-supported urban health system. In addition, recommendations for program sustainability over time are discussed. PMID:24328918

  20. Coordinated Care Management For Dementia In A Large, Academic Health System

    PubMed Central

    Tan, Zaldy S.; Jennings, Lee; Reuben, David

    2014-01-01

    Alzheimer’s disease and other dementias are chronic, incurable diseases that require coordinated care that addresses the medical, behavioral, and social aspects of the disease. With funding from the Center for Medicare and Medicaid Innovation (the Innovation Center), we launched a dementia care program in which a nurse practitioner acting as a dementia care manager worked with primary care physicians to develop and implement a dementia care plan that offers training and support to caregivers, manages care transitions, and facilitates access to community-based services. Post-visit surveys showed high levels of caregiver satisfaction. As program enrollment grows, outcomes will be tracked based on the triple aim developed by the Institute for Healthcare Improvement and adopted by the Centers for Medicare and Medicaid Services: better care, better health, and lower cost and utilization. The program, if successful at achieving the triple aim, may serve as a national model for how dementia and other chronic diseases can be managed in partnership with primary care practices. The program may also inform policy and reimbursement decisions for the recently released transitional care management codes and the complex chronic care management codes to be released by Medicare in 2015. PMID:24711323

  1. Multiple chronic disorders - health care system’s modern challenge in the Maccabi Health Care System

    PubMed Central

    2014-01-01

    Background One of the major challenges health care systems face in modern time is treating chronic disorders. In recent years, the increasing occurrence of multiple chronic disorders (MCC) in single individuals has compounded the complexity of health care. In 2008, it was estimated that worldwide as many as one quarter of the population between the ages of sixty five to sixty nine suffered from two or more chronic conditions and this prevalence rose with age. Clinical guidelines provide guidance for management of single disorders, but not for MCC. The aim of the present study was the study of the prevalence, distribution and impact of MCC in a large Israeli health system. Methods We performed a cross-sectional study of MCC in the Maccabi Healthcare System (MHS), Israel’s second largest healthcare service, providing care for approximately two million people. Data regarding chronic conditions was collected through electronic medical records and organizational records, as was demographic and socioeconomic data. Age and sex specific data were compared with previously published data from Scotland. Results Two thirds of the population had two or more chronic disorders. This is significantly higher than previously published rates. A correlation between patient age and number of chronic disorders was found, as was a correlation between number of chronic disorders and low socioeconomic status, with the exception of children due to a high prevalence of learning disabilities, asthma, and visual disturbances. Discussion MCC is very prevalent in the MHS population, increases with age, and except for children is more prevalent in lower socioeconomic classes, possibly due to the a combination of the structure of the Israeli universal insurance and requirements of the ministry of education for exemptions and benefits. A higher than previously reported prevalence of MCC may be due to the longtime use of use of integrated electronic medical records. Conclusions To effectively deal

  2. The family experience of care in chronic situation.

    PubMed

    Bellato, Roseney; Araújo, Laura Filomena Santos de; Dolina, Janderléia Valéria; Musquim, Cleciene Dos Anjos; Corrêa, Geovana Hagata de Lima Souza Thaines

    2016-06-01

    An essay that aims to reflect on the family experience of care in chronic situation, increasing the understanding of the family as the primary caregiver. It is based on comprehensive approach in studies conducted in three matrix searches from family care experiences. We have taken three axes to organize our reflections: a) conformation of family care in chronic situation, highlighting the multiple costs incurred to the family, which can exhaust the potential of care and establish or increase its vulnerability if it is not backed by networks support and sustenance; b) family rearrangements for the care, giving visibility to care cores in which many loved family members share the care, dynamic, plural and changeable way; c) self care modeling family care, pointing to the range of possibilities of the person taking care of diseased conditions supported by people close to them. We learn that the family takes care of itself in everyday life and in the illness experience, creating networks that can provide you support and sustenance. Thus, professionals in health practices should shape up in a longitudinal and very personal way, by reference to the family care, supporting him in what is his own. Ensaio que tem por objetivo refletir sobre a experiência familiar de cuidado na situação crônica, ampliando a compreensão da família como cuidadora primária. Embasa-se em estudos de abordagem compreensiva realizados em três pesquisas matriciais que abordaram experiências familiares de cuidado. Tomamos três eixos para organizar nossas reflexões: a) conformação do cuidado familiar na situação crônica, destacando os múltiplos custos gerados à família, que podem exaurir seus potenciais de cuidado, instaurando ou ampliando sua vulnerabilidade se não for amparada por redes de apoio e sustentação; b) rearranjos familiares para o cuidado, dando visibilidade aos núcleos de cuidado compartilhados pelos diversos entes familiares, de modo dinâmico, plural e mut

  3. The family experience of care in chronic situation.

    PubMed

    Bellato, Roseney; Araújo, Laura Filomena Santos de; Dolina, Janderléia Valéria; Musquim, Cleciene Dos Anjos; Corrêa, Geovana Hagata de Lima Souza Thaines

    2016-06-01

    An essay that aims to reflect on the family experience of care in chronic situation, increasing the understanding of the family as the primary caregiver. It is based on comprehensive approach in studies conducted in three matrix searches from family care experiences. We have taken three axes to organize our reflections: a) conformation of family care in chronic situation, highlighting the multiple costs incurred to the family, which can exhaust the potential of care and establish or increase its vulnerability if it is not backed by networks support and sustenance; b) family rearrangements for the care, giving visibility to care cores in which many loved family members share the care, dynamic, plural and changeable way; c) self care modeling family care, pointing to the range of possibilities of the person taking care of diseased conditions supported by people close to them. We learn that the family takes care of itself in everyday life and in the illness experience, creating networks that can provide you support and sustenance. Thus, professionals in health practices should shape up in a longitudinal and very personal way, by reference to the family care, supporting him in what is his own. Ensaio que tem por objetivo refletir sobre a experiência familiar de cuidado na situação crônica, ampliando a compreensão da família como cuidadora primária. Embasa-se em estudos de abordagem compreensiva realizados em três pesquisas matriciais que abordaram experiências familiares de cuidado. Tomamos três eixos para organizar nossas reflexões: a) conformação do cuidado familiar na situação crônica, destacando os múltiplos custos gerados à família, que podem exaurir seus potenciais de cuidado, instaurando ou ampliando sua vulnerabilidade se não for amparada por redes de apoio e sustentação; b) rearranjos familiares para o cuidado, dando visibilidade aos núcleos de cuidado compartilhados pelos diversos entes familiares, de modo dinâmico, plural e mut

  4. [Integrated care for patients with advanced chronic obstructive pulmonary disease].

    PubMed

    Jassem, Ewa; Górecka, Dorota; Krakowiak, Piotr; Kozielski, Jerzy; Słomiński, J Marek; Krajnik, Małgorzata; Fal, Andrzej M

    2010-01-01

    Chronic obstructive pulmonary disease (COPD) is the third cause of mortality and disability (assessed by DALY) among patients above 60 year old. Severe and very severe COPD (FEV(1) = equal or less than 50% and 30% of expected value, respectively) is estimated at 20% of all COPD patients. Advanced COPD usually leads to physical and mental deterioration, the patients often manage with the problems caused by the disease and other comorbidities poorly. This leads to increased risk of COPD exacerbations and further deterioration of the patient's status, increased costs of medical care and eventually increased risk of death. Current organization of medical care for those patients does not provide adequate health and social support for them. However, it seems that introducing an integrated approach proposed by World Health Organization, could improve the situation of advanced COPD patients. In Poland, this kind of care has been provided in advanced cancer patients throughout stationary palliative care units and hospices during the last several years. This experience should be helpful in integrating actions of general practitioners and specialized nurses, as well as providing access for the specialists' consultations according to the individual needs of the patients. It should also allow for broad cooperation with auxiliary staff, such as social workers, medical assistants and volunteers, as well as psychologists and clergymen (especially in the terminal phase of the disease).

  5. 25 CFR 36.90 - What recreation, academic tutoring, student safety, and health care services must homeliving...

    Code of Federal Regulations, 2011 CFR

    2011-04-01

    ... 25 Indians 1 2011-04-01 2011-04-01 false What recreation, academic tutoring, student safety, and... What recreation, academic tutoring, student safety, and health care services must homeliving programs..., recreation, and health care services for their students, as deemed necessary by the local school board...

  6. 25 CFR 36.90 - What recreation, academic tutoring, student safety, and health care services must homeliving...

    Code of Federal Regulations, 2012 CFR

    2012-04-01

    ... 25 Indians 1 2012-04-01 2011-04-01 true What recreation, academic tutoring, student safety, and... What recreation, academic tutoring, student safety, and health care services must homeliving programs..., recreation, and health care services for their students, as deemed necessary by the local school board...

  7. 25 CFR 36.90 - What recreation, academic tutoring, student safety, and health care services must homeliving...

    Code of Federal Regulations, 2014 CFR

    2014-04-01

    ... 25 Indians 1 2014-04-01 2014-04-01 false What recreation, academic tutoring, student safety, and... What recreation, academic tutoring, student safety, and health care services must homeliving programs..., recreation, and health care services for their students, as deemed necessary by the local school board...

  8. 25 CFR 36.90 - What recreation, academic tutoring, student safety, and health care services must homeliving...

    Code of Federal Regulations, 2013 CFR

    2013-04-01

    ... 25 Indians 1 2013-04-01 2013-04-01 false What recreation, academic tutoring, student safety, and... What recreation, academic tutoring, student safety, and health care services must homeliving programs..., recreation, and health care services for their students, as deemed necessary by the local school board...

  9. 25 CFR 36.90 - What recreation, academic tutoring, student safety, and health care services must homeliving...

    Code of Federal Regulations, 2010 CFR

    2010-04-01

    ... 25 Indians 1 2010-04-01 2010-04-01 false What recreation, academic tutoring, student safety, and... What recreation, academic tutoring, student safety, and health care services must homeliving programs..., recreation, and health care services for their students, as deemed necessary by the local school board...

  10. Developing caring connections: mentorship in the academic setting.

    PubMed

    Vance, C; Bamford, P

    1998-03-01

    The mentoring connections that we have experienced in our school of nursing have eased difficult situations and have promoted self-awareness, personal and professional growth, and leadership behaviors. Various circumstances result in behaviors reflective of issues of culture, race, self-esteem and knowledge, values, ethics, experience, and conflict management. Some of these issues are related to oppressed group behavior, inadequate communication and conflict resolution skills, lack of exposure to diverse academic and professional experiences, and a need to learn management of feelings in effective ways. As faculty, administrators, students, and alumni, we struggle with those issues, knowing that resolution of them is beyond the traditional modes of teaching-learning, academic relationships and professional socialization. We wish that we and our students and alumni will experience an increased connectedness to the school and profession. We also wish that we might, as a result of our mentor connections, individually and collectively develop self-determination, self-esteem and confidence, leadership skills, and inner directness. The Mentor Connection Program was initiated in response to these strong wishes and has been a motivating framework for the reciprocal growth in us all. As for the future, we will continue our research and evaluation studies, refine the matching criteria, support and expand the mentoring dyads, strengthen faculty-faculty mentoring relationships, and seek funding resources for expansion and research. We are seeing the positive effects of active mentoring on students, faculty, and alumni on issues related to teaching and learning, support, hardiness, and self-reflection. Mentors produce leaders. Nursing's collective leadership will, we believe, depend to a large extent on our mentoring relationships with each other. PMID:9582745

  11. Academic Achievement and Aging out of Care: Foster Parents' Perceptions

    ERIC Educational Resources Information Center

    Mack, Robert D.

    2012-01-01

    Foster children experience multiple barriers and challenges that, amongst other issues, prevent them from achieving academically. At the age of 18, foster youth are forced out of the Department of Children and Families care, leading many of them to become homeless or to return to the homes from which they were displaced. Scholarly literature and…

  12. Partnership for Health Care: An Academic Nursing Center in a Rural Community College.

    ERIC Educational Resources Information Center

    LeMone, Priscilla; McDaniel, Roxanne W.; Sullivan, Toni J.

    1998-01-01

    The University of Missouri-Columbia Sinclair School of Nursing collaborates with Moberly Area Community College in providing holistic health care services to rural college students. This academic nursing center is based on nursing models rather than medical models of health. (JOW)

  13. Neighborhood Crime and Self-Care: Risks for Aggression and Lower Academic Performance

    ERIC Educational Resources Information Center

    Lord, Heather; Mahoney, Joseph L.

    2007-01-01

    This longitudinal study evaluated associations among official rates of neighborhood crime, academic performance, and aggression in a sample of 581 children in 1st-3rd grade (6.3-10.6 years old). It was hypothesized that the influence of crime depends on children's unsupervised exposure to the neighborhood context through self-care. Average weekly…

  14. Development of an Academic Consortium for Nurse-Managed Primary Care.

    ERIC Educational Resources Information Center

    Pohl, Joanne M.; Bostrom, Andrea C.; Talarczyk, Geraldine; Cavanagh, Stephen

    2001-01-01

    The Michigan Academic Consortium brought together four universities' nursing schools to address advanced practice issues in nurse-managed primary health care. The collaboration enabled participants to leverage financial resources and take advantage of partnership opportunities. Challenges included multiple management practices, competition, and…

  15. The Academic, Behavioral, and Mental Health Status of Children and Youth at Entry to Residential Care

    ERIC Educational Resources Information Center

    Trout, Alexandra L.; Hagaman, Jessica L.; Chmelka, M. Beth; Gehringer, Robert; Epstein, Michael H.; Reid, Robert

    2008-01-01

    Often considered a "last resort placement," residential settings serve a broad range of children who present significant risks. While much is known about emotional and behavioral functioning, less is known about academic strengths and limitations. This study evaluated 127 children at intake into a residential care program to determine demographic,…

  16. Concept of Care, Caring Expectations, and Caring Frustrations of the Elderly Suffering from Chronic Illness

    ERIC Educational Resources Information Center

    de Guzman, Allan B.; Santos, Charisse Izobelle Q.; Santos, Ivan Benedict A.; Santos, Jedda A.; Santos, Justin E.; Santos, Justo Martin S.; Santos, Vincent Emmanuelle E.

    2012-01-01

    While it is true that elderly concepts of care and caring expectations have been ascertained in previous literatures, little is known about how the elderly population views caring frustrations--particularly that of the Filipino elderly. This study purports to surface the lebenswelt of healthcare expectations and frustrations based on the…

  17. Quality indicators for academic nursing primary care centers.

    PubMed

    Mackey, Thomas A; McNiel, Nancy O

    2002-01-01

    ANCs, by definition, deliver more than clinical services to patients and communities. The unique identifier that separates ANCs from other primary care/ambulatory care centers is the educational service they offer to students and other faculty in the school of nursing to which they belong. Therefore, measuring the quality of an ANC must include a measurement of the educational properties that it possesses in addition to the usual quality measurements by such organizations as AAAHC, JCAHO, CHAP, and AAACN. Unless these properties are included and measured by an ANC, it becomes difficult to justify the existence of such a clinic within a school of nursing. ANCs are encouraged to develop quality evaluation programs aimed at evaluating the educational aspects as well as the administrative and clinical aspects of their operations. PMID:11944532

  18. How do patients with exacerbated chronic obstructive pulmonary disease experience care in the intensive care unit?

    PubMed Central

    Torheim, Henny; Kvangarsnes, Marit

    2014-01-01

    The aim was to gain insight into how patients with advanced chronic obstructive pulmonary disease (COPD) experience care in the acute phase. The study has a qualitative design with a phenomenological approach. The empirics consist of qualitative in-depth interviews with ten patients admitted to the intensive care units in two Norwegian hospitals. The interviews were carried out from November 2009 to June 2011. The data have been analysed through meaning condensation, in accordance with Amadeo Giorgi's four-step method. Kari Martinsen's phenomenological philosophy of nursing has inspired the study. An essential structure of the patients' experiences of care in the intensive care unit by acute COPD-exacerbation may be described as: Feelings of being trapped in a life-threatening situation in which the care system assumes control over their lives. This experience is conditioned not only by the medical treatment, but also by the entire interaction with the caregivers. The essence of the phenomenon is presented through three themes which describe the patient's lived experience: preserving the breath of life, vulnerable interactions and opportunities for better health. Acute COPD-exacerbation is a traumatic experience and the patients become particularly vulnerable when they depend on others for breathing support. The phenomenological analysis shows that the patients experience good care during breath of life preservation when the care is performed in a way that gives patients more insight into their illness and gives new opportunities for the future. PMID:24313779

  19. Luxury Primary Care, Academic Medical Centers, and the Erosion of Science and Professional Ethics

    PubMed Central

    Donohoe, Martin

    2004-01-01

    Medical schools and teaching hospitals have been hit particularly hard by the financial crisis affecting health care in the United States. To compete financially, many academic medical centers have recruited wealthy foreign patients and established luxury primary care clinics. At these clinics, patients are offered tests supported by little evidence of their clinical and/or cost effectiveness, which erodes the scientific underpinnings of medical practice. Given widespread disparities in health, wealth, and access to care, as well as growing cynicism and dissatisfaction with medicine among trainees, the promotion by these institutions of an overt, two-tiered system of care, which exacerbates inequities and injustice, erodes professional ethics. Academic medical centers should divert their intellectual and financial resources away from luxury primary care and toward more equitable and just programs designed to promote individual, community, and global health. The public and its legislators should, in turn, provide adequate funds to enable this. Ways for academic medicine to facilitate this largesse are discussed. PMID:14748866

  20. In the Netherlands, rich interaction among professionals conducting disease management led to better chronic care.

    PubMed

    Cramm, Jane Murray; Nieboer, Anna Petra

    2012-11-01

    Disease management programs based on the Chronic Care Model are expected to improve the quality of chronic care delivery. However, evidence to date for such improvement and how it is achieved is scarce. In 2010 and again in 2011, we surveyed professionals in twenty-two primary care practices in the Netherlands that had implemented the Chronic Care Model of disease management beginning in 2009. The responses showed that, over time, chronic illness care delivery improved to advanced levels. The gains were attributed primarily to improved relational coordination-that is, raising the quality of communication and task integration among professionals from diverse disciplines who share common objectives. These findings may have implications for other disease management efforts by collaborative care teams, in that they suggest that diverse health care professionals must be strongly connected to provide effective, holistic care.

  1. Developing a sustainable foot care clinic in a homeless shelter within an academic-community partnership.

    PubMed

    Schoon, Patricia M; Champlin, Barbara E; Hunt, Roberta J

    2012-12-01

    Nursing faculty are confronted with the need to design community learning activities with vulnerable populations to prepare students for nursing practice. The creation of sustainable academic-community partnerships with agencies providing care to underserved populations meets this challenge. This article describes the development and implementation of a foot care clinic in a homeless shelter, created through a model of curricular integration, faculty engagement, and a long-term academic-community partnership. A transformative pedagogical approach based on service-learning was used to facilitate student understanding of social justice through activities that promote citizenship, develop advocacy skills, and increase knowledge and skills related to the role of the public health nurse in the community. The process of designing and developing a community clinical learning activity and the essential components for sustainability are discussed. Student outcomes are addressed. Recommendations for implementing a foot care clinic within an academic–community partnership are outlined. PMID:23362514

  2. Multiple Chronic Conditions: Prevalence, Health Consequences, and Implications for Quality, Care Management, and Costs

    PubMed Central

    Shields, Alexandra E.; Lee, Todd A.; Gibson, Teresa B.; Marder, William D.; Weiss, Kevin B.; Blumenthal, David

    2007-01-01

    Persons with multiple chronic conditions are a large and growing segment of the US population. However, little is known about how chronic conditions cluster, and the ramifications of having specific combinations of chronic conditions. Clinical guidelines and disease management programs focus on single conditions, and clinical research often excludes persons with multiple chronic conditions. Understanding how conditions in combination impact the burden of disease and the costs and quality of care received is critical to improving care for the 1 in 5 Americans with multiple chronic conditions. This Medline review of publications examining somatic chronic conditions co-occurring with 1 or more additional specific chronic illness between January 2000 and March 2007 summarizes the state of our understanding of the prevalence and health challenges of multiple chronic conditions and the implications for quality, care management, and costs. PMID:18026807

  3. Value-Based Health Care for Chronic Care: Aligning Outcomes Measurement with the Patient Perspective

    PubMed Central

    Forsberg, Helena Hvitfeldt; Essén, Anna; Ernestam, Sofia

    2016-01-01

    Background: Value-based health care is increasingly used for developing health care services by relating patient outcomes to costs. A hierarchical value scorecard for creating outcome measurements has been suggested: the 3-tier model. The objective of this study was to test the model against the patient's view of value in a chronic care setting. Methods: Semistructured interviews with 22 persons with rheumatoid arthritis were conducted, transcribed, and analyzed using qualitative content analysis. Themes were extracted, and the model was critically applied and revised. Results: The study validates existing dimensions in the model but suggests adding information, social health, predictability, and continuity to make it more useful and representative of patients' preferences. Conclusion: Although the model aims to focus on outcomes relevant to patients, it lacks dimensions important to individuals with rheumatoid arthritis. The data illustrate difficulties in finding patients' preferred outcomes and imply tactics for arriving at meaningful measurements. PMID:27749717

  4. Rethinking prevention in primary care: applying the chronic care model to address health risk behaviors.

    PubMed

    Hung, Dorothy Y; Rundall, Thomas G; Tallia, Alfred F; Cohen, Deborah J; Halpin, Helen Ann; Crabtree, Benjamin F

    2007-01-01

    This study examines the Chronic Care Model (CCM) as a framework for preventing health risk behaviors such as tobacco use, risky drinking, unhealthy dietary patterns, and physical inactivity. Data were obtained from primary care practices participating in a national health promotion initiative sponsored by the Robert Wood Johnson Foundation. Practices owned by a hospital health system and exhibiting a culture of quality improvement were more likely to offer recommended services such as health risk assessment, behavioral counseling, and referral to community-based programs. Practices that had a multispecialty physician staff and staff dieticians, decision support in the form of point-of-care reminders and clinical staff meetings, and clinical information systems such as electronic medical records were also more likely to offer recommended services. Adaptation of the CCM for preventive purposes may offer a useful framework for addressing important health risk behaviors.

  5. Stakeholders’ perception on the organization of chronic care: a SWOT analysis to draft avenues for health care reforms

    PubMed Central

    2014-01-01

    Background Adequate care for individuals living with chronic illnesses calls for a healthcare system redesign, moving from acute, disease-centered to patient-centered models. The aim of this study was to identify Belgian stakeholders’ perceptions on the strengths, weaknesses, opportunities and threats of the healthcare system for people with chronic diseases in Belgium. Methods Four focus groups were held with stakeholders from the micro and meso level, in addition to two interviews with stakeholders who could not attend the focus group sessions. Data collection and the discussion were based on the Chronic Care model. Thematic analysis of the transcripts allowed for the identification of the strengths, weaknesses, opportunities and threats of the current health care system with focus on chronic care. Results Informants stressed the overall good quality of the acute health care system and the level of reimbursement of care as an important strength of the current system. In contrast, the lack of integration of care was identified as one of the biggest weaknesses of today’s health care system, along with the unclear definitions of the roles and functions of health professionals involved in care processes. Patient education to support self-management exists for patients with diabetes and/or terminal kidney failure but not for those living with other or multiple chronic conditions. The current overall fee-for-service system is a barrier to integrated care, as are the lack of incentives for integrated care. Attending multidisciplinary meetings, for example, is underfinanced to date. Finally, clinical information systems lack interoperability, which further impedes the information flow across settings and disciplines. Conclusion Our study’s methods allowed for the identification of problematic domains in the health system for people living with chronic conditions. These findings provided useful insights surrounding perceived priorities. This methodology may inspire

  6. Academic Medicine's Critical Role in the "Third Curve" of Health Care.

    PubMed

    Paz, Harold L

    2016-05-01

    Over the last several years, the health care landscape has changed at an unprecedented rate due to new economic and regulatory forces ushered in by the Affordable Care Act and the introduction of innovative technologies, such as personalized medicine, that are poised to open the door to consumer-driven health care. Tremendous pressure exists on academic health centers to rapidly evolve clinically while not abandoning their unique academic mission. The convergence of personalized medicine, new digital technologies, and changes in health professionals' scope of practice alongside new payment structures will accelerate the move to a patient-centered health system. In this Commentary, the author argues that these new tools and resources must be embraced to improve the health of patients. With the traditional, fee-for-service model of care as "Curve I" and the post-Flexner era of population-based medicine as "Curve II," the author identifies the emergence of "Curve III," which is characterized by patient-centered, consumer-directed models of care. As the old models of health care undergo transition and the impact of technology and analytics grow, future practitioners must be trained to embrace this change and function effectively in the "third curve" of consumer-driven health care.

  7. Associations between perceived chronic care quality, perceived patient centeredness, and illness representations among persons with diabetes.

    PubMed

    Thomas, Joseph; Iyer, Neeraj N; Collins, William B

    2014-01-01

    Patient beliefs about their illness can motivate behaviors consistent with good disease management. Perceived high-quality chronic care would be expected to increase likelihood of having such beliefs. Associations between perceived quality of chronic care and illness representations, and associations between patient centeredness and illness representations were assessed among persons with diabetes. A mail survey of diabetic patients visiting a multispecialty physician network serving urban and suburban populations in a large midwestern city was conducted. The Patient Assessment of Chronic Illness Care-5A questionnaire was used to assess perceived chronic care quality and patient centeredness. The Brief Illness Perception Questionnaire was used to assess illness representations. Of 500 mailed surveys, 89 completed surveys were returned. The sample consisted mostly of retirees (61%), Whites (81%), and women (60%). Higher perceived chronic care quality was associated with better disease understanding of diabetes (0.24, p = .05). Patients reporting higher patient centeredness (or lower patient-centeredness scores) indicated better disease understanding (-0.26, p = .04) and those reporting higher patient centeredness (or lower patient-centeredness scores) perceived less impact of illness (0.29, p = .02). Chronic care quality as defined in the Chronic Care Model and consistency of chronic care with patient expectations (patient centeredness) was associated with illness representations favorable for good self-care management.

  8. Effectiveness of Stepped Care for Chronic Fatigue Syndrome: A Randomized Noninferiority Trial

    ERIC Educational Resources Information Center

    Tummers, Marcia; Knoop, Hans; Bleijenberg, Gijs

    2010-01-01

    Objective: In this randomized noninferiority study, the effectiveness and efficiency of stepped care for chronic fatigue syndrome (CFS) was compared to care as usual. Stepped care was formed by guided self-instruction, followed by cognitive behavior therapy (CBT) if the patient desired it. Care as usual encompassed CBT after a waiting period.…

  9. Systems medicine and integrated care to combat chronic noncommunicable diseases

    PubMed Central

    2011-01-01

    We propose an innovative, integrated, cost-effective health system to combat major non-communicable diseases (NCDs), including cardiovascular, chronic respiratory, metabolic, rheumatologic and neurologic disorders and cancers, which together are the predominant health problem of the 21st century. This proposed holistic strategy involves comprehensive patient-centered integrated care and multi-scale, multi-modal and multi-level systems approaches to tackle NCDs as a common group of diseases. Rather than studying each disease individually, it will take into account their intertwined gene-environment, socio-economic interactions and co-morbidities that lead to individual-specific complex phenotypes. It will implement a road map for predictive, preventive, personalized and participatory (P4) medicine based on a robust and extensive knowledge management infrastructure that contains individual patient information. It will be supported by strategic partnerships involving all stakeholders, including general practitioners associated with patient-centered care. This systems medicine strategy, which will take a holistic approach to disease, is designed to allow the results to be used globally, taking into account the needs and specificities of local economies and health systems. PMID:21745417

  10. Patient autonomy in chronic care: solving a paradox

    PubMed Central

    Reach, Gérard

    2014-01-01

    The application of the principle of autonomy, which is considered a cornerstone of contemporary bioethics, is sometimes in obvious contradiction with the principle of beneficence. Indeed, it may happen in chronic care that the preferences of the health care provider (HCP), who is largely focused on the prevention of long term complications of diseases, differ from those, more present oriented, preferences of the patient. The aims of this narrative review are as follows: 1) to show that the exercise of autonomy by the patient is not always possible; 2) where the latter is not possible, to examine how, in the context of the autonomy principle, someone (a HCP) can decide what is good (a treatment) for someone else (a patient) without falling into paternalism. Actually this analysis leads to a paradox: not only is the principle of beneficence sometimes conflicting with the principle of autonomy, but physician’s beneficence may enter into conflict with the mere respect of the patient; and 3) to propose a solution to this paradox by revisiting the very concepts of the autonomous person, patient education, and trust in the patient–physician relationship: this article provides an ethical definition of patient education. PMID:24376345

  11. The relation between third graders' after-school care and social, academic, and emotional functioning.

    PubMed

    Vandell, D L; Corasaniti, M A

    1988-08-01

    Outcome differences associated with types of after-school care were explored among 150 white, predominantly middle-class third graders from a suburban school system. Children returned home to their mothers, attended day-care centers, stayed with sitters, or returned home alone or with siblings. No differences were found between latchkey and mother-care children in terms of their classroom sociometric nominations, academic grades, standardized test scores, conduct grades, self-reports of self-competence, or parent and teacher ratings of the children. Significant differences were found for children who attended day-care centers after school. These children received more negative peer nominations, made lower academic grades, and had lower standardized test scores than either mother-care or latchkey children. The children who stayed with sitters after school received more negative peer nominations than the latchkey and mother-care children but, in other areas, resembled these groups. These outcome differences were apparent in both divorced and intact families. Factors contributing to these differences are examined. PMID:3168625

  12. The relation between third graders' after-school care and social, academic, and emotional functioning.

    PubMed

    Vandell, D L; Corasaniti, M A

    1988-08-01

    Outcome differences associated with types of after-school care were explored among 150 white, predominantly middle-class third graders from a suburban school system. Children returned home to their mothers, attended day-care centers, stayed with sitters, or returned home alone or with siblings. No differences were found between latchkey and mother-care children in terms of their classroom sociometric nominations, academic grades, standardized test scores, conduct grades, self-reports of self-competence, or parent and teacher ratings of the children. Significant differences were found for children who attended day-care centers after school. These children received more negative peer nominations, made lower academic grades, and had lower standardized test scores than either mother-care or latchkey children. The children who stayed with sitters after school received more negative peer nominations than the latchkey and mother-care children but, in other areas, resembled these groups. These outcome differences were apparent in both divorced and intact families. Factors contributing to these differences are examined.

  13. An Evaluation of Collaborative Interventions to Improve Chronic Illness Care: Framework and Study Design

    ERIC Educational Resources Information Center

    Cretin, Shan; Shortell, Stephen M.; Keeler, Emmett B.

    2004-01-01

    The authors' dual-purpose evaluation assesses the effectiveness of formal collaboratives in stimulating organizational changes to improve chronic illness care (the chronic care model or CCM). Intervention and comparison sites are compared before and after introduction of the CCM. Multiple data sources are used to measure the degree of…

  14. [Care as a cross-cutting element in the health care of complex chronic patients].

    PubMed

    Rico-Blázquez, Milagros; Sánchez Gómez, Sheila; Fuentelsaz Gallego, Carmen

    2014-01-01

    The care of people who live with chronic diseases is currently a priority on the roadmaps of all health care services. Within these strategies, there needs to be a specific approach required for a population group that is defined by having multiple diseases and the associated comorbidity. This group is especially vulnerable, fragile, and require very complex care, which uses up a high quantity of social health resources. The estimated prevalence in Spain is 1.4% in the general population, and approximately 5% in people over 64 years. The social and healthcare of this population requires a person-centered approach, as a paradigm of caring for the patients and not of the diseases. The models must leap from the segmented approach to diseases to a holistic and integrated vision, taking into account the social and psycho-affective situation, the experience of the patient, the family context, and the approach of human experience/response that these processes produce. The health professionals need support tools that can guide them and help in making clinical decisions in this population group. The clinical practice guidelines for the approach of patients with co-morbidity and multiple diseases have numerous limitations. Expert recommendations in this sense, lead us to a multidisciplinary approach, with self-care and self-health management as a cross-cutting element of healthcare.

  15. [Home care of children with chronic diseases: cooperation between hospital and home care workers].

    PubMed

    Cologna, M; Zeni, F; Bobbi, C

    1996-01-01

    Newborns with chronic problems needing continuous and special care even after discharge are not very frequent but represent a challenge for the caring team. The discharge program of the Neonatal Care ward of Trento hospital includes several steps: discharge meetings of teh neonatologist and the nurse responsible for the child, the head nurse, the psychologist and, when possible, the social worker; a training program for the parents; the coordination of communications and interventions of the home-care nurses and a detailed post-discharge planning. From 1995 a home-hospital program, as an alternative to the hospital admission was started. To describe how the team functions and stress the need of a close integration among the team members, the case of Ahmed is presented. This case faced the team with several challenges, because of the lack of parent's knowledge of the italian language and of the severity of the child's problems. Every care plan is developed building on newborn's needs and patients' resources. Data on the patients-problems dealt with from 1991 to 1995 and the interventions and resources needed are presented.

  16. [Care as a cross-cutting element in the health care of complex chronic patients].

    PubMed

    Rico-Blázquez, Milagros; Sánchez Gómez, Sheila; Fuentelsaz Gallego, Carmen

    2014-01-01

    The care of people who live with chronic diseases is currently a priority on the roadmaps of all health care services. Within these strategies, there needs to be a specific approach required for a population group that is defined by having multiple diseases and the associated comorbidity. This group is especially vulnerable, fragile, and require very complex care, which uses up a high quantity of social health resources. The estimated prevalence in Spain is 1.4% in the general population, and approximately 5% in people over 64 years. The social and healthcare of this population requires a person-centered approach, as a paradigm of caring for the patients and not of the diseases. The models must leap from the segmented approach to diseases to a holistic and integrated vision, taking into account the social and psycho-affective situation, the experience of the patient, the family context, and the approach of human experience/response that these processes produce. The health professionals need support tools that can guide them and help in making clinical decisions in this population group. The clinical practice guidelines for the approach of patients with co-morbidity and multiple diseases have numerous limitations. Expert recommendations in this sense, lead us to a multidisciplinary approach, with self-care and self-health management as a cross-cutting element of healthcare. PMID:24440550

  17. Spanning boundaries and creating strong patient relationships to coordinate care are strategies used by experienced chronic condition care coordinators.

    PubMed

    Ehrlich, Carolyn; Kendall, Elizabeth; Muenchberger, Heidi

    2012-08-01

    People with complex chronic conditions frequently need to navigate their own way through and around a fragmented and siloed health care system. Care coordination is a defining principle of primary care and is frequently proposed as a solution to this problem. However, care coordination requires more time and effort than primary care physicians alone have the capacity to deliver. Although registered nurses (RNs) are skilled team members who can be included in the delivery of coordinated patient care, any model of care coordination that involves RNs needs to fit within the existing health care delivery system. In this study, which used qualitative techniques based on grounded theory and included face-to-face interviews and open coding and theoretical sampling until data saturation was achieved, and which was one component of a larger action research study, we aimed to gain an understanding of the difference between usual chronic condition care and the work of chronic condition care coordination. The researchers interviewed general practitioners and RNs from various general practice sites who were actively coordinating care. Four unique processes were found to define care coordination implementation, namely: (1) moving beyond usual practice by spanning boundaries; (2) relationship-based care; (3) agreed roles and routines among relevant parties; and (4) committing to chronic condition care coordination. The findings suggested that existing professional and organisational cultures required negotiation before care coordination could be integrated into existing contexts. The challenge, however, seems to be in acknowledging and overcoming professional practice boundaries that define existing care through reflective practice and shared resourcing.

  18. Spanning boundaries and creating strong patient relationships to coordinate care are strategies used by experienced chronic condition care coordinators.

    PubMed

    Ehrlich, Carolyn; Kendall, Elizabeth; Muenchberger, Heidi

    2012-08-01

    People with complex chronic conditions frequently need to navigate their own way through and around a fragmented and siloed health care system. Care coordination is a defining principle of primary care and is frequently proposed as a solution to this problem. However, care coordination requires more time and effort than primary care physicians alone have the capacity to deliver. Although registered nurses (RNs) are skilled team members who can be included in the delivery of coordinated patient care, any model of care coordination that involves RNs needs to fit within the existing health care delivery system. In this study, which used qualitative techniques based on grounded theory and included face-to-face interviews and open coding and theoretical sampling until data saturation was achieved, and which was one component of a larger action research study, we aimed to gain an understanding of the difference between usual chronic condition care and the work of chronic condition care coordination. The researchers interviewed general practitioners and RNs from various general practice sites who were actively coordinating care. Four unique processes were found to define care coordination implementation, namely: (1) moving beyond usual practice by spanning boundaries; (2) relationship-based care; (3) agreed roles and routines among relevant parties; and (4) committing to chronic condition care coordination. The findings suggested that existing professional and organisational cultures required negotiation before care coordination could be integrated into existing contexts. The challenge, however, seems to be in acknowledging and overcoming professional practice boundaries that define existing care through reflective practice and shared resourcing. PMID:23050573

  19. Commentary: dinosaurs fated for extinction? Health care delivery at academic health centers.

    PubMed

    Becker, Bryan N; Formisano, Roger A; Getto, Carl J

    2010-05-01

    Health care delivery at academic health centers (AHCs) can be viewed as dinosaur-like. Both are large and complex entities that consume many resources and are slow to adapt to competitive predatory forces. The potential for severe climate shifts, with changes in payer mix, competition from the private sector, and health care reform all occurring in the current health care system, could precipitate either the beginning of extinction for the AHC dinosaur or, hopefully, stimulate its evolution and development into a new model of health care delivery.Given the importance of clinical revenue to the entirety of the AHC enterprise, there is incentive for AHCs to maintain and indeed expand their clinical care delivery mechanisms. Yet, AHCs are institutions of investigation and inquiry. New models of care delivery and their impact on the current clinical care system must be developed through local demonstration projects and experimental clinical models. These models must be studied, and the findings should be shared with the community.The authors argue that this course of action will be challenging because traditional workflows must be restricted to improve care coordination and a changing workforce demographic. It will also require thoughtful approaches to reward innovative clinical work and new directions in strategic management by institution leaders. This commentary outlines recommendations to stave off extinction and enhance the next generation of clinical care delivery at AHCs.

  20. Improving access to effective care for people with chronic respiratory symptoms in low and middle income countries

    PubMed Central

    2015-01-01

    Chronic respiratory symptoms are amongst the most common complaints among low and middle-income country (LMICs) populations and they are expected to remain common over the 10 to 20 year horizon. The underlying diseases (predominantly chronic obstructive pulmonary disease, asthma and tuberculosis) cause, and threaten to increasingly cause, substantial morbidity and mortality. Effective treatment is available for these conditions but LMICs health systems are not well set up to provide accessible clinical diagnostic pathways that lead to sustainable and affordable management plans especially for the chronic non communicable respiratory diseases. There is a need for clinical and academic capacity building together with well-conducted health systems research to underpin health service strengthening, policy and decision-making. There is an opportunity to integrate solutions for improving access to effective care for people with chronic respiratory symptoms with approaches to tackle other major population health issues that depend on well-functioning health services such as chronic communicable (e.g. HIV) and non-communicable (e.g. cardiovascular and metabolic) diseases.

  1. "Absence Makes the Heart Grow Fonder": Students with Chronic Illness Seeking Academic Continuity through Interaction with Their Teachers at School

    ERIC Educational Resources Information Center

    Wilkie, Karina J.

    2012-01-01

    Increasing numbers of young people experience disruption to their schooling owing to chronic illness. Absence from the day-to-day life of their school for prolonged or accumulative periods of time can erode their sense of belonging and create anxiety about falling behind academically. Maintaining positive connections to school can meet their…

  2. One approach to care for patients infected with human immunodeficiency virus in an academic medical center.

    PubMed Central

    Jacobs, J. L.; Damson, L. C.; Rogers, D. E.

    1996-01-01

    The human immunodeficiency virus (HIV) epidemic poses unprecedented challenges to the health-care system. Caregivers must contend both with the complicated clinical syndromes associated with HIV infection and with issues that are central to the epidemic, such as discrimination, isolation, poverty, and substance abuse. Our HIV treatment program combines and enhances the resources of an academic medical center in a multidisciplinary care model. All patients, regardless of payor class, are offered services from 10 different disciplines. The same team of clinicians follows patients in the clinic and hospital. The program is flexible, non-hierarchical, and open to community participation. This approach may be a useful model for other institutions. PMID:8982523

  3. Healthcare professional acceptance of telemonitoring for chronic care patients in primary care

    PubMed Central

    2012-01-01

    Background A pilot experimentation of a telemonitoring system for chronic care patients is conducted in the Bilbao Primary Care Health Region (Basque Country, Spain). It seems important to understand the factors related to healthcare professionals’ acceptance of this new technology in order to inform its extension to the whole healthcare system. This study aims to examine the psychosocial factors related to telemonitoring acceptance among healthcare professionals and to apply a theory-based instrument. Methods A validated questionnaire, based on an extension of the Technology Acceptance Model (TAM), was distributed to a total of 605 nurses, general practitioners and paediatricians. Logistic regression analysis was performed to test the theoretical model. Adjusted odds ratios (OR) and their 95% confidence intervals (CI) were computed. Results A response rate of 44.3% was achieved. The original TAM model was good at predicting intention to use the telemonitoring system. However, the extended model, that included other theoretical variables, was more powerful. Perceived Usefulness, Compatibility, and Facilitators were the significant predictors of intention. A detailed analysis showed that intention to use telemonitoring was best predicted by healthcare professionals’ beliefs that they would obtain adequate training and technical support and that telemonitoring would require important changes in their practice. Conclusion The extended TAM explained a significant portion of the variance in healthcare professionals' intention to use a telemonitoring system for chronic care patients in primary care. The perception of facilitators in the organisational context is the most important variable to consider for increasing healthcare professionals’ intention to use the new technology. PMID:23194420

  4. Bridging the gap between managed care and academic medicine: an innovative fellowship.

    PubMed

    Bischof, R O; Smith, R L; Nash, D B; Murray, J F; Louis, D Z; Hanchak, N A; Schlackman, N

    1997-01-01

    Numerous challenges face academic medicine in the era of managed care. This environment is stimulating the development of innovative educational programs that can adapt to changes in the healthcare system. The U.S. Quality Algorithms Managed Care Fellowship at Jefferson Medical College is one response to these challenges. Two postresidency physicians are chosen as fellows each year. The 1-year curriculum is organized into four 3-month modules covering such subjects as biostatistics and epidemiology, medical informatics, the theory and practice of managed care, managed care finance, integrated healthcare systems, quality assessment and improvement, clinical parameters and guidelines, utilization management, and risk management. The fellowship may serve as a possible prototype for future post-graduate education.

  5. Wound Chronicity, Inpatient Care, and Chronic Kidney Disease Predispose to MRSA Infection in Diabetic Foot Ulcers

    PubMed Central

    Yates, Christopher; May, Kerry; Hale, Thomas; Allard, Bernard; Rowlings, Naomi; Freeman, Amy; Harrison, Jessica; McCann, Jane; Wraight, Paul

    2009-01-01

    OBJECTIVE To determine the microbiological profile of diabetes-related foot infections (DRFIs) and the impact of wound duration, inpatient treatment, and chronic kidney disease (CKD). RESEARCH DESIGN AND METHODS Postdebridement microbiological samples were collected from individuals presenting with DRFIs from 1 January 2005 to 31 December 2007. RESULTS A total of 653 specimens were collected from 379 individuals with 36% identifying only one isolate. Of the total isolates, 77% were gram-positive bacteria (staphylococci 43%, streptococci 13%). Methicillin-resistant Staphylococcus aureus (MRSA) was isolated from 23%; risk factors for MRSA included prolonged wound duration (odds ratio 2.31), inpatient management (2.19), and CKD (OR 1.49). Gram-negative infections were more prevalent with inpatient management (P = 0.002) and prolonged wound duration (P < 0.001). Pseudomonal isolates were more common in chronic wounds (P < 0.001). CONCLUSIONS DRFIs are predominantly due to gram-positive aerobes but are usually polymicrobial and increase in complexity with inpatient care and ulcer duration. In the presence of prolonged duration, inpatient management, or CKD, empiric MRSA antibiotic cover should be considered. PMID:19587371

  6. Impact of Campus-Based Child Care on the Academic Success of Student-Parents at SUNY Community Colleges.

    ERIC Educational Resources Information Center

    Fadale, LaVerna M.; Winter, Gene M.

    The focus of this study was the relationship between campus-based child care services at the State University of New York (SUNY) community colleges and the academic success of student-parents. Academic success was defined as completion of a degree or certificate program, transfer, or continued enrollment. Data were collected through surveys mailed…

  7. Patients’ experience of chronic illness care in a network of teaching settings

    PubMed Central

    Houle, Janie; Beaulieu, Marie-Dominique; Lussier, Marie-Thérèse; Del Grande, Claudio; Pellerin, Jean-Pierre; Authier, Marie; Duplain, Réjean; Tran, Tri Minh; Allison, François

    2012-01-01

    Abstract Objective To evaluate chronic illness care delivery from the patient’s perspective and to examine its main correlates. Design Cross-sectional, descriptive study using questionnaires and medical chart review. Setting Nine teaching family practices in Quebec. Participants A total of 364 patients with diabetes, hypertension, or chronic obstructive pulmonary disease. Main outcomes measures Score on the Patient Assessment of Chronic Illness Care (PACIC) questionnaire, which evaluates the patient’s perspective on the care received based on the chronic care model (CCM); patients characteristics (sex, level of education, number of chronic illnesses); patient-physician relationship (relational continuity, interpersonal communication assessed from the patient’s perspective); and interdisciplinary care and technical quality of care abstracted from patients’ medical charts. Results The mean PACIC score obtained (2.8 out of 5) indicates that, on average, CCM-concordant care “generally did not occur” or occurred only “sometimes” in this network of teaching practices. However, with a mean technical quality-of-care score of nearly 80%, physicians in this network showed a high degree of adherence to clinical guidelines for the chronic illnesses under study. Patient education level lower than high school was negatively associated with PACIC scores, while positive associations were found with male sex, number of chronic illnesses, relational continuity, interpersonal communication, interdisciplinary care, and technical quality of care. Conclusion Patients with less education reported receiving less CCM-concordant care. The patient-physician relationship was the strongest correlate of PACIC scores, while interdisciplinary care and technical quality of care had modest contributions. PMID:23242897

  8. Short and long term improvements in quality of chronic care delivery predict program sustainability.

    PubMed

    Cramm, Jane Murray; Nieboer, Anna Petra

    2014-01-01

    Empirical evidence on sustainability of programs that improve the quality of care delivery over time is lacking. Therefore, this study aims to identify the predictive role of short and long term improvements in quality of chronic care delivery on program sustainability. In this longitudinal study, professionals [2010 (T0): n=218, 55% response rate; 2011 (T1): n=300, 68% response rate; 2012 (T2): n=265, 63% response rate] from 22 Dutch disease-management programs completed surveys assessing quality of care and program sustainability. Our study findings indicated that quality of chronic care delivery improved significantly in the first 2 years after implementation of the disease-management programs. At T1, overall quality, self-management support, delivery system design, and integration of chronic care components, as well as health care delivery and clinical information systems and decision support, had improved. At T2, overall quality again improved significantly, as did community linkages, delivery system design, clinical information systems, decision support and integration of chronic care components, and self-management support. Multilevel regression analysis revealed that quality of chronic care delivery at T0 (p<0.001) and quality changes in the first (p<0.001) and second (p<0.01) years predicted program sustainability. In conclusion this study showed that disease-management programs based on the chronic care model improved the quality of chronic care delivery over time and that short and long term changes in the quality of chronic care delivery predicted the sustainability of the projects.

  9. Getting what we pay for: innovations lacking in provider payment reform for chronic disease care.

    PubMed

    Tynan, Ann; Draper, Debra A

    2008-06-01

    Despite wide recognition that existing physician and hospital payment methods used by health plans and other payers do not foster high-quality and efficient care for people with chronic conditions, little innovation in provider payment strategies is occurring, according to a new study by the Center for Studying Health System Change (HSC) commissioned by the California HealthCare Foundation. This is particularly disconcerting because the nation faces an increasing prevalence of chronic disease, resulting in continued escalation of related health care costs and diminished quality of life for more Americans. To date, most efforts to improve care of patients with chronic conditions have focused on paying vendors, such as disease management firms, to intervene with patients or redesigning care delivery without reforming underlying physician and hospital payment methods. While there is active discussion and anticipation of physician and hospital payment reform, current efforts are limited largely to experimental or small-scale pilot programs. More fundamental payment reform efforts in practice are virtually nonexistent. Existing payment systems, primarily fee for service, encourage a piecemeal approach to care delivery rather than a coordinated approach appropriate for patients with chronic conditions. While there is broad agreement that existing provider payment methods are not well aligned with optimal chronic disease care, there are significant barriers to reforming payment for chronic disease care, including: (1) fragmented care delivery; (2) lack of payment for non-physician providers and services supportive of chronic disease care; (3) potential for revenue reductions for some providers; and (4) lack of a viable reform champion. Absent such reform, however, efforts to improve the quality and efficiency of care for chronically ill patients are likely to be of limited success.

  10. Getting what we pay for: innovations lacking in provider payment reform for chronic disease care.

    PubMed

    Tynan, Ann; Draper, Debra A

    2008-06-01

    Despite wide recognition that existing physician and hospital payment methods used by health plans and other payers do not foster high-quality and efficient care for people with chronic conditions, little innovation in provider payment strategies is occurring, according to a new study by the Center for Studying Health System Change (HSC) commissioned by the California HealthCare Foundation. This is particularly disconcerting because the nation faces an increasing prevalence of chronic disease, resulting in continued escalation of related health care costs and diminished quality of life for more Americans. To date, most efforts to improve care of patients with chronic conditions have focused on paying vendors, such as disease management firms, to intervene with patients or redesigning care delivery without reforming underlying physician and hospital payment methods. While there is active discussion and anticipation of physician and hospital payment reform, current efforts are limited largely to experimental or small-scale pilot programs. More fundamental payment reform efforts in practice are virtually nonexistent. Existing payment systems, primarily fee for service, encourage a piecemeal approach to care delivery rather than a coordinated approach appropriate for patients with chronic conditions. While there is broad agreement that existing provider payment methods are not well aligned with optimal chronic disease care, there are significant barriers to reforming payment for chronic disease care, including: (1) fragmented care delivery; (2) lack of payment for non-physician providers and services supportive of chronic disease care; (3) potential for revenue reductions for some providers; and (4) lack of a viable reform champion. Absent such reform, however, efforts to improve the quality and efficiency of care for chronically ill patients are likely to be of limited success. PMID:18630402

  11. Primary Care Management of Chronic Constipation in Asia: The ANMA Chronic Constipation Tool

    PubMed Central

    Ghoshal, Uday C; Gonlachanvit, Sutep; Chua, Andrew Seng Boon; Myung, Seung-Jae; Rajindrajith, Shaman; Patcharatrakul, Tanisa; Choi, Myung-Gyu; Wu, Justin C Y; Chen, Min-Hu; Gong, Xiao-Rong; Lu, Ching-Liang; Chen, Chien-Lin; Pratap, Nitesh; Abraham, Philip; Hou, Xiao-Hua; Ke, Meiyun; Ricaforte-Campos, Jane D; Syam, Ari Fahrial; Abdullah, Murdani

    2013-01-01

    Chronic constipation (CC) may impact on quality of life. There is substantial patient dissatisfaction; possible reasons are failure to recognize underlying constipation, inappropriate dietary advice and inadequate treatment. The aim of these practical guidelines intended for primary care physicians, and which are based on Asian perspectives, is to provide an approach to CC that is relevant to the existing health-care infrastructure. Physicians should not rely on infrequent bowel movements to diagnose CC as many patients have one or more bowel movement a day. More commonly, patients present with hard stool, straining, incomplete feeling, bloating and other dyspeptic symptoms. Physicians should consider CC in these situations and when patients are found to use laxative containing supplements. In the absence of alarm features physicians may start with a 2-4 week therapeutic trial of available pharmacological agents including osmotic, stimulant and enterokinetic agents. Where safe to do so, physicians should consider regular (as opposed to on demand dosing), combination treatment and continuous treatment for at least 4 weeks. If patients do not achieve satisfactory response, they should be referred to tertiary centers for physiological evaluation of colonic transit and pelvic floor function. Surgical referral is a last resort, which should be considered only after a thorough physiological and psychological evaluation. PMID:23667746

  12. Fostering innovation in medicine and health care: what must academic health centers do?

    PubMed

    Dzau, Victor J; Yoediono, Ziggy; Ellaissi, William F; Cho, Alex H

    2013-10-01

    There is a real need for innovation in health care delivery, as well as in medicine, to address related challenges of access, quality, and affordability through new and creative approaches. Health care environments must foster innovation, not just allowing it but actively encouraging it to happen anywhere and at every level in health care and medicine-from the laboratory, to the operating room, bedside, and clinics. This paper reviews the essential elements and environmental factors important for health-related innovation to flourish in academic health systems.The authors maintain that innovation must be actively cultivated by teaching it, creating "space" for and supporting it, and providing opportunities for its implementation. The authors seek to show the importance of these three fundamental principles and how they can be implemented, highlighting examples from across the country and their own institution.Health innovation cannot be relegated to a second-class status by the urgency of day-to-day operations, patient care, and the requirements of traditional research. Innovation needs to be elevated to a committed endeavor and become a part of an organization's culture, particularly in academic health centers.

  13. An answer to chronicity in the Basque Country: primary care-based population health management.

    PubMed

    Nuño-Solinís, Roberto; Orueta, Juan F; Mateos, Maider

    2012-01-01

    Chronic conditions have an impact on individuals since they represent a restraint on quality of life, functional status, and productivity of people who suffer from them but they also compromise the sustainability of health systems. In 2010, the Strategy for Tackling the Challenge of Chronicity in the Basque Country was published. It contains policies and projects aimed at reinventing the health delivery model with the purpose of improving the quality of care for chronic patients and advancing toward a more sustainable, proactive, and integrated model. We present 3 projects here: population stratification, integrated care initiatives, and innovation from health care staff.

  14. Chronic care model strategies in the United States and Germany deliver patient-centered, high-quality diabetes care.

    PubMed

    Stock, Stephanie; Pitcavage, James M; Simic, Dusan; Altin, Sibel; Graf, Christian; Feng, Wen; Graf, Thomas R

    2014-09-01

    Improving the quality of care for chronic diseases is an important issue for most health care systems in industrialized nations. One widely adopted approach is the Chronic Care Model (CCM), which was first developed in the late 1990s. In this article we present the results from two large surveys in the United States and Germany that report patients' experiences in different models of patient-centered diabetes care, compared to the experiences of patients who received routine diabetes care in the same systems. The study populations were enrolled in either Geisinger Health System in Pennsylvania or Barmer, a German sickness fund that provides medical insurance nationwide. Our findings suggest that patients with type 2 diabetes who were enrolled in the care models that exhibited key features of the CCM were more likely to receive care that was patient-centered, high quality, and collaborative, compared to patients who received routine care. This study demonstrates that quality improvement can be realized through the application of the Chronic Care Model, regardless of the setting or distinct characteristics of the program.

  15. The changing nature of chronic care and coproduction of care between primary care professionals and patients with COPD and their informal caregivers.

    PubMed

    Cramm, Jane Murray; Nieboer, Anna Petra

    2016-01-01

    The aim of this study was to investigate whether care delivery in accordance with a care model is associated with co-productive relationships between professionals and COPD patients and their informal caregivers. A co-productive relationship refers to productive patient-professional interaction or shared decision making. This cross-sectional study was conducted in 2014 among 411 patients (out of 981) enrolled in the Dutch COPD care program Kennemer Lucht and 62 professionals treating them (out of 97). Kennemer Lucht COPD involved multicomponent interventions within all six dimensions of the chronic care model (organizational support, community, self-management, decision support, delivery system design, and information and communications technology) to improve the quality of care for patients with COPD. This approach was expected to improve relational coproduction of care between professionals and patients with COPD and their informal caregivers. Results show clearly that the perceived quality of chronic care delivery is related significantly to productive interaction/relational coproduction of care. The strength of the relationship between perceptions of quality of chronic care and relational coproduction among patients is strong (r=0.5; P≤0.001) and among professionals moderate (r=0.4; P≤0.001 relational coproduction with patients and informal caregivers). Furthermore, patients' perceptions of the quality of chronic care were associated with the existence of productive interaction with health care professionals (β=0.7; P≤0.001). The changing nature of chronic care is associated with coproduction of care, leading to the development of more productive relationships between primary care professionals and COPD patients and their informal caregivers. Further research is necessary to determine how best to sustain these developments.

  16. The changing nature of chronic care and coproduction of care between primary care professionals and patients with COPD and their informal caregivers

    PubMed Central

    Cramm, Jane Murray; Nieboer, Anna Petra

    2016-01-01

    The aim of this study was to investigate whether care delivery in accordance with a care model is associated with co-productive relationships between professionals and COPD patients and their informal caregivers. A co-productive relationship refers to productive patient–professional interaction or shared decision making. This cross-sectional study was conducted in 2014 among 411 patients (out of 981) enrolled in the Dutch COPD care program Kennemer Lucht and 62 professionals treating them (out of 97). Kennemer Lucht COPD involved multicomponent interventions within all six dimensions of the chronic care model (organizational support, community, self-management, decision support, delivery system design, and information and communications technology) to improve the quality of care for patients with COPD. This approach was expected to improve relational coproduction of care between professionals and patients with COPD and their informal caregivers. Results show clearly that the perceived quality of chronic care delivery is related significantly to productive interaction/relational coproduction of care. The strength of the relationship between perceptions of quality of chronic care and relational coproduction among patients is strong (r=0.5; P≤0.001) and among professionals moderate (r=0.4; P≤0.001 relational coproduction with patients and informal caregivers). Furthermore, patients’ perceptions of the quality of chronic care were associated with the existence of productive interaction with health care professionals (β=0.7; P≤0.001). The changing nature of chronic care is associated with coproduction of care, leading to the development of more productive relationships between primary care professionals and COPD patients and their informal caregivers. Further research is necessary to determine how best to sustain these developments. PMID:26869783

  17. Chronic disease management and the home-care alternative in Ontario, Canada.

    PubMed

    Tsasis, Peter

    2009-08-01

    The pressure on our health-care system to deliver efficient, quality and cost-effective care is increasing. The debate on its sustainability is also expanding. These challenges can be managed with revisions to our health-care policy frameworks governing how and what public health-care services are delivered. Chronic disease management and home care can together ease many of the present and future pressures facing the health-care system. However, the current level of investment and the present policy are not effectively supporting movement in this direction. Updating the Canada Health Act to reflect the realities of our health-care system, and developing policies to support the areas of interdisciplinary teamwork and system integration are needed to facilitate chronic disease management and home care in Canada. This article lays out the challenges, highlights the impending issues and suggests a framework for moving forward.

  18. Health Care in the Community: Developing Academic/Practice Partnerships for Care Coordination and Managing Transitions.

    PubMed

    Fortier, Mary E; Perron, Tracy; Fountain, Donna M; Hinic, Katherine; Vargas, Maryelena; Swan, Beth Ann; Heelan-Fancher, Lisa

    2015-01-01

    The delivery of health care is quickly changing from an acute care to a community-based setting. Faculty development and mastery in the use of new technologies, such as high-definition simulation and virtual communities are crucial for effective student learning outcomes. Students' benefits include opportunities for hands-on experience in various patient care scenarios, realtime faculty feedback regarding their critical reasoning and clinical performance, interdisciplinary collaboration, and access to a nonthreatening learning environment. The results of this study provide some evidence of the benefits of developing faculty and nursing curricula that addresses the shift from an ilness-based, acute hospital model, to a community and population health-based preventive model. PMID:26259341

  19. Adaptive leadership framework for chronic illness: framing a research agenda for transforming care delivery.

    PubMed

    Anderson, Ruth A; Bailey, Donald E; Wu, Bei; Corazzini, Kirsten; McConnell, Eleanor S; Thygeson, N Marcus; Docherty, Sharron L

    2015-01-01

    We propose the Adaptive Leadership Framework for Chronic Illness as a novel framework for conceptualizing, studying, and providing care. This framework is an application of the Adaptive Leadership Framework developed by Heifetz and colleagues for business. Our framework views health care as a complex adaptive system and addresses the intersection at which people with chronic illness interface with the care system. We shift focus from symptoms to symptoms and the challenges they pose for patients/families. We describe how providers and patients/families might collaborate to create shared meaning of symptoms and challenges to coproduce appropriate approaches to care. PMID:25647829

  20. Forging partnerships between rural women with chronic conditions and their health care providers.

    PubMed

    Cudney, Shirley; Weinert, Clarann; Kinion, Elizabeth

    2011-03-01

    Successful adaptation to chronic illness is enhanced by active client-health care provider partnerships. The purposes of this article are to (a) examine the health care partnership needs of western rural women with chronic illness who participated in a computer-based support and education project, (b) describe how the role of the women in the partnership can be maximized by the use of a personal health record and improving health literacy, and (c) discuss ways health care providers can enhance their role in the partnership by careful listening and creating environments conducive to forging productive client-provider partnerships.

  1. [Part I. End-stage chronic organ failures: a position paper on shared care planning. The Integrated Care Pathway].

    PubMed

    Gristina, Giuseppe R; Orsi, Luciano; Carlucci, Annalisa; Causarano, Ignazio R; Formica, Marco; Romanò, Massimo

    2014-01-01

    In Italy the birth rate decrease together with the continuous improvement of living conditions on one hand, and the health care progress on the other hand, led in recent years to an increasing number of patients with chronic mono- or multi-organ failures and in an extension of their life expectancy. However, the natural history of chronic failures has not changed and the inescapable disease's worsening at the end makes more rare remissions, increasing hospital admissions rate and length of stay. Thus, when the "end-stage" get close clinicians have to engage the patient and his relatives in an advance care planning aimed to share a decision making process regarding all future treatments and related ethical choices such as patient's best interests, rights, values, and priorities. A right approach to the chronic organ failures end-stage patients consists therefore of a careful balance between the new powers of intervention provided by the biotechnology and pharmacology (intensive care), both with the quality of remaining life supplied by physicians to these patients (proportionality and beneficence) and the effective resources rationing and allocation (distributive justice). However, uncertainty still marks the criteria used by doctors to assess prognosis of these patients in order to make decisions concerning intensive or palliative care. The integrated care pathway suggested in this position paper shared by nine Italian medical societies, has to be intended as a guide focused to identify end-stage patients and choosing for them the best care option between intensive treatments and palliative care. PMID:24553592

  2. Implementation of an Interdisciplinary, Team-Based Complex Care Support Health Care Model at an Academic Medical Center: Impact on Health Care Utilization and Quality of Life

    PubMed Central

    Ritchie, Christine; Andersen, Robin; Eng, Jessica; Garrigues, Sarah K.; Intinarelli, Gina; Kao, Helen; Kawahara, Suzanne; Patel, Kanan; Sapiro, Lisa; Thibault, Anne; Tunick, Erika; Barnes, Deborah E.

    2016-01-01

    Introduction The Geriatric Resources for the Assessment and Care of Elders (GRACE) program has been shown to decrease acute care utilization and increase patient self-rated health in low-income seniors at community-based health centers. Aims To describe adaptation of the GRACE model to include adults of all ages (named Care Support) and to evaluate the process and impact of Care Support implementation at an urban academic medical center. Setting 152 high-risk patients (≥5 ED visits or ≥2 hospitalizations in the past 12 months) enrolled from four medical clinics from 4/29/2013 to 5/31/2014. Program Description Patients received a comprehensive in-home assessment by a nurse practitioner/social worker (NP/SW) team, who then met with a larger interdisciplinary team to develop an individualized care plan. In consultation with the primary care team, standardized care protocols were activated to address relevant key issues as needed. Program Evaluation A process evaluation based on the Consolidated Framework for Implementation Research identified key adaptations of the original model, which included streamlining of standardized protocols, augmenting mental health interventions and performing some assessments in the clinic. A summative evaluation found a significant decline in the median number of ED visits (5.5 to 0, p = 0.015) and hospitalizations (5.5 to 0, p<0.001) 6 months before enrollment in Care Support compared to 6 months after enrollment. In addition, the percent of patients reporting better self-rated health increased from 31% at enrollment to 64% at 9 months (p = 0.002). Semi-structured interviews with Care Support team members identified patients with multiple, complex conditions; little community support; and mild anxiety as those who appeared to benefit the most from the program. Discussion It was feasible to implement GRACE/Care Support at an academic medical center by making adaptations based on local needs. Care Support patients experienced

  3. Academic health sciences librarians' contributions to institutional animal care and use committees.

    PubMed

    Steelman, Susan C; Thomas, Sheila L

    2014-07-01

    The study gathered data about librarians' membership in institutional animal care and use committees (IACUCs) and their professional activities supporting animal researchers. Libraries affiliated with medical schools that were members of the Association of American Medical Colleges were surveyed. A survey was distributed via library directors' email discussion lists and direct email messages. Sixty surveys were completed: 35 (58%) reported that librarians performed database searches for researchers, and 22 (37%) reported that a librarian currently serves on the IACUC. The survey suggests that academic health sciences librarians provide valuable, yet underutilized, services to support animal research investigators.

  4. Academic health sciences librarians' contributions to institutional animal care and use committees.

    PubMed

    Steelman, Susan C; Thomas, Sheila L

    2014-07-01

    The study gathered data about librarians' membership in institutional animal care and use committees (IACUCs) and their professional activities supporting animal researchers. Libraries affiliated with medical schools that were members of the Association of American Medical Colleges were surveyed. A survey was distributed via library directors' email discussion lists and direct email messages. Sixty surveys were completed: 35 (58%) reported that librarians performed database searches for researchers, and 22 (37%) reported that a librarian currently serves on the IACUC. The survey suggests that academic health sciences librarians provide valuable, yet underutilized, services to support animal research investigators. PMID:25031565

  5. Chronic pain disorders in HIV primary care: clinical characteristics and association with healthcare utilization.

    PubMed

    Jiao, Jocelyn M; So, Eric; Jebakumar, Jebakaran; George, Mary Catherine; Simpson, David M; Robinson-Papp, Jessica

    2016-04-01

    Chronic pain is common in HIV, but incompletely characterized, including its underlying etiologies, its effect on healthcare utilization, and the characteristics of affected patients in the HIV primary care setting. These data are needed to design and justify appropriate clinic-based pain management services. Using a clinical data warehouse, we analyzed one year of data from 638 patients receiving standard-of-care antiretroviral therapy in a large primary care HIV clinic, located in the Harlem neighborhood of New York City. We found that 40% of patients carried one or more chronic pain diagnoses. The most common diagnoses were degenerative musculoskeletal disorders (eg, degenerative spinal disease and osteoarthritis), followed by neuropathic pain and headache disorders. Many patients (16%) had multiple chronic pain diagnoses. Women, older patients, and patients with greater burdens of medical illness, and psychiatric and substance use comorbidities were disproportionately represented among those with chronic pain diagnoses. Controlling for overall health status, HIV patients with chronic pain had greater healthcare utilization including emergency department visits and radiology procedures. In summary, our study demonstrates the high prevalence of chronic pain disorders in the primary care HIV clinic. Colocated interventions for chronic pain in this setting should not only focus on musculoskeletal pain but also account for complex multifaceted pain syndromes, and address the unique biopsychosocial features of this population. Furthermore, because chronic pain is prevalent in HIV and associated with increased healthcare utilization, developing clinic-based pain management programs could be cost-effective.

  6. Primary Care Management of Chronic Nonmalignant Pain in Veterans: A Qualitative Study

    ERIC Educational Resources Information Center

    Ruiz, Jorge G.; Qadri, S. Sobiya; Nader, Samir; Wang, Jia; Lawler, Timothy; Hagenlocker, Brian; Roos, Bernard A.

    2010-01-01

    Clinicians managing older patients with chronic pain play an important role. This paper explores the attitudes of primary care clinicians (PCPs) toward chronic nonmalignant pain management and their experiences using a clinical decision support system. Our investigation followed a qualitative approach based on grounded theory. Twenty-one PCPs…

  7. Chronic pain disorders in HIV primary care: clinical characteristics and association with healthcare utilization.

    PubMed

    Jiao, Jocelyn M; So, Eric; Jebakumar, Jebakaran; George, Mary Catherine; Simpson, David M; Robinson-Papp, Jessica

    2016-04-01

    Chronic pain is common in HIV, but incompletely characterized, including its underlying etiologies, its effect on healthcare utilization, and the characteristics of affected patients in the HIV primary care setting. These data are needed to design and justify appropriate clinic-based pain management services. Using a clinical data warehouse, we analyzed one year of data from 638 patients receiving standard-of-care antiretroviral therapy in a large primary care HIV clinic, located in the Harlem neighborhood of New York City. We found that 40% of patients carried one or more chronic pain diagnoses. The most common diagnoses were degenerative musculoskeletal disorders (eg, degenerative spinal disease and osteoarthritis), followed by neuropathic pain and headache disorders. Many patients (16%) had multiple chronic pain diagnoses. Women, older patients, and patients with greater burdens of medical illness, and psychiatric and substance use comorbidities were disproportionately represented among those with chronic pain diagnoses. Controlling for overall health status, HIV patients with chronic pain had greater healthcare utilization including emergency department visits and radiology procedures. In summary, our study demonstrates the high prevalence of chronic pain disorders in the primary care HIV clinic. Colocated interventions for chronic pain in this setting should not only focus on musculoskeletal pain but also account for complex multifaceted pain syndromes, and address the unique biopsychosocial features of this population. Furthermore, because chronic pain is prevalent in HIV and associated with increased healthcare utilization, developing clinic-based pain management programs could be cost-effective. PMID:26683238

  8. Individualized Health Care Plans: Supporting Children With Chronic Conditions in the Classroom

    ERIC Educational Resources Information Center

    Hopkins, Amanda F.; Hughes, Mary-alayne

    2016-01-01

    Due to the major advances in technology and the sciences, advances in the medical treatment options for children with chronic conditions are being made at an astonishing rate. In the health care field, "children with chronic conditions" is a generic phrase that typically refers to children with physical, developmental, behavioral, or…

  9. [From chronic disease to multimorbidity: Which impact on organization of health care].

    PubMed

    Belche, Jean-Luc; Berrewaerts, Marie-Astrid; Ketterer, Frédéric; Henrard, Gilles; Vanmeerbeek, Marc; Giet, Didier

    2015-11-01

    Healthcare systems are concerned with the growing prevalence of chronic diseases. Single disease approach, based on the Chronic Care Model, is known to improve specific indicators for the targeted disease. However, the co-existence of several chronic disease, or multimorbidity, within a same patient is the most frequent situation. The fragmentation of care, as consequence of the single disease approach, has negative impact on the patient and healthcare professionals. A person centred approach is a method addressing the combination of health issues of each patient. The coordination and synthesis role is key to ensure continuity of care for the patient within a network of healthcare professionals from several settings of care. This function is the main characteristic of an organized first level of care. PMID:26358669

  10. [From chronic disease to multimorbidity: Which impact on organization of health care].

    PubMed

    Belche, Jean-Luc; Berrewaerts, Marie-Astrid; Ketterer, Frédéric; Henrard, Gilles; Vanmeerbeek, Marc; Giet, Didier

    2015-11-01

    Healthcare systems are concerned with the growing prevalence of chronic diseases. Single disease approach, based on the Chronic Care Model, is known to improve specific indicators for the targeted disease. However, the co-existence of several chronic disease, or multimorbidity, within a same patient is the most frequent situation. The fragmentation of care, as consequence of the single disease approach, has negative impact on the patient and healthcare professionals. A person centred approach is a method addressing the combination of health issues of each patient. The coordination and synthesis role is key to ensure continuity of care for the patient within a network of healthcare professionals from several settings of care. This function is the main characteristic of an organized first level of care.

  11. Re-designing Orem's Self-care Theory for Patients with Chronic Hepatitis

    PubMed Central

    Hasanpour-Dehkordi, Ali; Mohammadi, Nooredin; Nikbakht-Nasrabadi, Alireza

    2016-01-01

    Background: Hepatitis is an inflammatory disease which has many adverse effects on patients’ life because of its chronic nature. Since Orem's theory of self-care is a grounded theory, the concepts and applications of this theory in patients with chronic hepatitis who have special needs may lead to some challenges. The purpose of this study was to explore self-care in patients with chronic hepatitis. Methods/Design: A directed content analysis was used in this qualitative study. Participants were recruited from a metropolitan area. Data were collected through semi-structured interviews. The verbatim transcripts of the participants’ interviews were analyzed according to directed content analysis. Results: In this study, four themes, suggested by Orem, were drawn from the data according to directed content analysis. The codes generated from the data were classified into concepts and then the concepts were assigned into these four themes. These themes were needs in the matrix of time and place, self-care agency, need for change in self-care and consequences of hepatitis. Conclusion: The use of Orem's self-care theory cannot meet the need for self-care in hepatitis patients because these patients have vital sexual, respect and belonging, physical, economical, and psychological-behavioral needs, and lack adequate knowledge about self-care. Consequently, the specific self-care model developed in this study helps health professionals identify self-care activities in patients with chronic hepatitis. PMID:27803560

  12. 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.

  13. Implementation of chronic illness care in German primary care practices – how do multimorbid older patients view routine care? A cross-sectional study using multilevel hierarchical modeling

    PubMed Central

    2014-01-01

    Background In primary care, patients with multiple chronic conditions are the rule rather than the exception. The Chronic Care Model (CCM) is an evidence-based framework for improving chronic illness care, but little is known about the extent to which it has been implemented in routine primary care. The aim of this study was to describe how multimorbid older patients assess the routine chronic care they receive in primary care practices in Germany, and to explore the extent to which factors at both the practice and patient level determine their views. Methods This cross-sectional study used baseline data from an observational cohort study involving 158 general practitioners (GP) and 3189 multimorbid patients. Standardized questionnaires were employed to collect data, and the Patient Assessment of Chronic Illness Care (PACIC) questionnaire used to assess the quality of care received. Multilevel hierarchical modeling was used to identify any existing association between the dependent variable, PACIC, and independent variables at the patient level (socio-economic factors, weighted count of chronic conditions, instrumental activities of daily living, health-related quality of life, graded chronic pain, no. of contacts with GP, existence of a disease management program (DMP) disease, self-efficacy, and social support) and the practice level (age and sex of GP, years in current practice, size and type of practice). Results The overall mean PACIC score was 2.4 (SD 0.8), with the mean subscale scores ranging from 2.0 (SD 1.0, subscale goal setting/tailoring) to 3.5 (SD 0.7, delivery system design). At the patient level, higher PACIC scores were associated with a DMP disease, more frequent GP contacts, higher social support, and higher autonomy of past occupation. At the practice level, solo practices were associated with higher PACIC values than other types of practice. Conclusions This study shows that from the perspective of multimorbid patients receiving care in German

  14. Care Management Processes Used Less Often For Depression Than For Other Chronic Conditions In US Primary Care Practices.

    PubMed

    Bishop, Tara F; Ramsay, Patricia P; Casalino, Lawrence P; Bao, Yuhua; Pincus, Harold A; Shortell, Stephen M

    2016-03-01

    Primary care physicians play an important role in the diagnosis and management of depression. Yet little is known about their use of care management processes for depression. Using national survey data for the period 2006-13, we assessed the use of five care management processes for depression and other chronic illnesses among primary care practices in the United States. We found significantly less use for depression than for asthma, congestive heart failure, or diabetes in 2012-13. On average, practices used fewer than one care management process for depression, and this level of use has not changed since 2006-07, regardless of practice size. In contrast, use of diabetes care management processes has increased significantly among larger practices. These findings may indicate that US primary care practices are not well equipped to manage depression as a chronic illness, despite the high proportion of depression care they provide. Policies that incentivize depression care management, including additional quality metrics, should be considered. PMID:26953291

  15. Improving Population Health by Incorporating Chronic Disease and Injury Prevention Into Value-Based Care Models.

    PubMed

    Petersen, Ruth; Rushing, Jill; Nelson, Sharon; Rhyne, Sharon

    2016-01-01

    Today's health system transformation provides a prime opportunity to leverage the capacity of public health to reduce the burden of chronic disease and injury, improve population health, and contain health care costs. Health care settings and organizations should support public health capacity as a key investment in population health.

  16. Caring for People with Chronic Fatigue Syndrome: Perceived Stress Versus Satisfaction.

    ERIC Educational Resources Information Center

    Ferrari, Joseph R.; Jason, Leonard A.

    1997-01-01

    Examined adult caregivers (N=96) caring for persons with Chronic Fatigue Syndrome (CFS) on a long-term basis. Results indicate no significant sex difference regarding caregiver stress and satisfaction. The more life satisfaction caregivers reported, the less stress and more satisfaction they experienced in caring for a person with CFS. (RJM)

  17. The Care Needs of Community-Dwelling Seniors Suffering from Advanced Chronic Obstructive Pulmonary Disease

    ERIC Educational Resources Information Center

    Wilson, Donna M.; Ross, Carolyn; Goodridge, Donna; Davis, Penny; Landreville, Alison; Roebuck, Kim

    2008-01-01

    Aim: This study was undertaken to determine the care needs of Canadian seniors living at home with advanced chronic obstructive pulmonary disease (COPD). Background: COPD is a leading cause of morbidity and mortality worldwide. Although hospitalizations for illness exacerbations and end-stage care may be common, most persons with COPD live out…

  18. Improving Population Health by Incorporating Chronic Disease and Injury Prevention Into Value-Based Care Models.

    PubMed

    Petersen, Ruth; Rushing, Jill; Nelson, Sharon; Rhyne, Sharon

    2016-01-01

    Today's health system transformation provides a prime opportunity to leverage the capacity of public health to reduce the burden of chronic disease and injury, improve population health, and contain health care costs. Health care settings and organizations should support public health capacity as a key investment in population health. PMID:27422946

  19. Medication Adherence and Health Care Utilization in Pediatric Chronic Illness: A Systematic Review

    PubMed Central

    Hommel, Kevin A.

    2013-01-01

    BACKGROUND AND OBJECTIVE: Advanced understanding of modifiable predictors of health care use in pediatric chronic illness is critical to reducing health care costs. We examined the relationship between medication non-adherence and health care use in children and adolescents who have a chronic medical condition. METHODS: A systematic review of articles by using PubMed, PsycINFO, and CINAHL was conducted. Additional studies were identified by searching reference sections of relevant manuscripts. Studies that tested the relationship between medication non-adherence and health care use (ie, hospitalizations, emergency department visits, outpatient visits) or cost in children and adolescents (mean age ≤18 years) who have a chronic medical condition were included. Extraction of articles was completed by using predefined data fields. RESULTS: Ten studies met our inclusion criteria. Nine of the 10 studies reviewed (90%) demonstrated a relationship between medication non-adherence and increased health care use. The directionality of this relationship varied depending on the outcome variable of interest. CONCLUSIONS: Medication non-adherence is related to increased health care use in children and adolescents who have a chronic medical condition and should be addressed in clinical care. Future studies should include randomized controlled trials examining the impact of adherence promotion efforts on health care use and costs. PMID:23999953

  20. Consequences of caring for a child with a chronic disease: Employment and leisure time of parents.

    PubMed

    Hatzmann, Janneke; Peek, Niels; Heymans, Hugo; Maurice-Stam, Heleen; Grootenhuis, Martha

    2014-12-01

    Chronically ill children require several hours of additional care per day compared to healthy children. As parents provide most of this care, they have to incorporate it into their daily schedule, which implies a reduction in time for other activities. The study aimed to assess the effect of having a chronically ill child on parental employment and parental leisure activity time, and to explore the role of demographic, social, and disease-related variables in relation to employment and leisure activities. Outcomes of 576 parents of chronically ill children and 441 parents of healthy school children were analyzed with multivariate regression. Having a chronically ill child was negatively related with family employment, maternal labor force participation, and leisure activity time. Use of child care was positively related to family and maternal employment of the total group of parents. Within parents of chronically ill children, most important finding was the negative relation of dependency of the child on daily care and low parental educational level with family and maternal employment. In conclusion, parents of chronically ill children, mothers in particular, are disadvantaged in society probably due to the challenge of combining child care with work and leisure time.

  1. Utilisation of health care system by chronic pain patients who applied for disability pensions.

    PubMed

    Højsted, J; Alban, A; Hagild, K; Eriksen, J

    1999-09-01

    The objective of this study was to investigate how economic compensation for disability (disability pensions) to chronic pain patients affected their utilisation of health care services. The study was carried out as a register investigation. Inclusion of 144 study patients was based on records from 1989 and 1990 of the Rehabilitation and Pension Board in the Municipality of Copenhagen. Only patients of Danish origin with chronic non-malignant pain were included. The study period was divided into three: Subperiod 1: The year preceding the submission of the application for a disability pension. Subperiod 2: The period from the submission of the application to the decision was made. Subperiod 3: The year following the final decision of the health authorities. The patients were divided into 4 Subgroups according to whether disability pensions was awarded or rejected, or whether the patients accepted or appealed the decision. Based on number and charges of visits to the GPs the total costs of care in the primary sector were calculated. By means of number of bed days, visits to outpatients clinics, operations, blood samples, and various investigations, the total costs of hospital care were calculated. We found that application for a disability pension in chronic pain patients significantly influenced the health care utilisation. Chronic pain patients had a significantly lower health care utilisation after receiving a disability pension than before the pension was awarded. Chronic pain patients who did not get a disability pension and those who were not satisfied with the level of the pension awarded, maintained their health care utilisation after the decision. The mean health care use by the patients who appealed the level of the pension was three times higher than the mean health care use by the patients who accepted the level of the pension awarded. The study may indicate that lack of or insufficient economic compensation from the social system in chronic pain patients

  2. The potential conflict between policy and ethics in caring for undocumented immigrants at academic health centers.

    PubMed

    Cacari Stone, Lisa; Steimel, Leah; Vasquez-Guzman, Estela; Kaufman, Arthur

    2014-04-01

    Academic health centers (AHCs) are at the forefront of delivering care to the diverse medically underserved and uninsured populations in the United States, as well as training the majority of the health care workforce, who are professionally obligated to serve all patients regardless of race or immigration status. Despite AHCs' central leadership role in these endeavors, few consolidated efforts have emerged to resolve potential conflicts between national, state, and local policies that exclude certain classifications of immigrants from receiving federal public assistance and health professionals' social missions and ethical oath to serve humanity. For instance, whereas the 2010 Patient Protection and Affordable Care Act provides a pathway to insurance coverage for more than 30 million Americans, undocumented immigrants and legally documented immigrants residing in the United States for less than five years are ineligible for Medicaid and excluded from purchasing any type of coverage through state exchanges. To inform this debate, the authors describe their experience at the University of New Mexico Hospital (UNMH) and discuss how the UNMH has responded to this challenge and overcome barriers. They offer three recommendations for aligning AHCs' social missions and professional ethics with organizational policies: (1) that AHCs determine eligibility for financial assistance based on residency rather than citizenship, (2) that models of medical education and health professions training provide students with service-learning opportunities and applied community experience, and (3) that frontline staff and health care professionals receive standardized training on eligibility policies to minimize discrimination towards immigrant patients.

  3. Legal, financial, and ethical ambiguities for Mexican American families: caring for children with chronic conditions.

    PubMed

    Rehm, Roberta S

    2003-05-01

    The author reports findings from a study about experiences of 17 Mexican American families caring for children with serious chronic conditions. Legal, financial, and ethical ambiguities arose when parents' desire to provide necessary care for their children and providers' professional commitment to offer this care conflicted with United States laws, including welfare reform initiatives, requiring providers to determine eligibility before providing care to immigrants and to report undocumented care seekers to authorities. Families frequently felt intimidated because health care systems are complex, and legal residency status often varied among family members. Findings imply that official policy and education of family members should aim to assure that children with chronic conditions receive needed services without relying on providers to enforce immigration laws. PMID:12756688

  4. Comparable sustained virologic suppression between community and academic-based HIV care settings

    PubMed Central

    Chu, Carolyn; Heo, Moonseong; Peshansky, Alex; Umanski, Galina; Meissner, Paul; Voss, Cindy; Selwyn, Peter A.

    2015-01-01

    Purpose The HIV/AIDS epidemic in the United States is evolving due to factors including aging and geographical diffusion. Provider shortages are also driving the restructuring of HIV care delivery away from specialized settings, and family medicine providers may play a larger role in the future. We attempted to compare the effectiveness of HIV treatment delivered at community versus hospital care settings. Methods The outcome of interest was sustained virologic suppression defined as two consecutive HIV-1 RNA measurements ≤ 400 copies/mL within one year after antiretroviral initiation. We used data from the multi-state HIV Research Network cohort to compare sustained virologic suppression outcomes among 15,047 HIV-infected adults followed from 2000–2008 at five community- and eight academic hospital-based ambulatory care sites. Community-based sites were mostly staffed by family medicine and general internal medicine physicians with HIV expertise whereas hospital sites were primarily staffed by infectious disease subspecialists. Multivariate mixed-effects logistic regression controlling for potential confounding variables was applied to account for clustering effects of study sites. Results In an unadjusted analysis, the rate of sustained virologic suppression was significantly higher among subjects treated in the community-based care settings: 1,646/2,314 (71.1%) vs. 8,416/12,733 (66.1%) (p < 0.01). In the adjusted multivariate model with potential confounding variables, the rate was higher, although not statistically significant, in the community-based settings (AOR = 1.26, 95% CI 0.73–2.16). Conclusion Antiretroviral therapy can be delivered effectively through community-based treatment settings. This finding is potentially important for new program development to shift HIV care into community-based settings as the landscape of accountable care, health reform, and HIV funding and resources evolves. PMID:25567825

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

    PubMed Central

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

    2016-01-01

    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. PMID:27629064

  6. 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

    2016-01-01

    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. PMID:27629064

  7. A Mobile Care Coordination System for the Management of Complex Chronic Disease.

    PubMed

    Haynes, Sarah; Kim, Katherine K

    2016-01-01

    There is global concern about healthcare cost, quality, and access as the prevalence of complex and chronic diseases, such as heart disease, continues to grow. Care for patients with complex chronic disease involves diverse practitioners and multiple transitions between medical centers, physician practices, clinics, community resources, and patient homes. There are few systems that provide the flexibility to manage these varied and complex interactions. Participatory and user-centered design methodology was applied to the first stage of building a mobile platform for care coordination for complex, chronic heart disease. Key informant interviews with patients, caregivers, clinicians, and care coordinators were conducted. Thematic analysis led to identification of priority user functions including shared care plan, medication management, symptom management, nutrition, physical activity, appointments, personal monitoring devices, and integration of data and workflow. Meaningful stakeholder engagement contributes to a person-centered system that enhances health and efficiency. PMID:27332252

  8. A Mobile Care Coordination System for the Management of Complex Chronic Disease.

    PubMed

    Haynes, Sarah; Kim, Katherine K

    2016-01-01

    There is global concern about healthcare cost, quality, and access as the prevalence of complex and chronic diseases, such as heart disease, continues to grow. Care for patients with complex chronic disease involves diverse practitioners and multiple transitions between medical centers, physician practices, clinics, community resources, and patient homes. There are few systems that provide the flexibility to manage these varied and complex interactions. Participatory and user-centered design methodology was applied to the first stage of building a mobile platform for care coordination for complex, chronic heart disease. Key informant interviews with patients, caregivers, clinicians, and care coordinators were conducted. Thematic analysis led to identification of priority user functions including shared care plan, medication management, symptom management, nutrition, physical activity, appointments, personal monitoring devices, and integration of data and workflow. Meaningful stakeholder engagement contributes to a person-centered system that enhances health and efficiency.

  9. Bridging knowledge to develop an action plan for integrated care for chronic diseases in Greece.

    PubMed

    Tsiachristas, Apostolos; Lionis, Christos; Yfantopoulos, John

    2015-01-01

    The health, social and economic impact of chronic diseases is well documented in Europe. However, chronic diseases threaten relatively more the 'memorandum and peripheral' Eurozone countries (i.e., Greece, Spain, Portugal and Ireland), which were under heavy recession after the economic crisis in 2009. Especially in Greece, where the crisis was the most severe across Europe, the austerity measures affected mainly people with chronic diseases. As a result, the urgency to tackle the threat of chronic diseases in Greece by promoting public health and providing effective chronic care while flattening the rising health care expenditure is eminent. In many European countries, integrated care is seen as a means to achieve this. The aim of this paper was to support Greek health policy makers to develop an action plan from 2015 onwards, to integrate care by bridging local policy context and needs with knowledge and experience from other European countries. To achieve this aim, we adopted a conceptual framework developed by the World Health Organization on one hand to analyse the status of integrated care in Greece, and on the other to develop an action plan for reform. The action plan was based on an analysis of the Greek health care system regarding prerequisite conditions to integrate care, a clear understanding of its context and successful examples of integrated care from other European countries. This study showed that chronic diseases are poorly addressed in Greece and integrated care is in embryonic stage. Greek policy makers have to realise that this is the opportunity to make substantial reforms in chronic care. Failing to reform towards integrated care would lead to the significant risk of collapse of the Greek health care system with all associated negative consequences. The action plan provided in this paper could support policy makers to make the first serious step to face this challenge. The details and specifications of the action plan can only be decided by

  10. Bridging knowledge to develop an action plan for integrated care for chronic diseases in Greece.

    PubMed

    Tsiachristas, Apostolos; Lionis, Christos; Yfantopoulos, John

    2015-01-01

    The health, social and economic impact of chronic diseases is well documented in Europe. However, chronic diseases threaten relatively more the 'memorandum and peripheral' Eurozone countries (i.e., Greece, Spain, Portugal and Ireland), which were under heavy recession after the economic crisis in 2009. Especially in Greece, where the crisis was the most severe across Europe, the austerity measures affected mainly people with chronic diseases. As a result, the urgency to tackle the threat of chronic diseases in Greece by promoting public health and providing effective chronic care while flattening the rising health care expenditure is eminent. In many European countries, integrated care is seen as a means to achieve this. The aim of this paper was to support Greek health policy makers to develop an action plan from 2015 onwards, to integrate care by bridging local policy context and needs with knowledge and experience from other European countries. To achieve this aim, we adopted a conceptual framework developed by the World Health Organization on one hand to analyse the status of integrated care in Greece, and on the other to develop an action plan for reform. The action plan was based on an analysis of the Greek health care system regarding prerequisite conditions to integrate care, a clear understanding of its context and successful examples of integrated care from other European countries. This study showed that chronic diseases are poorly addressed in Greece and integrated care is in embryonic stage. Greek policy makers have to realise that this is the opportunity to make substantial reforms in chronic care. Failing to reform towards integrated care would lead to the significant risk of collapse of the Greek health care system with all associated negative consequences. The action plan provided in this paper could support policy makers to make the first serious step to face this challenge. The details and specifications of the action plan can only be decided by

  11. Bridging knowledge to develop an action plan for integrated care for chronic diseases in Greece

    PubMed Central

    Lionis, Christos; Yfantopoulos, John

    2015-01-01

    The health, social and economic impact of chronic diseases is well documented in Europe. However, chronic diseases threaten relatively more the ‘memorandum and peripheral’ Eurozone countries (i.e., Greece, Spain, Portugal and Ireland), which were under heavy recession after the economic crisis in 2009. Especially in Greece, where the crisis was the most severe across Europe, the austerity measures affected mainly people with chronic diseases. As a result, the urgency to tackle the threat of chronic diseases in Greece by promoting public health and providing effective chronic care while flattening the rising health care expenditure is eminent. In many European countries, integrated care is seen as a means to achieve this. The aim of this paper was to support Greek health policy makers to develop an action plan from 2015 onwards, to integrate care by bridging local policy context and needs with knowledge and experience from other European countries. To achieve this aim, we adopted a conceptual framework developed by the World Health Organization on one hand to analyse the status of integrated care in Greece, and on the other to develop an action plan for reform. The action plan was based on an analysis of the Greek health care system regarding prerequisite conditions to integrate care, a clear understanding of its context and successful examples of integrated care from other European countries. This study showed that chronic diseases are poorly addressed in Greece and integrated care is in embryonic stage. Greek policy makers have to realise that this is the opportunity to make substantial reforms in chronic care. Failing to reform towards integrated care would lead to the significant risk of collapse of the Greek health care system with all associated negative consequences. The action plan provided in this paper could support policy makers to make the first serious step to face this challenge. The details and specifications of the action plan can only be decided

  12. Perspective: Prospective health care and the role of academic medicine: lead, follow, or get out of the way.

    PubMed

    Snyderman, Ralph; Yoediono, Ziggy

    2008-08-01

    The authors contend that the crisis facing the U.S. health care system is in large part a consequence of that system's disease-oriented, reactive, and sporadic approach to care, and they suggest that a prospective approach to health care, which emphasizes personalized medicine and strategic health planning, would be a more rational way to prevent disease and maximize health. During recent years, personalized, predictive, preventive, and participatory medicine--that is, prospective care--has been receiving increasing attention as a solution to the U.S. health care crisis. Advocacy has been mainly from industry, government, large employers, and private insurers. However, academic medicine, as a whole, has not played a leading role in this movement. The authors believe that academic medicine has the opportunity and responsibility to play a far greater role in the conception and development of better models to deliver health care. In doing so, it could lead the transformation of today's dysfunctional system of medical care to that of a prospective approach that emphasizes personalization, prediction, prevention, and patient participation. Absent contributing to improving how care is delivered, academic medicine's leadership in our nation's health will be bypassed.

  13. [How to Define Good Health Care: An Ethical Framework for the Evaluation of Health Care for the Chronically Ill].

    PubMed

    Klingler, C; Marckmann, G

    2015-09-01

    In Germany we face an increase in chronic illnesses and a health care system not adjusted to the specific needs of this patient group. Innovative health care management programmes (for example, disease management programmes) might be able to play an important role in overcoming the existing deficits. By developing and implementing such programmes we are, how-ever, implicitly touching upon normative issues, but only rarely are the ethical aspects of these programmes discussed explicitly and evaluated in a systematic way. Against this backdrop, we have developed an ethical framework as a tool for evaluating general health care and innovative programmes for the chronically ill. The framework comprises on the one hand a list of criteria that define good health care in the context of chronic illness. Based on a coherentist conception of ethical justification, we developed 8 criteria (among others "the autonomy of patients concerning therapy, use of data and other life choices have to be promoted and respected") for the context of chronic illness. On the other hand, the framework provides a methodological approach to apply the criteria in 6 steps in order to evaluate a specific programme. Thereby, we want to give orienta-tion to policy makers and practitioners concerning the normative underpinnings of their work and support them in identifying relevant ethical requirements and potential problems at an early stage. PMID:25314688

  14. [How to Define Good Health Care: An Ethical Framework for the Evaluation of Health Care for the Chronically Ill].

    PubMed

    Klingler, C; Marckmann, G

    2015-09-01

    In Germany we face an increase in chronic illnesses and a health care system not adjusted to the specific needs of this patient group. Innovative health care management programmes (for example, disease management programmes) might be able to play an important role in overcoming the existing deficits. By developing and implementing such programmes we are, how-ever, implicitly touching upon normative issues, but only rarely are the ethical aspects of these programmes discussed explicitly and evaluated in a systematic way. Against this backdrop, we have developed an ethical framework as a tool for evaluating general health care and innovative programmes for the chronically ill. The framework comprises on the one hand a list of criteria that define good health care in the context of chronic illness. Based on a coherentist conception of ethical justification, we developed 8 criteria (among others "the autonomy of patients concerning therapy, use of data and other life choices have to be promoted and respected") for the context of chronic illness. On the other hand, the framework provides a methodological approach to apply the criteria in 6 steps in order to evaluate a specific programme. Thereby, we want to give orienta-tion to policy makers and practitioners concerning the normative underpinnings of their work and support them in identifying relevant ethical requirements and potential problems at an early stage.

  15. Aligning health information technologies with effective service delivery models to improve chronic disease care

    PubMed Central

    Bauer, Amy M.; Thielke, Stephen M.; Katon, Wayne; Unützer, Jürgen; Areán, Patricia

    2014-01-01

    Objective Healthcare reforms in the United States, including the Affordable Care and HITECH Acts, and the NCQA criteria for the Patient Centered Medical Home have promoted health information technology (HIT) and the integration of general medical and mental health services. These developments, which aim to improve chronic disease care have largely occurred in parallel, with little attention to the need for coordination. In this article, the fundamental connections between HIT and improvements in chronic disease management are explored. We use the evidence-based collaborative care model as an example, with attention to health literacy improvement for supporting patient engagement in care. Method A review of the literature was conducted to identify how HIT and collaborative care, an evidence-based model of chronic disease care, support each other. Results Five key principles of effective collaborative care are outlined: care is patient-centered, evidence-based, measurement-based, population-based, and accountable. The potential role of HIT in implementing each principle is discussed. Key features of the mobile health paradigm are described, including how they can extend evidence-based treatment beyond traditional clinical settings. Conclusion HIT, and particularly mobile health, can enhance collaborative care interventions, and thus improve the health of individuals and populations when deployed in integrated delivery systems. PMID:24963895

  16. Perceived Health Status and Utilization of Specialty Care: Racial and Ethnic Disparities in Patients with Chronic Diseases

    ERIC Educational Resources Information Center

    Glover, Saundra; Bellinger, Jessica D.; Bae, Sejong; Rivers, Patrick A.; Singh, Karan P.

    2010-01-01

    Objective: The objective of this study is to determine racial and ethnic variations in specialty care utilization based on (a) perceived health status and (b) chronic disease status. Methods: Variations in specialty care utilization, by perceived health and chronic disease status, were examined using the Commonwealth Fund Health Care Quality…

  17. Chronic disease management: a review of current performance across quality of care domains and opportunities for improving osteoarthritis care.

    PubMed

    Brand, Caroline A; Ackerman, Ilana N; Bohensky, Megan A; Bennell, Kim L

    2013-02-01

    Osteoarthritis is the most prevalent chronic joint disease worldwide. The incidence and prevalence are increasing as the population ages and lifestyle risk factors such as obesity increase. There are several evidence-based clinical practice guidelines available to guide clinician decision making, but there is evidence that care provided is suboptimal across all domains of quality: effectiveness, safety, timeliness and appropriateness, patient-centered care, and efficiency. System, clinician, and patient barriers to optimizing care need to be addressed. Innovative models designed to meet patient needs and those that harness social networks must be developed, especially to support those with mild to moderate disease.

  18. Gender differences in acute and chronic pain in the emergency department: results of the 2014 Academic Emergency Medicine consensus conference pain section.

    PubMed

    Musey, Paul I; Linnstaedt, Sarah D; Platts-Mills, Timothy F; Miner, James R; Bortsov, Andrey V; Safdar, Basmah; Bijur, Polly; Rosenau, Alex; Tsze, Daniel S; Chang, Andrew K; Dorai, Suprina; Engel, Kirsten G; Feldman, James A; Fusaro, Angela M; Lee, David C; Rosenberg, Mark; Keefe, Francis J; Peak, David A; Nam, Catherine S; Patel, Roma G; Fillingim, Roger B; McLean, Samuel A

    2014-12-01

    Pain is a leading public health problem in the United States, with an annual economic burden of more than $630 billion, and is one of the most common reasons that individuals seek emergency department (ED) care. There is a paucity of data regarding sex differences in the assessment and treatment of acute and chronic pain conditions in the ED. The Academic Emergency Medicine consensus conference convened in Dallas, Texas, in May 2014 to develop a research agenda to address this issue among others related to sex differences in the ED. Prior to the conference, experts and stakeholders from emergency medicine and the pain research field reviewed the current literature and identified eight candidate priority areas. At the conference, these eight areas were reviewed and all eight were ratified using a nominal group technique to build consensus. These priority areas were: 1) gender differences in the pharmacological and nonpharmacological interventions for pain, including differences in opioid tolerance, side effects, or misuse; 2) gender differences in pain severity perceptions, clinically meaningful differences in acute pain, and pain treatment preferences; 3) gender differences in pain outcomes of ED patients across the life span; 4) gender differences in the relationship between acute pain and acute psychological responses; 5) the influence of physician-patient gender differences and characteristics on the assessment and treatment of pain; 6) gender differences in the influence of acute stress and chronic stress on acute pain responses; 7) gender differences in biological mechanisms and molecular pathways mediating acute pain in ED populations; and 8) gender differences in biological mechanisms and molecular pathways mediating chronic pain development after trauma, stress, or acute illness exposure. These areas represent priority areas for future scientific inquiry, and gaining understanding in these will be essential to improving our understanding of sex and gender

  19. Gender Differences in Acute and Chronic Pain in the Emergency Department: Results of the 2014 Academic Emergency Medicine Consensus Conference Pain Section

    PubMed Central

    Musey, Paul I.; Linnstaedt, Sarah D.; Platts-Mills, Timothy F.; Miner, James R.; Bortsov, Andrey V.; Safdar, Basmah; Bijur, Polly; Rosenau, Alex; Tsze, Daniel S.; Chang, Andrew K.; Dorai, Suprina; Engel, Kirsten; Feldman, James A.; Fusaro, Angela M.; Lee, David C.; Rosenberg, Mark; Keefe, Francis J.; Peak, David A.; Nam, Catherine S.; Patel, Roma G.; Fillingim, Roger B.; McLean, Samuel A.

    2015-01-01

    Pain is a leading public health problem in the United States, with an annual economic burden of more than $630 billion, and is one of the most common reasons that individuals seek emergency department (ED) care. There is a paucity of data regarding sex differences in the assessment and treatment of acute and chronic pain conditions in the ED. The Academic Emergency Medicine consensus conference convened in Dallas, Texas in May of 2014 to develop a research agenda to address this issue among others related to sex differences in the ED. Prior to the conference, experts and stakeholders from emergency medicine and the pain research field reviewed the current literature and identified eight candidate priority areas. At the conference, these eight areas were reviewed and all eight were ratified using a nominal group technique to build consensus. These priority areas were: 1) gender differences in the pharmacologic and non-pharmacologic interventions for pain, including differences in opioid tolerance, side effects, or misuse; 2) gender differences in pain severity perceptions, clinically meaningful differences in acute pain, and pain treatment preferences; 3) gender differences in pain outcomes of ED patients across the lifespan; 4) gender differences in the relationship between acute pain and acute psychological responses; 5) the influence of physician-patient gender differences and characteristics on the assessment and treatment of pain; 6) gender differences in the influence of acute stress and chronic stress on acute pain responses; 7) gender differences in biologic mechanisms and molecular pathways mediating acute pain in ED populations; and 8) gender differences in biologic mechanisms and molecular pathways mediating chronic pain development after trauma, stress, or acute illness exposure. These areas represent priority areas for future scientific inquiry, and gaining understanding in these will be essential to improving our understanding of sex and gender

  20. The eHealth Enhanced Chronic Care Model: A Theory Derivation Approach

    PubMed Central

    Greenwood, Deborah A; Paterniti, Debora A; Ward, Deborah; Miller, Lisa M Soederberg

    2015-01-01

    Background Chronic illnesses are significant to individuals and costly to society. When systematically implemented, the well-established and tested Chronic Care Model (CCM) is shown to improve health outcomes for people with chronic conditions. Since the development of the original CCM, tremendous information management, communication, and technology advancements have been established. An opportunity exists to improve the time-honored CCM with clinically efficacious eHealth tools. Objective The first goal of this paper was to review research on eHealth tools that support self-management of chronic disease using the CCM. The second goal was to present a revised model, the eHealth Enhanced Chronic Care Model (eCCM), to show how eHealth tools can be used to increase efficiency of how patients manage their own chronic illnesses. Methods Using Theory Derivation processes, we identified a “parent theory”, the Chronic Care Model, and conducted a thorough review of the literature using CINAHL, Medline, OVID, EMBASE PsychINFO, Science Direct, as well as government reports, industry reports, legislation using search terms “CCM or Chronic Care Model” AND “eHealth” or the specific identified components of eHealth. Additionally, “Chronic Illness Self-management support” AND “Technology” AND several identified eHealth tools were also used as search terms. We then used a review of the literature and specific components of the CCM to create the eCCM. Results We identified 260 papers at the intersection of technology, chronic disease self-management support, the CCM, and eHealth and organized a high-quality subset (n=95) using the components of CCM, self-management support, delivery system design, clinical decision support, and clinical information systems. In general, results showed that eHealth tools make important contributions to chronic care and the CCM but that the model requires modification in several key areas. Specifically, (1) eHealth education is

  1. A Parent's Journey: Incorporating Principles of Palliative Care into Practice for Children with Chronic Neurologic Diseases.

    PubMed

    Brown, Allyson; Clark, Jonna D

    2015-09-01

    Rather than in conflict or in competition with the curative model of care, pediatric palliative care is a complementary and transdisciplinary approach used to optimize medical care for children with complex medical conditions. It provides care to the whole child, including physical, mental, and spiritual dimensions, in addition to support for the family. Through the voice of a parent, the following case-based discussion demonstrates how the fundamentals of palliative care medicine, when instituted early in the course of disease, can assist parents and families with shared medical decision making, ultimately improving the quality of life for children with life-limiting illnesses. Pediatric neurologists, as subspecialists who provide medical care for children with chronic and complex conditions, should consider invoking the principles of palliative care early in the course of a disease process, either through applying general facets or, if available, through consultation with a specialty palliative care service. PMID:26358425

  2. Patient-Assessed Chronic Illness Care (PACIC) scenario in an Indian homeopathic hospital.

    PubMed

    Koley, Munmun; Saha, Subhranil; Ghosh, Shubhamoy; Nag, Goutam; Kundu, Monojit; Mondal, Ramkumar; Purkait, Rajib; Patra, Supratim; Ali, Seikh Swaif

    2016-01-01

    Homeopathy research has focused on chronic conditions; however, the extent to which current homeopathic care is compliant with the Chronic Care Model (CCM) has been sparsely shown. As the Bengali Patient-Assessed Chronic Illness Care (PACIC)-20 was not available, the English questionnaire was translated and evaluated in a government homeopathic hospital in West Bengal, India. The translation was done in six steps, and approved by an expert committee. Face validity was tested by 15 people for comprehension. Test/retest reliability (reproducibility) was tested on 30 patients with chronic conditions. Internal consistency was tested in 377 patients suffering from various chronic conditions. The questionnaire showed acceptable test/retest reliability [intraclass correlation coefficient (ICC) 0.57-0.75; positive to strong positive correlations; p < 0.0001] for all domains and the total score, strong internal consistency (Cronbach's α = 0.86 overall and 0.65-0.82 for individual subscales), and large responsiveness (1.11). The overall mean score percentage seemed to be moderate at 69.5 ± 8.8%. Gender and presence of chronic conditions did not seem to vary significantly with PACIC-20 subscale scores (p > 0.05); however, monthly household income had a significant influence (p < 0.05) on the subscales except for "delivery system or practice design." Overall, chronic illness care appeared to be quite promising and CCM-compliant. The psychometric properties of the Bengali PACIC-20 were satisfactory, rendering it a valid and reliable instrument for assessing chronic illness care among the patients attending a homeopathic hospital.

  3. Patient-Assessed Chronic Illness Care (PACIC) scenario in an Indian homeopathic hospital

    PubMed Central

    Koley, Munmun; Saha, Subhranil; Ghosh, Shubhamoy; Nag, Goutam; Kundu, Monojit; Mondal, Ramkumar; Purkait, Rajib; Patra, Supratim; Ali, Seikh Swaif

    2015-01-01

    Homeopathy research has focused on chronic conditions; however, the extent to which current homeopathic care is compliant with the Chronic Care Model (CCM) has been sparsely shown. As the Bengali Patient-Assessed Chronic Illness Care (PACIC)-20 was not available, the English questionnaire was translated and evaluated in a government homeopathic hospital in West Bengal, India. The translation was done in six steps, and approved by an expert committee. Face validity was tested by 15 people for comprehension. Test/retest reliability (reproducibility) was tested on 30 patients with chronic conditions. Internal consistency was tested in 377 patients suffering from various chronic conditions. The questionnaire showed acceptable test/retest reliability [intraclass correlation coefficient (ICC) 0.57–0.75; positive to strong positive correlations; p < 0.0001] for all domains and the total score, strong internal consistency (Cronbach’s α = 0.86 overall and 0.65–0.82 for individual subscales), and large responsiveness (1.11). The overall mean score percentage seemed to be moderate at 69.5 ± 8.8%. Gender and presence of chronic conditions did not seem to vary significantly with PACIC-20 subscale scores (p > 0.05); however, monthly household income had a significant influence (p < 0.05) on the subscales except for “delivery system or practice design.” Overall, chronic illness care appeared to be quite promising and CCM-compliant. The psychometric properties of the Bengali PACIC-20 were satisfactory, rendering it a valid and reliable instrument for assessing chronic illness care among the patients attending a homeopathic hospital. PMID:26933640

  4. Integrated and consumer-directed care: a necessary paradigm shift for rural chronic ill health.

    PubMed

    Ranson, Nicole E; Terry, Daniel R; Glenister, Kristen; Adam, Bill R; Wright, Julian

    2016-01-01

    Chronic ill health has recently emerged as the most important health issue on a global scale. Rural communities are disproportionally affected by chronic ill health. Many health systems are centred on the management of acute conditions and are often poorly equipped to deal with chronic ill health. Cardiovascular disease (CVD) is one of the most prominent chronic ill health conditions and the principal cause of mortality worldwide. In this paper, CVD is used as an example to demonstrate the disparity between rural and urban experience of chronic ill health, access to medical care and clinical outcomes. Advances have been made to address chronic ill health through improving self-management strategies, health literacy and access to medical services. However, given the higher incidence of chronic health conditions and poorer clinical outcomes in rural communities, it is imperative that integrated health care emphasises greater collaboration between services. It is also vital that rural GPs are better supported to work with their patients, and that they use consumer-directed approaches to empower patients to direct and coordinate their own care.

  5. Chronic kidney disease care in the US safety net.

    PubMed

    Tuot, Delphine S; Grubbs, Vanessa

    2015-01-01

    The US Health Care System provides a patchwork of services, known as the safety net, for the uninsured, underinsured, and indigent populations who would otherwise have little access to health care services. Individuals who rely on safety-net facilities are from racial/ethnic minority groups, have low socioeconomic status, and often have low health literacy and/or limited English proficiency. They shoulder a disproportionate burden of CKD in the United States and experience excess CKD-associated morbidity and mortality. Suboptimal delivery of CKD care may be contributing and is an area of active translational research. Several initiatives that show promise in improving safety-net CKD care delivery include those that enhance diagnostic and management skills of primary care providers, rely on comprehensive care management programs led by nonphysicians, and leverage technology to enhance patient access to virtual nephrology expertise. Uncovering better ways to translate scientific evidence into practice for vulnerable patients with CKD is a formidable challenge that will require national surveillance of CKD quality measures across diverse ambulatory health systems, including safety nets. Only then will the nephrology community be to identify and share best practices to enhance health and mitigate disparities of care among patients with CKD. PMID:25573515

  6. The Experiences of Advanced Practice Nurses Caring for Patients with Substance Use Disorder and Chronic Pain.

    PubMed

    St Marie, Barbara

    2016-10-01

    Management of chronic pain is a challenge shared by healthcare providers in various clinical settings. The epidemic of opioid misuse has escalated this challenge. A gap exists in understanding barriers and facilitators to practices of advanced practice registered nurses (APRNs) caring for patients with chronic pain and substance use disorder (SUD). The purpose of this study was to examine the APRNs' experiences while caring for patients with coexisting SUD and chronic pain to help envision better ways to manage pain and direct educational initiatives. Qualitative narrative method. Telephone interviews. Twenty APRNs caring for patients with coexisting SUD and chronic pain were recruited nationwide through the American Society for Pain Management Nursing list serve. Semistructured interviews with thematic analysis. Participants identified 1) a shift of patients from other healthcare providers into the APRNs' practices; 2) barriers to accessing nonmedical modalities for managing pain, including insurance coverage, geographic location, and the patient's desire for only medication management; 3) the role of the APRN in caring for this population contained subthemes of educating and guiding patients through a process of change, applying risk strategies to keep patients safe, and educating colleagues on implementing risk management strategies while prescribing opioids. The APRNs identified barriers to providing care for patients with coexisting SUD and chronic pain. They also described the role of APRNs in providing focused education regarding risk management strategies for assessment, prescribing opioids to manage pain, and minimizing risk. PMID:27567096

  7. Prevalence and costs of chronic conditions in the VA health care system.

    PubMed

    Yu, Wei; Ravelo, Arliene; Wagner, Todd H; Phibbs, Ciaran S; Bhandari, Aman; Chen, Shuo; Barnett, Paul G

    2003-09-01

    Chronic conditions are among the most common causes of death and disability in the United States. Patients with such conditions receive disproportionate amounts of health care services and therefore cost more per capita than the average patient. This study assesses the prevalence among the Department of Veterans Affairs (VA) health care users and VA expenditures (costs) of 29 common chronic conditions. The authors used regression to identify the marginal impact of these conditions on total, inpatient, outpatient, and pharmacy costs. Excluding costs of contracted medical services at non-VA facilities, total VA health care expenditures in fiscal year 1999 (FY1999) were $14.3 billion. Among the 3.4 million VA patients in FY1999, 72 percent had 1 or more of the 29 chronic conditions, and these patients accounted for 96 percent of the total costs ($13.7 billion). In addition, 35 percent (1.2 million) of VA health care users had 3 or more of the 29 chronic conditions. These individuals accounted for 73 percent of the total cost. Overall, VA health care users have more chronic diseases than the general population. PMID:15095551

  8. [Care of the chronically ill: strategic challenge, macro-management and health policies].

    PubMed

    Gómez-Picard, Patricia; Fuster-Culebras, Juli

    2014-01-01

    The prevalence of chronic diseases is increasing, with the patients who suffer from them having greater need for healthcare. This fact forces a redirection in the health system, currently focused on the acute diseases, to achieve an efficient care. For this reason, it is necessary to work at all levels, starting with political decisions. These decisions should be based on the technical and scientific evidence available. Health planning is essential to establish care strategies, defining the actions to ensure the coordination and continuity of care, and also the redefinition of professional roles, where primary care nurses assume more competencies, becoming key professionals in the care of the chronic patient. The new model should include the professionalization of the management of health services. Information and communication technologies will play an important role in the development of strategies, but considering them as the tools that they are, allowing for the patient to be the focus of attention, and ensuring the privacy and the confidentiality.

  9. The U.S. health care system is in crisis: implications for academic medical centers and their missions.

    PubMed

    Lofgren, Richard; Karpf, Michael; Perman, Jay; Higdon, Courtney M

    2006-08-01

    The medical care system in the United States is in crisis. Health care costs are escalating and threatening coverage for millions of people. Concerns about the quality of care and patient safety are heightening; patients and payers now publicly share these concerns and want to make providers more accountable. Traditionally, the response to rising health care costs has been to modify reimbursement models and incentives. Currently there is a movement to shift the responsibility of cost containment to the patients. The authors express doubts about the overall effectiveness of this strategy and propose reengineering the health care system to improve quality and efficiency. Leaders of academic medical centers must understand the forces and dynamics of change, and the potential institutional response to improve the quality and efficiency of their delivery systems and to preserve their missions: clinical care, education, research, and community service. As they suggest the operational changes needed to respond to this evolving health care environment, the authors discuss the implications for the various missions. The graduates of training programs must be prepared to function within multidisciplinary teams and constantly seek ways to improve quality and efficiency to ensure that care is accessible, affordable, and safe. Academic medical centers need to expand their research agenda to develop more expertise in quality and process improvement research. Additionally, they must provide the leadership to foster the transition from an era of "managed care" to an era of "organized systems of care."

  10. Development of a questionnaire to evaluate practitioners’ confidence and knowledge in primary care in managing chronic kidney disease

    PubMed Central

    2014-01-01

    Background In the UK, chronic disease, including chronic kidney disease (CKD) is largely managed in primary care. We developed a tool to assess practitioner confidence and knowledge in managing CKD compared to other chronic diseases. This questionnaire was part of a cluster randomised quality improvement interventions in chronic kidney disease (QICKD; ISRCTN56023731). Methods The questionnaire was developed by family physicians, primary care nurses, academics and renal specialists. We conducted three focus groups (n = 7, 6, and 8) to refine the questionnaire using groups of general practitioners, practice nurses and trainees in general practice. We used paper based versions to develop the questionnaire and online surveys to test it. Practitioners in a group of volunteer, trial practices received the questionnaire twice. We measured its reliability using Cohen’s Kappa (K). Results The practitioners in the focus groups reached a consensus as to the key elements to include in the instrument. We achieved a 73.1% (n = 57/78) initial response rate for our questionnaire; of these 57, 54 completed the questionnaire a second time. Family physicians made up the largest single group of respondents (47.4%, n = 27). Initial response showed more female (64.9%, n = 37) than male (35.1%, n = 20) respondents. The reliability results from retesting showed that there was moderate agreement (k > 0.4) on all questions; with many showing substantial agreement (k > 0.6). There was substantial agreement in the questions about loop diuretics (k = 0.608, CI 0.432-0.784, p < 0.001), confidence in managing hypertension (k = 0.628, 95%CI 0.452-0.804, p < 0.001), diastolic blood pressure treatment thresholds in CKD (k = 0.608, 95%CI 0.436-0.780, p < 0.001) and the rate of decline of eGFR that would prompt referral (k = 0.764, 95%CI 0.603-0.925, p < 0.001). Conclusion The QICKD-CCQ is a reliable instrument for measuring confidence and

  11. Chronic Kidney Disease (CKD) Treatment Burden Among Low-Income Primary Care Patients

    PubMed Central

    Kahn, Linda S.; Vest, Bonnie M.; Madurai, Nethra; Singh, Ranjit; York, Trevor R.M.; Cipparone, Charlotte W.; Reilly, Sarah; Malik, Khalid S.; Fox, Chester H.

    2015-01-01

    Objective This study explored the self-management strategies and treatment burden experienced by low income US primary care patients with chronic kidney disease. Methods Semi-structured interviews were conducted with 34 patients from two primary care practices on Buffalo’s East Side, a low-income community. Qualitative analysis was undertaken using an inductive thematic content analysis approach. We applied Normalization Process Theory (NPT) to the concept of treatment burden to interpret and categorize our findings. Results The sample was predominantly African-American (79%) and female (59%). Most patients (79%) had a diagnosis of Stage 3 CKD. Four major themes were identified corresponding to NPT and treatment burden: (1) Coherence – making sense of CKD; (2) Cognitive participation – enlisting support and organizing personal resources; (3) Collective action – self-management work; and (4) Reflexive monitoring – further refining chronic illness self-care in the context of CKD. For each component we identified barriers hindering patients’ ability to accomplish the necessary tasks. Conclusions Our findings highlight the substantial treatment burden faced by inner-city primary care patients self-managing CKD in combination with other chronic illnesses. Health care providers’ awareness of treatment burden can inform the development of person-centered care plans that can help patients to better manage their chronic illnesses. PMID:25416418

  12. PACE: has it changed the chronic care paradigm?

    PubMed

    Lynch, Marty; Hernandez, Mauro; Estes, Carroll

    2008-01-01

    The Program of All-inclusive Care for the Elderly (PACE) grew out of a small community organization in San Francisco and has been replicated by non-profit organizations in a number of other communities across the country. The authors review the successes of PACE as reported in the literature and discuss reasons for its limited growth as well as its significant influence on state and federal long term care policy. They argue that PACE has significantly changed how we think of long term care through its pioneering work fully integrating medical and long term care. PACE has also provided an influential model for breaking down the funding silos that characterize the medical and long term care services arena. State Medicaid agencies and Medicare have learned from PACE. Health plans and private long term insurers may also still learn from PACE. However, the fact that only a little more than 10,000 elders have enrolled in PACE nationwide prevents the authors from finding that PACE has brought about significant structural change in a long term care industry dominated by for-profit nursing homes.

  13. Does trust in health care influence the use of complementary and alternative medicine by chronically ill people?

    PubMed Central

    van den Brink-Muinen, A; Rijken, PM

    2006-01-01

    Background People's trust in health care and health care professionals is essential for the effectiveness of health care, especially for chronically ill people, since chronic diseases are by definition (partly) incurable. Therefore, it may be understandable that chronically ill people turn to complementary and alternative medicine (CAM), often in addition to regular care. Chronically ill people use CAM two to five times more often than non-chronically ill people. The trust of chronically ill people in health care and health care professionals and the relationship of this with CAM use have not been reported until now. In this study, we examine the influence of chronically ill people's trust in health care and health care professionals on CAM use. Methods The present sample comprises respondents of the 'Panel of Patients with Chronic Diseases' (PPCD). Patients (≥25 years) were selected by GPs. A total of 1,625 chronically ill people were included. Trust and CAM use was measured by a written questionnaire. Statistical analyses were t tests for independent samples, Chi-square and one-way analysis of variance, and logistic regression analysis. Results Chronically ill people have a relatively low level of trust in future health care. They trust certified alternative practitioners less than regular health care professionals, and non-certified alternative practitioners less still. The less trust patients have in future health care, the more they will be inclined to use CAM, when controlling for socio-demographic and disease characteristics. Conclusion Trust in future health care is a significant predictor of CAM use. Chronically ill people's use of CAM may increase in the near future. Health policy makers should, therefore, be alert to the quality of practising alternative practitioners, for example by insisting on professional certification. Equally, good quality may increase people's trust in public health care. PMID:16848897

  14. Systematic review: unmet supportive care needs in people diagnosed with chronic liver disease

    PubMed Central

    Valery, Patricia C; Powell, Elizabeth; Moses, Neta; Volk, Michael L; McPhail, Steven M; Clark, Paul J; Martin, Jennifer

    2015-01-01

    Objective People with chronic liver disease, particularly those with decompensated cirrhosis, experience several potentially debilitating complications that can have a significant impact on activities of daily living and quality of life. These impairments combined with the associated complex treatment mean that they are faced with specific and high levels of supportive care needs. We aimed to review reported perspectives, experiences and concerns of people with chronic liver disease worldwide. This information is necessary to guide development of policies around supportive needs screening tools and to enable prioritisation of support services for these patients. Design Systematic searches of PubMed, MEDLINE, CINAHL and PsycINFO from the earliest records until 19 September 2014. Data were extracted using standardised forms. A qualitative, descriptive approach was utilised to analyse and synthesise data. Results The initial search yielded 2598 reports: 26 studies reporting supportive care needs among patients with chronic liver disease were included, but few of them were patient-reported needs, none used a validated liver disease-specific supportive care need assessment instrument, and only three included patients with cirrhosis. Five key domains of supportive care needs were identified: informational or educational (eg, educational material, educational sessions), practical (eg, daily living), physical (eg, controlling pruritus and fatigue), patient care and support (eg, support groups), and psychological (eg, anxiety, sadness). Conclusions While several key domains of supportive care needs were identified, most studies included hepatitis patients. There is a paucity of literature describing the supportive care needs of the chronic liver disease population likely to have the most needs—namely those with cirrhosis. Assessing the supportive care needs of people with chronic liver disease have potential utility in clinical practice for facilitating timely referrals

  15. Management of adults with paediatric-onset chronic liver disease: strategic issues for transition care.

    PubMed

    Vajro, Pietro; Ferrante, Lorenza; Lenta, Selvaggia; Mandato, Claudia; Persico, Marcello

    2014-04-01

    Advances in the management of children with chronic liver disease have enabled many to survive into adulthood with or without their native livers, so that the most common of these conditions are becoming increasingly common in adult hepatology practice. Because the aetiologies of chronic liver disease in children may vary significantly from those in adulthood, adults with paediatric-onset chronic liver disease may often present with clinical manifestations unfamiliar to their adulthood physician. Transition of medical care to adult practice requires that the adulthood medical staff (primary physicians and subspecialists) have a comprehensive knowledge of childhood liver disease and their implications, and of the differences in caring for these patients. Pending still unavailable Scientific Society guidelines, this article examines causes, presentation modes, evaluation, management, and complications of the main paediatric-onset chronic liver diseases, and discusses key issues to aid in planning a program of transition from paediatric to adult patients.

  16. A Chronic Disease State Simulation in an Ambulatory Care Elective Course

    PubMed Central

    Roberson, Cindy Leslie A.; Prasad-Reddy, Lalita

    2015-01-01

    Objective. To implement a chronic disease state simulation in an ambulatory care elective course and to assess the simulation’s impact on students’ perceptions of their empathy toward patients and of their counseling skills. Design. The chronic disease state simulation occurred over 2 weeks. Students alternated playing the role of patient and pharmacist. As patients, students adhered to medication regimens, lifestyle modifications, and blood glucose or blood pressure monitoring. As pharmacists, students conducted patient interviews, and provided education and counseling. Empathy and counseling skills were assessed through course surveys, written reflections, and SOAP notes. Assessment. Results from a cohort of 130 students indicated the simulation enhanced students’ perceptions of their abilities to empathize with and counsel patients with chronic diseases. Conclusion. The chronic disease state simulation provides a novel approach to develop skills needed for working with complex patient cases in ambulatory care settings. PMID:26839423

  17. Health Systems Innovation at Academic Health Centers: Leading in a New Era of Health Care Delivery.

    PubMed

    Ellner, Andrew L; Stout, Somava; Sullivan, Erin E; Griffiths, Elizabeth P; Mountjoy, Ashlin; Phillips, Russell S

    2015-07-01

    Challenged by demands to reduce costs and improve service delivery, the U.S. health care system requires transformational change. Health systems innovation is defined broadly as novel ideas, products, services, and processes-including new ways to promote healthy behaviors and better integrate health services with public health and other social services-which achieve better health outcomes and/or patient experience at equal or lower cost. Academic health centers (AHCs) have an opportunity to focus their considerable influence and expertise on health systems innovation to create new approaches to service delivery and to nurture leaders of transformation. AHCs have traditionally used their promotions criteria to signal their values; creating a health systems innovator promotion track could be a critical step towards creating opportunities for innovators in academic medicine. In this Perspective, the authors review publicly available promotions materials at top-ranked medical schools and find that while criteria for advancement increasingly recognize systems innovation, there is a lack of specificity on metrics beyond the traditional yardstick of peer-reviewed publications. In addition to new promotions pathways and alternative evidence for the impact of scholarship, other approaches to fostering health systems innovation at AHCs include more robust funding for career development in health systems innovation, new curricula to enable trainees to develop skills in health systems innovation, and new ways for innovators to disseminate their work. AHCs that foster health systems innovation could meet a critical need to contribute both to the sustainability of our health care system and to AHCs' continued leadership role within it.

  18. Health Systems Innovation at Academic Health Centers: Leading in a New Era of Health Care Delivery.

    PubMed

    Ellner, Andrew L; Stout, Somava; Sullivan, Erin E; Griffiths, Elizabeth P; Mountjoy, Ashlin; Phillips, Russell S

    2015-07-01

    Challenged by demands to reduce costs and improve service delivery, the U.S. health care system requires transformational change. Health systems innovation is defined broadly as novel ideas, products, services, and processes-including new ways to promote healthy behaviors and better integrate health services with public health and other social services-which achieve better health outcomes and/or patient experience at equal or lower cost. Academic health centers (AHCs) have an opportunity to focus their considerable influence and expertise on health systems innovation to create new approaches to service delivery and to nurture leaders of transformation. AHCs have traditionally used their promotions criteria to signal their values; creating a health systems innovator promotion track could be a critical step towards creating opportunities for innovators in academic medicine. In this Perspective, the authors review publicly available promotions materials at top-ranked medical schools and find that while criteria for advancement increasingly recognize systems innovation, there is a lack of specificity on metrics beyond the traditional yardstick of peer-reviewed publications. In addition to new promotions pathways and alternative evidence for the impact of scholarship, other approaches to fostering health systems innovation at AHCs include more robust funding for career development in health systems innovation, new curricula to enable trainees to develop skills in health systems innovation, and new ways for innovators to disseminate their work. AHCs that foster health systems innovation could meet a critical need to contribute both to the sustainability of our health care system and to AHCs' continued leadership role within it. PMID:25738387

  19. Socioeconomic Status and Dissatisfaction With Health Care Among Chronically Ill African Americans

    PubMed Central

    Becker, Gay; Newsom, Edwina

    2003-01-01

    Addressing differences in social class is critical to an examination of racial disparities in health care. Low socioeconomic status is an important determinant of access to health care. Results from a qualitative, in-depth interview study of 60 African Americans who had one or more chronic illnesses found that low-income respondents expressed much greater dissatisfaction with health care than did middle-income respondents. Low socioeconomic status has potentially deadly consequences for several reasons: its associations with other determinants of health status, its relationship to health insurance or the absence thereof, and the constraints on care at sites serving people who have low incomes. PMID:12721135

  20. Value-based reengineering: twenty-first century chronic care models.

    PubMed

    Graf, Thomas R; Bloom, Frederick J; Tomcavage, Janet; Davis, Duane E

    2012-06-01

    The need for improved models of chronic care is great and will become critical over the next years as the Medicare-aged population doubles. Many promising models have been developed by outstanding groups across the country. This article reviews key strategies used by successful models in chronic disease management and discusses in detail how Geisinger has evolved and organized its cohesive delivery model. PMID:22608864

  1. Opioid prescribing for chronic nonmalignant pain in primary care: challenges and solutions.

    PubMed

    Olsen, Yngvild; Daumit, Gail L

    2004-01-01

    Evaluating and treating patients with chronic nonmalignant pain, especially with opioid medications, often causes discomfort on the part of primary care physicians. A number of patient-, physician-, and system-related issues converge to make treating chronic pain a complex matter. Patient-related issues include an inability to define a clear anatomic cause for patients' pain, comorbid psychiatric conditions, and past and current substance abuse. Physicians lack training on the appropriate evaluation and treatment of chronic nonmalignant pain, fear creating addicts, and often face intense pharmaceutical industry pressure to prescribe medications. A paucity of practical clinical practice guidelines, controversy over the effectiveness of opioids on chronic nonmalignant pain, and concern about potential legal and regulatory ramifications add to the complexity of caring for these patients. Possible multifaceted solutions exist to minimize provider discomfort and improve their ability to treat patients appropriately. Examples include comprehensive, practical multidimensional guidelines on the evaluation and treatment of chronic nonmalignant pain, Web-based teleconferenced consultations with subspecialists, reduced pharmaceutical pressure, enhanced continuing medical education and pregraduate training, multispecialty coordinated care of patients with adequate reimbursement for such care, and physician access to state-based systems to track opioid prescriptions. PMID:15248372

  2. Practitioner perspectives from seven health professional groups on core competencies in the context of chronic care.

    PubMed

    Fouche, Christa; Kenealy, Timothy; Mace, Jennifer; Shaw, John

    2014-11-01

    The prevalence of chronic illness is growing worldwide and management is increasingly undertaken by interprofessional teams, yet education is still generally provided in separate professions. The aim of this study was to explore the perspectives of New Zealand healthcare practitioners from seven professional groups involved in chronic care (general practice medicine, nursing, occupational therapy, pharmacy, physiotherapy, social work, and speech language therapy) on the core competencies required of those working in this area. The study was set in the context of the chronic care and shared decision-making (SDM) models. The core competencies for chronic care practitioners proposed by the World Health Organisation were used to shape the research questions. Focus groups with expert clinicians (n = 20) and semi-structured interviews with practitioners (n = 32) were undertaken. Findings indicated a high level of agreement that the core competencies were appropriate and relevant for chronic care practitioners but that many educational and practice gaps existed and interprofessional education in New Zealand was not currently addressing these gaps. Among the key issues highlighted for attention by educators and policy-makers were the following: teams and teamwork, professional roles and responsibilities, interprofessional communication, cultural competence, better engagement with patients, families, and carers, and common systems, information sharing and confidentiality.

  3. Quality of chronic kidney disease management in primary care: a retrospective study

    PubMed Central

    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

    Background Early detection and appropriate management of chronic kidney disease (CKD) in primary care are essential to reduce morbidity and mortality. Aim 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. Design and setting Retrospective study using data between 2008 and 2011 from 47 general practices (207 469 patients of whom 162 562 were adults). Method 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. Results 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. Conclusion 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. Key pointsQuality 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

  4. Leveraging HIV platforms to work toward comprehensive primary care in rural Malawi: the Integrated Chronic Care Clinic.

    PubMed

    Wroe, Emily B; Kalanga, Noel; Mailosi, Bright; Mwalwanda, Stanley; Kachimanga, Chiyembekezo; Nyangulu, Kondwani; Dunbar, Elizabeth; Kerr, Lila; Nazimera, Lawrence; Dullie, Luckson

    2015-12-01

    This case study describes an integrated chronic care clinic that utilizes a robust HIV program as a platform for NCD screening and treatment. A unique model, the integrated chronic care clinic provides longitudinal care for patients with an array of chronic diseases including HIV and common NCDs, allowing for a single visit for all of a patient's conditions. Set in Malawi's remote Neno District, this clinic structure aims to (1) increase access to care for NCD patients, (2) maximize efficiency given the severe human resource shortages, and (3) replicate strong HIV outcomes for patients with other chronic conditions. The goal is to increase the number of health facilities in Neno capable of fully delivering Malawi's Essential Health Package, the set of cost-effective interventions endorsed by Malawi MOH to reduce burden of disease and leading causes of death. While implementation is ongoing and processes are evolving, this model of healthcare delivery has already improved the accessibility of NCD care by allowing patients to have all of their chronic conditions treated on the same day at their nearest health facility, notably without additional investment of human and financial resources. Currently, 6781 patients on antiretroviral therapy and 721 patients with NCDs are benefitting, including 379 with hypertension, 187 with asthma, 144 with epilepsy, and 76 with diabetes. Among the NCD patient population, 15.1% are HIV-positive. Success hinged largely on several factors, including clear leadership and staff ownership of their specific duties, and a well-defined and uniform patient flow process. Furthermore, deliberate and regular conversations about challenges allowed for constant iteration and improvement of processes. Moving forward, several tasks remain. We are refining the data management process to further consolidate medical records, along with integrating our tracking processes for clients who miss appointments. Additionally, we are exploring opportunities for

  5. Engaging Patients in Online Self-Care Technologies for Chronic Disease Management.

    PubMed

    Picton, Peter; Wiljer, David; Urowitz, Sara; Cafazzo, Joseph A

    2016-01-01

    A common perception is that the use of Internet-based self-care systems is best suited for a younger, tech-proficient population, and that these systems will increase the burden on patients with complex chronic conditions. The study stratified patients with diabetes into three regimens of use of an Internet-based diabetes self-care portal. Results show that patients were more likely to adhere to a diurnal regimen than a variable regimen, and older patients, over the age of 60, were more adherent than younger patients, regardless of regimen. This suggests that common misconceptions should be reconsidered when prescribing Internet-based interventions for patients with chronic illness.

  6. Integrated care for chronic migraine patients: epidemiology, burden, diagnosis and treatment options.

    PubMed

    Diener, Hans-Christoph; Solbach, Kasja; Holle, Dagny; Gaul, Charly

    2015-08-01

    Migraine is a common neurological disorder, characterised by severe headaches. Epidemiological studies in the USA and Europe have identified a subgroup of migraine patients with chronic migraine. Chronic migraine is defined as ≥15 headache days per month for ≥3 months, in which ≥8 days of the month meet criteria for migraine with or without aura, or respond to treatment specifically for migraine. Chronic migraine is associated with a higher burden of disease, more severe psychiatric comorbidity, greater use of healthcare resources, and higher overall costs than episodic migraine (<15 headache days per month). There is a strong need to improve diagnosis and therapeutic treatment of chronic migraine. Primary care physicians, as well as hospital-based physicians, are integral to the identification and treatment of these patients. The latest epidemiological data, as well as treatment options for chronic migraine patients, are reviewed here.

  7. [Adding value to the care at the final stage of chronic diseases].

    PubMed

    Vacas Guerrero, Mercedes

    2014-01-01

    There is a growing number of people with advanced chronic health conditions and with palliative care needs who die without their health and social needs satisfied. This is enough to redefine the traditional models of care in order to focus on the person, rather than on the disease. In these new models, the important role of nursing is unquestionably to promote an approach based on comprehensive care, coordination and continuity, and at a social health level appropriate to respond to the care of patients who require complex long-term care. The nurse contribution in the end stages of chronic conditions must be in the value of care. Taking care of someone is to be concerned about them. And this is related to attitude, commitment and responsibility. In the care of patients who live in a situation of extreme vulnerability, it is possible to help them feel warmth, confident, relieve their suffering, respect their autonomy, and help them them find sense and hope, through daily tasks. With gestures, words and facial expressions that go with this care, it is possible to preserve patient dignity.

  8. Medicare and chronic disease management: integrated care as an exceptional circumstance?

    PubMed

    Taylor, Michael J; Swerissen, Hal

    2010-05-01

    Chronic disease represents a significant challenge to the design and reform of the Australian healthcare system. The Medicare Benefits Schedule (MBS) provides a framework of numerous chronic disease management programs; however, their use at the patient level is complex. This analysis of the MBS chronic disease framework uses a hypothetical case study of a diabetic patient (with disease-related complications and a complex psychosocial background) to illustrate the difficulties in delivering appropriate multidisciplinary chronic disease care under the MBS. The complexities at each step - from care planning, service provision, and monitoring and review - are described, as are the intricacies involved in providing patient care under different MBS programs as well as those in the broader health and community care system. As demonstrated by this case study, under certain circumstances the provision of truly integrated care to this hypothetical patient would constitute an 'exceptional circumstance' under the MBS. Although quality improvement efforts can improve functioning within the limitations of the current system, system-wide reforms are necessary to overcome complexity and fragmentation.

  9. Social Determinants of Health, the Chronic Care Model, and Systemic Lupus Erythematosus

    PubMed Central

    Williams, Edith M.; Ortiz, Kasim; Browne, Teri

    2014-01-01

    Systemic lupus erythematosus (SLE) is a chronic inflammatory rheumatic disease that disproportionately affects African Americans and other minorities in the USA. Public health attention to SLE has been predominantly epidemiological. To better understand the effects of this cumulative disadvantage and ultimately improve the delivery of care, specifically in the context of SLE, we propose that more research attention to the social determinants of SLE is warranted and more transdisciplinary approaches are necessary to appropriately address identified social determinants of SLE. Further, we suggest drawing from the chronic care model (CCM) for an understanding of how community-level factors may exacerbate disparities explored within social determinant frameworks or facilitate better delivery of care for SLE patients. Grounded in social determinants of health (SDH) frameworks and the CCM, this paper presents issues relative to accessibility to suggest that more transdisciplinary research focused on the role of place could improve care for SLE patients, particularly the most vulnerable patients. It is our hope that this paper will serve as a springboard for future studies to more effectively connect social determinants of health with the chronic care model and thus more comprehensively address adverse health trajectories in SLE and other chronic conditions. PMID:26464854

  10. Medicare and chronic disease management: integrated care as an exceptional circumstance?

    PubMed

    Taylor, Michael J; Swerissen, Hal

    2010-05-01

    Chronic disease represents a significant challenge to the design and reform of the Australian healthcare system. The Medicare Benefits Schedule (MBS) provides a framework of numerous chronic disease management programs; however, their use at the patient level is complex. This analysis of the MBS chronic disease framework uses a hypothetical case study of a diabetic patient (with disease-related complications and a complex psychosocial background) to illustrate the difficulties in delivering appropriate multidisciplinary chronic disease care under the MBS. The complexities at each step - from care planning, service provision, and monitoring and review - are described, as are the intricacies involved in providing patient care under different MBS programs as well as those in the broader health and community care system. As demonstrated by this case study, under certain circumstances the provision of truly integrated care to this hypothetical patient would constitute an 'exceptional circumstance' under the MBS. Although quality improvement efforts can improve functioning within the limitations of the current system, system-wide reforms are necessary to overcome complexity and fragmentation. PMID:20497727

  11. [Social and organizational innovation to tackle the challenge of integrated care of the chronically ill].

    PubMed

    Nuño-Solinís, Roberto

    2014-01-01

    The increase in life expectancy, coupled with other factors, has led to an increase in the prevalence of chronic diseases and multiple morbidity. This has led to the need to develop new health and social care models, which will allow managing these efficiently and in a sustainable manner. In particular, there seems to be consensus on the need to move towards integrated, patient-centered, and more proactive care. Thus, in recent years, chronic care models have been developed at international, national and regional level, as well as introducing strategies to tackle the challenge of chronic illness. However, the implementation of actions facilitating the change towards this new model of care does not seem to be an easy task. This paper presents some of the strategic lines and initiatives carried out by the Department of Health of the Basque Government. These actions can be described within a social and organizational innovation framework, as a means for effective implementation of interventions and strategies that shape the model required for the improved care of chronic illnesses within a universal and tax-funded health system.

  12. Contextual barriers to implementation in primary care: an ethnographic study of a programme to improve chronic kidney disease care

    PubMed Central

    Armstrong, Natalie; Herbert, Georgia; Brewster, Liz

    2016-01-01

    Background. Context is important in implementation—we know that what works in one setting may not work in the same way elsewhere. Primary care has been described as a unique context both in relation to the care delivered and efforts to carry out research and implementation of new evidence. Objective. To explore some of the distinctive features of the primary care environment that may influence implementation. Methods. We conducted an ethnographic study involving observations, interviews and documentary analysis of the ENABLE-CKD project, which involved general practices implementing a chronic kidney disease care bundle and offering self-management support tools to patients. Analysis was based on the constant comparative method. Results. Four elements of the primary care environment emerged as important influences on the extent to which implementation was successful. First, the nature of delivering care in this setting meant that prioritizing one condition over others was problematic. Second, the lack of alignment with financial and other incentives affected engagement. Third, the project team lacked mechanisms through which engagement could be mandated. Fourth, working relationships within practices impacted on engagement. Conclusions. Those seeking to implement interventions in primary care need to consider the particular context if they are to secure successful implementation. We suggest that there are particular kinds of interventions, which may be best suited to the primary care context. PMID:27297465

  13. Nurse-led management of chronic disease in a residential care setting.

    PubMed

    Neylon, Julie

    2015-11-01

    Introduction of the advanced nurse practitioner (ANP) role has enabled nurses to develop their clinical knowledge and skills, providing greater service provision and improved access to healthcare services. It can also help with the challenges of providing care to an ageing population in primary care. This article reports on the evaluation of an ANP-led clinic in two residential care homes that provides annual reviews for chronic disease management (CDM). A mixed method approach was used to evaluate the service using clinical data obtained from the electronic patient record system and software and patient satisfaction questionnaires. The number of patients receiving CDM reviews in the homes increased as a result of the clinic. Completed satisfaction questionnaires further demonstrated patients' satisfaction and willingness to engage with the service. The service highlights the ANP's effectiveness in managing residential care home patients with chronic diseases and improving their access to healthcare services.

  14. Improving chronic care delivery and outcomes: the impact of the cystic fibrosis Care Center Network.

    PubMed

    Mogayzel, Peter J; Dunitz, Jordan; Marrow, Laura C; Hazle, Leslie A

    2014-04-01

    Cystic fibrosis (CF) is a multisystem, life-shortening genetic disease that requires complex care. To facilitate this expert, multidisciplinary care, the CF Foundation established a Care Center Network and accredited the first care centres in 1961. This model of care brings together physicians and specialists from other disciplines to provide care, facilitate basic and clinical research, and educate the next generation of providers. Although the Care Center Network has been invaluable in achieving substantial gains in survival and quality of life, additional opportunities for improvements in CF care exist. In 1999, analysis of data from the CF Foundation's Patient Registry detected variation in care practices and outcomes across centres, identifying opportunities for improvement. In 2002, the CF Foundation launched a comprehensive quality improvement (QI) initiative to enhance care by assembling national experts to develop a strategic plan to disseminate QI training and processes throughout the Care Center Network. The QI strategies included developing leadership (nationally and within each care centre), identifying best CF care practices, and incorporating people with CF and their families into improvement efforts. The goal was to improve the care for every person with CF in the USA. Multiple tactics were undertaken to implement the strategic plan and disseminate QI training and tools throughout the Care Center Network. In addition, strategies to foster collaboration between care centre staff and individuals with CF and their families became a cornerstone of QI efforts. Today it is clear that the application of QI principles within the CF Care Center Network has improved adherence to clinical guidelines and achievement of important health outcomes.

  15. Secondary transmission of varicella vaccine virus in a chronic care facility for children.

    PubMed

    Grossberg, Richard; Harpaz, Rafael; Rubtcova, Elena; Loparev, Vladimir; Seward, Jane F; Schmid, D Scott

    2006-06-01

    A 16-year-old varicella-seronegative resident at a chronic care facility received varicella vaccine; 15 days later he developed severe varicella. Subsequently, a 13-year-old resident and a 39-year-old health care worker developed mild varicella. We demonstrate that vaccine-strain virus was transmitted to both persons, and that transmission included at least 2 variant vaccine strains.

  16. Pathways towards chronic care-focused healthcare systems: evidence from Spain.

    PubMed

    García-Goñi, Manuel; Hernández-Quevedo, Cristina; Nuño-Solinís, Roberto; Paolucci, Francesco

    2012-12-01

    Increasing healthcare expenditure is a matter of concern in many countries, particularly in relation to the underlying drivers of such escalation that include ageing, medical innovation, and changes in the burden of disease, such as the growing prevalence of chronic diseases. Most healthcare systems in developed countries have been designed to 'cure' acute episodes, rather than to 'manage' chronic conditions, and therefore they are not suitably or efficiently organized to respond to the changing needs and preferences of users. New models of chronic care provision have been developed to respond to the changing burden of disease and there is already considerable practical experience in several different countries showing their advantages but also the difficulties associated with their implementation. In this paper, we focus on the Spanish experience in terms of policy changes and pilot studies focused on testing the feasibility of moving towards chronic care models. In particular, we discuss a framework that identifies and analyses ten key prerequisites to achieving high performing chronic care-based healthcare systems and apply it to the current Spanish National Health System (NHS). We find that the design of the Spanish NHS already meets some of these pre-requisites. However, other features are still in their early stages of development or are being applied only in limited geographical and clinical contexts. We outline the policies that are being implemented and the pathway that the Spanish NHS is taking to address the crucial challenge of the transition towards an optimal health system focused on chronic care. Given the current evidence and trends, we expect that the pathway for developing a chronicity strategy being followed by the Spanish NHS will significantly transform its current healthcare delivery model in the next few years.

  17. The efficiency of chronic disease care in sub-Saharan Africa.

    PubMed

    Geldsetzer, Pascal; Ortblad, Katrina; Bärnighausen, Till

    2016-01-01

    The number of people needing chronic disease care is projected to increase in sub-Saharan Africa as a result of expanding human immunodeficiency virus (HIV) treatment coverage, rising life expectancies, and lifestyle changes. Using nationally representative data of healthcare facilities, Di Giorgio et al. found that many HIV clinics in Kenya, Uganda, and Zambia appear to have considerable untapped capacity to provide care for additional patients. These findings highlight the potential for increasing the efficiency of clinical processes for chronic disease care at the facility level. Important questions for future research are how estimates of comparative technical efficiency across facilities change, when they are adjusted for quality of care and the composition of patients by care complexity. Looking ahead, substantial research investment will be needed to ensure that we do not forgo the opportunity to learn how efficiency changes, as chronic care is becoming increasingly differentiated by patient type and integrated across diseases and health systems functions.Please see related article: http://bmcmedicine.biomedcentral.com/articles/10.1186/s12916-016-0653-z. PMID:27566531

  18. International care models for chronic kidney disease: methods and economics--United States.

    PubMed

    Crooks, Peter

    2004-01-01

    In the United States, there is a major chronic kidney disease (CKD) problem with over 8 million adults having stage 3 or 4 CKD. There is good medical evidence that many of these patients can benefit from focused interventions. And while there are strong theoretical reasons to believe these interventions are cost-effective, there are little published data to back up this assertion. However, despite the lack of financial data proving cost-effectiveness and against the background of a disorganized health care system in the US, some models of CKD care are being employed. At the present time, the most comprehensive models of care in the US are emerging in vertically integrated health care programs. Other models of care are developing in the setting of managed care health plans that employ CKD disease management programs, either developed internally or in partnership with renal disease management companies.

  19. Environmental control systems in chronic care hospitals and nursing homes.

    PubMed

    Symington, D C; Lywood, D W; Lawson, J S; MacLean, J

    1986-05-01

    Fifteen severely disabled people residing in institutions were provided with a simple environmental control system which performed five different functions. The disabled people used the equipment an average of ten times a day. Two hours of nursing care by nursing staff would have been required to perform these functions. The cost of the equipment was $1.35 a day. Both the residents and the nursing staff reacted favorably to this innovation. The main benefits which resulted were a heightened sense of independence on the part of the disabled people and a reduction of frustration levels of both the residents and the nursing staff. A considerable savings in nursing care was also achieved. PMID:3085634

  20. Iron deficiency intravenous substitution in a Swiss academic primary care division: analysis of practices

    PubMed Central

    Varcher, Monica; Zisimopoulou, Sofia; Braillard, Olivia; Favrat, Bernard; Junod Perron, Noëlle

    2016-01-01

    Background Iron deficiency is a common problem in primary care and is usually treated with oral iron substitution. With the recent simplification of intravenous (IV) iron administration (ferric carboxymaltose) and its approval in many countries for iron deficiency, physicians may be inclined to overutilize it as a first-line substitution. Objective The aim of this study was to evaluate iron deficiency management and substitution practices in an academic primary care division 5 years after ferric carboxymaltose was approved for treatment of iron deficiency in Switzerland. Methods All patients treated for iron deficiency during March and April 2012 at the Geneva University Division of Primary Care were identified. Their medical files were analyzed for information, including initial ferritin value, reasons for the investigation of iron levels, suspected etiology, type of treatment initiated, and clinical and biological follow-up. Findings were assessed using an algorithm for iron deficiency management based on a literature review. Results Out of 1,671 patients, 93 were treated for iron deficiency. Median patients’ age was 40 years and 92.5% (n=86) were female. The average ferritin value was 17.2 μg/L (standard deviation 13.3 μg/L). The reasons for the investigation of iron levels were documented in 82% and the suspected etiology for iron deficiency was reported in 67%. Seventy percent of the patients received oral treatment, 14% IV treatment, and 16% both. The reasons for IV treatment as first- and second-line treatment were reported in 57% and 95%, respectively. Clinical and biological follow-up was planned in less than two-thirds of the cases. Conclusion There was no clear overutilization of IV iron substitution. However, several steps of the iron deficiency management were not optimally documented, suggesting shortcuts in clinical reasoning. PMID:27445502

  1. Nilotinib 300 mg twice daily: an academic single-arm study of newly diagnosed chronic phase chronic myeloid leukemia patients

    PubMed Central

    Castagnetti, Fausto; Breccia, Massimo; Gugliotta, Gabriele; Martino, Bruno; D’Adda, Mariella; Stagno, Fabio; Carella, Angelo Michele; Avanzini, Paolo; Tiribelli, Mario; Trabacchi, Elena; Visani, Giuseppe; Gobbi, Marco; Salvucci, Marzia; Levato, Luciano; Binotto, Gianni; Capalbo, Silvana Franca; Bochicchio, Maria Teresa; Soverini, Simona; Cavo, Michele; Martinelli, Giovanni; Alimena, Giuliana; Pane, Fabrizio; Saglio, Giuseppe; Rosti, Gianantonio; Baccarani, Michele

    2016-01-01

    The introduction and the extended clinical use of nilotinib in the first-line treatment of chronic myeloid leukemia have been based on company-sponsored trials. Independent confirmations are extremely important. We report an investigator-sponsored study of nilotinib 300 mg twice daily in 130 chronic myeloid leukemia patients in early chronic phase. A deep molecular response was achieved in 46% (MR4.0) and 17% (MR4.5) of patients at 2 years; 58% of the enrolled patients achieved a MR4.0 at least once, with a sustained MR4.0 in 52% of them. With a median observation of 29 months (range 24–37 months), 77% of patients were still on treatment with nilotinib. The reasons for permanent discontinuation were: 3% progression, 5% failure or suboptimal response, 8% adverse events, 1% treatment-free remission, and 5% other reasons. Thirteen thrombotic arterial events were reported in 12 patients. A prospective evaluation of metabolic effects showed an increase of fasting glucose without significant variations of glycated hemoglobin, an increase of total cholesterol (both low density lipoprotein and high density lipoprotein fractions) and a decrease of triglycerides. This study confirms a high and rapid efficacy of nilotinib 300 mg twice daily and provides detailed information on the type and incidence of non-hematologic and metabolic adverse events (clinicaltrials.gov identifier: 01535391). PMID:27470600

  2. Working Mothers of Children with Chronic Illness: Narratives of Working and Caring

    ERIC Educational Resources Information Center

    Vickers, Margaret; Parris, Melissa; Bailey, Jeff

    2004-01-01

    This paper reports the initial findings of an exploratory, qualitative study of the life and work of people who are working full-time and also caring for a child with chronic illness. The demands of such a lifestyle are significant. Respondents--all women--often reported "doing-it-all" while constantly being frustrated and challenged in their…

  3. Web-Based Self-Management in Chronic Care: A Study of Change in Patient Activation

    ERIC Educational Resources Information Center

    Solomon, Michael R.

    2010-01-01

    Web-based self-management interventions (W-SMIs) are designed to help a large number of chronically ill people become more actively engaged in their health care. Despite the potential to engage more patients in self-managing their health, the use of W-SMIs by patients and their clinicians is low. Using a self-management conceptual model based on…

  4. Home Care for Children with Chronic Illnesses and Severe Disabilities: A Bibliography and Resource Guide.

    ERIC Educational Resources Information Center

    Wells, Alice; And Others

    The bibliography and resource guide summarizes relevant research and information on home care for children with disabilities and chronic illnesses, including those with such diagnoses as spina bifida, cerebral palsy, severe mental retardation, acquired immune deficiency syndrome (AIDS), hemophilia, sickle cell anemia, autism, or failure-to-thrive…

  5. Comparing and improving chronic illness primary care in Sweden and the USA.

    PubMed

    Øvretveit, John; Ramsay, Patricia; Shortell, Stephen M; Brommels, Mats

    2016-06-13

    Purpose - The purpose of this paper is to identify opportunities for improving primary care services for people with chronic illnesses by comparing how Sweden and US services use evidence-based practices (EBPs), including digital health technologies (DHTs). Design/methodology/approach - A national primary healthcare center (PHCC) heads surveys in 2012-2013 carried out in both countries in 2006. Findings - There are large variations between the two countries. The largest, regarding effective DHT use in primary care centers, were that few Swedish primary healthcare compared to US heads reported having reminders or prompts at the point of care (38 percent Sweden vs 84 percent USA), despite Sweden's established electronic medical records (EMR). Swedish heads also reported 30 percent fewer centers receiving laboratory results (67 percent Sweden vs 97 percent USA). Regarding following other EBPs, 70 percent of Swedish center heads reported their physicians had easy access to diabetic patient lists compared to 14 percent in the USA. Most Swedish PHCC heads (96 percent) said they offered same day appointment compared to 36 percent in equivalent US practices. Practical implications - There are opportunities for improvement based on significant differences in effective practices between the countries, which demonstrates to primary care leaders that their peers elsewhere potentially provide better care for people with chronic illnesses. Some improvements are under primary care center control and can be made quickly. There is evidence that people with chronic illnesses in these two countries are suffering unnecessarily owing to primary care staff failing to provide proven EBP, which would better meet patient needs. Public finance has been invested in DHT, which are not being used to their full potential. Originality/value - The study shows the gaps between current and potential proven effective EBPs for services to patients with chronic conditions. Findings suggest possible

  6. Comparing and improving chronic illness primary care in Sweden and the USA.

    PubMed

    Øvretveit, John; Ramsay, Patricia; Shortell, Stephen M; Brommels, Mats

    2016-06-13

    Purpose - The purpose of this paper is to identify opportunities for improving primary care services for people with chronic illnesses by comparing how Sweden and US services use evidence-based practices (EBPs), including digital health technologies (DHTs). Design/methodology/approach - A national primary healthcare center (PHCC) heads surveys in 2012-2013 carried out in both countries in 2006. Findings - There are large variations between the two countries. The largest, regarding effective DHT use in primary care centers, were that few Swedish primary healthcare compared to US heads reported having reminders or prompts at the point of care (38 percent Sweden vs 84 percent USA), despite Sweden's established electronic medical records (EMR). Swedish heads also reported 30 percent fewer centers receiving laboratory results (67 percent Sweden vs 97 percent USA). Regarding following other EBPs, 70 percent of Swedish center heads reported their physicians had easy access to diabetic patient lists compared to 14 percent in the USA. Most Swedish PHCC heads (96 percent) said they offered same day appointment compared to 36 percent in equivalent US practices. Practical implications - There are opportunities for improvement based on significant differences in effective practices between the countries, which demonstrates to primary care leaders that their peers elsewhere potentially provide better care for people with chronic illnesses. Some improvements are under primary care center control and can be made quickly. There is evidence that people with chronic illnesses in these two countries are suffering unnecessarily owing to primary care staff failing to provide proven EBP, which would better meet patient needs. Public finance has been invested in DHT, which are not being used to their full potential. Originality/value - The study shows the gaps between current and potential proven effective EBPs for services to patients with chronic conditions. Findings suggest possible

  7. The Use of Self-Care Agency To Meet the Need for Solitude and Social Interaction by Chronically Ill Individuals.

    ERIC Educational Resources Information Center

    Burns, Margaret A.

    This study examined the effect of chronic illness on the individual's ability to meet his or her need for solitude and for social interaction by exploring how chronically ill individuals used their own ability (self-care agency) to meet these needs. Subjects were 90 chronically ill older persons, 30 of whom were living at home, 30 who lived in a…

  8. Partnerships to provide care and medicine for chronic diseases: a model for emerging markets.

    PubMed

    Goroff, Michael; Reich, Michael R

    2010-12-01

    The challenge of expanding access to treatment and medicine for chronic diseases in emerging markets is both a public health imperative and a commercial opportunity. Cross-sector partnerships-involving a pharmaceutical manufacturer; a local health care provider; and other private, public, and nonprofit entities-could address this challenge. Such partnerships would provide integrated, comprehensive care and medicines for a specific chronic disease, with medicines directly supplied to the partnership at preferential prices by the manufacturer. The model discussed here requires additional specification, using real numbers and specific contexts, to assess its feasibility. Still, we believe that this model has the potential for public health and private business to cooperate in addressing the rising problem of chronic diseases in emerging markets.

  9. Chronic care management of globesity: promoting healthier lifestyles in traditional and mHealth based settings

    PubMed Central

    Castelnuovo, Gianluca; Pietrabissa, Giada; Manzoni, Gian Mauro; Corti, Stefania; Ceccarini, Martina; Borrello, Maria; Giusti, Emanuele M.; Novelli, Margherita; Cattivelli, Roberto; Middleton, Nicole A.; Simpson, Susan G.; Molinari, Enrico

    2015-01-01

    Obesity and being overweight could be real chronic conditions above all if there are other complications such as type 2 diabetes, cardiovascular diseases, hypertension, dyslipidemia, hypercholesterolemia, cancer, and various psychosocial and psychopathological disorders. Due to the multifactorial etiology of obesity, evidence-based interventions to improve weight loss, maintain a healthy weight, and reduce related comorbidities combine different treatment approaches: dietetic, nutritional, physical, behavioral, psychological, and, in some situations, pharmacological and surgical. There are significant limitations in this multidisciplinary chronic care management of obesity, most notably those regarding costs and long-term adherence and efficacy. Programs including eHealth platforms and new technologies could overcome limitations connected to the traditional in-patient chronic care management of obesity, thus providing promising opportunities in enhancing weight reduction and reducing complications in terms of long-term efficacy and effectiveness across clinical, organizational, and economic perspectives. PMID:26528215

  10. [Chronic obstructive lung disease management programmes do not benefit the coordination of care pathways].

    PubMed

    Gjersøe, Peter; Morsø, Lars; Jensen, Morten Sall; Qvist, Peter

    2014-09-29

    Chronic obstructive lung disease (COLD) is a challenging condition for both primary and secondary health-care providers. Disease management programmes (DMP's) have been expected to lead to evident improvements in the continuum of care for COLD. The utility of a COLD management programme was evaluated in a study based on interviews among general practitioners and COLD specialists. Clinicians preferred short practical guidelines to the DMP. The DMP was found useless as a tool to improve the coordination of care pathways. Complimentary interventions to improve clinical cooperation across sectors are recommended.

  11. The Pursuit of Preventive Care for Chronic Illness: Turning Healthy People into Chronic Patients

    PubMed Central

    Kreiner, Meta J.; Hunt, Linda M.

    2013-01-01

    Preventive health care has become prominent in clinical medicine in the United States, emphasizing risk assessment and control, rather than addressing the signs and symptoms of pathology. Current clinical guidelines, reinforced by evidence-based decision aids and quality of care assessment, encourage clinicians to focus on maintaining rigid test thresholds which are based on population norms. While achieving these goals may benefit the total population, this may be of no benefit or even harmful to individual patients. In order to explore how this phenomenon is manifest in clinical care, and consider some factors that promote and sustain this trend, we analyze observations of over 100 clinical consultations, and open-ended interviews with 58 primary care clinicians and 70 of their patients. Both clinicians and patients equated at-risk states with illness, and viewed the associated interventions not as prevention, but as treatment. This conflation of risk and disease redefines clinical success such that reducing the threat of anticipated future illness requires acceptance of aggressive treatments and any associated adverse effects in the present. While the expanding emphasis on preventive medicine may improve the health profile of the total population, the implications of these innovations for the well-being of individual patients merits careful reconsideration. PMID:24372285

  12. The pursuit of preventive care for chronic illness: turning healthy people into chronic patients.

    PubMed

    Kreiner, Meta J; Hunt, Linda M

    2014-07-01

    Preventive health care has become prominent in clinical medicine in the US, emphasising risk assessment and control, rather than addressing the signs and symptoms of pathology. Current clinical guidelines, reinforced by evidence-based decision aids and quality of care assessment, encourage clinicians to focus on maintaining rigid test thresholds that are based on population norms. While achieving these goals may benefit the total population, this may be of no benefit or even harmful to individual patients. In order to explore how this phenomenon is manifested in clinical care and consider some factors that promote and sustain this trend, we analysed observations of over 100 clinical consultations, and open-ended interviews with 58 primary care clinicians and 70 of their patients. Both clinicians and patients equated at-risk states with illness and viewed the associated interventions not as prevention, but as treatment. This conflation of risk and disease redefines clinical success such that reducing the threat of anticipated future illness requires the acceptance of aggressive treatments and any associated adverse effects in the present. While the expanding emphasis on preventive medicine may improve the health profile of the total population, the implications of these innovations for the wellbeing of individual patients merits careful reconsideration. PMID:24372285

  13. An overview of integrative care options for patients with chronic wounds.

    PubMed

    Rosenbaum, Cathy

    2012-05-01

    Integrative care incorporates aspects of traditional and nontraditional medicine, also often referred to as holistic or complementary and alternative medicine. Providing integrative wound care involves addressing physical, psychosocial, and spiritual components of the whole person. Several care models, including the Seven Balance Point Model, include holistic considerations, as well as promotion of physical health recommendations involving nutrition, sleep, exercise, and emotional, social, and spiritual well-being. The quality of life of patients with chronic wounds may be negatively affected by chronic and procedural pain, sleep disturbance, social, and emotional concerns. Although research into the role of integrative medicine in wound care is limited, experiences from other disciplines suggest wound pain may be addressed using acupuncture, yoga, biofeedback, guided imagery, massage, healing touch and therapeutic touch, aromatherapy, and topical medical-grade honey. In addition, patients who are incontinent or have incontinence-related skin damage or peristomal complications may benefit from biofeedback to better control incontinence. Research to increase understanding about the role of holistic care for patients with wound, stoma, and continence-related problems in general, and its effect on the quality of life of palliative care patients in particular, will help clinicians provide evidence-based and patient-centered care. PMID:22562939

  14. An Evolving Identity: How Chronic Care Is Transforming What it Means to Be a Physician.

    PubMed

    Bogetz, Alyssa L; Bogetz, Jori F

    2015-12-01

    Physician identity and the professional role physicians play in health care is rapidly evolving. Over 130 million adults and children in the USA have complex and chronic diseases, each of which is shaped by aspects of the patient's social, psychological, and economic status. These patients have lifelong health care needs that require the ongoing care of multiple health care providers, access to community services, and the involvement of patients' family support networks. To date, physician professional identity formation has centered on autonomy, authority, and the ability to "heal." These notions of identity may be counterproductive in chronic disease care, which demands interdependency between physicians, their patients, and teams of multidisciplinary health care providers. Medical educators can prepare trainees for practice in the current health care environment by providing training that legitimizes and reinforces a professional identity that emphasizes this interdependency. This commentary outlines the important challenges related to this change and suggests potential strategies to reframe professional identity to better match the evolving role of physicians today.

  15. [Using eHealth in the Continuity Care of Chronic Kidney Disease: Opportunities and Considerations].

    PubMed

    Chen, Yu-Chi; Chang, Polun

    2016-04-01

    Kidney disease is a common complication of chronic diseases among adult and elderly populations. As early-stage chronic kidney disease (CKD) is asymptomatic, CKD patients are frequently unaware of their condition and fail to implement requisite self-care in a timely fashion. Furthermore, the shortage of case-management manpower and difficulties in follow-up have led to high incidence rates for CKD worldwide. Integrative and continuous care is key to preventing CKD. How to implement this care effectively is a challenge. However, innovative technologies, online information, and cloud technology are increasingly providing access to good-quality healthcare beyond the traditional limitations of time and location. This environment is not only increasing the participation of patients in their care and collaboration among healthcare team members but is also improving the continuity, accessibility, and promptness of care service in order to promote the effectiveness of disease management. While the primary aim of innovative technologies is to make healthcare more cost-effective, it is also causing disparities in healthcare. Within the high-tech e-healthcare system, the ability of patients to utilize these new services relates directly to their health behaviors and quality of care. Thus, emergent e-healthcare system services should be made as patient-centered as possible in order to maximize the benefits in terms of both cost and patient care. Furthermore, improving the eHealth literacy of patients is crucial to promoting innovative technology within healthcare services. PMID:27026552

  16. Linkcare--enabling continuity of care for the chronically ill across levels and profession.

    PubMed

    Mikalsen, Marius; Walderhaug, Ståle; Meland, Per Håkon; Winnem, Ole Martin

    2007-01-01

    Chronic diseases are increasing rapidly and this phenomenon is becoming a major burden to the health delivery system around the world. A new health care paradigm with focus on chronic treatment and care will actualize the need for interoperable standards based services due to the complexity of care where different health levels and professions are involved. Given the complexity of the domain, we argue the need for a systematic and formal approach to the development of interoperable information systems if there shall be any real support of the cooperating actors. We describe our work on technical interoperability done in the Linkcare project addressing new models of care and technology to support them in the domain of the chronically ill using concrete results from an architecture built using the MAFIIA architecture framework and the UML 2.0 profile for software services, and argue that building formal architectural descriptions on the basis of shared interface descriptions and profiles are an important part of achieving continuity of care based on sustainable health systems.

  17. Providing Care for Patients with Chronic Migraine: Diagnosis, Treatment, and Management.

    PubMed

    Dougherty, Carrie; Silberstein, Stephen D

    2015-09-01

    Chronic migraine, a subtype of migraine defined as ≥ 15 headache days per month for ≥ 3 months, in which ≥ 8 days per month meet criteria for migraine with or without aura or respond to migraine-specific treatment, is a disabling, underdiagnosed, and undertreated disorder associated with significant disability, poor health-related quality of life, and high economic burden. The keys to caring for chronic migraine patients include: (1) making a proper diagnosis; (2) identifying and eliminating exacerbating factors; (3) assessing for medication overuse (patients with chronic headache often overuse acute medications); and (4) continued management. Communication between patient and physician about treatment goals is important. The patient management guidelines presented in this article should help physicians improve treatment success and proactively address common comorbidities among their patients with chronic migraine.

  18. EQUIP: Implementing chronic care principles and applying formative evaluation methods to improve care for schizophrenia: QUERI Series

    PubMed Central

    Brown, Alison H; Cohen, Amy N; Chinman, Matthew J; Kessler, Christopher; Young, Alexander S

    2008-01-01

    Background This paper presents a case study that demonstrates the evolution of a project entitled "Enhancing QUality-of-care In Psychosis" (EQUIP) that began approximately when the U.S. Department of Veterans Affairs' Quality Enhancement Research Initiative (QUERI), and implementation science were emerging. EQUIP developed methods and tools to implement chronic illness care principles in the treatment of schizophrenia, and evaluated this implementation using a small-scale controlled trial. The next iteration of the project, EQUIP-2, was further informed by implementation science and the use of QUERI tools. Methods This paper reports the background, development, results and implications of EQUIP, and also describes ongoing work in the second phase of the project (EQUIP-2). The EQUIP intervention uses implementation strategies and tools to increase the adoption and implementation of chronic illness care principles. In EQUIP-2, these strategies and tools are conceptually grounded in a stages-of-change model, and include clinical and delivery system interventions and adoption/implementation tools. Formative evaluation occurs in conjunction with the intervention, and includes developmental, progress-focused, implementation-focused, and interpretive evaluation. Results Evaluation of EQUIP provided an understanding of quality gaps and how to address related problems in schizophrenia. EQUIP showed that solutions to quality problems in schizophrenia differ by treatment domain and are exacerbated by a lack of awareness of evidence-based practices. EQUIP also showed that improving care requires creating resources for physicians to help them easily implement practice changes, plus intensive education as well as product champions who help physicians use these resources. Organizational changes, such as the addition of care managers and informatics systems, were shown to help physicians with identifying problems, making referrals, and monitoring follow-up. In EQUIP-2, which is

  19. Caring for a chronically ill infant: a paradigm case of maternal rehearsal in the neonatal intensive care unit.

    PubMed

    Hayes, N; Stainton, M C; McNeil, D

    1993-12-01

    This study examines a mother's perspective of caring for a chronically ill infant coming home from the neonatal intensive care unit. Understanding the meaning of the situation for the parent can foster excellence in clinical practice that is based on understanding derived from descriptions of their experience. This paper presents a paradigm case extracted from a larger phenomenological study that is examining the high-risk perinatal experience. Hermeneutic methods used for analysis led to the discovery of five meanings in the experience for the parent: (a) uncertainty; (b) experiencing the baby as powerful; (c) striving to gain acceptance from the baby; (d) blurred territory in taking up the practices of care; and (e) being alone and vulnerable. PMID:8133433

  20. [Chronic hepatitis C: standard of care and perspective].

    PubMed

    Aghemo, Alessio; De Nicola, Stella

    2016-07-01

    Chronic hepatitis C (HCV) is a major health problem with more than 150 million people infected worldwide. It is the leading cause of cirrhosis, hepatocellular carcinoma and liver transplantation in western countries. Nowadays the disease is curable in most patients as the development of directly acting antivirals against HCV allows between 90 and 95% of patients who receive treatment to achieve viral eradication. This innovation has been made possible by the understanding of the HCV life cycle as well as the development of in vitro models of HCV replication, that have led to the discovery of 3 key steps in the HCV life cycle that can be targeted to halt viral replication. Drugs targeting the NS3 Protease, the NS5A protein as well as the NS5B polymerase are now commercially available in Europe. By combining these drugs for 12 or 24 weeks, most HCV-positive patients can be cured of their infection. Still the treatment cascade requires at the moment expert management, due to the relative complexity and need for individualization of the current regimens, as well as the need for monitoring for side effects during treatment. This, together with low diagnostic rates in the general population and high pricing of directly acting antivirals is a major hurdle to universal treatment of HCV and emphasizes the need for simplier pangenotypic, ribavirin free anti-HCV regimens that are now in advanced phase of development and should enter the field in the next 12-18 months. PMID:27571464

  1. Mothers' and fathers' involvement with school-age children's care and academic activities in Navajo Indian families.

    PubMed

    Hossain, Ziarat; Anziano, Michael C

    2008-04-01

    This exploratory study examined mothers' and fathers' reports of time involvement in their school-age children's care and academic activities. The study also explored the relationship between parents' socioeconomic status (SES) variables (age, education, income, work hours, and length of marriage) and their relative involvement with children. Mother and father dyads from 34 two-parent Navajo (Diné) Indian families with a second- or third-grade child participated in the study. Repeated measures analysis of variance showed that mothers invested significantly more time in children's care on demand and academic activities than fathers, but the differences in maternal and paternal perceptions of time involvement in routine care were not significant. The gender of the child did not influence the amount of time parents invested in children's care and academic activities. Mothers' involvement with children was not related to any of the SES variables. Fathers' involvement was significantly associated with work hours and length of marriage, and work hours produced significant interaction with fathers' involvement with children. Findings are discussed in light of gender role differences in parental involvement with children within Navajo families. PMID:18426283

  2. Naturopathic Practice at North American Academic Institutions: Description of 300,483 Visits and Comparison to Conventional Primary Care

    PubMed Central

    Chamberlin, Steven R; Oberg, Erica; Hanes, Douglas A; Calabrese, Carlo

    2014-01-01

    This study collected patient visit data to explore similarities and differences between conventional and naturopathic primary care (PC). Administrative data from practice management software systems from the main teaching clinics of four of the eight accredited North American naturopathic academic institutions were abstracted into an integrated database containing five years (2006–2010) of visit, patient, laboratory, and prescribing data. Descriptive analyses of healthcare services were compared to the National Ambulatory Medical Care Survey (NAMCS). Over the five-year period, 300,483 patient visits to naturopathic doctors occurred at clinics, excluding visits at clinics operated by the schools in community settings. Patients were 69% female; mean age was 39 (SE 0.09). Older adults (>65) comprised 9% of the population and children (<16) comprised 8%. Comparing academic naturopathic clinics to national conventional PC (NAMCS), we found more patients paid out of pocket at naturopathic clinics (50 vs. 4%) and naturopathic clinics more frequently offered discounted care (26 vs. 0.3%). There was a 44% overlap in the most frequent 25 diagnoses for PC at conventional community clinics. Overall, these data suggest substantial similarities in care offered by academic naturopathic clinics, at which most Naturopathic Doctor (ND) students are trained, and by conventional PC practices. PMID:24899792

  3. A Randomized Control Trial of a Chronic Care Intervention for Homeless Women with Alcohol Use Problems

    PubMed Central

    Upshur, Carole; Weinreb, Linda; Bharel, Monica; Reed, George; Frisard, Christine

    2014-01-01

    A clinician-randomized trial was conducted using the chronic care model for disease management for alcohol use problems among n=82 women served in a health care for the homeless clinic. Women with problem alcohol use received either usual care or an intervention consisting of a Primary Care Provider (PCP) brief intervention, referral to addiction services, and on-going support from a Care Manager (CM) for 6 months. Both groups significantly reduced their alcohol consumption, with a small effect size favoring intervention at 3 months, but there were no significant differences between groups in reductions in drinking or in housing stability, or mental or physical health. However, intervention women had significantly more frequent participation in substance use treatment services. Baseline differences and small sample size limit generalizability, although substantial reductions in drinking for both groups suggest screening and PCP brief treatment are promising interventions for homeless women with alcohol use problems. PMID:25488504

  4. Breaking barriers to care: a community of solution for chronic disease management.

    PubMed

    Sanders, Jim; Solberg, Bill; Gauger, Michael

    2013-01-01

    For 10 years the Medical College of Wisconsin and Columbia St. Mary's Hospital have joined together in a partnership to work within some of Milwaukee's most impoverished neighborhoods. Beginning simply by providing health care through a free clinic, the partnership soon was confronted with numerous examples of barriers to care being experienced by patients. A community-based participatory action process allowed the local population to give voice to the local realities of barriers to care. Here we combine our anecdotal clinical experience, the neighborhood's input, and an example of a successful program from a low-resource international setting to create a novel approach to treating chronic disease in uninsured populations. This model of care has been successful for 2 reasons. First, the model shows good health outcomes at low cost. Second, solid community partnerships with care providers, churches, and other groups have been formed in support of the model, ensuring its credibility and sustainability.

  5. Patterns of Care Among Patients Receiving Radiation Therapy for Bone Metastases at a Large Academic Institution

    SciTech Connect

    Ellsworth, Susannah G.; Alcorn, Sara R.; Hales, Russell K.; McNutt, Todd R.; DeWeese, Theodore L.; Smith, Thomas J.

    2014-08-01

    Purpose: This study evaluates outcomes and patterns of care among patients receiving radiation therapy (RT) for bone metastases at a high-volume academic institution. Methods and Materials: Records of all patients whose final RT course was for bone metastases from April 2007 to July 2012 were identified from electronic medical records. Chart review yielded demographic and clinical data. Rates of complicated versus uncomplicated bone metastases were not analyzed. Results: We identified 339 patients whose final RT course was for bone metastases. Of these, 52.2% were male; median age was 65 years old. The most common primary was non-small-cell lung cancer (29%). Most patients (83%) were prescribed ≤10 fractions; 8% received single-fraction RT. Most patients (52%) had a documented goals of care (GOC) discussion with their radiation oncologist; hospice referral rates were higher when patients had such discussions (66% with vs 50% without GOC discussion, P=.004). Median life expectancy after RT was 96 days. Median survival after RT was shorter based on inpatient as opposed to outpatient status at the time of consultation (35 vs 136 days, respectively, P<.001). Hospice referrals occurred for 56% of patients, with a median interval between completion of RT and hospice referral of 29 days and a median hospice stay of 22 days. Conclusions: These data document excellent adherence to American Society for Radiation Oncolology Choosing Wisely recommendation to avoid routinely using >10 fractions of palliative RT for bone metastasis. Nonetheless, single-fraction RT remains relatively uncommon. Participating in GOC discussions with a radiation oncologist is associated with higher rates of hospice referral. Inpatient status at consultation is associated with short survival.

  6. In-Home Care for Optimizing Chronic Disease Management in the Community

    PubMed Central

    2013-01-01

    Background The emerging attention on in-home care in Canada assumes that chronic disease management will be optimized if it takes place in the community as opposed to the health care setting. Both the patient and the health care system will benefit, the latter in terms of cost savings. Objectives To compare the effectiveness of care delivered in the home (i.e., in-home care) with no home care or with usual care/care received outside of the home (e.g., health care setting). Data Sources A literature search was performed on January 25, 2012, using OVID MEDLINE, OVID MEDLINE In-Process and Other Non-Indexed Citations, OVID EMBASE, EBSCO Cumulative Index to Nursing & Allied Health Literature (CINAHL), the Wiley Cochrane Library, and the Centre for Reviews and Dissemination database, for studies published from January 1, 2006, until January 25, 2012. Review Methods An evidence-based analysis examined whether there is a difference in mortality, hospital utilization, health-related quality of life (HRQOL), functional status, and disease-specific clinical measures for in-home care compared with no home care for heart failure, atrial fibrillation, coronary artery disease, stroke, chronic obstructive pulmonary disease, diabetes, chronic wounds, and chronic disease / multimorbidity. Data was abstracted and analyzed in a pooled analysis using Review Manager. When needed, subgroup analysis was performed to address heterogeneity. The quality of evidence was assessed by GRADE. Results The systematic literature search identified 1,277 citations from which 12 randomized controlled trials met the study criteria. Based on these, a 12% reduced risk for in-home care was shown for the outcome measure of combined events including all-cause mortality and hospitalizations (relative risk [RR]: 0.88; 95% CI: 0.80–0.97). Patients receiving in-home care had an average of 1 less unplanned hospitalization (mean difference [MD]: –1.03; 95% CI: –1.53 to –0.53) and an average of 1 less

  7. Latin American Cancer Research Coalition. Community primary care/academic partnership model for cancer control.

    PubMed

    Kreling, Barbara A; Cañar, Janet; Catipon, Ericson; Goodman, Michelle; Pallesen, Nancy; Pomeroy, Jyl; Rodriguez, Yosselyn; Romagoza, Juan; Sheppard, Vanessa B; Mandelblatt, Jeanne; Huerta, Elmer E

    2006-10-15

    The Latin American Cancer Research Coalition (LACRC) was funded by NCI as a Special Populations Network to 1) provide training to clinic staff in cancer control and foster development of Latino faculty training, 2) conduct a needs assessment with the community clinics, 3) enhance the ability of the clinics to promote healthy lifestyles, 4) collaborate on research projects to improve use of early detection, and 5) explore partnerships to increase access to culturally competent cancer care. The LACRC developed a model for cancer control focused on community-based clinics as the focal point for in-reach and community outreach targeted to Latinos to reduce cancer disparities. This framework was designed to link the community to local hospitals and academic centers, build capacity, and promote diffusion of innovations directly into delivery systems. Eight research projects submitted by junior investigator/clinic teams have been funded by NCI. These research projects range from recruiting for clinical trials to prevention to survivorship. The LACRC has trained 6 cancer control coordinators from partner sites and educated 59 undergraduate minority student interns in aspects of cancer control research. Central to LACRC's success to date has been the creation and maintenance of an infrastructure of trusting relationships, especially those developed between clinician/investigators and individuals within the greater Latino community. Community clinics can be effective agents for cancer control among Latinos. Latinos are likely to participate in research conducted by culturally representative teams of researchers using culturally appropriate recruiting strategies. Cancer 2006. (c) 2006 American Cancer Society. PMID:16986105

  8. Achieving Effective Universal Health Coverage And Diagonal Approaches To Care For Chronic Illnesses.

    PubMed

    Knaul, Felicia Marie; Bhadelia, Afsan; Atun, Rifat; Frenk, Julio

    2015-09-01

    Health systems in low- and middle-income countries were designed to provide episodic care for acute conditions. However, the burden of disease has shifted to be overwhelmingly dominated by chronic conditions and illnesses that require health systems to function in an integrated manner across a spectrum of disease stages from prevention to palliation. Low- and middle-income countries are also aiming to ensure health care access for all through universal health coverage. This article proposes a framework of effective universal health coverage intended to meet the challenge of chronic illnesses. It outlines strategies to strengthen health systems through a "diagonal approach." We argue that the core challenge to health systems is chronicity of illness that requires ongoing and long-term health care. The example of breast cancer within the broader context of health system reform in Mexico is presented to illustrate effective universal health coverage along the chronic disease continuum and across health systems functions. The article concludes with recommendations to strengthen health systems in order to achieve effective universal health coverage. PMID:26355053

  9. A chronic grief intervention for dementia family caregivers in long-term care.

    PubMed

    Paun, Olimpia; Farran, Carol J; Fogg, Louis; Loukissa, Dimitra; Thomas, Peggy E; Hoyem, Ruby

    2015-01-01

    Dementia caregivers do not relinquish their role after placing family members in long-term care and they experience increased chronic grief. The Chronic Grief Management Intervention (CGMI) is a12-week group-based program that uses guided discussion to deliver knowledge of Alzheimer's or a related dementia and teach skills in communication, conflict resolution, and chronic grief management in dementia caregivers who placed their family members in long-term care. Using a quasi-experimental design, 83 caregivers from 15 long-term care facilities received either the CGMI (n = 34) or a comparison condition consisting of two check-in calls (n = 49). In this pilot study, we examined the feasibility of implementing the CGMI and evaluated the effects of the intervention on caregivers' knowledge and skill and their chronic grief and depression. The intervention was feasible and resulted in significant improvement in caregivers' heartfelt sadness and longing at 3 months and a significant drop in their guilt at the 6-month follow-up. PMID:24510968

  10. Achieving Effective Universal Health Coverage And Diagonal Approaches To Care For Chronic Illnesses.

    PubMed

    Knaul, Felicia Marie; Bhadelia, Afsan; Atun, Rifat; Frenk, Julio

    2015-09-01

    Health systems in low- and middle-income countries were designed to provide episodic care for acute conditions. However, the burden of disease has shifted to be overwhelmingly dominated by chronic conditions and illnesses that require health systems to function in an integrated manner across a spectrum of disease stages from prevention to palliation. Low- and middle-income countries are also aiming to ensure health care access for all through universal health coverage. This article proposes a framework of effective universal health coverage intended to meet the challenge of chronic illnesses. It outlines strategies to strengthen health systems through a "diagonal approach." We argue that the core challenge to health systems is chronicity of illness that requires ongoing and long-term health care. The example of breast cancer within the broader context of health system reform in Mexico is presented to illustrate effective universal health coverage along the chronic disease continuum and across health systems functions. The article concludes with recommendations to strengthen health systems in order to achieve effective universal health coverage.

  11. Living In A Country With A Strong Primary Care System Is Beneficial To People With Chronic Conditions.

    PubMed

    Hansen, Johan; Groenewegen, Peter P; Boerma, Wienke G W; Kringos, Dionne S

    2015-09-01

    In light of the growing pressure that multiple chronic diseases place on health care systems, we investigated whether strong primary care was associated with improved health outcomes for the chronically ill. We did this by combining country- and individual-level data for the twenty-seven countries of the European Union, focusing on people's self-rated health status and whether or not they had severe limitations or untreated conditions. We found that people with chronic conditions were more likely to be in good or very good health in countries that had a stronger primary care structure and better coordination of care. People with more than two chronic conditions benefited most: Their self-rated health was higher if they lived in countries with a stronger primary care structure, better continuity of care, and a more comprehensive package of primary care services. In general, while having access to a strong primary care system mattered for people with chronic conditions, the degree to which it mattered differed across specific subgroups (for example, people with primary care-sensitive conditions) and primary care dimensions. Primary care reforms, therefore, should be person centered, addressing the needs of subgroups of patients while also finding a balance between structure and service delivery.

  12. Effects of Educational Interventions for Chronic Airway Disease on Primary Care.

    PubMed

    Lee, Jung Yeon; Yoo, Kwang Ha; Kim, Deog Kyeom; Kim, Sang-Ha; Kim, Tae-Eun; Kim, Tae-Hyung; Rhee, Chin Kook; Park, Yong Bum; Yoon, Hyoung Kyu; Yum, Ho-Kee

    2016-07-01

    Education has been known to essential for management of chronic airway diseases. However the real benefits remain unclear. We evaluated the effectiveness of an organized educational intervention for chronic airway diseases directed at primary care physicians and patients. The intervention was a 1-month education program of three visits, during which subjects were taught about their disease, an action plan in acute exacerbation and inhaler technique. Asthma control tests (ACT) for asthma and, chronic obstructive pulmonary disease (COPD) assessment tests (CAT) for COPD subjects were compared before and after education as an index of quality of life. Educational effectiveness was also measured associated with improvement of their knowledge for chronic airway disease itself, proper use of inhaler technique, and satisfaction of the subjects and clinicians before and after education. Among the 285 participants, 60.7% (n = 173) were men and the mean age was 62.2 ± 14.7. ACT for asthma and CAT in COPD patients were significantly improved by 49.7% (n = 79) and 51.2% (n = 65) more than MCID respectively after education (P < 0.05). In all individual items, knowledge about their disease, inhaler use and satisfaction of the patients and clinicians were also improved after education (P < 0.05). This study demonstrates the well-organized education program for primary care physicians and patients is a crucial process for management of chronic airway diseases.

  13. Prescription opioid abuse, chronic pain, and primary care: a Co-occurring Disorders Clinic in the chronic disease model.

    PubMed

    Pade, Patricia A; Cardon, Karen E; Hoffman, Richard M; Geppert, Cynthia M A

    2012-12-01

    Abuse of opioids has become a public health crisis. The historic separation between the addiction and pain communities and a lack of training in medical education have made treatment difficult to provide, especially in primary care. The Co-occurring Disorders Clinic (COD) was established to treat patients with co-morbid chronic pain and addiction. This retrospective chart review reports results of a quality improvement project using buprenorphine/naloxone to treat co-occurring chronic non-cancer pain (CNCP) and opioid dependence in a primary care setting. Data were collected for 143 patients who were induced with buprenorphine/naloxone (BUP/NLX) between June 2009 and November 2011. Ninety-three patients (65%) continued to be maintained on the medication and seven completed treatment and were no longer taking any opioid (5%). Pain scores showed a modest, but statistically significant improvement on BUP/NLX, which was contrary to our expectations and may be an important factor in treatment retention for this challenging population. PMID:22980449

  14. Minimally Disruptive Medicine: A Pragmatically Comprehensive Model for Delivering Care to Patients with Multiple Chronic Conditions

    PubMed Central

    Leppin, Aaron L.; Montori, Victor M.; Gionfriddo, Michael R.

    2015-01-01

    An increasing proportion of healthcare resources in the United States are directed toward an expanding group of complex and multimorbid patients. Federal stakeholders have called for new models of care to meet the needs of these patients. Minimally Disruptive Medicine (MDM) is a theory-based, patient-centered, and context-sensitive approach to care that focuses on achieving patient goals for life and health while imposing the smallest possible treatment burden on patients’ lives. The MDM Care Model is designed to be pragmatically comprehensive, meaning that it aims to address any and all factors that impact the implementation and effectiveness of care for patients with multiple chronic conditions. It comprises core activities that map to an underlying and testable theoretical framework. This encourages refinement and future study. Here, we present the conceptual rationale for and a practical approach to minimally disruptive care for patients with multiple chronic conditions. We introduce some of the specific tools and strategies that can be used to identify the right care for these patients and to put it into practice. PMID:27417747

  15. [Perspectives of chronically ill patients concerning medical care in Guadalajara, Mexico: a qualitative study].

    PubMed

    Mercado Martínez, F J; Ramos Herrera, I M; Valdez Curiel, E

    2000-01-01

    This paper reports partial findings from a broader study on the experience of people with chronic diseases. The objective was to explore the perspectives of diabetic patients towards medical care. A qualitative study was conducted in a poor neighborhood of Guadalajara, Mexico. Thirty subjects with diabetes mellitus participated in the study. Data was gathered by open and semi-open interviews in the subjects' homes and over the course of one year. Data were analyzed using a combination of content and conversational analyzing techniques. Three perspectives predominated when participants evaluated medical care: some define it as good, some as ambivalent, and the rest as bad. These perspectives were closely linked to their disease experience and available medical options according to their material resources. These perspectives change with time, are specific to each available service and type of medical care, and are constructed in terms of all the subjects' present chronic illnesses. Those treated through the social security system evaluate the care in negative terms, with the opposite occurring with those treated in public health care centers and private facilities. Implications regarding health care reform are discussed.

  16. Chronic Disease Patients’ Experiences With Accessing Health Care in Rural and Remote Areas

    PubMed Central

    Brundisini, F; Giacomini, M; DeJean, D; Vanstone, M; Winsor, S; Smith, A

    2013-01-01

    Background Rurality can contribute to the vulnerability of people with chronic diseases. Qualitative research can identify a wide range of health care access issues faced by patients living in a remote or rural setting. Objective To systematically review and synthesize qualitative research on the advantages and disadvantages rural patients with chronic diseases face when accessing both rural and distant care. Data Sources This report synthesizes 12 primary qualitative studies on the topic of access to health care for rural patients with chronic disease. 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 major themes were identified: geography, availability of health care professionals, and rural culture. First, geographic distance from services poses access barriers, worsened by transportation problems or weather conditions. Community supports and rurally located services can help overcome these challenges. Second, the limited availability of health care professionals (coupled with low education or lack of peer support) increases the feeling of vulnerability. When care is available locally, patients appreciate long-term relationships with individual clinicians and care personalized by familiarity with the patient as a person. Finally, patients may feel culturally marginalized in the urban health care context, especially if health literacy is low. A culture of self-reliance and community belonging in rural areas may incline patients to do without distant care and may mitigate feelings of vulnerability. Limitations Qualitative research findings are not intended to generalize directly to populations, although meta-synthesis across a number of qualitative studies builds an increasingly robust understanding that is more likely to be transferable. Selected studies

  17. Setting standards at the forefront of delivery system reform: aligning care coordination quality measures for multiple chronic conditions.

    PubMed

    DuGoff, Eva H; Dy, Sydney; Giovannetti, Erin R; Leff, Bruce; Boyd, Cynthia M

    2013-01-01

    The primary study objective is to assess how three major health reform care coordination initiatives (Accountable Care Organizations, Independence at Home, and Community-Based Care Transitions) measure concepts critical to care coordination for people with multiple chronic conditions. We find that there are major differences in quality measurement across these three large and politically important programs. Quality measures currently used or proposed for these new health reform-related programs addressing care coordination primarily capture continuity of care. Other key areas of care coordination, such as care transitions, patient-centeredness, and cross-cutting care across multiple conditions are infrequently addressed. The lack of a comprehensive and consistent measure set for care coordination will pose challenges for healthcare providers and policy makers who seek, respectively, to provide and reward well-coordinated care. In addition, this heterogeneity in measuring care coordination quality will generate new information, but will inhibit comparisons between these care coordination programs.

  18. Incomplete medication adherence of chronically ill patients in German primary care

    PubMed Central

    Hüther, Jakob; von Wolff, Alessa; Stange, Dorit; Härter, Martin; Baehr, Michael; Dartsch, Dorothee C; Kriston, Levente

    2013-01-01

    Background Incomplete medication adherence is a major problem in health care worldwide. Patients who adhere to medical treatment have a better prognosis and create fewer costs. Objective To assess the degree of incomplete adherence of chronically ill routine primary care patients in a German setting and analyze the association between incomplete medication adherence, as well as clinical and sociodemographic patient characteristics. Methods: In a cross-sectional survey, chronically ill patients were asked to assess their adherence in primary care retrospectively using the Medication Adherence Report Scale (MARS-D) questionnaire. To investigate the association of incomplete adherence with sociodemographic and clinical data, univariate and multivariate analyses were conducted. Results In total, 62.1% of 190 patients were categorized as incompletely adherent. The mean MARS-D score was 23.5 (standard deviation = 2.7). Analyses revealed no statistically significant associations at P < 0.05 between degree of adherence and patient characteristics. The total explained variance amounted to 11.8% (Nagelkerke’s R2 = 0.118) in the multivariate analysis. Conclusion Previously reported results regarding associations of sociodemographic and clinical data with incomplete medication adherence could not be confirmed for this sample of chronically ill patients. In order to be able to provide guidelines for the reduction of incomplete medication adherence in German primary care, further research is needed. PMID:23569363

  19. [Community resources prescription for self-care improvement in chronic illnesses. Clinical case management in Primary Health Care].

    PubMed

    Pérez-Vico-Díaz de Rada, Lucía; González-Suárez, Miriam; Duarte-Clíments, Gonzalo; Brito-Brito, Pedro Ruymán

    2014-01-01

    A case is presented of a 52 year-old male seen in a Primary Care nursing clinic for a type 2 diabetes mellitus metabolic control. The frequency of the visits increased due to perceived difficulties caused by changing the medical treatment. A focused interview was conducted under functional health patterns framework. The patient was unable to write or read, had not worked for the last 25 years, and expressed a lack of control over his self-care. An action plan was prepared, prioritizing Ineffective Health Maintenance, Powerlessness, and Impaired Social Interaction NANDA-I nursing diagnoses. The goals were set at improving knowledge and control over his disease and participating in leisure activities. To achieve these, the social health resources in the area were contacted, and agreed that the patient could attend activities that could improve his self-care and his quality of life. An improvement in his diabetes control was observed in the following evaluations, with an increase in his level of knowledge and self-care. The Primary Health care nurse should consider available community resources by using a comprehensive approach to chronic diseases for their therapeutic benefit and management, especially in those patients with adverse sociocultural conditions.

  20. Run the numbers. Case study: using management accounting in an academic health care setting.

    PubMed

    Quintana, Olga; Ortiz, Cesar A

    2003-03-01

    Management accounting can help administrators manage academic physician practices. Its basic cost-capturing systems can instill accountability and behavior modification in those directly responsible. PMID:12661223

  1. An overview of advance care planning for patients with advanced chronic kidney disease: The basics.

    PubMed

    Wasylynuk, Betty Ann; Davison, Sara N

    2016-01-01

    As the number of Canadians living with end-stage kidney disease (ESKD) continues to grow, even higher numbers are living with advanced chronic kidney disease (CKD). Many of these people will eventually require renal replacement therapy (RRT), either dialysis or transplantation. More than 50% of patients starting RRT today are aged 65 or older, with the fastest growing group being patients 75 years and older. Despite advances to dialysis technology and dialysis care, the mortality rates remain high and dialysis patients' end-of-life care may not align with their preferences or values. Advance care planning (ACP) is an essential component of quality comprehensive kidney care. Kidney care teams develop strong relationships with their patients and are well positioned to integrate ACP into routine kidney care. This article defines ACP, outlines the essential components of ACP, and discusses the benefits, challenges, and special considerations of ACP. By enhancing the kidney care team's understanding of ACP, this article aims to assist in integrating ACP into routine kidney care for patients with advanced CKD. PMID:27215058

  2. Evaluation of a mentorship program to support chronic kidney disease care

    PubMed Central

    Pang, Jocelyn; Grill, Allan; Bhatt, Monisha; Woodward, Graham L.; Brimble, Scott

    2016-01-01

    Abstract Problem addressed Primary care providers (PCPs) are ideally situated to detect and manage patients with chronic kidney disease (CKD), but they could use more support from nephrologists to accomplish this. Objective of program To improve early detection and management of CKD in primary care, and improve referrals to nephrologists through education and greater partnership between nephrologists and PCPs. Program description Nephrologists provided mentorship to PCPs in Ontario through a collaborative relationship. Nephrologists provided PCPs with educational orientation sessions and need-based advice on patient cases. Conclusion Primary care providers with more than 5 years of experience were more likely to use the program. Primary care providers expressed high satisfaction with the program and reported that it was effective in supporting routine CKD screening efforts, management of early CKD, appropriate referrals, and building a collaborative relationship with nephrologists. PMID:27521409

  3. Understanding and treatment of chronic abdominal pain in pediatric primary care.

    PubMed

    Schurman, Jennifer Verrill; Kessler, Emily D; Friesen, Craig A

    2014-10-01

    This study examined the practices used by primary care pediatricians to assess and treat chronic abdominal pain (CAP), as an initial step in guiding clinical practice guideline (CPG) development. A survey was mailed to a random sample of office-based pediatrician members (primary care pediatricians [PCPs]) of the American Medical Association. PCPs (n = 470) provided information about the typical presentation of CAP, assessment/treatment approaches used in their own practice, their definition of a functional gastrointestinal disorder (FGID), and their familiarity with the Rome Criteria for diagnosing FGIDs. Substantial variability among PCPs was noted across all these areas. Results suggest that perceptions and practices of pediatric CAP vary widely among PCPs; no single standard of care emerged to guide development of a CPG for this population. Future research should evaluate the efficacy of specific strategies currently in use to identify potential opportunities for improving assessment and treatment of CAP in pediatric primary care.

  4. The College Experience for Students with Chronic Illness: Implications for Academic Advising

    ERIC Educational Resources Information Center

    Houman, Katie M.; Stapley, Janice C.

    2013-01-01

    A purposive sample (2 males, 3 females) of students (aged 18-29 years) with chronic illness completed standardized measures and a semi-structured interview. Content analysis of the interview data revealed two themes: stress exacerbating symptoms of illness and a desire for a support group on campus. Viewed through the theory of emerging adulthood,…

  5. CKD as a Model for Improving Chronic Disease Care through Electronic Health Records.

    PubMed

    Drawz, Paul E; Archdeacon, Patrick; McDonald, Clement J; Powe, Neil R; Smith, Kimberly A; Norton, Jenna; Williams, Desmond E; Patel, Uptal D; Narva, Andrew

    2015-08-01

    Electronic health records have the potential to improve the care of patients with chronic medical conditions. CKD provides a unique opportunity to show this potential: the disease is common in the United States, there is significant room to improve CKD detection and management, CKD and its related conditions are defined primarily by objective laboratory data, CKD care requires collaboration by a diverse team of health care professionals, and improved access to CKD-related data would enable identification of a group of patients at high risk for multiple adverse outcomes. However, to realize the potential for improvement in CKD-related care, electronic health records will need to provide optimal functionality for providers and patients and interoperability across multiple health care settings. The goal of the National Kidney Disease Education Program Health Information Technology Working Group is to enable and support the widespread interoperability of data related to kidney health among health care software applications to optimize CKD detection and management. Over the course of the last 2 years, group members met to identify general strategies for using electronic health records to improve care for patients with CKD. This paper discusses these strategies and provides general goals for appropriate incorporation of CKD-related data into electronic health records and corresponding design features that may facilitate (1) optimal care of individual patients with CKD through improved access to clinical information and decision support, (2) clinical quality improvement through enhanced population management capabilities, (3) CKD surveillance to improve public health through wider availability of population-level CKD data, and (4) research to improve CKD management practices through efficiencies in study recruitment and data collection. Although these strategies may be most effectively applied in the setting of CKD, because it is primarily defined by laboratory

  6. Essential Elements of an Academic Program for Whatcom County Public School Students Challenged with Social/Emotional and/or Chronic Mental Health Disorders

    ERIC Educational Resources Information Center

    Jewell-Jenkins, Carolyn

    2009-01-01

    This study identifies essential program elements for Whatcom Discovery Center, a Northwest Educational Service District cooperative program providing academic and social/emotional development services to students who are challenged with severe social/emotional and/or chronic mental health disorders. The seven (7) Superintendents and seven (7)…

  7. Treating anemia of chronic kidney disease in the primary care setting: cardiovascular outcomes and management recommendations.

    PubMed

    Schmidt, Rebecca J; Dalton, Cheryl L

    2007-10-02

    Anemia is an underrecognized but characteristic feature of chronic kidney disease (CKD), associated with significant cardiovascular morbidity, hospitalization, and mortality. Since their inception nearly two decades ago, erythropoiesis-stimulating agents (ESAs) have revolutionized the care of patients with renal anemia, and their use has been associated with improved quality of life and reduced hospitalizations, inpatient costs, and mortality. Hemoglobin targets >/=13 g/dL have been linked with adverse events in recent randomized trials, raising concerns over the proper hemoglobin range for ESA treatment. This review appraises observational and randomized studies of the outcomes of erythropoietic treatment and offers recommendations for managing renal anemia in the primary care setting.

  8. Practitioners' Perceptions of the Academic Preparation of Funeral Directors and Embalmers in the Context of Changing Death Care Preferences in the United States

    ERIC Educational Resources Information Center

    LuBrant, Michael Paul

    2013-01-01

    This study investigated practitioners' perceptions of the a) importance, b) academic preparation related to, and c) adequacy of, funeral service education at academic programs accredited by the American Board of Funeral Service Education (ABFSE) in the context of changing death care preferences in the United States. Participants in this…

  9. Engaging Patients in Online Self-Care Technologies for Chronic Disease Management.

    PubMed

    Picton, Peter; Wiljer, David; Urowitz, Sara; Cafazzo, Joseph A

    2016-01-01

    A common perception is that the use of Internet-based self-care systems is best suited for a younger, tech-proficient population, and that these systems will increase the burden on patients with complex chronic conditions. The study stratified patients with diabetes into three regimens of use of an Internet-based diabetes self-care portal. Results show that patients were more likely to adhere to a diurnal regimen than a variable regimen, and older patients, over the age of 60, were more adherent than younger patients, regardless of regimen. This suggests that common misconceptions should be reconsidered when prescribing Internet-based interventions for patients with chronic illness. PMID:27009709

  10. Cultural intersections in the care of Mexican American children with chronic conditions.

    PubMed

    Rehm, Roberta S

    2003-01-01

    Cultural intersections occur whenever people from different cultures meet. Intracultural intersections may also occur between people with a similar heritage but different life experiences. Cultural intersections can present challenges in communication and understanding between people with differing values and priorities. At the same time, they offer opportunities for growth, illuminate universal suffering, and foster compassion. This article describes cultural intersections experienced by Mexican American parents of children with chronic conditions. These intersections affect relationships between parents and among parents, nurses, and other health care providers, sometimes providing unexpected insights for parents about their own lives and experiences. Nurses who are aware of cultural intersections in their practices can enhance their appreciation for the diversity existing within and between cultural groups, while focusing on the universal goal of providing excellent care for children with chronic conditions.

  11. Using the chronic care model to address tobacco in health care delivery organizations: a pilot experience in Washington state.

    PubMed

    Carlini, Beatriz H; Schauer, Gillian; Zbikowski, Susan; Thompson, Juliet

    2010-09-01

    This article describes a Washington State-based Systems Change Pilot Project in which the chronic care model and the model for improvement were used as tools to promote tobacco cessation-related changes within a health care system. Three diverse sites participated in the pilot. Site teams tailored plan-do-study-act tests to site circumstances, addressing current resources and barriers to implementing change. Teams tested system changes that incorporated tobacco use documentation into the routine health services provided. Findings from this pilot suggest that (a) even simple changes with minimal disruption of services can make a difference in improving documentation of tobacco use status; (b) changes to routine practices of health organizations may not be sustainable if ongoing quality assurance mechanisms are not developed; and (c) systems implemented for other disease states within the same organization or patient population are not instinctively applied to tobacco, because of a multitude of factors.

  12. Treating chronic insomnia in long-term care: a look at nonpharmacologic options.

    PubMed

    Dornberger, Sherrie

    2008-01-01

    It is important to establish a goal when a resident is diagnosed with chronic insomnia. Based on clinical studies, sleep hygiene should be the first step in managing insomnia. Long-term care facilities should identify environmental factors that may put residents at risk for insomnia. CBT has been studied and shown to be effetive in the management of chronic insomnia, especially in older adults at risk for complications associated with drug therapy. Various CBT options are available. The type of CBT used should be individualized depending upon the resident and resources available within the facility. Drug therapy can be added if CBT alone is ineffective. The next article in this series will discuss pharmacologic options to manage chronic insomnia.

  13. Caring Mentoring for Academic Literacy: A Case Study of a Teacher Education College in Israel

    ERIC Educational Resources Information Center

    Wolffensperger, Yochie

    2010-01-01

    This article describes aspects of research relating to the influences of mentoring on the teaching and learning of academic literacy conducted at the College Centre for Academic Literacy (WAL) at a teacher education college in Israel. This multiple case study, based on the principles of grounded theory, describes five cases. Data were collected…

  14. The Chronic Care Model and Technological Research and Innovation: A Scoping Review at the Crossroads

    PubMed Central

    Berntsen, Gro Karine Rosvold; Koricho, Absera Teshome; Sygna, Karin; Ruland, Cornelia

    2015-01-01

    Background Information and communication technologies (ICT) are key to optimizing the outcomes of the Chronic Care Model (CCM), currently acknowledged as the best synthesis of available evidence for chronic illness prevention and management. At the same time, CCM can offer a needed framework for increasing the relevance and feasibility of ICT innovation and research in health care. Little is known about how and to what extent CCM and ICT research inform each other to leverage mutual strengths. The current study examines: What characterizes work being done at the crossroads of CCM and ICT research and innovation? Objective Our aim is identify the gaps and potential that lie between the research domains CCM and ICT, thus enabling more substantive questions and opportunities for accelerating improvements in ICT-supported chronic care. Methods Using a scoping study approach, we developed a search strategy applied to medical and technical databases resulting in 1054 titles and abstracts that address CCM and ICT. After iteratively adapting our inclusion/exclusion criteria to balance between breadth and feasibility, 26 publications from 20 studies were found to fulfill our criteria. Following initial coding of each article according to predefined categories (eg, type of article, CCM component, ICT, health issue), a 1st level analysis was conducted resulting in a broad range of categories. These were gradually reduced by constantly comparing them for underlying commonalities and discrepancies. Results None of the studies included were from technical databases and interventions relied mostly on “old-fashioned” technologies. Technologies supporting “productive interactions” were often one-way (provider to patient), and it was sometimes difficult to decipher how CCM was guiding intervention design. In particular, the major focus on ICT to support providers did not appear unique to the challenges of chronic care. Challenges in facilitating CCM components through ICT

  15. Interprofessional teamwork and team interventions in chronic care: A systematic review.

    PubMed

    Körner, Mirjam; Bütof, Sarah; Müller, Christian; Zimmermann, Linda; Becker, Sonja; Bengel, Jürgen

    2016-01-01

    To identify key features of teamwork and interventions for enhancing interprofessional teamwork (IPT) in chronic care and to develop a framework for further research, we conducted a systematic literature review of IPT in chronic care for the years 2002-2014. Database searches yielded 3217 abstracts, 21 of which fulfilled inclusion criteria. We identified two more studies on the topic by scanning the reference lists of included articles, which resulted in a final total of 23 included studies. The key features identified in the articles (e.g., team member characteristics, common task, communication, cooperation, coordination, responsibility, participation, staff satisfaction, patient satisfaction, and efficiency) were structured in line with the input-process-output model, and evaluated interventions, such as tools, workshops, and changes in team structure, were added to the model. The most frequently evaluated team interventions were complex intervention programs. All but one of the 14 evaluation studies resulted in enhancement of teamwork and/or staff-related, patient-related, and organization-related outcome criteria. To date, there is no consensus about the main features of IPT and the most effective team interventions in chronic care. However, the findings may be used to standardize the implementation and evaluation of IPT and team interventions in practice and for further research.

  16. Challenges in personalised management of chronic diseases-heart failure as prominent example to advance the care process.

    PubMed

    Brunner-La Rocca, Hans-Peter; Fleischhacker, Lutz; Golubnitschaja, Olga; Heemskerk, Frank; Helms, Thomas; Hoedemakers, Thom; Allianses, Sandra Huygen; Jaarsma, Tiny; Kinkorova, Judita; Ramaekers, Jan; Ruff, Peter; Schnur, Ivana; Vanoli, Emilio; Verdu, Jose; Zippel-Schultz, Bettina

    2015-01-01

    Chronic diseases are the leading causes of morbidity and mortality in Europe, accounting for more than 2/3 of all death causes and 75 % of the healthcare costs. Heart failure is one of the most prominent, prevalent and complex chronic conditions and is accompanied with multiple other chronic diseases. The current approach to care has important shortcomings with respect to diagnosis, treatment and care processes. A critical aspect of this situation is that interaction between stakeholders is limited and chronic diseases are usually addressed in isolation. Health care in Western countries requires an innovative approach to address chronic diseases to provide sustainability of care and to limit the excessive costs that may threaten the current systems. The increasing prevalence of chronic diseases combined with their enormous economic impact and the increasing shortage of healthcare providers are among the most critical threats. Attempts to solve these problems have failed, and future limitations in financial resources will result in much lower quality of care. Thus, changing the approach to care for chronic diseases is of utmost social importance. PMID:26913090

  17. Divorce and Childhood Chronic Illness: A Grounded Theory of Trust, Gender, and Third-Party Care Providers.

    PubMed

    Russell, Luke T; Coleman, Marilyn; Ganong, Lawrence H; Gayer, Debra

    2016-05-01

    Divorced parents face distinct challenges in providing care for chronically ill children. Children's residence in two households necessitates the development of family-specific strategies to ensure coparents' supervision of regimen adherence and the management of children's health care. Utilizing a risk and resilience perspective, a grounded theory study was conducted with 14 divorced parents of children with chronic illnesses. The importance of trust, gender, and relationships with third-party care providers emerged as key themes related to the development of effective coparenting relationships for maintaining children's health. Divorced parents were best able to support the management of their children's chronic conditions when care providers operated as neutral third parties and intermediaries. Collaborative family care may require health care practitioners to avoid being drawn into contentious inter-parental conflicts. PMID:27021310

  18. Divorce and Childhood Chronic Illness: A Grounded Theory of Trust, Gender, and Third-Party Care Providers.

    PubMed

    Russell, Luke T; Coleman, Marilyn; Ganong, Lawrence H; Gayer, Debra

    2016-05-01

    Divorced parents face distinct challenges in providing care for chronically ill children. Children's residence in two households necessitates the development of family-specific strategies to ensure coparents' supervision of regimen adherence and the management of children's health care. Utilizing a risk and resilience perspective, a grounded theory study was conducted with 14 divorced parents of children with chronic illnesses. The importance of trust, gender, and relationships with third-party care providers emerged as key themes related to the development of effective coparenting relationships for maintaining children's health. Divorced parents were best able to support the management of their children's chronic conditions when care providers operated as neutral third parties and intermediaries. Collaborative family care may require health care practitioners to avoid being drawn into contentious inter-parental conflicts.

  19. Home Palliative Care for Patients with Advanced Chronic Kidney Disease: Preliminary Results

    PubMed Central

    Teruel, José L.; Rexach, Lourdes; Burguera, Victor; Gomis, Antonio; Fernandez-Lucas, Milagros; Rivera, Maite; Diaz, Alicia; Collazo, Sergio; Liaño, Fernando

    2015-01-01

    Healthcare for patients with advanced chronic kidney disease (ACKD) on conservative treatment very often poses healthcare problems that are difficult to solve. At the end of 2011, we began a program based on the care and monitoring of these patients by Primary Care Teams. ACKD patients who opted for conservative treatment were offered the chance to be cared for mainly at home by the Primary Care doctor and nurse, under the coordination of the Palliative Care Unit and the Nephrology Department. During 2012, 2013, and 2014, 76 patients received treatment in this program (mean age: 81 years; mean Charlson age-comorbidity index: 10, and mean glomerular filtration rate: 12.4 mL/min/1.73 m2). The median patient follow-up time (until death or until 31 December 2014) was 165 days. During this period, 51% of patients did not have to visit the hospital’s emergency department and 58% did not require hospitalization. Forty-eight of the 76 patients died after a median time of 135 days in the program; 24 (50%) died at home. Our experience indicates that with the support of the Palliative Care Unit and the Nephrology Department, ACKD patients who are not dialysis candidates may be monitored at home by Primary Care Teams. PMID:27417813

  20. [Health care organisation and chronic disease. A mobility-based approach].

    PubMed

    Vignes, Maguelone

    2015-01-01

    HIV/AIDS has been considered to be a chronic disease since highly active antiretroviral therapies became available at the end of the 1990s. As a result, people living with HIV now need to adjust their lives to a situation of medical dependence. Accessing and transitioning between health care services, and coordinating multiple recourses between services as well as the patient's own activities, often require an invisible but considerable amount of work for the patient. This work consists of anticipating deterioration of their state of health, developing techniques to harmonize their use of health care services and their changing expectations about health care services. A doctoral thesis in sociology on "urban health pathways" of HIV-positive people studied the social and spatial mobility aspects of this work. Illness experiences were collected in Brussels (Belgium) and Rouen (France) and analysed by the typological method. Identification of "modes of action" highlights this work of HIV-infected people during two phases of their life with the virus: firstly, acceptance of the needfor health care and social services and, secondly, adaptation to an effectively or potentially worsening health condition. Such modes of action reveal different definitions of the quality of health-care from the patient's point of view and the way patients move through the health care supply to achieve this quality. Interview-based data collection encountered the same difficulties as other previous qualitative studies on HIV Focusing on the mobility of chronic patients can provide useful findings for the organization of health care services. PMID:26168614

  1. Understanding the management of early-stage chronic kidney disease in primary care: a qualitative study

    PubMed Central

    Blakeman, Tom; Protheroe, Joanne; Chew-Graham, Carolyn; Rogers, Anne; Kennedy, Anne

    2012-01-01

    Background Primary care is recognised to have an important role in the delivery of care for people with chronic kidney disease (CKD). However, there is evidence that CKD management is currently suboptimal, with a range of practitioner concerns about its management. Aim To explore processes underpinning the implementation of CKD management in primary care. Design and setting Qualitative study in general practices participating in a chronic kidney disease collaborative undertaken as part of the National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care (CLAHRC) for Greater Manchester. Method Semi-structured interviews were conducted with GPs and practice nurses (n = 21). Normalisation Process Theory provided a framework for generation and analysis of the data. Results A predominant theme was anxiety about the disclosure of early-stage CKD with patients. The tensions experienced related to identifying and discussing CKD in older people and patients with stage 3A, embedding early-stage CKD within vascular care, and the distribution of work within the practice team. Participants provided accounts of work undertaken to resolve the difficulties encountered, with efforts having tended to focus on reassuring patients. Analysis also highlighted how anxiety surrounding disclosure influenced, and was shaped by, the organisation of care for people with CKD and associated long-term conditions. Conclusion Offering reassurance alone may be of limited benefit, and current management of early-stage CKD in primary care may miss opportunities to address susceptibility to kidney injury, improve self-management of vascular conditions, and improve the management of multimorbidity. PMID:22520910

  2. Telehomecare Communication and Self-Care in Chronic Conditions: Moving Towards a Shared Understanding

    PubMed Central

    Shea, Kimberly; Chamoff, Breanna

    2012-01-01

    Background Remote telemonitoring of patients’ vital signs is a rapidly increasing practice. While methods of communication in remote electronic monitoring differ from those in traditional home health care, the understanding shared by the nurse, patient, and family members remains the same: patients’ self-care behaviors affect exacerbations of chronic health conditions. The purpose of this paper is to examine the relationship between communication and information integration into the daily lives of patients with chronic illnesses and offer best practice recommendations for telehomecare nurses. Methods The original study utilized the Social Relations Model to examine relationships within 43 triads composed of patients with chronic conditions, home helpers and their nurse (THN) involved in telehomecare at three Veterans Health Administrations. This secondary descriptive and correlational analysis compared 43 patients’ and 9 THNs’ ratings of themselves and each other on communication (frequency, timeliness and understanding) and the use of patients’ daily telemonitored information. Results There was almost no correlation between patients’ perception of THNs’ communication (frequency [r = .05], timeliness [r = .09] and understandability [r = .03]) and patients’ integration of information into daily health practices. However, significant correlations were found between the THNs’ perception of patients’ communication frequency and timeliness, and integration, (p = .02), (p < .001) respectively. Conclusions This study suggests that frequent phone communication may lead the remote THN to believe patients are integrating blood pressure, weight and other information into daily self-care behaviors, when in fact the patient reports that they are not. The influence of a halo effect on the THN may cloud an accurate perception of what is actually occurring. Remote communication may require more attention to THNs educating patients about shared understandings

  3. Integrated care programmes for adults with chronic conditions: a meta-review

    PubMed Central

    Martínez-González, Nahara Anani; Berchtold, Peter; Ullman, Klara; Busato, André; Egger, Matthias

    2014-01-01

    Objective To review systematic reviews and meta-analyses of integrated care programmes in chronically ill patients, with a focus on methodological quality, elements of integration assessed and effects reported. Design Meta-review of systematic reviews and meta-analyses identified in Medline (1946–March 2012), Embase (1980–March 2012), CINHAL (1981–March 2012) and the Cochrane Library of Systematic Reviews (issue 1, 2012). Main Outcome Measures Methodological quality assessed by the 11-item Assessment of Multiple Systematic Reviews (AMSTAR) checklist; elements of integration assessed using a published list of 10 key principles of integration; effects on patient-centred outcomes, process quality, use of healthcare and costs. Results Twenty-seven systematic reviews were identified; conditions included chronic heart failure (CHF; 12 reviews), diabetes mellitus (DM; seven reviews), chronic obstructive pulmonary disease (COPD; seven reviews) and asthma (five reviews). The median number of AMSTAR checklist items met was five: few reviewers searched for unpublished literature or described the primary studies and interventions in detail. Most reviews covered comprehensive services across the care continuum or standardization of care through inter-professional teams, but organizational culture, governance structure or financial management were rarely assessed. A majority of reviews found beneficial effects of integration, including reduced hospital admissions and re-admissions (in CHF and DM), improved adherence to treatment guidelines (DM, COPD and asthma) or quality of life (DM). Few reviews showed reductions in costs. Conclusions Systematic reviews of integrated care programmes were of mixed quality, assessed only some components of integration of care, and showed consistent benefits for some outcomes but not others. PMID:25108537

  4. Assessment of Continuity of Care among Patients with Multiple Chronic Conditions in Italy

    PubMed Central

    Napolitano, Francesco; Napolitano, Paola; Garofalo, Luca; Recupito, Marianna; Angelillo, Italo F.

    2016-01-01

    The aims of the present study were to evaluate the extent of continuity of care and to investigate its association with several factors among a sample of outpatients with chronic diseases in Italy. The survey was conducted, using face to face interview, from March to December 2014 in a random sample of 633 outpatients with chronic conditions who were going in cardiology, metabolic disorders, and respiratory ambulatory center of four hospitals. A multivariate ordered logistic regression model was used to identify factors associated with the outpatients continuity of care. The mean of the Bice-Boxerman continuity of care (COC) index related to the entire sample was 0.44, and 27.9%, 58.4%, 13.7% had a low, intermediate, and high value of the index based on the tertiles of the distribution. The results of the ordered logistic regression analysis showed that female patients, those older, those who had a lower score of Katz Index of independence in activities of daily living, those who had a lower Charlson et al. comorbidity score, and those who had no hospitalization in the last year, were significantly more likely to have a higher value of the COC index. Patients who had completed a secondary school education had significantly lower odds of having a high value of COC index in comparison to patients with a college degree educational level. Policy makers and clinicians involved in the care of patients should implement comprehensively and efficiently efforts in order to improve the continuity of care in patients with chronic diseases. PMID:27140202

  5. Quality of Care for Patients with Chronic Respiratory Diseases: Data for Accreditation Plan in Primary Healthcare.

    PubMed

    Kurpas, Donata; Szwamel, Katarzyna; Mroczek, Bożena

    2016-01-01

    There are scarce reports in the literature on factors affecting the assessment of the quality of care for patients with chronic respiratory diseases. Such information is relevant in the accreditation process on implementing the healthcare. The study group consisted of 133 adult patients with chronic respiratory diseases and 125 adult patients with chronic non-respiratory diseases. In the present study, the level of satisfaction from healthcare provided by the primary healthcare unit, disease acceptance, quality of life, health behaviors, and met needs were examined, as well as associations between variables with the use of correspondence analysis. The results are that in patients with chronic respiratory diseases an increase in satisfaction depends on the improvement of well-being in the mental sphere. The lack of problems with obtaining a referral to a specialist and a higher level of fulfilled needs also have a positive effect. Additionally, low levels of satisfaction should be expected in those patients with chronic respiratory diseases who wait for an appointment in front of the office for a long time, report problems with obtaining a referral to additional tests, present a low level of health behaviors, and have a low index of benefits.

  6. Suicide Risk in Adolescents with Chronic Illness: Implications for Primary Care and Specialty Pediatric Practice--A Review

    ERIC Educational Resources Information Center

    Greydanus, Donald; Patel, Dilip; Pratt, Helen

    2010-01-01

    Suicide in adolescents is a global tragedy. Research-identified correlates of suicide in youth include depression, academic failure, loss of friends, social isolation, and substance abuse, among others. This review focuses on the potential link between chronic illness in adolescents and increased suicide risk. Research suggests that chronic…

  7. Integrating mental health into chronic care in South Africa: the development of a district mental healthcare plan

    PubMed Central

    Petersen, Inge; Fairall, Lara; Bhana, Arvin; Kathree, Tasneem; Selohilwe, One; Brooke-Sumner, Carrie; Faris, Gill; Breuer, Erica; Sibanyoni, Nomvula; Lund, Crick; Patel, Vikram

    2016-01-01

    Background In South Africa, the escalating prevalence of chronic illness and its high comorbidity with mental disorders bring to the fore the need for integrating mental health into chronic care at district level. Aims To develop a district mental healthcare plan (MHCP) in South Africa that integrates mental healthcare for depression, alcohol use disorders and schizophrenia into chronic care. Method Mixed methods using a situation analysis, qualitative key informant interviews, theory of change workshops and piloting of the plan in one health facility informed the development of the MHCP. Results Collaborative care packages for the three conditions were developed to enable integration at the organisational, facility and community levels, supported by a human resource mix and implementation tools. Potential barriers to the feasibility of implementation at scale were identified. Conclusions The plan leverages resources and systems availed by the emerging chronic care service delivery platform for the integration of mental health. This strengthens the potential for future scale up. PMID:26447176

  8. Assessment of Customer Service in Academic Health Care Libraries (ACSAHL): an instrument for measuring customer service*†

    PubMed Central

    Crossno, Jon E.; Berkins, Brenda; Gotcher, Nancy; Hill, Judith L.; McConoughey, Michelle; Walters, Mitchel

    2001-01-01

    Objectives: In a pilot study, the library had good results using SERVQUAL, a respected and often-used instrument for measuring customer satisfaction. The SERVQUAL instrument itself, however, received some serious and well-founded criticism from the respondents to our survey. The purpose of this study was to test the comparability of the results of SERVQUAL with a revised and shortened instrument modeled on SERVQUAL. The revised instrument, the Assessment of Customer Service in Academic Health Care Libraries (ACSAHL), was designed to better assess customer service in academic health care libraries. Methods: Surveys were sent to clients who had used the document delivery services at three academic medical libraries in Texas over the previous twelve to eighteen months. ACSAHL surveys were sent exclusively to clients at University of Texas (UT) Southwestern, while the client pools at the two other institutions were randomly divided and provided either SERVQUAL or ACSAHL surveys. Results: Results indicated that more respondents preferred the shorter ACSAHL instrument to the longer and more complex SERVQUAL instrument. Also, comparing the scores from both surveys indicated that ACSAHL elicited comparable results. Conclusions: ACSAHL appears to measure the same type of data in similar settings, but additional testing is recommended both to confirm the survey's results through data replication and to investigate whether the instrument applies to different service areas. PMID:11337948

  9. Pharmacoeconomic research--facilitating collaboration among academic institutions, managed-care organizations, and the pharmaceutical industry: a conference report.

    PubMed

    Draugalis, J R; Coons, S J

    1995-01-01

    To provide a venue to allow for the exchange of information among parties interested in pharmacoeconomic research opportunities within managed-care organizations, an invitational conference was conducted by The University of Arizona's Center for Pharmaceutical Economics on January 20 and 21, 1994, in Tucson, Arizona. The purpose of the conference was to bring together representatives from managed-care organizations, academic institutions, and the pharmaceutical industry to discuss opportunities for collaboration, as well as consider the barriers to conducting pharmacoeconomic research in the managed-care setting. Challenges to collaboration include database development, the need for an integrated perspective, sensitivity to marketing matters, and a variety of technical and organizational barriers. To overcome these barriers, the interested groups must develop trust, recognize common ground, share risk, and communicate effectively. This article describes the emerging themes of the conference based on transcripts of formal presentations and participants' comments. PMID:7758064

  10. P02.02. Quality Improvement Study Suggesting the Value of Point-of-Care Documentation of Quality of Life Vital Signs in an Academic Integrative Health Center

    PubMed Central

    Lynn, Misti; Mikhail, Eriny; Bogle, Richard; Elam, Roy

    2013-01-01

    Focus Area: Supporting Behavioral Change Rigorous quality improvement and outcome reporting within interdisciplinary academic integrative health centers (IHCs) is a realm requiring significant focus in an era of skyrocketing healthcare costs, especially in management of complex chronic illness. In one southeastern US academic IHC seeing primarily (>80%) patients with chronic pain, treatment modalities include yoga, physical therapy (PT), cognitive-based therapy (CBT), acupuncture, and group therapy. A random sample of returning patients at this IHC completed a paper survey querying the following: treatment length and modalities used as a patient at this IHC; current pain, fatigue, and anxiety levels (0–10); change in pain, fatigue, anxiety, and quality of life (−5, “much worse,” to 5, “much better”) since first visit to this IHC. Seventy-seven responses were collected. Mean and median scores were calculated for current pain (m=3.9, SD=2.6, M=4), fatigue (m=4.7, SD=3.0, M=4), anxiety (m=3.5, SD=2.7, M=3), as well as changes in QOL (m=2.8, SD=1.7, M=3), pain (m=2.4, SD=1.9, M=3), anxiety (m=2.4, SD=1.7, M=3), and fatigue (m=1.8, SD=1.7, M=3). Increasing time following treatment was associated with improved QOL (P=.045, r=0.232) as was an increasing number of services utilized (P=.021, r=0.263). Associated with these QOL changes were improved pain (P<.01, r=0.561), fatigue (P<.01, r=0.604), and anxiety (P<0.01, r=0.495) while more severe current pain (P=.002, r=−.347) and fatigue (P=.015, r=−0.277) upon survey completion inversely predicted QOL change. A two-tailed t-test revealed that patients finding PT useful reported improved QOL (P=.008), anxiety (P=.008), fatigue (P=.006), and pain (P=.003) compared to those not. Patients reporting acupuncture useful enjoyed lower anxiety (P=.016) and improved pain (P=.037) while those finding yoga useful reported improved anxiety (P=.005). Together, these data suggest the potential value of implementing a more

  11. Complexity in caring for an ageing heart failure population: concomitant chronic conditions and age related impairments.

    PubMed

    De Geest, Sabina; Steeman, Els; Leventhal, Marcia E; Mahrer-Imhof, Romy; Hengartner-Kopp, Beatrice; Conca, Antoinette; Bernasconi, Arlette T; Petry, Heidi; Brunner-La Rocca, Hanspeter

    2004-12-01

    The complexity of caring for the ageing heart failure (HF) population is further complicated by concomitant chronic conditions (i.e., polypharmacy, depression), age related impairments (i.e., hearing, visual and cognitive impairments, impairments in activities of daily living (ADL/IADL), and other issues (e.g., health illiteracy, lack of social support). This paper provides an overview of these risk factors, outlines how they individually and in interplay endanger favourable outcome by putting patients at risk for poor self-management. Moreover, suggestions are made on how these issues could be addressed and integrated in heart failure management by applying gerontological care principles in caring for the ageing heart failure population.

  12. Characterizing Adults Receiving Primary Medical Care in New York City: Implications for Using Electronic Health Records for Chronic Disease Surveillance

    PubMed Central

    Romo, Matthew L.; Lurie-Moroni, Elizabeth; Perlman, Sharon E.; Newton-Dame, Remle; Thorpe, Lorna E.; McVeigh, Katharine H.

    2016-01-01

    Introduction Electronic health records (EHRs) from primary care providers can be used for chronic disease surveillance; however, EHR-based prevalence estimates may be biased toward people who seek care. This study sought to describe the characteristics of an in-care population and compare them with those of a not-in-care population to inform interpretation of EHR data. Methods We used data from the 2013–2014 New York City Health and Nutrition Examination Survey (NYC HANES), considered the gold standard for estimating disease prevalence, and the 2013 Community Health Survey, and classified participants as in care or not in care, on the basis of their report of seeing a health care provider in the previous year. We used χ2 tests to compare the distribution of demographic characteristics, health care coverage and access, and chronic conditions between the 2 populations. Results According to the Community Health Survey, approximately 4.1 million (71.7%) adults aged 20 or older had seen a health care provider in the previous year; according to NYC HANES, approximately 4.7 million (75.1%) had. In both surveys, the in-care population was more likely to be older, female, non-Hispanic, and insured compared with the not-in-care population. The in-care population from the NYC HANES also had a higher prevalence of diabetes (16.7% vs 6.9%; P < .001), hypercholesterolemia (35.7% vs 22.3%; P < .001), and hypertension (35.5% vs 26.4%; P < .001) than the not-in-care population. Conclusion Systematic differences between in-care and not-in-care populations warrant caution in using primary care data to generalize to the population at large. Future efforts to use primary care data for chronic disease surveillance need to consider the intended purpose of data collected in these systems as well as the characteristics of the population using primary care. PMID:27126554

  13. Preconception care: screening and management of chronic disease and promoting psychological health

    PubMed Central

    2014-01-01

    Introduction A large proportion of women around the world suffer from chronic diseases including mental health diseases. In the United States alone, over 12% of women of reproductive age suffer from a chronic medical condition, especially diabetes and hypertension. Chronic diseases significantly increase the odds for poor maternal and newborn outcomes in pregnant women. Methods A systematic review and meta-analysis of the evidence was conducted to ascertain the possible impact of preconception care for preventing and managing chronic diseases and promoting psychological health on maternal, newborn and child health outcomes. A comprehensive strategy was used to search electronic reference libraries, and both observational and clinical controlled trials were included. Cross-referencing and a separate search strategy for each preconception risk and intervention ensured wider study capture. Results Maternal prepregnancy diabetic care is a significant intervention that reduces the occurrence of congenital malformations by 70% (95% Confidence Interval (CI): 59-78%) and perinatal mortality by 69% (95% CI: 47-81%). Furthermore, preconception management of epilepsy and phenylketonuria are essential and can optimize maternal, fetal and neonatal outcomes if given before conception. Ideally changes in antiepileptic drug therapy should be made at least 6 months before planned conception. Interventions specifically targeting women of reproductive age suffering from a psychiatric condition show that group-counseling and interventions leading to empowerment of women have reported non-significant reduction in depression (economic skill building: Mean Difference (MD) -7.53; 95% CI: -17.24, 2.18; counseling: MD-2.92; 95% CI: -13.17, 7.33). Conclusion While prevention and management of the chronic diseases like diabetes and hypertension, through counseling, and other dietary and pharmacological intervention, is important, delivering solutions to prevent and respond to women

  14. Management of Chronic Diseases in Sub-Saharan Africa: Cross-Fertilisation between HIV/AIDS and Diabetes Care.

    PubMed

    van Olmen, Josefien; Schellevis, François; Van Damme, Wim; Kegels, Guy; Rasschaert, Freya

    2012-01-01

    There is growing attention for chronic diseases in sub-Saharan Africa (SSA) and for bridges between the management of HIV/AIDS and other (noncommunicable) chronic diseases. This becomes more urgent with increasing numbers of people living with both HIV/AIDS and other chronic conditions. This paper discusses the commonalities between chronic diseases by reviewing models of care, focusing on the two most dominant ones, diabetes mellitus type 2 (DM2) and HIV/AIDS. We argue that in order to cope with care for HIV patients and diabetes patients, health systems in SSA need to adopt new strategies taking into account essential elements of chronic disease care. We developed a "chronic dimension framework," which analyses the "disease dimension," the "health provider dimension," the patient or "person dimension," and the "environment dimension" of chronic diseases. Applying this framework to HIV/AIDS and DM2 shows that it is useful to think about management of both in tandem, comparing care delivery platforms and self-management strategies. A literature review on care delivery models for diabetes and HIV/AIDS in SSA revealed potential elements for cross-fertilisation: rapid scale-up approaches through the public health approach by simplification and decentralisation; community involvement, peer support, and self-management strategies; and strengthening health services.

  15. Pediatric Solid Organ Transplant Recipients: Transition to Home and Chronic Illness Care

    PubMed Central

    Lerret, Stacee M; Weiss, Marianne; Stendahl, Gail; Chapman, Shelley; Menendez, Jerome; Williams, Laurel; Nadler, Michelle; Neighbors, Katie; Amsden, Katie; Cao, Yumei; Nugent, Melodee; Alonso, Estella; Simpson, Pippa

    2014-01-01

    Pediatric solid organ transplant recipients are medically fragile and present with complex care issues requiring high-level management at home. Parents of hospitalized children have reported inadequate preparation for discharge, resulting in problems transitioning from hospital to home and independently self-managing their child’s complex care needs. The aim of this study was to investigate factors associated with the transition from hospital to home and chronic illness care for parents of heart, kidney, liver, lung, or multivisceral recipients. Fifty-one parents from five pediatric transplant centers completed questionnaires on the day of hospital discharge and telephone interviews at 3-week, 3-month, and 6-months following discharge from the hospital. Care coordination (p = .02) and quality of discharge teaching (p < .01) was significantly associated with parent readiness for discharge. Readiness for hospital discharge was subsequently significantly associated with post-discharge coping difficulty (p = .02) at 3-weeks, adherence with medication administration (p = .03) at 3-months, and post-discharge coping difficulty (p = .04) and family management (p = .02) at 6-months post-discharge. The results underscore the important aspect of education and care coordination in preparing patients and families to successfully self-manage after hospital discharge. Assessing parental readiness for hospital discharge is another critical component for identifying risk of difficulties in managing post-discharge care. PMID:25425201

  16. Reengineering acute episodic and chronic care delivery: the Geisinger Health System experience.

    PubMed

    Slotkin, Jonathan R; Casale, Alfred S; Steele, Glenn D; Toms, Steven A

    2012-07-01

    Comparative effectiveness research (CER) represents an evolution in clinical decision-making research that allows for the study of heterogeneous groups of patients with complex diseases processes. It has foundations in decision science, reliability science, and health care policy research. Health care finance will increasingly rely on CER for guidance in the coming years. There is increasing awareness of the importance of decreasing unwarranted variation in health care delivery. In the past 7 years, Geisinger Health System has performed broad reengineering of its acute episodic and chronic care delivery models utilizing macrosystem-level application of CER principles. These provider-driven process initiatives have resulted in significant improvement across all segments of care delivery, improved patient outcomes, and notable cost containment. These programs have led to the creation of novel pricing models, and when "hardwired" throughout a care delivery system, they can lead to correct medical decision making by 100% of providers in all patient encounters. Neurosurgery as a specialty faces unique challenges and opportunities with respect to broad adoption and application of CER techniques. PMID:22746233

  17. Pediatric solid organ transplant recipients: transition to home and chronic illness care.

    PubMed

    Lerret, Stacee M; Weiss, Marianne E; Stendahl, Gail L; Chapman, Shelley; Menendez, Jerome; Williams, Laurel; Nadler, Michelle L; Neighbors, Katie; Amsden, Katie; Cao, Yumei; Nugent, Melodee; Alonso, Estella M; Simpson, Pippa

    2015-02-01

    Pediatric SOT recipients are medically fragile and present with complex care issues requiring high-level management at home. Parents of hospitalized children have reported inadequate preparation for discharge, resulting in problems transitioning from hospital to home and independently self-managing their child's complex care needs. The aim of this study was to investigate factors associated with the transition from hospital to home and chronic illness care for parents of heart, kidney, liver, lung, or multivisceral recipients. Fifty-one parents from five pediatric transplant centers completed questionnaires on the day of hospital discharge and telephone interviews at three wk, three months, and six months following discharge from the hospital. Care coordination (p = 0.02) and quality of discharge teaching (p < 0.01) was significantly associated with parent readiness for discharge. Readiness for hospital discharge was subsequently significantly associated with post-discharge coping difficulty (p = 0.02) at three wk, adherence with medication administration (p = 0.03) at three months, and post-discharge coping difficulty (p = 0.04) and family management (p = 0.02) at six months post-discharge. The results underscore the important aspect of education and care coordination in preparing patients and families to successfully self-manage after hospital discharge. Assessing parental readiness for hospital discharge is another critical component for identifying risk of difficulties in managing post-discharge care. PMID:25425201

  18. Reengineering acute episodic and chronic care delivery: the Geisinger Health System experience.

    PubMed

    Slotkin, Jonathan R; Casale, Alfred S; Steele, Glenn D; Toms, Steven A

    2012-07-01

    Comparative effectiveness research (CER) represents an evolution in clinical decision-making research that allows for the study of heterogeneous groups of patients with complex diseases processes. It has foundations in decision science, reliability science, and health care policy research. Health care finance will increasingly rely on CER for guidance in the coming years. There is increasing awareness of the importance of decreasing unwarranted variation in health care delivery. In the past 7 years, Geisinger Health System has performed broad reengineering of its acute episodic and chronic care delivery models utilizing macrosystem-level application of CER principles. These provider-driven process initiatives have resulted in significant improvement across all segments of care delivery, improved patient outcomes, and notable cost containment. These programs have led to the creation of novel pricing models, and when "hardwired" throughout a care delivery system, they can lead to correct medical decision making by 100% of providers in all patient encounters. Neurosurgery as a specialty faces unique challenges and opportunities with respect to broad adoption and application of CER techniques.

  19. Chronic Care Management for Dependence on Alcohol and Other Drugs: The AHEAD Randomized Trial

    PubMed Central

    Saitz, Richard; Cheng, Debbie M.; Winter, Michael; Kim, Theresa W.; Meli, Seville M.; Allensworth-Davies, Don; Lloyd-Travaglini, Christine A.; Samet, Jeffrey H.

    2014-01-01

    Importance People with substance dependence have health consequences, high healthcare utilization and frequent comorbidity but often receive poor quality care overall and for dependence. Chronic care management has been proposed as an approach to improve care and outcomes. Objective To determine whether chronic care management (CCM) for alcohol and other drug (AOD) dependence improves substance use outcomes compared to usual primary care. Design, Setting, and Participants The AHEAD study was a randomized trial in people with AOD dependence, not necessarily seeking treatment, at a Boston hospital-based primary care practice. Of the 655 eligible participants, 563 (86%) were randomized. Study participants were recruited from September 2006 to September 2008 from a free-standing residential detoxification unit (74%) and referrals from an urban teaching hospital and advertisements (26%). Participants were randomized to CCM (n=282) or no CCM (n=281). Intervention CCM included longitudinal care coordinated with a primary care clinician, motivational enhancement therapy, relapse prevention counseling, and on-site medical, addiction and psychiatric treatment, social work assistance and referrals (including mutual help). The no CCM group received a primary care appointment, and a list of treatment resources including a phone number to arrange counseling. Main Outcome and Measure The primary outcome was self-reported abstinence from opioids, stimulants or heavy drinking. Biomarkers were secondary outcomes. We employed longitudinal analyses for data from 3, 6 and 12 months (last interview January 21, 2010). Results Of 563 participants, 95% completed 12-month follow-up. Baseline characteristics of the study participants were similar across randomization groups, but differed significantly for race and depressive symptoms. There was no significant difference in abstinence from opioids, stimulants or heavy drinking between the CCM (44%) and control (42%) groups (adjusted odds

  20. [Empowerment and power: their relationship in the proces of caring for the chronically ill in primary care].

    PubMed

    Riba Bellera, Lydia; Boixadera Vendrell, Mireia; Buendía Surroca, Carmen; Martorell Poveda, Maria Antònia; Piñeiro Méndez, Pilar; Zamora Sánchez, Juan José

    2014-06-01

    The concepts of "power" and "empowerment" are used in various disciplines, both political and social. Now are these terms frequently in the field of health. Our goal is to know its meaning as a synonym of expressions: "energy", "force", "domain", "vigour", "power", "capacity", "authority" and "control", which have been always within our practice nurse's own lexicon. Semantically analyzing them will help us in the understanding of its nuance. The literature review facilitates their understanding and allows us to link these words within the management of care. In this way we can propose diagnoses, interventions and outcomes specifically related to these concepts, which will help us optimize the efficiency in the management of care plans. The purpose of various collective nurses from different institutions is that the person is able to not generate dependencies and have the option of choosing your own lifestyle according to their culture and environment, independently or with the help. Generate knowledge is to generate power. The person should be educated and informed, to be expert and active and taking action to help control and minimize the progression of your health problem chronic and its possible complications. We are in the process of reformulation of the health system, whether it is private or public, and is necessary to know the power of the various actors involved in the management of the care to us. Each of these main actors--person ill, family/caregiver or nurse--has to know what is his role in this process.

  1. The Effect of Chairside Chronic Disease Screenings by Oral Health Professionals on Health Care Costs

    PubMed Central

    Greenberg, Barbara; Vujicic, Marko; Glick, Michael

    2014-01-01

    Objectives. We estimated short-term health care cost savings that would result from oral health professionals performing chronic disease screenings. Methods. We used population data, estimates of chronic disease prevalence, and rates of medication adherence from the literature to estimate cost savings that would result from screening individuals aged 40 years and older who have seen a dentist but not a physician in the last 12 months. We estimated 1-year savings if patients identified during screening in a dental setting were referred to a physician, completed their referral, and started pharmacological treatment. Results. We estimated that medical screenings for diabetes, hypertension, and hypercholesterolemia in dental offices could save the health care system from $42.4 million ($13.51 per person screened) to $102.6 million ($32.72 per person screened) over 1 year, dependent on the rate of referral completion from the dental clinic to the physician's office. Conclusions. Oral health professionals can potentially play a bigger role in detecting chronic disease in the US population. Additional prevention and monitoring activities over the long term could achieve even greater savings and health benefits. PMID:24524531

  2. Negative pressure wound therapy technologies for chronic wound care in the home setting: A systematic review.

    PubMed

    Rhee, Susan M; Valle, M Frances; Wilson, Lisa M; Lazarus, Gerald; Zenilman, Jonathan M; Robinson, Karen A

    2015-01-01

    The use of negative pressure wound therapy (NPWT) is increasing in both the inpatient and outpatient settings. We conducted a systematic review on the efficacy and safety of NPWT for the treatment of chronic wounds in the home setting. We searched MEDLINE, Embase, the Cochrane Central Register of Controlled Trials, and the Cumulative Index to Nursing and Allied Health Literature, up to June 2014. Two independent reviewers screened search results. Seven studies met our criteria for inclusion. Six of the studies compared NPWT devices to other wound care methods and one study compared two different NPWT technologies. Data were limited by variability in the types of comparator groups, methodological limitations, and poor reporting of outcomes. We were unable to draw conclusions about the efficacy or safety of NPWT for the treatment of chronic wounds in the home setting due to the insufficient evidence. Consensus is needed on the methods of conducting and reporting wound care research so that future studies are able inform decisions about the use of NPWT in the home environment for chronic wounds.

  3. Connected health and integrated care: Toward new models for chronic disease management.

    PubMed

    Chouvarda, Ioanna G; Goulis, Dimitrios G; Lambrinoudaki, Irene; Maglaveras, Nicos

    2015-09-01

    The increasingly aging population in Europe and worldwide brings up the need for the restructuring of healthcare. Technological advancements in electronic health can be a driving force for new health management models, especially in chronic care. In a patient-centered e-health management model, communication and coordination between patient, healthcare professionals in primary care and hospitals can be facilitated, and medical decisions can be made timely and easily communicated. Bringing the right information to the right person at the right time is what connected health aims at, and this may set the basis for the investigation and deployment of the integrated care models. In this framework, an overview of the main technological axes and challenges around connected health technologies in chronic disease management are presented and discussed. A central concept is personal health system for the patient/citizen and three main application areas are identified. The connected health ecosystem is making progress, already shows benefits in (a) new biosensors, (b) data management, (c) data analytics, integration and feedback. Examples are illustrated in each case, while open issues and challenges for further research and development are pinpointed.

  4. Multimorbidity in chronic disease: impact on health care resources and costs

    PubMed Central

    McPhail, Steven M

    2016-01-01

    Effective and resource-efficient long-term management of multimorbidity is one of the greatest health-related challenges facing patients, health professionals, and society more broadly. The purpose of this review was to provide a synthesis of literature examining multimorbidity and resource utilization, including implications for cost-effectiveness estimates and resource allocation decision making. In summary, previous literature has reported substantially greater, near exponential, increases in health care costs and resource utilization when additional chronic comorbid conditions are present. Increased health care costs have been linked to elevated rates of primary care and specialist physician occasions of service, medication use, emergency department presentations, and hospital admissions (both frequency of admissions and bed days occupied). There is currently a paucity of cost-effectiveness information for chronic disease interventions originating from patient samples with multimorbidity. The scarcity of robust economic evaluations in the field represents a considerable challenge for resource allocation decision making intended to reduce the burden of multimorbidity in resource-constrained health care systems. Nonetheless, the few cost-effectiveness studies that are available provide valuable insight into the potential positive and cost-effective impact that interventions may have among patients with multiple comorbidities. These studies also highlight some of the pragmatic and methodological challenges underlying the conduct of economic evaluations among people who may have advanced age, frailty, and disadvantageous socioeconomic circumstances, and where long-term follow-up may be required to directly observe sustained and measurable health and quality of life benefits. Research in the field has indicated that the impact of multimorbidity on health care costs and resources will likely differ across health systems, regions, disease combinations, and person

  5. Multimorbidity in chronic disease: impact on health care resources and costs.

    PubMed

    McPhail, Steven M

    2016-01-01

    Effective and resource-efficient long-term management of multimorbidity is one of the greatest health-related challenges facing patients, health professionals, and society more broadly. The purpose of this review was to provide a synthesis of literature examining multimorbidity and resource utilization, including implications for cost-effectiveness estimates and resource allocation decision making. In summary, previous literature has reported substantially greater, near exponential, increases in health care costs and resource utilization when additional chronic comorbid conditions are present. Increased health care costs have been linked to elevated rates of primary care and specialist physician occasions of service, medication use, emergency department presentations, and hospital admissions (both frequency of admissions and bed days occupied). There is currently a paucity of cost-effectiveness information for chronic disease interventions originating from patient samples with multimorbidity. The scarcity of robust economic evaluations in the field represents a considerable challenge for resource allocation decision making intended to reduce the burden of multimorbidity in resource-constrained health care systems. Nonetheless, the few cost-effectiveness studies that are available provide valuable insight into the potential positive and cost-effective impact that interventions may have among patients with multiple comorbidities. These studies also highlight some of the pragmatic and methodological challenges underlying the conduct of economic evaluations among people who may have advanced age, frailty, and disadvantageous socioeconomic circumstances, and where long-term follow-up may be required to directly observe sustained and measurable health and quality of life benefits. Research in the field has indicated that the impact of multimorbidity on health care costs and resources will likely differ across health systems, regions, disease combinations, and person

  6. [The wound care center in surgery: an interdisciplinary concept for diagnostic and treatment of chronic wounds].

    PubMed

    Coerper, S; Schäffer, M; Enderle, M; Schott, U; Köveker, G; Becker, H D

    1999-04-01

    In Germany there is no standardized wound care for patients with chronic wounds in specialized centers. We have established a wound care unit for the past 6 years. The principal concept of therapy was characterized by standardized local surgery, moist wound dressings and concomitant treatment of the underlying disease. We performed local therapy, coordinated the interdisciplinary treatment and developed a new wound documentation system for quality control. We established a close network, integrating general practitioners and home care organizations to realize a mainly outpatient treatment supported by short hospital therapy. Exclusive outpatient treatment was performed in 42% of all patients. According to our prospective data, we achieved an improvement in wound care: 69% of the wounds resistant to therapy for a mean of 30 months healed within 12 months after therapy according to our protocol. Our data strongly supported the importance of local surgery: neither wound depth nor wound infection had any influence on the healing rate, presumably due to radical excisional debridement of necrotic tissue. The presented data justify on medical and economic grounds the establishment of such wound care centers in Germany. PMID:10354850

  7. A First Step on the Journey to High-Quality Chronic Illness Care.

    PubMed

    Wagner, Edward H

    2016-01-01

    The Atlantic Healthcare Collaboration (AHC) conducted a quality improvement initiative to improve chronic disease prevention and management for the four Atlantic provinces and their regional health authorities. Leaders and front-line teams carried out a range of projects, each suited to the needs of that region. This initiative helped build the case for improvement, increased the motivation to change, exposed participants to proven ideas for improvement and supported participating organizations in developing the capacity and culture to test, implement and spread improvements. The AHC also created a politically safe learning community with the potential to support and sustain the work of chronic care improvement over time. In carrying this initiative forward, the greatest challenge will be the magnitude of work to be done. PMID:27009640

  8. The Chronic Care Model: A Collaborative Approach to Preventing and Treating Asthma in Infants and Young Children

    ERIC Educational Resources Information Center

    Wessel, Lois; Spain, Jacqueline

    2005-01-01

    The authors that a collaborative approach between parents and professionals is the best way to care for a young child with asthma. They use Ed Wagner's transdisciplinary 1998 Chronic Care Model as their preferred method for collaboration. More than 5 million children in the U.S. are currently affected by asthma, and a growing body of evidence…

  9. An Academic Medical Center's Experience with Mandatory Managed Care for Medicaid Recipients.

    ERIC Educational Resources Information Center

    Hillman, Alan L.; And Others

    1991-01-01

    This paper reports on experiences and concerns of the Hospital of the University of Pennsylvania as a participating primary care site in a Medicaid managed care program (HealthPASS). Discussed are the modification of existing activities to meet increased care demands and administrative demands, and characteristics of HealthPASS that have impeded…

  10. The Effect of Foster Care Experience and Characteristics on Academic Achievement

    ERIC Educational Resources Information Center

    Calix, Alexandra

    2009-01-01

    This study examined the effect of foster care experience and characteristics on educational outcomes. The typical strategy in examining the effect foster care has on educational outcomes is to compare the educational achievement of youth with foster care experience to that of their peers or to national norms. This strategy fails to take selection…

  11. Depression predicts future emergency hospital admissions in primary care patients with chronic physical illness

    PubMed Central

    Guthrie, Elspeth A.; Dickens, Chris; Blakemore, Amy; Watson, Jennifer; Chew-Graham, Carolyn; Lovell, Karina; Afzal, Cara; Kapur, Navneet; Tomenson, Barbara

    2016-01-01

    Objective More than 15 million people currently suffer from a chronic physical illness in England. The objective of this study was to determine whether depression is independently associated with prospective emergency hospital admission in patients with chronic physical illness. Method 1860 primary care patients in socially deprived areas of Manchester with at least one of four exemplar chronic physical conditions completed a questionnaire about physical and mental health, including a measure of depression. Emergency hospital admissions were recorded using GP records for the year before and the year following completion of the questionnaire. Results The numbers of patients who had at least one emergency admission in the year before and the year after completion of the questionnaire were 221/1411 (15.7%) and 234/1398 (16.7%) respectively. The following factors were independently associated with an increased risk of prospective emergency admission to hospital: having no partner (OR 1.49, 95% CI 1.04 to 2.15); having ischaemic heart disease (OR 1.60, 95% CI 1.04 to 2.46); having a threatening experience (OR 1.16, 95% CI 1.04 to 1.29); depression (OR 1.58, 95% CI 1.04 to 2.40); and emergency hospital admission in the year prior to questionnaire completion (OR 3.41, 95% CI 1.98 to 5.86). Conclusion To prevent potentially avoidable emergency hospital admissions, greater efforts should be made to detect and treat co-morbid depression in people with chronic physical illness in primary care, with a particular focus on patients who have no partner, have experienced threatening life events, and have had a recent emergency hospital admission. PMID:26919799

  12. Academic health centers and care of undocumented immigrants in the United States: servant leaders or uncourageous followers?

    PubMed

    Acosta, David A; Aguilar-Gaxiola, Sergio

    2014-04-01

    Public dialogue and debate about the health care overhaul in the United States is centered on one contentious question: Is there a moral obligation to ensure that all people (including undocumented immigrants) within its borders have access to affordable health care? For academic health centers (AHCs), which often provide safety-net care to the uninsured, this question has moral and social implications. An estimated 11 million undocumented immigrants living in the United States (80% of whom are Latino) are uninsured and currently prohibited from purchasing exchange coverage under the Patient Protection and Affordable Care Act, even at full cost. The authors attempt to dispel the many misconceptions and distorted assumptions surrounding the use of health services by this vulnerable population. The authors also suggest that AHCs need to recalibrate their mission to focus on social accountability as well as the ethical and humanistic practice of medicine for all people, recognizing the significance of inclusion over exclusion in making progress on population health and health care. AHCs play a crucial role, both in educational policy and as a safety-net provider, in reducing health disparities that negatively impact vulnerable populations. Better health for all is possible through better alignment, collaboration, and partnering with other AHCs and safety-net providers. Through servant leadership, AHCs can be the leaders that this change imperative demands.

  13. Academic health centers and care of undocumented immigrants in the United States: servant leaders or uncourageous followers?

    PubMed

    Acosta, David A; Aguilar-Gaxiola, Sergio

    2014-04-01

    Public dialogue and debate about the health care overhaul in the United States is centered on one contentious question: Is there a moral obligation to ensure that all people (including undocumented immigrants) within its borders have access to affordable health care? For academic health centers (AHCs), which often provide safety-net care to the uninsured, this question has moral and social implications. An estimated 11 million undocumented immigrants living in the United States (80% of whom are Latino) are uninsured and currently prohibited from purchasing exchange coverage under the Patient Protection and Affordable Care Act, even at full cost. The authors attempt to dispel the many misconceptions and distorted assumptions surrounding the use of health services by this vulnerable population. The authors also suggest that AHCs need to recalibrate their mission to focus on social accountability as well as the ethical and humanistic practice of medicine for all people, recognizing the significance of inclusion over exclusion in making progress on population health and health care. AHCs play a crucial role, both in educational policy and as a safety-net provider, in reducing health disparities that negatively impact vulnerable populations. Better health for all is possible through better alignment, collaboration, and partnering with other AHCs and safety-net providers. Through servant leadership, AHCs can be the leaders that this change imperative demands. PMID:24556781

  14. Improving Interprofessional and Coproductive Outcomes of Care for Patients with Chronic Obstructive Pulmonary Disease

    PubMed Central

    Moreo, Kathleen; Greene, Laurence; Sapir, Tamar

    2016-01-01

    In the U.S., suboptimal care quality for patients with chronic obstructive pulmonary disease (COPD) is reflected by high rates of emergency department visits and hospital readmissions, as well as excessive costs. Moreover, a substantial proportion of COPD patients do not receive guideline-directed therapies. In quality improvement (QI) programs, these types of health care problems are commonly addressed through interventions that primarily or exclusively support physicians in aligning their practices with guidelines and clinical quality measures. However, the root causes of many deficits in health care quality are not necessarily “physician centric.” Instead, they often involve suboptimal collaboration among members of interprofessional health care teams and gaps in coproductive relationships among patients and providers. We conducted a QI project to identify interprofessional and coproductive correlates of COPD care quality in the context of a continuing education program designed to advance knowledge and skill among patients, providers, and the interprofessional COPD team regarding coproductive COPD care. Participants in the program included providers in 30 primary care practices across the U.S. who, along with their own COPD patients and a separate cohort of patients from COPD advocacy groups, completed a patient-provider survey study designed to identify alignments and mismatches in coproductive perceptions and behaviors, a private survey feedback session for each practice's team, and online/mobile educational activities on COPD. In addition, more than 1,000 additional providers and 200 patients participated in just the online/mobile education. From the patient perspective, baseline measures indicated a high rate of dissatisfaction with COPD treatment plans and suboptimal coproductive interaction with members of the interprofessional health care team. Across providers, there were gaps and variation in provision of patient education, attitudes and practices

  15. Assessment of a primary and tertiary care integrated management model for chronic obstructive pulmonary disease

    PubMed Central

    Bolíbar, Ignasi; Plaza, Vicente; Llauger, Mariantònia; Amado, Ester; Antón, Pedro A; Espinosa, Ana; Domínguez, Leandra; Fraga, Mar; Freixas, Montserrat; de la Fuente, Josep A; Liguerre, Iskra; Medrano, Casimira; Peiro, Meritxell; Pou, Mariantònia; Sanchis, Joaquin; Solanes, Ingrid; Valero, Carles; Valverde, Pepi

    2009-01-01

    Background The diagnosis and treatment of patients with chronic obstructive pulmonary disease (COPD) in Spain continues to present challenges, and problems are exacerbated when there is a lack of coordinated follow-up between levels of care. This paper sets out the protocol for assessing the impact of an integrated management model for the care of patients with COPD. The new model will be evaluated in terms of 1) improvement in the rational utilization of health-care services and 2) benefits reflected in improved health status and quality of life for patients. Methods/Design A quasi-experimental study of the effectiveness of a COPD management model called COPD PROCESS. The patients in the study cohorts will be residents of neighborhoods served by two referral hospitals in Barcelona, Spain. One area comprises the intervention group (n = 32,248 patients) and the other the control group (n = 32,114 patients). The study will include pre- and post-intervention assessment 18 months after the program goes into effect. Analyses will be on two datasets: clinical and administrative data available for all patients, and clinical assessment information for a cohort of 440 patients sampled randomly from the intervention and control areas. The main endpoints will be the hospitalization rates in the two health-care areas and quality-of-life measures in the two cohorts. Discussion The COPD PROCESS model foresees the integrated multidisciplinary management of interventions at different levels of the health-care system through coordinated routine clinical practice. It will put into practice diagnostic and treatment procedures that are based on current evidence, multidisciplinary consensus, and efficient use of available resources. Care pathways in this model are defined in terms of patient characteristics, level of disease severity and the presence or absence of exacerbation. The protocol covers the full range of care from primary prevention to treatment of complex cases. PMID

  16. Using an integrated COC index and multilevel measurements to verify the care outcome of patients with multiple chronic conditions

    PubMed Central

    2012-01-01

    Background The increasing prevalence of multiple chronic conditions has accentuated the importance of coordinating and integrating health care services. Patients with better continuity of care (COC) have a lower utilization rate of emergency department (ED) services, lower hospitalization and better care outcomes. Previous COC studies have focused on the care outcome of patients with a single chronic condition or that of physician-patient relationships; few studies have investigated the care outcome of patients with multiple chronic conditions. Using multi-chronic patients as subjects, this study proposes an integrated continuity of care (ICOC) index to verify the association between COC and care outcomes for two scopes of chronic conditions, at physician and medical facility levels. Methods This study used a dataset of 280,840 subjects, obtained from the Longitudinal Health Insurance Database (LHID 2005), compiled by the National Health Research Institutes, of the National Health Insurance Bureau of Taiwan. Principal Component Analysis (PCA) was used to integrate the indices of density, dispersion and sequence into ICOC to measure COC outcomes - the utilization rate of ED services and hospitalization. A Generalized Estimating Equations model was used to verify the care outcomes. Results We discovered that the higher the COC at medical facility level, the lower the utilization rate of ED services and hospitalization for patients; by contrast, the higher the COC at physician level, the higher the utilization rate of ED services (odds ratio > 1; Exp(β) = 2.116) and hospitalization (odds ratio > 1; Exp(β) = 1.688). When only those patients with major chronic conditions with the highest number of medical visits were considered, it was found that the higher the COC at both medical facility and physician levels, the lower the utilization rate of ED services and hospitalization. Conclusions The study shows that ICOC is more stable than single indices and

  17. An outbreak of Trichophyton tonsurans dermatophytosis in a chronic care institution for the elderly.

    PubMed

    Kane, J; Leavitt, E; Summerbell, R C; Krajden, S; Kasatiya, S S

    1988-06-01

    A nosocomial outbreak of dermatophytosis caused by Trichophyton tonsurans var. sulfureum subvar. perforans is reported in a nursing home for the elderly. The outbreak affected six residents and persisted for nine months despite remedial medical and sanitary measures. In a survey designed to determine the potential role of fomites in disease transmission, 129 environmental sites were sampled. A high proportion (22.3%) of the samples yielded T. tonsurans, including samples from beds, floors, and washroom facilities. Methods for the control of dermatophyte outbreaks in chronic care institutions are discussed.

  18. [THE ORGANIZATION OF MEDICAL CARE OF PATIENTS WITH SEVERE AND CHRONIC FORMS OF TUBERCULOSIS].

    PubMed

    Pianzova, T V; Kopilova, I F

    2015-01-01

    The demand in palliative care was analyzed using sampling of 43 patients with severe and chronic forms of tuberculosis. The study applied hospital Anxiety and Depression Scale (HADS), Charlson scale and visual analogue pain scale. The patients had both various physical symptoms and psychological and social problems. It is demonstrated that patients with severe forms of tuberculosis in 50% of cases had high level of comorbidity at the expense of severe concomitant and background diseases requiring simultaneous therapy and dynamic monitoring by physicians of various specialties, including participation of psychologist and psychotherapist.

  19. Activating people to address their health care needs: learning from people with lived experience of chronic illnesses.

    PubMed

    Stanhope, Victoria; Henwood, Benjamin F

    2014-08-01

    One of the primary goals of health care reform is improving the quality and reducing the costs of care for people with co-morbid mental health and physical health conditions. One strategy is to integrate primary and behavioral health care through care coordination and patient activation. This qualitative study using community based participatory research methods informs the development of integrated care by presenting the perspectives of those with lived experience of chronic illnesses and homelessness. Themes presented include the internal and external barriers to addressing health needs and the key role of peer support in overcoming these barriers.

  20. Treating anemia of chronic kidney disease in the primary care setting: cardiovascular outcomes and management recommendations

    PubMed Central

    Schmidt, Rebecca J; Dalton, Cheryl L

    2007-01-01

    Anemia is an underrecognized but characteristic feature of chronic kidney disease (CKD), associated with significant cardiovascular morbidity, hospitalization, and mortality. Since their inception nearly two decades ago, erythropoiesis-stimulating agents (ESAs) have revolutionized the care of patients with renal anemia, and their use has been associated with improved quality of life and reduced hospitalizations, inpatient costs, and mortality. Hemoglobin targets ≥13 g/dL have been linked with adverse events in recent randomized trials, raising concerns over the proper hemoglobin range for ESA treatment. This review appraises observational and randomized studies of the outcomes of erythropoietic treatment and offers recommendations for managing renal anemia in the primary care setting. PMID:17910755

  1. Strengths of primary healthcare regarding care provided for chronic kidney disease 1

    PubMed Central

    de Paula, Elaine Amaral; Costa, Mônica Barros; Colugnati, Fernando Antonio Basile; Bastos, Rita Maria Rodrigues; Vanelli, Chislene Pereira; Leite, Christiane Chaves Augusto; Caminhas, Márcio Santos; de Paula, Rogério Baumgratz

    2016-01-01

    ABSTRACT Objective: to assess the structure and results obtained by the "Chronic Renal Patients Care Program" in a Brazilian city. Method: epidemiological, cross-sectional study conducted in 14 PHC units and a secondary center from 2010 to 2013. The Donabedian Model was the methodological framework used. A total of 14 physicians, 13 supervisors, and 11 community health agents from primary healthcare were interviewed for the assessment of structure and process and 1,534 medical files from primary healthcare and 282 from secondary care were consulted to assess outcomes. Results: most units lacked sufficient offices for physicians and nurses to provide consultations, had incomplete staffing, and most professionals had not received proper qualification to provide care for chronic renal disease. Physicians from PHC units classified as capable more frequently referred patients to the secondary care service in the early stages of chronic renal disease (stage 3B) when compared to physicians of units considered not capable (58% vs. 36%) (p=0.049). Capable PHC units also more frequently presented stabilized glomerular filtration rates (51%) when compared to partially capable units (36%) and not capable units (44%) (p=0.046). Conclusion: patients cared for by primary healthcare units that scored higher in structure and process criteria presented better clinical outcomes. Objective: to identify the coping strategies of family members of patients with mental disorders and relate them to family member sociodemographic variables and to the patient's clinical variables. Method: this was a descriptive study conducted at a psychiatric hospital in the interior of the state of São Paulo, with 40 family members of hospitalized patients over the age of 18, and who followed the patient before and during hospitalization. We used tools to characterize the subjects and the Folkman and Lazarus Inventory of Coping Strategies. Results: the coping strategies most often used by family members

  2. A comparison of how four countries use health IT to support care for people with chronic conditions.

    PubMed

    Adler-Milstein, Julia; Sarma, Nandini; Woskie, Liana R; Jha, Ashish K

    2014-09-01

    Countries around the globe are investing in health information and communications technologies (ICTs) as critical tools for improving care for chronically ill patients. We profiled four high-income nations with varied health ICT strategies--Australia, Canada, Denmark, and the United States--to describe their use of ICTs to improve chronic care. Our goal was to identify common challenges and opportunities for cross-national learning. We found four key themes. First, although all four countries have a national strategy for health ICT adoption, strategies are implemented and adapted to chronic care needs regionally, which creates the challenge of spreading successful efforts across regions. Second, each country struggles with how to ensure that clinical information follows patients seamlessly between care settings. Third, although each nation is pursuing telehealth solutions as a component of chronic care, the telehealth initiatives are usually stand-alone efforts that are not well integrated into other ICT solutions, such as electronic health records. Finally, countries have made progress in improving patients' access to their clinical data but have not fully succeeded in engaging patients to apply the data to improve care. These common themes suggest that although the four nations have different health care systems and ICT strategies, all of them face a similar set of challenges, creating an opportunity for cross-national learning. PMID:25201660

  3. A comparison of how four countries use health IT to support care for people with chronic conditions.

    PubMed

    Adler-Milstein, Julia; Sarma, Nandini; Woskie, Liana R; Jha, Ashish K

    2014-09-01

    Countries around the globe are investing in health information and communications technologies (ICTs) as critical tools for improving care for chronically ill patients. We profiled four high-income nations with varied health ICT strategies--Australia, Canada, Denmark, and the United States--to describe their use of ICTs to improve chronic care. Our goal was to identify common challenges and opportunities for cross-national learning. We found four key themes. First, although all four countries have a national strategy for health ICT adoption, strategies are implemented and adapted to chronic care needs regionally, which creates the challenge of spreading successful efforts across regions. Second, each country struggles with how to ensure that clinical information follows patients seamlessly between care settings. Third, although each nation is pursuing telehealth solutions as a component of chronic care, the telehealth initiatives are usually stand-alone efforts that are not well integrated into other ICT solutions, such as electronic health records. Finally, countries have made progress in improving patients' access to their clinical data but have not fully succeeded in engaging patients to apply the data to improve care. These common themes suggest that although the four nations have different health care systems and ICT strategies, all of them face a similar set of challenges, creating an opportunity for cross-national learning.

  4. 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. PMID:25561647

  5. Is client-centred care planning for chronic disease sustainable? Experience from rural South Australia.

    PubMed

    Fuller, Jeffrey; Harvey, Peter; Misan, Gary

    2004-07-01

    This qualitative evaluation of a chronic disease self-management project in rural South Australia considers the sustainability of client-centred care planning under current organisational and funding arrangements. The study involved consultation with a range of five stakeholder types over two stages (40 in the beginning stage and 39 in the middle stage) about their satisfaction with the care planning and self-management approach used in the project. All stakeholder types valued the client-centred approach because they perceived that clients were better able to accept and deal with the long-term management of their condition. However, this required that care planning should deal with a wider range of issues than just medical management, and so it took longer, which raised its sustainability in general practice under the current funding through the national health insurance programme (Medicare). The study concludes that sustainability may be addressed through further research into the role of and funding for peer-led self-management groups and the employment of care planners in organisational settings that are conducive to a client-centred approach. PMID:15272887

  6. Chronic kidney disease guideline implementation in primary care: a qualitative report from the TRANSLATE CKD study

    PubMed Central

    Vest, Bonnie M.; York, Trevor R.M.; Sand, Jessica; Fox, Chester H.; Kahn, Linda S.

    2016-01-01

    Background Primary care physicians (PCPs) are optimally situated to identify and manage early-stage chronic kidney disease (CKD). Nonetheless, studies have documented suboptimal PCP understanding, awareness, and management of early CKD. The TRANSLATE CKD study is an ongoing national mixed-methods cluster randomized control trial that examines the implementation of evidence-based guidelines for CKD into primary care practice. Methods As part of mixed-methods process evaluation, semi-structured interviews were conducted by phone with 27 providers participating in the study. Interviews were audio-taped and transcribed. Thematic content analysis was used to identify themes. Themes were categorized according to the four domains of Normalization Process Theory (NPT). Results Identified themes illuminated the complex work undertaken in primary care practices to manage CKD. Barriers to guideline implementation were identified in each of the four NPT domains, including: 1) lack of knowledge and understanding around CKD (coherence), 2) difficulties engaging providers and patients in CKD management (cognitive participation), 3) limited time and competing demands (collective action), and 4) challenges obtaining and utilizing data to monitor progress (reflexive monitoring). Conclusions Addressing the barriers to implementation with concrete interventions at the levels at which they occur, informed by NPT, will ultimately improve the quality of CKD patient care. PMID:26355134

  7. 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.

  8. ‘Reality and desire’ in the care of advanced chronic kidney disease

    PubMed Central

    Marrón, Belén; Craver, Lourdes; Remón, César; Prieto, Mario; Gutiérrez, Josep Mª; Ortiz, Alberto

    2010-01-01

    There is a long distance between the actual worldwide reality in advanced chronic kidney disease care and the desire of how these patients should be managed to decrease cardiovascular and general morbidity and mortality. Implementation of adequate infrastructures may improve clinical outcomes and increase the use of home renal replacement therapies (RRT). Current pitfalls should be addressed to optimise care: inadequate medical training for nephrological referral and RRT selection, late referral to nephrologists, inadequate patient education for choice of RRT modality, lack of multidisciplinary advanced kidney disease clinics and lack of programmed RRT initiation. These deficiencies generate unintended consequences, such as inequality of care and limitations in patient education and selection-choice for RRT technique with limited use of peritoneal dialysis. Multidisciplinary advanced kidney disease clinics may have a direct impact on patient survival, morbidity and quality of life. There is a common need to reduce health care costs and scenarios increasing PD incidence show better efficiency. The following proposals may help to improve the current situation: defining the scope of the problem, disseminating guidelines with specific targets and quality indicators, optimising medical speciality training, providing adequate patient education, specially through the use of general decision making tools that will allow patients to choose the best possible RRT in accordance with their values, preferences and medical advice, increasing planned dialysis starts and involving all stakeholders in the process. PMID:25984045

  9. 'Reality and desire' in the care of advanced chronic kidney disease.

    PubMed

    Marrón, Belén; Craver, Lourdes; Remón, César; Prieto, Mario; Gutiérrez, Josep M; Ortiz, Alberto

    2010-10-01

    There is a long distance between the actual worldwide reality in advanced chronic kidney disease care and the desire of how these patients should be managed to decrease cardiovascular and general morbidity and mortality. Implementation of adequate infrastructures may improve clinical outcomes and increase the use of home renal replacement therapies (RRT). Current pitfalls should be addressed to optimise care: inadequate medical training for nephrological referral and RRT selection, late referral to nephrologists, inadequate patient education for choice of RRT modality, lack of multidisciplinary advanced kidney disease clinics and lack of programmed RRT initiation. These deficiencies generate unintended consequences, such as inequality of care and limitations in patient education and selection-choice for RRT technique with limited use of peritoneal dialysis. Multidisciplinary advanced kidney disease clinics may have a direct impact on patient survival, morbidity and quality of life. There is a common need to reduce health care costs and scenarios increasing PD incidence show better efficiency. The following proposals may help to improve the current situation: defining the scope of the problem, disseminating guidelines with specific targets and quality indicators, optimising medical speciality training, providing adequate patient education, specially through the use of general decision making tools that will allow patients to choose the best possible RRT in accordance with their values, preferences and medical advice, increasing planned dialysis starts and involving all stakeholders in the process.

  10. Population management, systems-based practice, and planned chronic illness care: integrating disease management competencies into primary care to improve composite diabetes quality measures.

    PubMed

    Kimura, Joe; DaSilva, Karen; Marshall, Richard

    2008-02-01

    The increasing prevalence of chronic illnesses in the United States requires a fundamental redesign of the primary care delivery system's structure and processes in order to meet the changing needs and expectations of patients. Population management, systems-based practice, and planned chronic illness care are 3 potential processes that can be integrated into primary care and are compatible with the Chronic Care Model. In 2003, Harvard Vanguard Medical Associates, a multispecialty ambulatory physician group practice based in Boston, Massachusetts, began implementing all 3 processes across its primary care practices. From 2004 to 2006, the overall diabetes composite quality measures improved from 51% to 58% for screening (HgA1c x 2, low-density lipoprotein, blood pressure in 12 months) and from 13% to 17% for intermediate outcomes (HgA1c care and the positive impact of those changes on overall diabetes quality of care.

  11. GPs’ views on managing advanced chronic kidney disease in primary care: a qualitative study

    PubMed Central

    Tonkin-Crine, Sarah; Santer, Miriam; Leydon, Geraldine M; Murtagh, Fliss EM; Farrington, Ken; Caskey, Fergus; Rayner, Hugh; Roderick, Paul

    2015-01-01

    Background Chronic kidney disease (CKD) has become a significant part of the GP’s workload since the introduction of the National Institute for Health and Care Excellence guidelines in 2008. Patients with advanced CKD (stages G4 and G5) often have comorbidities, varied disease progression, and are likely to be older. GPs may experience difficulties with management decisions for patients with advanced CKD, including when to refer to nephrology. Aim To explore GPs’ views of managing patients with advanced CKD and referral to secondary care. Design and setting Qualitative study with GPs in four areas of England: London, Bristol, Birmingham, and Stevenage. Method Semi-structured interviews with 19 GPs. Transcribed interviews were thematically analysed. Results GPs had little experience of managing patients with advanced CKD, including those on dialysis or having conservative care (treatment without dialysis or a transplant), and welcomed guidance. Some GPs referred patients based on renal function alone and some used wider criteria including age and multimorbidity. GPs reported a tension between national guidance and local advice, and some had learnt from experience that patients were discharged back to primary care. GPs with more experience of managing CKD referred patients later, or sometimes not at all, if there were no additional problems and if dialysis was seen as not in the patient’s interests. Conclusion GPs want guidance on managing older patients with advanced CKD and comorbidities, which better incorporates agreement between local and national recommendations to clarify referral criteria. GPs are not generally aware of conservative care programmes provided by renal units, however, they appear happy to contribute to such care or alternatively, lead conservative management with input from renal teams. PMID:26120137

  12. Impact of chronic disease self-management programs on type 2 diabetes management in primary care

    PubMed Central

    Forjuoh, Samuel N; Ory, Marcia G; Jiang, Luohua; Vuong, Ann M; Bolin, Jane N

    2014-01-01

    AIM: To assess the effectiveness of the Chronic Disease Self-Management Program (CDSMP) on glycated hemoglobin A1c (HbA1c) and selected self-reported measures. METHODS: We compared patients who received a diabetes self-care behavioral intervention, the CDSMP developed at the Stanford University, with controls who received usual care on their HbA1c and selected self-reported measures, including diabetes self-care activities, health-related quality of life (HRQOL), pain and fatigue. The subjects were a subset of participants enrolled in a randomized controlled trial that took place at seven regional clinics of a university-affiliated integrated healthcare system of a multi-specialty group practice between January 2009 and June 2011. The primary outcome was change in HbA1c from randomization to 12 mo. Data were analyzed using multilevel statistical models and linear mixed models to provide unbiased estimates of intervention effects. RESULTS: Demographic and baseline clinical characteristics were generally comparable between the two groups. The average baseline HbA1c values in the CDSMP and control groups were 9.4% and 9.2%, respectively. Significant reductions in HbA1c were seen at 12 mo for the two groups, with adjusted changes around 0.6% (P < 0.0001), but the reductions did not differ significantly between the two groups (P = 0.885). Few significant differences were observed in participants’ diabetes self-care activities. No significant differences were observed in the participants’ HRQOL, pain, or fatigue measures. CONCLUSION: The CDSMP intervention may not lower HbA1c any better than good routine care in an integrated healthcare system. More research is needed to understand the benefits of self-management programs in primary care in different settings and populations. PMID:24936263

  13. Palliative Care Education in Nurse Practitioner Programs: A Survey of Academic Deans.

    PubMed

    Jensen-Seaman, Kari; Hebert, Randy S

    2016-01-01

    The need for clinicians trained in palliative care will increase as more Americans live with life-limiting illness. Although multiple studies have described the nature of palliative care education in prelicensure programs, there have been no similar studies of nurse practitioner programs. We surveyed 101 nurse practitioner programs. Most programs provide little instruction in palliative care; education is often limited to a few hours of lecture. One-third of programs offer no instruction. Although palliative care is an important component of advanced practice nursing practice, programs may not be providing adequate education.

  14. SA HealthPlus: A Controlled Trial of a Statewide Application of a Generic Model of Chronic Illness Care

    PubMed Central

    Battersby, Malcolm; Harvey, Peter; Mills, P David; Kalucy, Elizabeth; Pols, RG; Frith, Peter A; McDonald, Peter; Esterman, Adrian; Tsourtos, George; Donato, Ronald; Pearce, Rodney; McGowan, Christopher

    2007-01-01

    SA HealthPlus, one of nine national Australian coordinated care trials, addressed chronic illness care by testing whether coordinated care would improve health outcomes at the cost of usual care. SA HealthPlus compared a generic model of coordinated care for 3,115 intervention patients with the usual care for 1,488 controls. Service coordinators and the behavioral and care-planning approach were new. The health status (SF-36) in six of eight projects improved, and those patients who had been hospitalized in the year immediately preceding the trial were the most likely to save on costs. A mid-trial review found that health benefits from coordinated care depended more on patients' self-management than the severity of their illness, a factor leading to the Flinders Model of Self-Management Support. PMID:17319806

  15. [Care of chronically ill geriatric patients with the cooperation of relatives].

    PubMed

    Huber, F; Stähelin, H B; Bloch, F

    1984-01-01

    In the first stage of the project "assistance of relatives for the care of chronically ill people" in context of the National Research Programme No 8 (Economy and efficacy of the Swiss Health System) a representative random sample of elderly longterm patients was arranged in Basle and the situation regarding their relatives investigated. Altogether 473 relatives were contacted. Finally 343 interviews with next-of-kin were held and as many questionnaires filled out. The main aim of the questioning in the first part of the study was to know who would be able to participate in the care at the hospital on a part-time basis. Basing on the results, it may be presumed that about 30% of the relatives of chronically ill patients who have regular personal contact with them are ready and willing to participate actively in a co-operative model set-up of a nursing institution. In the second stage the way should be paved for the management of a pilot-station. During the research programme between 1983 and 1985, the model-idea should be examined for its practicability. Afterwards it can be judged if the basic idea of the project evidences a real progress or remains a social-medical utopia.

  16. Measuring health-related quality of life in adults with chronic conditions in primary care settings

    PubMed Central

    Hand, Carri

    2016-01-01

    Abstract Objective To describe health-related quality of life (HRQOL) conceptual frameworks, critically review 3 commonly used HRQOL scales relevant to adults with chronic conditions in primary care settings, and make recommendations for using HRQOL scales in primary care practice. Data sources Information was accessed regarding HRQOL conceptual and theoretical approaches. A comprehensive search strategy identified 3 commonly used scales that met the review criteria and evidence regarding use of the scales in adults with chronic conditions in community settings. Scale selection Scales were selected if they were designed for clinical use; were easy to administer; were generic and broad in content areas; and contained some individualized items. Scales were critiqued according to content development, theoretical basis, psychometric properties, scoring, feasibility, the concepts being measured, and the number of items that measured an individualized concept. Synthesis Early HRQOL approaches focused on health and functional status while recent approaches incorporate individualized concepts such as the person’s own values and the environment. The abbreviated World Health Organization Quality of Life Scale (WHOQOL-BREF), the 36-Item Short Form Health Survey (SF-36), and the Duke Health Profile were critiqued. All address physical, mental, and social domains, while the WHOQOL-BREF also addresses environment. Psychometric evidence supports use of the SF-36 and WHOQOL-BREF with this population. The SF-36 has the most evidence of responsiveness but has some floor and ceiling effects, while the WHOQOL-BREF does not appear to have floor or ceiling effects but has limited evidence of responsiveness. The WHOQOL-BREF has the highest proportion of individualized items. Conclusion Measurement of HRQOL in adults with chronic conditions can support patient management and contribute to primary care service evaluation. Scales that are based on a broad definition of health and that

  17. Families living with chronic illness: beliefs about illness, family, and health care.

    PubMed

    Årestedt, Liselott; Benzein, Eva; Persson, Carina

    2015-05-01

    Beliefs can be described as the lenses through which we view the world. With emerging illness, beliefs about the illness experience become important for nurses to understand to enhance well-being and healing. The aim of this study was to illuminate illness beliefs of families living with chronic illness. A qualitative design was chosen, including repeated narrative research interviews with seven Swedish families living with chronic illness. Hermeneutic analysis was used to interpret the transcribed family interviews. The result described beliefs in families, both within and across families. Both core beliefs and secondary beliefs about illness, family, and health care were revealed. Illness beliefs have importance for how families respond to and manage situations that arise from their encounters with illness. Nurses have to make space for and listen to families' stories of illness to become aware of what beliefs may support and encourage family well-being and healing. The Illness Beliefs Model provides a touchstone whereby nurses can distinguish both individual and shared beliefs within families living with chronic illness and provide ideas for family intervention if needed.

  18. Depression and Ambulatory Care Sensitive Hospitalizations among Medicare Beneficiaries with Chronic Physical Conditions

    PubMed Central

    Bhattacharya, Rituparna; Shen, Chan; Sambamoorthi, Usha

    2014-01-01

    Objective We examined the association between depression and hospitalizations for Ambulatory Care Sensitive Conditions (H-ACSC) among Medicare beneficiaries with chronic physical conditions. Methods We used a retrospective longitudinal design using multiple years (2002-2009) of linked fee-for-service Medicare claims and survey data from Medicare Current Beneficiary Survey (MCBS) data to create six longitudinal panels. We followed individuals in each panel for a period of three years; first year served as the baseline and subsequent two years served as the follow-up. We measured depression, chronic physical conditions and other characteristics at baseline and examined H-ACSC at two follow-up. We identified chronic physical conditions from survey data and H-ACSC and depression from fee-for-service Medicare claims.. We analyzed unadjusted and adjusted relationships between depression and the risk of H-ACSC with chi-square tests and logistic regressions. Results Among all Medicare beneficiaries, 9.3% had diagnosed depression. Medicare beneficiaries with depression had higher rates of any H-ACSC as compared to those without depression (13.6% vs 7.7%). Multivariable regression indicated that compared to those without depression, Medicare beneficiaries with depression were more likely to experience any H-ACSC. Conclusions Depression was associated with greater risk of H-ACSC, suggesting that healthcare quality measures may need to include depression as a risk-adjustment variable. PMID:24999083

  19. Development and Validation of the Chinese Health Literacy Scale for Chronic Care

    PubMed Central

    Leung, Angela Yee Man; Cheung, Mike Kwun Ting; Lou, Vivian Wei Qun; Chan, Felix Hon Wai; Ho, Celina Kit Yee; Do, Tsui Ling; Chan, Sophia Siu Chee; Chi, Iris

    2013-01-01

    This study aims to develop and test the psychometric properties of the Chinese Health Literacy Scale for Chronic Care (CHLCC). This is a methodological study with a sample of 262 patients 65 years of age and older who had chronic illnesses. Pearson's correlation, independent sample t tests, and analyses of variance were used. The CHLCC showed a significant positive correlation with Chinese literacy levels (r = 0.80; p < .001) but was negatively correlated with age (r = −0.31; p < .001). Respondents who were male (t = 4.34; p < .001) and who had reached Grade 12 or higher in school (F = 51.80; p < .001) had higher CHLCC scores than did their counterparts. Individuals with high levels of health literacy had fewer hospitalizations than did their counterparts (β = −0.31; incidence rate ratio = 0.73; p < .05). The CHLCC also displayed good internal reliability (Cronbach's α = 0.91) and good test-retest reliability (intraclass correlation coefficient = 0.77; p < .01). The CHLCC is a valid and reliable measure for assessing health literacy among Chinese patients with chronic illness. The scale could be used by practitioners before implementing health promotion and education. PMID:24093357

  20. Home healthcare settop-box for senior chronic care using ISO/IEEE 11073 PHD standard.

    PubMed

    Lim, Joon-Ho; Park, Chanyong; Park, Soo-Jun

    2010-01-01

    As the number of seniors with chronic disease increases, the need of home healthcare settop-box is increased to manage their chronic disease in their home environment. Using the home healthcare settop-box, the patients can regularly check their health data, and finally, it can lead the decrease of medical expenses. For the home healthcare settop-box, the most important factor is the standard compatibility, which can interoperate with standard devices of any other companies. In this paper, we propose a home healthcare settop-box using ISO/IEEE 11073 PHD standard. It collects health data according to the PHD standard, and provides a chronic-care service based on the collected data. The proposed settop-box is connected with 3 devices of weigh scale, blood pressure monitor, and glucose meter, and tested at 10 homes for a month. Lastly, the proposed settop-box can be used for various healthcare services such as Google Health and Telemedicine Services using a healthcare platform server.

  1. Improving Primary Health Care in Chronic Musculoskeletal Conditions through Digital Media: The PEOPLE Meeting

    PubMed Central

    Cott, Cheryl; Jones, C Allyson; Badley, Elizabeth M; Davis, Aileen M

    2013-01-01

    Background Musculoskeletal (MSK) conditions are the most common cause of severe chronic pain and disability worldwide. Despite the impact of these conditions, disparity exists in accessing high quality basic care. As a result, effective treatments do not always reach people who need services. The situation is further hampered by the current models of care that target resources to a limited area of health services (eg, joint replacement surgery), rather than the entire continuum of MSK health, which includes services provided by primary care physicians and health professionals. The use of digital media offers promising solutions to improve access to services. However, our knowledge in this field is limited. To advance the use of digital media in improving MSK care, we held a research planning meeting entitled “PEOPLE: Partnership to Enable Optimal Primary Health Care by Leveraging Digital Media in Musculoskeletal Health”. This paper reports the discussion during the meeting. Objective The objective of this study was to: (1) identify research priorities relevant to using digital media in primary health care for enhancing MSK health, and (2) develop research collaboration among researchers, clinicians, and patient/consumer communities. Methods The PEOPLE meeting included 26 participants from health research, computer science/digital media, clinical communities, and patient/consumer groups. Based on consultations with each participant prior to the meeting, we chose to focus on 3 topics: (1) gaps and issues in primary health care for MSK health, (2) current application of digital media in health care, and (3) challenges to using digital media to improve MSK health in underserviced populations. Results The 2-day discussion led to emergence of 1 overarching question and 4 research priorities. A main research priority was to understand the characteristics of those who are not able to access preventive measures and treatment for early MSK diseases. Participants

  2. Diagnosis of patients with chronic heart failure in primary care: usefulness of history, examination, and investigations.

    PubMed Central

    Khunti, K; Baker, R; Grimshaw, G

    2000-01-01

    Chronic heart failure is a common clinical syndrome that may have different causes. Its incidence and prevalence are predicted to rise substantially over the next 10 years. There are therefore major consequences for resource provision, especially in primary care, where most patients are managed. Chronic heart failure is a serious condition with high morbidity and mortality. There is good evidence to show that treatment with angiotensin-converting enzyme (ACE) inhibitors in patients with left ventricular systolic dysfunction improves symptoms and signs, slows progression of heart failure, reduces hospitalisation rates, and improves survival. Despite this evidence, primary care studies show that patients with heart failure are incorrectly diagnosed and inadequately treated. Most patients present in general practice, and because effective treatment relies on a correct diagnosis, this is a key step in the appropriate management of heart failure. The aim of this paper is to review the evidence about the usefulness of signs, symptoms, and investigations in diagnosing heart failure in primary care. To identify relevant studies for this review, four strategies were used: a MEDLINE search from 1993 to January 1998 using the diagnosis search filter; a MEDLINE search from 1993 to January 1998 using the guideline search filter to locate published heart failure guidelines; a search for review articles in the Cochrane Library; and a check of references in the studies identified. The search terms included MeSH terms and the keywords 'heart failure' and 'diagnosis'. All searches were limited to humans and English language articles. Studies were included in this review on the basis of quality and relevance to primary care. The review shows that symptoms and signs are important because they alert clinicians to the possibility of heart failure as a diagnosis. However, they are not sufficiently specific for confirming left ventricular systolic dysfunction. From the evidence available

  3. Implementation of a program for type 2 diabetes based on the Chronic Care Model in a hospital-centered health care system: "the Belgian experience"

    PubMed Central

    Sunaert, Patricia; Bastiaens, Hilde; Feyen, Luc; Snauwaert, Boris; Nobels, Frank; Wens, Johan; Vermeire, Etienne; Van Royen, Paul; De Maeseneer, Jan; De Sutter, An; Willems, Sara

    2009-01-01

    Background Most research publications on Chronic Care Model (CCM) implementation originate from organizations or countries with a well-structured primary health care system. Information about efforts made in countries with a less well-organized primary health care system is scarce. In 2003, the Belgian National Institute for Health and Disability Insurance commissioned a pilot study to explore how care for type 2 diabetes patients could be organized in a more efficient way in the Belgian healthcare setting, a setting where the organisational framework for chronic care is mainly hospital-centered. Methods Process evaluation of an action research project (2003–2007) guided by the CCM in a well-defined geographical area with 76,826 inhabitants and an estimated number of 2,300 type 2 diabetes patients. In consultation with the region a program for type 2 diabetes patients was developed. The degree of implementation of the CCM in the region was assessed using the Assessment of Chronic Illness Care survey (ACIC). A multimethod approach was used to evaluate the implementation process. The resulting data were triangulated in order to identify the main facilitators and barriers encountered during the implementation process. Results The overall ACIC score improved from 1.45 (limited support) at the start of the study to 5.5 (basic support) at the end of the study. The establishment of a local steering group and the appointment of a program manager were crucial steps in strengthening primary care. The willingness of a group of well-trained and motivated care providers to invest in quality improvement was an important facilitator. Important barriers were the complexity of the intervention, the lack of quality data, inadequate information technology support, the lack of commitment procedures and the uncertainty about sustainable funding. Conclusion Guided by the CCM, this study highlights the opportunities and the bottlenecks for adapting chronic care delivery in a primary

  4. Creating and Maintaining a Successful Service Line in an Academic Medical Center at the Dawn of Value-Based Care: Lessons Learned From the Heart and Vascular Service Line at UMass Memorial Health Care.

    PubMed

    Phillips, Robert A; Cyr, Jay; Keaney, John F; Messina, Louis M; Meyer, Theo E; Tam, Stanley K C; Korenda, Kathleen; Darrigo, Melinda; Kumar, Pooja; Challapalli, Sailu

    2015-10-01

    The service line (SL) model has been proven to help shift health care toward value-based services, which is characterized by coordinated, multidisciplinary, high-quality, and cost-effective care. However, academic medical centers struggle with how to effectively set up SL structures that overcome the organizational and cultural challenges associated with simultaneously delivering the highest-value care for the patient and advancing the academic mission. In this article, the authors examine the evolution of UMass Memorial Health Care's heart and vascular service line (HVSL) from 2006 to 2011 and describe the impact on its success of multiple strategic decisions. These include key academic physician leadership recruitments and engagement via a matrixed governance and management model; development of multidisciplinary teams; empowerment of SL leadership through direct accountability and authority over programs and budgets; joint educational and training programs; incentives for academic achievement; and co-localization of faculty, personnel, and facilities. The authors also explore the barriers to success, including the need to overcome historical departmental-based silos, cultural and training differences among disciplines, confusion engendered by a matrixed reporting structure, and faculty's unfamiliarity with the financial and organizational skills required to operate a successful SL. Also described here is the impact that successful implementation of the SL has on creating high-quality services, increased profitability, and contribution to the financial stability and academic achievement of the academic medical center. PMID:26222322

  5. Creating and Maintaining a Successful Service Line in an Academic Medical Center at the Dawn of Value-Based Care: Lessons Learned From the Heart and Vascular Service Line at UMass Memorial Health Care.

    PubMed

    Phillips, Robert A; Cyr, Jay; Keaney, John F; Messina, Louis M; Meyer, Theo E; Tam, Stanley K C; Korenda, Kathleen; Darrigo, Melinda; Kumar, Pooja; Challapalli, Sailu

    2015-10-01

    The service line (SL) model has been proven to help shift health care toward value-based services, which is characterized by coordinated, multidisciplinary, high-quality, and cost-effective care. However, academic medical centers struggle with how to effectively set up SL structures that overcome the organizational and cultural challenges associated with simultaneously delivering the highest-value care for the patient and advancing the academic mission. In this article, the authors examine the evolution of UMass Memorial Health Care's heart and vascular service line (HVSL) from 2006 to 2011 and describe the impact on its success of multiple strategic decisions. These include key academic physician leadership recruitments and engagement via a matrixed governance and management model; development of multidisciplinary teams; empowerment of SL leadership through direct accountability and authority over programs and budgets; joint educational and training programs; incentives for academic achievement; and co-localization of faculty, personnel, and facilities. The authors also explore the barriers to success, including the need to overcome historical departmental-based silos, cultural and training differences among disciplines, confusion engendered by a matrixed reporting structure, and faculty's unfamiliarity with the financial and organizational skills required to operate a successful SL. Also described here is the impact that successful implementation of the SL has on creating high-quality services, increased profitability, and contribution to the financial stability and academic achievement of the academic medical center.

  6. Chronic obstructive pulmonary disease and associated health-care resource use - North Carolina, 2007 and 2009.

    PubMed

    2012-03-01

    Chronic obstructive pulmonary disease (COPD), including emphysema and chronic bronchitis, is a progressive condition in which airflow becomes limited, making it difficult to breathe. Chronic lower respiratory diseases, primarily COPD, are the third leading cause of death in the United States, and 5.1% of U.S. adults report a diagnosis of emphysema or chronic bronchitis. Smoking is the primary cause of COPD, and at least 75% of COPD deaths are attributable to smoking in the United States. Information on state-specific prevalence of COPD is sparse, as are data on the use of COPD-related health-care resources. To understand how COPD affects adults in North Carolina and what resources are used by persons with COPD, 2007 and 2009 data from the North Carolina COPD module of the Behavioral Risk Factor Surveillance System (BRFSS) were analyzed. Among 26,227 respondents, 5.7% reported ever having been told by a health professional that they had COPD. Most adults with COPD reported ever having had a diagnostic breathing test (76.4% in 2007 and 82.4% in 2009). Among adults with COPD, 43.0% reported having gone to a physician and 14.9% visited an emergency department (ED) or were admitted to a hospital (2007) for COPD-related symptoms in the previous 12 months. Only 48.1% of persons reported daily use of medications for their COPD (2007). These results indicate that many adults with COPD might not have had adequate diagnostic spirometry, and many who might benefit from daily medications, such as long-acting bronchodilators and inhaled corticosteroids, are not taking them. Continued and expanded surveillance is needed to evaluate the effectiveness of prevention and intervention programs and support efforts to educate the public and physicians about COPD symptoms, diagnosis, and treatment.

  7. The evolution of chronic pain among patients with musculoskeletal problems: a pilot study in primary care.

    PubMed

    Potter, R G; Jones, J M

    1992-11-01

    Little is known about the evolution of chronic pain in primary care. Forty five patients with a four week history of musculoskeletal pain were assessed and followed up over 26 weeks by a research nurse using a structured interview and formal assessment instruments. Patients aged 18 to 65 years were recruited on presentation at two semirural Cheshire general practices and subsequently interviewed on a domiciliary visit. Twenty patients (44%) continued to have pain at 26 weeks and these patients were considered to have chronic pain. Nineteen patients had no pain after 12 weeks and a further six had no pain after 26 weeks; these patients together formed the group with acute pain. Comparing the two groups at entry into the study (pain of four weeks' duration) demonstrated significantly higher visual analogue scale scores for intensity of pain (P < 0.01) and a higher incidence of depression (P < 0.01) in the group which subsequently developed chronic pain. In this group, the presence of depression at 12 weeks was associated with higher visual analogue scale scores (P < 0.05) but at 26 weeks scores were similar in depressed and non-depressed patients. The correlation between visual analogue scale score for intensity of pain and the use of passive coping strategies to cope with pain appeared more strongly positive with duration of pain (P < 0.05 at 26 weeks). It is suggested that high pain intensity scores, the presence of depression, and the increasing use of passive coping strategies may be identifiable associations with the development of chronic pain. Areas for further research are identified.

  8. Primary care interventions to improve transition of youth with chronic health conditions from paediatric to adult healthcare: a systematic review

    PubMed Central

    Bhawra, Jasmin; Toulany, Alene; Cohen, Eyal; Moore Hepburn, Charlotte; Guttmann, Astrid

    2016-01-01

    Objective To determine effective interventions to improve primary care provider involvement in transitioning youth with chronic conditions from paediatric to adult care. Design Systematic review. Multiple electronic databases were searched including Ovid MEDLINE, EMBASE and Web of Science (from 1 January 1947 to 5 August 2015). Evidence quality was assessed using a 36-point scoring system for disparate study designs. Setting Studies with paediatric-to-adult transition programmes and interventions involving primary care providers or in primary care settings. Participants Youth aged 16 years and over. Outcomes Relevant outcomes were grouped into 3 main domains based on the Triple Aim Framework: experience of care, population health, cost. Results A total of 1888 unique citations were identified, yielding 3 studies for inclusion. Overall, primary care provider roles were not well defined. 2 studies used case managers to facilitate referrals to primary care, and the remaining study was the only 1 situated in a primary care setting. None of the studies examined transition in all 3 Triple Aim Framework domains. The most commonly reported outcomes were in the cost domain. Conclusions There is limited empiric evidence to guide primary care interventions to improve transition outcomes for youth with chronic conditions. Future research and policy should focus on developing and evaluating coordinated transition interventions to better integrate primary care for high need populations. PMID:27150188

  9. A study protocol for performance evaluation of a new academic intensive care unit facility: impact on patient care

    PubMed Central

    Ferri, Mauricio; Zygun, David A; Harrison, Alexandra; Stelfox, Henry T

    2013-01-01

    Background Healthcare facility construction is increasing because of population demand and the need to replace ageing infrastructure. Research suggests that there may be a relationship between healthcare environment and patient care. To date, most evaluations of new healthcare facilities are derived from techniques used in other industries and focus on physical, financial and architectural performance. However, few studies have evaluated the impact of healthcare facility design on processes and outcomes of patient care. Study aims The primary objective of this study was to investigate the impact of relocation to a new intensive care unit (ICU) facility on clinical performance measures. This study also proposes to develop and test a framework for facility performance evaluation using accepted ICU design guidelines and Donabedian's model for healthcare quality. Methods and analysis We will utilise a mixed-methods, observational, retrospective, controlled, before-and-after design to take advantage of the quasiexperimental conditions created with the construction of a new ICU facility in Calgary, Canada. For the qualitative substudy, we will conduct individual interviews with end-users to understand their impressions and experiences with the new environment and perform thematic analysis. For the quantitative substudy, we will compare process of care indicators and patient outcomes for the 12-month period before and after relocation to the new facility. Two other local ICU facilities that did not undergo structural change during the study period will serve as controls. We will triangulate qualitative and quantitative results utilising a novel framework. Ethics and dissemination The results of this study will contribute in understanding the impact of new ICU facilities on clinical performance measures centred on patients, their families and healthcare providers. The framework will complement existing building performance evaluation techniques and help healthcare

  10. Mental Health Service Use for Patients with Co-occurring Mental and Physical Chronic Health Care Needs in Primary Care Settings

    PubMed Central

    Haynes-Maslow, Lindsey; Roberts, Megan C.; Dusetzina, Stacie B.

    2016-01-01

    Background Individuals with mental illness experience poor health and may die prematurely from chronic illness. Understanding whether the presence of co-occurring chronic physical health conditions complicates mental health treatment is important, particularly among patients seeking treatment in primary care settings. Objectives Examine (1) whether the presence of chronic physical conditions is associated with mental health service use for individuals with depression who visit a primary care physician, and (2) whether race modifies this relationship. Research Design Secondary analysis of the National Ambulatory Medical Care Survey, a survey of patient-visits collected annually from a random sample of 3,000 physicians in office-based settings. Subjects Office visits from 2007–2010 were pooled for adults ages 35–85 with a depression diagnosis at the time of visit (N=3,659 visits). Measures Mental health services were measured using a dichotomous variable indicating whether mental health services were provided during the office visit or a referral made for: (1) counseling, including psychotherapy and other mental health counseling and/or (2) prescribing of psychotropic medications. Results Most patient office visits (70%) where a depression diagnosis was recorded also had co-occurring chronic physical conditions recorded. The presence of at least one physical chronic condition was associated with a 6% decrease in the probability of receiving any mental health services (p<0.05). There were no differences in service use by race/ethnicity after controlling for other factors. Conclusions Additional research is needed on medical care delivery among patients with co-occurring health conditions, particularly as the health care system moves towards an integrated care model. PMID:26147863

  11. [Integration of mental health and chronic non-communicable diseases in Peru: challenges and opportunities for primary care settings].

    PubMed

    Diez-Canseco, Francisco; Ipince, Alessandra; Toyama, Mauricio; Benate-Galvez, Ysabel; Galán-Rodas, Edén; Medina-Verástegui, Julio César; Sánchez-Moreno, David; Araya, Ricardo; Miranda, J Jaime

    2014-01-01

    In this article, the relationship between mental health and chronic non-communicable diseases is discussed as well as the possibility to address them in a comprehensive manner in the Peruvian health system. First, the prevalence estimates and the burden of chronic non-communicable diseases and mental disorders worldwide and in Peru are reviewed. Then, the detrimental impact of depression in the early stages as well as the progress of diabetes and cardiovascular diseases is described. Additionally, the gap between access to mental health care in Peru is analyzed. Lastly, the alternatives to reduce the gap are explored. Of these alternatives, the integration of mental health into primary care services is emphasized; as a feasible way to meet the care needs of the general population, and people with chronic diseases in particular, in the Peruvian context.

  12. Acupuncture and chiropractic care for chronic pain in an integrated health plan: a mixed methods study

    PubMed Central

    2011-01-01

    Background Substantial recent research examines the efficacy of many types of complementary and alternative (CAM) therapies. However, outcomes associated with the "real-world" use of CAM has been largely overlooked, despite calls for CAM therapies to be studied in the manner in which they are practiced. Americans seek CAM treatments far more often for chronic musculoskeletal pain (CMP) than for any other condition. Among CAM treatments for CMP, acupuncture and chiropractic (A/C) care are among those with the highest acceptance by physician groups and the best evidence to support their use. Further, recent alarming increases in delivery of opioid treatment and surgical interventions for chronic pain--despite their high costs, potential adverse effects, and modest efficacy--suggests the need to evaluate real world outcomes associated with promising non-pharmacological/non-surgical CAM treatments for CMP, which are often well accepted by patients and increasingly used in the community. Methods/Design This multi-phase, mixed methods study will: (1) conduct a retrospective study using information from electronic medical records (EMRs) of a large HMO to identify unique clusters of patients with CMP (e.g., those with differing demographics, histories of pain condition, use of allopathic and CAM health services, and comorbidity profiles) that may be associated with different propensities for A/C utilization and/or differential outcomes associated with such care; (2) use qualitative interviews to explore allopathic providers' recommendations for A/C and patients' decisions to pursue and retain CAM care; and (3) prospectively evaluate health services/costs and broader clinical and functional outcomes associated with the receipt of A/C relative to carefully matched comparison participants receiving traditional CMP services. Sensitivity analyses will compare methods relying solely on EMR-derived data versus analyses supplementing EMR data with conventionally collected patient

  13. "No me ponían mucha importancia": care-seeking experiences of undocumented Mexican immigrant women with chronic illness.

    PubMed

    Chandler, Juliet T; Malone, Ruth E; Thompson, Lisa M; Rehm, Roberta S

    2012-01-01

    This interpretive phenomenological study explored the health care-seeking experiences of undocumented Mexican immigrant women. Interviews and observations were conducted with 26 uninsured Mexican immigrant women with a chronic illness residing in California. Participant narratives revealed that their health care seeking experiences were often characterized by a lack of recognition of their human plight and devaluation of their personhood. Both structural and social barriers to care exist for immigrant women. Modifying current policies to allow undocumented immigrants more options to access care could help reduce stigma, reduce suffering, and encourage clinicians to recognize their humanity and their legitimate medical needs.

  14. Rehabilitation of women from the Middle East living with chronic pain--perceptions from health care professionals.

    PubMed

    Zander, Viktoria; Eriksson, Henrik; Christensson, Kyllike; Müllersdorf, Maria

    2015-01-01

    Meeting patients from other countries constitutes a challenge for health care. The purpose of this study was to increase knowledge about tacit understandings of treatment in practice by determining the perceptions of chronic pain and rehabilitation directed to resettled women from the Middle East, from a variety of health care professionals within primary care. Based on the results, we find a need to support and increase knowledge among health care professionals to involve the patient and consider her beliefs, expectations, background, current life situation, and spirituality, and to involve family in rehabilitation. PMID:25513750

  15. Within-team Patterns of Communication and Referral in Multimodal Treatment of Chronic Low Back Pain Patients by an Integrative Care Team

    PubMed Central

    O'Connor, Bonnie B.; Eisenberg, David M.; Buring, Julie E.; Liang, Catherine L.; Osypiuk, Kamila; Levy, Donald B.

    2015-01-01

    Background: Nonspecific chronic low back pain (CLBP) is a highly prevalent and costly public health problem with few treatment options that provide consistent and greater than modest benefits. Treatment of CLBP is shifting from unimodal to multimodal and multidisciplinary approaches, including biopsychosocially-based complementary and integrative care. Multidisciplinary approaches require unique levels of communication and coordination amongst clinicians; however, to date few studies have evaluated patterns of communication and decision making amongst clinicians collaborating in the care of challenging patients with CLBP. Methods: As part of an observational study evaluating the effectiveness and cost-effectiveness of an integrative, team-based care model for the treatment of CLBP, we used multiple qualitative research methods to characterize within-team cross-referral and communication amongst jointly-trained practitioners representing diverse biomedical and complementary disciplines. Patterns of communication and coordinated care are summarized for 3 cases of CLBP treated by multiple members (≥3) of an integrative medical team embedded within an academic hospital. Results: Patients were aged from 36 to 88 years with varied comorbidities. Qualitative content analysis revealed 5 emergent themes regarding integrative patient care and treatment decision in this clinic: (1) the fundamental importance of the clinic's formal teamwork training; (2) the critical communicative and collaborative function of regular team meetings; (3) the importance to patient care goals of having the varied disciplines practicing “under one roof”; (4) a universal commitment to understanding and treating patients as whole persons; and (5) a shared philosophy of helping patients to help themselves. These key themes are all interconnected and form the foundation of the clinic's culture. Conclusions: Our qualitative findings provide context for current trends in enhancing patient

  16. Office-Based Case Finding for Chronic Obstructive Pulmonary Disease in Older Adults in Primary Care.

    PubMed

    Lee, Linda; Patel, Tejal; Hillier, Loretta M; Milligan, James

    2016-01-01

    Background. Chronic Obstructive Pulmonary Disease (COPD) is underdiagnosed in primary care. Aim. To explore the utility of proactive identification of COPD in patients 75 years of age and older in a Canadian primary care setting. Methods. Canadian Thoracic Society (CTS) screening questions were administered to patients with a smoking history of 20 pack-years or more; those with a positive screen were referred for postbronchodilator spirometry. Results. A total of 107 patients (21%), of 499 screened, had a 20-pack-year smoking history; 105 patients completed the CTS screening. Forty-four (42%) patients were positive on one or more questions on the screening; significantly more patients with a previous diagnosis of COPD (64%) were positive on the CTS compared to those without a previous diagnosis of COPD (30%). Of those who were not previously diagnosed with COPD (N = 11), four (36%) were newly diagnosed with COPD. Conclusion. A systematic two-stage method of screening for COPD, using CTS screening questions followed by spirometric confirmation, is feasible in the context of a busy primary care setting. More research is needed to assess the value of restricting screening to patients with a smoking history of 20 pack-years and on the sensitivity and specificity of these measures. PMID:27445513

  17. Recent developments in the care, treatment, and rehabilitation of the chronic mentally ill in Norway.

    PubMed

    Ogar, B

    1983-04-01

    As in most other Western nations, the ideology shaping mental health care in Norway has shifted since World War II from a traditional institutional approach to a community-based concept of treatment for the chronic patient. And as in many other countries, communities have been poorly equipped to deal with the influx of deinstitutionalized patients. Few appropriate community alternatives have been developed to care for hospitalized patients, many of whom must remain institutionalized. The author reports on a 1979 census of Norway's mental patients which showed that about half of the mental hospital patients could be expected to remain in the hospital because adequate community facilities did not exist. However, the author says, there is a new interest in Norway in reducing the number of hospital beds and transferring more patients to community programs; one large mental hospital has recently been closed. Legislation focusing on patients' rights and new research on "quality of life" of patients are also pushing mental health care into the community, he says.

  18. Office-Based Case Finding for Chronic Obstructive Pulmonary Disease in Older Adults in Primary Care

    PubMed Central

    Lee, Linda

    2016-01-01

    Background. Chronic Obstructive Pulmonary Disease (COPD) is underdiagnosed in primary care. Aim. To explore the utility of proactive identification of COPD in patients 75 years of age and older in a Canadian primary care setting. Methods. Canadian Thoracic Society (CTS) screening questions were administered to patients with a smoking history of 20 pack-years or more; those with a positive screen were referred for postbronchodilator spirometry. Results. A total of 107 patients (21%), of 499 screened, had a 20-pack-year smoking history; 105 patients completed the CTS screening. Forty-four (42%) patients were positive on one or more questions on the screening; significantly more patients with a previous diagnosis of COPD (64%) were positive on the CTS compared to those without a previous diagnosis of COPD (30%). Of those who were not previously diagnosed with COPD (N = 11), four (36%) were newly diagnosed with COPD. Conclusion. A systematic two-stage method of screening for COPD, using CTS screening questions followed by spirometric confirmation, is feasible in the context of a busy primary care setting. More research is needed to assess the value of restricting screening to patients with a smoking history of 20 pack-years and on the sensitivity and specificity of these measures. PMID:27445513

  19. Mad, homeless, and unwanted. A history of the care of the chronic mentally ill in America.

    PubMed

    Grob, G N

    1994-09-01

    The history of the care and treatment of the mentally ill in America for nearly four centuries offers a sobering example of a cyclical pattern that alternated between enthusiastic optimism and fatalistic pessimism. In the nineteenth century an affinity for institutional solutions led to the creation of the mental hospital, an institution designed to promote recovery and to enable the individual to return to the community. No institution ever lives up to the claims of its promoters, and the mental hospital was no exception. Plagued by a variety of problems, its reputation and image were slowly tarnished. When it became clear that hospitals were caring for large numbers of chronic patients, the stage was set for an attack on its legitimacy after World War II. Its detractors insisted that a community-based policy could succeed where an institutional policy had failed, and that it was possible to identify mental illnesses in the early stages, at which time treatment would prevent the advent of chronicity. Between the 1940s and 1960s, there was a sustained attack on institutional care that finally succeeded when Congress enacted and the president signed a piece of legislation that shifted the locus of care and treatment back to the community. The community mental health policy proved no less problematic than its institutional predecessor. Indeed, the emergence of a new group of young chronic mentally ill persons in the 1970s and 1980s created entirely new problems, for the individuals who constituted this group proved difficult to treat and to care for under any circumstances. Each of these stages was marked by unrealistic expectations and rhetorical claims that had little basis in fact. In their quest to build public support and legitimate their cherished policy, psychiatric activists invariably insisted that they possessed the means to prevent and to cure severe mental disorders. When such expectations proved unrealistic, they placed the blame either upon callous

  20. Incremental Benefit of a Home Visit Following Discharge for Patients with Multiple Chronic Conditions Receiving Transitional Care

    PubMed Central

    Jackson, Carlos; Kasper, Elizabeth W.; Williams, Christianna

    2016-01-01

    Abstract Transitional care management is effective at reducing hospital readmissions among patients with multiple chronic conditions, but evidence is lacking on the relative benefit of the home visit as a component of transitional care. The sample included non-dual Medicaid recipients with multiple chronic conditions enrolled in Community Care of North Carolina (CCNC), with a hospital discharge between July 2010 and December 2012. Using claims data and care management records, this study retrospectively examined whether home visits reduced the odds of 30-day readmission compared to less intensive transitional care support, using multivariate logistic regression to control for demographic and clinical characteristics. Additionally, the researchers examined group differences within clinical risk strata on inpatient admissions and total cost of care in the 6 months following hospital discharge. Of 35,174 discharges receiving transitional care from a CCNC care manager, 21% (N = 7468) included a home visit. In multivariate analysis, home visits significantly reduced the odds of readmission within 30 days (odds ratio = 0.52, 95% confidence interval 0.48–0.57). At the 6-month follow-up, home visits were associated with fewer inpatient admissions within 4 of 6 clinical risk strata, and lower total costs of care for highest risk patients (average per member per month cost difference $970; P < 0.01). For complex chronic patients, home visits reduced the likelihood of a 30-day readmission by almost half compared to less intensive forms of nurse-led transitional care support. Higher risk patients experienced the greatest benefit in terms of number of inpatient admissions and total cost of care in the 6 months following discharge. (Population Health Management 2016;19:163–170) PMID:26431255

  1. Roles of managers in academic health centers: strategies for the managed care environment.

    PubMed

    Guo, Kristina L

    2002-03-01

    This article addresses survival strategies of academic health centers (AHCs) in responding to market pressures and government reforms. Using six case studies of AHCs, the study links strategic changes in structure and management to managerial role performance. Utilizing Mintzberg's classification of work roles, the roles of liaison, monitor, entrepreneur, and resource allocator were found to be used by top-level managers as they implement strategies to enhance the viability of their AHCs. Based on these new roles, the study recommends improving management practices through education and training as well as changing organizational culture to support management decision making and foster the continued growth of managers and their AHCs.

  2. A meta-analysis of hypnosis for chronic pain problems: a comparison between hypnosis, standard care, and other psychological interventions.

    PubMed

    Adachi, Tomonori; Fujino, Haruo; Nakae, Aya; Mashimo, Takashi; Sasaki, Jun

    2014-01-01

    Hypnosis is regarded as an effective treatment for psychological and physical ailments. However, its efficacy as a strategy for managing chronic pain has not been assessed through meta-analytical methods. The objective of the current study was to conduct a meta-analysis to assess the efficacy of hypnosis for managing chronic pain. When compared with standard care, hypnosis provided moderate treatment benefit. Hypnosis also showed a moderate superior effect as compared to other psychological interventions for a nonheadache group. The results suggest that hypnosis is efficacious for managing chronic pain. Given that large heterogeneity among the included studies was identified, the nature of hypnosis treatment is further discussed.

  3. A meta-analysis of hypnosis for chronic pain problems: a comparison between hypnosis, standard care, and other psychological interventions.

    PubMed

    Adachi, Tomonori; Fujino, Haruo; Nakae, Aya; Mashimo, Takashi; Sasaki, Jun

    2014-01-01

    Hypnosis is regarded as an effective treatment for psychological and physical ailments. However, its efficacy as a strategy for managing chronic pain has not been assessed through meta-analytical methods. The objective of the current study was to conduct a meta-analysis to assess the efficacy of hypnosis for managing chronic pain. When compared with standard care, hypnosis provided moderate treatment benefit. Hypnosis also showed a moderate superior effect as compared to other psychological interventions for a nonheadache group. The results suggest that hypnosis is efficacious for managing chronic pain. Given that large heterogeneity among the included studies was identified, the nature of hypnosis treatment is further discussed. PMID:24256477

  4. Determinants of access to chronic illness care: a mixed-methods evaluation of a national multifaceted chronic disease package for Indigenous Australians

    PubMed Central

    Bailie, Jodie; Schierhout, Gill; Laycock, Alison; Kelaher, Margaret; Percival, Nikki; O'Donoghue, Lynette; McNeair, Tracy; Bailie, Ross

    2015-01-01

    Objectives Indigenous Australians have a disproportionately high burden of chronic illness, and relatively poor access to healthcare. This paper examines how a national multicomponent programme aimed at improving prevention and management of chronic disease among Australian Indigenous people addressed various dimensions of access. Design Data from a place-based, mixed-methods formative evaluation were analysed against a framework that defines supply and demand-side dimensions to access. The evaluation included 24 geographically bounded ‘sentinel sites’ that included a range of primary care service organisations. It drew on administrative data on service utilisation, focus group and interview data on community members’ and service providers’ perceptions of chronic illness care between 2010 and 2013. Setting Urban, regional and remote areas of Australia that have relatively large Indigenous populations. Participants 670 community members participated in focus groups; 374 practitioners and representatives of regional primary care support organisations participated in in-depth interviews. Results The programme largely addressed supply-side dimensions of access with less focus or impact on demand-side dimensions. Application of the access framework highlighted the complex inter-relationships between dimensions of access. Key ongoing challenges are achieving population coverage through a national programme, reaching high-need groups and ensuring provision of ongoing care. Conclusions Strategies to improve access to chronic illness care for this population need to be tailored to local circumstances and address the range of dimensions of access on both the demand and supply sides. These findings highlight the importance of flexibility in national programme guidelines to support locally determined strategies. PMID:26614617

  5. Chronic Illness Self-care and the Family Lives of Older Adults: A Synthetic Review Across Four Ethnic Groups

    PubMed Central

    Gallant, Mary P.; Spitze, Glenna; Grove, Joshua G.

    2010-01-01

    The purpose of this paper is to integrate the literature on family and social ties among older ethnic minority men and women with the literature on chronic illness self-care among elders in these groups, in order to increase understanding of social influences on self-care behavior, raise questions for future research, and inform culturally appropriate interventions to maximize the health-promoting potential of social relationships. The paper presents demographic and chronic illness prevalence information, and then summarizes literature about patterns of chronic illness self-care behaviors for older African-Americans, Latinos, Asian-Americans, and American Indians in the U.S. For each group, the sociological literature about residential, cultural, and socioeconomic patterns, family lives, and other social ties is then reviewed, and the self-care literature that has accounted for these patterns is discussed. Finally, six themes are outlined and related questions are identified to further illuminate the social context of older adults’ chronic illness self-care. PMID:20177963

  6. Chronic Pain and Health Care Spending: An Analysis of Longitudinal Data from the Medical Expenditure Panel Survey

    PubMed Central

    Stockbridge, Erica L; Suzuki, Sumihiro; Pagán, José A

    2015-01-01

    Objective To estimate average incremental health care expenditures associated with chronic pain by health care service category, expanding on prior research that focused on specific pain conditions instead of general pain, excluded low levels of pain, or did not incorporate pain duration. Data Source Medical Expenditure Panel Survey (MEPS) data (2008–2011; N = 26,671). Study Design Differences in annual expenditures for adults at different levels of pain that interferes with normal work, as measured by the SF-12, were estimated using recycled predictions from two-part logit-generalized linear regression models. Principal Findings “A little bit” of chronic pain-related interference was associated with a $2,498 increase in total adjusted expenditures over no pain interference (p < .0001) and a $1,008 increase over nonchronic pain interference (p = .0001). Moderate and severe chronic pain-related interference was associated with a $3,707 and $5,804 increase in expenditures over no pain interference and a $2,218 and $4,315 increase over nonchronic interference, respectively (p < .0001). Expenditure increases were most pronounced for inpatient and hospital outpatient expenditures compared to other types of health care expenditures. Conclusions Chronic pain limitations are associated with higher health care expenditures. Results underscore the substantial cost of pain to the health care system. PMID:25424348

  7. The impact of poverty, chronic illnesses, and health insurance status on out-of-pocket health care expenditures in later life.

    PubMed

    Kim, Jinhyun; Richardson, Virginia

    2014-10-01

    This study aims to examine poverty, chronic illnesses, health insurance, and health care expenditures, within the context of a political economy of aging perspective. Subsamples of 1,773 older adults from the Medical Expenditure Panel Survey were selected for analyses. The results showed that chronic illnesses influenced out-of-pocket health care costs. Older persons with more than one health insurance spent less on out-of-pocket health care costs. The results have implications for health care social workers concerned with the growing costs of chronic illnesses, implementing integrated care, and advocating for extending public health insurance coverage especially for our most impoverished older adults.

  8. An academic-community partnership to improve care for the underserved.

    PubMed

    Fancher, Tonya L; Keenan, Craig; Meltvedt, Caitlyn; Stocker, Timothy; Harris, Tracie; Morfín, José; McCarron, Robert; Kulkarni-Date, Mrinalini; Henderson, Mark C

    2011-02-01

    Despite the need for a robust primary care workforce, the number of students and residents choosing general internal medicine careers continues to decline. In this article, the authors describe their efforts at the University of California, Davis School of Medicine to bolster interest in internal medicine careers and improve the quality of care for medically underserved populations through a tailored third-year residency track developed in partnership with the Sacramento County Department of Health and Human Services. The Transforming Education and Community Health (TEACH) Program improves continuity of care between inpatient and outpatient settings, creates a new multidisciplinary teaching clinic in the Sacramento County health system, and prepares residents to provide coordinated care for vulnerable populations. Since its inception in 2005, 25 residents have graduated from the TEACH Program. Compared with national rates, TEACH graduates are more likely to practice general internal medicine and to practice in medically underserved settings. TEACH residents report high job satisfaction and provide equal or higher-quality diabetes care than that indicated by national benchmarks. The authors provide an overview of the TEACH Program, including curriculum details, preliminary outcomes, barriers to continued and expanded implementation, and thoughts about the future of the program. PMID:21169777

  9. Quality of life and use of health care resources among patients with chronic depression

    PubMed Central

    Villoro, Renata; Merino, María; Hidalgo-Vega, Alvaro

    2016-01-01

    Purpose This study estimates the health-related quality of life and the health care resource utilization of patients diagnosed with chronic depression (CD) in Spain. Patients and methods We used the Spanish National Health Survey 2011–2012, a cross-sectional survey representative at the national level, that selects people aged between 18 and 64 years (n=14,691). We estimated utility indices through the EuroQol five-dimensional descriptive system questionnaire included in the survey. We calculated percentage use of health care resources (medical visits, hospitalizations, emergency services, and drug consumption) and average number of resources used when available. A systematic comparison was made between people diagnosed with CD and other chronic conditions (OCCs). The chi-square test, Mann–Whitney U-test, and Kruskal–Wallis test were used to determine the statistical significance of differences between comparison groups. Multivariate analyses (Poisson regression, logistic regression, and linear regression) were also carried out to assess the relationship between quality of life and consumption of health care resources. Results Approximately, 6.1% of the subjects aged between 18 and 64 years were diagnosed with CD (average age 48.3±11 years, 71.7% females). After controlling for age, sex, and total number of comorbidities, a diagnosis of CD reduced utility scores by 0.09 (P<0.05) vs OCCs, and increased the average number of hospitalizations by 15%, the average number of days at hospital by 51%, and the average number of visits to emergency services by 15% (P<0.05). CD also increased the average number of visits to secondary care by 14% and visits to general practitioners by 4%. People with CD had a higher probability of consuming drugs than people with OCCs (odds ratio [OR]: 1.24, P<0.05), but only 38.6% took antidepressants. Conclusion People with CD had significantly lower health-related quality of life than people with OCCs. CD was associated with

  10. Framing Disparities Along the Continuum of Care From Chronic Kidney Disease to Transplantation: Barriers and Interventions

    PubMed Central

    Ladin, Keren; Rodrigue, James R.; Hanto, Douglas W.

    2009-01-01

    Research in renal transplantation continues to document scores of disparities affecting vulnerable populations at various stages along the transplantation process. Given that both biological and environmental determinants contribute significantly to variation, identifying factors underlying an unfairly biased distribution of the disease burden is crucial. Confounded definitions and gaps in understanding causal pathways impede effectiveness of interventions aimed at alleviating disparities. This paper offers an operational definition of disparities in the context of a framework aimed at facilitating interventional research. Utilizing an original framework describing the entire continuum of the transplant process from diagnosis of chronic kidney disease through successful transplant, this paper explores the case of racial disparities, illustrating key factors predicting and perpetuating disparities. Though gaps in current research leave us unable to identify which stages of the transplant pathway adversely affect most people, by identifying key risk factors across the continuum of care, this paper highlights areas suited for targeted interventions and presents recommendations for improvement and future research. PMID:19344460

  11. Framing disparities along the continuum of care from chronic kidney disease to transplantation: barriers and interventions.

    PubMed

    Ladin, K; Rodrigue, J R; Hanto, D W

    2009-04-01

    Research in renal transplantation continues to document scores of disparities affecting vulnerable populations at various stages along the transplantation process. Given that both biological and environmental determinants contribute significantly to variation, identifying factors underlying an unfairly biased distribution of the disease burden is crucial. Confounded definitions and gaps in understanding causal pathways impede effectiveness of interventions aimed at alleviating disparities. This article offers an operational definition of disparities in the context of a framework aimed at facilitating interventional research. Utilizing an original framework describing the entire continuum of the transplant process from diagnosis of chronic kidney disease through successful transplant, this article explores the case of racial disparities, illustrating key factors predicting and perpetuating disparities. Though gaps in current research leave us unable to identify which stages of the transplant pathway adversely affect most people, by identifying key risk factors across the continuum of care, this article highlights areas suited for targeted interventions and presents recommendations for improvement and future research.

  12. A New Multidisciplinary Home Care Telemedicine System to Monitor Stable Chronic Human Immunodeficiency Virus-Infected Patients: A Randomized Study

    PubMed Central

    León, Agathe; Cáceres, César; Fernández, Emma; Chausa, Paloma; Martin, Maite; Codina, Carles; Rousaud, Araceli; Blanch, Jordi; Mallolas, Josep; Martinez, Esteban; Blanco, Jose L.; Laguno, Montserrat; Larrousse, Maria; Milinkovic, Ana; Zamora, Laura; Canal, Neus; Miró, Josep M.; Gatell, Josep M.; Gómez, Enrique J.; García, Felipe

    2011-01-01

    Background Antiretroviral therapy has changed the natural history of human immunodeficiency virus (HIV) infection in developed countries, where it has become a chronic disease. This clinical scenario requires a new approach to simplify follow-up appointments and facilitate access to healthcare professionals. Methodology We developed a new internet-based home care model covering the entire management of chronic HIV-infected patients. This was called Virtual Hospital. We report the results of a prospective randomised study performed over two years, comparing standard care received by HIV-infected patients with Virtual Hospital care. HIV-infected patients with access to a computer and broadband were randomised to be monitored either through Virtual Hospital (Arm I) or through standard care at the day hospital (Arm II). After one year of follow up, patients switched their care to the other arm. Virtual Hospital offered four main services: Virtual Consultations, Telepharmacy, Virtual Library and Virtual Community. A technical and clinical evaluation of Virtual Hospital was carried out. Findings Of the 83 randomised patients, 42 were monitored during the first year through Virtual Hospital (Arm I) and 41 through standard care (Arm II). Baseline characteristics of patients were similar in the two arms. The level of technical satisfaction with the virtual system was high: 85% of patients considered that Virtual Hospital improved their access to clinical data and they felt comfortable with the videoconference system. Neither clinical parameters [level of CD4+ T lymphocytes, proportion of patients with an undetectable level of viral load (p = 0.21) and compliance levels >90% (p = 0.58)] nor the evaluation of quality of life or psychological questionnaires changed significantly between the two types of care. Conclusions Virtual Hospital is a feasible and safe tool for the multidisciplinary home care of chronic HIV patients. Telemedicine should be considered as an

  13. Practical Approach to Detection and Management of Chronic Kidney Disease for the Primary Care Clinician.

    PubMed

    Vassalotti, Joseph A; Centor, Robert; Turner, Barbara J; Greer, Raquel C; Choi, Michael; Sequist, Thomas D

    2016-02-01

    A panel of internists and nephrologists developed this practical approach for the Kidney Disease Outcomes Quality Initiative to guide assessment and care of chronic kidney disease (CKD) by primary care clinicians. Chronic kidney disease is defined as a glomerular filtration rate (GFR) <60 mL/min/1.73 m(2) and/or markers of kidney damage for at least 3 months. In clinical practice the most common tests for CKD include GFR estimated from the serum creatinine concentration (eGFR) and albuminuria from the urinary albumin-to-creatinine ratio. Assessment of eGFR and albuminuria should be performed for persons with diabetes and/or hypertension but is not recommended for the general population. Management of CKD includes reducing the patient's risk of CKD progression and risk of associated complications, such as acute kidney injury and cardiovascular disease, anemia, and metabolic acidosis, as well as mineral and bone disorder. Prevention of CKD progression requires blood pressure <140/90 mm Hg, use of angiotensin-converting enzyme inhibitors or angiotensin receptor blockers for patients with albuminuria and hypertension, hemoglobin A1c ≤7% for patients with diabetes, and correction of CKD-associated metabolic acidosis. To reduce patient safety hazards from medications, the level of eGFR should be considered when prescribing, and nephrotoxins should be avoided, such as nonsteroidal anti-inflammatory drugs. The main reasons to refer to nephrology specialists are eGFR <30 mL/min/1.73 m(2), severe albuminuria, and acute kidney injury. The ultimate goal of CKD management is to prevent disease progression, minimize complications, and promote quality of life.

  14. Role of the Chronic Dental Disease Scheme in Enhanced Primary Care: allied health or allied outlier?

    PubMed

    Lam, Raymond; Kruger, Estie; Tennant, Marc

    2013-01-01

    This study aims to provide a comparative analysis of the Chronic Dental Disease Scheme (CDSS) and the Allied Health Profession (AHP) program as they related to the greater Enhanced Primary Care Scheme introduced by the Australian Government to manage patients with chronic and complex diseases. A retrospective analysis of data pertaining to Medicare items related to dentistry and the allied health professions were extracted from the Medicare Benefits Schedule database online, and formed the basis of this study. The highest proportion of services was provided in the state of New South Wales. There appears to be synergy in the utilisation of services with jurisdictions either overutilising or underutilising services. Costs to the Enhanced Primary Care Scheme under the CDSS model (fee for service) were up to 40 times more expensive compared with the AHP model (fee per visit). Costs and treatment associated with the CDSS experienced an increase of 13350% during the period 2007-08, coincident with an increase in subsidization. Reconstructive dentistry accounted for the majority of the increase. Gender disparities in dentistry were less distinct when compared with AHPs and were postulated to be due to males presenting with conditions that were more progressive requiring more invasive treatment. A comparative analysis indicates significant differences in costs, nature of treatment and the manner of remuneration between dentistry and the AHPs. A fee for service schedule as evidenced by the CDSS is dependent on the degree of financial incentive as indicated by patterns in utilisation over time. The amount of treatment considered necessary may be influenced by the level of subsidy with treatment that may not reflect disease management. The AHP model, which is based around a fee for visit schedule, is not without its deficiencies but has not experienced significant rises in cost compared with the CDSS.

  15. Patient-Centred Care of Older Adults With Cardiovascular Disease and Multiple Chronic Conditions.

    PubMed

    Kim, Dae Hyun; Rich, Michael W

    2016-09-01

    Multimorbidity, defined as the presence of 2 or more chronic conditions, is common among older adults with cardiovascular disease. These individuals are at increased risk for poor health outcomes and account for a large proportion of health care utilization. Clinicians are challenged with the heterogeneity of this population, the complexity of the treatment regimen, limited high-quality evidence, and fragmented health care systems. Each treatment recommended by a clinical practice guideline for a single cardiovascular disease might be rational, but the combination of all evidence-based recommendations can be impractical or even harmful to individuals with multimorbidity. These challenges can be overcome with a patient-centred approach that incorporates the individual's preferences, relevant evidence, the overall and condition-specific prognosis, clinical feasibility of treatments, and interactions with other treatments and coexisting chronic conditions. The ultimate goal is to maximize benefits and minimize harms by optimizing adherence to the most essential treatments, while acknowledging trade-offs between treatments for different health conditions. It might be necessary to discontinue therapies that are not essential or potentially harmful to decrease the risk of drug-drug and drug-disease interactions from polypharmacy. A decision to initiate, withhold, or stop a treatment should be on the basis of the time horizon to benefits vs the individual's prognosis. In this review, we illustrate how cardiologists and general practitioners can adopt a patient-centred approach to focus on the aspects of cardiovascular and noncardiovascular health that have the greatest effect on functioning and quality of life in older adults with cardiovascular disease and multimorbidity. PMID:27378591

  16. Role of the Chronic Dental Disease Scheme in Enhanced Primary Care: allied health or allied outlier?

    PubMed

    Lam, Raymond; Kruger, Estie; Tennant, Marc

    2013-01-01

    This study aims to provide a comparative analysis of the Chronic Dental Disease Scheme (CDSS) and the Allied Health Profession (AHP) program as they related to the greater Enhanced Primary Care Scheme introduced by the Australian Government to manage patients with chronic and complex diseases. A retrospective analysis of data pertaining to Medicare items related to dentistry and the allied health professions were extracted from the Medicare Benefits Schedule database online, and formed the basis of this study. The highest proportion of services was provided in the state of New South Wales. There appears to be synergy in the utilisation of services with jurisdictions either overutilising or underutilising services. Costs to the Enhanced Primary Care Scheme under the CDSS model (fee for service) were up to 40 times more expensive compared with the AHP model (fee per visit). Costs and treatment associated with the CDSS experienced an increase of 13350% during the period 2007-08, coincident with an increase in subsidization. Reconstructive dentistry accounted for the majority of the increase. Gender disparities in dentistry were less distinct when compared with AHPs and were postulated to be due to males presenting with conditions that were more progressive requiring more invasive treatment. A comparative analysis indicates significant differences in costs, nature of treatment and the manner of remuneration between dentistry and the AHPs. A fee for service schedule as evidenced by the CDSS is dependent on the degree of financial incentive as indicated by patterns in utilisation over time. The amount of treatment considered necessary may be influenced by the level of subsidy with treatment that may not reflect disease management. The AHP model, which is based around a fee for visit schedule, is not without its deficiencies but has not experienced significant rises in cost compared with the CDSS. PMID:22951045

  17. How precise is the evaluation of chronic wounds by health care professionals?

    PubMed

    Stremitzer, Stefan; Wild, Thomas; Hoelzenbein, Thomas

    2007-06-01

    Chronic wounds are a growing challenge for physicians and health insurance agencies. The burden of affected patients is enormous, because of pain but also because of long-lasting therapies and dependence on nursing services. In other areas of medicine, computer-based diagnostics is established, yet, accurate wound documentation is rarely conducted and is often limited to size measurement with a ruler and a rough photo documentation. Objective assessment of lesions by evaluation of granulation tissue, fibrin coverage and necrosis is not performed. The aim of this study was to investigate the spread and variety in judgement of a chronic wound. A diabetic ulcer was described by 16 wound therapists (eight physicians and eight nurses). Granulation tissue, fibrin coverage, necrosis, size and depth of the lesion, wound exudate and wound edges were judged, and the therapeutical consequences were determined. Study data show an extensive inhomogeneity and a wide spread of the results, like in no other field of medical diagnostics. This could be shown in the group of physicians, as well as in the group of nursing personnel. As the choice of treatment by a specialist is based upon the assessment of the wound, it is possible that in practice it can lead to suboptimal therapy. This is a consequence of varying treating physicians and subsequent changes in treatment regimens. This results in a prolongation of treatment and burden for the patient. Circumstances like this contribute to rising of costs in this area of the health care system. The goal is to apply objective wound diagnostic technologies in the field of chronic wounds to catch up with other diagnostic procedures. PMID:17651230

  18. The Family Challenge of Caring for the Chronically Mentally Ill: A Phenomenological Study

    PubMed Central

    Shamsaei, Farshid; Cheraghi, Fatemeh; Esmaeilli, Ravanbakhsh

    2015-01-01

    Background: Family caregiving for patients with chronic mental illness is influenced by various factors such as political, socioeconomic, and cultural contexts as well as related policies and health services. Objectives: The purpose of this study was to explore the challenges with which the family caregivers of patients with chronic mental illness have to contend. Materials and Methods: The research design was qualitative with a phenomenological approach. The research population consisted of 16 long-term carers expressing interest in participating in the project. The carers were the family members of mentally ill relatives who collected their monthly medications at Farshchian Psychiatry Hospital in Hamadan in 2012. Purposive sampling was used to draw the sample. Data were collected by individual in-depth semi-structured interviews, which were tape-recorded and analyzed via Colaizzi’s phenomenological method. Rigor was assessed regarding credibility, dependability, conformability, and transferability. Results: Our findings highlighted 4 main themes, namely stress and emotional distress, need for education and information, socioeconomic effects and support, and physical strain. Conclusions: Families experience frustrations when providing support and care to their mentally ill relatives. They, therefore, need appropriate support and intervention by mental health services. PMID:26576169

  19. To Trach or Not to Trach: Uncertainty in the Care of the Chronically Critically Ill.

    PubMed

    Bice, Thomas; Nelson, Judith E; Carson, Shannon S

    2015-12-01

    The number of chronically critically ill patients requiring prolonged mechanical ventilation and receiving a tracheostomy is steadily increasing. Early tracheostomy in patients requiring prolonged mechanical ventilation has been proposed to decrease duration of mechanical ventilation and intensive care unit stay, reduce mortality, and improve patient comfort. However, these benefits have been difficult to demonstrate in clinical trials. So how does one determine the appropriate timing for tracheostomy placement in your patient? Here we review the potential benefits and consequences of tracheostomy, the available evidence for tracheostomy timing, communication surrounding the tracheostomy decision, and a patient-centered approach to tracheostomy. Patients requiring > 10 days of mechanical ventilation who are expected to survive their hospitalization likely benefit from tracheostomy, but protocols involving routine early tracheostomy placement do not improve patient outcomes. However, patients with neurologic injury, provided they have a good prognosis for meaningful recovery, may benefit from early tracheostomy. In chronically critically ill patients with poor prognosis, tracheostomy is unlikely to provide benefit and should only be pursued if it is consistent with the patient's values, goals, and preferences. In this setting, communication with patients and surrogates regarding tracheostomy and prognosis becomes paramount. For the foreseeable future, decisions surrounding tracheostomy will remain relevant and challenging. PMID:26595045

  20. Ancillary therapy and supportive care of chronic graft-versus-host disease: national institutes of health consensus development project on criteria for clinical trials in chronic Graft-versus-host disease: V. Ancillary Therapy and Supportive Care Working Group Report.

    PubMed

    Couriel, Daniel; Carpenter, Paul A; Cutler, Corey; Bolaños-Meade, Javier; Treister, Nathaniel S; Gea-Banacloche, Juan; Shaughnessy, Paul; Hymes, Sharon; Kim, Stella; Wayne, Alan S; Chien, Jason W; Neumann, Joyce; Mitchell, Sandra; Syrjala, Karen; Moravec, Carina K; Abramovitz, Linda; Liebermann, Jerry; Berger, Ann; Gerber, Lynn; Schubert, Mary; Filipovich, Alexandra H; Weisdorf, Daniel; Schubert, Mark M; Shulman, Howard; Schultz, Kirk; Mittelman, Barbara; Pavletic, Steven; Vogelsang, Georgia B; Martin, Paul J; Lee, Stephanie J; Flowers, Mary E D

    2006-04-01

    The Ancillary Therapy and Supportive Care Working Group had 3 goals: (1) to establish guidelines for ancillary therapy and supportive care in chronic graft-versus-host disease (GVHD), including treatment for symptoms and recommendations for patient education, preventive measures, and appropriate follow-up; (2) to provide guidelines for the prevention and management of infections and other common complications of treatment for chronic GVHD; and (3) to highlight the areas with the greatest need for clinical research. The definition of "ancillary therapy and supportive care" embraces the most frequent immunosuppressive or anti-inflammatory interventions used with topical intent and any other interventions directed at organ-specific control of symptoms or complications resulting from GVHD and its therapy. Also included in the definition are educational, preventive, and psychosocial interventions with this same objective. Recommendations are organized according to the strength and quality of evidence supporting them and cover the most commonly involved organs, including the skin, mouth, female genital tract, eyes, gastrointestinal tract, and lungs. Recommendations are provided for prevention of infections, osteoporosis, and steroid myopathy and management of neurocognitive and psychosocial adverse effects related to chronic GVHD. Optimal care of patients with chronic GVHD often requires a multidisciplinary approach. PMID:16545722

  1. Enhancing Provider Knowledge and Patient Screening for Palliative Care Needs in Chronic Multi-morbid Patients Receiving Home-based Primary Care

    PubMed Central

    Wharton, Tracy; Manu, Erika; Vitale, Caroline A.

    2014-01-01

    This paper describes a pilot model to increase palliative care knowledge and collaboration among providers, and to systematically identify chronic multi-morbid homecare patients who would benefit from focused discussion of potential palliative care (PC) needs. Thirty healthcare providers from a home-based primary care team attended interdisciplinary trainings. The Palliative Performance Scale (PPS) tool was used to trigger discussions of potential palliative needs at team rounds for patients who scored below a cutoff point on the tool. PPS implementation added little burden on nurses, and triggered a discussion in 51 flagged patients. The tool successfully identified 75% of patients who died or were discharged. Screening was systematic and consistent, and resulted in targeted discussions about PC needs without generating additional burden on our palliative care consult service. This model shows promise for enhancing collaborative patient care and access to PC. PMID:24280188

  2. Effects of chronic academic stress on mental state and expression of glucocorticoid receptor α and β isoforms in healthy Japanese medical students.

    PubMed

    Kurokawa, Ken; Tanahashi, Toshihito; Murata, Akiho; Akaike, Yoko; Katsuura, Sakurako; Nishida, Kensei; Masuda, Kiyoshi; Kuwano, Yuki; Kawai, Tomoko; Rokutan, Kazuhito

    2011-07-01

    Chronic academic stress responses were assessed by measuring mental state, salivary cortisol levels, and the glucocorticoid receptor (GR) gene expression in healthy Japanese medical students challenging the national medical license examination. Mental states of 17 male and 9 female medical undergraduates, aged 25.0 ± 1.2 years (mean ± SD), were assessed by the State and Trait Anxiety Inventory (STAI) and the Self-Rating Depression Scale (SDS) 2 months before, 2 days before, and 1 month after the examination. At the same time points, saliva and blood were collected. STAI-state scores peaked 2 days before the examination. Scores on STAI-trait and SDS, and salivary cortisol levels were consistently higher during the pre-examination period. One month after the examination, all these measures had significantly decreased to baseline levels. Real-time reverse transcription PCR showed that this chronic anxious state did not change the expression of the functional GRα mRNA isoform in peripheral leukocytes, while it resulted in reduced expression of the GRβ isoform 2 days before the examination. Our results replicate and extend a significant impact of chronic academic stressors on the mental state of healthy Japanese medical students and suggest a possible association of GRβ gene in response to psychological stress.

  3. The lived experience of giving spiritual care: a phenomenological study of nephrology nurses working in acute and chronic hemodialysis settings.

    PubMed

    Deal, Belinda; Grassley, Jane S

    2012-01-01

    The purpose of this study was to explore the lived experiences of nephrology nurses giving spiritual care in acute and chronic hemodialysis settings. Ten nurses were interviewed. Five themes were identified: a) drawing close, b) drawing from the well of my spiritual resources, c), sensing the pain of spiritual distress, d) lacking resources to give spiritual care, and e) giving spiritual care is like diving down deep. The study findings suggest that patients and nurses draw close during the giving of spiritual care, that nurses have spiritual resources they use to prepare for and give spiritual care, and that giving spiritual care can have an emotional cost. These findings have implications for nursing practice, nursing education, and nursing research.

  4. Inequality and inequity in access to health care and treatment for chronic conditions in China: the Guangzhou Biobank Cohort Study.

    PubMed

    Elwell-Sutton, Timothy M; Jiang, Chao Qiang; Zhang, Wei Sen; Cheng, Kar Keung; Lam, Tai H; Leung, Gabriel M; Schooling, C M

    2013-08-01

    Non-communicable diseases (NCDs) are a large and rapidly-growing problem in China and other middle-income countries. Clinical treatment of NCDs is long-term and expensive, so it may present particular problems for equality and horizontal equity (equal treatment for equal need) in access to health care, although little is known about this at present in low- and middle-income countries. To address this gap, and inform policy for a substantial proportion of the global population, we examined inequality and inequity in general health care utilization (doctor consultations and hospital admissions) and in treatment of chronic conditions (hypertension, hyperglycaemia and dyslipidaemia), in 30 499 Chinese adults aged ≥50 years from one of China's richest provinces, using the Guangzhou Biobank Cohort Study (2003-2008). We used concentration indices to test for inequality and inequity in utilization by household income per head. Inequality was decomposed to show the contributions of income, indicators of 'need for health care' (age, sex, self-rated health, coronary heart disease risk and chronic obstructive pulmonary disease) and non-need factors (education, occupation, out-of-pocket health care payments and health insurance). We found inequality and inequity in treatment of chronic conditions but not in general health care utilization. Using more objective and specific measures of 'need for health care' increased estimates of inequity for treatment of chronic conditions. Income and non-need factors (especially health insurance, education and occupation) made the largest contributions to inequality. Further work is needed on why access to treatment for chronic conditions in China is restricted for those on low incomes and how these inequities can be mitigated.

  5. Creating an Academic and Rural Community Network To Improve Diabetes Care.

    ERIC Educational Resources Information Center

    Smith, Carol A.; Kennedy, Diane M.; Lahoz, Monina Rasay; Hislop, David A.; Erkel, Elizabeth E.

    The South Carolina Rural Interdisciplinary Program in Training (SCRIPT) provides practical educational experiences for students from multiple health care majors in rural communities in the Low Country (Southern region) of South Carolina. Faculty from the Medical University of South Carolina joined with staff from the Low Country Area Health…

  6. Development of an anticoagulation stewardship program at a large tertiary care academic institution.

    PubMed

    Padron, Maria; Miyares, Marta A

    2015-02-01

    Pharmacist-directed anticoagulation management services (AMSs) have been shown to significantly lower anticoagulation-related mortality, length of hospital stay, bleeding complications, blood transfusion requirements, and cost of therapy. AMSs are only 1 component of an anticoagulation stewardship program. Frequently, stewardship programs are limited to inpatient populations. Incorporating components that facilitate transition to outpatient status will ideally encompass complete care. The purpose of this program was to expand anticoagulation services and standardize care by implementing a full-service stewardship program including a transition of care service. The first component of the study involved medication surveillance for inpatients on anticoagulation therapy. The second component involved transitioning patients on anticoagulation, primarily with venous thromboembolism (VTE) to outpatient management. Finally, the pharmacist identified areas for optimization. Optimization involved developing or updating protocols to reflect updates in the literature as well as updating institution-specific information resources. Interventions made through medication surveillance and utilization of the VTE transition of care services translated into a total cost savings of approximately US$270 320. A postgraduate, first-year pharmacy resident contributed to improving patient outcomes while reducing utilization of hospital services and obtaining substantial cost savings through participation in anticoagulation stewardship services.

  7. Attachment Theory, Teacher Motivation & Pastoral Care: A Challenge for Teachers and Academics

    ERIC Educational Resources Information Center

    Riley, Philip

    2013-01-01

    The hypothesis that an unconscious need for a corrective emotional experience (CEE) drives the choice to care for others was investigated via attachment style and feelings of anger at students and staff. Data were obtained from 750 pre-service and experienced teachers, including 179 principals, who completed one of two versions of the Experiences…

  8. Culture shock and synergy. Academic/managed care/corporate alliances in outcomes management.

    PubMed

    Berman, W H; Darling, H; Hurt, S W; Hunkeler, E M

    1994-01-01

    The Behavioral Health Outcomes Study is a partnership in conducting outcomes measurement involving a corporate healthcare purchaser, five managed behavioral healthcare organizations and academic researchers. The goals of this study are to: evaluate the feasibility of incorporating patient self-reported data in outcomes research; identify factors that may be predictors of outcome; and evaluate the effectiveness of an employee-sponsored aftercare program. The differing perspectives and needs of the three partners have created a number of challenges in the areas of goals, confidentiality, proprietary vs. open access issues and methodology. However, after the study's first year, it is clear not only that outcomes research can be conducted under such a partnership, but that the partnership generates a kind of synergy in problem-solving.

  9. Academic and Mental Health Outcomes of Youth Placed in Out-of-Home Care: The Role of School Stability and Engagement

    ERIC Educational Resources Information Center

    Leonard, Skyler S.; Gudiño, Omar G.

    2016-01-01

    Background: Youth placed in out-of-home care are at significant risk of low academic achievement and poor mental health. Few studies have considered the potential effects of school-related factors, such as school placement stability and school engagement, on youth outcomes. Objective: The current study examined the potential main effects of school…

  10. Barriers and enablers to good communication and information-sharing practices in care planning for chronic condition management.

    PubMed

    Lawn, Sharon; Delany, Toni; Sweet, Linda; Battersby, Malcolm; Skinner, Timothy

    2015-01-01

    Our aim was to document current communication and information-sharing practices and to identify the barriers and enablers to good practices within the context of care planning for chronic condition management. Further aims were to make recommendations about how changes to policy and practice can improve communication and information sharing in primary health care. A mixed-method approach was applied to seek the perspectives of patients and primary health-care workers across Australia. Data was collected via interviews, focus groups, non-participant observations and a national survey. Data analysis was performed using a mix of thematic, discourse and statistical approaches. Central barriers to effective communication and information sharing included fragmented communication, uncertainty around client and interagency consent, and the unacknowledged existence of overlapping care plans. To be most effective, communication and information sharing should be open, two-way and inclusive of all members of health-care teams. It must also only be undertaken with the appropriate participant consent, otherwise this has the potential to cause patients harm. Improvements in care planning as a communication and information-sharing tool may be achieved through practice initiatives that reflect the rhetoric of collaborative person-centred care, which is already supported through existing policy in Australia. General practitioners and other primary care providers should operationalise care planning, and the expectation of collaborative and effective communication of care that underpins it, within their practice with patients and all members of the care team. To assist in meeting these aims, we make several recommendations.

  11. Managing and monitoring chronic non-communicable diseases in a primary health care clinic, Lilongwe, Malawi

    PubMed Central

    Manjomo, R. C.; Mwagomba, B.; Ade, S.; Ali, E.; Ben-Smith, A.; Khomani, P.; Bondwe, P.; Nkhoma, D.; Douglas, G. P.; Tayler-Smith, K.; Chikosi, L.; Gadabu, O. J.

    2016-01-01

    Setting: Patients with chronic non-communicable diseases attending a primary health care centre, Lilongwe, Malawi. Objective: Using an electronic medical record monitoring system, to describe the quarterly and cumulative disease burden, management and outcomes of patients registered between March 2014 and June 2015. Design: A cross-sectional study. Results: Of 1135 patients, with new registrations increasing each quarter, 66% were female, 21% were aged ⩾65 years, 20% were obese, 53% had hypertension alone, 18% had diabetes alone, 12% had asthma, 10% had epilepsy and 7% had both hypertension and diabetes. In every quarter, about 30% of patients did not attend the clinic and 19% were registered as lost to follow-up (not seen for ⩾1 year) in the last quarter. Of those attending, over 90% were prescribed medication, and 80–90% with hypertension and/or diabetes had blood pressure/blood glucose measured. Over 85% of those with epilepsy had no seizures and 60–75% with asthma had no severe attacks. Control of blood pressure (41–51%) and diabetes (15–38%) was poor. Conclusion: It is feasible to manage patients with non-communicable diseases in a primary health care setting in Malawi, although more attention is needed to improve clinic attendance and the control of hypertension and diabetes. PMID:27358797

  12. The role of primary care physicians in early diagnosis and treatment of chronic gastrointestinal diseases

    PubMed Central

    Gikas, Aristofanis; Triantafillidis, John K

    2014-01-01

    Chronic gastrointestinal disorders are a source of substantial morbidity, mortality, and cost. They are common in general practice, and the primary care physician (PCP) has a central role in the early detection and management of these problems. The need to make cost-effective diagnostic and treatment decisions, avoid unnecessary investigation and referral, provide long-term effective control of symptoms, and minimize the risk of complications constitute the main challenges that PCPs face. The literature review shows that, although best practice standards are available, a considerable number of PCPs do not routinely follow them. Low rates of colorectal cancer screening, suboptimal testing and treatment of Helicobacter pylori infection, inappropriate use of proton pump inhibitors, and the fact that most PCPs are still approaching the irritable bowel disease as a diagnosis of exclusion represent the main gaps between evidence-based guidelines and clinical practice. This manuscript points out that updating of knowledge and skills of PCPs via continuing medical education is the only way for better adherence with standards and improving quality of care for patients with gastrointestinal diseases. PMID:24648750

  13. A review of chronic pain impact on patients, their social environment and the health care system

    PubMed Central

    Dueñas, María; Ojeda, Begoña; Salazar, Alejandro; Mico, Juan Antonio; Failde, Inmaculada

    2016-01-01

    Chronic pain (CP) seriously affects the patient’s daily activities and quality of life, but few studies on CP have considered its effects on the patient’s social and family environment. In this work, through a review of the literature, we assessed several aspects of how CP influences the patient’s daily activities and quality of life, as well as its repercussions in the workplace, and on the family and social environment. Finally, the consequences of pain on the health care system are discussed. On the basis of the results, we concluded that in addition to the serious consequences on the patient’s life, CP has a severe detrimental effect on their social and family environment, as well as on health care services. Thus, we want to emphasize on the need to adopt a multidisciplinary approach to treatment so as to obtain more comprehensive improvements for patients in familial and social contexts. Accordingly, it would be beneficial to promote more social- and family-oriented research initiatives. PMID:27418853

  14. 38 CFR 17.44 - Hospital care for certain retirees with chronic disability (Executive Orders 10122, 10400 and...

    Code of Federal Regulations, 2013 CFR

    2013-07-01

    ... 38 Pensions, Bonuses, and Veterans' Relief 1 2013-07-01 2013-07-01 false Hospital care for certain retirees with chronic disability (Executive Orders 10122, 10400 and 11733). 17.44 Section 17.44 Pensions, Bonuses, and Veterans' Relief DEPARTMENT OF VETERANS AFFAIRS MEDICAL Hospital, Domiciliary and...

  15. 38 CFR 17.44 - Hospital care for certain retirees with chronic disability (Executive Orders 10122, 10400 and...

    Code of Federal Regulations, 2012 CFR

    2012-07-01

    ... 38 Pensions, Bonuses, and Veterans' Relief 1 2012-07-01 2012-07-01 false Hospital care for certain retirees with chronic disability (Executive Orders 10122, 10400 and 11733). 17.44 Section 17.44 Pensions, Bonuses, and Veterans' Relief DEPARTMENT OF VETERANS AFFAIRS MEDICAL Hospital, Domiciliary and...

  16. 38 CFR 17.44 - Hospital care for certain retirees with chronic disability (Executive Orders 10122, 10400 and...

    Code of Federal Regulations, 2014 CFR

    2014-07-01

    ... 38 Pensions, Bonuses, and Veterans' Relief 1 2014-07-01 2014-07-01 false Hospital care for certain retirees with chronic disability (Executive Orders 10122, 10400 and 11733). 17.44 Section 17.44 Pensions, Bonuses, and Veterans' Relief DEPARTMENT OF VETERANS AFFAIRS MEDICAL Hospital, Domiciliary and...

  17. 38 CFR 17.44 - Hospital care for certain retirees with chronic disability (Executive Orders 10122, 10400 and...

    Code of Federal Regulations, 2011 CFR

    2011-07-01

    ... 38 Pensions, Bonuses, and Veterans' Relief 1 2011-07-01 2011-07-01 false Hospital care for certain retirees with chronic disability (Executive Orders 10122, 10400 and 11733). 17.44 Section 17.44 Pensions, Bonuses, and Veterans' Relief DEPARTMENT OF VETERANS AFFAIRS MEDICAL Hospital, Domiciliary and...

  18. 38 CFR 17.44 - Hospital care for certain retirees with chronic disability (Executive Orders 10122, 10400 and...

    Code of Federal Regulations, 2010 CFR

    2010-07-01

    ... 38 Pensions, Bonuses, and Veterans' Relief 1 2010-07-01 2010-07-01 false Hospital care for certain retirees with chronic disability (Executive Orders 10122, 10400 and 11733). 17.44 Section 17.44 Pensions, Bonuses, and Veterans' Relief DEPARTMENT OF VETERANS AFFAIRS MEDICAL Hospital, Domiciliary and...

  19. Depression in patients with chronic pain attending a specialised pain treatment centre: prevalence and impact on health care costs

    PubMed Central

    Rayner, Lauren; Hotopf, Matthew; Petkova, Hristina; Matcham, Faith; Simpson, Anna; McCracken, Lance M.

    2016-01-01

    Abstract This cross-sectional study aimed to determine the prevalence and impact of depression on health care costs in patients with complex chronic pain. The sample included 1204 patients attending a tertiary pain management service for people with chronic disabling pain, unresponsive to medical treatment. As part of routine care, patients completed a web-based questionnaire assessing mental and physical health, functioning, and service use in the preceding 3 months. Depression was assessed using the 9-item Patient Health Questionnaire. Self-report health care utilisation was measured across 4 domains: general practitioner contacts, contacts with secondary/tertiary care doctors, accident and emergency department visits, and days hospitalised. The participation rate was 89%. Seven hundred and thirty-two patients (60.8%; 95% CI 58.0-63.6) met criteria for probable depression, and 407 (33.8%) met the threshold for severe depression. Patients with depression were more likely to be unable to work because of ill health and reported greater work absence, greater pain-related interference with functioning, lower pain acceptance, and more generalised pain. Mean total health care costs per 3-month period were £731 (95% CI £646-£817) for patients with depression, compared with £448 (95% CI £366-£530) for patients without depression. A positive association between severe depression and total health care costs persisted after controlling for key demographic, functional, and clinical covariates using multiple linear regression models. These findings reveal the extent, severity, and impact of depression in patients with chronic pain and make evident a need for action. Effective treatment of depression may improve patient health and functioning and reduce the burden of chronic pain on health care services. PMID:26963849

  20. Depression in patients with chronic pain attending a specialised pain treatment centre: prevalence and impact on health care costs.

    PubMed

    Rayner, Lauren; Hotopf, Matthew; Petkova, Hristina; Matcham, Faith; Simpson, Anna; McCracken, Lance M

    2016-07-01

    This cross-sectional study aimed to determine the prevalence and impact of depression on health care costs in patients with complex chronic pain. The sample included 1204 patients attending a tertiary pain management service for people with chronic disabling pain, unresponsive to medical treatment. As part of routine care, patients completed a web-based questionnaire assessing mental and physical health, functioning, and service use in the preceding 3 months. Depression was assessed using the 9-item Patient Health Questionnaire. Self-report health care utilisation was measured across 4 domains: general practitioner contacts, contacts with secondary/tertiary care doctors, accident and emergency department visits, and days hospitalised. The participation rate was 89%. Seven hundred and thirty-two patients (60.8%; 95% CI 58.0-63.6) met criteria for probable depression, and 407 (33.8%) met the threshold for severe depression. Patients with depression were more likely to be unable to work because of ill health and reported greater work absence, greater pain-related interference with functioning, lower pain acceptance, and more generalised pain. Mean total health care costs per 3-month period were £731 (95% CI £646-£817) for patients with depression, compared with £448 (95% CI £366-£530) for patients without depression. A positive association between severe depression and total health care costs persisted after controlling for key demographic, functional, and clinical covariates using multiple linear regression models. These findings reveal the extent, severity, and impact of depression in patients with chronic pain and make evident a need for action. Effective treatment of depression may improve patient health and functioning and reduce the burden of chronic pain on health care services.

  1. Patient-Centered Medical Home Features and Health Care Expenditures of Medicare Beneficiaries with Chronic Disease Dyads.

    PubMed

    Philpot, Lindsey M; Stockbridge, Erica L; Padrón, Norma A; Pagán, José A

    2016-06-01

    Three out of 4 Medicare beneficiaries have multiple chronic conditions, and managing the care of this growing population can be complex and costly because of care coordination challenges. This study assesses how different elements of the patient-centered medical home (PCMH) model may impact the health care expenditures of Medicare beneficiaries with the most prevalent chronic disease dyads (ie, co-occurring high cholesterol and high blood pressure, high cholesterol and heart disease, high cholesterol and diabetes, high cholesterol and arthritis, heart disease and high blood pressure). Data from the 2007-2011 Medical Expenditure Panel Survey suggest that increased access to PCMH features may differentially impact the distribution of health care expenditures across health care service categories depending on the combination of chronic conditions experienced by each beneficiary. For example, having no difficulty contacting a provider after regular hours was associated with significantly lower outpatient expenditures for beneficiaries with high cholesterol and diabetes (n = 635; P = 0.038), but it was associated with significantly higher inpatient expenditures for beneficiaries with high blood pressure and high cholesterol (n = 1599; P = 0.015), and no significant differences in expenditures in any category for beneficiaries with high blood pressure and heart disease (n = 1018; P > 0.05 for all categories). However, average total health care expenditures are largely unaffected by implementing the PCMH features considered. Understanding how the needs of Medicare beneficiaries with multiple chronic conditions can be met through the adoption of the PCMH model is important not only to be able to provide high-quality care but also to control costs. (Population Health Management 2016;19:206-211).

  2. Cross-sectional survey of older patients' views regarding multidisciplinary care for chronic conditions in general practice.

    PubMed

    Bonney, Andrew; Magee, Christopher; Pearson, Russell

    2014-01-01

    The ageing population and increasing prevalence of chronic illness have contributed to the need for significant primary care reform, including increased use of multidisciplinary care and task substitution. This cross-sectional study explores conditions under which older patients would accept having health professionals other than their general practitioner (GP) involved in their care for chronic disease management (CDM). Ten practices were randomly sampled from a contiguous major city and inner regional area. Questionnaires were distributed to consecutive patients aged 60 years and over in each practice. Agency theory was used to inform analyses. Statistical analysis was undertaken using Wald's test, growth modelling and linear regression, controlling for the clustered design. The response rate was 53% (n=272). Most respondents (79%) had at least one chronic health condition. Respondents were more comfortable with GP than with practice nurse management in the CDM scenario (Wald's test=105.49, P<0.001). Comfort with practice nurse CDM was positively associated with increased contact with their GP at the time of the visit (β=0.41, P<0.001), negatively associated with the number of the respondent's chronic conditions (β=-0.13, P=0.030) and not associated with the frequency of other health professional visits. Agency theory suggests that patients employ continuity of care to optimise factors important in CDM: information symmetry and goal alignment. Our findings are consistent with the theory and lend support to ensuring that interpersonal continuity of care is not lost in health care reform. Further research exploring patients' acceptance of differing systems of care is required.

  3. Pharmacotherapeutic management of chronic noncancer pain in primary care: lessons for pharmacists

    PubMed Central

    Jouini, Ghaya; Choinière, Manon; Martin, Elisabeth; Perreault, Sylvie; Berbiche, Djamal; Lussier, David; Hudon, Eveline; Lalonde, Lyne

    2014-01-01

    Purpose Describe the pharmacotherapeutic management of primary-care patients with chronic noncancer pain, assess their satisfaction with pain treatment, and identify the determinants of their satisfaction. Methods A cohort study was conducted in Quebec (Canada). Patients reporting chronic noncancer pain with an average pain intensity of at least 4 on a 0–10 scale (10= worst possible pain) and having an active analgesic prescription from a primary-care physician were recruited. They completed a telephone interview and a self-administered questionnaire to document their pain, emotional well-being, satisfaction with treatment, and barriers/beliefs/attitudes about pain and its treatment. Information on pharmacotherapy was based on an administrative provincial database and pharmacies’ charts. Determinants of patients’ satisfaction were identified using multivariate linear regression models. Results Four hundred and eighty six patients participated. Their mean age was 58.4 years and they had had pain for a mean of 11.7 years (standard deviation, ±11.1) at an average pain intensity of 6.5 in the past week. Although 90% reported adverse gastrointestinal effects, 36.4% and 54.4% of these patients took no over-the-counter or prescribed medication for constipation or nausea, respectively. On a scale from 0–100, the mean overall satisfaction score was 64.7 (95% confidence interval [CI] =63.5–65.9). Patient satisfaction was low, particularly regarding the “information about pain and its treatment” (mean 50.6; 95% CI =47.6–53.7) and “treatment efficacy” (mean 53.6; 95% CI =51.5–55.6) subscales. The overall treatment satisfaction score decreased with more pain disability, probable depression and anxiety, more barriers to pain treatment, higher incidence of nausea, and use of over-the-counter analgesics. Conclusion In primary care, patients’ level of satisfaction with their pain treatment is not optimal. This study underlines how the expanded scope of

  4. Mind body medicine in the care of a U.S. Marine with chronic pain: a case report.

    PubMed

    Millegan, Jeffrey; Morrison, Theodore; Bhakta, Jagruti; Ram, Vasudha

    2014-09-01

    Many service members suffer from chronic pain that can be difficult to adequately treat. Frustration has led to more openness among service members to complementary and alternative medicine modalities. This report follows JK, a Marine with chronic pain related to an injury while on combat deployment through participation in a 6-week self-care-based Mind Body Medicine program and for 7 months after completion of the program. JK developed and sustained a regular meditation practice throughout the follow-up period. JK showed a noticeable reduction in perceived disability and improvements in psychological health, sleep latency/duration and quality of life. This report supports further study into the efficacy and feasibility of self-care-based mind body medicine in the treatment of chronic pain in the military medical setting.

  5. Comparison of primary health-care models in the management of chronic kidney disease.

    PubMed

    Cueto-Manzano, Alfonso M; Martínez-Ramírez, Héctor R; Cortés-Sanabria, Laura

    2013-05-01

    Negative lifestyle habits (potential risks for chronic kidney disease, CKD) are rarely modified by physicians in a conventional health-care model (CHCM). Multidisciplinary strategies may have better results; however, there is no information on their application in the early stages of CKD. Thus, the aim of this study was to compare a multiple intervention model versus CHCM on lifestyle and renal function in patients with type 2 diabetes mellitus and CKD stage 1-2. In a prospective cohort study, a family medicine unit (FMU) was assigned a multiple intervention model (MIM) and another continued with conventional health-care model (CHCM). MIM patients received an educational intervention guided by a multidisciplinary team (family physician (FP), social worker, dietitian, physical trainer); self-help groups functioned with free activities throughout the study. CHCM patients were managed only by the FP, who decided if patients needed referral to other professionals. Thirty-nine patients were studied in each cohort. According to a lifestyle questionnaire, no baseline differences were found between cohorts, but results reflected an unhealthy lifestyle. After 6 months of follow-up, both cohorts showed significant improvement in their dietary habits. Compared to CHCM diet, exercise, emotional management, knowledge of disease, and adherence to treatment showed greater improvement in the MIM. Blood pressure decreased in both cohorts, but body mass index, waist circumference, and HbA1C significantly decreased only in MIM. Glomerular filtration rate (GFR) was maintained equally in both cohorts, but albuminuria significantly decreased only in MIM. In conclusion, MIM achieves better control of lifestyle-related variables and CKD risk factors in type 2 diabetes mellitus (DM2) patients with CKD stage 1-2. Broadly, implementation of a MIM in primary health care may produce superior results that might assist in preventing the progression of CKD.

  6. Comparison of primary health-care models in the management of chronic kidney disease

    PubMed Central

    Cueto-Manzano, Alfonso M; Martínez-Ramírez, Héctor R; Cortés-Sanabria, Laura

    2013-01-01

    Negative lifestyle habits (potential risks for chronic kidney disease, CKD) are rarely modified by physicians in a conventional health-care model (CHCM). Multidisciplinary strategies may have better results; however, there is no information on their application in the early stages of CKD. Thus, the aim of this study was to compare a multiple intervention model versus CHCM on lifestyle and renal function in patients with type 2 diabetes mellitus and CKD stage 1–2. In a prospective cohort study, a family medicine unit (FMU) was assigned a multiple intervention model (MIM) and another continued with conventional health-care model (CHCM). MIM patients received an educational intervention guided by a multidisciplinary team (family physician (FP), social worker, dietitian, physical trainer); self-help groups functioned with free activities throughout the study. CHCM patients were managed only by the FP, who decided if patients needed referral to other professionals. Thirty-nine patients were studied in each cohort. According to a lifestyle questionnaire, no baseline differences were found between cohorts, but results reflected an unhealthy lifestyle. After 6 months of follow-up, both cohorts showed significant improvement in their dietary habits. Compared to CHCM diet, exercise, emotional management, knowledge of disease, and adherence to treatment showed greater improvement in the MIM. Blood pressure decreased in both cohorts, but body mass index, waist circumference, and HbA1C significantly decreased only in MIM. Glomerular filtration rate (GFR) was maintained equally in both cohorts, but albuminuria significantly decreased only in MIM. In conclusion, MIM achieves better control of lifestyle-related variables and CKD risk factors in type 2 diabetes mellitus (DM2) patients with CKD stage 1–2. Broadly, implementation of a MIM in primary health care may produce superior results that might assist in preventing the progression of CKD. PMID:25018986

  7. Gender Differences in Symptoms and Care Delivery for Chronic Obstructive Pulmonary Disease

    PubMed Central

    Raparla, Swetha; Plauschinat, Craig A.; Giardino, Nicholas D.; Rogers, Barbara; Beresford, Julien; Bentkover, Judith D.; Schachtner-Appel, Amy; Curtis, Jeffrey L.; Martinez, Fernando J.; Han, MeiLan K.

    2012-01-01

    Abstract Background Morbidity and mortality for women with chronic obstructive pulmonary disease (COPD) are increasing, and little is known about gender differences in perception of COPD care. Methods Surveys were administered to a convenience sample of COPD patients to evaluate perceptions about symptoms, barriers to care, and sources of information about COPD. Results Data on 295 female and 273 male participants were analyzed. With similar frequencies, women and men reported dyspnea and rated their health as poor/very poor. Although more women than men reported annual household income <$30,000, no significant gender differences in frequency of health insurance, physician visits, or ever having had spirometry were detected. In adjusted models (1) women were more likely to report COPD diagnostic delay (odds ratio [OR] 1.66, 95% confidence interval [CI] 1.13-2.45, p=0.01), although anxiety (OR 1.83, 95% CI 1.10-3.06, p=0.02) and history of exacerbations (OR 1.60, 95% CI 1.08-2.37, p=0.01) were also significant predictors, (2) female gender was associated with difficulty reaching one's physician (OR 2.54, 95% CI 1.33-4.86, p=0.004), as was prior history of exacerbations (OR 2.25, 95% CI 1.21-4.20, p=0.01), and (3) female gender (OR 2.15, 95% CI 1.10-4.21, p=0.02) was the only significant predictor for finding time spent with their physician as insufficient. Conclusions Significant gender-related differences in the perception of COPD healthcare delivery exist, revealing an opportunity to better understand what influences these attitudes and to improve care for both men and women. PMID:23210491

  8. Enhancing Palliative Care for Low-Income Elders with Chronic Disease: Feasibility of a Hospice Consultation Model

    PubMed Central

    Kramer, Betty J.; Cleary, Jim; Mahoney, Jane E.

    2013-01-01

    Challenges exist in assimilating palliative care within community based services for nursing home eligible low-income elders with complex chronic illness as they approach the end of life. This study assessed the feasibility of a consultation model, with hospice clinicians working with three Care Wisconsin Partnership Program teams. Consults occurred primarily during team meetings and also informally and on joint patient visits and were primarily with the palliative care nurse addressing physical issues. 57% of consultant recommendations were implemented. Benefits of consultation were identified with focus groups of clinical staff as were opportunities and barriers to the implementation. Models of integration are proposed. PMID:25494931

  9. STAAR: improving the reliability of care coordination and reducing hospital readmissions in an academic medical centre

    PubMed Central

    Carter, Jocelyn Alexandria; Carr, Laura S; Collins, Jacqueline; Doyle Petrongolo, Joanne; Hall, Kathryn; Murray, Jane; Smith, Jessica; Tata, Lee Ann

    2015-01-01

    Setting Massachusetts General Hospital embarked on a 4-year project to reduce readmissions in a high volume general medicine unit (November 2009 to September 2013). Objective To reduce 30-day readmissions to 10% through improved care coordination. Design As a before–after study, a total of 7586 patients admitted to the medicine unit during the intervention period included 2620 inpatients meeting high risk for readmission criteria. Of those, 2620 patients received nursing interventions and 539 patients received pharmacy interventions. Intervention The introduction of a Discharge Nurse (D/C RN) for patient/family coaching and a Transitional Care Pharmacist (TC PharmD) for predischarge medication reconciliation and postdischarge patient phone calls. Other interventions included modifications to multidisciplinary care rounds and electronic medication reconciliation. Main outcome measure All-cause 30-day readmission rates. Results Readmission rates decreased by 30% (21% preintervention to 14.5% postintervention) (p<0.05). From July 2010 to December 2011, rates of readmission among high-risk patients who received the D/C RN intervention with or without the TC PharmD medication reconciliation/education intervention decreased to 15.9% (p=0.59). From January to June 2010, rates of readmission among high-risk patients who received the TC PharmD postdischarge calls decreased to 12.9% (p=0.55). From June 2010 to December 2011, readmission rates for patients on the medical unit that did not receive the designated D/C RN or TC PharmD interventions decreased to 15.8% (p=0.61) and 16.2% (0.31), respectively. Conclusions A multidisciplinary approach to improving care coordination reduced avoidable readmissions both among those who received interventions and those who did not. This further demonstrated the importance of multidisciplinary collaboration. PMID:26246901

  10. Agreement between self-reported and general practitioner-reported chronic conditions among multimorbid patients in primary care - results of the MultiCare Cohort Study

    PubMed Central

    2014-01-01

    Background Multimorbidity is a common phenomenon in primary care. Until now, no clinical guidelines for multimorbidity exist. For the development of these guidelines, it is necessary to know whether or not patients are aware of their diseases and to what extent they agree with their doctor. The objectives of this paper are to analyze the agreement of self-reported and general practitioner-reported chronic conditions among multimorbid patients in primary care, and to discover which patient characteristics are associated with positive agreement. Methods The MultiCare Cohort Study is a multicenter, prospective, observational cohort study of 3,189 multimorbid patients, ages 65 to 85. Data was collected in personal interviews with patients and GPs. The prevalence proportions for 32 diagnosis groups, kappa coefficients and proportions of specific agreement were calculated in order to examine the agreement of patient self-reported and general practitioner-reported chronic conditions. Logistic regression models were calculated to analyze which patient characteristics can be associated with positive agreement. Results We identified four chronic conditions with good agreement (e.g. diabetes mellitus κ = 0.80;PA = 0,87), seven with moderate agreement (e.g. cerebral ischemia/chronic stroke κ = 0.55;PA = 0.60), seventeen with fair agreement (e.g. cardiac insufficiency κ = 0.24;PA = 0.36) and four with poor agreement (e.g. gynecological problems κ = 0.05;PA = 0.10). Factors associated with positive agreement concerning different chronic diseases were sex, age, education, income, disease count, depression, EQ VAS score and nursing care dependency. For example: Women had higher odds ratios for positive agreement with their GP regarding osteoporosis (OR = 7.16). The odds ratios for positive agreement increase with increasing multimorbidity in almost all of the observed chronic conditions (OR = 1.22-2.41). Conclusions For multimorbidity research, the

  11. A tool to measure whether business management capacity in general practice impacts on the quality of chronic illness care.

    PubMed

    Holton, Christine H; Proudfoot, Judith G; Jayasinghe, Upali W; Grimm, Jane; Bubner, Tanya K; Winstanley, Julie; Harris, Mark F; Beilby, Justin J

    2010-11-01

    Our aim was to develop a tool to identify specific features of the business and financial management of practices that facilitate better quality care for chronic illness in primary care. Domains of management were identified, resulting in the development of a structured interview tool that was administered in 97 primary care practices in Australia. Interview items were screened and subjected to factor analysis, subscales identified and the overall model fit determined. The instrument's validity was assessed against another measure of quality of care. Analysis provided a four-factor solution containing 21 items, which explained 42.5% of the variance in the total scores. The factors related to administrative processes, human resources, marketing analysis and business development. All scores increased significantly with practice size. The business development subscale and total score were higher for rural practices. There was a significant correlation between the business development subscale and quality of care. The indicators of business and financial management in the final tool appear to be useful predictors of the quality of care. The instrument may help inform policy regarding the structure of general practice and implementation of a systems approach to chronic illness care. It can provide information to practices about areas for further development.

  12. Physician - nurse practitioner teams in chronic disease management: the impact on costs, clinical effectiveness, and patients' perception of care.

    PubMed

    Litaker, David; Mion, Lorraine; Planavsky, Loretta; Kippes, Christopher; Mehta, Neil; Frolkis, Joseph

    2003-08-01

    Increasing demand to deliver and document therapeutic and preventive care sharpens the need for disease management strategies that accomplish these goals efficiently while preserving quality of care. The purpose of this study was to compare selected outcomes for a new chronic disease management program involving a nurse practitioner - physician team with those of an existing model of care. One hundred fifty-seven patients with hypertension and diabetes mellitus were randomly assigned to their primary care physician and a nurse practitioner or their primary care physician alone. Costs for personnel directly involved in patient management, calculated from hourly rates and encounter time with patients, and pre- and post-study glycosylated hemoglobin (HbA(1c)), high-density lipoprotein cholesterol (HDL-c), satisfaction with care and health-related quality of life (HRQoL) were assessed. Although 1-year costs for personnel were higher in the team-treated group, participants experienced significant improvements in mean HbA(1c) ( - 0.7%, p = 0.02) and HDL-c ( + 2.6 mg dL( - 1), p = 0.02). Additionally, satisfaction with care improved significantly for team-treated subjects in several sub-scales whereas the mean change over time in HRQoL did not differ significantly between groups. This study demonstrates the value of a complementary team approach to chronic disease management in improving patient-derived and clinical outcomes at modest incremental costs.

  13. Amount of health care and self-care following a randomized clinical trial comparing flexion-distraction with exercise program for chronic low back pain

    PubMed Central

    Cambron, Jerrilyn A; Gudavalli, M Ram; McGregor, Marion; Jedlicka, James; Keenum, Michael; Ghanayem, Alexander J; Patwardhan, Avinash G; Furner, Sylvia E

    2006-01-01

    Background Previous clinical trials have assessed the percentage of participants who utilized further health care after a period of conservative care for low back pain, however no chiropractic clinical trial has determined the total amount of care during this time and any differences based on assigned treatment group. The objective of this clinical trial follow-up was to assess if there was a difference in the total number of office visits for low back pain over one year after a four week clinical trial of either a form of physical therapy (Exercise Program) or a form of chiropractic care (Flexion Distraction) for chronic low back pain. Methods In this randomized clinical trial follow up study, 195 participants were followed for one year after a four-week period of either a form of chiropractic care (FD) or a form of physical therapy (EP). Weekly structured telephone interview questions regarded visitation of various health care practitioners and the practice of self-care for low back pain. Results Participants in the physical therapy group demonstrated on average significantly more visits to any health care provider and to a general practitioner during the year after trial care (p < 0.05). No group differences were noted in the number of visits to a chiropractor or physical therapist. Self-care was initiated by nearly every participant in both groups. Conclusion During a one-year follow-up, participants previously randomized to physical therapy attended significantly more health care visits than those participants who received chiropractic care. PMID:16930489

  14. Chronic-disease patients and their use of out-of-hours primary health care: a cross-sectional study

    PubMed Central

    2014-01-01

    Background The general practitioner (GP) plays an important role for chronic disease care. Continuous and close contact with daytime general practice is intended to prevent medical problems arising outside office hours due to already diagnosed chronic disease. However, previous studies indicate that patients with chronic diseases are frequent users of out-of-hours primary care services (OOH), but knowledge is limited on reasons for encounter (RFE), severity of symptoms, and OOH patient handling. We aimed to describe contacts to the OOH services from patients with chronic heart disease, lung disease, severe psychiatric disorders, diabetes, and cancer in terms of RFE, OOH GP diagnosis, assessed severity of symptoms, and actions taken by the GP. Methods Eligible patients (aged 18 years and older) were randomly sampled from a one-year cross-sectional study comprising 15,229 contacts to the OOH services in the Central Denmark Region. A cohort of patients with one or more of the five selected chronic diseases were identified by linking data on the Danish civil registration number (CPR) through specific nationwide Danish health registers. Results Out of 13,930 identified unique patients, 4,912 had at least one of the five chronic diseases. In total, 25.9% of all calls to the OOH services came from this chronic disease patient group due to an acute exacerbation; 32.6% of these calls came from patients with psychiatric diagnoses. Patients with chronic disease were more likely to receive a face-to-face contact than the remaining group of patients, except for calls from patients with a psychiatric disorder who were more often completed through a telephone consultation. Patients with heart disease calling due to a new health problem formed the largest proportion of all OOH referrals to hospital (13.3%) compared to calls from the other groups with chronic disease (3.4-6.7%). Conclusions A third of the patients randomly sampled by their OOH call had one or more of the five

  15. A primary care, multi-disciplinary disease management program for opioid-treated patients with chronic non-cancer pain and a high burden of psychiatric comorbidity

    PubMed Central

    Chelminski, Paul R; Ives, Timothy J; Felix, Katherine M; Prakken, Steven D; Miller, Thomas M; Perhac, J Stephen; Malone, Robert M; Bryant, Mary E; DeWalt, Darren A; Pignone, Michael P

    2005-01-01

    Background Chronic non-cancer pain is a common problem that is often accompanied by psychiatric comorbidity and disability. The effectiveness of a multi-disciplinary pain management program was tested in a 3 month before and after trial. Methods Providers in an academic general medicine clinic referred patients with chronic non-cancer pain for participation in a program that combined the skills of internists, clinical pharmacists, and a psychiatrist. Patients were either receiving opioids or being considered for opioid therapy. The intervention consisted of structured clinical assessments, monthly follow-up, pain contracts, medication titration, and psychiatric consultation. Pain, mood, and function were assessed at baseline and 3 months using the Brief Pain Inventory (BPI), the Center for Epidemiological Studies-Depression Scale scale (CESD) and the Pain Disability Index (PDI). Patients were monitored for substance misuse. Results Eighty-five patients were enrolled. Mean age was 51 years, 60% were male, 78% were Caucasian, and 93% were receiving opioids. Baseline average pain was 6.5 on an 11 point scale. The average CESD score was 24.0, and the mean PDI score was 47.0. Sixty-three patients (73%) completed 3 month follow-up. Fifteen withdrew from the program after identification of substance misuse. Among those completing 3 month follow-up, the average pain score improved to 5.5 (p = 0.003). The mean PDI score improved to 39.3 (p < 0.001). Mean CESD score was reduced to 18.0 (p < 0.001), and the proportion of depressed patients fell from 79% to 54% (p = 0.003). Substance misuse was identified in 27 patients (32%). Conclusions A primary care disease management program improved pain, depression, and disability scores over three months in a cohort of opioid-treated patients with chronic non-cancer pain. Substance misuse and depression were common, and many patients who had substance misuse identified left the program when they were no longer prescribed opioids

  16. The Role of Social Workers in Spiritual Care to Facilitate Coping With Chronic Illness and Self-Determination in Advance Care Planning.

    PubMed

    Francoeur, Richard B; Burke, Nancy; Wilson, Alicia M

    2016-01-01

    Spiritual values and beliefs of patients and families influence resilience during chronic illness and shape patient choices during advance care planning. The spiritual needs of Baby Boomers will be more diverse than previous generations, in connection with the questioning, experimental mind-set of this group and the fact that it includes a higher proportion of immigrant populations outside the Judeo-Christian tradition. Social workers are trained explicitly to intervene with diverse populations and are well positioned to offer spiritual support in ways that do not necessarily conform to traditional religions. To the extent of their individual expertise and competence, social workers should assess and provide spiritual care to clients, including those who either are underserved or prefer not to seek assistance from clergy or chaplains because they feel alienated from religious institutions and representatives. They should also be aware of ethical dilemmas in consulting with spiritual care professionals in developing spiritual interventions. Social work education should address clients' humanistic and existential concerns, beliefs and behaviors of the major religions, and forms of nontraditional religious and spiritual experiences; it should also provide experiential opportunities for engaging with grief and earlier advance care planning. There should be attention to different theodical perspectives of the major religions regarding the problem of good and evil, which may preoccupy even clients who no longer participate in organized religion, because these unresolved existential issues may weaken client coping with chronic conditions and may diminish clarity and self-awareness for engaging authentically and effectively in advance care planning.

  17. The Role of Social Workers in Spiritual Care to Facilitate Coping With Chronic Illness and Self-Determination in Advance Care Planning.

    PubMed

    Francoeur, Richard B; Burke, Nancy; Wilson, Alicia M

    2016-01-01

    Spiritual values and beliefs of patients and families influence resilience during chronic illness and shape patient choices during advance care planning. The spiritual needs of Baby Boomers will be more diverse than previous generations, in connection with the questioning, experimental mind-set of this group and the fact that it includes a higher proportion of immigrant populations outside the Judeo-Christian tradition. Social workers are trained explicitly to intervene with diverse populations and are well positioned to offer spiritual support in ways that do not necessarily conform to traditional religions. To the extent of their individual expertise and competence, social workers should assess and provide spiritual care to clients, including those who either are underserved or prefer not to seek assistance from clergy or chaplains because they feel alienated from religious institutions and representatives. They should also be aware of ethical dilemmas in consulting with spiritual care professionals in developing spiritual interventions. Social work education should address clients' humanistic and existential concerns, beliefs and behaviors of the major religions, and forms of nontraditional religious and spiritual experiences; it should also provide experiential opportunities for engaging with grief and earlier advance care planning. There should be attention to different theodical perspectives of the major religions regarding the problem of good and evil, which may preoccupy even clients who no longer participate in organized religion, because these unresolved existential issues may weaken client coping with chronic conditions and may diminish clarity and self-awareness for engaging authentically and effectively in advance care planning. PMID:27187806

  18. A randomized trial of practice facilitation to improve the delivery of chronic illness care in primary care: initial and sustained effects

    PubMed Central

    2013-01-01

    Background Practice facilitation (PF) is an implementation strategy now commonly used in primary care settings for improvement initiatives. PF occurs when a trained external facilitator engages and supports the practice in its change efforts. The purpose of this group-randomized trial is to assess PF as an intervention to improve the delivery of chronic illness care in primary care. Methods A randomized trial of 40 small primary care practices who were randomized to an initial or a delayed intervention (control) group. Trained practice facilitators worked with each practice for one year to implement tailored changes to improve delivery of diabetes care within the Chronic Care Model framework. The Assessment of Chronic Illness Care (ACIC) survey was administered at baseline and at one-year intervals to clinicians and staff in both groups of practices. Repeated-measures analyses of variance were used to assess the main effects (mean differences between groups) and the within-group change over time. Results There was significant improvement in ACIC scores (p < 0.05) within initial intervention practices, from 5.58 (SD 1.89) to 6.33 (SD 1.50), compared to the delayed intervention (control) practices where there was a small decline, from 5.56 (SD 1.54) to 5.27 (SD 1.62). The increase in ACIC scores was sustained one year after withdrawal of the PF intervention in the initial intervention group, from 6.33 (SD 1.50) to 6.60 (SD 1.94), and improved in the delayed intervention (control) practices during their one year of PF intervention, from 5.27 (SD 1.62) to 5.99 (SD 1.75). Conclusions Practice facilitation resulted in a significant and sustained improvement in delivery of care consistent with the CCM as reported by those involved in direct patient care in small primary care practices. The impact of the observed change on clinical outcomes remains uncertain. Trial registration This protocol followed the CONSORT guidelines and is registered per ICMJE guidelines

  19. Development of an Automated Healthcare Kiosk for the Management of Chronic Disease Patients in the Primary Care Setting.

    PubMed

    Ng, Grace; Tan, Nicolette; Bahadin, Juliana; Shum, Eugene; Tan, Sze Wee

    2016-07-01

    An increase in the prevalence of chronic disease has led to a rise in the demand for primary healthcare services in many developed countries. Healthcare technology tools may provide the leverage to alleviate the shortage of primary care providers. Here we describe the development and usage of an automated healthcare kiosk for the management of patients with stable chronic disease in the primary care setting. One-hundred patients with stable chronic disease were recruited from a primary care clinic. They used a kiosk in place of doctors' consultations for two subsequent follow-up visits. Patient and physician satisfaction with kiosk usage were measured on a Likert scale. Kiosk blood pressure measurements and triage decisions were validated and optimized. Patients were assessed if they could use the kiosk independently. Patients and physicians were satisfied with all areas of kiosk usage. Kiosk triage decisions were accurate by the 2nd month of the study. Blood pressure measurements by the kiosk were equivalent to that taken by a nurse (p = 0.30, 0.14). Independent kiosk usage depended on patients' language skills and educational levels. Healthcare kiosks represent an alternative way to manage patients with stable chronic disease. They have the potential to replace physician visits and improve access to primary healthcare. Patients welcome the use of healthcare technology tools, including those with limited literacy and education. Optimization of environmental and patient factors may be required prior to the implementation of kiosk-based technology in the healthcare setting. PMID:27240840

  20. Pathology service line: a model for accountable care organizations at an academic medical center.

    PubMed

    Sussman, Ira; Prystowsky, Michael B

    2012-05-01

    Accountable care is designed to manage the health of patients using a capitated cost model rather than fee for service. Pay for performance is an attempt to use quality and not service reduction as the way to decrease costs. Pathologists will have to demonstrate value to the system. This value will include (1) working with clinical colleagues to optimize testing protocols, (2) reducing unnecessary testing in both clinical and anatomic pathology, (3) guiding treatment by helping to personalize therapy, (4) designing laboratory information technology solutions that will promote and facilitate accurate, complete data mining, and (5) administering efficient cost-effective laboratories. The pathology service line was established to improve the efficiency of delivering pathology services and to provide more effective support of medical center programs. We have used this model effectively at the Montefiore Medical Center for the past 14 years. PMID:22333926

  1. Comparative Effectiveness of Risk-Stratified Care Management in Reducing Readmissions in Medicaid Adults With Chronic Disease.

    PubMed

    Hewner, Sharon; Wu, Yow-Wu Bill; Castner, Jessica

    2016-01-01

    Hospitalized adult Medicaid recipients with chronic disease are at risk for rehospitalization within 90 days of discharge, but most research has focused on the Medicare population. The purpose of this study is to examine the impact of population-based care management intensity on inpatient readmissions in Medicaid adults with pre-existing chronic disease. Retrospective analyses of 2,868 index hospital admissions from 2012 New York State Medicaid Data Warehouse claims compared 90-day post-discharge utilization in populations with and without transitional care management interventions. High intensity managed care organization interventions were associated with higher outpatient and lower emergency department post-discharge utilization than low intensity fee-for-service management. However, readmission rates were higher for the managed care cases. Shorter time to readmission was associated with managed care, diagnoses that include heart and kidney failure, shorter length of stay for index hospitalization, and male sex; with no relationship to age. This unexpected result flags the need to re-evaluate readmission as a quality indicator in the complex Medicaid population. Quality improvement efforts should focus on care continuity during transitions and consider population-specific factors that influence readmission. Optimum post-discharge utilization in the Medicaid population requires a balance between outpatient, emergency and inpatient services to improve access and continuity. PMID:26730804

  2. Assessing Quality of Life and Medical Care in Chronic Angina: An Internet Survey

    PubMed Central

    2016-01-01

    Background Angina is a clinical syndrome whose recognition relies heavily on self-report, so its identification can be challenging. Most data come from cohorts identified by physicians and nurses at the point of care; however, current widespread access to the Internet makes identification of community cohorts feasible and offers a complementary picture of angina. Objective To describe a population self-identified as experiencing chronic angina by use of an Internet survey. Methods Using email and an Internet portal, we invited individuals with a diagnosis of angina and recent symptoms to complete an Internet survey on treatment and quality of life (QOL). In total, 1147 surveys were received. The main analysis was further limited to those reporting a definite coronary heart disease (CHD) history (N=646, 56% of overall). Results Overall, about 15% reported daily angina and 40% weekly angina. Those with more frequent angina were younger, more often depressed, and reported a shorter time since diagnosis. They also had substantially worse treatment satisfaction, physical function, and overall QOL. Fewer than 40% were on ≥ 2 anti-anginals, even with daily angina. The subjects without a history of definite CHD had unexpectedly low use of antianginal and evidence-based medicines, suggesting either a lack of specificity in the use of self-reported angina to identify patients with CHD or lack of access to care. Conclusions Use of inexpensive electronic tools can identify community-based angina cohorts for clinical research. Limitation to subjects with a definite history of CHD lends diagnostic face validity to the approach; however, other symptomatic individuals are also identified. PMID:27125492

  3. An integrated care facilitation model improves quality of life and reduces use of hospital resources by patients with chronic obstructive pulmonary disease and chronic heart failure.

    PubMed

    Bird, Stephen; Noronha, Michelle; Sinnott, Helen

    2010-01-01

    As part of the Department of Human Services Hospital Admissions Risk Program (HARP), a group of acute and community based health care providers located in the western suburbs of Melbourne formed a consortium to reduce the demand on hospital emergency services and improve health outcomes for patients with chronic obstructive pulmonary disease (COPD) and chronic heart failure (CHF). The model of care was designed by a team of multidisciplinary specialists and medical consultants. In addition to receiving normal care, patients recruited to the project were assessed by 'Care Facilitators', who identified unmet health care needs and provided information, advice and education for the patient concerning their condition and self-management. Patients declining recruitment received all normal care services. The patients' rates of emergency department (ED) presentations, inpatient admissions and hospital inpatient bed-days before and after their recruitment were calculated from the Western Health patient activity records, and pre- versus post-recruitment rates were compared using ANOVA. Changes relative to the ongoing use by those who declined recruitment were compared using the group-by-time interaction. Patient health outcomes were assessed using established disease-specific tools, and pre- versus post-recruitment values were compared using paired t-tests. Patients recruited to the COPD project reduced (P<0.05) their emergency presentations, admissions and hospital inpatient bed-days by 10, 25 and 18%, respectively, whereas those declining recruitment increased their usage by 45, 41 and 51% respectively. Recruited CHF patients also displayed reductions in emergency presentations (39%), admissions (36%) and hospital inpatient bed-days (33%), whereas those who declined recruitment displayed lesser reductions for ED presentations (26%) and admissions (20%), and increased their use of hospital inpatient bed-days (15%). The recruited COPD patients reported a significant

  4. Relevance of Hypersexual Disorder to Family Medicine and Primary Care as a Complex Multidimensional Chronic Disease Construct

    PubMed Central

    Vrijhoef, Bert; De Maeseneer, Jan; Vansintejan, Johan; Devroey, Dirk

    2013-01-01

    Hypersexual disorder (HD) is not defined in a uniform way in the psychiatric literature. In the absence of solid evidence on prevalence, causes, empirically validated diagnostic criteria, instruments for diagnosis, consistent guidelines on treatment options, medical and psychosocial consequences, and type of caregivers that need to be involved, HD remains a controversial and relatively poorly understood chronic disease construct. The role of family medicine in the detection, treatment, and followup of HD is not well studied. The purpose of this paper is to describe the complexity of HD as a multidimensional chronic disease construct and its relevance to family medicine and primary care. PMID:24066230

  5. Effects of multiple chronic conditions on health care costs: an analysis based on an advanced tree-based regression model

    PubMed Central

    2013-01-01

    Background To analyze the impact of multimorbidity (MM) on health care costs taking into account data heterogeneity. Methods Data come from a multicenter prospective cohort study of 1,050 randomly selected primary care patients aged 65 to 85 years suffering from MM in Germany. MM was defined as co-occurrence of ≥3 conditions from a list of 29 chronic diseases. A conditional inference tree (CTREE) algorithm was used to detect the underlying structure and most influential variables on costs of inpatient care, outpatient care, medications as well as formal and informal nursing care. Results Irrespective of the number and combination of co-morbidities, a limited number of factors influential on costs were detected. Parkinson’s disease (PD) and cardiac insufficiency (CI) were the most influential variables for total costs. Compared to patients not suffering from any of the two conditions, PD increases predicted mean total costs 3.5-fold to approximately € 11,000 per 6 months, and CI two-fold to approximately € 6,100. The high total costs of PD are largely due to costs of nursing care. Costs of inpatient care were significantly influenced by cerebral ischemia/chronic stroke, whereas medication costs were associated with COPD, insomnia, PD and Diabetes. Except for costs of nursing care, socio-demographic variables did not significantly influence costs. Conclusions Irrespective of any combination and number of co-occurring diseases, PD and CI appear to be most influential on total health care costs in elderly patients with MM, and only a limited number of factors significantly influenced cost. Trial registration Current Controlled Trials ISRCTN89818205 PMID:23768192

  6. Teaching high-value, cost-conscious care to residents: the Alliance for Academic Internal Medicine–American College of Physicians Curriculum.

    PubMed

    Smith, Cynthia D

    2012-08-21

    Health care expenditures are projected to reach nearly 20% of the U.S. gross domestic product by 2020. Up to $765 billion of this spending has been identified as potentially avoidable; many of the avoidable costs have been attributed to unnecessary services. Postgraduate trainees have historically received little specific training in the stewardship of health care resources and minimal feedback on resource utilization and its effect on the cost of care. This article describes a new curriculum that was developed collaboratively by the Alliance for Academic Internal Medicine and the American College of Physicians to address this training gap. The curriculum introduces a simple, stepwise framework for delivering high-value care and focuses on teaching trainees to incorporate high-value, cost-conscious care principles into their clinical practice. It consists of ten 1-hour, case-based, interactive sessions designed to be flexibly incorporated into the existing conference structure of a residency training program.

  7. Self-reported chronic pain is associated with physical performance in older people leaving aged care rehabilitation

    PubMed Central

    Pereira, Leani Souza Máximo; Sherrington, Catherine; Ferreira, Manuela L; Tiedemann, Anne; Ferreira, Paulo H; Blyth, Fiona M; Close, Jacqueline CT; Taylor, Morag; Lord, Stephen R

    2014-01-01

    Background/objectives The impact of pain on the physical performance of patients in aged care rehabilitation is not known. The study sought to assess 1) the prevalence of pain in older people being discharged from inpatient rehabilitation; 2) the association between self-reported pain and physical performance in people being discharged from inpatient rehabilitation; and 3) the association between self-reported pain and physical performance in this population, after adjusting for potential confounding factors. Methods This was an observational cross-sectional study of 420 older people at two inpatient aged care rehabilitation units. Physical performance was assessed using the Lower Limb Summary Performance Score. Pain was assessed with questions about the extent to which participants were troubled by pain, the duration of symptoms, and the impact of chronic pain on everyday activity. Depression and the number of comorbidities were assessed by questionnaire and medical file audit. Cognition was assessed with the Mini-Mental State Examination. Results Thirty percent of participants reported chronic pain (pain lasting more than 3 months), and 17% reported that this pain interfered with daily activities to a moderate or greater extent. Chronic pain (P=0.013) and chronic pain affecting daily activities (P<0.001) were associated with a poorer Lower Limb Summary Performance Score. The relationship between chronic pain affecting daily activities and Lower Limb Summary Performance Score remained significant (P=0.001) after adjusting for depression, age, comorbidities, and Mini-Mental State Examination score. This model explained 10% of the variability in physical performance. Conclusion One-third of participants reported chronic pain, and close to one-fifth reported that this pain interfered with daily activities. Chronic pain was associated with impaired physical performance, and this relationship persisted after adjusting for likely confounding factors. PMID:24523583

  8. A Randomized Trial Comparing Yoga, Stretching, and a Self-care Book for Chronic Low Back Pain

    PubMed Central

    Sherman, Karen J.; Cherkin, Daniel C.; Wellman, Robert D.; Cook, Andrea J.; Hawkes, Rene J.; Delaney, Kristin; Deyo, Richard A.

    2012-01-01

    Background Chronic low back pain is a common problem lacking highly effective treatment options. Small trials suggest that yoga may have benefits for this condition. This trial was designed to determine whether yoga is more effective than conventional stretching exercises or a self-care book for primary care patients with chronic low back pain. Methods 228 adults with chronic low back pain were randomized to 12 weekly classes of yoga (n=92) or conventional stretching exercises (n=91) or a self-care book (n=45). Back-related functional status (modified Roland Disability Questionnaire, 23-point scale) and bothersomeness of pain (11-point numerical scale) at 12 weeks were the primary outcomes. Outcomes were assessed at baseline, 6, 12 and 26 weeks by interviewers unaware of treatment group. Results After adjustment for baseline values, 12-week outcomes for the yoga group were superior to those for the self-care group (mean difference for function = −2.5 [95% CI= −3.7 to −1.3; P<0.001]; mean difference for symptoms = −1.1 [95% CI= −1.7 to −0.4; P<0.001]). At 26 weeks, function for the yoga group remained superior (mean difference = −1.8 [95% CI= − 3.1 to −0.5; P<0.0001]). Yoga was not superior to conventional stretching exercises at any time point. Conclusions Yoga classes were more effective than a self-care book, but not stretching classes, in improving function and reducing symptoms due to chronic low back pain, with benefits lasting at least several months. PMID:22025101

  9. Clinical decision rule for primary care patient with acute low back pain at risk of developing chronic pain

    PubMed Central

    Mehling, Wolf E.; Ebell, Mark H.; Avins, Andrew L.; Hecht, Frederick M.

    2015-01-01

    Background Context Primary care clinicians need to identify candidates for early interventions to prevent patients with acute pain from developing chronic pain. Purpose We conducted a 2-year prospective cohort study of risk factors for the progression to chronic pain and developed and internally validated a clinical decision rule (CDR) that stratifies patients into low, medium and high-risk groups for chronic pain. Study Design/Setting Prospective cohort study in primary care. Patient Sample Patients with acute low back pain (LBP; ≤30 days duration) Outcome measures Self-reported perceived non-recovery and chronic pain. Methods Patients were surveyed at baseline, 6 months and 2 years. We conducted bivariate and multivariate regression analyses of demographic, clinical and psychosocial variables for chronic pain outcomes, developed a CDR and assessed its performance by calculating the bootstrapped areas under the receiver operating characteristic curve (AUC) and likelihood ratios. This study was supported by NIH/NCCAM grants K23 AT002298, R21 AT004467, NIH/NCCAM K24 AT007827, the Research Evaluation and Allocation Committee (REAC) of the University of California San Francisco, and the Mount Zion Health Fund, San Francisco. The funding agencies played no role in design and conduct of the study; collection, management, analysis, and interpretation of the data; and preparation, review, or approval of the manuscript. The authors report no conflict of interests. Results 605 patients enrolled. 13% had chronic pain at 6 months, 19% at 2 years. An eight-item CDR was most parsimonious for classifying patients into three risk levels. Bootstrapped AUC was 0.76 (0.70–0.82) for the 6-month CDR. Each 10-point score increase (60-point range) was associated with an odds ratio of 11.1 (10.8–11.4) for developing chronic pain. Using a <5% probability of chronic pain as the cutoff for low risk and a >40% probability for high risk, likelihood ratios were 0.26 (0.14–0.48) and 4

  10. [Pain management in patients with chronic rheumatic pain--a model for primary medical care].

    PubMed

    Häuser, W; Biewer, W

    1997-04-18

    A rheumatologist and a medical psychotherapist collaborate in offering periodically a cognitive behavioral treatment program for pain control for the patients of a rheumatological practice. The program consists of a biopsychosocial model of chronic pain, individualized relaxation training combining progressive muscle relaxation and some elements of autogenous training and meditation, several attention-related techniques and cognitive restructuring. From 1993 to 1995, 50 patients took part in five training courses. The compliance of the patients was satisfactory and the drop-out rate low (8%). In a post hoc interview 4 weeks later and another 2 years after the end of the training most of the patients assessed the program as useful for reduction of pain, increase of activity and enhancement of mood. Psychotherapeutic experience in group therapy or special training for non-psychotherapeutic physicians with continuous supervision is necessary in order to conduct a qualified treatment program. Within medical primary care, rheumatologists can motivate their patients towards active pain management, which can help to prepare patients for further psychotherapy in cases with psychiatric disorders and/or severe psychosocial strains.

  11. Towards a wireless patient: chronic illness, scarce care and technological innovation in the United Kingdom.

    PubMed

    May, Carl; Finch, Tracy; Mair, Frances; Mort, Maggie

    2005-10-01

    'Modernization' is a key health policy objective in the UK. It extends across a range of public service delivery and organizational contexts, and also means there are radical changes in perspective on professional behaviour and practice. New information and communications technologies have been seen as one of the key mechanisms by which these changes can be engendered. In particular, massive investment in information technologies promises the rapid distribution and deployment of patient-centred information across internal organizational boundaries. While the National Health Service (NHS) sits on the edge of a pound sterling 6 billion investment in electronic patient records, other technologies find their status as innovative vehicles for professional behaviour change and service delivery in question. In this paper, we consider the ways that telemedicine and telehealthcare systems have been constructed first as a field of technological innovation, and more recently, as management solutions to problems around the distribution of health care. We use NHS responses to chronic illness as a medium for understanding these shifts. In particular, we draw attention to the shifting definitions of 'innovation' and to the ways that these shifts define a move away from notions of technological advance towards management control.

  12. Telemedicine system for the care of patients with neuromuscular disease and chronic respiratory failure

    PubMed Central

    Morete, Emilio; González, Francisco

    2014-01-01

    Introduction Neuromuscular diseases cause a number of limitations which may be improved by using a telemedicine system. These include functional impairment and dependence associated with muscle weakness, the insidious development of respiratory failure and episodes of exacerbation. Material and methods The present study involved three patients with severe neuromuscular disease, chronic respiratory failure and long-term mechanical ventilation, who were followed up using a telemedicine platform. The telemedicine system is based on videoconferencing and telemonitoring of cardiorespiratory variables (oxygen saturation, heart rate, blood pressure and electrocardiogram). Two different protocols were followed depending on whether the patient condition was stable or unstable. Results Over a period of 5 years, we analyzed a series of variables including use of the system, patient satisfaction and clinical impact. Overall we performed 290 videoconference sessions, 269 short monitoring oximetry measurements and 110 blood pressure measurements. With respect to the clinical impact, after enrolment in the telemedicine program, the total number of hospital admissions fell from 18 to 3. Conclusions Our findings indicate that the system was user friendly for patients and care givers. Patient satisfaction scores were acceptable. The telemedicine system was effective for the home treatment of three patients with severe neuromuscular diseases and reduced the need for hospital admissions. PMID:25395959

  13. Helping students survive institutionalized patients and burn-out in staff in chronic psychiatric care facilities.

    PubMed

    Bissell, B P; Feather, R B; Ryan, D M

    1984-01-01

    In summary, we have discussed the problem of institutionalized patients and burn-out in staff as well as the effect they both have on nursing students during their mental health-psychiatric nursing rotation. The stages in which specific student behaviors occur during the psychiatric nursing rotation as a result of the students' perceptions, and the interventions faculty members can employ in decreasing the subjective aspects of these perceptions have also been presented. We conclude that nursing students will emerge from their experience with better understanding of institutionalization and burn-out, and better equipped to cope with reality shock if they are introduced to these concepts early in the lecture series and are sent to a variety of psychiatric care facilities for observational experience. The facilities selected should be those in which patients are coping with less chronic behavior problems than found in state hospitals and where observable behavioral changes in patients are measured in weeks or months, rather than years. Facilities such as outpatient clinics and crisis intervention centers where clients may be more stabilized, less overwhelming, and have more resources available to them would meet these criteria. Finally, we recommend that instructors be made more aware than they are of the institutionalization and burn-out process early in their teaching responsibilities; that faculty group discussions on institutionalization as maladaptive behavior be held; and that the faculty encourage an open atmosphere where students can discuss their reactions to institutionalization in patients and burn-out in staff freely.

  14. Information and Communication Technology–Enabled Person-Centered Care for the “Big Five” Chronic Conditions: Scoping Review

    PubMed Central

    Simonse, Lianne WL

    2015-01-01

    Background Person-centered information and communication technology (ICT) could encourage patients to take an active part in their health care and decision-making process, and make it possible for patients to interact directly with health care providers and services about their personal health concerns. Yet, little is known about which ICT interventions dedicated to person-centered care (PCC) and connected-care interactions have been studied, especially for shared care management of chronic diseases. The aim of this research is to investigate the extent, range, and nature of these research activities and identify research gaps in the evidence base of health studies regarding the “big 5” chronic diseases: diabetes mellitus, cardiovascular disease, chronic respiratory disease, cancer, and stroke. Objective The objective of this paper was to review the literature and to scope the field with respect to 2 questions: (1) which ICT interventions have been used to support patients and health care professionals in PCC management of the big 5 chronic diseases? and (2) what is the impact of these interventions, such as on health-related quality of life and cost efficiency? Methods This research adopted a scoping review method. Three electronic medical databases were accessed: PubMed, EMBASE, and Cochrane Library. The research reviewed studies published between January 1989 and December 2013. In 5 stages of systematic scanning and reviewing, relevant studies were identified, selected, and charted. Then we collated, summarized, and reported the results. Results From the initial 9380 search results, we identified 350 studies that qualified for inclusion: diabetes mellitus (n=103), cardiovascular disease (n=89), chronic respiratory disease (n=73), cancer (n=67), and stroke (n=18). Persons with one of these chronic conditions used ICT primarily for self-measurement of the body, when interacting with health care providers, with the highest rates of use seen in chronic

  15. Assessment of a primary care-based telemonitoring intervention for home care patients with heart failure and chronic lung disease. The TELBIL study

    PubMed Central

    2011-01-01

    Background Telemonitoring technology offers one of the most promising alternatives for the provision of health care services at the patient's home. The primary aim of this study is to evaluate the impact of a primary care-based telemonitoring intervention on the frequency of hospital admissions. Methods/design A primary care-based randomised controlled trial will be carried out to assess the impact of a telemonitoring intervention aimed at home care patients with heart failure (HF) and/or chronic lung disease (CLD). The results will be compared with those obtained with standard health care practice. The duration of the study will be of one year. Sixty patients will be recruited for the study. In-home patients, diagnosed with HF and/or CLD, aged 14 or above and with two or more hospital admissions in the previous year will be eligible. For the intervention group, telemonitoring will consist of daily patient self-measurements of respiratory-rate, heart-rate, blood pressure, oxygen saturation, weight and body temperature. Additionally, the patients will complete a qualitative symptom questionnaire daily using the telemonitoring system. Routine telephone contacts will be conducted every fortnight and additional telephone contacts will be carried out if the data received at the primary care centre are out of the established limits. The control group will receive usual care. The primary outcome measure is the number of hospital admissions due to any cause that occurred in a period of 12 months post-randomisation. The secondary outcome measures are: duration of hospital stay, hospital admissions due to HF or CLD, mortality rate, use of health care resources, quality of life, cost-effectiveness, compliance and patient and health care professional satisfaction with the new technology. Discussion The results of this study will shed some light on the effects of telemonitoring for the follow-up and management of chronic patients from a primary care setting. The study may

  16. The Cost of Caring for the Chronically Ill: The Case for Insurance. Hearing before the Special Committee on Aging. United States Senate, Ninety-Eighth Congress, Second Session.

    ERIC Educational Resources Information Center

    Congress of the U.S., Washington, DC. Senate Special Committee on Aging.

    This document provides witness testimony and prepared statements from the Congressional hearing called to investigate the cost of long-term care for the chronically ill and disabled. The merits of a public-private initiative on long-term care insurance are considered by the witnesses, who include a woman struggling to care for herself and her son,…

  17. Students' Attitudes, Academic Performance and Preferences for Content Delivery in a Very Large Self-Care Course Redesign.

    PubMed

    Camiel, Lana Dvorkin; Mistry, Amee; Schnee, David; Tataronis, Gary; Taglieri, Catherine; Zaiken, Kathy; Patel, Dhiren; Nigro, Stefanie; Jacobson, Susan; Goldman, Jennifer

    2016-05-25

    Objective. To evaluate students' performance/attitudes toward a flipped team-based learning (TBL) format in a "very large" self-care course based on student content delivery preference. Design. Third-year students enrolled in the course were surveyed regarding elements of redesign and homework completion. Additionally, their performance and incoming grade point average were evaluated. Assessment. A survey was completed by 286 of 305 students. Nineteen percent of respondents preferred traditional content delivery, whereas 30% preferred flipped TBL, 48% preferred a mixed format, and 3% had no preference. The grades achieved in the course were: A (49%), B (48%), C (3%) and D (0%). The majority completed "all" or "most" of the homework, appreciated attributes of course redesign, felt home preparation and in-class activities engaged them, and reported improved communication/evaluation skills. Content delivery preference significantly affected attitudes. Conclusion. Students positively received a flipped team-based learning classroom format, especially those who preferred flipped TBL or mixed content delivery. A minority with preference for traditional teaching style did not enjoy the new format; however, their academic performance did not differ significantly from those who did. PMID:27293234

  18. Students' Attitudes, Academic Performance and Preferences for Content Delivery in a Very Large Self-Care Course Redesign.

    PubMed

    Camiel, Lana Dvorkin; Mistry, Amee; Schnee, David; Tataronis, Gary; Taglieri, Catherine; Zaiken, Kathy; Patel, Dhiren; Nigro, Stefanie; Jacobson, Susan; Goldman, Jennifer

    2016-05-25

    Objective. To evaluate students' performance/attitudes toward a flipped team-based learning (TBL) format in a "very large" self-care course based on student content delivery preference. Design. Third-year students enrolled in the course were surveyed regarding elements of redesign and homework completion. Additionally, their performance and incoming grade point average were evaluated. Assessment. A survey was completed by 286 of 305 students. Nineteen percent of respondents preferred traditional content delivery, whereas 30% preferred flipped TBL, 48% preferred a mixed format, and 3% had no preference. The grades achieved in the course were: A (49%), B (48%), C (3%) and D (0%). The majority completed "all" or "most" of the homework, appreciated attributes of course redesign, felt home preparation and in-class activities engaged them, and reported improved communication/evaluation skills. Content delivery preference significantly affected attitudes. Conclusion. Students positively received a flipped team-based learning classroom format, especially those who preferred flipped TBL or mixed content delivery. A minority with preference for traditional teaching style did not enjoy the new format; however, their academic performance did not differ significantly from those who did.

  19. Students’ Attitudes, Academic Performance and Preferences for Content Delivery in a Very Large Self-Care Course Redesign

    PubMed Central

    Mistry, Amee; Schnee, David; Tataronis, Gary; Taglieri, Catherine; Zaiken, Kathy; Patel, Dhiren; Nigro, Stefanie; Jacobson, Susan; Goldman, Jennifer

    2016-01-01

    Objective. To evaluate students’ performance/attitudes toward a flipped team-based learning (TBL) format in a “very large” self-care course based on student content delivery preference. Design. Third-year students enrolled in the course were surveyed regarding elements of redesign and homework completion. Additionally, their performance and incoming grade point average were evaluated. Assessment. A survey was completed by 286 of 305 students. Nineteen percent of respondents preferred traditional content delivery, whereas 30% preferred flipped TBL, 48% preferred a mixed format, and 3% had no preference. The grades achieved in the course were: A (49%), B (48%), C (3%) and D (0%). The majority completed “all” or “most” of the homework, appreciated attributes of course redesign, felt home preparation and in-class activities engaged them, and reported improved communication/evaluation skills. Content delivery preference significantly affected attitudes. Conclusion. Students positively received a flipped team-based learning classroom format, especially those who preferred flipped TBL or mixed content delivery. A minority with preference for traditional teaching style did not enjoy the new format; however, their academic performance did not differ significantly from those who did. PMID:27293234

  20. Cost-effective care a phone call away: a nurse-managed telephonic program for patients with chronic heart failure.

    PubMed

    Slater, M Renee; Phillips, Denise M; Woodard, Elizabeth K

    2008-01-01

    Health care providers and health care systems are challenged to find cost-effective ways to address the costs associated with heart failure. A multidisciplinary team of nurses, physicians, pharmacists, and dieticians was assembled at New Hanover Regional Medical Center (Wilmington, NC) to develop strategies to decrease the readmission rate without compromising patient care. The team developed a disease management program that included comprehensive inpatient education, as well as an outpatient telephonic program to reinforce education after discharge. Goals were to reduce readmissions of patients with heart failure, to decrease the cost per case of each patient with chronic heart failure, and to reduce the length of stay for patients who were readmitted. The CHF Telephonic Program was extremely successful in meeting patient-focused and organizational goals related to readmissions, length of stay, and cost of care.

  1. Chronic Kidney Disease in Primary Care: Outcomes after Five Years in a Prospective Cohort Study

    PubMed Central

    Shardlow, Adam; McIntyre, Natasha J.; Fluck, Richard J.; McIntyre, Christopher W.; Taal, Maarten W.

    2016-01-01

    Background Chronic kidney disease (CKD) is commonly managed in primary care, but most guidelines have a secondary care perspective emphasizing the risk of end-stage kidney disease (ESKD) and need for renal replacement therapy. In this prospective cohort study, we sought to study in detail the natural history of CKD in primary care to better inform the appropriate emphasis for future guidance. Methods and Findings In this study, 1,741 people with CKD stage 3 were individually recruited from 32 primary care practices in Derbyshire, United Kingdom. Study visits were undertaken at baseline, year 1, and year 5. Binomial logistic regression and Cox proportional hazards models were used to model progression, CKD remission, and all-cause mortality. We used Kidney Disease: Improving Global Outcomes (KDIGO) criteria to define CKD progression and defined CKD remission as the absence of diagnostic criteria (estimated glomerular filtration rate [eGFR] >60 ml/min/1.73 m2 and urine albumin-to-creatinine ratio [uACR] <3 mg/mmol) at any study visit. Participants were predominantly elderly (mean ± standard deviation (SD) age 72.9 ± 9.0 y), with relatively mild reduction in GFR (mean ± SD eGFR 53.5 ± 11.8 mL/min/1,73 m2) and a low prevalence of albuminuria (16.9%). After 5 y, 247 participants (14.2%) had died, most of cardiovascular causes. Only 4 (0.2%) developed ESKD, but 308 (17.7%) evidenced CKD progression by KDIGO criteria. Stable CKD was observed in 593 participants (34.1%), and 336 (19.3%) met the criteria for remission. Remission at baseline and year 1 was associated with a high likelihood of remission at year 5 (odds ratio [OR] = 23.6, 95% CI 16.5–33.9 relative to participants with no remission at baseline and year 1 study visits). Multivariable analyses confirmed eGFR and albuminuria as key risk factors for predicting adverse as well as positive outcomes. Limitations of this study include reliance on GFR estimated using the Modification of Diet in Renal Disease study

  2. End-of-life care for persons with advanced chronic obstructive pulmonary disease: report of a national interdisciplinary consensus meeting.

    PubMed

    Goodridge, D M; Marciniuk, D D; Brooks, D; van Dam, A; Hutchinson, S; Bailey, P; Baxter, S; Dorasamy, P; Dumont, S; Hassan, S; Hernandez, P; Kerigan, A; Rocker, G; Wilson, D; Young, J

    2009-01-01

    While systemic shortcomings in meeting the needs of individuals with progressive chronic illnesses at the end of life have been well documented, there is growing interest in improving both care and quality of life for persons with advanced chronic obstructive pulmonary disease (COPD). For instance, the American Thoracic Society has issued an official statement on palliative care for patients with respiratory diseases, affirming that the prevention, relief, reduction and soothing of symptoms "without affecting a cure" must become an integral component of standard care. A recent Medline search located 1015 articles related to palliative or end-of life care for people with COPD published between 2001 and 2008, compared with only 336 articles published before 2001. To address the needs of Canadian patients, an interdisciplinary consensus meeting, funded by the Canadian Institutes of Health Research and supported by the Canadian Thoracic Society, the Canadian Respiratory Health Professionals and the Canadian Lung Association was convened in Toronto, Ontario, on November 22, 2008, to begin examining the quality of end-of-life care for individuals with COPD in Canada. The present report summarizes the background to and outcomes of this consensus meeting.

  3. Case Management in Primary Care for Frequent Users of Health Care Services With Chronic Diseases: A Qualitative Study of Patient and Family Experience

    PubMed Central

    Hudon, Catherine; Chouinard, Maud-Christine; Diadiou, Fatoumata; Lambert, Mireille; Bouliane, Danielle

    2015-01-01

    PURPOSE Although case management (CM) is increasingly being implemented to address the complex needs of vulnerable clienteles, few studies have examined the patient experience of CM. This study aimed to examine the experience of patients and their family members with care integration as part of a primary care CM intervention. Patients in the study were frequent users of health care services who had chronic diseases. METHODS A descriptive, qualitative approach was conducted involving 25 patients and 8 of their family members. Data were collected through in-depth interviews of the patients and 2 focus groups of family members and were analyzed thematically. RESULTS While some participants did not fully understand the CM intervention and a few believed that it involved too many appointments, the CM nurses were patients’ preferred contact with primary care. The nurses actively involved the patients in developing and carrying out their individualized services plans (ISPs) with other health care partners. Patients felt that their needs were taken into consideration, especially regarding access to the health care system. The case manager facilitated access to information as well as communication and coordination among health care and community partners. This improved communication comforted the patients and nurtured a relationship of trust. Participants were actively involved in decision-making. Their ISPs helped them know where they were going and improved transitions between services. CONCLUSIONS The experience of patients and family members was overall very positive regarding care integration. They reported improved access, communication, coordination, and involvement in decision-making as well as better health care transitions. PMID:26553891

  4. Tyrosine Kinase Inhibitors for the Treatment of Chronic-Phase Chronic Myeloid Leukemia: Long-Term Patient Care and Management

    PubMed Central

    Bauer,1, Stephanie; Buchanan,2, Susan; Ryan,3, Irene

    2016-01-01

    Several tyrosine kinase inhibitors (TKIs) are now approved for the treatment of chronic myeloid leukemia in chronic phase. The efficacy of these drugs has been repeatedly demonstrated, as has their tolerability in most patients. However, late and chronic toxicities become an important issue for many patients facing long-term TKI exposure. For patients on long-term imatinib, gastrointestinal events, fluid retention, muscle cramps, fatigue, and hepatotoxicity are among the most common and most clinically relevant adverse events (AEs). A few of these have also emerged as important AEs with some of the newer TKIs. Distinct long-term toxicity concerns have emerged for dasatinib (pleural effusion, pulmonary hypertension, headache, and dyspnea) and nilotinib (rash, headache, myalgia, alopecia, and hyperglycemia), whereas due to the recent approval of bosutinib and ponatinib, their long-term toxicity profiles have not been fully characterized. Clinical experience with each of these drugs is accumulating, and ensuring proper adherence and monitoring for potential AEs is essential for effective treatment. PMID:27713843

  5. Academic Achievement Trajectories of Homeless and Highly Mobile Students: Resilience in the Context of Chronic and Acute Risk

    ERIC Educational Resources Information Center

    Cutuli, J. J.; Desjardins, Christopher David; Herbers, Janette E.; Long, Jeffrey D.; Heistad, David; Chan, Chi-Keung; Hinz, Elizabeth; Masten, Ann S.

    2013-01-01

    Analyses examined academic achievement data across third through eighth grades ("N" = 26,474), comparing students identified as homeless or highly mobile (HHM) with other students in the federal free meal program (FM), reduced price meals (RM), or neither (General). Achievement was lower as a function of rising risk status (General greater than RM…

  6. Barriers and facilitators to self-care in chronic heart failure: a meta-synthesis of qualitative studies.

    PubMed

    Siabani, Soraya; Leeder, Stephen R; Davidson, Patricia M

    2013-01-01

    Chronic heart failure (CHF) is a costly condition that places large demands on self-care. Failure to adhere with self-care recommendations is common and associated with frequent hospitalization. Understanding the factors that enable or inhibit self-care is essential in developing effective health care interventions. This qualitative review was conducted to address the research question, "What are the barriers and facilitators to self-care among patients with CHF?" Electronic databases including Medline, EMBASE, CINAHL, Web of Science, Scopus and Google scholar were searched. Articles were included if they were peer reviewed (1995 to 2012), in English language and investigated at least one contextual or individual factor impacting on self-care in CHF patients > 18years. The criteria defined by Kuper et al. including clarity and appropriateness of sampling, data collection and data analysis were used to appraise the quality of articles. Twenty-three articles met the inclusion criteria. Factors impacting on self-care were included factors related to symptoms of CHF and the self-care process; factors related to personal characteristics; and factors related to environment and self-care system. Important factors such as socioeconomic situation and education level have not been explored extensively and there were minimal data on the influence of age, gender, self-confidence and duration of disease. Although there is an emerging literature, further research is required to address the barriers and facilitators to self-care in patients with CHF in order to provide an appropriate guide for intervention strategies to improve self-care in CHF. PMID:23961394

  7. [Design of an educational tool for Primary Care patients with chronic non-specific low back pain].

    PubMed

    Díaz-Cerrillo, Juan Luis; Rondón-Ramos, Antonio

    2015-02-01

    Current scientific evidence on the management of chronic non-specific low back pain highlights the benefits of physical exercise. This goal is frequently undermined due to lack of education of the subjects on the multifactorial, benign, and non-specific nature of low back pain, which can lead to a chronic disease with genuine psychosocial risk factors. Its influence may not only interfere with individual decision to adopt more adaptive coping behaviors, but also with the endogenous mechanisms of pain neuromodulation. Thus, the educational strategies and control of these factors have become important objectives to be incorporated into the management of the disorder and research guidelines. This paper presents the theoretical models and the scientific basis on which it has based the design of an educational tool for patients with chronic non-specific low back pain treated in Primary Care physiotherapy. Structure, content and objectives are also presented.

  8. Selected Aspects of Mental Health of Elderly Patients with Chronic Back Pain Treated in Primary Care Centers

    PubMed Central

    Cabak, Anna; Dąbrowska-Zimakowska, Anna; Tomaszewski, Paweł; Łyp, Marek; Kaczor, Ryszard; Tomaszewski, Wiesław; Fijałkowska, Barbara; Kotela, Ireneusz

    2015-01-01

    Background Improvement of the effectiveness and efficiency of chronic back pain therapy is a continuing challenge on an international scale. The aim of the present study was to tentatively assess mental health of patients with chronic back pain treated in primary care centers. Material/Methods The study enrolled 100 persons over 50 years of age. The back pain group consisted of 53 patients with chronic back pain and the control group consisted of 47 pain-free persons. The assessment of mental health used a Polish version of the international Goldberger’s General Health Questionnaire (GHQ-28). ANOVA (1- and 2-factor) analysis of variance, Tukey’s test, and Pearson’s simple correlation were used to analyze the significance of differences, with the significance level set at α=0.05. Results All patients with chronic back pain, regardless of their age and gender, displayed poorer mental well-being compared to the control group: their overall score was higher by over 7 points than in persons without back pain (F1.96=14.8; p<0.001). Men with back pain were significantly more susceptible to depression than women (F2.96=5.5; p<0.05), compared to the control group. The duration of back pain also showed a significant (p<0.05) direct correlation with the overall mental health score from the questionnaire. Mental health was considerably poorer among patients occasionally (p<0.001) and regularly (p<0.05) consuming analgesics than among persons who did not do so. Conclusions The study revealed that mental health was markedly poorer in patients with chronic back pain than in healthy controls. A preliminary assessment of aspects of mental health should be given more attention in the rehabilitation of patients with chronic back pain treated in primary care center outpatient clinics. PMID:26522877

  9. Improving the prevention and management of chronic disease in low-income and middle-income countries: a priority for primary health care.

    PubMed

    Beaglehole, Robert; Epping-Jordan, Joanne; Patel, Vikram; Chopra, Mickey; Ebrahim, Shah; Kidd, Michael; Haines, Andy

    2008-09-13

    The burden of chronic diseases, such as heart disease, cancer, diabetes, and mental disorders is high in low-income and middle-income countries and is predicted to increase with the ageing of populations, urbanisation, and globalisation of risk factors. Furthermore, HIV/AIDS is increasingly becoming a chronic disorder. An integrated approach to the management of chronic diseases, irrespective of cause, is needed in primary health care. Management of chronic diseases is fundamentally different from acute care, relying on several features: opportunistic case finding for assessment of risk factors, detection of early disease, and identification of high risk status; a combination of pharmacological and psychosocial interventions, often in a stepped-care fashion; and long-term follow-up with regular monitoring and promotion of adherence to treatment. To meet the challenge of chronic diseases, primary health care will have to be strengthened substantially. In the many countries with shortages of primary-care doctors, non-physician clinicians will have a leading role in preventing and managing chronic diseases, and these personnel need appropriate training and continuous quality assurance mechanisms. More evidence is needed about the cost-effectiveness of prevention and treatment strategies in primary health care. Research on scaling-up should be embedded in large-scale delivery programmes for chronic diseases with a strong emphasis on assessment. PMID:18790317

  10. Improving the prevention and management of chronic disease in low-income and middle-income countries: a priority for primary health care.

    PubMed

    Beaglehole, Robert; Epping-Jordan, Joanne; Patel, Vikram; Chopra, Mickey; Ebrahim, Shah; Kidd, Michael; Haines, Andy

    2008-09-13

    The burden of chronic diseases, such as heart disease, cancer, diabetes, and mental disorders is high in low-income and middle-income countries and is predicted to increase with the ageing of populations, urbanisation, and globalisation of risk factors. Furthermore, HIV/AIDS is increasingly becoming a chronic disorder. An integrated approach to the management of chronic diseases, irrespective of cause, is needed in primary health care. Management of chronic diseases is fundamentally different from acute care, relying on several features: opportunistic case finding for assessment of risk factors, detection of early disease, and identification of high risk status; a combination of pharmacological and psychosocial interventions, often in a stepped-care fashion; and long-term follow-up with regular monitoring and promotion of adherence to treatment. To meet the challenge of chronic diseases, primary health care will have to be strengthened substantially. In the many countries with shortages of primary-care doctors, non-physician clinicians will have a leading role in preventing and managing chronic diseases, and these personnel need appropriate training and continuous quality assurance mechanisms. More evidence is needed about the cost-effectiveness of prevention and treatment strategies in primary health care. Research on scaling-up should be embedded in large-scale delivery programmes for chronic diseases with a strong emphasis on assessment.

  11. Is Europe putting theory into practice? A qualitative study of the level of self-management support in chronic care management approaches

    PubMed Central

    2013-01-01

    Background Self-management support is a key component of effective chronic care management, yet in practice appears to be the least implemented and most challenging. This study explores whether and how self-management support is integrated into chronic care approaches in 13 European countries. In addition, it investigates the level of and barriers to implementation of support strategies in health care practice. Methods We conducted a review among the 13 participating countries, based on a common data template informed by the Chronic Care Model. Key informants presented a sample of representative chronic care approaches and related self-management support strategies. The cross-country review was complemented by a Dutch case study of health professionals’ views on the implementation of self-management support in practice. Results Self-management support for chronically ill patients remains relatively underdeveloped in Europe. Similarities between countries exist mostly in involved providers (nurses) and settings (primary care). Differences prevail in mode and format of support, and materials used. Support activities focus primarily on patients’ medical and behavioral management, and less on emotional management. According to Dutch providers, self-management support is not (yet) an integral part of daily practice; implementation is hampered by barriers related to, among others, funding, IT and medical culture. Conclusions Although collaborative care for chronic conditions is becoming more important in European health systems, adequate self-management support for patients with chronic disease is far from accomplished in most countries. There is a need for better understanding of how we can encourage both patients and health care providers to engage in productive interactions in daily chronic care practice, which can improve health and social outcomes. PMID:23530744

  12. Further Effort is Needed to Improve Management of Chronic Pain in Primary Care. Results from the Arkys Project

    PubMed Central

    Piccinocchi, Gaetano; Piccinocchi, Roberto

    2016-01-01

    Treatment of chronic pain is challenging. The Arkys project was initiated in Italy to assist general practitioners (GPs) in the management of chronic pain. The main objective of this study was to determine the usefulness of Arkys for selecting new therapeutic strategies. An online interactive questionnaire for assessing pain and guiding therapeutic decisions was made available to GPs participating to Arkys. The GPs were invited to complete the questionnaire for each patient who presented moderate-severe chronic pain, and to decide on a new analgesic treatment based on the information provided by the questionnaire. Two hundred and forty four GPs participated with a total of 3035 patients. Patients (mean age 68.9 years) had mostly chronic non-cancer pain (87.7%). In 42.3%, pain had neuropathic components. Only 53.6% of patients were in treatment with analgesics (strong opioids, 38.9%; NSAIDs, 32.6%; weak opioids, 25.6%; anti-epileptics, 17.3%; paracetamol, 14.9%). Use of the questionnaire resulted in the prescription of analgesics to all patients and in increased prescription of strong opioids (69.7%). NSAID prescription decreased (12.8%), while anti-epileptics use remained stable. These findings show that current management of chronic pain in primary care is far from optimal and that efforts are needed to educate GPs and improve guideline implementation. PMID:27478585

  13. Further Effort is Needed to Improve Management of Chronic Pain in Primary Care. Results from the Arkys Project.

    PubMed

    Piccinocchi, Gaetano; Piccinocchi, Roberto

    2016-04-26

    Treatment of chronic pain is challenging. The Arkys project was initiated in Italy to assist general practitioners (GPs) in the management of chronic pain. The main objective of this study was to determine the usefulness of Arkys for selecting new therapeutic strategies. An online interactive questionnaire for assessing pain and guiding therapeutic decisions was made available to GPs participating to Arkys. The GPs were invited to complete the questionnaire for each patient who presented moderate-severe chronic pain, and to decide on a new analgesic treatment based on the information provided by the questionnaire. Two hundred and forty four GPs participated with a total of 3035 patients. Patients (mean age 68.9 years) had mostly chronic non-cancer pain (87.7%). In 42.3%, pain had neuropathic components. Only 53.6% of patients were in treatment with analgesics (strong opioids, 38.9%; NSAIDs, 32.6%; weak opioids, 25.6%; anti-epileptics, 17.3%; paracetamol, 14.9%). Use of the questionnaire resulted in the prescription of analgesics to all patients and in increased prescription of strong opioids (69.7%). NSAID prescription decreased (12.8%), while anti-epileptics use remained stable. These findings show that current management of chronic pain in primary care is far from optimal and that efforts are needed to educate GPs and improve guideline implementation. PMID:27478585

  14. Building equity in chronic disease management in Thailand: a whole-system provincial trial of systematic, pro-active chronic illness care.

    PubMed

    Wanitkun, N; Batterham, R; Vichathai, C; Leetongin, G; Osborne, R H

    2011-03-01

    Thailand has a history of implementing innovative and proactive policies to address the health needs of its population. Since 1962 Thailand has implemented initiatives that led to it having a health system characterized by a primary care focus, decentralization and mechanisms to maximize equity and universal access to basic care at the local level. Thai health structures initially evolved to meet challenges including infectious and developmental diseases and later HIV. Early in the 21st century chronic illness rapidly became the greatest cause of morbidity and mortality and the question has arisen how Thailand can adapt its strong health system to deal with the new epidemics. This article describes an effort to reorient provincial health services to meet the needs of the increasing number of people with diabetes and heart disease. It describes measures taken to build on the equity-promoting elements of the Thai health system. The project included; a situational analysis, development and implementation of a chronic disease self-management intervention implemented by nurses and alignment of provincial health services. The self-management intervention is currently being evaluated within a clustered randomized control trial. The evaluation has been developed to fit with the focus on equity in relation to both selection criteria and the outcomes that are being assessed.

  15. Academic achievement trajectories of homeless and highly mobile students: resilience in the context of chronic and acute risk.

    PubMed

    Cutuli, J J; Desjardins, Christopher David; Herbers, Janette E; Long, Jeffrey D; Heistad, David; Chan, Chi-Keung; Hinz, Elizabeth; Masten, Ann S

    2013-01-01

    Analyses examined academic achievement data across third through eighth grades (N = 26,474), comparing students identified as homeless or highly mobile (HHM) with other students in the federal free meal program (FM), reduced price meals (RM), or neither (General). Achievement was lower as a function of rising risk status (General > RM > FM > HHM). Achievement gaps appeared stable or widened between HHM students and lower risk groups. Math and reading achievement were lower, and growth in math was slower in years of HHM identification, suggesting acute consequences of residential instability. Nonetheless, 45% of HHM students scored within or above the average range, suggesting academic resilience. Results underscore the need for research on risk and resilience processes among HHM students to address achievement disparities.

  16. Academic Achievement Trajectories of Homeless and Highly Mobile Students: Resilience in the Context of Chronic and Acute Risk

    PubMed Central

    Cutuli, J. J.; Desjardins, Christopher David; Herbers, Janette E.; Long, Jeffrey D.; Heistad, David; Chan, Chi-Keung; Hinz, Elizabeth; Masten, Ann S.

    2012-01-01

    Analyses examined academic achievement data across 3rd through 8th grades (N = 26,474), comparing students identified as homeless or highly mobile (HHM) to other students in the federal free meal program (FM), reduced-price meals (RM), or neither (General). Achievement was lower as a function of rising risk status (General > RM > FM > HHM). Achievement gaps appeared stable or widened between HHM students and lower-risk groups. Math and reading achievement were lower and growth in math was slower in years of HHM identification, suggesting acute consequences of residential instability. Nonetheless, 45% of HHM students scored within or above the average range, suggesting academic resilience. Results underscore the need for research on risk and resilience processes among HHM students to address achievement disparities. PMID:23110492

  17. Effectiveness of a new health care organization model in primary care for chronic cardiovascular disease patients based on a multifactorial intervention: the PROPRESE randomized controlled trial

    PubMed Central

    2013-01-01

    Background To evaluate the effectiveness of a new multifactorial intervention to improve health care for chronic ischemic heart disease patients in primary care. The strategy has two components: a) organizational for the patient/professional relationship and b) training for professionals. Methods/design Experimental study. Randomized clinical trial. Follow-up period: one year. Study setting: primary care, multicenter (15 health centers). For the intervention group 15 health centers are selected from those participating in ESCARVAL study. Once the center agreed to participate patients are randomly selected from the total amount of patients with ischemic heart disease registered in the electronic health records. For the control group a random sample of patients with ischemic heart disease is selected from all 72 health centers electronic records. Intervention components: a) Organizational intervention on the patient/professional relationship. Centered on the Chronic Care Model, the Stanford Expert Patient Program and the Kaiser Permanente model: Teamwork, informed and active patient, decision making shared with the patient, recommendations based on clinical guidelines, single electronic medical history per patient that allows the use of indicators for risk monitoring and stratification. b) Formative strategy for professionals: 4 face-to-face training workshops (one every 3 months), monthly update clinical sessions, online tutorial by a cardiologist, availability through the intranet of the action protocol and related documents. Measurements: Blood pressure, blood glucose, HbA1c, lipid profile and smoking. Frequent health care visits. Number of hospitalizations related to vascular disease. Therapeutic compliance. Drug use. Discussion This study aims to evaluate the efficacy of a multifactorial intervention strategy involving patients with ischemic heart disease for the improvement of the degree of control of the cardiovascular risk factors and of the quality of life

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