complex continuing care: Topics by Science.gov

Sample records for complex continuing care

The Importance of and the Complexities Associated With Measuring Continuity of Care During Resident Training: Possible Solutions Do Exist.

PubMed

Carney, Patricia A; Conry, Colleen M; Mitchell, Karen B; Ericson, Annie; Dickinson, W Perry; Martin, James C; Carek, Peter J; Douglass, Alan B; Eiff, M Patrice

2016-04-01

Evolutions in care delivery toward the patient-centered medical home have influenced important aspects of care continuity. Primary responsibility for a panel of continuity patients is a foundational requirement in family medicine residencies. In this paper we characterize challenges in measuring continuity of care in residency training in this new era of primary care. We synthesized the literature and analyzed information from key informant interviews and group discussions with residency faculty and staff to identify the challenges and possible solutions for measuring continuity of care during family medicine training. We specifically focused on measuring interpersonal continuity at the patient level, resident level, and health care team level. Challenges identified in accurately measuring interpersonal continuity of care during residency training include: (1) variability in empanelment approaches for all patients, (2) scheduling complexity in different types of visits, (3) variability in ability to attain continuity counts at the level of the resident, and (4) shifting make-up of health care teams, especially in residency training. Possible solutions for each challenge are presented. Philosophical issues related to continuity are discussed, including whether true continuity can be achieved during residency training and whether qualitative rather than quantitative measures of continuity are better suited to residencies. Measuring continuity of care in residency training is challenging but possible, though improvements in precision and assessment of the comprehensive nature of the relationships are needed. Definitions of continuity during training and the role continuity measurement plays in residency need further study.
Clinicians’ views on improving inter-organizational care transitions

PubMed Central

2013-01-01

Background Patients with complex health conditions frequently require care from multiple providers and are particularly vulnerable to poorly executed transitions from one healthcare setting to another. Poorly executed care transitions can result in negative patient outcomes (e.g. medication errors, delays in treatment) and increased healthcare spending due to re-hospitalization or emergency room visits by patients. Little is known about care transitions from acute care to complex continuing care and rehabilitation settings. Thus, a qualitative study was undertaken to explore clinicians’ perceptions of strategies aimed at improving patient care transitions from acute care hospitals to complex continuing care and rehabilitation healthcare organizations. Methods A qualitative study using semi-structured interviews was conducted with clinicians employed at two selected healthcare facilities: an acute care hospital and a complex continuing care/rehabilitation organization, respectively. Analysis of the transcripts involved the creation of a coding schema using the content analyses outlined by Ryan and Bernard. In total, 31 interviews were conducted with clinicians at the participating study sites. Results Three themes emerged from the data to delineate what study participants described as strategies to ensure quality inter-organizational transitions of patients transferred from acute care to the complex continuing care and rehabilitation hospital. These themes are: 1) communicating more effectively; 2) being vigilant around the patients’ readiness for transfer and care needs; and 3) documenting more accurately and completely in the patient transfer record. Conclusion Our study provides insights from the perspectives of multiple clinicians that have important implications for health care leaders and clinicians in their efforts to enhance inter-organizational care transitions. Of particular importance is the need to have a collective and collaborative approach amongst clinicians during the inter-organizational care transition process. Study findings also suggest that the written patient transfer record needs to be augmented with a verbal report whereby the receiving clinician has an opportunity to discuss with a clinician from the acute care hospital the patient’s status on discharge and plan of care. Integral to future research efforts is designing and testing out interventions to optimize inter-organizational care transitions and feedback loops for complex medical patients. PMID:23899326
Innovation in Education for Health Care Assistants: A Case Study of a Programme Related to Children with Complex and Continuing Health Needs

ERIC Educational Resources Information Center

Hewitt-Taylor, Jaqui

2012-01-01

This paper describes the development of a programme of learning aimed at meeting the needs of health care assistants (HCAs) who provide support for children with complex and continuing health needs and their families. Following a pilot study of the principles of course provision, a Certificate in Higher Education in care of the child with complex…
Continuity of care in mental health: understanding and measuring a complex phenomenon.

PubMed

Burns, T; Catty, J; White, S; Clement, S; Ellis, G; Jones, I R; Lissouba, P; McLaren, S; Rose, D; Wykes, T

2009-02-01

Continuity of care is considered by patients and clinicians an essential feature of good quality care in long-term disorders, yet there is general agreement that it is a complex concept. Most policies emphasize it and encourage systems to promote it. Despite this, there is no accepted definition or measure against which to test policies or interventions designed to improve continuity. We aimed to operationalize a multi-axial model of continuity of care and to use factor analysis to determine its validity for severe mental illness. A multi-axial model of continuity of care comprising eight facets was operationalized for quantitative data collection from mental health service users using 32 variables. Of these variables, 22 were subsequently entered into a factor analysis as independent components, using data from a clinical population considered to require long-term consistent care. Factor analysis produced seven independent continuity factors accounting for 62.5% of the total variance. These factors, Experience and Relationship, Regularity, Meeting Needs, Consolidation, Managed Transitions, Care Coordination and Supported Living, were close but not identical to the original theoretical model. We confirmed that continuity of care is multi-factorial. Our seven factors are intuitively meaningful and appear to work in mental health. These factors should be used as a starting-point in research into the determinants and outcomes of continuity of care in long-term disorders.
A needs assessment to determine the need for respiratory therapy in complex continuing care: A methods paper.

PubMed

Nickerson, Jason W

2015-01-01

There is an emerging demand for complex continuing care for patients who are too ill to safely return home, but for whom hospitalization in an acute care environment is unnecessary or inappropriate. Despite the need and medical complexity of these patients, few respiratory therapists are practising in this environment, and little evidence exists to guide the implementation of respiratory therapy services in this setting. In response to a perceived need for greater respiratory services at Saint Vincent Hospital (Ottawa, Ontario), a needs assessment was undertaken to assess the prevalence of respiratory diseases and for increased respiratory therapist coverage at this complex continuing care hospital. An initial literature review was conducted to guide the assessment, and identified only one tool of relevance, which was obtained and formed the basis of the further development of tools for collecting data at the hospital level and on patient care units at the facility. This needs assessment tool was expanded to include priority areas of relevance that fall within the scope of practice of respiratory therapists, and was supplemented by the analysis of administrative databases and qualitative data gathered through unit walkthroughs and unstructured key informant interviews. A health systems framework was used to structure recommendations for the development of interventions and programs for this patient population. The burden of respiratory disease was significant, and included a high prevalence of inhaled medication and oxygen use, and a significant workload that could be attributed to addressing the respiratory needs of patients. A range of tools and methods are needed to conduct needs assessments for respiratory therapy in complex continuing care. Using multiple data sources, a significant burden of respiratory diseases was present at the Saint Vincent Hospital; further studies in other complex continuing care hospitals are needed to understand the significance of these findings among this patient population more generally.
Continuity of care: an Italian clinical experience.

PubMed

Tarquini, Roberto; Coletta, Davide; Mazzoccoli, Gianluigi; Gensini, Gian Franco

2013-10-01

Recently, there is a growing interest in the concept of "continuity of care," since patients, being older and more complex, are increasingly seen by an array of providers in a wide variety of organizations and places. Different models of continuity of care have been proposed, yet no single model of care coordination has been proven to be universally applicable across patient (and disease) populations. In the present paper, we introduce a novel model of continuity of care, the Ospedale Santa Verdiana, in Castelfiorentino (Tuscany, Italy), and its first period (1 year) of implementation, since January 2010. There are two main cornerstones: (a) the clinical and urgent need to bridge the gap between primary care and hospital care; and (b) the development and implementation of a model of continuity and coordination of care, which target the so-called complex patient. It is not specific for a single disease but it works "across diseases." There are three driving forces: (a) "primary care" since one of the two Hospital Coordinators is a primary care physician; (b) "hospital care" since patients in the decompensated phase often require hospitalization; and (c) the "University of Florence", which is the "glue". The duties of the Hospital Coordinator, who is an assistant professor at University of Florence, are to guarantee an efficacious and dynamic communication between primary care physicians and hospitalists, and by creating a school for practitioners of the continuity and coordination of care, to make this model exportable.
Continuing Professional Development: Pedagogical Practices of Interprofessional Simulation in Health Care

ERIC Educational Resources Information Center

Nyström, Sofia; Dahlberg, Johanna; Edelbring, Samuel; Hult, Håkan; Abrandt Dahlgren, Madeleine

2017-01-01

The increasing complexity of health care practice makes continuing professional development (CPD) essential for health care professionals. Simulation-based training is a CPD activity that is often applied to improve interprofessional collaboration and the quality of care. The aim of this study is to explore simulation as a pedagogical practice for…
A Profile of Patients With Traumatic Brain Injury Within Home Care, Long-Term Care, Complex Continuing Care, and Institutional Mental Health Settings in a Publicly Insured Population.

PubMed

Colantonio, Angela; Hsueh, Jayden; Petgrave, Josian; Hirdes, John P; Berg, Katherine

2015-01-01

To describe the sociodemographic and clinical profile of people with traumatic brain injury (TBI) in home care, nursing homes, and complex continuing care settings in a national sample. Cross-sectional study using available Resident Assessment Instrument (RAI 2.0 and RAI Home Care [HC]) national databases in Canada from 1996 to 2011. The profile of people with TBI was compared with patients with and without prespecified neurological conditions within each setting. Adults 18 years and older identified with TBI (n = 10 878) and adult patients with other neurological (n = 422 300) and non-neurological (n = 571 567) conditions. Demographic and clinical characteristics, functional characteristics, mood and behavior, and treatment and medication variables. Data from Canadian home care (RAI-HC), mental health (RAI-MH), nursing home, and complex continuing care facilities (RAI Minimum Data Set 2.0). Patients with TBI were significantly different on almost all items. They were among the youngest in care settings, and psychotropic drug use by this population was among the highest in at least 2 settings. These data can inform the planning for appropriate care and resources for patients with TBI in a range of settings.
Nursing essential principles: continuous renal replacement therapy.

PubMed

Richardson, Annette; Whatmore, Jayne

2015-01-01

This article aims to guide critical care nurses with the care and management of patients on continuous renal replacement therapy (CRRT). CRRT, a highly specialized therapy involving complex nursing care, is used widely in the intensive care unit to treat patients with acute kidney injury. A literature search was conducted using CINAHL, Medline from PubMed and BNI using the search terms CRRT or continuous veno-venous haemofiltration and nursing or nurses from 2000 onwards and limited to the English language. The appraised evidence and expert opinion is used in this article. Four essential nursing principles for CRRT are reviewed (1) the importance of continuous assessment of the indications to influence the appropriate mode; (2) ensuring good vascular access; (3) the avoidance of unnecessary interruptions and (4) the prevention of complications. The identified four essential nursing principles provide guidance on this complex aspects of nursing practice. Specific nursing research to guide the care and management of this therapy is limited so should be explored in the future. Critical care nurses caring for and managing patients on CRRT require an understanding of how to deliver safe CRRT. © 2014 British Association of Critical Care Nurses.
Unlocking information for coordination of care in Australia: a qualitative study of information continuity in four primary health care models

PubMed Central

2013-01-01

Background Coordination of care is considered a key component of patient-centered health care systems, but is rarely defined or operationalised in health care policy. Continuity, an aspect of coordination, is the patient’s experience of care over time, and is often described in terms of three dimensions: information, relational and management continuity. With the current health policy focus on both the use of information technology and care coordination, this study aimed to 1) explore how information continuity supports coordination and 2) investigate conditions required to support information continuity. Methods Four diverse Australian primary health care initiatives were purposively selected for inclusion in the study. Each has improved coordination as an aim or fundamental principle. Each organization was asked to identify practitioners, managers and decision makers who could provide insight into the use of information for care coordination to participate in the study. Using in-depth semi-structured interviews, we explored four questions covering the scope and use of information, the influence of governance, data ownership and confidentiality and the influence of financial incentives and quality improvement on information continuity and coordination. Data were thematically analyzed using NVivo 8. Results The overall picture that emerged across all four cases was that whilst accessibility and continuity of information underpin effective care, they are not sufficient for coordination of care for complex conditions. Shared information reduced unnecessary repetition and provided health professionals with the opportunity to access records of care from other providers, but participants described their role in coordination in terms of the active involvement of a person in care rather than the passive availability of information. Complex issues regarding data ownership and confidentiality often hampered information sharing. Successful coordination in each case was associated with responsiveness to local rather than system level factors. Conclusions The availability of information is not sufficient to ensure continuity for the patient or coordination from the systems perspective. Policy directed at information continuity must give consideration to the broader ‘fit’ with management and relational continuity and provide a broad base that allows for local responsiveness in order for coordination of care to be achieved. PMID:23497291
Unlocking information for coordination of care in Australia: a qualitative study of information continuity in four primary health care models.

PubMed

Banfield, Michelle; Gardner, Karen; McRae, Ian; Gillespie, James; Wells, Robert; Yen, Laurann

2013-03-13

Coordination of care is considered a key component of patient-centered health care systems, but is rarely defined or operationalised in health care policy. Continuity, an aspect of coordination, is the patient's experience of care over time, and is often described in terms of three dimensions: information, relational and management continuity. With the current health policy focus on both the use of information technology and care coordination, this study aimed to 1) explore how information continuity supports coordination and 2) investigate conditions required to support information continuity. Four diverse Australian primary health care initiatives were purposively selected for inclusion in the study. Each has improved coordination as an aim or fundamental principle. Each organization was asked to identify practitioners, managers and decision makers who could provide insight into the use of information for care coordination to participate in the study. Using in-depth semi-structured interviews, we explored four questions covering the scope and use of information, the influence of governance, data ownership and confidentiality and the influence of financial incentives and quality improvement on information continuity and coordination. Data were thematically analyzed using NVivo 8. The overall picture that emerged across all four cases was that whilst accessibility and continuity of information underpin effective care, they are not sufficient for coordination of care for complex conditions. Shared information reduced unnecessary repetition and provided health professionals with the opportunity to access records of care from other providers, but participants described their role in coordination in terms of the active involvement of a person in care rather than the passive availability of information. Complex issues regarding data ownership and confidentiality often hampered information sharing. Successful coordination in each case was associated with responsiveness to local rather than system level factors. The availability of information is not sufficient to ensure continuity for the patient or coordination from the systems perspective. Policy directed at information continuity must give consideration to the broader 'fit' with management and relational continuity and provide a broad base that allows for local responsiveness in order for coordination of care to be achieved.
Evaluation of a Specialized Yoga Program for Persons Admitted to a Complex Continuing Care Hospital: A Pilot Study

PubMed Central

Kuluski, Kerry; Bechsgaard, Gitte; Ridgway, Jennifer; Katz, Joel

2016-01-01

Introduction. The purpose of this study was to evaluate a specialized yoga intervention for inpatients in a rehabilitation and complex continuing care hospital. Design. Single-cohort repeated measures design. Methods. Participants (N = 10) admitted to a rehabilitation and complex continuing care hospital were recruited to participate in a 50–60 min Hatha Yoga class (modified for wheelchair users/seated position) once a week for eight weeks, with assigned homework practice. Questionnaires on pain (pain, pain interference, and pain catastrophizing), psychological variables (depression, anxiety, and experiences with injustice), mindfulness, self-compassion, and spiritual well-being were collected at three intervals: pre-, mid-, and post-intervention. Results. Repeated measures ANOVAs revealed a significant main effect of time indicating improvements over the course of the yoga program on the (1) anxiety subscale of the Hospital Anxiety and Depression Scale, F(2,18) = 4.74, p < .05, and η p 2 = .35, (2) Self-Compassion Scale-Short Form, F(2,18) = 3.71, p < .05, and η p 2 = .29, and (3) Magnification subscale of the Pain Catastrophizing Scale, F(2,18) = 3. 66, p < .05, and η p 2 = .29. Discussion. The results suggest that an 8-week Hatha Yoga program improves pain-related factors and psychological experiences in individuals admitted to a rehabilitation and complex continuing care hospital. PMID:28115969
Complex systems thinking in emergency medicine: A novel paradigm for a rapidly changing and interconnected health care landscape.

PubMed

Widmer, Matthew A; Swanson, R Chad; Zink, Brian J; Pines, Jesse M

2017-12-27

The specialty of emergency medicine is experiencing the convergence of a number of transformational forces in the United States, including health care reform, technological advancements, and societal shifts. These bring both opportunity and uncertainty. 21ST CENTURY CHALLENGES: Persistent challenges such as the opioid epidemic, rising health care costs, misaligned incentives, patients with multiple chronic diseases, and emergency department crowding continue to plague the acute, unscheduled care system. The traditional approach to health care practice and improvement-reductionism-is not adequate for the complexity of the twenty-first century. Reductionist thinking will likely continue to produce unintended consequences and suboptimal outcomes. Complex systems thinking provides a perspective and set of tools better suited for the challenges and opportunities facing public health in general, and emergency medicine more specifically. This article introduces complex systems thinking and argues for its application in the context of emergency medicine by drawing on the history of the circumstances surrounding the formation of the specialty and by providing examples of its application to several practice challenges. © 2017 John Wiley & Sons, Ltd.
Policy choices in dementia care-An exploratory analysis of the Alberta continuing care system (ACCS) using system dynamics.

PubMed

Cepoiu-Martin, Monica; Bischak, Diane P

2018-02-01

The increase in the incidence of dementia in the aging population and the decrease in the availability of informal caregivers put pressure on continuing care systems to care for a growing number of people with disabilities. Policy changes in the continuing care system need to address this shift in the population structure. One of the most effective tools for assessing policies in complex systems is system dynamics. Nevertheless, this method is underused in continuing care capacity planning. A system dynamics model of the Alberta Continuing Care System was developed using stylized data. Sensitivity analyses and policy evaluations were conducted to demonstrate the use of system dynamics modelling in this area of public health planning. We focused our policy exploration on introducing staff/resident benchmarks in both supportive living and long-term care (LTC). The sensitivity analyses presented in this paper help identify leverage points in the system that need to be acknowledged when policy decisions are made. Our policy explorations showed that the deficits of staff increase dramatically when benchmarks are introduced, as expected, but at the end of the simulation period, the difference in deficits of both nurses and health care aids are similar between the 2 scenarios tested. Modifying the benchmarks in LTC only versus in both supportive living and LTC has similar effects on staff deficits in long term, under the assumptions of this particular model. The continuing care system dynamics model can be used to test various policy scenarios, allowing decision makers to visualize the effect of a certain policy choice on different system variables and to compare different policy options. Our exploration illustrates the use of system dynamics models for policy making in complex health care systems. © 2017 John Wiley & Sons, Ltd.
Community Nursing Care of Chinese-Australian Cancer Patients: A Qualitative Study.

PubMed

McKenzie, Heather; Kwok, Cannas; Tsang, Heidi; Moreau, Elizabeth

2015-01-01

Providing quality care and support to cancer patients from minority cultures can challenge community nurses when language barriers and cultural complexities intersect with the need for complex care. This article reports on a qualitative study that explores interactions between community nurses and Chinese-Australian cancer patients. The research method focused on particular nurse-patient encounters and involved preencounter and postencounter interviews with the nurse, postencounter interviews with the patient, and observation of the encounters. Participants included community nurses, Chinese cancer patients being cared for at home, and their carers if present. Four themes were conceptualized: (1) the impact of language barriers on nurse-patient interactions, (2) patient understandings of the scope and objectives of healthcare services, (3) cultural complexities and sensitivities, and (4) valued care and support. The study demonstrates that, although many nurses do provide comprehensive, culturally competent care, language barriers can lead to task-oriented rather than comprehensive approaches, and other cultural complexities do have an impact on patient experiences and on the quality of nurse-patient interactions. Nevertheless, most patient participants experienced a feeling of security as a result of regular contact with a community nursing service. Cancer patients with complex care needs but limited English proficiency require support to negotiate complicated community services networks. Culturally competent community nurses can provide this support. The study highlights the need for continuing cultural competence education for community nurses and the importance of careful discharge planning to ensure continuity of care for this vulnerable patient group.
Human Caring in the Social Work Context: Continued Development and Validation of a Complex Measure

ERIC Educational Resources Information Center

Ellis, Jacquelyn I.; Ellett, Alberta J.; DeWeaver, Kevin

2007-01-01

Objectives: (a) to continue the development of a measure of human caring in the context of social work practice and (b) to expand a line of inquiry exploring the relationship between human caring characteristics and the retention of public child welfare workers. Methodology: Surveys were received from a sample (n = 786) child welfare workers in…
Project Continuity: A Handicapped Children's Early Education Project. Final Report, October 1, 1986 to September 30, 1989.

ERIC Educational Resources Information Center

Jackson, Barbara; Quinn, Judy

The final report describes Project Continuity, a federally funded effort to provide continuity of care for handicapped infants with chronic illness or complex medical needs while in the acute care setting and to facilitate transition of the infant into the home environment. Goals were accomplished within the context of a family-centered…
A population-based analysis of incentive payments to primary care physicians for the care of patients with complex disease

PubMed Central

Lavergne, M. Ruth; Law, Michael R.; Peterson, Sandra; Garrison, Scott; Hurley, Jeremiah; Cheng, Lucy; McGrail, Kimberlyn

2016-01-01

Background: In 2007, the province of British Columbia implemented incentive payments to primary care physicians for the provision of comprehensive, continuous, guideline-informed care for patients with 2 or more chronic conditions. We examined the impact of this program on primary care access and continuity, rates of hospital admission and costs. Methods: We analyzed all BC patients who qualified for the incentive based on their diagnostic profile. We tracked primary care contacts and continuity, hospital admissions (total, via the emergency department and for targeted conditions), and cost of physician services, hospital care and pharmaceuticals, for 24 months before and 24 months after the intervention. Results: Of 155 754 eligible patients, 63.7% had at least 1 incentive payment billed. Incentive payments had no impact on primary care contacts (change in contacts per patient per month: 0.016, 95% confidence interval [CI] −0.047 to 0.078) or continuity of care (mean monthly change: 0.012, 95% CI −0.001 to 0.024) and were associated with increased total rates of hospital admission (change in hospital admissions per 1000 patients per month: 1.46, 95% CI 0.04 to 2.89), relative to preintervention trends. Annual costs per patient did not decline (mean change: $455.81, 95% CI −$2.44 to $914.08). Interpretation: British Columbia’s $240-million investment in this program improved compensation for physicians doing the important work of caring for complex patients, but did not appear to improve primary care access or continuity, or constrain resource use elsewhere in the health care system. Policymakers should consider other strategies to improve care for this patient population. PMID:27527484
Provider connectedness and communication patterns: extending continuity of care in the context of the circle of care

PubMed Central

2013-01-01

Background Continuity is an important aspect of quality of care, especially for complex patients in the community. We explored provider perceptions of continuity through a system’s lens. The circle of care was used as the system. Methods Soft systems methodology was used to understand and improve continuity for end of life patients in two communities. Participants: Physicians, nurses, pharmacists in two communities in British Columbia, involved in end of life care. Two debates/discussion groups were completed after the interviews and initial analysis to confirm findings. Interview recordings were qualitatively analyzed to extract components and enablers of continuity. Results 32 provider interviews were completed. Findings from this study support the three types of continuity described by Haggerty and Reid (information, management, and relationship continuity). This work extends their model by adding features of the circle of care that influence and enable continuity: Provider Connectedness the sense of knowing and trust between providers who share care of a patient; a set of ten communication patterns that are used to support continuity across the circle of care; and environmental factors outside the circle that can indirectly influence continuity. Conclusions We present an extended model of continuity of care. The components in the model can support health planners consider how health care is organized to promote continuity and by researchers when considering future continuity research. PMID:23941179
Implementation of behavioral health interventions in real world scenarios: Managing complex change.

PubMed

Clark, Khaya D; Miller, Benjamin F; Green, Larry A; de Gruy, Frank V; Davis, Melinda; Cohen, Deborah J

2017-03-01

A practice embarks on a radical reformulation of how care is designed and delivered when it decides to integrate medical and behavioral health care for its patients and success depends on managing complex change in a complex system. We examined the ways change is managed when integrating behavioral health and medical care. Observational cross-case comparative study of 19 primary care and community mental health practices. We collected mixed methods data through practice surveys, observation, and semistructured interviews. We analyzed data using a data-driven, emergent approach. The change management strategies that leadership employed to manage the changes of integrating behavioral health and medical care included: (a) advocating for a mission and vision focused on integrated care; (b) fostering collaboration, with a focus on population care and a team-based approaches; (c) attending to learning, which includes viewing the change process as continuous, and creating a culture that promoted reflection and continual improvement; (d) using data to manage change, and (e) developing approaches to finance integration. This paper reports the change management strategies employed by practice leaders making changes to integrate care, as observed by independent investigators. We offer an empirically based set of actionable recommendations that are relevant to a range of leaders (policymakers, medical directors) and practice members who wish to effectively manage the complex changes associated with integrated primary care. (PsycINFO Database Record (c) 2017 APA, all rights reserved).

Handoffs in care--can we make them safer?

PubMed

Streitenberger, Kim; Breen-Reid, Karen; Harris, Cheryl

2006-12-01

In today's complex and rapidly changing health care environments, patient harm may result if important patient information is not communicated from one health care provider to another during handoffs in care. Issues involving communication, continuity of care, and care planning are cited as a root cause in more than 80% of reported sentinel events. In light of the inherent risks associated with handoffs in care, the use of strategies that reduce the impact of human factors on effective communication and standardize the communication process is essential to ensure appropriate communication patient information and that a plan of care is continued through the process.
Using a complex adaptive system lens to understand family caregiving experiences navigating the stroke rehabilitation system.

PubMed

Ghazzawi, Andrea; Kuziemsky, Craig; O'Sullivan, Tracey

2016-10-01

Family caregivers provide the stroke survivor with social support and continuity during the transition home from a rehabilitation facility. In this exploratory study we examined family caregivers' perceptions and experiences navigating the stroke rehabilitation system. The theories of continuity of care and complex adaptive systems were integrated to examine the transition from a stroke rehabilitation facility to the patient's home. This study provides an understanding of the interacting complexities at the macro and micro levels. A convenient sample of family caregivers (n = 14) who provide care for a stroke survivor were recruited 4-12 weeks following the patient's discharge from a stroke rehabilitation facility in Ontario, Canada. Interviews were conducted with family caregivers to examine their perceptions and experiences navigating the stroke rehabilitation system. Directed and inductive content analysis and the theory of Complex Adaptive Systems were used to interpret the perceptions of family caregivers. Health system policies and procedures at the macro-level determined the types and timing of information being provided to caregivers, and impacted continuity of care and access to supports and services at the micro-level. Supports and services in the community, such as outpatient physiotherapy services, were limited or did not meet the specific needs of the stroke survivors or family caregivers. Relationships with health providers, informational support, and continuity in case management all influence the family caregiving experience and ultimately the quality of care for the stroke survivor, during the transition home from a rehabilitation facility.
Feasibility of and barriers to continuity of care in US general surgery residencies with an 80-hour duty week.

PubMed

Morrissey, Shawna; Dumire, Russell; Bost, James; Gregory, James S

2011-03-01

The current level of continuity of care for following up a single patient through preoperative evaluation, surgery, and postoperative care is unknown. A survey of residents was performed, asking for their best guess regarding the number of patients seen for 6 common and 4 uncommon surgeries, and ranking barriers to continuity of care. The length of time to achieve single-patient continuity of care in 5 patients was derived as well as the creation of odds ratios for the barriers. A total of 274 residents (56 programs) completed surveys. Residency length was 7 years for common surgeries and 9 for complex surgeries. The 30-hour work restrictions, inability to attend clinic, and floor/ward duties were the barriers to continuity of care. These data were unaffected by type of program, the presence of a night float system, or residency year. Achieving the level of continuity of care used in this article will require a radical change in the length or structure of general surgery residency programs. Copyright © 2011 Elsevier Inc. All rights reserved.
Extending “Continuity of Care” to include the Contribution of Family Carers

PubMed Central

Parsons, John; Sheridan, Nicolette; Kenealy, Timothy; Peckham, Allie

2017-01-01

Background: Family carers, as a “shadow workforce”, are foundational to the day-to-day integration of health service delivery for older family members living with complex health needs. This paper utilises Haggerty’s model of continuity of care to explore the contribution of family carers’ to the provision of care and support for an older family member’s chronic condition within the context of health service delivery. Methods: We analysed data from interviews of 13 family carers in a case study of primary health care in New Zealand – a Maori Provider Organisation – to determine the alignment of family caregiving with the three levels of continuity of care (relational continuity, informational continuity, and management continuity). Results: We found alignment of family caregiving tasks, responsibilities, and relationships with the three levels of continuity of care. Family carers 1) partnered with providers to extend chronic care to the home; 2) transferred and contributed information from one provider/service to another; 3) supported consistent and flexible management of care. Discussion: The Maori Provider Organisation supported family carer-provider partnership enabled by shared Maori cultural values and social mandate of building family-centred wellbeing. Relational continuity was the most important level of continuity of care; it sets precedence for family carers and providers to establish the other levels – informational and management – continuity of care for their family member cared for. Family carers need to be considered as active partners working alongside responsive primary health care providers and organisation in the implementation of chronic care. PMID:28970752
Children, Families, and Disparities: Pediatric Provisions in the Affordable Care Act.

PubMed

Grace, Aimee M; Horn, Ivor; Hall, Robert; Cheng, Tina L

2015-10-01

The Affordable Care Act has caused and continues to cause sweeping changes throughout the health system in the United States. Poorly explained, complex, controversial, confusing, and subject to continuous legal and regulatory definition, the law stands as a hallmark piece of legislation that will change the health sector in America forever. This article summarizes the Affordable Care Act with a focus on children, families, and disparities. Also provided is the context of the current system of health care coverage in the United States. Published by Elsevier Inc.
The Influence of Cultural Immersion on Transcultural Self-Efficacy for Nursing Students at Private Faith-Based Baccalaureate Nursing Programs

ERIC Educational Resources Information Center

Schroeder, Pamela A.

2012-01-01

As multicultural populations throughout the world continually increase, complex challenges and health care disparities are being created. Nurses spend more time in patient care management than any other health care professionals. The need for nurses to provide culturally competent care for increasingly diverse patient populations is critical to…
Continuous care and patients' basic needs during weaning from mechanical ventilation: A qualitative study.

PubMed

Khalafi, Ali; Elahi, Nasrin; Ahmadi, Fazlollah

2016-12-01

Mechanical ventilation is associated with a number of risks and complications. Thus, rapid and safe weaning from mechanical ventilation is of great importance. Weaning is a complex and challenging process, requiring continuous care and knowledge of the patient. The aim of the present study was to describe the continuous care process during weaning as well as to analyse the facilitators and obstacles to the weaning process from start to finish from the perspective of intensive care unit (ICU) staff, particularly nurses. Twenty-two ICU staff members, including nurses and physicians, and three patients hospitalised in the ICU were enrolled in this qualitative study. Semi-structured interviews were used for data collection and the transcripts were analysed using qualitative content analysis. 'Continuous care' was found to be the patients' basic need during weaning from mechanical ventilation. Uninterrupted, stable, comprehensive and dynamic care and monitoring with immediate response to all physiological and psychological changes were features of continuous care. The three main themes identified by this study were time spent with the patient, comprehensive supervision and maintenance of the quality of care during shifts. Continuous and constant care should be provided during the weaning process. Such care will help to provide health care staff with a deeper understanding of the patient and his or her continuous changes, leading to a timely and favourable response during weaning. To achieve this goal, skill, communication and organisational changes are essential. Copyright © 2016 Elsevier Ltd. All rights reserved.
A Framework of Complex Adaptive Systems: Parents As Partners in the Neonatal Intensive Care Unit.

PubMed

DʼAgata, Amy L; McGrath, Jacqueline M

2016-01-01

Advances in neonatal care are allowing for increased infant survival; however, neurodevelopmental complications continue. Using a complex adaptive system framework, a broad analysis of the network of agents most influential to vulnerable infants in the neonatal intensive care unit (NICU) is presented: parent, nurse, and organization. By exploring these interconnected relationships and the emergent behaviors, a model of care that increases parental caregiving in the NICU is proposed. Supportive parent caregiving early in an infant's NICU stay has the potential for more sensitive caregiving and enhanced opportunities for attachment, perhaps positively impacting neurodevelopment.
Health Care Aides' Struggle to Build and Maintain Relationships with Families in Complex Continuing Care Settings

ERIC Educational Resources Information Center

McGilton, Katherine S.; Guruge, Sepali; Librado, Ruby; Bloch, Lois; Boscart, Veronique

2008-01-01

Research on the relationships between health care aides (HCAs) and families of clients has been situated mainly in long-term care settings and includes scant findings about the perceptions of HCAs. Based on the findings of a larger qualitative study using a grounded theory approach, this paper addresses the topic of HCA-family relationships in…
Looking Under the Streetlight? A Framework for Differentiating Performance Measures by Level of Care in a Value-Based Payment Environment

PubMed Central

Van Such, Monica B.; Nesse, Robert E.; Dilling, James A.; Swensen, Stephen J.; Thompson, Kristine M.; Orlowski, Janis M.; Santrach, Paula J.

2017-01-01

The majority of quality measures used to assess providers and hospitals are based on easily obtained data, focused on a few dimensions of quality, and developed mainly for primary/community care and population health. While this approach supports efforts focused on addressing the triple aim of health care, many current quality report cards and assessments do not reflect the breadth or complexity of many referral center practices. In this article, the authors highlight the differences between population health efforts and referral care and address issues related to value measurement and performance assessment. They discuss why measures may need to differ across the three levels of care (primary/community care, secondary care, complex care) and illustrate the need for further risk adjustment to eliminate referral bias. With continued movement toward value-based purchasing, performance measures and reimbursement schemes need to reflect the increased level of intensity required to provide complex care. The authors propose a framework to operationalize value measurement and payment for specialty care, and they make specific recommendations to improve performance measurement for complex patients. Implementing such a framework to differentiate performance measures by level of care involves coordinated efforts to change both policy and operational platforms. An essential component of this framework is a new model that defines the characteristics of patients who require complex care and standardizes metrics that incorporate those definitions. PMID:28353502
Looking Under the Streetlight? A Framework for Differentiating Performance Measures by Level of Care in a Value-Based Payment Environment.

PubMed

Naessens, James M; Van Such, Monica B; Nesse, Robert E; Dilling, James A; Swensen, Stephen J; Thompson, Kristine M; Orlowski, Janis M; Santrach, Paula J

2017-07-01

The majority of quality measures used to assess providers and hospitals are based on easily obtained data, focused on a few dimensions of quality, and developed mainly for primary/community care and population health. While this approach supports efforts focused on addressing the triple aim of health care, many current quality report cards and assessments do not reflect the breadth or complexity of many referral center practices.In this article, the authors highlight the differences between population health efforts and referral care and address issues related to value measurement and performance assessment. They discuss why measures may need to differ across the three levels of care (primary/community care, secondary care, complex care) and illustrate the need for further risk adjustment to eliminate referral bias.With continued movement toward value-based purchasing, performance measures and reimbursement schemes need to reflect the increased level of intensity required to provide complex care. The authors propose a framework to operationalize value measurement and payment for specialty care, and they make specific recommendations to improve performance measurement for complex patients. Implementing such a framework to differentiate performance measures by level of care involves coordinated efforts to change both policy and operational platforms. An essential component of this framework is a new model that defines the characteristics of patients who require complex care and standardizes metrics that incorporate those definitions.
Patient-centred communication intervention study to evaluate nurse-patient interactions in complex continuing care

PubMed Central

2012-01-01

Background Communication impairment is a frequent consequence of stroke. Patients who cannot articulate their needs respond with frustration and agitation, resulting in poor optimization of post-stroke functions. A key component of patient-centred care is the ability of staff to communicate in a way that allows them to understand the patient’s needs. We developed a patient-centred communication intervention targeting registered and unregulated nursing staff caring for complex continuing care patients with communication impairments post stroke. Research objectives include 1) examining the effects of the intervention on patients’ quality of life, depression, satisfaction with care, and agitation; and (2) examining the extent to which the intervention improves staff’s attitudes and knowledge in caring for patients with communication impairments. The intervention builds on a previous pilot study. Methods/design A quasi-experimental repeated measures non-equivalent control group design in a complex continuing care facility is being used. Patients with a communication impairment post-stroke admitted to the facility are eligible to participate. All staff nurses are eligible. Baseline data are collected from staff and patients. Follow-up will occur at 1 and 3 months post-intervention. Subject recruitment and data collection from 60 patients and 30 staff will take approximately 36 months. The Patient-Centred Communication Intervention consists of three components: (1) development of an individualized patient communication care plan; (2) a one-day workshop focused on communication and behavioural management strategies for nursing staff; and (3) a staff support system. The intervention takes comprehensive patient assessments into account to inform the development of communication and behavioural strategies specifically tailored to each patient. Discussion The Patient-Centred Communication Intervention will provide staff with strategies to facilitate interactions with patients and to minimize agitation associated with considerable stress. The improvement of these interactions will lead to a reduction of agitation, which has the additional significance of increasing patients’ well-being, quality of life, and satisfaction with care. Trial registration ClinicalTrials.gov Identifier NCT01654029 PMID:23050517
Mental health services conceptualised as complex adaptive systems: what can be learned?

PubMed

Ellis, Louise A; Churruca, Kate; Braithwaite, Jeffrey

2017-01-01

Despite many attempts at promoting systems integration, seamless care, and partnerships among service providers and users, mental health services internationally continue to be fragmented and piecemeal. We exploit recent ideas from complexity science to conceptualise mental health services as complex adaptive systems (CASs). The core features of CASs are described and Australia's headspace initiative is used as an example of the kinds of problems currently being faced. We argue that adopting a CAS lens can transform services, creating more connected care for service users with mental health conditions.
Competence by Simulation: The Expert Nurse Continuing Education Experience Utilizing Simulation

ERIC Educational Resources Information Center

Underwood, Douglas W.

2013-01-01

Registered nurses practice in an environment that involves complex healthcare issues requiring continuous learning and evaluation of cognitive and technical skills to ensure safe and quality patient care. The purpose of this basic qualitative study was to gain a better understanding of the continuing educational needs of the expert nurse. This…
Complex Care Options for Patients With Advanced Heart Failure Approaching End of Life.

PubMed

Wordingham, Sara E; McIlvennan, Colleen K; Dionne-Odom, J Nicholas; Swetz, Keith M

2016-02-01

Care for patients with advanced cardiac disease continues to evolve in a complex milieu of therapeutic options, advanced technological interventions, and efforts at improving patient-centered care and shared decision-making. Despite improvements in quality of life and survival with these interventions, optimal supportive care across the advanced illness trajectory remains diverse and heterogeneous. Herein, we outline challenges in prognostication, communication, and caregiving in advanced heart failure and review the unique needs of patients who experience frequent hospitalizations, require chronic home inotropic support, and who have implantable cardioverter-defibrillators and mechanical circulatory support in situ, to name a few.
Becoming-Worker: Vocational Training for Workers in Aged Care

ERIC Educational Resources Information Center

Somerville, Margaret

2006-01-01

Women's care work sits on the boundary between unpaid work in the private domain and poorly paid, low-status work in the public sphere. It continues to be a site for the expression of complex, high-level knowledge and skills, and of ongoing gender oppression. The aged-care industry is a particularly salient example of such work. It is a…
Safety threats and opportunities to improve interfacility care transitions: insights from patients and family members.

PubMed

Jeffs, Lianne; Kitto, Simon; Merkley, Jane; Lyons, Renee F; Bell, Chaim M

2012-01-01

To explore patients' and family members' perspectives on how safety threats are detected and managed across care transitions and strategies that improve care transitions from acute care hospitals to complex continuing care and rehabilitation health care organizations. Poorly executed care transitions can result in additional health care spending due to adverse outcomes and delays as patients wait to transfer from acute care to facilities providing different levels of care. Patients and their families play an integral role in ensuring they receive safe care, as they are the one constant in care transitions processes. However, patients' and family members' perspectives on how safety threats are detected and managed across care transitions from health care facility to health care facility remain poorly understood. This qualitative study used semistructured interviews with patients (15) and family members (seven) who were transferred from an acute care hospital to a complex continuing care/rehabilitation care facility. Data were analyzed using a directed content analytical approach. OUR RESULTS REVEALED THREE KEY OVERARCHING THEMES IN THE PERCEPTIONS: lacking information, getting "funneled through" too soon, and difficulty adjusting to the shift from total care to almost self-care. Several patients and families described their expectations and experiences associated with their interfacility care transitions as being uninformed about their transfer or that transfer happened too early. In addition, study participants identified the need for having a coordinated approach to care transitions that engages patients and family members. Study findings provide patients' and family members' perspectives on key safety threats and how to improve care transitions. Of particular importance is the need for patients and family members to play a more active role in their care transition planning and self-care management.
[The Professional Practice of Midwives in Home-based Postnatal Care: A Literature Analysis].

PubMed

Simon, S; Schnepp, W; Zu Sayn-Wittgenstein, F

2017-02-01

Due to the reduction of the length of stay in hospital, postnatal care today takes place primarily in the ambulant sector. Midwives provide the health care and support young families. This literature study examines home-based postnatal care from the perspectives of midwives with the aim of exploring how midwives provide postnatal care and what influencing factors exist. A systematic literature search was conducted. Studies that integrated the perceptions of midwives during their work in home-based postpartum care were included. A thematic analysis of the selected articles was undertaken. Besides monitoring the health and well-being of mother and child, the focus of postnatal care is on psychosocial aspects and on support and advice on issues concerning the new situation and structural changes in the family. However, midwives do not always feel sufficiently prepared for dealing with complex psychosocial issues and require extra knowledge and better access to information. Besides temporal limitations of midwives, continuity of care as well as different care approaches are also relevant. Home-based postnatal care constitutes complex professional procedures during an important period of life of women and their families. Besides ensuring continuity of care, appropriate knowledge resources and midwifery skills are required. The development of theory-guided concepts, improved training and further training programmes as well as a clearly defined provider contract can support the professional behaviour patterns of midwives. © Georg Thieme Verlag KG Stuttgart · New York.
Genetics and Genomics of Acute Neurologic Disorders.

PubMed

Maserati, Megan; Alexander, Sheila A

2018-01-01

Neurologic diseases and injuries are complex and multifactorial, making risk prediction, targeted treatment modalities, and outcome prognostication difficult and elusive. Genetics and genomics have affected clinical practice in many aspects in medicine, particularly cancer treatment. Advancements in knowledge of genetic and genomic variability in neurologic disease and injury are growing rapidly. Although these data are not yet ready for use in clinical practice, research continues to progress and elucidate information that eventually will provide answers to complex neurologic questions and serve as a platform to provide individualized care plans aimed at improving outcomes. This article provides a focused review of relevant literature on genetics, genomics, and common complex neurologic disease and injury likely to be seen in the acute care setting. ©2018 American Association of Critical-Care Nurses.
Forced Separations and Forced Reunions in the Foster Care System

ERIC Educational Resources Information Center

Lillas, Constance M.; Langer, Lester; Drinane, Monica

2005-01-01

The juvenile court system has undergone tremendous changes over the past century, but much still needs to change in order to fully meet the complex needs of very young children. This article examines the challenges that the juvenile court system faces in preserving and supporting continuity of children's care in physically safe and…

Patient Experienced Continuity of Care in the Psychiatric Healthcare System—A Study Including Immigrants, Refugees and Ethnic Danes

PubMed Central

Jensen, Natasja Koitzsch; Johansen, Katrine Schepelern; Kastrup, Marianne; Krasnik, Allan; Norredam, Marie

2014-01-01

Aim: The purpose of this study was to investigate continuity of care in the psychiatric healthcare system from the perspective of patients, including vulnerable groups such as immigrants and refugees. Method: The study is based on 19 narrative interviews conducted with 15 patients with diverse migration backgrounds (immigrants, descendents, refugees, and ethnic Danes). Patients were recruited from a community psychiatric centre situated in an area with a high proportion of immigrants and refugees. Data were analysed through the lens of a theoretical framework of continuity of care in psychiatry, developed in 2004 by Joyce et al., which encompasses four domains: accessibility, individualised care, relationship base and service delivery. Results: Investigating continuity of care, we found issues of specific concern to immigrants and refugees, but also commonalities across the groups. For accessibility, areas pertinent to immigrants and refugees include lack of knowledge concerning mental illness and obligations towards children. In terms of individualised care, trauma, additional vulnerability, and taboo concerning mental illness were of specific concern. In the domain of service delivery, social services included assistance with immigration papers for immigrants and refugees. In the relationship base domain, no differences were identified. Implications for priority area: The treatment courses of patients in the psychiatric field are complex and diverse and the patient perspective of continuity of care provides important insight into the delivery of care. The study highlights the importance of person-centred care irrespective of migration background though it may be beneficial to have an awareness of areas that may be of more specific concern to immigrants and refugees. Conclusions: The study sheds light on concerns specific to immigrants and refugees in a framework of continuity of care, but also commonalities across the patient groups. PMID:25233017
Perspectives on the state-of-the-science in rehabilitation medicine and its implications for Medicare postacute care policies.

PubMed

Gage, Barbara; Stineman, Margaret; Deutsch, Anne; Mallinson, Trudy; Heinemann, Allen; Bernard, Shulamit; Constantine, Roberta

2007-12-01

Better measurement of the case-mix complexity of patients receiving rehabilitation services is critical to understanding variations in the outcomes achieved by patients treated in different postacute care (PAC) settings. The Medicare program recognized this issue and is undertaking a major initiative to develop a new patient-assessment instrument that would standardize case-mix measurement in inpatient rehabilitation facilities, long-term care hospitals, skilled nursing facilities, and home health agencies. The new instrument, called the Continuity Assessment Record and Evaluation Tool, builds on the scientific advances in measurement to develop standard measures of medical acuity, functional status, cognitive impairment, and social support related to resource need, outcomes, and continuity of care for use in all PAC settings.
Perspectives of policy and political decision makers on access to formal dementia care: expert interviews in eight European countries.

PubMed

Broda, Anja; Bieber, Anja; Meyer, Gabriele; Hopper, Louise; Joyce, Rachael; Irving, Kate; Zanetti, Orazio; Portolani, Elisa; Kerpershoek, Liselot; Verhey, Frans; Vugt, Marjolein de; Wolfs, Claire; Eriksen, Siren; Røsvik, Janne; Marques, Maria J; Gonçalves-Pereira, Manuel; Sjölund, Britt-Marie; Woods, Bob; Jelley, Hannah; Orrell, Martin; Stephan, Astrid

2017-08-03

As part of the ActifCare (ACcess to Timely Formal Care) project, we conducted expert interviews in eight European countries with policy and political decision makers, or representatives of relevant institutions, to determine their perspectives on access to formal care for people with dementia and their carers. Each ActifCare country (Germany, Ireland, Italy, The Netherlands, Norway, Portugal, Sweden, United Kingdom) conducted semi-structured interviews with 4-7 experts (total N = 38). The interview guide addressed the topics "Complexity and Continuity of Care", "Formal Services", and "Public Awareness". Country-specific analysis of interview transcripts used an inductive qualitative content analysis. Cross-national synthesis focused on similarities in themes across the ActifCare countries. The analysis revealed ten common themes and two additional sub-themes across countries. Among others, the experts highlighted the need for a coordinating role and the necessity of information to address issues of complexity and continuity of care, demanded person-centred, tailored, and multidisciplinary formal services, and referred to education, mass media and campaigns as means to raise public awareness. Policy and political decision makers appear well acquainted with current discussions among both researchers and practitioners of possible approaches to improve access to dementia care. Experts described pragmatic, realistic strategies to influence dementia care. Suggested innovations concerned how to achieve improved dementia care, rather than transforming the nature of the services provided. Knowledge gained in these expert interviews may be useful to national decision makers when they consider reshaping the organisation of dementia care, and may thus help to develop best-practice strategies and recommendations.
Reference centres for adults with rare and complex cancers - Policy recommendations to improve the organisation of care in Belgium.

PubMed

Stordeur, S; Vrijens, F; Leroy, R

2016-02-01

Rare and/or complex cancers call for a very specific expertise and adequate infrastructure. In Belgium, every hospital with a programme in oncology can deliver care for adults with rare and/or complex cancer types, without having demonstrated a specific know-how to adequately manage these patients. Therefore, the Minister of Health ordered a scenario for the organisation of care for adults with rare and/or complex cancers, taking into account the current Belgian situation and relevant foreign experience. Combined methods were used in this study: a literature review, the consultation of stakeholders, in depth discussions in 14 multidisciplinary groups leading to concrete proposals for several rare/complex cancers and the consultation of a panel of expert pathologists. The core recommendation is the set-up of shared care networks around reference centres, with multidisciplinary teams of recognised expertise in specific rare/complex cancers. The definition of minimum caseloads for hospitals and medical specialists, the evaluation of the quality of care, a model of diagnostic confirmation and the set-up of a national portal website which provides information on rare and/or complex cancers and reference centres are highly recommended. It is no longer practicable, efficient or ethical that every hospital or every practitioner continues to offer care for every rare/complex cancer. Improving the quality of rare/complex cancer care requires to concentrate expertise and sophisticated infrastructure in reference centres. Furthermore, the formation of networks between reference centres and peripheral centres will allow a delivery of care combining expertise and proximity. The next step is the translation of the recommendations into policy decisions. It is very well realised that this will take some courage and that a certain degree of resistance will have to be surmounted, but eventually, the best interest of the patient should prevail. Copyright © 2015 Elsevier Masson SAS. All rights reserved.
Incorporating Budget Impact Analysis in the Implementation of Complex Interventions: A Case of an Integrated Intervention for Multimorbid Patients within the CareWell Study.

PubMed

Soto-Gordoa, Myriam; Arrospide, Arantzazu; Merino Hernández, Marisa; Mora Amengual, Joana; Fullaondo Zabala, Ane; Larrañaga, Igor; de Manuel, Esteban; Mar, Javier

2017-01-01

To develop a framework for the management of complex health care interventions within the Deming continuous improvement cycle and to test the framework in the case of an integrated intervention for multimorbid patients in the Basque Country within the CareWell project. Statistical analysis alone, although necessary, may not always represent the practical significance of the intervention. Thus, to ascertain the true economic impact of the intervention, the statistical results can be integrated into the budget impact analysis. The intervention of the case study consisted of a comprehensive approach that integrated new provider roles and new technological infrastructure for multimorbid patients, with the aim of reducing patient decompensations by 10% over 5 years. The study period was 2012 to 2020. Given the aging of the general population, the conventional scenario predicts an increase of 21% in the health care budget for care of multimorbid patients during the study period. With a successful intervention, this figure should drop to 18%. The statistical analysis, however, showed no significant differences in costs either in primary care or in hospital care between 2012 and 2014. The real costs in 2014 were by far closer to those in the conventional scenario than to the reductions expected in the objective scenario. The present implementation should be reappraised, because the present expenditure did not move closer to the objective budget. This work demonstrates the capacity of budget impact analysis to enhance the implementation of complex interventions. Its integration in the context of the continuous improvement cycle is transferable to other contexts in which implementation depth and time are important. Copyright © 2017 International Society for Pharmacoeconomics and Outcomes Research (ISPOR). Published by Elsevier Inc. All rights reserved.
Primary care in an unstable security, humanitarian, economic and political context: the Kurdistan Region of Iraq.

PubMed

Shukor, Ali R; Klazinga, Niek S; Kringos, Dionne S

2017-08-23

This study presents a descriptive synthesis of Kurdistan Region of Iraq's (KRI) primary care system, which is undergoing comprehensive primary care reforms within the context of a cross-cutting structural economic adjustment program and protracted security, humanitarian, economic and political crises. The descriptive analysis used a framework operationalizing Starfield's classic primary care model for health services research. A scoping review was performed using relevant sources, and expert consultations were conducted for completing and validating data. The descriptive analysis presents a complex narrative of a primary care system undergoing classical developmental processes of transitioning middle-income countries. The system is simultaneously under tremendous pressure to adapt to the continuously changing, complex and resource-intensive needs of sub-populations exhibiting varying morbidity patterns, within the context of protracted security, humanitarian, economic, and political crises. Despite exhibiting significant resilience in the face of the ongoing crises, the continued influx of IDPs and Syrian refugees, coupled with extremely limited resources and weak governance at policy, organizational and clinical levels threaten the sustainability of KRI's public primary care system. Diverse trajectories to the strengthening and development of primary care are underway by local and international actors, notably the World Bank, RAND Corporation, UN organizations and USAID, focusing on varying imperatives related to the protracted humanitarian and economic crises. The convergence, interaction and outcomes of the diverse initiatives and policy approaches in relation to the development of KRI's primary care system are complex and highly uncertain. A common vision of primary care is required to align resources, initiatives and policies, and to enable synergy between all local and international actors involved in the developmental and humanitarian response. Further research that integrates the knowledge synthesized in this article, and enables actors in KRI to learn from their own experiences and efforts, along with those of other jurisdictions, would be invaluable towards the ongoing development of primary care.
Case Management for Patients with Complex Multimorbidity: Development and Validation of a Coordinated Intervention between Primary and Hospital Care

PubMed Central

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

2017-01-01

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

PubMed

Hoffmann, Michael; MacCarthy, Sarah; Batson, Ashley; Crawford-Roberts, Ann; Rasanathan, Jennifer; Nunn, Amy; Silva, Luis Augusto; Dourado, Ines

2016-01-01

Global and national HIV/AIDS policies utilize the care cascade to emphasize the importance of continued engagement in HIV services from diagnosis to viral suppression. Several studies have documented barriers that men experience in accessing services at specific stages of care, but few have analyzed how these barriers operate along the care cascade. Brazil offers a unique setting for analyzing barriers to HIV care because it is a middle-income country with a large HIV epidemic and free, universal access to HIV/AIDS services. Semi-structured interviews were conducted in 2011 with HIV-infected men (n = 25) receiving care at the only HIV/AIDS state reference center in Salvador, Brazil, the third largest city in the country. Interviews were transcribed and coded for analysis. Researchers identified barriers to services along the care cascade: health service-related obstacles (poor-quality care, lengthy wait times, and drug supply problems); psychosocial and emotional challenges (fear of disclosure and difficulty accepting HIV diagnosis); indirect costs (transportation and absenteeism at work or school); low perceived risk of HIV; and toxicity and complexity of antiretroviral drug (ARV) regimens. The stages of the care cascade interrupted by each barrier were also identified. Most barriers affected multiple, and often all, stages of care, while toxicity and complexity of ARV regimens was only present at a single care stage. Efforts to eliminate more prevalent barriers have the potential to improve care continuity at multiple stages. Going forward, assessing the relative impact of barriers along one's entire care trajectory can help tailor improvements in service provision, facilitate achievement of viral suppression, and improve access to life-saving testing, treatment, and care.
An Innovative Continuing Nursing Education Program Targeting Key Geriatric Conditions for Hospitalized Older People in China

ERIC Educational Resources Information Center

Xiao, Lily Dongxia; Shen, Jun; Wu, Haifeng; Ding, Fu; He, Xizhen; Zhu, Yueping

2013-01-01

A lack of knowledge in registered nurses about geriatric conditions is one of the major factors that contribute to these conditions being overlooked in hospitalized older people. In China, an innovative geriatric continuing nursing education program aimed at developing registered nurses' understanding of the complex care needs of hospitalized…
Suicide prevention: increasing education and awareness.

PubMed

Grandin, L D; Yan, L J; Gray, S M; Jamison, K R; Sachs, G S

2001-01-01

Suicide is a serious and complex public health problem. Health care providers, including both psychiatrists and primary care physicians, are just beginning to understand the intricacies involved in suicide and its prevention. Suicide rates continue to rise, making the education of the public and physicians regarding awareness and prevention, recognition of a wide range of risk factors, and research into suicide prevention strategies very important.
Continuous Palliative Sedation for Existential Distress? A Survey of Canadian Palliative Care Physicians' Views.

PubMed

Voeuk, Anna; Nekolaichuk, Cheryl; Fainsinger, Robin; Huot, Ann

2017-01-01

Palliative sedation can be used for refractory symptoms during end-of-life care. However, continuous palliative sedation (CPS) for existential distress remains controversial due to difficulty determining when this distress is refractory. The aim was to determine the opinions and practices of Canadian palliative care physicians regarding CPS for existential distress. A survey focusing on experience and views regarding CPS for existential distress was sent to 322 members of the Canadian Society of Palliative Care Physicians. Eighty-one surveys returned (accessible target, 314), resulting in a response rate of 26%. One third (31%) of the respondents reported providing CPS for existential distress. On a 5-point Likert-type scale, 40% of participants disagreed, while 43% agreed that CPS could be used for existential distress alone. Differing opinions exist regarding this complex and potentially controversial issue, necessitating the education of health-care professionals and increased awareness within the general public.
The changing flow of management information systems in long-term care facilities.

PubMed

Stokes, D F

1997-08-01

Over the past three decades, the long-term care community has seen continual increases in the complexity and sophistication of management information systems. These changes have been brought about by the ever-increasing demands on owners and managers to provide accurate and timely data to both regulators and financial investors. The evolution of these systems has increased rapidly in recent years as the nation attempts to reinvent the funding mechanisms for long-term care.
Exploration of funding models to support hybridisation of Australian primary health care organisations.

PubMed

Reddy, Sandeep

2017-09-01

Primary Health Care (PHC) funding in Australia is complex and fragmented. The focus of PHC funding in Australia has been on volume rather than comprehensive primary care and continuous quality improvement. As PHC in Australia is increasingly delivered by hybrid style organisations, an appropriate funding model that matches this set-up while addressing current issues with PHC funding is required. This article discusses and proposes an appropriate funding model for hybrid PHC organisations.
Relationship between women's characteristics and continuum of care for maternal health in Kenya: Complex survey analysis using structural equation modeling.

PubMed

Owili, Patrick Opiyo; Muga, Miriam Adoyo; Chou, Yiing-Jenq; Hsu, Yi-Hsin Elsa; Huang, Nicole; Chien, Li-Yin

2017-09-01

The objective of this study was to understand and estimate the complex relationships in the continuum of care for maternal health to provide information to improve maternal and newborn health outcomes. Women (n = 4,082) aged 15-49 years in the 2008/2009 Kenya Demographic and Health Survey data were used to explore the complex relationships in the continuum of care for maternal health (i.e., before, during, and after delivery) using structural equation modeling. Results showed that the use of antenatal care was significantly positively related to the use of delivery care (β = 0.06; adjusted odds ratio [AOR] = 1.06; 95% confidence interval [CI]: 1.02-1.10) but not postnatal care, while delivery care was associated with postnatal care (β = 0.68; AOR = 1.97; 95% CI: 1.75-2.22). Socioeconomic status was significantly related to all elements in the continuum of care for maternal health; barriers to delivery of care and personal characteristics were only associated with the use of delivery care (β = 0.34; AOR = 1.40; 95% CI: 1.30-1.52) and postnatal care (β = 0.03; AOR = 1.03; 95% CI: 1.01-1.05), respectively. The three periods of maternal health care were related to each other. Developing a referral system of continuity of care is critical in the Sustainable Development Goals era.
A cornerstone of healthy aging: do we need to rethink the concept of adherence in the elderly?

PubMed

Giardini, Anna; Maffoni, Marina; Kardas, Przemyslaw; Costa, Elisio

2018-01-01

Worldwide, the population is aging and this trend will increase in the future due to medical, technological and scientific advancements. To take care of the elderly is highly demanding and challenging for the health care system due to their frequent condition of chronicity, multimorbidity and the consequent complex management of polypharmacy. Nonadherence to medications and to medical plans is a well-recognized public health problem and a very urgent issue in this population. For this reason, some considerations to identify a new shared approach to integrated care of older people are described. The concept of adherence should be considered as a complex and continuous process where family, caregivers and patients' beliefs come into play. Moreover, a new culture of adherence should contemplate the complexity of multimorbidity, as well as the necessity to renegotiate the medication regimen on the basis of each patient's needs.
Road map to esophagectomy for nurses.

PubMed

Logue, Barbara; Griffin, Scott

2011-08-01

Esophageal cancer, although considered uncommon in the United States, continues to exhibit increased incidence. Esophageal cancer now ranks seventh among cancers in mortality for men in the United States. Even as treatment continues to advance, the mortality rate remains high, with a 5-year survival rate less than 35%. Esophageal cancer typically is discovered in advanced stages, which reduces the treatment options. When disease is locally advanced, esophagectomy remains the standard for treatment. Surgery remains challenging and complicated. Multiple surgical approaches are available, with the choice determined by tumor location and stage of disease. Recovery is often fraught with complications-both physical and emotional. Nursing care revolves around complex care managing multiple body systems and providing effective education and emotional support for both patients and patients' families. Even after recovery, local recurrence and distant metastases are common. Early diagnosis, surgical advancement, and improvements in postoperative care continue to improve outcomes.
Patient care information systems and physicians: the transition from technology icon to health care instrument.

PubMed

Bria, W F

1993-11-01

We have discussed several important transitions now occurring in PCIS that promise to improve the utility and availability of these systems for the average physician. Charles Babbage developed the first computers as "thinking machines" so that we may extend our ability to grapple with more and more complex problems. If current trends continue, we will finally witness the evolution of patient care computing from information icons of the few to clinical instruments improving the quality of medical decision making and care for all patients.
The Roles of Chronic Disease Complexity, Health System Integration, and Care Management in Post-Discharge Healthcare Utilization in a Low-Income Population.

PubMed

Hewner, Sharon; Casucci, Sabrina; Castner, Jessica

2016-08-01

Economically disadvantaged individuals with chronic disease have high rates of in-patient (IP) readmission and emergency department (ED) utilization following initial hospitalization. The purpose of this study was to explore the relationships between chronic disease complexity, health system integration (admission to accountable care organization [ACO] hospital), availability of care management interventions (membership in managed care organization [MCO]), and 90-day post-discharge healthcare utilization. We used de-identified Medicaid claims data from two counties in western New York. The study population was 114,295 individuals who met inclusion criteria, of whom 7,179 had index hospital admissions in the first 9 months of 2013. Individuals were assigned to three disease complexity segments based on presence of 12 prevalent conditions. The 30-day inpatient (IP) readmission rates ranged from 6% in the non-chronic segment to 12% in the chronic disease complexity segment and 21% in the organ system failure complexity segment. Rehospitalization rates (both inpatient and emergency department [ED]) were lower for patients in MCOs and ACOs than for those in fee-for-service care. Complexity of chronic disease, initial hospitalization in a facility that was part of an ACO, MCO membership, female gender, and longer length of stay were associated with a significantly longer time to readmission in the first 90 days, that is, fewer readmissions. Our results add to evidence that high-value post-discharge utilization (fewer IP or ED rehospitalizations and early outpatient follow-up) require population-based transitional care strategies that improve continuity between settings and take into account the illness complexity of the Medicaid population. © 2016 Wiley Periodicals, Inc. © 2016 Wiley Periodicals, Inc.
Leveraging data to systematically improve care: coronary artery disease management at Geisinger.

PubMed

Graf, Thomas; Erskine, Alistair; Steele, Glenn D

2014-01-01

Coronary artery disease is complex chronic disease best managed by a team empowered by actionable data and a comprehensive approach, the ability to improve intermediate outcomes was dramatically enhanced after Geisinger created a system of care to do so. Continuous measurement of critical data elements of process and intermediate outcome measures allows the delivery of actionable information to the most appropriate team member, including the patients and family as team members. Continuous monitoring of the overall program looking for trends and opportunities across sites and regions allows for program enhancements. The comprehensive "all-or-none" bundled approach to care, which has already realized a 300% improvement, will be further enhanced by incorporating additional "Big Data" flows.
The continuing care retirement community executive: a manager for all seasons.

PubMed

Hurley, R E; Brewer, K P

1991-01-01

The continuing care retirement community industry is a growing source of residential and health care services for the elderly population. It is also a relatively new and expanding career path for both health care and hospitality managers. Using in-depth interviews with executives in a sample of 26 communities, this study provides one of the most complete portraits to date of the nature of managing these communities. The findings indicate that these organizations are complex and multifaceted, demanding versatile skills and abilities. Most critical are those skills that enable a manager to interact effectively with residents and staff to build and maintain a hospitable, accommodating community environment. As competition in the industry intensifies, community viability may become synonymous with customer satisfaction. Management training and development will need to be highly attentive to the distinctive features of these intriguing organizations.

Psychiatric and addiction consultation for patients in critical care.

PubMed

Kaiser, Susan

2012-03-01

Practicing within the paradigm of compartmentalized specially treatment without a collaborative practice is ineffective for the chemical dependency and dual diagnosis population. Chemical dependency is not well understood as a disease, evidenced by barriers cited from the 2005 Survey on Drug Use and Health. Recovery from addiction and dual diagnosis logically demands an integrated and science-based treatment approach with unified standards for care and improved educational standards for preparation of care providers. Consultation and collaboration with addiction and psychiatric specialists is needed to establish consistency in standards for treatment and holistic care, essential for comorbidity. Continued learning and research about the complexity of the addiction process and comorbidity will provide continued accurate information about the harmful effects of alcoholism and drug abuse which in turn will empower individuals to make informed choices and result in better treatment and social policies.
The component alignment model: a new approach to health care information technology strategic planning.

PubMed

Martin, J B; Wilkins, A S; Stawski, S K

1998-08-01

The evolving health care environment demands that health care organizations fully utilize information technologies (ITs). The effective deployment of IT requires the development and implementation of a comprehensive IT strategic plan. A number of approaches to health care IT strategic planning exist, but they are outdated or incomplete. The component alignment model (CAM) introduced here recognizes the complexity of today's health care environment, emphasizing continuous assessment and realignment of seven basic components: external environment, emerging ITs, organizational infrastructure, mission, IT infrastructure, business strategy, and IT strategy. The article provides a framework by which health care organizations can develop an effective IT strategic planning process.
[A MODEL OF COMPREHENSIVE CARE FOR COMPLEX CHRONIC PATIENT. EXPERIENCE OF A TERRITORY].

PubMed

Torres, Montserrat; Fabrellas, Núria; Solà, Montserrat; Rubio Merchán, Antonia; Camañes Garcia, Neus; Berlanga, Sofía

2015-03-01

The Increase in life expectancy has brought an increase in chronic diseases. The evolution of chronic disease is the cause of several organic and systemic dysfunctions, leading to physical and mental limitations that determine the need for some aid to perform basic vital tasks. Primary health care has a key role in the monitoring of fragility, chronicity, and complexity of population. However, in order to address properly high complexity diseases it is necessary to know and coordinate the different resources existing inside the territory. THE DEVELOPMENT OF THE MODEL FOR ACTION: THE IMPLEMENTATIONS OF A FUNCTIONAL UNIT. The Primary Health Care must ensure equity, accessibility, longitudinally, and continuity of care, bearing in mind that health outcomes must be optimal. There are several health care providers in the Delta del Llobregat SAP, so it was implemented a strategic plan focused on the coordination and/or the reconciliation of all the devices involved in the assistance in order to provide comprehensive attention to the patient. The patients included in this program were to be identified as CCP (Complex chronic Patient), in an evolved and tributary phase of intensive follow-up. CONCLUSIONS. The identification ofpatients listed as CCP and at clinical risk allows a comprehensive monitoring in order to prevent exacerbations and overuse of unscheduled hospital resources.
Integrality in Brazil and Venezuela: similarities and complementarities.

PubMed

Santos, Carla Targino Bruno Dos; Barros, Ione Silva; Amorim, Anne Caroline Coelho Leal Árias; Rocha, Dais Gonçalves; Mendonça, Ana Valéria Machado; Sousa, Maria Fátima de

2018-04-01

This study aims to compare Primary Health Care (PHC) in Brazil and Venezuela, considering its characteristics as to integrality. It has a qualitative approach, using documental analysis, semi-structured interviews with key informants and field diary notes. We observed the three realms of integrality inherent to the health work process: comprehensive and holistic care, the individual viewed as a complex being with multiple needs, requiring the connection of various health knowledge; continuity of care in institutional micro-policy with interprofessional articulation, in order to consider individual care; continuity of care in macro-policy, when a shift to other levels of care is needed; intersectoriality was also included, when the needs of an individual and community require a cross-sectoral coordination, with action on determinants and conditionants of the health-disease process. It is worth highlighting the natural tendency to include a comprehensive community medical training. We conclude that those countries strengthened by democracy draw their integrality practices closer, as well as the construction of social and health policies for underprivileged populations to achieve equity.
The Future of Interprofessional Education and Practice for Dentists and Dental Education.

PubMed

Andrews, Elizabeth A

2017-08-01

In the ever-changing landscape of education, health professions programs must be adaptable and forward-thinking. Programs need to understand the services students should be educated to provide over the next 25 years. The movement to increase collaboration among health professionals to improve health care outcomes is a significant priority for all health professions. Complex medical issues frequently seen in patients can best be addressed with interprofessional health care teams. Training future health care providers to work in such teams facilitates collaborative care and can result in improved outcomes for patients. What skills will dental students need in 2040 to practice as part of these interprofessional teams? Important skills needed for success are collaboration, communication, professionalism, and the ability to manage medically complex patients. These abilities are in alignment with the four Interprofessional Education Collaborative (IPEC) core competency domains and will continue to be key skills necessary in the future. Transitioning to a one university approach for preclinical and clinical training along with development of an all-inclusive electronic health record will drive this model forward. Faculty training and continuing education for clinicians, residents, and allied health providers will be necessary for comprehensive adoption of a team-based collaborative care system. With the health care delivery system moving towards more patient-centered, team-based care, interprofessional education helps future clinicians develop into confident team members who will lead health care into the future and produce better patient outcomes. This article was written as part of the project "Advancing Dental Education in the 21 st Century."
Using the balanced scorecard to align strategy and performance in long-term care.

PubMed

Macdonald, M

1998-01-01

The Sisters of Charity of Ottawa Health Service (SCOHS) is a Canadian health care corporation that has adapted Kaplan and Norton's balanced scorecard to enhance strategic management and measurement in a multisite health care facility comprising long term care, continuing complex care, rehabilitative services, palliative care and ambulatory care. This article discusses how the SCOHS has incorporated the following principles into the balanced scorecard: demonstration of cause and effect; inclusion of outcomes and performance drivers; linkage to fiscal and utilization indicators; and integration of the mission and values of the organization. Examples of corporate level outcomes and performance measures are provided in the form of lead and lag indicators.
Complexity leadership: a healthcare imperative.

PubMed

Weberg, Dan

2012-01-01

The healthcare system is plagued with increasing cost and poor quality outcomes. A major contributing factor for these issues is that outdated leadership practices, such as leader-centricity, linear thinking, and poor readiness for innovation, are being used in healthcare organizations. Complexity leadership theory provides a new framework with which healthcare leaders may practice leadership. Complexity leadership theory conceptualizes leadership as a continual process that stems from collaboration, complex systems thinking, and innovation mindsets. Compared to transactional and transformational leadership concepts, complexity leadership practices hold promise to improve cost and quality in health care. © 2012 Wiley Periodicals, Inc.
Risks and benefits of citrate anticoagulation for continuous renal replacement therapy.

PubMed

Shum, H P; Yan, W W; Chan, T M

2015-04-01

Heparin, despite its significant side-effects, is the most commonly used anticoagulant for continuous renal replacement therapy in critical care setting. In recent years, citrate has gained much popularity by improving continuous renal replacement therapy circuit survival and decreasing blood transfusion requirements. However, its complex metabolic consequences warrant modification in the design of the citrate-based continuous renal replacement therapy protocol. With thorough understanding of the therapeutic mechanism of citrate, a simple and practicable protocol can be devised. Citrate-based continuous renal replacement therapy can be safely and widely used in the clinical setting with appropriate clinical staff training.
Deprivation and quality of primary care services: evidence for persistence of the inverse care law from the UK Quality and Outcomes Framework.

PubMed

McLean, G; Sutton, M; Guthrie, B

2006-11-01

To examine whether the quality of primary care measured by the 2004 contract varies with socioeconomic deprivation. Retrospective analysis of publicly available data, comparing quality indicators used for payment that allow exclusion of patients (payment quality) and indicators based on the care delivered to all patients (delivered quality). 1024 general practices in Scotland. Regression coefficients summarising the relationships between deprivation and payment and delivered quality. Little systematic association is found between payment quality and deprivation but, for 17 of the 33 indicators examined, delivered quality falls with increasing deprivation. Absolute differences in delivered quality are small for most simpler process measures, such as recording of smoking status or blood pressure. Greater inequalities are seen for more complex process measures such as diagnostic procedures, some intermediate outcome measures such as glycaemic control in diabetes and measures of treatment such as influenza immunisation. The exclusions system succeeds in not penalising practices financially for the characteristics of the population they serve, but does not reward the additional work required in deprived areas and contributes to a continuation of the inverse care law. The contract data collected prevent examination of most complex process or treatment measures and this analysis is likely to underestimate the extent of continuing inequalities in care. Broader lessons cannot be drawn on the effect on inequalities of this new set of incentives until changes are made to the way contract data are collected and analysed.
Primary Care Practice Transformation Is Hard Work

PubMed Central

Crabtree, Benjamin F.; Nutting, Paul A.; Miller, William L.; McDaniel, Reuben R.; Stange, Kurt C.; Jaén, Carlos Roberto; Stewart, Elizabeth

2010-01-01

Background Serious shortcomings remain in clinical care in the United States despite widespread use of improvement strategies for enhancing clinical performance based on knowledge transfer approaches. Recent calls to transform primary care practice to a patient-centered medical home present even greater challenges and require more effective approaches. Methods Our research team conducted a series of National Institutes of Health funded descriptive and intervention projects to understand organizational change in primary care practice settings, emphasizing a complexity science perspective. The result was a developmental research effort that enabled the identification of critical lessons relevant to enabling practice change. Results A summary of findings from a 15-year program of research highlights the limitations of viewing primary care practices in the mechanistic terms that underlie current or traditional approaches to quality improvement. A theoretical perspective that views primary care practices as dynamic complex adaptive systems with “agents” who have the capacity to learn, and the freedom to act in unpredictable ways provides a better framework for grounding quality improvement strategies. This framework strongly emphasizes that quality improvement interventions should not only use a complexity systems perspective, but also there is a need for continual reflection, careful tailoring of interventions, and ongoing attention to the quality of interactions among agents in the practice. Conclusions It is unlikely that current strategies for quality improvement will be successful in transforming current primary care practice to a patient-centered medical home without a stronger guiding theoretical foundation. Our work suggests that a theoretical framework guided by complexity science can help in the development of quality improvement strategies that will more effectively facilitate practice change. PMID:20856145
42 CFR 482.51 - Condition of participation: Surgical services.

Code of Federal Regulations, 2014 CFR

2014-10-01

... HUMAN SERVICES (CONTINUED) STANDARDS AND CERTIFICATION CONDITIONS OF PARTICIPATION FOR HOSPITALS... surgical services, the services must be well organized and provided in accordance with acceptable standards... with inpatient care in accordance with the complexity of services offered. (a) Standard: Organization...
42 CFR 482.51 - Condition of participation: Surgical services.

Code of Federal Regulations, 2013 CFR

2013-10-01

... HUMAN SERVICES (CONTINUED) STANDARDS AND CERTIFICATION CONDITIONS OF PARTICIPATION FOR HOSPITALS... surgical services, the services must be well organized and provided in accordance with acceptable standards... with inpatient care in accordance with the complexity of services offered. (a) Standard: Organization...
42 CFR 482.51 - Condition of participation: Surgical services.

Code of Federal Regulations, 2011 CFR

2011-10-01

... HUMAN SERVICES (CONTINUED) STANDARDS AND CERTIFICATION CONDITIONS OF PARTICIPATION FOR HOSPITALS... surgical services, the services must be well organized and provided in accordance with acceptable standards... with inpatient care in accordance with the complexity of services offered. (a) Standard: Organization...
42 CFR 482.51 - Condition of participation: Surgical services.

Code of Federal Regulations, 2012 CFR

2012-10-01

... HUMAN SERVICES (CONTINUED) STANDARDS AND CERTIFICATION CONDITIONS OF PARTICIPATION FOR HOSPITALS... surgical services, the services must be well organized and provided in accordance with acceptable standards... with inpatient care in accordance with the complexity of services offered. (a) Standard: Organization...
Change management in an environment of ongoing primary health care system reform: A case study of Australian primary health care services.

PubMed

Javanparast, Sara; Maddern, Janny; Baum, Fran; Freeman, Toby; Lawless, Angela; Labonté, Ronald; Sanders, David

2018-01-01

Globally, health reforms continue to be high on the health policy agenda to respond to the increasing health care costs and managing the emerging complex health conditions. Many countries have emphasised PHC to prevent high cost of hospital care and improve population health and equity. The existing tension in PHC philosophies and complexity of PHC setting make the implementation and management of these changes more difficult. This paper presents an Australian case study of PHC restructuring and how these changes have been managed from the viewpoint of practitioners and middle managers. As part of a 5-year project, we interviewed PHC practitioners and managers of services in 7 Australian PHC services. Our findings revealed a policy shift away from the principles of comprehensive PHC including health promotion and action on social determinants of health to one-to-one disease management during the course of study. Analysis of the process of change shows that overall, rapid, and top-down radical reforms of policies and directions were the main characteristic of changes with minimal communication with practitioners and service managers. The study showed that services with community-controlled model of governance had more autonomy to use an emergent model of change and to maintain their comprehensive PHC services. Change is an inevitable feature of PHC systems continually trying to respond to health care demand and cost pressures. The implementation of change in complex settings such as PHC requires appropriate change management strategies to ensure that the proposed reforms are understood, accepted, and implemented successfully. Copyright © 2017 John Wiley & Sons, Ltd.
Working With Socially and Medically Complex Patients: When Care Transitions Are Circular, Overlapping, and Continual Rather Than Linear and Finite.

PubMed

Roberts, Shauna R; Crigler, Jane; Ramirez, Cristina; Sisco, Deborah; Early, Gerald L

2015-01-01

The care coordination program described here evolved from 5 years of trial and learning related to how to best serve our high-cost, high-utilizing, chronically ill, urban core patient population. In addition to medical complexity, they have daily challenges characteristic of persons served by Safety-Net health systems. Many have unstable health insurance status. Others have insecure housing. A number of patients have a history of substance use and mental illness. Many have fractured social supports. Although some of the best-known care transition models have been successful in reducing rehospitalizations and cost among patients studied, these models were developed for a relatively high functioning patient population with social support. We describe a successful approach targeted at working with patients who require a more intense and lengthy care coordination intervention to self-manage and reduce the cost of caring for their medical conditions. Using a diverse team and a set of replicable processes, we have demonstrated statistically significant reduction in the use of hospital and emergency services. Our intervention leverages the strengths and resilience of patients, focuses on trust and self-management, and targets heterogeneous "high-utilizer" patients with medical and social complexity.
Continuity in health care: lessons from supply chain management.

PubMed

Meijboom, Bert R; Bakx, Saskia J W G C; Westert, Gert P

2010-01-01

In health care, multidisciplinary collaboration is both indispensable and complicated. We discuss organizational problems that occur in situations where multiple health care providers are required to cooperate for patients with complex needs. Four problem categories, labelled as communication, patient safety, waiting times and integration are distinguished. Then we develop a supply chain perspective on these problems in the sense of discussing remedies according to supply chain management (SCM) literature. This perspective implies a business focus on inter-organizational conditions and requirements necessary for delivering health care and cure across organizational borders. We conclude by presenting some strategic and policy recommendations.
The coordination hub: Toward patient-centered and collaborative care processes.

PubMed

Winge, Monica; Johannesson, Paul; Perjons, Erik; Wangler, Benkt

2015-12-01

The organization and processes of today's health and social care are becoming ever more complex as a consequence of societal trends, including an aging population and an increased reliance on care at home. One aspect of the increased complexity is that a single patient may receive care from several care providers, which easily results in situations with potentially incoherent, uncoordinated, and interfering care processes. In order to describe and analyze such situations, the article introduces the notion of a process conglomeration. This is defined as a set of patient-care processes that all concern the same patient, that are overlapping in time, and that all are sharing the overall goal of improving or maintaining the health and social well-being of the patient. Problems and challenges of process conglomerations are investigated using coordination theory and models for continuous process improvement. In order to address the challenges, a solution is proposed in the form of a Coordination Hub, being an integrated software service that offers a number of information services for coordinating the activities of the processes in a process conglomeration. © The Author(s) 2014.
Interprofessional mental health training in rural primary care: findings from a mixed methods study.

PubMed

Heath, Olga; Church, Elizabeth; Curran, Vernon; Hollett, Ann; Cornish, Peter; Callanan, Terrence; Bethune, Cheri; Younghusband, Lynda

2015-05-01

The benefits of interprofessional care in providing mental health services have been widely recognized, particularly in rural communities where access to health services is limited. There continues to be a need for more continuing interprofessional education in mental health intervention in rural areas. There have been few reports of rural programs in which mental health content has been combined with training in collaborative practice. The current study used a sequential mixed-method and quasi-experimental design to evaluate the impact of an interprofessional, intersectoral education program designed to enhance collaborative mental health capacity in six rural sites. Quantitative results reveal a significant increase in positive attitudes toward interprofessional mental health care teams and self-reported increases in knowledge and understanding about collaborative mental health care delivery. The analysis of qualitative data collected following completion of the program, reinforced the value of teaching mental health content within the context of collaborative practice and revealed practice changes, including more interprofessional and intersectoral collaboration. This study suggests that imbedding explicit training in collaborative care in content focused continuing professional education for more complex and chronic health issues may increase the likelihood that professionals will work together to effectively meet client needs.
Information management for aged care provision in Australia: development of an aged care minimum dataset and strategies to improve quality and continuity of care.

PubMed

Davis, Jenny; Morgans, Amee; Burgess, Stephen

2016-04-01

Efficient information systems support the provision of multi-disciplinary aged care and a variety of organisational purposes, including quality, funding, communication and continuity of care. Agreed minimum data sets enable accurate communication across multiple care settings. However, in aged care multiple and poorly integrated data collection frameworks are commonly used for client assessment, government reporting and funding purposes. To determine key information needs in aged care settings to improve information quality, information transfer, safety, quality and continuity of care to meet the complex needs of aged care clients. Modified Delphi methods involving five stages were employed by one aged care provider in Victoria, Australia, to establish stakeholder consensus for a derived minimum data set and address barriers to data quality. Eleven different aged care programs were identified; with five related data dictionaries, three minimum data sets, five program standards or quality frameworks. The remaining data collection frameworks related to diseases classification, funding, service activity reporting, and statistical standards and classifications. A total of 170 different data items collected across seven internal information systems were consolidated to a derived set of 60 core data items and aligned with nationally consistent data collection frameworks. Barriers to data quality related to inconsistencies in data items, staff knowledge, workflow, system access and configuration. The development an internal aged care minimum data set highlighted the critical role of primary data quality in the upstream and downstream use of client information; and presents a platform to build national consistency across the sector.

Surgical data science: The new knowledge domain

PubMed Central

Vedula, S. Swaroop; Hager, Gregory D.

2017-01-01

Healthcare in general, and surgery/interventional care in particular, is evolving through rapid advances in technology and increasing complexity of care with the goal of maximizing quality and value of care. While innovations in diagnostic and therapeutic technologies have driven past improvements in quality of surgical care, future transformation in care will be enabled by data. Conventional methodologies, such as registry studies, are limited in their scope for discovery and research, extent and complexity of data, breadth of analytic techniques, and translation or integration of research findings into patient care. We foresee the emergence of Surgical/Interventional Data Science (SDS) as a key element to addressing these limitations and creating a sustainable path toward evidence-based improvement of interventional healthcare pathways. SDS will create tools to measure, model and quantify the pathways or processes within the context of patient health states or outcomes, and use information gained to inform healthcare decisions, guidelines, best practices, policy, and training, thereby improving the safety and quality of healthcare and its value. Data is pervasive throughout the surgical care pathway; thus, SDS can impact various aspects of care including prevention, diagnosis, intervention, or post-operative recovery. Existing literature already provides preliminary results suggesting how a data science approach to surgical decision-making could more accurately predict severe complications using complex data from pre-, intra-, and post-operative contexts, how it could support intra-operative decision-making using both existing knowledge and continuous data streams throughout the surgical care pathway, and how it could enable effective collaboration between human care providers and intelligent technologies. In addition, SDS is poised to play a central role in surgical education, for example, through objective assessments, automated virtual coaching, and robot-assisted active learning of surgical skill. However, the potential for transforming surgical care and training through SDS may only be realized through a cultural shift that not only institutionalizes technology to seamlessly capture data but also assimilates individuals with expertise in data science into clinical research teams. Furthermore, collaboration with industry partners from the inception of the discovery process promotes optimal design of data products as well as their efficient translation and commercialization. As surgery continues to evolve through advances in technology that enhance delivery of care, SDS represents a new knowledge domain to engineer surgical care of the future. PMID:28936475
Surgical data science: The new knowledge domain.

PubMed

Vedula, S Swaroop; Hager, Gregory D

2017-04-01

Healthcare in general, and surgery/interventional care in particular, is evolving through rapid advances in technology and increasing complexity of care with the goal of maximizing quality and value of care. While innovations in diagnostic and therapeutic technologies have driven past improvements in quality of surgical care, future transformation in care will be enabled by data. Conventional methodologies, such as registry studies, are limited in their scope for discovery and research, extent and complexity of data, breadth of analytic techniques, and translation or integration of research findings into patient care. We foresee the emergence of Surgical/Interventional Data Science (SDS) as a key element to addressing these limitations and creating a sustainable path toward evidence-based improvement of interventional healthcare pathways. SDS will create tools to measure, model and quantify the pathways or processes within the context of patient health states or outcomes, and use information gained to inform healthcare decisions, guidelines, best practices, policy, and training, thereby improving the safety and quality of healthcare and its value. Data is pervasive throughout the surgical care pathway; thus, SDS can impact various aspects of care including prevention, diagnosis, intervention, or post-operative recovery. Existing literature already provides preliminary results suggesting how a data science approach to surgical decision-making could more accurately predict severe complications using complex data from pre-, intra-, and post-operative contexts, how it could support intra-operative decision-making using both existing knowledge and continuous data streams throughout the surgical care pathway, and how it could enable effective collaboration between human care providers and intelligent technologies. In addition, SDS is poised to play a central role in surgical education, for example, through objective assessments, automated virtual coaching, and robot-assisted active learning of surgical skill. However, the potential for transforming surgical care and training through SDS may only be realized through a cultural shift that not only institutionalizes technology to seamlessly capture data but also assimilates individuals with expertise in data science into clinical research teams. Furthermore, collaboration with industry partners from the inception of the discovery process promotes optimal design of data products as well as their efficient translation and commercialization. As surgery continues to evolve through advances in technology that enhance delivery of care, SDS represents a new knowledge domain to engineer surgical care of the future.
Specialty-care access for community health clinic patients: processes and barriers.

PubMed

Ezeonwu, Mabel C

2018-01-01

Community health clinics/centers (CHCs) comprise the US's core health-safety net and provide primary care to anyone who walks through their doors. However, access to specialty care for CHC patients is a big challenge. In this descriptive qualitative study, semistructured interviews of 37 referral coordinators of CHCs were used to describe their perspectives on processes and barriers to patients' access to specialty care. Analysis of data was done using content analysis. The process of coordinating care referrals for CHC patients is complex and begins with a provider's order for consultation and ends when the referring provider receives the specialist's note. Poverty, specialist and referral coordinator shortages, lack of insurance, insurance acceptability by providers, transport and clinic-location factors, lack of clinic-hospital affiliations, and poor communication between primary and specialty providers constitute critical barriers to specialty-care access for patients. Understanding the complexities of specialty-care coordination processes and access helps determine the need for comprehensive and uninterrupted access to quality health care for vulnerable populations. Guaranteed access to primary care at CHCs has not translated into improved access to specialty care. It is critical that effective policies be pursued to address the barriers and minimize interruptions in care, and to ensure continuity of care for all patients needing specialty care.
Implementation of a Transdisciplinary Team for the Transition Support of Medically and Socially Complex Youth.

PubMed

Ciccarelli, Mary R; Gladstone, Erin B; Armstrong Richardson, Eprise A J

2015-01-01

This article reports the ongoing work of a statewide transition support program which serves youth ages 11 to 22 with medically complex conditions and socially complex lives. Seven years of transition support services have led to program evolution demonstrated via a descriptive summary of the patients along with both families' and primary care providers' responses to satisfaction surveys. An illustrative case is used to highlight the types of expertise needed in specialized transition service delivery for patients with significant complexity. The team's analysis of their transdisciplinary work processes further explains the work. Nearly three hundred youth with complex needs are served yearly. Families and primary care providers express high satisfaction with the support of the services. The case example shows the broad array of transition-specific services engaged beyond the usual skill set of pediatric or adult care coordination teams. Transdisciplinary team uses skills in collaboration, support, learning, and compromise within a trusting and respectful environment. They describe the shared responsibility and continuous learning of the whole team. Youth with complex medical conditions and complex social situations are at higher risk for problems during transition. Serving this population with a transdisciplinary model is time consuming and requires advanced expertise but, with those investments, we can meet the expectations of the youth, their families and primary care providers. Successful transdisciplinary teamwork requires sustained and focused investment. Further work is needed to describe the complexity of this service delivery along with distinct transition outcomes and costs comparisons. Copyright © 2015 Elsevier Inc. All rights reserved.
[EMOTIONAL MANAGEMENT AND CRITICAL THINKING IN THE AID RELATIONSHIP OF THE HOLISTIC CARE OF PALLIATIVE PATIENTS].

PubMed

De Blas Gómez, Irene; Rodríguez García, Marta

2015-05-01

To care for palliative patients is essential that healthcare professionals develop emotional competencies. This means acquiring the habit of self reflection and be emphatic with other people, in order to be able to identify the personal emotions of patients, family and team. Reflection involves a continuing effort to reason about aspects of professional practice, especially on issues as complex as suffering and death. Both reflective reasoning and emotional management are vital in an Aid Relationship. For nursing healthcare professionals, to care the emotional aspects means becoming aware of their own and others feelings, and get to understand and accept to handle them properly. Nursing actions involves many qualities of social competence, such as empathy, understanding, communication skills, honesty, flexibility and adaptability to the individual needs of people cared. In the context of palliative care patients and their families all these aspects are fundamental and are part of the same philosophy. Emotional education still remains a challenge in our profession both in the initial and continuing training.
Distribution of physical therapists working on public and private establishments in different levels of complexity of health care in Brazil.

PubMed

Costa, Larissa R; Costa, José L R; Oishi, Jorge; Driusso, Patricia

2012-01-01

The Brazilian Health System is organized on a regional and hierarchical form with three levels of complexity of health care. The Primary Care represents the first element of a continuing health care process, complemented by specialized actions. However, the centrality of the specialized care is still a problem in Brazil, especially in the private sector. Studies on the distribution of professionals in the health system allowing the formulation of appropriate policies are needed. To investigate the distribution of physical therapists in the levels of complexity of health care and between public and private establishments, according to data from the National Register of Health Service Providers (NRHSP). A descriptive cross-sectional study was performed considering NRHSP-national bank data collected in March 2010 and demographic census 2010 data. Data were analyzed through descriptive statistics techniques. We identified 53,181 registries of physical therapists, 60% linked to the private sector. Only 13% of all entries were linked to primary care. The predominance in specialized care occurred in the public sector (65%) and private sector (100%). The specialized establishments of private sector linked to the southeast region (16,043) were the main sites of physical therapists. Only the public sector in the south had a majority in the Primary Care. When considering the sizes of the cities, there is focus on specialist care in bigger cities. This study identified the concentration of physical therapists in the specialized care, mostly in metropolis and big cities and in the private sector, with restricted to participation in the primary care.
Automatic flexible endoscope reprocessors.

PubMed

Muscarella, L F

2000-04-01

Reprocessing medical instruments is a complex and controversial discipline. If all instruments were constructed of materials not damaged by heat, pressure, and moisture, instrument reprocessing would be greatly simplified. As the number of novel and complex instruments entering the market continues to increase, periodic review of the health care facility's instrument reprocessing protocols to ensure their safety and effectiveness is important. This article reviews the advantages and the limitations of automatic flexible endoscope reprocessors.
Understanding the complexity of redesigning care around the clinical microsystem.

PubMed

Barach, P; Johnson, J K

2006-12-01

The microsystem is an organizing design construct in which social systems cut across traditional discipline boundaries. Because of its interdisciplinary focus, the clinical microsystem provides a conceptual and practical framework for simplifying complex organizations that deliver care. It also provides an important opportunity for organizational learning. Process mapping and microworld simulation may be especially useful for redesigning care around the microsystem concept. Process mapping, in which the core processes of the microsystem are delineated and assessed from the perspective of how the individual interacts with the system, is an important element of the continuous learning cycle of the microsystem and the healthcare organization. Microworld simulations are interactive computer based models that can be used as an experimental platform to test basic questions about decision making misperceptions, cause-effect inferences, and learning within the clinical microsystem. Together these tools offer the user and organization the ability to understand the complexity of healthcare systems and to facilitate the redesign of optimal outcomes.
'I don't know how we coped before': a study of respite care for children in the home and hospice.

PubMed

Eaton, Nicola

2008-12-01

To describe the experiences of families, whose children have life-limiting and life-threatening conditions and who have complex healthcare needs, of receiving respite care at home or in a hospice. Respite provision is an extremely important service in assisting families to cope with the extra stresses and problems of coping with children with complex healthcare needs. There are different issues when the venue is home or a hospice. Semi-structured interviews were carried out with families of children with complex healthcare needs, receiving respite care at home or in a hospice. A convenience sample of 11 families was interviewed using an interview schedule, exploring their experiences of the service and their views on the service. The areas of concern identified as significant to all the families were referral to respite service, service organisation, communication, relinquishing control to respite carers and satisfaction with service. Within the provision of respite care, there needs to be more overt referral systems and criteria, negotiation of appropriate roles, continuity of care, regular assessment of need and acknowledgement of the difficulty, which parents have in relinquishing control to respite carers. High-quality respite care for families involves more than just organising a respite session. Healthcare professionals organising and providing care could manage a service more effectively, if taking the above issues into consideration.
The business of palliative medicine--part 6: clinical operations in a comprehensive integrated program.

PubMed

Lagman, Ruth L; Walsh, Declan; LeGrand, Susan B; Davis, Mellar P

2011-03-01

The medical care of individuals with advanced disease is complex and has historically been fragmented and suboptimal. Palliative medicine attempts to address these needs. The Harry R. Horvitz Center for Palliative Medicine at the Cleveland Clinic is an established comprehensive integrated program. Structured and seamless clinical operations are important to ensure the best delivery of high-quality medical care and continuity for those affected by life-limiting illness.
The power of partnership to shape the future of nursing: the evolution of the clinical nurse leader.

PubMed

Tornabeni, Jolene; Miller, Judith Fitzgerald

2008-07-01

This article describes the evolution of the clinical nurse leader role and demonstrates the vital nature of partnerships between academia and practice in the design and implementation of this new role. The health care system as it exists in the United States may put patients at risk in terms of safety and quality of care. Nursing leadership from across the US recognized a need for nursing practice and academia to work in partnership to develop workable and effective solutions. The vision was of a nurse generalist who would be prepared to address the complexities that make the current systems dysfunctional. Review, share experiences and discuss the benefits of engaging stakeholders with broad and diverse viewpoints. Engaging a group of stakeholders with diverse backgrounds, varied world views and experiences for the purpose of developing common mutually beneficial goals, creates synergy and greater commitment to the goals, which results in success. The power of partnership in the development and implementation of the CNL is evident. Old ways of trying to 'go it alone' are no longer viable in a complex health care environment. With continued collaboration, practice and academia can continue to confront challenges and develop effective solutions.
Can complexity science inform physician leadership development?

PubMed

Grady, Colleen Marie

2016-07-04

Purpose The purpose of this paper is to describe research that examined physician leadership development using complexity science principles. Design/methodology/approach Intensive interviewing of 21 participants and document review provided data regarding physician leadership development in health-care organizations using five principles of complexity science (connectivity, interdependence, feedback, exploration-of-the-space-of-possibilities and co-evolution), which were grouped in three areas of inquiry (relationships between agents, patterns of behaviour and enabling functions). Findings Physician leaders are viewed as critical in the transformation of healthcare and in improving patient outcomes, and yet significant challenges exist that limit their development. Leadership in health care continues to be associated with traditional, linear models, which are incongruent with the behaviour of a complex system, such as health care. Physician leadership development remains a low priority for most health-care organizations, although physicians admit to being limited in their capacity to lead. This research was based on five principles of complexity science and used grounded theory methodology to understand how the behaviours of a complex system can provide data regarding leadership development for physicians. The study demonstrated that there is a strong association between physician leadership and patient outcomes and that organizations play a primary role in supporting the development of physician leaders. Findings indicate that a physician's relationship with their patient and their capacity for innovation can be extended as catalytic behaviours in a complex system. The findings also identified limiting factors that impact physicians who choose to lead, such as reimbursement models that do not place value on leadership and medical education that provides minimal opportunity for leadership skill development. Practical Implications This research provides practical applications for physician leadership development and emphasizes that it is incumbent upon physicians and organizations to focus attention on this to achieve improved patient and organizational outcomes. Originality/value This study pairing complexity science and physician leadership represents a unique way to view the development of physician leaders within the context of the complex system that is health care.
Nurse retention in a correctional facility: a study of the relationship between the nurses' perceived barriers and benefits.

PubMed

Chafin, W Sue; Biddle, Wendy L

2013-04-01

Retention of nursing staff is more complex in a correctional facility. After a period of 3 years, only 20% of the staff remained employed at this study facility. Without retention of qualified correctional nurses, there are decreases in access to care, gaps in continuity of care, and less time for mentorship. Trained correctional nurses improve patient and staff safety, provide more education, and are more team-oriented. The purpose of this study was to identify barriers and benefits to nursing staff satisfaction with their job and the likelihood that they will continue to work in correctional settings. Practice and patient care will be favorably impacted if correctional nurses are provided with services such as new hire orientation, clinical ladder programs to recruit and retain nursing staff, and teambuilding.
Ambient-aware continuous care through semantic context dissemination.

PubMed

Ongenae, Femke; Famaey, Jeroen; Verstichel, Stijn; De Zutter, Saar; Latré, Steven; Ackaert, Ann; Verhoeve, Piet; De Turck, Filip

2014-12-04

The ultimate ambient-intelligent care room contains numerous sensors and devices to monitor the patient, sense and adjust the environment and support the staff. This sensor-based approach results in a large amount of data, which can be processed by current and future applications, e.g., task management and alerting systems. Today, nurses are responsible for coordinating all these applications and supplied information, which reduces the added value and slows down the adoption rate.The aim of the presented research is the design of a pervasive and scalable framework that is able to optimize continuous care processes by intelligently reasoning on the large amount of heterogeneous care data. The developed Ontology-based Care Platform (OCarePlatform) consists of modular components that perform a specific reasoning task. Consequently, they can easily be replicated and distributed. Complex reasoning is achieved by combining the results of different components. To ensure that the components only receive information, which is of interest to them at that time, they are able to dynamically generate and register filter rules with a Semantic Communication Bus (SCB). This SCB semantically filters all the heterogeneous care data according to the registered rules by using a continuous care ontology. The SCB can be distributed and a cache can be employed to ensure scalability. A prototype implementation is presented consisting of a new-generation nurse call system supported by a localization and a home automation component. The amount of data that is filtered and the performance of the SCB are evaluated by testing the prototype in a living lab. The delay introduced by processing the filter rules is negligible when 10 or fewer rules are registered. The OCarePlatform allows disseminating relevant care data for the different applications and additionally supports composing complex applications from a set of smaller independent components. This way, the platform significantly reduces the amount of information that needs to be processed by the nurses. The delay resulting from processing the filter rules is linear in the amount of rules. Distributed deployment of the SCB and using a cache allows further improvement of these performance results.
Integrating Social Determinants of Health into Primary Care Clinical and Informational Workflow during Care Transitions

PubMed Central

Hewner, Sharon; Casucci, Sabrina; Sullivan, Suzanne; Mistretta, Francine; Xue, Yuqing; Johnson, Barbara; Pratt, Rebekah; Lin, Li; Fox, Chester

2017-01-01

Context: Care continuity during transitions between the hospital and home requires reliable communication between providers and settings and an understanding of social determinants that influence recovery. Case Description: The coordinating transitions intervention uses real time alerts, delivered directly to the primary care practice for complex chronically ill patients discharged from an acute care setting, to facilitate nurse care coordinator led telephone outreach. The intervention incorporates claims-based risk stratification to prioritize patients for follow-up and an assessment of social determinants of health using the Patient-centered Assessment Method (PCAM). Results from transitional care are stored and transmitted to qualified healthcare providers across the continuum. Findings: Reliance on tools that incorporated interoperability standards facilitated exchange of health information between the hospital and primary care. The PCAM was incorporated into both the clinical and informational workflow through the collaboration of clinical, industry, and academic partners. Health outcomes improved at the study practice over their baseline and in comparison with control practices and the regional Medicaid population. Major Themes: Current research supports the potential impact of systems approaches to care coordination in improving utilization value after discharge. The project demonstrated that flexibility in developing the informational and clinical workflow was critical in developing a solution that improved continuity during transitions. There is additional work needed in developing managerial continuity across settings such as shared comprehensive care plans. Conclusions: New clinical and informational workflows which incorporate social determinant of health data into standard practice transformed clinical practice and improved outcomes for patients.
Patient Loyalty in a Mature IDS Market: Is Population Health Management Worth It?

PubMed Central

Carlin, Caroline S

2014-01-01

Objective To understand patient loyalty to providers over time, informing effective population health management. Study Setting Patient care-seeking patterns over a 6-year timeframe in Minnesota, where care systems have a significant portion of their revenue generated by shared-saving contracts with public and private payers. Study Design Weibull duration and probit models were used to examine patterns of patient attribution to a care system and the continuity of patient affiliation with a care system. Clustering of errors within family unit was used to account for within-family correlation in unobserved characteristics that affect patient loyalty. Data Collection The payer provided data from health plan administrative files, matched to U.S. Census-based characteristics of the patient's neighborhood. Patients were retrospectively attributed to health care systems based on patterns of primary care. Principal Findings I find significant patient loyalty, with past loyalty a very strong predictor of future relationship. Relationships were shorter when the patient's health status was complex and when the patient's care system was smaller. Conclusions Population health management can be beneficial to the care system making this investment, particularly for patients exhibiting prior continuity in care system choice. The results suggest that co-located primary and specialty services are important in maintaining primary care loyalty. PMID:24461030
Holistic Care for Patients During Weaning from Mechanical Ventilation: A Qualitative Study

PubMed Central

Khalafi, Ali; Elahi, Nasrin; Ahmadi, Fazlollah

2016-01-01

Background Weaning patients from mechanical ventilation is a complex and highly challenging process. It requires continuity of care, the overall assessment of patients, and a focus on all aspects of patients’ needs by critical care nurses. Objectives The aim of the present study was to explore holistic care while patients are being weaned from mechanical ventilation from the perspective of the critical care nurses. Methods The study was carried out in the intensive care units (ICUs) of six hospitals in Ahvaz, Iran, from 2014 to 2015. In this qualitative study, 25 ICU staff including nurses, nurse managers, and nurse educators were selected by means of purposive sampling. Semi-structured interviews were used for data collection. The interview transcripts were then analyzed using qualitative content analysis. Results The four main themes that emerged to explain nurses’ experiences of holistic care when weaning patients from mechanical ventilation include continuous care, a holistic overview of the patient, promoting human dignity, and the overall development of well-being. Conclusions It was found that avoiding routine pivotal expertise, increasing consciousness of the nonphysical aspects of patients while providing treatment and presenting exclusive care, utilizing experienced ICU nurses, and placing more emphasis on effective communication with patients in order to honor them as human beings can all enhance the holistic quality of care. PMID:28191345
Holistic Care for Patients During Weaning from Mechanical Ventilation: A Qualitative Study.

PubMed

Khalafi, Ali; Elahi, Nasrin; Ahmadi, Fazlollah

2016-11-01

Weaning patients from mechanical ventilation is a complex and highly challenging process. It requires continuity of care, the overall assessment of patients, and a focus on all aspects of patients' needs by critical care nurses. The aim of the present study was to explore holistic care while patients are being weaned from mechanical ventilation from the perspective of the critical care nurses. The study was carried out in the intensive care units (ICUs) of six hospitals in Ahvaz, Iran, from 2014 to 2015. In this qualitative study, 25 ICU staff including nurses, nurse managers, and nurse educators were selected by means of purposive sampling. Semi-structured interviews were used for data collection. The interview transcripts were then analyzed using qualitative content analysis. The four main themes that emerged to explain nurses' experiences of holistic care when weaning patients from mechanical ventilation include continuous care, a holistic overview of the patient, promoting human dignity, and the overall development of well-being. It was found that avoiding routine pivotal expertise, increasing consciousness of the nonphysical aspects of patients while providing treatment and presenting exclusive care, utilizing experienced ICU nurses, and placing more emphasis on effective communication with patients in order to honor them as human beings can all enhance the holistic quality of care.
Patient loyalty in a mature IDS market: is population health management worth it?

PubMed

Carlin, Caroline S

2014-06-01

To understand patient loyalty to providers over time, informing effective population health management. Patient care-seeking patterns over a 6-year timeframe in Minnesota, where care systems have a significant portion of their revenue generated by shared-saving contracts with public and private payers. Weibull duration and probit models were used to examine patterns of patient attribution to a care system and the continuity of patient affiliation with a care system. Clustering of errors within family unit was used to account for within-family correlation in unobserved characteristics that affect patient loyalty. The payer provided data from health plan administrative files, matched to U.S. Census-based characteristics of the patient's neighborhood. Patients were retrospectively attributed to health care systems based on patterns of primary care. I find significant patient loyalty, with past loyalty a very strong predictor of future relationship. Relationships were shorter when the patient's health status was complex and when the patient's care system was smaller. Population health management can be beneficial to the care system making this investment, particularly for patients exhibiting prior continuity in care system choice. The results suggest that co-located primary and specialty services are important in maintaining primary care loyalty. © Health Research and Educational Trust.
The Role of Care Coordinator for Children with Complex Care Needs: A Systematic Review

PubMed Central

Hillis, Rowan; Larkin, Philip J; Cawley, Des; Connolly, Michael

2016-01-01

Introduction: This systematic review seeks to identify the intended components of the role of care coordinator for children with complex care needs and the factors that determine its composition in practice. Theory and methods: The initial search identified 1,157 articles, of which 37 met the inclusion criteria. They were quality assessed using the SIGN hierarchy of evidence structure. Results: Core components of the role include: coordination of care needs, planning and assessment, specialist support, emotional support, administration and logistics and continuing professional development. Influencing factors on the role include the external environment (political and socio-economic), the internal environment (organisational structure and funding protocols), the skills, qualifications and experience of the coordinator, the family circumstances and the nature of the interaction between the care coordinator and the family. Discussion: The lack of consistent terminology creates challenges and there is a need for greater consensus on this issue. Organisations and healthcare professionals need to recognise the extent to which contextual factors influence the role of a care coordinator in practice and plan accordingly. Despite evidence that suggests that the role is pivotal in ensuring that care needs are sustained, there remains great variability in the understanding of the role of a care coordinator for this population. Conclusions: As the provision of care increasingly moves closer to home there is a need for greater understanding of the nature and composition of the interaction between care coordinators and families to determine the extent to which appropriate services are being provided. Further work in this area should take into consideration any potential variance in service provision, for example any potential inequity arising due to geographic location. It is also imperative, where appropriate, to seek the views of children with complex care needs and their siblings about their experiences. PMID:27616967

Toward patient-centered, personalized and personal decision support and knowledge management: a survey.

PubMed

Leong, T-Y

2012-01-01

This paper summarizes the recent trends and highlights the challenges and opportunities in decision support and knowledge management for patient-centered, personalized, and personal health care. The discussions are based on a broad survey of related references, focusing on the most recent publications. Major advances are examined in the areas of i) shared decision making paradigms, ii) continuity of care infrastructures and architectures, iii) human factors and system design approaches, iv) knowledge management innovations, and v) practical deployment and change considerations. Many important initiatives, projects, and plans with promising results have been identified. The common themes focus on supporting the individual patients who are playing an increasing central role in their own care decision processes. New collaborative decision making paradigms and information infrastructures are required to ensure effective continuity of care. Human factors and usability are crucial for the successful development and deployment of the relevant systems, tools, and aids. Advances in personalized medicine can be achieved through integrating genomic, phenotypic and other biological, individual, and population level information, and gaining useful insights from building and analyzing biological and other models at multiple levels of abstraction. Therefore, new Information and Communication Technologies and evaluation approaches are needed to effectively manage the scale and complexity of biomedical and health information, and adapt to the changing nature of clinical decision support. Recent research in decision support and knowledge management combines heterogeneous information and personal data to provide cost-effective, calibrated, personalized support in shared decision making at the point of care. Current and emerging efforts concentrate on developing or extending conventional paradigms, techniques, systems, and architectures for the new predictive, preemptive, and participatory health care model for patient-centered, personalized medicine. There is also an increasing emphasis on managing complexity with changing care models, processes, and settings.
Specialty-care access for community health clinic patients: processes and barriers

PubMed Central

Ezeonwu, Mabel C

2018-01-01

Introduction Community health clinics/centers (CHCs) comprise the US’s core health-safety net and provide primary care to anyone who walks through their doors. However, access to specialty care for CHC patients is a big challenge. Materials and methods In this descriptive qualitative study, semistructured interviews of 37 referral coordinators of CHCs were used to describe their perspectives on processes and barriers to patients’ access to specialty care. Analysis of data was done using content analysis. Results The process of coordinating care referrals for CHC patients is complex and begins with a provider’s order for consultation and ends when the referring provider receives the specialist’s note. Poverty, specialist and referral coordinator shortages, lack of insurance, insurance acceptability by providers, transport and clinic-location factors, lack of clinic–hospital affiliations, and poor communication between primary and specialty providers constitute critical barriers to specialty-care access for patients. Conclusion Understanding the complexities of specialty-care coordination processes and access helps determine the need for comprehensive and uninterrupted access to quality health care for vulnerable populations. Guaranteed access to primary care at CHCs has not translated into improved access to specialty care. It is critical that effective policies be pursued to address the barriers and minimize interruptions in care, and to ensure continuity of care for all patients needing specialty care. PMID:29503559
Patient safety principles in family medicine residency accreditation standards and curriculum objectives

PubMed Central

Kassam, Aliya; Sharma, Nishan; Harvie, Margot; O’Beirne, Maeve; Topps, Maureen

2016-01-01

Abstract Objective To conduct a thematic analysis of the College of Family Physicians of Canada’s (CFPC’s) Red Book accreditation standards and the Triple C Competency-based Curriculum objectives with respect to patient safety principles. Design Thematic content analysis of the CFPC’s Red Book accreditation standards and the Triple C curriculum. Setting Canada. Main outcome measures Coding frequency of the patient safety principles (ie, patient engagement; respectful, transparent relationships; complex systems; a just and trusting culture; responsibility and accountability for actions; and continuous learning and improvement) found in the analyzed CFPC documents. Results Within the analyzed CFPC documents, the most commonly found patient safety principle was patient engagement (n = 51 coding references); the least commonly found patient safety principles were a just and trusting culture (n = 5 coding references) and complex systems (n = 5 coding references). Other patient safety principles that were uncommon included responsibility and accountability for actions (n = 7 coding references) and continuous learning and improvement (n = 12 coding references). Conclusion Explicit inclusion of patient safety content such as the use of patient safety principles is needed for residency training programs across Canada to ensure the full spectrum of care is addressed, from community-based care to acute hospital-based care. This will ensure a patient safety culture can be cultivated from residency and sustained into primary care practice. PMID:27965349
Legislative and Policy Developments and Imperatives for Advancing the Primary Care Behavioral Health (PCBH) Model.

PubMed

Freeman, Dennis S; Hudgins, Cathy; Hornberger, Joel

2018-06-01

The Primary Care Behavioral Health (PCBH) practice model continues to gain converts among primary care and behavioral health professionals as the evidence supporting its effectiveness continues to accumulate. Despite a growing number of practices and organizations using the model effectively, widespread implementation has been hampered by outmoded policies and regulatory barriers. As policymakers and legislators begin to recognize the contributions that PCBH model services make to the care of complex patients and the expansion of access to those in need of behavioral health interventions, some encouraging policy initiatives are emerging and the policy environment is becoming more favorable to implementation of the PCBH model. This article outlines the necessity for policy change, exposing the policy issues and barriers that serve to limit the practice of the PCBH model; highlights innovative approaches some states are taking to foster integrated practice; and discusses the compatibility of the PCBH model with the nation's health care reform agenda. Psychologists have emerged as leaders in the design and implementation of PCBH model integration and are encouraged to continue to advance the model through the demonstration of efficient and effective clinical practice, participation in the expansion of an appropriately trained workforce, and advocacy for the inclusion of this practice model in emerging healthcare systems and value-based payment methodologies.
Dignity in health-care: a critical exploration using feminism and theories of recognition.

PubMed

Aranda, Kay; Jones, Andrea

2010-09-01

Growing concerns over undignified health-care has meant the concept of dignity is currently much discussed in the British National Health Service. This has led to a number of policies attempting to reinstate dignity as a core ethical value governing nursing practice and health-care provision. Yet these initiatives continue to draw upon a concept of dignity which remains reliant upon a depoliticised, ahistorical and decontexualised subject. In this paper, we argue the need to revise the dignity debate through the lens of feminism and theories of recognition. Postmodern feminist theories provide major challenges to what remain dominant liberal approaches as they pay attention to the contingent, reflexive, and affective aspects of care work. Theories of recognition provide a further critical resource for understanding how moral obligations and responsibilities towards others and our public and private responses to difference arise. This re-situates dignity as a highly contested and politicised concept involving complex moral deliberations and diverse political claims of recognition. The dignity debate is thus moved beyond simplistic rational injunctions to care, or to care more, and towards critical discussions of complex politicised, moral practices infused with power that involve the recognition of difference in health-care.
Building A High Quality Oncology Nursing Workforce Through Lifelong Learning: The De Souza Model.

PubMed

Esplen, Mary Jane; Wong, Jiahui; Green, Esther; Richards, Joy; Li, Jane

2018-01-05

AbstractCancer is one of the leading causes of death in the world. Along with increased new cases, cancer care has become increasingly complex due to advances in diagnostics and treatments, greater survival, and new models of palliative care. Nurses are a critical resource for cancer patients and their families. Their roles and responsibilities are expanding across the cancer care continuum, calling for specialized training and support. Formal education prepares nurses for entry level of practice, however, it does not provide the specialized competencies required for quality care of cancer patients. There is urgent need to align the educational system to the demands of the health care system, ease transition from formal academic systems to care settings, and to instill a philosophy of lifelong learning. We describe a model of education developed by de Souza Institute in Canada, based on the Novice to Expert specialty training framework, and its success in offering structured oncology continuing education training to nurses, from undergraduate levels to continued career development in the clinical setting. This model may have global relevance, given the challenge in managing the demand for high quality care in all disease areas and in keeping pace with the emerging advances in technologies.
Excitation of Continuous and Discrete Modes in Incompressible Boundary Layers

NASA Technical Reports Server (NTRS)

Ashpis, David E.; Reshotko, Eli

1998-01-01

This report documents the full details of the condensed journal article by Ashpis & Reshotko (JFM, 1990) entitled "The Vibrating Ribbon Problem Revisited." A revised formal solution of the vibrating ribbon problem of hydrodynamic stability is presented. The initial formulation of Gaster (JFM, 1965) is modified by application of the Briggs method and a careful treatment of the complex double Fourier transform inversions. Expressions are obtained in a natural way for the discrete spectrum as well as for the four branches of the continuous spectra. These correspond to discrete and branch-cut singularities in the complex wave-number plane. The solutions from the continuous spectra decay both upstream and downstream of the ribbon, with the decay in the upstream direction being much more rapid than that in the downstream direction. Comments and clarification of related prior work are made.
Landmark lecture on cardiac intensive care and anaesthesia: continuum and conundrums.

PubMed

Laussen, Peter C

2017-12-01

Cardiac anesthesia and critical care provide an important continuum of care for patients with congenital heart disease. Clinicians in both areas work in complex environments in which the interactions between humans and technology is critical. Understanding our contributions to outcomes (modifiable risk) and our ability to perceive and predict an evolving clinical state (low failure-to-predict rate) are important performance metrics. Improved methods for capturing continuous physiologic signals will allow for new and interactive approaches to data visualization, and for sophisticated and iterative data modeling that will help define a patient's phenotype and response to treatment (precision physiology).
Economics of ICU organization and management.

PubMed

Wunsch, Hannah; Gershengorn, Hayley; Scales, Damon C

2012-01-01

The intensive care unit (ICU) is a complex system and the economic implications of altering care patterns in the ICU can be difficult to unravel. Few studies have specifically examined the economics of implementing organizational and management changes or acknowledged the many competing economic interests of patient, hospital,payer, and society. With continuously increasing healthcare costs,there is a great need for more studies focused on the optimal organization of the ICU. These studies should not focus solely on reductions in ICU length of stay but should strive to measure the true costs of care within a given healthcare system.
Healthcare improvement as planned system change or complex responsive processes? a longitudinal case study in general practice

PubMed Central

2013-01-01

Background Interest in how to implement evidence-based practices into routine health care has never been greater. Primary care faces challenges in managing the increasing burden of chronic disease in an ageing population. Reliable prescriptions for translating knowledge into practice, however, remain elusive, despite intense research and publication activity. This study seeks to explore this dilemma in general practice by challenging the current way of thinking about healthcare improvement and asking what can be learned by looking at change through a complexity lens. Methods This paper reports the local level of an embedded case study of organisational change for better chronic illness care over more than a decade. We used interviews, document review and direct observation to explore how improved chronic illness care developed in one practice. This formed a critical case to compare, using pattern matching logic, to the common prescription for local implementation of best evidence and a rival explanation drawn from complexity sciences interpreted through modern sociology and psychology. Results The practice changed continuously over more than a decade to deliver better chronic illness care in line with research findings and policy initiatives – re-designing care processes, developing community linkages, supporting patient self-management, using guidelines and clinical information systems, and integrating nurses into the practice team. None of these improvements was designed and implemented according to an explicit plan in response to a documented gap in chronic disease care. The process that led to high quality chronic illness care exhibited clear complexity elements of co-evolution, non-linearity, self-organisation, emergence and edge of chaos dynamics in a network of agents and relationships where a stable yet evolving way of organizing emerged from local level communicative interaction, power relating and values based choices. Conclusions The current discourse of implementation science as planned system change did not match organisational reality in this critical case of improvement in general practice. Complexity concepts translated in human terms as complex responsive processes of relating fit the pattern of change more accurately. They do not provide just another fashionable blueprint for change but inform how researchers, policymakers and providers participate in improving healthcare. PMID:23617833
Integrated versus fragmented implementation of complex innovations in acute health care.

PubMed

Woiceshyn, Jaana; Blades, Kenneth; Pendharkar, Sachin R

Increased demand and escalating costs necessitate innovation in health care. The challenge is to implement complex innovations-those that require coordinated use across the adopting organization to have the intended benefits. We wanted to understand why and how two of five similar hospitals associated with the same health care authority made more progress with implementing a complex inpatient discharge innovation whereas the other three experienced more difficulties in doing so. We conducted a qualitative comparative case study of the implementation process at five comparable urban hospitals adopting the same inpatient discharge innovation mandated by their health care authority. We analyzed documents and conducted 39 interviews of the health care authority and hospital executives and frontline managers across the five sites over a 1-year period while the implementation was ongoing. In two and a half years, two of the participating hospitals had made significant progress with implementing the innovation and had begun to realize benefits; they exemplified an integrated implementation mode. Three sites had made minimal progress, following a fragmented implementation mode. In the former mode, a semiautonomous health care organization developed a clear overall purpose and chose one umbrella initiative to implement it. The integrative initiative subsumed the rest and guided resource allocation and the practices of hospital executives, frontline managers, and staff who had bought into it. In contrast, in the fragmented implementation mode, the health care authority had several overlapping, competing innovations that overwhelmed the sites and impeded their implementation. Implementing a complex innovation across hospital sites required (a) early prioritization of one initiative as integrative, (b) the commitment of additional (traded off or new) human resources, (c) deliberate upfront planning and continual support for and evaluation of implementation, and (d) allowance for local customization within the general principles of standardization.
Practice paper of the academy of nutrition and dietetics: principles of productivity in food and nutrition services: applications in the 21st century health care reform era.

PubMed

Gregoire, Mary B; Theis, Monica L

2015-07-01

Food and nutrition services, along with the health care organizations they serve, are becoming increasingly complex. These complexities are driven by sometimes conflicting (if not polarizing) human, department, organization, and environment factors and will require that managers shift how they think about and approach productivity in the context of the greater good of the organization and, perhaps, even society. Traditional, single-factor approaches to productivity measurements, while still valuable in the context of departmental trend analysis, are of limited value when assessing departmental performance in the context of an organization's goals and values. As health care continues to change and new models of care are introduced, food and nutrition services managers will need to consider innovative approaches to improve productivity that are consistent with their individual health care organization's vision and mission. Use of process improvement tools such as Lean and Six Sigma as strategies for evaluating and improving food and nutrition services efficiency should be considered. Copyright © 2015 Academy of Nutrition and Dietetics. Published by Elsevier Inc. All rights reserved.
Can doctors and administrators work together?

PubMed

Gill, S L

1987-01-01

The working relationship between physicians and health care organizations has dramatically changed since the introduction of competitive factors. Fifer suggests that future doctors may have as many as five or six economic relationships with their associated health care system, in contrast to the singular role as admitting physician of the past. The physician will continue to admit patients, but may also belong to an HMO or some other joint venture (freestanding ambulatory care center, outpatient laboratory, etc.), be salaried part time for leadership roles, be a leader in some other parallel economic venture, etc. Physicians are already assuming multiple roles as health care providers, private entrepreneurs, and joint venture partners with hospitals. Hospitals and health care systems also continue to change through vertical and horizontal integration. Traditional clinical departments are becoming blended into product line entities, and a sophisticated executive team of market-oriented specialists now augments the traditional administrative leadership. So, from a tradition of predictable roles, relationships, and authority structures, we are now attempting to thrive and prosper with many new partners in an integrated, complex, and conflict-ridden set of interrelationships.
Integrating patient safety into the clinical microsystem

PubMed Central

Mohr, J; Batalden, P; Barach, P

2004-01-01

Healthcare institutions continue to face challenges in providing safe patient care in increasingly complex organisational and regulatory environments while striving to maintain financial viability. The clinical microsystem provides a conceptual and practical framework for approaching organisational learning and delivery of care. Tensions exist between the conceptual theory and the daily practical applications of providing safe and effective care within healthcare systems. Healthcare organisations are often complex, disorganised, and opaque systems to their users and their patients. This disorganisation may lead to patient discomfort and harm as well as much waste. Healthcare organisations are in some sense conglomerates of smaller systems, not coherent monolithic organisations. The microsystem unit allows organisational leaders to embed quality and safety into a microsystem's developmental journey. Leaders can set the stage for making safety a priority for the organisation while allowing individual microsystems to create innovative strategies for improvement. PMID:15576690
Addressing the conundrum of multimorbidity in heart failure: Do we need a more strategic approach to improve health outcomes?

PubMed

Stewart, Simon; Riegel, Barbara; Thompson, David R

2016-02-01

There is clear evidence across the globe that the clinical complexity of patients presenting to hospital with the syndrome of heart failure is increasing - not only in terms of the presence of concurrent disease states, but with additional socio-demographic risk factors that complicate treatment. Management strategies that treat heart failure as the main determinant of health outcomes ignores the multiple and complex issues that will inevitably erode the efficacy and efficiency of current heart failure management programmes. This complex problem (or conundrum) requires a different way of thinking around the complex interactions that underpin poor outcomes in heart failure. In this context, we present the COordinated NUrse-led inteNsified Disease management for continuity of caRe for mUltiMorbidity in Heart Failure (CONUNDRUM-HF) matrix that may well inform future research and models of care to achieve better health outcomes in this rapidly increasing patient population. © The European Society of Cardiology 2015.
Unequal cancer survivorship care: addressing cultural and sociodemographic disparities in the clinic.

PubMed

Surbone, Antonella; Halpern, Michael T

2016-12-01

The number of individuals diagnosed with cancer is growing worldwide. Cancer patients from underserved populations have widely documented disparities through the continuum of cancer care. As the number of cancer survivors (i.e., individuals who have completed cancer treatment) from underserved populations also continue to grow, these individuals may continue to experience barriers to survivorship care, resulting in persistent long-term negative impacts on health and quality of life. In addition, there is limited participation of survivors from underserved populations in clinical trials and other research studies. To address disparities and change practices in survivorship care, a better understanding of the roles of both socioeconomic status (SES) and of culture in cancer care disparities and the relevance of these to providing high-quality care is needed. SES and culture often overlap but are not identical; understanding the impact of each is especially relevant to survivorship care. To enhance health equity among cancer survivors, clinicians need to practice culturally competent care, address cultural beliefs and practices that may influence survivors' beliefs and activities, gain awareness of historical patterns of medical care in the survivor's community, and consider how barriers to cross-cultural communications may hinder communication in clinical settings. While the design and implementation of survivorship care programs emphasizing effectiveness and equity is complex and potentially time consuming, it is critical for providing optimal care for all survivors, including those from the most vulnerable populations.
Barriers to the Accessibility and Continuity of Health-Care Services in People with Multiple Sclerosis

PubMed Central

Bishop, Malachy; Pionke, J.J.; Strauser, David; Santens, Ryan L.

2017-01-01

Background: Individuals with multiple sclerosis (MS) face a range of barriers to accessing and using health-care services. The aim of this review was to identify specific barriers to accessing and using health-care services based on a continuum of the health-care delivery system. Methods: Literature searches were conducted in the PubMed, PsycINFO, CINAHL, and Web of Science databases. The following terms were searched as subject headings, key words, or abstracts: health care, access, barriers, physical disability, and multiple sclerosis. The literature search produced 361 potentially relevant citations. After screening titles, abstracts, and citations, eight citations were selected for full-text review. Results: Health-care barriers were divided into three continuous phases of receiving health care. In the before-visit phase, the most commonly identified barrier was transportation. In the during-visit phase, communication quality was the major concern. In the after-visit phase, discontinued referral was the major barrier encountered. Conclusions: There are multiple interrelated barriers to accessing and using health-care services along the health-care delivery continuum for people with MS and its associated physical disabilities, ranging from complex and long-recognized barriers that will likely require extended advocacy to create policy changes to issues that can and should be addressed through relatively minor changes in health-care delivery practices, improved care coordination, and increased provider awareness, education, and responsiveness to patients' needs. PMID:29270089
Effectiveness of multicomponent interventions in primary healthcare settings to promote continuous smoking cessation in adults: a systematic review

PubMed Central

Martín Cantera, Carlos; Puigdomènech, Elisa; Ballvé, Jose Luis; Arias, Olga Lucía; Clemente, Lourdes; Casas, Ramon; Roig, Lydia; Pérez-Tortosa, Santiago; Díaz-Gete, Laura; Granollers, Sílvia

2015-01-01

Objective The objective of the present review is to evaluate multicomponent/complex primary care (PC) interventions for their effectiveness in continuous smoking abstinence by adult smokers. Design A systematic review of randomised and non-randomised controlled trials was undertaken. Eligibility criteria for included studies Selected studies met the following criteria: evaluated effects of a multicomponent/complex intervention (with 2 or more intervention components) in achieving at least 6-month abstinence in adult smokers who visited a PC, biochemical confirmation of abstinence, intention-to-treat analysis and results published in English/Spanish. Methods We followed PRISMA statement to report the review. We searched the following data sources: MEDLINE, Web of Science, Scopus (from inception to February 2014), 3 key journals and a tobacco research bulletin. The Scottish Intercollegiate Guidelines Network checklists were used to evaluate methodological quality. Data selection, evaluation and extraction were done independently, using a paired review approach. Owing to the heterogeneity of interventions in the studies included, a meta-analysis was not conducted. Results Of 1147 references identified, 9 studies were selected (10 204 participants, up to 48 months of follow-up, acceptable methodological quality). Methodologies used were mainly individual or group sessions, telephone conversations, brochures or quit-smoking kits, medications and economic incentives for doctors and no-cost medications for smokers. Complex interventions achieved long-term continuous abstinence ranging from 7% to 40%. Behavioural interventions were effective and had a dose–response effect. Both nicotine replacement and bupropion therapy were safe and effective, with no observed differences. Conclusions Multicomponent/complex interventions in PC are effective and safe, appearing to achieve greater long-term continuous smoking cessation than usual care and counselling alone. Selected studies were heterogeneous and some had significant losses to follow-up. Our results show that smoking interventions should include more than one component and a strong follow-up of the patient to maximise results. PMID:26428333
Exploring ward nurses' perceptions of continuing education in clinical settings.

PubMed

Govranos, Melissa; Newton, Jennifer M

2014-04-01

Health care systems demand that nurses are flexible skilful workers who maintain currency and competency in order to deliver safe effective patient centered care. Nurses must continually build best practice into their care and acquire lifelong learning. Often this learning is acquired within the work environment and is facilitated by the clinical nurse educator. Understanding clinical nurses' values and needs of continuing education is necessary to ensure appropriate education service delivery and thus enhance patient care. To explore clinical ward-based nurses' values and perceptions towards continuing education and what factors impact on continuing education in the ward. A case study approach was utilized. A major teaching hospital in Melbourne, Australia. A range of clinical nursing staff (n=23). Four focus groups and six semi-structured individual interviews were undertaken. Focus group interviews explored participants' values and perceptions on continuing education through a values clarification tool. Thematic analysis of interviews was undertaken to identify themes and cluster data. Three central themes: 'culture and attitudes', 'what is learning?' and 'being there-being seen', emerged reflecting staffs' values and perceptions of education and learning in the workplace. Multiple factors influence ward nurses' ability and motivation to incorporate lifelong learning into their practice. Despite variance in nurses' values and perceptions of CE in clinical environments, CE was perceived as important. Nurses yearned for changes to facilitate lifelong learning and cultivate a learning culture. Clinical nurse educators need to be cognizant of adult learners' characteristics such as values, beliefs, needs and potential barriers, to effectively facilitate support in a challenging and complex learning environment. Organizational support is essential so ward managers in conjunction with educational departments can promote and sustain continuing education, lifelong learning and a culture conducive to learning. © 2013.
Telephone calls postdischarge from hospital to home: a literature review.

PubMed

Hand, Kristin E; Cunningham, Regina S

2014-02-01

The oncology population is particularly affected by hospital readmissions because hospitalized patients with cancer often have complex needs. The complexity and diversity of care requirements create substantial challenges in planning for appropriate postdischarge support. Implementing postdischarge telephone calls in the population of patients with cancer could offer a low-cost intervention to address the complex needs of patients during the transition from hospital to home. The goal of the current literature review is to provide an understanding about postdischarge telephone calls in patients with cancer. Findings from this review support the notion that discharge phone calls could improve care continuity for patients transitioning from hospital to home. The literature review outlines information related to telephone call content, timing, and structure for healthcare systems that want to use a postdischarge telephone intervention for patients with cancer. However, additional research is needed to develop and test cancer-specific protocols.

From Inpatient to Clinic to Home to Hospice and Back: Using the "Pop Up" Pediatric Palliative Model of Care.

PubMed

Mherekumombe, Martha F

2018-04-26

Children and young people with life-limiting illnesses who need palliative care often have complex diverse medical conditions that may involve multiple hospital presentations, medical admissions, care, or transfer to other medical care facilities. In order to provide patients with holistic care in any location, palliative care clinicians need to carefully consider the ways to maintain continuity of care which enhances the child's quality of life. An emerging model of care known as "Pop Up" describes the approaches to supporting children and young people in any facility. A Pop Up is a specific intervention over and above the care that is provided to a child, young person and their family aimed at improving the confidence of local care providers to deliver ongoing care. This paper looks at some of the factors related to care transfer for pediatric palliative patients from one care facility to another, home and the impact of this on the family and medical care.
From Inpatient to Clinic to Home to Hospice and Back: Using the “Pop Up” Pediatric Palliative Model of Care

PubMed Central

Mherekumombe, Martha F.

2018-01-01

Children and young people with life-limiting illnesses who need palliative care often have complex diverse medical conditions that may involve multiple hospital presentations, medical admissions, care, or transfer to other medical care facilities. In order to provide patients with holistic care in any location, palliative care clinicians need to carefully consider the ways to maintain continuity of care which enhances the child’s quality of life. An emerging model of care known as “Pop Up” describes the approaches to supporting children and young people in any facility. A Pop Up is a specific intervention over and above the care that is provided to a child, young person and their family aimed at improving the confidence of local care providers to deliver ongoing care. This paper looks at some of the factors related to care transfer for pediatric palliative patients from one care facility to another, home and the impact of this on the family and medical care. PMID:29701661
Simulation: a new approach to teaching ethics.

PubMed

Buxton, Margaret; Phillippi, Julia C; Collins, Michelle R

2015-01-01

The importance of ethical conduct in health care was acknowledged as early as the fifth century in the Hippocratic Oath and continues to be an essential element of clinical practice. Providers face ethical dilemmas that are complex and unfold over time, testing both practitioners' knowledge and communication skills. Students learning to be health care providers need to develop the knowledge and skills necessary to negotiate complex situations involving ethical conflict. Simulation has been shown to be an effective learning environment for students to learn and practice complex and overlapping skills sets. However, there is little guidance in the literature on constructing effective simulation environments to assist students in applying ethical concepts. This article describes realistic simulations with trained, standardized patients that present ethical problems to graduate-level nurse-midwifery students. Student interactions with the standardized patients were monitored by faculty and peers, and group debriefing was used to help explore students' emotions and reactions. Student feedback postsimulation was exceedingly positive. This simulation could be easily adapted for use by health care education programs to assist students in developing competency with ethics. © 2014 by the American College of Nurse-Midwives.
Teaching complex trauma care in a curriculum challenges critical thinking and clinical judgment--how nurses can help.

PubMed

West, Margaret Mary; Bross, Gina; Snyder, Melissa

2007-01-01

Incorporating complex content into a nursing curriculum presents students with the knowledge and thinking skills necessary to enter a career in nursing. A level 1 trauma center is a prefect environment to advance these thinking skills. Nurses act as professional role models and teachers as they clarify and explain their thinking to a student. When experienced nurses show invitational behaviors to students and share their knowledge with them, they ignite a strong desire within the student to progress. Caring, communication, and inclusion are key components that synergize the teaching/learning experience. The development of critical thinking is a continuous process that is best achieved through collaboration between the student, faculty, and professional, experienced nurses.
Managing information technology human resources in health care.

PubMed

Mahesh, Sathiadev; Crow, Stephen M

2012-01-01

The health care sector has seen a major increase in the use of information technology (IT). The increasing permeation of IT into the enterprise has resulted in many non-IT employees acquiring IT-related skills and becoming an essential part of the IT-enabled enterprise. Health care IT employees work in a continually changing environment dealing with new specializations that are often unfamiliar to other personnel. The widespread use of outsourcing and offshoring in IT has introduced a third layer of complexity in the traditional hierarchy and its approach to managing human resources. This article studies 3 major issues in managing these human resources in an IT-enabled health care enterprise and recommends solutions to the problem.
Family physicians and dementia in Canada: Part 2. Understanding the challenges of dementia care.

PubMed

Pimlott, Nicholas J G; Persaud, Malini; Drummond, Neil; Cohen, Carole A; Silvius, James L; Seigel, Karen; Hollingworth, Gary R; Dalziel, William B

2009-05-01

To explore the challenges Canadian family physicians face in providing dementia care. Qualitative study using focus groups. Academic family practice clinics in Calgary, Alta, Ottawa, Ont, and Toronto, Ont. Eighteen family physicians. We conducted 4 qualitative focus groups of 4 to 6 family physicians whose practices we had audited in a previous study. Focus group transcripts were analyzed using the principles of thematic analysis. Five major themes related to the provision of dementia care by family physicians emerged: 1) diagnostic uncertainty; 2) the complexity of dementia; 3) time as a paradox in the provision of dementia care; 4) the importance of patients' families; 5) and familiarity with patients. Participants expressed uncertainty about diagnosing dementia and a strong need for expert verification of diagnoses owing to the complexity of dementia. Time, patients' family members, and familiarity with patients were seen as both barriers and enablers in the provision of dementia care. Family physicians face many challenges in providing dementia care. The results of this study and the views of family physicians should be considered in the development and dissemination of future dementia guidelines, as well as by specialist colleagues, policy makers, and those involved in developing continuing physician education about dementia.
Impact of specialist palliative care on coping with Parkinson's disease: patients and carers.

PubMed

Badger, Nathan J; Frizelle, Dorothy; Adams, Debi; Johnson, Miriam J

2018-06-01

UK guidelines recommend palliative care access for people with Parkinson's disease; however, this remains sporadic, and it is unknown whether specialist palliative care helps patients and carers cope with this distressing condition. This study aimed to explore whether, and how, access to specialist palliative care services affected patients' and carers' coping with Parkinson's disease. Semistructured interviews were conducted, audio-recorded and verbatim transcribed. Data were analysed using interpretative phenomenological analysis. Participants were patients with advanced idiopathic Parkinson's disease (n=3), and carers of people with Parkinson's disease (n=5, however, one diagnosis was reviewed) receiving care from an integrated specialist palliative care and Parkinson's disease service in North East England. Access to specialist palliative care helped participants cope with some aspects of advanced Parkinson's disease. Three superordinate themes were developed:' managing uncertainty', 'impacts on the self' and 'specialist palliative care maintaining a positive outlook'. Specialist palliative care helped patients and carers cope with advanced Parkinson's disease. Specialist palliative care is a complex intervention that acknowledges the complex and holistic nature of Parkinson's disease, enabling health in some domains despite continued presence of pathology. These exploratory findings support the utility of this approach for people living with Parkinson's disease. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.
Supporting Goal-Oriented Primary Health Care for Seniors with Complex Care Needs Using Mobile Technology: Evaluation and Implementation of the Health System Performance Research Network, Bridgepoint Electronic Patient Reported Outcome Tool.

PubMed

Steele Gray, Carolyn; Wodchis, Walter P; Upshur, Ross; Cott, Cheryl; McKinstry, Brian; Mercer, Stewart; Palen, Ted E; Ramsay, Tim; Thavorn, Kednapa

2016-06-24

Older adults experiencing multiple chronic illnesses are at high risk of hospitalization and health decline if they are unable to manage the significant challenges posed by their health conditions. Goal-oriented care approaches can provide better care for these complex patients, but clinicians find the process of ascertaining goals "too complex and too-time consuming," and goals are often not agreed upon between complex patients and their providers. The electronic patient reported outcomes (ePRO) mobile app and portal offers an innovative approach to creating and monitoring goal-oriented patient-care plans to improve patient self-management and shared decision-making between patients and health care providers. The ePRO tool also supports proactive patient monitoring by the patient, caregiver(s), and health care provider. It was developed with and for older adults with complex care needs as a means to improve their quality of life. Our proposed project will evaluate the use, effectiveness, and value for money of the ePRO tool in a 12-month multicenter, randomized controlled trial in Ontario; targeting individuals 65 or over with two or more chronic conditions that require frequent health care visits to manage their health conditions. Intervention groups using the ePRO tool will be compared with control groups on measures of quality of life, patient experience, and cost-effectiveness. We will also evaluate the implementation of the tool. The proposed project presented in this paper will be funded through the Canadian Institute for Health Research (CIHR) eHealth Innovation Partnerships Program (eHIPP) program (CIHR-348362). The expected completion date of the study is November, 2019. We anticipate our program of work will support improved quality of life and patient self-management, improved patient-centered primary care delivery, and will encourage the adoption of goal-oriented care approaches across primary health care systems. We have partnered with family health teams and quality improvement organizations in Ontario to ensure that our research is practical and that findings are shared widely. We will work with our established international network to develop an implementation framework to support continued adaptation and adoption across Canada and internationally.
Supporting Goal-Oriented Primary Health Care for Seniors with Complex Care Needs Using Mobile Technology: Evaluation and Implementation of the Health System Performance Research Network, Bridgepoint Electronic Patient Reported Outcome Tool

PubMed Central

Wodchis, Walter P; Upshur, Ross; Cott, Cheryl; McKinstry, Brian; Mercer, Stewart; Palen, Ted E; Ramsay, Tim; Thavorn, Kednapa

2016-01-01

Background Older adults experiencing multiple chronic illnesses are at high risk of hospitalization and health decline if they are unable to manage the significant challenges posed by their health conditions. Goal-oriented care approaches can provide better care for these complex patients, but clinicians find the process of ascertaining goals “too complex and too-time consuming,” and goals are often not agreed upon between complex patients and their providers. The electronic patient reported outcomes (ePRO) mobile app and portal offers an innovative approach to creating and monitoring goal-oriented patient-care plans to improve patient self-management and shared decision-making between patients and health care providers. The ePRO tool also supports proactive patient monitoring by the patient, caregiver(s), and health care provider. It was developed with and for older adults with complex care needs as a means to improve their quality of life. Objective Our proposed project will evaluate the use, effectiveness, and value for money of the ePRO tool in a 12-month multicenter, randomized controlled trial in Ontario; targeting individuals 65 or over with two or more chronic conditions that require frequent health care visits to manage their health conditions. Methods Intervention groups using the ePRO tool will be compared with control groups on measures of quality of life, patient experience, and cost-effectiveness. We will also evaluate the implementation of the tool. Results The proposed project presented in this paper will be funded through the Canadian Institute for Health Research (CIHR) eHealth Innovation Partnerships Program (eHIPP) program (CIHR–143559). The expected completion date of the study is November, 2019. Conclusions We anticipate our program of work will support improved quality of life and patient self-management, improved patient-centered primary care delivery, and will encourage the adoption of goal-oriented care approaches across primary health care systems. We have partnered with family health teams and quality improvement organizations in Ontario to ensure that our research is practical and that findings are shared widely. We will work with our established international network to develop an implementation framework to support continued adaptation and adoption across Canada and internationally. PMID:27341765
Enhanced Primary Care Treatment of Behavioral Disorders With ECHO Case-Based Learning.

PubMed

Komaromy, Miriam; Bartlett, Judy; Manis, Kathryn; Arora, Sanjeev

2017-09-01

The Extension for Community Healthcare Outcomes (ECHO) model offers a way for primary care providers to develop expertise in addressing behavioral health issues of primary care patients. It provides an alternative to traditional continuing medical education (CME) for ongoing training and support for health care providers. ECHO uses videoconferencing to connect multiple primary care teams simultaneously with academic specialists and builds capacity via mentorship and case-based learning. ECHO aims to expand access to care by developing capacity to treat common, complex conditions in underserved areas. Participants in an integrated addictions and psychiatry teleECHO program reported that when they presented a patient case, the feedback they received was highly valuable and led them to change their care plans more than 75% of the time. ECHO is an effective model for teaching primary care teams about behavioral health and may be more effective than traditional CME approaches.
Time-Related Decay or Interference-Based Forgetting in Working Memory?

ERIC Educational Resources Information Center

Portrat, Sophie; Barrouillet, Pierre; Camos, Valerie

2008-01-01

The time-based resource-sharing model of working memory assumes that memory traces suffer from a time-related decay when attention is occupied by concurrent activities. Using complex continuous span tasks in which temporal parameters are carefully controlled, P. Barrouillet, S. Bernardin, S. Portrat, E. Vergauwe, & V. Camos (2007) recently…
Enacting Change through Action Learning: Mobilizing and Managing Power and Emotion

ERIC Educational Resources Information Center

Conklin, James; Cohen-Schneider, Rochelle; Linkewich, Beth; Legault, Emma

2012-01-01

This paper reports on a study of how action learning facilitates the movement of knowledge between social contexts. The study involved a community organization that provides educational services related to aphasia and members of a complex continuing care (CCC) practice that received training from the agency. People with aphasia (PWA) (a disability…
Sustainability of depression care improvements: success of a practice change improvement collaborative.

PubMed

Nease, Donald E; Nutting, Paul A; Graham, Deborah G; Dickinson, W Perry; Gallagher, Kaia M; Jeffcott-Pera, Michelle

2010-01-01

Long-term sustainment of improvements in care continues to challenge primary care practices. During the 2 years after of our Improving Depression Care collaborative, we examined how well practices were sustaining their depression care improvements. Our study design used a qualitative interview follow-up of a modified learning collaborative intervention. We conducted telephone interviews with practice champions from 15 of the original 16 practices. Interviews were conducted during a 3-month period in 2008, and were recorded and professionally transcribed. Data on each of the depression care improvements and the change management strategy emphasized during the learning collaborative were summarized after review of the primary data and a consensus process to resolve differing interpretations. During the period from 15 months to 3 years since our project began, depression screening or case finding was sustained in 14 of 15 practices. Thirteen practices sustained use of the 9-item Patient Health Questionnaire for depression monitoring, and one additional practice initiated it. Seven practices initiated self-management support and 2 of 3 practices sustained it. In contrast, tracking and case management proved difficult to sustain, with only 4 of 8 practices continuing this activity. Diffusion of use of the 9-item Patient Health Questionnaire to other clinicians in the practice was maintained in all but 3 practices and expanded in one practice. Six of the practices continued to use the change management strategy, including all 4 of the practices that sustained tracking. Practices demonstrated long-term sustained improvement in depression care with the exception of tracking and care management, which may be a more challenging innovation to sustain. We hypothesize that sustaining complex depression care innovations may require active management by the practice.
Costs and coverage. Pressures toward health care reform.

PubMed Central

Lee, P R; Soffel, D; Luft, H S

1992-01-01

Signs of discontent with the health care system are growing. Calls for health care reform are largely motivated by the continued increase in health care costs and the large number of people without adequate health insurance. For the past 20 years, health care spending has risen at rates higher than the gross national product. As many as 35 million people are without health insurance. As proposals for health care reform are developed, it is useful to understand the roots of the cost problem. Causes of spiraling health care costs include "market failure" in the health care market, expansion in technology, excessive administrative costs, unnecessary care and defensive medicine, increased patient complexity, excess capacity within the health care system, and low productivity. Attempts to control costs, by the federal government for the Medicare program and then by the private sector, have to date been mostly unsuccessful. New proposals for health care reform are proliferating, and important changes in the health care system are likely. PMID:1441510
From Community to Meta-Community Mental Health Care.

PubMed

Bouras, Nick; Ikkos, George; Craig, Thomas

2018-04-20

Since the 1960s, we have witnessed the development and growth of community mental health care that continues to dominate mental health policy and practice. Several high-income countries have implemented community mental health care programmes but for many others, including mostly low- and middle-income countries, it remains an aspiration. Although community mental health care has been positive for many service users, it has also had severe shortcomings. Expectations that it would lead to fuller social integration have not been fulfilled and many service users remain secluded in sheltered or custodial environments with limited social contacts and no prospect of work. Others receive little or no service at all. In today’s complex landscape of increasingly specialised services for people with mental health problems, the number of possible interfaces between services is increasing. Together with existing uneven financing systems and a context of constant change, these interfaces are challenging us to develop effective care pathways adjusted to the needs of service users and their carers. This discussion paper reviews the developments in community mental health care over the recent years and puts forward the concept of “Meta-Community Mental Health Care”. “Meta-Community Mental Health Care” embraces pluralism in understanding and treating psychiatric disorders, acknowledges the complexities of community provision, and reflects the realities and needs of the current era of care.
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.
Medicare home health payment reform may jeopardize access for clinically complex and socially vulnerable patients.

PubMed

Rosati, Robert J; Russell, David; Peng, Timothy; Brickner, Carlin; Kurowski, Daniel; Christopher, Mary Ann; Sheehan, Kathleen M

2014-06-01

The Affordable Care Act directed Medicare to update its home health prospective payment system to reflect more recent data on costs and use of services-an exercise known as rebasing. As a result, the Centers for Medicare and Medicaid Services will reduce home health payments 3.5 percent per year in the period 2014-17. To determine the impact that these reductions could have on beneficiaries using home health care, we examined the Medicare reimbursement margins and the use of services in a national sample of 96,621 episodes of care provided by twenty-six not-for-profit home health agencies in 2011. We found that patients with clinically complex conditions and social vulnerability factors, such as living alone, had substantially higher service delivery costs than other home health patients. Thus, the socially vulnerable patients with complex conditions represent less profit-lower-to-negative Medicare margins-for home health agencies. This financial disincentive could reduce such patients' access to care as Medicare payments decline. Policy makers should consider the unique characteristics of these patients and ensure their continued access to Medicare's home health services when planning rebasing and future adjustments to the prospective payment system. Project HOPE—The People-to-People Health Foundation, Inc.
Digital monitoring and care: Virtual medicine.

PubMed

Shinbane, Jerold S; Saxon, Leslie A

2016-11-01

Remote digital health monitoring technologies can be synergistically organized to create a virtual medical system providing more continuous care centered on the patient rather than the bricks and mortar medical complex. Utilization of the digitalized patient health monitoring can facilitate diagnosis, treatment plans, physician-patient interaction, and accelerate the progress of medical research, education, and training. The field of cardiac electrophysiology has been an early adopter of this shift in care and serves as a paradigm applicable to all areas of medicine. The overall impact of this remote virtual care model on the quality of medical care and patient experience requires greater study, as well as vigilance as to the differences between technology and care in order to preserve the intangible and immeasurable factors that bring humanity to the art and science of medicine. Copyright © 2016 Elsevier Inc. All rights reserved.
Reducing health care's carbon footprint--the power of nursing.

PubMed

Muñoz, Aliria

2012-11-01

Global warming and environmentalism continue to be national and international issues as their complexities and implications become better understood. One ironic contributor to the degradation of the environment is the health care system. Serving as clinical laboratories, hotels, restaurants, and offices that never close, U.S. hospitals produce more than 2 million tons of waste annually. Although the consequences and significance of health care's carbon footprint are undeniable, strategies to reduce this impact are challenging. This article discusses how the role, traits, and knowledge of nurses combined with their positions in the health care system make them key players in creating an environmentally sustainable health care industry. With an analysis of environmental action versus inaction, this article explores how nurses at the forefront of health care are equipped to change practice that will reach far beyond the bedside.
On the Scene: Developing a Nurse Care Coordinator Role at City of Hope.

PubMed

Johnson, Shirley A; Giesie, Pamela D; Ireland, Anne M; Rice, Robert David; Thomson, Brenda K

2016-01-01

We describe the development of an oncology solid tumor disease-focused care coordination model. Consistent with our strategic plan to provide patient- and family-centered care and to organize care around disease management teams, we developed the role of nurse care coordinator as an integral team member in our care delivery model. Managing a defined high-risk patient population across the care trajectory, these nurses provide stable points of contact and continuity for patients and families as they navigate the complex treatments and systems required to deliver cancer care. We describe role delineation and staffing models; role clarity between the role of the nurse care coordinator and the case manager; core curriculum development; the use of workflow management tools to support the touch points of the patient and members of the care team; and the incorporation of electronic medical records and data streams to inform the care delivery model. We identify measures that we will use to evaluate the success of our program.

Meeting the Housing and Care Needs of Older Homeless Adults: A Permanent Supportive Housing Program Targeting Homeless Elders.

PubMed

Brown, Rebecca T; Thomas, M Lori; Cutler, Deborah F; Hinderlie, Mark

2013-01-01

The homeless population is aging faster than the general population in the United States. As this vulnerable population continues to age, addressing complex care and housing needs will become increasingly important. This article reviews the often-overlooked issue of homelessness among older adults, including their poor health status and unique care needs, the factors that contribute to homelessness in this population, and the costs of homelessness to the U.S. health care system. Permanent supportive housing programs are presented as a potential solution to elder homelessness, and Hearth, an outreach and permanent supportive housing model in Boston, is described. Finally, specific policy changes are presented that could promote access to housing among the growing older homeless population.
[Risk management in anesthesia and critical care medicine].

PubMed

Eisold, C; Heller, A R

2017-03-01

Throughout its history, anesthesia and critical care medicine has experienced vast improvements to increase patient safety. Consequently, anesthesia has never been performed on such a high level as it is being performed today. As a result, we do not always fully perceive the risks involved in our daily activity. A survey performed in Swiss hospitals identified a total of 169 hot spots which endanger patient safety. It turned out that there is a complex variety of possible errors that can only be tackled through consistent implementation of a safety culture. The key elements to reduce complications are continuing staff education, algorithms and standard operating procedures (SOP), working according to the principles of crisis resource management (CRM) and last but not least the continuous work-up of mistakes identified by critical incident reporting systems.
Using the Affective Domain to Enhance Teaching of the ACGME Competencies in Anesthesiology Training.

PubMed

Yanofsky, Samuel D; Nyquist, Julie G

2010-01-01

Teaching and assessing the advanced competencies will continue to be a challenge. Incorporating new and nontraditional skills into an already complex and challenging clinical curriculum and practice is not easy. This makes development of methods for curricular design, teaching and assessment of anesthesiology resident and fellow performance essential. The Domains of learning, particularly the Affective Domain can serve as an organizing structure for developing objectives and selecting teaching and assessment techniques. Using the Affective Domain to select targeted teaching techniques might help foster development of key beliefs and values that underlie the advanced competencies (and sub-competencies). Targeted teaching, outside of the patient care arena, when combined with traditional clinical teaching practices, may help to ensure continued performance of desired behaviors. These include acting in a consultative role for other health professionals (ICS), providing culturally responsive care (Professionalism), using evidence to enhance the care of patients (PBLI), and advocating for quality of care and working to enhance patient safety (SBP). As educators, our aim is not only to impact knowledge, attitudes and skills, but to impact the daily behavior of our graduates.
Using the Affective Domain to Enhance Teaching of the ACGME Competencies in Anesthesiology Training

PubMed Central

2010-01-01

Teaching and assessing the advanced competencies will continue to be a challenge. Incorporating new and nontraditional skills into an already complex and challenging clinical curriculum and practice is not easy. This makes development of methods for curricular design, teaching and assessment of anesthesiology resident and fellow performance essential. The Domains of learning, particularly the Affective Domain can serve as an organizing structure for developing objectives and selecting teaching and assessment techniques. Using the Affective Domain to select targeted teaching techniques might help foster development of key beliefs and values that underlie the advanced competencies (and sub-competencies). Targeted teaching, outside of the patient care arena, when combined with traditional clinical teaching practices, may help to ensure continued performance of desired behaviors. These include acting in a consultative role for other health professionals (ICS), providing culturally responsive care (Professionalism), using evidence to enhance the care of patients (PBLI), and advocating for quality of care and working to enhance patient safety (SBP). As educators, our aim is not only to impact knowledge, attitudes and skills, but to impact the daily behavior of our graduates. PMID:27175387
Reducing errors through a web-based self-management support system.

PubMed

Ekstedt, Mirjam; Børøsund, Elin; Svenningsen, Ina K; Ruland, Cornelia M

2014-01-01

Web-based self-management support systems SMSS, can successfully assist a wide range of patients with information and self-management support. O or as a stand-alone service, are e-messages. This study describes how one component of a multi component SMSS, an e-message service, in which patients with breast cancer could direct questions to nurses, physicians or social workers at the hospital where they were being treated, had an influence on safety and continuity of care. Ninety-one dialogues consisting of 284 messages were analysed. The communications between patients and the healthcare team revealed that the e-messages service served as a means for quality assurance of information, for double-checking and for coordination of care. We give examples of how an e-mail service may improve patients' knowledge in a process of taking control over their own care - increasingly important in a time of growing complexity and specialization in healthcare. It remains to be tested whether an e-message service can improve continuity of care and prevent or mitigate medical mishaps.
Interdisciplinary integration for quality improvement: the Cleveland Veterans Affairs Medical Center Firm System.

PubMed

Aucott, J N; Pelecanos, E; Bailey, A J; Shupe, T C; Romeo, J H; Ravdin, J I; Aron, D C

1995-04-01

Many of the characteristics of Firm Systems lend themselves to the application of principles of continuous quality improvement (CQI). A Firm System is defined as two or more parallel practices organized on the principle of continuity of relationships between patients and an interdisciplinary group of health care professionals and trainees. Firm Systems are organized around the care of the patient or customer and emphasize access, continuity, and quality of care. The Firm System was implemented at the Cleveland Veterans Affairs Medical Center (VAMC) not as a CQI initiative per se, but as an effort to coordinate the processes involved in the delivery of patient care. The primary goals of this implementation were to improve the quality of patient care, medical education, and health care research. The main strategy to deal with problems caused by uncoordinated care were to move from a departmental approach to an integrated interdisciplinary approach. This approach represented a paradigm shift within the organization that extended to planning, documentation, and the general work environment. Most important, the institution had leaders who were committed to the Firm System and willing to authorize resources to ensure its success. VA hospitals are ideal settings for Firm Systems because they provide longitudinal, comprehensive care with a centralized, prepaid payment mechanism, and they have well-developed information systems that allow the random assignment of patients to Firms. Recommendations to others interested in implementing Firm Systems include creation of a written plan that can gain general support; identification of resources needed for successful implementation; remembering that the patient is the most important customer, as well as that complex systems have many customers; monitoring of performance; and the importance of randomizing patients and providers.
High-performance teams and the physician leader: an overview.

PubMed

Majmudar, Aalap; Jain, Anshu K; Chaudry, Joseph; Schwartz, Richard W

2010-01-01

The complexity of health care delivery within the United States continues to escalate in an exponential fashion driven by an explosion of medical technology, an ever-expanding research enterprise, and a growing emphasis on evidence-based practices. The delivery of care occurs on a continuum that spans across multiple disciplines, now requiring complex coordination of care through the use of novel clinical teams. The use of teams permeates the health care industry and has done so for many years, but confusion about the structure and role of teams in many organizations contributes to limited effectiveness and suboptimal outcomes. Teams are an essential component of graduate medical education training programs. The health care industry's relative lack of focus regarding the fundamentals of teamwork theory has contributed to ineffective team leadership at the physician level. As a follow-up to our earlier manuscripts on teamwork, this article clarifies a model of teamwork and discusses its application to high-performance teams in health care organizations. Emphasized in this discussion is the role played by the physician leader in ensuring team effectiveness. By educating health care professionals on the fundamentals of high-performance teamwork, we hope to stimulate the development of future physician leaders who use proven teamwork principles to achieve the goals of trainee education and excellent patient care. Copyright 2010 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.
The development and optimisation of a primary care-based whole system complex intervention (CARE Plus) for patients with multimorbidity living in areas of high socioeconomic deprivation

PubMed Central

O'Brien, Rosaleen; Fitzpatrick, Bridie; Higgins, Maria; Guthrie, Bruce; Watt, Graham; Wyke, Sally

2016-01-01

Objectives To develop and optimise a primary care-based complex intervention (CARE Plus) to enhance the quality of life of patients with multimorbidity in the deprived areas. Methods Six co-design discussion groups involving 32 participants were held separately with multimorbid patients from the deprived areas, voluntary organisations, general practitioners and practice nurses working in the deprived areas. This was followed by piloting in two practices and further optimisation based on interviews with 11 general practitioners, 2 practice nurses and 6 participating multimorbid patients. Results Participants endorsed the need for longer consultations, relational continuity and a holistic approach. All felt that training and support of the health care staff was important. Most participants welcomed the idea of additional self-management support, though some practitioners were dubious about whether patients would use it. The pilot study led to changes including a revised care plan, the inclusion of mindfulness-based stress reduction techniques in the support of practitioners and patients, and the stream-lining of the written self-management support material for patients. Discussion We have co-designed and optimised an augmented primary care intervention involving a whole-system approach to enhance quality of life in multimorbid patients living in the deprived areas. CARE Plus will next be tested in a phase 2 cluster randomised controlled trial. PMID:27068113
The formation, elements of success, and challenges in managing a critical care program: Part I.

PubMed

St Andre, Arthur

2015-04-01

Leaders of critical care programs have significant responsibility to develop and maintain a system of intensive care. At inception, those clinician resources necessary to provide and be available for the expected range of patient illness and injury and throughput are determined. Simultaneously, non-ICU clinical responsibilities and other expectations, such as education of trainees and participation in hospital operations, must be understood. To meet these responsibilities, physicians must be recruited, mentored, and retained. The physician leader may have similar responsibilities for nonphysician practitioners. In concert with other critical care leaders, the service adopts a model of care and assembles an ICU team of physicians, nurses, nonphysician providers, respiratory therapists, and others to provide clinical services. Besides clinician resources, leaders must assure that services such as radiology, pharmacy, the laboratory, and information services are positioned to support the complexities of ICU care. Metrics are developed to report success in meeting process and outcomes goals. Leaders evolve the system of care by reassessing and modifying practice patterns to continually improve safety, efficacy, and efficiency. Major emphasis is placed on the importance of continuity, consistency, and communication by expecting practitioners to adopt similar practices and patterns. Services anticipate and adapt to evolving expectations and resource availability. Effective services will result when skilled practitioners support one another and ascribe to a service philosophy of care.
Developing Training Programs to Save Lives: Serving Students with Complex or Emergency Healthcare Needs

ERIC Educational Resources Information Center

Urso, Annmarie; Rozalski, Michael

2014-01-01

The number of students with special health care needs (SHCN; McPherson, Arango & Fox, 1998) and the frequency of life-threatening health emergencies in schools (e.g., asthma, diabetes, severe allergic reactions, cardiac arrest, seizure disorders), continues to increase. It has become increasingly important for teachers to be trained in…
Current trends in pharmacy benefit designs: a threat to disease management in chronic complex diseases.

PubMed

Owens, Gary; Emons, Matthew F; Christian-Herman, Jennifer; Lawless, Grant

2007-04-01

With a focus on those patients who are candidates for treatment with biologic agents, we review the impact that current pharmacy benefit trends have on patients with chronic complex diseases and how they affect opportunities for disease management in this unique patient population. Dramatic increases in health care costs have led to a variety of strategies to manage cost. Many of these strategies either limit access to care or increase the patient's responsibility for choosing and paying for care, especially for medications. These strategies have a disproportionate impact on patients with chronic complex diseases, particularly those who require the use of biologic medications. A fundamental prerequisite of disease management has been coverage of disease-modifying therapies. If current pharmacy benefit trends continue, unintended consequences will likely occur including lost opportunities for disease management. Current pharmacy benefit trends could adversely impact disease management, particularly for patients requiring the use of biologic agents. Health plans should consider innovative benefit designs that reflect an appropriate level of cost sharing across all key stake-holders, ensuring appropriate access to needed therapies. Additional research is needed to clarify the value of newer approaches to therapies or benefit design changes.
[Continuity of nutritional care at discharge in the era of ICT].

PubMed

Martínez Olmos, Miguel Ángel

2015-05-07

Telemedicine represents the union of information technology and telecommunication services in health. This allows the improvement of health care, especially in underserved areas, bringing professionals working in continuing education and improving patient care at home. The application of telemedicine in various hospital complexes, clinics and health centers, has helped to provide a better service, within the parameters of efficiency, effectiveness, cost-benefit, with increasing satisfaction of medical staff and patients. The development and application of various types of telemedicine, the technological development of audio, text, video and data, and constant improvement of infrastructure in telecommunications, have favored the expansion and development of telemedicine in various medical specialties. The use of electronic health records by different health professionals can have a positive impact on the care provided to patients. This should also be supported by the development of better health policies, legal security and greater awareness in health professionals and patients regarding the potential benefits. Regarding the clinical activity in Nutrition, new technologies also provide an opportunity to improve in various educational, preventive, diagnostic and treatment aspects, including shared track between Nutrition Units and Primary Care Teams, for patients who need home nutritional care at, with shared protocols, providing teleconsultation in required cases and avoiding unnecessary travel to hospital.
Patient-driven resource planning of a health care facility evacuation.

PubMed

Petinaux, Bruno; Yadav, Kabir

2013-04-01

The evacuation of a health care facility is a complex undertaking, especially if done in an immediate fashion, ie, within minutes. Patient factors, such as continuous medical care needs, mobility, and comprehension, will affect the efficiency of the evacuation and translate into evacuation resource needs. Prior evacuation resource estimates are 30 years old. Utilizing a cross-sectional survey of charge nurses of the clinical units in an urban, academic, adult trauma health care facility (HCF), the evacuation needs of hospitalized patients were assessed periodically over a two-year period. Survey data were collected on 2,050 patients. Units with patients having low continuous medical care needs during an emergency evacuation were the postpartum, psychiatry, rehabilitation medicine, surgical, and preoperative anesthesia care units, the Emergency Department, and Labor and Delivery Department (with the exception of patients in Stage II labor). Units with patients having high continuous medical care needs during an evacuation included the neonatal and adult intensive care units, special procedures unit, and operating and post-anesthesia care units. With the exception of the neonate group, 908 (47%) of the patients would be able to walk out of the facility, 492 (25.5%) would require a wheelchair, and 530 (27.5%) would require a stretcher to exit the HCF. A total of 1,639 patients (84.9%) were deemed able to comprehend the need to evacuate and to follow directions; the remainder were sedated, blind, or deaf. The charge nurses also determined that 17 (6.9%) of the 248 adult intensive care unit patients were too ill to survive an evacuation, and that in 10 (16.4%) of the 61 ongoing surgery cases, stopping the case was not considered to be safe. Heath care facilities can utilize the results of this study to model their anticipated resource requirements for an emergency evacuation. This will permit the Incident Management Team to mobilize the necessary resources both within the facility and the community to provide for the safest evacuation of patients.
An update on the recognition and treatment of non-convulsive status epilepticus in the intensive care unit.

PubMed

Kinney, Michael O; Kaplan, Peter W

2017-10-01

Non-convulsive status epilepticus (NCSE) is a complex and diverse condition which is often an under-recognised entity in the intensive care unit. When NCSE is identified the optimal treatment strategy is not always clear. Areas covered: This review is based on a literature review of the key literature in the field over the last 5-10 years. The articles were selected based on their importance to the field by the authors. Expert commentary: This review discusses the complex situations when a neurological consultation may occur in a critical care setting and provides an update on the latest evidence regarding the recognition of NCSE and the decision making around determining the aggressiveness of treatment. It also considers the ictal-interictal continuum of conditions which may be met with, particularly in the era of continuous EEG, and provides an approach for dealing with these. Suggestions for how the field will develop are discussed.
The art of letting go: referral to palliative care and its discontents.

PubMed

Broom, Alex; Kirby, Emma; Good, Phillip; Wootton, Julia; Adams, Jon

2013-02-01

Accompanying patients from active treatment towards specialist palliative care is a complex sphere of clinical practice that can be fraught with interpersonal and emotional challenges. While medical specialists are expected to break 'bad news' to their patients and ease their transitions to specialist palliative care if required, few have received formal training in such interpersonal complexities. Furthermore, there also often exists clinical ambiguity around whether to continue active treatment vis-à-vis refocusing on quality of life and palliation. In this paper we explore the experiences of twenty Australian medical specialists, focussing on issues such as: dilemmas around when and how to talk about dying and palliation; the art of referral and practices of representation; and, accounts of emotion and subjective influences on referral. The results illustrate how this transitional realm can be embedded in emotions, relationships and the allure of potentially life-prolonging intervention. We argue that the practice of referral should be understood as a relational and contextually-bound process. Copyright © 2012 Elsevier Ltd. All rights reserved.
Collaborative study for the establishment of the 2(nd) International Standard for Bleomycin Complex A2/B2.

PubMed

Jorajuria, S; Raphalen, C; Dujardin, V; Daas, A

2015-01-01

Organization (WHO) International Standard (IS) for bleomycin complex A2/B2. Eight laboratories from different countries participated. Potencies of the candidate material were estimated by microbiological assays with sensitive micro-organisms. To ensure continuity between consecutive batches, the 1(st) IS for bleomycin complex A2/B2 was used as a reference. Based on the results of the study, the 2(nd) IS for bleomycin complex A2/B2 was adopted at the meeting of the WHO Expert Committee for Biological Standardization (ECBS) in 2014 with an assigned potency of 12 500 International Units (IU) per vial. The 2(nd) IS for bleomycin complex A2/B2 is available from the European Directorate for the Quality of Medicines & HealthCare (EDQM).
Introducing the Index of Care: A web-based application supporting archaeological research into health-related care.

PubMed

Tilley, Lorna; Cameron, Tony

2014-09-01

The Index of Care is a web-based application designed to support the recently proposed four-stage 'bioarchaeology of care' methodology for identifying and interpreting health-related care provision in prehistory. The Index offers a framework for guiding researchers in 'thinking through' the steps of a bioarchaeology of care analysis; it continuously prompts consideration of biological and archaeological evidence relevant to care provision; it operationalises key concepts such as 'disability' and 'care'; and it encourages transparency in the reasoning underlying conclusions, facilitating review. This paper describes the aims, structure and content of the Index, and provides an example of its use. The Index of Care is freely available on-line; it is currently in active development, and feedback is sought to improve its utility and usability. This is the first time in bioarchaeology that an instrument for examining behaviour as complex as caregiving has been proposed. Copyright © 2014 Elsevier Inc. All rights reserved.
Integrated versus fragmented implementation of complex innovations in acute health care

PubMed Central

Woiceshyn, Jaana; Blades, Kenneth; Pendharkar, Sachin R.

2017-01-01

Background: Increased demand and escalating costs necessitate innovation in health care. The challenge is to implement complex innovations—those that require coordinated use across the adopting organization to have the intended benefits. Purpose: We wanted to understand why and how two of five similar hospitals associated with the same health care authority made more progress with implementing a complex inpatient discharge innovation whereas the other three experienced more difficulties in doing so. Methodology: We conducted a qualitative comparative case study of the implementation process at five comparable urban hospitals adopting the same inpatient discharge innovation mandated by their health care authority. We analyzed documents and conducted 39 interviews of the health care authority and hospital executives and frontline managers across the five sites over a 1-year period while the implementation was ongoing. Findings: In two and a half years, two of the participating hospitals had made significant progress with implementing the innovation and had begun to realize benefits; they exemplified an integrated implementation mode. Three sites had made minimal progress, following a fragmented implementation mode. In the former mode, a semiautonomous health care organization developed a clear overall purpose and chose one umbrella initiative to implement it. The integrative initiative subsumed the rest and guided resource allocation and the practices of hospital executives, frontline managers, and staff who had bought into it. In contrast, in the fragmented implementation mode, the health care authority had several overlapping, competing innovations that overwhelmed the sites and impeded their implementation. Practice Implications: Implementing a complex innovation across hospital sites required (a) early prioritization of one initiative as integrative, (b) the commitment of additional (traded off or new) human resources, (c) deliberate upfront planning and continual support for and evaluation of implementation, and (d) allowance for local customization within the general principles of standardization. PMID:26469705
Smart telemedicine support for continuous glucose monitoring: the embryo of a future global agent for diabetes care.

PubMed

Rigla, Mercedes

2011-01-01

Although current systems for continuous glucose monitoring (CGM) are the result of progressive technological improvement, and although a beneficial effect on glucose control has been demonstrated, few patients are using them. Something similar has happened to telemedicine (TM); in spite of the long-term experience, which began in the early 1980s, no TM system has been widely adopted, and presential visits are still almost the only way diabetologists and patients communicate. The hypothesis developed in this article is that neither CGM nor TM will ever be routinely implemented separately, and their consideration as essential elements for standard diabetes care will one day come from their integration as parts of a telemedical monitoring platform. This platform, which should include artificial intelligence for giving decision support to patients and physicians, will represent the core of a more complex global agent for diabetes care, which will provide control algorithms and risk analysis among other essential functions. © 2010 Diabetes Technology Society.
Termination of life support after major trauma.

PubMed

Sullivan, D J; Hansen-Flaschen, J

2000-06-01

As the population continues to age, greater numbers and more severely injured elderly patients require care in ICUs. With the attendant increase in the medical complexity of such patients, investigators anticipate that trauma and critical care resources will become increasingly stretched. Because of economic and societal forces, it will become increasingly important for trauma surgeons to appropriately counsel patients and their families regarding the outcome from their injuries and to become comfortable approaching families about withdrawal of support when medical futility is recognized. The authors propose the following guidelines for discussing limitation or termination of life support with patients and their families. Physicians should (1) discuss the patient's wishes regarding life support on admission or early in the hospital course; (2) at the initial discussion, establish who the decision maker will be if the patient is or becomes incapacitated; (3) maintain regular communication and continuity of care; and (4) inevitably, when conflict occurs, involve consultants and a hospital ethics committee for assistance in its resolution.

[The challenge of clinical complexity in the 21st century: Could frailty indexes be the answer?

PubMed

Amblàs-Novellas, Jordi; Espaulella-Panicot, Joan; Inzitari, Marco; Rexach, Lourdes; Fontecha, Benito; Romero-Ortuno, Roman

The number of older people with complex clinical conditions and complex care needs continues to increase in the population. This is presenting many challenges to healthcare professionals and healthcare systems. In the face of these challenges, approaches are required that are practical and feasible. The frailty paradigm may be an excellent opportunity to review and establish some of the principles of comprehensive Geriatric Assessment in specialties outside Geriatric Medicine. The assessment of frailty using Frailty Indexes provides an aid to the 'situational diagnosis' of complex clinical situations, and may help in tackling uncertainty in a person-centred approach. Copyright © 2016 SEGG. Publicado por Elsevier España, S.L.U. All rights reserved.
Ethical, legal, and social issues in the translation of genomics into health care.

PubMed

Badzek, Laurie; Henaghan, Mark; Turner, Martha; Monsen, Rita

2013-03-01

The rapid continuous feed of new information from scientific discoveries related to the human genome makes translation and incorporation of information into the clinical setting difficult and creates ethical, legal, and social challenges for providers. This article overviews some of the legal and ethical foundations that guide our response to current complex issues in health care associated with the impact of scientific discoveries related to the human genome. Overlapping ethical, legal, and social implications impact nurses and other healthcare professionals as they seek to identify and translate into practice important information related to new genomic scientific knowledge. Ethical and legal foundations such as professional codes, human dignity, and human rights provide the framework for understanding highly complex genomic issues. Ethical, legal, and social concerns of the health provider in the translation of genomic knowledge into practice including minimizing harms, maximizing benefits, transparency, confidentiality, and informed consent are described. Additionally, nursing professional competencies related to ethical, legal, and social issues in the translation of genomics into health care are discussed. Ethical, legal, and social considerations in new genomic discovery necessitate that healthcare professionals have knowledge and competence to respond to complex genomic issues and provide appropriate information and care to patients, families, and communities. Understanding the ethical, legal, and social issues in the translation of genomic information into practice is essential to provide patients, families, and communities with competent, safe, effective health care. © 2013 Sigma Theta Tau International.
The struggle for equality in healthcare continues.

PubMed

Rutledge, E O

2001-01-01

All healthcare providers, both institutional and individual, must make every effort to ensure that every person who seeks their medical care is offered competent, sincere, and equal treatment options. Unfortunately, this ideal scenario does not take into account the lack of diversity among care providers and the lack of culturally competent policies within healthcare delivery settings. As a result, many care providers continue to follow racially biased treatment practices and many organizations continue to ignore their public trust of providing fair treatment to everyone, regardless of skin color, gender, economic capabilities, etc. Although developing and implementing a diversity plan and culturally competent policies is very complex practically, politically, and programmatically for traditional institutional care providers, it must be done. The key ingredient to this effort is the absolute commitment and support of the organization's governing bodies and executive management. Institutions can certainly volunteer and begin to develop such programs that foster recruitment, selection, and retention of culturally competent care providers to ensure that equal healthcare is received by their patient populations. However, many institutions are already besieged by too many healthcare challenges to volunteer for such an effort. The Joint Commission on Accreditation of Healthcare Organizations and the National Council of Quality Assurance can certainly help jumpstart this effort by establishing an accreditation standard that requires all healthcare providers to establish and practice culturally competent care within their organizations. Providers must also embrace the diversity that is a part of our society and must not let race or ethnicity be a determining factor in offering treatment options.
'Two sides of the coin'--the value of personal continuity to GPs: a qualitative interview study.

PubMed

Ridd, Matthew; Shaw, Alison; Salisbury, Chris

2006-08-01

Continuity is thought to be important to GPs but the values behind this are unknown. To explore the values that doctors working in general practice attach to continuity of patient care and to outline how these values are applied in practice. In-depth qualitative interview with 24 GPs in England. Participants were purposefully sampled according to personal and practice characteristics. Analysis was thematic, drawing on the constant comparative method. The majority of doctors valued doctor-patient, or personal, continuity in their everyday work. It was most valued in patients with serious, complex or psychological problems. GPs believed that through their personal knowledge of the patient and the doctor-patient relationship, personal continuity enabled them to provide higher quality care. However, the benefits of personal continuity were balanced against problems, and GPs identified personal, professional and external constraints that limited its provision. GPs seemed to have resolved the tension between the benefits, limits and constraints they described by accepting an increased reliance on continuity being provided within teams. Personal continuity may offer important benefits to doctors and patients, but we do not know how unique its values are. In particular, it is not clear whether the same benefits can be achieved within teams, the level at which continuity is increasingly being provided. The relative advantages and limits of the different means of delivering continuity need to be better understood, before further policy changes that affect personal continuity are introduced.
Primary Care Practice Development: A Relationship-Centered Approach

PubMed Central

Miller, William L.; Crabtree, Benjamin F.; Nutting, Paul A.; Stange, Kurt C.; Jaén, Carlos Roberto

2010-01-01

PURPOSE Numerous primary care practice development efforts, many related to the patient-centered medical home (PCMH), are emerging across the United States with few guides available to inform them. This article presents a relationship-centered practice development approach to understand practice and to aid in fostering practice development to advance key attributes of primary care that include access to first-contact care, comprehensive care, coordination of care, and a personal relationship over time. METHODS Informed by complexity theory and relational theories of organizational learning, we built on discoveries from the American Academy of Family Physicians’ National Demonstration Project (NDP) and 15 years of research to understand and improve primary care practice. RESULTS Primary care practices can fruitfully be understood as complex adaptive systems consisting of a core (a practice’s key resources, organizational structure, and functional processes), adaptive reserve (practice features that enhance resilience, such as relationships), and attentiveness to the local environment. The effectiveness of these attributes represents the practice’s internal capability. With adequate motivation, healthy, thriving practices advance along a pathway of slow, continuous developmental change with occasional rapid periods of transformation as they evolve better fits with their environment. Practice development is enhanced through systematically using strategies that involve setting direction and boundaries, implementing sensing systems, focusing on creative tensions, and fostering learning conversations. CONCLUSIONS Successful practice development begins with changes that strengthen practices’ core, build adaptive reserve, and expand attentiveness to the local environment. Development progresses toward transformation through enhancing primary care attributes. PMID:20530396
Leading clinical handover improvement: a change strategy to implement best practices in the acute care setting.

PubMed

Clarke, Christina M; Persaud, Drepaul David

2011-03-01

Many contemporary acute care facilities lack safe and effective clinical handover practices resulting in patient transitions that are vulnerable to discontinuities in care, medical errors, and adverse patient safety events. This article is intended to supplement existing handover improvement literature by providing practical guidance for leaders and managers who are seeking to improve the safety and the effectiveness of clinical handovers in the acute care setting. A 4-stage change model has been applied to guide the application of strategies for handover improvement. Change management and quality improvement principles, as well as concepts drawn from safety science and high-reliability organizations, were applied to inform strategies. A model for handover improvement respecting handover complexity is presented. Strategies targeted to stages of change include the following: 1. Enhancing awareness of handover problems and opportunities with the support of strategic directions, accountability, end user involvement, and problem complexity recognition. 2. Identifying solutions by applying and adapting best practices in local contexts. 3. Implementing locally adapted best practices supported by communication, documentation, and training. 4. Institutionalizing practice changes through integration, monitoring, and active dissemination. Finally, continued evaluation at every stage is essential. Although gaps in handover process and function knowledge remain, efforts to improve handover safety and effectiveness are still possible. Continued evaluation is critical in building this understanding and to ensure that practice changes lead to improvements in patient safety, organizational effectiveness, and patient and provider satisfaction. Through handover knowledge building, fundamental changes in handover policies and practices may be possible.
From Community to Meta-Community Mental Health Care

PubMed Central

Bouras, Nick; Ikkos, George; Craig, Thomas

2018-01-01

Since the 1960s, we have witnessed the development and growth of community mental health care that continues to dominate mental health policy and practice. Several high-income countries have implemented community mental health care programmes but for many others, including mostly low- and middle-income countries, it remains an aspiration. Although community mental health care has been positive for many service users, it has also had severe shortcomings. Expectations that it would lead to fuller social integration have not been fulfilled and many service users remain secluded in sheltered or custodial environments with limited social contacts and no prospect of work. Others receive little or no service at all. In today’s complex landscape of increasingly specialised services for people with mental health problems, the number of possible interfaces between services is increasing. Together with existing uneven financing systems and a context of constant change, these interfaces are challenging us to develop effective care pathways adjusted to the needs of service users and their carers. This discussion paper reviews the developments in community mental health care over the recent years and puts forward the concept of “Meta-Community Mental Health Care”. “Meta-Community Mental Health Care” embraces pluralism in understanding and treating psychiatric disorders, acknowledges the complexities of community provision, and reflects the realities and needs of the current era of care. PMID:29677100
Identification of complex metabolic states in critically injured patients using bioinformatic cluster analysis.

PubMed

Cohen, Mitchell J; Grossman, Adam D; Morabito, Diane; Knudson, M Margaret; Butte, Atul J; Manley, Geoffrey T

2010-01-01

Advances in technology have made extensive monitoring of patient physiology the standard of care in intensive care units (ICUs). While many systems exist to compile these data, there has been no systematic multivariate analysis and categorization across patient physiological data. The sheer volume and complexity of these data make pattern recognition or identification of patient state difficult. Hierarchical cluster analysis allows visualization of high dimensional data and enables pattern recognition and identification of physiologic patient states. We hypothesized that processing of multivariate data using hierarchical clustering techniques would allow identification of otherwise hidden patient physiologic patterns that would be predictive of outcome. Multivariate physiologic and ventilator data were collected continuously using a multimodal bioinformatics system in the surgical ICU at San Francisco General Hospital. These data were incorporated with non-continuous data and stored on a server in the ICU. A hierarchical clustering algorithm grouped each minute of data into 1 of 10 clusters. Clusters were correlated with outcome measures including incidence of infection, multiple organ failure (MOF), and mortality. We identified 10 clusters, which we defined as distinct patient states. While patients transitioned between states, they spent significant amounts of time in each. Clusters were enriched for our outcome measures: 2 of the 10 states were enriched for infection, 6 of 10 were enriched for MOF, and 3 of 10 were enriched for death. Further analysis of correlations between pairs of variables within each cluster reveals significant differences in physiology between clusters. Here we show for the first time the feasibility of clustering physiological measurements to identify clinically relevant patient states after trauma. These results demonstrate that hierarchical clustering techniques can be useful for visualizing complex multivariate data and may provide new insights for the care of critically injured patients.
Care of the elderly program at the University of Alberta

PubMed Central

Charles, Lesley; Dobbs, Bonnie; Triscott, Jean; McKay, Rhianne

2014-01-01

Abstract Problem addressed The population is aging rapidly and there are implications for health care delivery in the face of few physicians specializing in care of the elderly (COE). Objective of program To train physicians wishing to provide COE services. Program description The COE program at the University of Alberta in Edmonton is an enhanced skills diploma program lasting 6 months to 1 year, with core program requirements including geriatric inpatient care, geriatric psychiatry, ambulatory care, continuing care, and outreach. There is a longitudinal clinic component and a research project requirement. The program is designed to cover the 85 core competencies in the CanMEDS– Family Medicine roles. Conclusion There is a need for COE physicians to provide clinical care as well as fill educational, administrative, and research roles to meet the health care needs of medically complex seniors. These physicians require alternative funding and a departmental home within a university if they are to provide an academic service. PMID:25551143
Meeting the Housing and Care Needs of Older Homeless Adults: A Permanent Supportive Housing Program Targeting Homeless Elders

PubMed Central

Brown, Rebecca T.; Thomas, M. Lori; Cutler, Deborah F.; Hinderlie, Mark

2014-01-01

The homeless population is aging faster than the general population in the United States. As this vulnerable population continues to age, addressing complex care and housing needs will become increasingly important. This article reviews the often-overlooked issue of homelessness among older adults, including their poor health status and unique care needs, the factors that contribute to homelessness in this population, and the costs of homelessness to the U.S. health care system. Permanent supportive housing programs are presented as a potential solution to elder homelessness, and Hearth, an outreach and permanent supportive housing model in Boston, is described. Finally, specific policy changes are presented that could promote access to housing among the growing older homeless population. PMID:24729832
Teaching of leprosy: current challenges*

PubMed Central

Alves, Cynthia Rossetti Portela; Ribeiro, Maria Mônica Freitas; Melo, Elza Machado; Araújo, Marcelo Grossi

2014-01-01

In the context of declining leprosy endemicity worldwide, keeping the interest in knowledge and expertise in leprosy alive has been a matter of concern. Approaching the problem only in primary care, without the proper integration with other levels of care in the health system fails to account for the complexity of the disease. Training professionals to work at different levels of health care is a current challenge. The objective of this review was to look for experiences related to the teaching of leprosy both in undergraduate courses in the field of health sciences and in training programs for professionals who work in patient care. We highlight the role of the dermatologist in the management of control programs, diagnosis and treatment of the disease, as well as in the continuous education of other health professionals. PMID:24937820
Activity Diagrams for DEVS Models: A Case Study Modeling Health Care Behavior

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

Ozmen, Ozgur; Nutaro, James J

Discrete Event Systems Specification (DEVS) is a widely used formalism for modeling and simulation of discrete and continuous systems. While DEVS provides a sound mathematical representation of discrete systems, its practical use can suffer when models become complex. Five main functions, which construct the core of atomic modules in DEVS, can realize the behaviors that modelers want to represent. The integration of these functions is handled by the simulation routine, however modelers can implement each function in various ways. Therefore, there is a need for graphical representations of complex models to simplify their implementation and facilitate their reproduction. In thismore » work, we illustrate the use of activity diagrams for this purpose in the context of a health care behavior model, which is developed with an agent-based modeling paradigm.« less
Flood, disaster, and turmoil: social issues in cleft and craniofacial care and crisis relief.

PubMed

Strauss, Ronald P; van Aalst, John A; Fox, Lynn; Stein, Margot; Moses, Michael; Cassell, Cynthia H

2011-11-01

To examine social issues in the conduct of cleft and craniofacial care through relief programs in disrupted crisis contexts. Social, health policy, and ethical analyses. At best, craniofacial team care is multidisciplinary, coordinated, and sustained, requiring a long-term relationship between team members, patients, and families. Disasters and societal turmoil interrupt such relationships, causing craniofacial care to become a secondary concern. Providing craniofacial team care in a crisis setting requires rebuilding disrupted coordination and communication. Crisis relief care involves a complex set of expectations and responsibilities and raises issues such as (1) quality assurance, infection control, appropriate standards of care, and follow-up care/continuity; (2) equity of access to services and clinical ethics in the context of war and/or deprivation; (3) training of visitors in the local nation or site; (4) disciplinary composition of teams, interprofessional communication/rivalry, and credentials of clinicians; (5) ownership of the site and local visitor relations; (6) fundraising and marketing strategies; and (7) ethical issues in the doctor-patient relationship. Specific ethical standards for international cleft and craniofacial care delivery also apply to domestic and global crisis relief contexts. Guidance on issues related to professional experience, informed consent, and continuity of care will help care providers address social and ethical issues raised in crisis relief programs. This paper proposes that the Position Paper of the American Cleft Palate-Craniofacial Association (ACPA) on International Treatment Programs should be used as a template to develop and disseminate a set of standards that apply to crisis relief.
Drawing them in: professional perspectives on the complexities of engaging 'culturally diverse' young people with sexual and reproductive health promotion and care in Sydney, Australia.

PubMed

Botfield, Jessica R; Newman, Christy E; Zwi, Anthony B

2017-04-01

Young people from minority ethnic, migrant and refugee backgrounds are widely recognised as being under-served by mainstream sexual and reproductive healthcare in developed economy nations. This paper documents the views of professionals in Australia on the complexities of, and best practice approaches to, engaging members of this group with sexual and reproductive health promotion and care. Semi-structured interviews were conducted with 23 purposively selected key informants (health service providers, policymakers, academics and community advocates). Interviews were transcribed verbatim and coded in NVivo10 using interpretive thematic analysis. Principles of 'cultural competence' were employed to structure the interpretation of findings. Five key themes reveal pivotal aspects of how professionals work in, and make sense of, this complex field. These may be summarised as: (1) appreciating the complexities of cultural diversity; (2) recognising structural barriers and disincentives to engagement; (3) normalising sexual health; (4) balancing 'youth-friendly' and 'culturally-competent' priorities; and (5) going beyond simple translation. As migration to Australia continues to diversify the population, an integrated, national approach to the design and delivery of sexual and reproductive health promotion and care would be of value, along with training and support for those involved. Implications may have resonance for other countries similarly engaged in facilitating the successful settlement of migrants and refugees.
Community health nursing, wound care, and...ethics?

PubMed

Bell, Sue Ellen

2003-09-01

Because of changing demographics and other factors, patients receiving care for wounds, ostomies, or incontinence are being referred in increasing numbers to community health nursing organizations for initial or continued care. As home-based wound care becomes big business, little discussion is being focused on the moral and ethical issues likely to arise in the high-tech home setting. Progressively more complex and expensive home care relies on family members to take on complicated care regimens in the face of decreasing numbers of allowable skilled nursing home visits. A framework and a principle-based theory for reflection on the character and content of moral and ethical conflicts are provided to encourage informed and competent care of patients in the home. Common moral and ethical conflicts for WOC nurses in the United States are presented. These conflicts include issues of wound care supply procurement; use of documentation to maximize care or profit; problems of quality, care consistency, and caregiver consent; and dilemmas of tiered health care options. The advantages of a framework to address ethical conflicts are discussed.
Eyes on the prize: reflections on the impact of the evolving digital ecology on the librarian as expert intermediary and knowledge coach, 1969-2009.

PubMed

Homan, J Michael

2010-01-01

The 2009 Janet Doe Lecture reflects on the continuing value and increasing return on investment of librarian-mediated services in the constantly evolving digital ecology and complex knowledge environment of the health sciences. The interrelationship of knowledge, decision making based on knowledge, technology used to access and retrieve knowledge, and the important linkage roles of expert librarian intermediaries is examined. Professional experiences from 1969 to 2009, occurring during a time of unprecedented changes in the digital ecology of librarianship, are the base on which the evolving role and value of librarians as knowledge coaches and expert intermediaries are examined. Librarian-mediated services linking knowledge and critical decision making in health care have become more valuable than ever as technology continues to reshape an increasingly complex knowledge environment.
Families’ Priorities Regarding Hospital-to-Home Transitions for Children With Medical Complexity

PubMed Central

O’Brien, Emily R.; Leslie, Laurel K.; Lindenauer, Peter K.; Mangione-Smith, Rita M.

2017-01-01

BACKGROUND: National health care policy recommends that patients and families be actively involved in discharge planning. Although children with medical complexity (CMC) account for more than half of pediatric readmissions, scalable, family-centered methods to effectively engage families of CMC in discharge planning are lacking. We aimed to systematically examine the scope of preferences, priorities, and goals of parents of CMC regarding planning for hospital-to-home transitions and to ascertain health care providers’ perceptions of families’ transitional care goals and needs. METHODS: We conducted semistructured interviews with parents and health care providers at a tertiary care hospital. Interviews were continued until thematic saturation was reached. Interviews were audio recorded, transcribed verbatim, and analyzed to identify emergent themes via a general inductive approach. RESULTS: Thirty-nine in-depth interviews were conducted, including 23 with family caregivers of CMC and 16 with health care providers. Families’ priorities, preferences, and goals for hospital-to-home transitions aligned with 7 domains: effective engagement with health care providers, respect for families’ discharge readiness, care coordination, timely and efficient discharge processes, pain and symptom control, self-efficacy to support recovery and ongoing child development, and normalization and routine. These domains also emerged in interviews with health care providers, although there were minor differences in themes discussed. CONCLUSIONS: Although CMC have diverse transitional care needs, their families’ priorities, preferences, and goals aligned with 7 domains that bridged their hospital admission with reestablishment of a home routine. This research provides essential foundational data to engage families in discharge planning, guiding the operationalization of national health policy recommendations. PMID:27940509
Interprofessional collaboration in the ICU: how to define?

PubMed

Rose, Louise

2011-01-01

The intensive care unit (ICU) is a dynamic, complex and, at times, highly stressful work environment that involves ongoing exposure to the complexities of interprofessional team functioning. Failures of communication, considered examples of poor collaboration among health care professionals, are the leading cause of inadvertent harm across all health care settings. Evidence suggests effective interprofessional collaboration results in improved outcomes for critically ill patients. One recent study demonstrated a link between low standardized mortality ratios and self-identified levels of collaboration. The aim of this paper is to discuss determinants and complexities of interprofessional collaboration, the evidence supporting its impact on outcomes in the ICU, and interventions designed to foster better interprofessional team functioning. Elements of effective interprofessional collaboration include shared goals and partnerships including explicit, complementary and interdependent roles; mutual respect; and power sharing. In the ICU setting, teams continually alter due to large staff numbers, shift work and staff rotations through the institution. Therefore, the ideal 'unified' team working together to provide better care and improve patient outcomes may be difficult to sustain. Power sharing is one of the most complex aspects of interprofessional collaboration. Ownership of specialized knowledge, technical skills, clinical territory, or even the patient, may produce interprofessional conflict when ownership is not acknowledged. Collaboration by definition implies interdependency as opposed to autonomy. Yet, much nursing literature focuses on achievement of autonomy in clinical decision-making, cited to improve job satisfaction, retention and patient outcomes. Autonomy of health care professionals may be an inappropriate goal when striving to foster interprofessional collaboration. Tools such as checklists, guidelines and protocols are advocated, by some, as ways for nurses to gain influence and autonomy in clinical decision-making. Protocols to guide ICU practices such as sedation and weaning reduce the duration of mechanical ventilation in some studies, while others have failed to demonstrate this advantage. Existing organizational strategies that facilitate effective collaboration between health care professionals may contribute to this lack of effect.
Family-centered maternity care for deaf refugees: the patient-centered medical home in action.

PubMed

Balachandra, Shirish K; Carroll, Jennifer K; Fogarty, Colleen T; Finigan, Elizabeth G

2009-12-01

The intersection of 2 underserved populations-refugees and deaf individuals-presents novel challenges to health care systems and has not been described previously. A patient-centered medical home (PCMH) is uniquely equipped to provide outstanding primary care to disadvantaged groups. As an illustrative case study, we present our experience applying principles of the PCMH to address an extremely challenging clinical situation: providing high-quality maternity care to a recently immigrated Vietnamese refugee couple lacking formal language skills. We describe how enhanced access, continuity, coordination, and cultural appropriateness can facilitate favorable outcomes in even daunting circumstances. By collaborating with multiple interpreters, the health center staff, and the extended family, we effectively mobilized an expanded system of care to ensure informed consent and shared decision making, ultimately culminating in a successful labor and vaginal delivery. Through organizational and individual commitment to the tenets of the PCMH, we demonstrate the particular strengths of family medicine training sites in caring for similar patients and families with complex cultural and linguistic barriers to care.
Health and social care management for older adults with multimorbidity: a multiperspective approach.

PubMed

Meranius, Martina Summer; Josefsson, Karin

2017-03-01

Multimorbidity, a condition common among older adults, may be regarded as a failure of a complex system. The aim of this study was to describe the core components in health and social care management for older adults with multimorbidity. A cross-sectional design included two methods: individual interviews and group discussions. A total of 105 participants included older adults with multimorbidity and their relatives, care staff and healthcare policymakers. Data were analysed using content analysis. The results show that seven core components comprise a multiperspective view of health and social care management for older adults with multimorbidity: political steering, leadership, cooperation, competence, support for relatives, availability and continuity. Steps should be taken to ensure that every older adult with multimorbidity has a treatment plan according to a multiperspective view to prevent fragmentation of their health care. This study provides relevant evidence developing a multiperspective model of health and social care management for older adults with multimorbidity. © 2016 Nordic College of Caring Science.

Bourdieu at the bedside: briefing parents in a pediatric hospital.

PubMed

LeGrow, Karen; Hodnett, Ellen; Stremler, Robyn; McKeever, Patricia; Cohen, Eyal

2014-12-01

The philosophy of family-centered care (FCC) promotes partnerships between families and staff to plan, deliver, and evaluate services for children and has been officially adopted by a majority of pediatric hospitals throughout North America. However, studies indicated that many parents have continued to be dissatisfied with their decision-making roles in their child's care. This is particularly salient for parents of children with chronic ongoing complex health problems. These children are dependent upon medical technology and require frequent hospitalizations during which parents must contribute to difficult decisions regarding their child's care. Given this clinical issue, an alternative theoretical perspective was explored to redress this problem. Pierre Bourdieu's theoretical concepts of field, capital, and habitus were used to analyze the hierarchical relationships in pediatric acute care hospitals and to design a briefing intervention aimed at improving parents' satisfaction with decision making in that health care setting. © 2014 John Wiley & Sons Ltd.
Local inpatient units may increase patients' utilization of outpatient services: a comparative cohort-study in Nordland County, Norway.

PubMed

Myklebust, Lars Henrik; Sørgaard, Knut; Wynn, Rolf

2015-01-01

In the last few decades, there has been a restructuring of the psychiatric services in many countries. The complexity of these systems may represent a challenge to patients that suffer from serious psychiatric disorders. We examined whether local integration of inpatient and outpatient services in contrast to centralized institutions strengthened continuity of care. Two different service-systems were compared. Service-utilization over a 4-year period for 690 inpatients was extracted from the patient registries. The results were controlled for demographic variables, model of service-system, central inpatient admission or local inpatient admission, diagnoses, and duration of inpatient stays. The majority of inpatients in the area with local integration of inpatient and outpatient services used both types of care. In the area that did not have beds locally, many patients that had been hospitalized did not receive outpatient follow-up. Predictors of inpatients' use of outpatient psychiatric care were: Model of service-system (centralized vs decentralized), a diagnosis of affective disorder, central inpatient admission only, and duration of inpatient stays. Psychiatric centers with local inpatient units may positively affect continuity of care for patients with severe psychiatric disorders, probably because of a high functional integration of inpatient and outpatient care.
Local inpatient units may increase patients’ utilization of outpatient services: a comparative cohort-study in Nordland County, Norway

PubMed Central

Myklebust, Lars Henrik; Sørgaard, Knut; Wynn, Rolf

2015-01-01

Objectives In the last few decades, there has been a restructuring of the psychiatric services in many countries. The complexity of these systems may represent a challenge to patients that suffer from serious psychiatric disorders. We examined whether local integration of inpatient and outpatient services in contrast to centralized institutions strengthened continuity of care. Methods Two different service-systems were compared. Service-utilization over a 4-year period for 690 inpatients was extracted from the patient registries. The results were controlled for demographic variables, model of service-system, central inpatient admission or local inpatient admission, diagnoses, and duration of inpatient stays. Results The majority of inpatients in the area with local integration of inpatient and outpatient services used both types of care. In the area that did not have beds locally, many patients that had been hospitalized did not receive outpatient follow-up. Predictors of inpatients’ use of outpatient psychiatric care were: Model of service-system (centralized vs decentralized), a diagnosis of affective disorder, central inpatient admission only, and duration of inpatient stays. Conclusion Psychiatric centers with local inpatient units may positively affect continuity of care for patients with severe psychiatric disorders, probably because of a high functional integration of inpatient and outpatient care. PMID:26604843
House Calls: California Program For Homebound Patients Reduces Monthly Spending, Delivers Meaningful Care.

PubMed

Melnick, Glenn A; Green, Lois; Rich, Jeremy

2016-01-01

In 2009 HealthCare Partners Affiliates Medical Group, based in Southern California, launched House Calls, an in-home program that provides, coordinates, and manages care primarily for recently discharged high-risk, frail, and psychosocially compromised patients. Its purpose is to reduce preventable emergency department visits and hospital readmissions. We present data over time from this well-established program to provide an example for other new programs that are being established across the United States to serve this population with complex needs. The findings show that the initial House Calls structure, staffing patterns, and processes differed across the geographic areas that it served, and that they also evolved over time in different ways. In the same time period, all areas experienced a reduction in operating costs per patient and showed substantial reductions in monthly per patient health care spending and hospital utilization after enrollment in the House Calls program, compared to the period before enrollment. Despite more than five years of experience, the program structure continues to evolve and adjust staffing and other features to accommodate the dynamic nature of this complex patient population. Project HOPE—The People-to-People Health Foundation, Inc.
Eliminating Inappropriate Telemetry Monitoring: An Evidence-Based Implementation Guide.

PubMed

Yeow, Raymond Y; Strohbehn, Garth W; Kagan, Calvin M; Petrilli, Christopher M; Krishnan, Jamuna K; Edholm, Karli; Sussman, L Scott; Blanck, Jaime F; Popa, Remus I; Pahwa, Amit K

2018-06-04

In-hospital continuous electrocardiographic monitoring, commonly referred to as telemetry, has allowed for rapid recognition of life-threatening conditions, including complex arrhythmias and myocardial ischemia. However, inappropriate use can lead to unnecessary downstream testing from "false alarms," which in turn affects clinician efficiency and increases health care costs without benefiting patients. For these reasons, the Society of Hospital Medicine's Choosing Wisely campaign recommended use of a protocol-driven discontinuation of telemetry. The American Heart Association (AHA) developed a set of Practice Standards for the appropriate use of telemetry monitoring in 2004, which they updated in 2017. Unfortunately, the AHA Practice Standards have not been widely adopted-with as many as 43% of monitored patients lacking a recommended indication for monitoring. Thus, we created an overview discussing the safety and efficacy of incorporating the AHA Practice Standards and a review of studies highlighting their successful incorporation within patient care workflow. We conclude by outlining an "implementation blueprint" for health system professionals and administrators seeking to change their institution's culture of telemetry use. As the health care landscape continues to shift, enacting high-value initiatives that improve patient safety and efficiency of care will be critical.
UK GPs' and practice nurses' views of continuity of care for patients with type 2 diabetes.

PubMed

Alazri, Mohammed H; Heywood, Philip; Neal, Richard D; Leese, Brenda

2007-04-01

Continuity of care is widely regarded as a core value of primary care. Type 2 diabetes is a common chronic disease with major health, social and economic impacts. Primary health care professionals in many countries are involved in the management of patients with type 2 diabetes, but their perspectives on continuity remain neglected in research. To explore UK GPs' and nurses' experiences of continuity of care for patients with type 2 diabetes in primary care settings. Semi-structured individual interviews were conducted with 16 GPs and 18 practice nurses who manage patients with type 2 diabetes recruited from 20 practices with various organizational structures in Leeds, UK. Three types of continuities were identified: relational continuity from the same health care professional, team continuity from a group of health care professionals and cross-boundary continuity across primary-secondary care settings. Relational continuity was influenced by the quality of the patient-health care professional relationship, policy of the National Health Service (NHS) in the UK (new General Medical Services contract), walk-in centres, the behaviour of receptionists and the structure and systems of the practice. Team and cross-boundary continuities were influenced by the relationship between team members and by effective communication. Relational continuity contributed to more 'personal care', but the usual health care professional might know less about diabetes. Team continuity was important in providing 'physical care', but patients could be confused by conflicting advice from different professionals. Cross-boundary continuity helps to provide 'expert advice', but is dependent upon effective communication. GPs and practice nurses dealing with patients with type 2 diabetes identified three types of continuities, each influenced by several factors. Relational continuity deals better with psychosocial care while team continuity promotes better physical care; therefore, imposing one type of continuity may inhibit good diabetic care. Cross-boundary continuity between primary and secondary care is fundamental to contemporary diabetic services and ways should be found to achieve more effective communication.
Family Medicine Panel Size with Care Teams: Impact on Quality.

PubMed

Angstman, Kurt B; Horn, Jennifer L; Bernard, Matthew E; Kresin, Molly M; Klavetter, Eric W; Maxson, Julie; Willis, Floyd B; Grover, Michael L; Bryan, Michael J; Thacher, Tom D

2016-01-01

The demand for comprehensive primary health care continues to expand. The development of team-based practice allows for improved capacity within a collective, collaborative environment. Our hypothesis was to determine the relationship between panel size and access, quality, patient satisfaction, and cost in a large family medicine group practice using a team-based care model. Data were retrospectively collected from 36 family physicians and included total panel size of patients, percentage of time spent on patient care, cost of care, access metrics, diabetic quality metrics, patient satisfaction surveys, and patient care complexity scores. We used linear regression analysis to assess the relationship between adjusted physician panel size, panel complexity, and outcomes. The third available appointments (P < .01) and diabetic quality (P = .03) were negatively affected by increased panel size. Patient satisfaction, cost, and percentage fill rate were not affected by panel size. A physician-adjusted panel size larger than the current mean (2959 patients) was associated with a greater likelihood of poor-quality rankings (≤25th percentile) compared with those with a less than average panel size (odds ratio [OR], 7.61; 95% confidence interval [CI], 1.13-51.46). Increased panel size was associated with a longer time to the third available appointment (OR, 10.9; 95% CI, 1.36-87.26) compared with physicians with panel sizes smaller than the mean. We demonstrated a negative impact of larger panel size on diabetic quality results and available appointment access. Evaluation of a family medicine practice parameters while controlling for panel size and patient complexity may help determine the optimal panel size for a practice. © Copyright 2016 by the American Board of Family Medicine.
Making sense of polarities in health organizations for policy and leadership.

PubMed

Martin, Carmel M

2010-10-01

Making sense of complex adaptive clinical practice and health systems is a pressing challenge as health services continue to struggle to adapt to changing internal and external constraints. In this Forum, we begin with Dervin's Sense-Making theories and research in communications. This provides a conceptual and theoretical context for this editions research on comparative complexity of family medicine consultations in the USA, models for adaptive leadership in clinical care and social networking to make sense of health promotion challenges for young people. Finally, a Sense-Making schema is proposed. © 2010 Blackwell Publishing Ltd.
Necrotizing enterocolitis: Pathophysiology from a historical context.

PubMed

Hackam, David; Caplan, Michael

2018-02-01

Necrotizing enterocolitis (NEC) continues to afflict approximately 7% of preterm infants born weighing less than 1500g, though recent investigations have provided novel insights into the pathogenesis of this complex disease. The disease has been a major cause of morbidity and mortality in neonatal intensive care units worldwide for many years, and our current understanding reflects exceptional observations made decades ago. In this review, we will describe NEC from a historical context and summarize seminal findings that underscore the importance of enteral feeding, the gut microbiota, and intestinal inflammation in this complex pathophysiology. Copyright © 2018. Published by Elsevier Inc.
Comment on "Redefining the age of Clovis: implications for the peopling of the Americas".

PubMed

Haynes, Gary; Anderson, David G; Ferring, C Reid; Fiedel, Stuart J; Grayson, Donald K; Haynes, C Vance; Holliday, Vance T; Huckell, Bruce B; Kornfeld, Marcel; Meltzer, David J; Morrow, Julie; Surovell, Todd; Waguespack, Nicole M; Wigand, Peter; Yohe, Robert M

2007-07-20

Waters and Stafford (Reports, 23 February 2007, p. 1122) provided useful information about the age of some Clovis sites but have not definitively established the temporal span of this cultural complex in the Americas. Only a continuing program of radiometric dating and careful stratigraphic correlations can address the lingering ambiguity about the emergence and spread of Clovis culture.
KSC-87PC-0266

NASA Image and Video Library

1987-03-16

CAPE CANAVERAL, Fla. -- At Cape Canaveral Air Force Station in Florida, the paylaod fairing of the Delta 182 launch vehicle is carefully moved into place as encapsulation procedures continue on the Palapa B2-P communications satellite at Launch Complex 17, Pad B. Palapa is scheduled for launch from Cape Canaveral for the government of Indonesia. Liftoff of Delta 182 and Palapa is scheduled for March 20. Photo Credit: NASA
Nurse turnover: a literature review - an update.

PubMed

Hayes, Laureen J; O'Brien-Pallas, Linda; Duffield, Christine; Shamian, Judith; Buchan, James; Hughes, Frances; Laschinger, Heather K Spence; North, Nicola

2012-07-01

Concerns related to the complex issue of nursing turnover continue to challenge healthcare leaders in every sector of health care. Voluntary nurse turnover is shown to be influenced by a myriad of inter-related factors, and there is increasing evidence of its negative effects on nurses, patients and health care organizations. The objectives were to conduct a comprehensive review of the related literature to examine recent findings related to the issue of nursing turnover and its causes and consequences, and to identify on methodological challenges and the implications of new evidence for future studies. A comprehensive search of the recent literature related to nursing turnover was undertaken to summarize findings published in the past six years. Electronic databases: MEDLINE, CINAHL and PubMed, reference lists of journal publications. Keyword searches were conducted for publications published 2006 or later that examined turnover or turnover intention in employee populations of registered or practical/enrolled or assistant nurses working in the hospital, long-term or community care areas. Literature findings are presented using an integrative approach and a table format to report individual studies. From about 330 citations or abstracts that were initially scanned for content relevance, 68 studies were included in this summary review. The predominance of studies continues to focus on determinants of nurse turnover in acute care settings. Recent studies offer insight into generational factors that should be considered in strategies to promote stable staffing in healthcare organizations. Nursing turnover continues to present serious challenges at all levels of health care. Longitudinal research is needed to produce new evidence of the relationships between nurse turnover and related costs, and the impact on patients and the health care team. Copyright © 2011 Elsevier Ltd. All rights reserved.
Primary Care-Mental Health Integration in the Veterans Affairs Health System: Program Characteristics and Performance.

PubMed

Cornwell, Brittany L; Brockmann, Laurie M; Lasky, Elaine C; Mach, Jennifer; McCarthy, John F

2018-06-01

The Veterans Health Administration (VHA) has achieved substantial national implementation of primary care-mental health integration (PC-MHI) services. However, little is known regarding program characteristics, variation in characteristics across settings, or associations between program fidelity and performance. This study identified core elements of PC-MHI services and evaluated their associations with program characteristics and performance. A principal-components analysis (PCA) of reports from 349 sites identified factors associated with PC-MHI fidelity. Analyses assessed the correlation among factors and between each factor and facility type (medical center or community-based outpatient clinic), primary care population size, and performance indicators (receipt of PC-MHI services, same-day access to mental health and primary care services, and extended duration of services). PCA identified seven factors: core implementation, care management (CM) assessments and supervision, CM supervision receipt, colocated collaborative care (CCC) by prescribing providers, CCC by behavioral health providers, participation in patient aligned care teams (PACTs) for special populations, and treatment of complex mental health conditions. Sites serving larger populations had greater core implementation scores. Medical centers and sites serving larger populations had greater scores for CCC by prescribing providers, CM assessments and supervision, and participation in PACTs. Greater core implementation scores were associated with greater same-day access. Sites with greater scores for CM assessments and supervision had lower scores for treatment of complex conditions. Outpatient clinics and sites serving smaller populations experienced challenges in integrated care implementation. To enhance same-day access, VHA should continue to prioritize PC-MHI implementation. Providing brief, problem-focused care may enhance CM implementation.
My Team of Care Study: A Pilot Randomized Controlled Trial of a Web-Based Communication Tool for Collaborative Care in Patients With Advanced Cancer.

PubMed

Voruganti, Teja; Grunfeld, Eva; Jamieson, Trevor; Kurahashi, Allison M; Lokuge, Bhadra; Krzyzanowska, Monika K; Mamdani, Muhammad; Moineddin, Rahim; Husain, Amna

2017-07-18

The management of patients with complex care needs requires the expertise of health care providers from multiple settings and specialties. As such, there is a need for cross-setting, cross-disciplinary solutions that address deficits in communication and continuity of care. We have developed a Web-based tool for clinical collaboration, called Loop, which assembles the patient and care team in a virtual space for the purpose of facilitating communication around care management. The objectives of this pilot study were to evaluate the feasibility of integrating a tool like Loop into current care practices and to capture preliminary measures of the effect of Loop on continuity of care, quality of care, symptom distress, and health care utilization. We conducted an open-label pilot cluster randomized controlled trial allocating patients with advanced cancer (defined as stage III or IV disease) with ≥3 months prognosis, their participating health care team and caregivers to receive either the Loop intervention or usual care. Outcome data were collected from patients on a monthly basis for 3 months. Trial feasibility was measured with rate of uptake, as well as recruitment and system usage. The Picker Continuity of Care subscale, Palliative care Outcomes Scale, Edmonton Symptom Assessment Scale, and Ambulatory and Home Care Record were patient self-reported measures of continuity of care, quality of care, symptom distress, and health services utilization, respectively. We conducted a content analysis of messages posted on Loop to understand how the system was used. Nineteen physicians (oncologists or palliative care physicians) were randomized to the intervention or control arms. One hundred twenty-seven of their patients with advanced cancer were approached and 48 patients enrolled. Of 24 patients in the intervention arm, 20 (83.3%) registered onto Loop. In the intervention and control arms, 12 and 11 patients completed three months of follow-up, respectively. A mean of 1.2 (range: 0 to 4) additional healthcare providers with an average total of 3 healthcare providers participated per team. An unadjusted between-arm increase of +11.4 was observed on the Picker scale in favor of the intervention arm. Other measures showed negligible changes. Loop was primarily used for medical care management, symptom reporting, and appointment coordination. The results of this study show that implementation of Loop was feasible. It provides useful information for planning future studies further examining effectiveness and team collaboration. Numerically higher scores were observed for the Loop arm relative to the control arm with respect to continuity of care. Future work is required to understand the incentives and barriers to participation so that the implementation of tools like Loop can be optimized. ClinicalTrials.gov NCT02372994; https://clinicaltrials.gov/ct2/show/NCT02372994 (Archived by WebCite at http://www.webcitation.org/6r00L4Skb). ©Teja Voruganti, Eva Grunfeld, Trevor Jamieson, Allison M Kurahashi, Bhadra Lokuge, Monika K Krzyzanowska, Muhammad Mamdani, Rahim Moineddin, Amna Husain. Originally published in the Journal of Medical Internet Research (http://www.jmir.org), 18.07.2017.
The genome projects: implications for dental practice and education.

PubMed

Wright, J T; Hart, T C

2002-05-01

Information from the Human Genome Project (HGP) and the integration of information from related areas of study and technology will dramatically change health care for the craniofacial complex. Approaches to risk assessment and diagnosis, prevention, early intervention, and management of craniofacial conditions are and will continue to evolve through the application of this new knowledge. While this information will advance our health care abilities, it is clear that the dental profession will face challenges regarding the acquisition, application, transfer, and effective and efficient use of this knowledge with regards to dental research, dental education, and clinical practice. Unraveling the human genomic sequence now allows accurate diagnosis of numerous craniofacial conditions. However, the greatest oral disease burden results from dental caries and periodontal disease that are complex disorders having both hereditary and environmental factors determining disease risk, progression, and course. Disease risk assessment, prevention, and therapy, based on knowledge from the HGP, will likely vary markedly for the different complex conditions affecting the head and neck. Integration of Information from the human genome, comparative and microbial genomics, proteomics, bioinformatics, and related technologies will provide the basis for proactive prevention and intervention and novel and more efficient treatment approaches. Oral health care practitioners will increasingly require knowledge of human genetics and the application of new molecular-based diagnostic and therapeutic technologies.
Labor market work and home care's unpaid caregivers: a systematic review of labor force participation rates, predictors of labor market withdrawal, and hours of work.

PubMed

Lilly, Meredith B; Laporte, Audrey; Coyte, Peter C

2007-12-01

As people continue to age and receive complex health care services at home, concern has arisen about the availability of family caregivers and their ability to combine employment with caregiving. This article evaluates the international research on unpaid caregivers and their labor market choices, highlighting three conclusions: first, caregivers in general are equally as likely to be in the labor force as noncaregivers; second, caregivers are more likely to work fewer hours in the labor market than noncaregivers, particularly if their caring commitments are heavy; and finally, only those heavily involved in caregiving are significantly more likely to withdraw from the labor market than noncaregivers. Policy recommendations are targeting greater access to formal care for "intensive" caregivers and developing workplace policies for employed caregivers.
Challenges to Native American health care.

PubMed

Noren, J; Kindig, D; Sprenger, A

1998-01-01

Native American health care programs face complex and unprecedented challenges resulting from the increased assumption of clinical operations by tribal authorities, shortfalls in Federal funding, modifications in state and Federal health and welfare programs, and intensifying involvement with managed care organizations. These challenges are further complicated by service populations that are increasing at a faster rate than the growth in funding. The authors conducted onsite surveys of 39 Native American health programs in 10 states in order to assess the organizational and management problems they faced. The trend toward transfer of health programs from the Indian Health Service to tribal operation seems likely to continue and accelerate. The survey results indicate that in order for programs to be effective in the long run, they will need to be guided by skilled managers able to adapt to these powerful changes in the health care environment.
Frail elderly patients. New model for integrated service delivery.

PubMed Central

Hébert, Rejean; Durand, Pierre J.; Dubuc, Nicole; Tourigny, André

2003-01-01

PROBLEM BEING ADDRESSED: Given the complex needs of frail older people and the multiplicity of care providers and services, care for this clientele lacks continuity. OBJECTIVE OF PROGRAM: Integrated service delivery (ISD) systems have been developed to improve continuity and increase the efficacy and efficiency of services. PROGRAM DESCRIPTION: The Program of Research to Integrate Services for the Maintenance of Autonomy (PRISMA) is an innovative ISD model based on coordination. It includes coordination between decision makers and managers of different organizations and services; a single entry point; a case-management process; individualized service plans; a single assessment instrument based on clients' functional autonomy, coupled with a case-mix classification system; and a computerized clinical chart for communicating between institutions and professionals for client monitoring. CONCLUSION: Preliminary results on the efficacy of this model showed a decreased incidence of functional decline, a decreased burden for caregivers, and a smaller proportion of older people wishing to enter institutions. PMID:12943358
The care delivery experience of hospitalized patients with complex chronic disease.

PubMed

Kuluski, Kerry; Hoang, Sylvia N; Schaink, Alexis K; Alvaro, Celeste; Lyons, Renee F; Tobias, Roy; Bensimon, Cécile M

2013-12-01

This study investigated what is important in care delivery from the perspective of hospital inpatients with complex chronic disease, a currently understudied population. One-on-one semi-structured interviews were conducted with inpatients at a continuing care/rehabilitation hospital (n = 116) in Canada between February and July 2011. The study design was mixed methods and reports on patient characteristics and care delivery experiences. Basic descriptive statistics were run using SPSS version 17, and thematic analysis on the transcripts was conducted using NVivo9 software. Patients had an average of 5 morbidities and several illness symptoms including activity of daily living impairments, physical pain and emotional disturbance. Three broad themes (each with one or more subthemes) were generated from the data representing important components of care delivery: components of the care plan (a comprehensive assessment, supported transitions and a bio-psycho-social care package); care capacity and quality (optimal staff to patient ratios, quicker response times, better patient-provider communication and consistency between providers) and the patient-provider relationships (characterized by respect and dignity). As health systems throughout the industrialized world move to sustain health budgets while optimizing quality of care, it is critical to better understand this population, so that appropriate metrics, services and policies can be developed. The study has generated a body of evidence on the important components of care delivery from the perspectives of a diverse group of chronically ill individuals who have spent a considerable amount of time in the health-care system. Moving forward, exploration around the appropriate funding models and skill mix is needed to move the evidence into changed practice. © 2013 John Wiley & Sons Ltd.
Integrated care in the emergency department: a complex adaptive systems perspective.

PubMed

Nugus, Peter; Carroll, Katherine; Hewett, David G; Short, Alison; Forero, Roberto; Braithwaite, Jeffrey

2010-12-01

Emergency clinicians undertake boundary-work as they facilitate patient trajectories through the Emergency Department (ED). Emergency clinicians must manage the constantly-changing dynamics at the boundaries of the ED and other hospital departments and organizations whose services emergency clinicians seek to integrate. Integrating the care that differing clinical groups provide, the services EDs offer, and patients' needs across this journey is challenging. The journey is usually accounted for in a linear way - as a "continuity of care" problem. In this paper, we instead conceptualize integrated care in the ED using a complex adaptive systems (CAS) perspective. A CAS perspective accounts for the degree to which other departments and units outside of the ED are integrated, and appropriately described, using CAS concepts and language. One year of ethnographic research was conducted, combining observation and semi-structured interviews, in the EDs of two tertiary referral hospitals in Sydney, Australia. We found the CAS approach to be salient to analyzing integrated care in the ED because the processes of categorization, diagnosis and discharge are primarily about the linkages between services, and the communication and negotiation required to enact those linkages, however imperfectly they occur in practice. Emergency clinicians rapidly process large numbers of high-need patients, in a relatively efficient system of care inadequately explained by linear models. A CAS perspective exposes integrated care as management of the patient trajectory within porous, shifting and negotiable boundaries. Copyright © 2010 Elsevier Ltd. All rights reserved.

Exploring staff diabetes medication knowledge and practices in regional residential care: triangulation study.

PubMed

Wellard, Sally Jane; Rasmussen, Bodil; Savage, Sally; Dunning, Trisha

2013-07-01

This study is drawn from a larger project that aimed to identify the staffing and organisational factors influencing the quality of diabetes care for older people living in residential care in regional Victoria, Australia. The focus of the current study is on medication management for residents with diabetes. With a continuous rise in diabetes in the population, there is an associated increase in the prevalence of diabetes in aged care residential settings. However, there is little specific guidance on how to manage diabetes in older people living in institutional settings who experience multiple concurrent chronic conditions. A triangulation strategy consisting of three phases. A one-shot cross-sectional survey (n = 68) focus group interviews and a case file audit (n = 20). Data were collected between May 2009-January 2010. Staff knowledge of diabetes and its contemporary medication management was found to be suboptimal. Challenges to managing residents with diabetes included limited time, resident characteristics and communication systems. Additionally, the variability in medical support available to residents and a high level of polypharmacy added to the complexity of medication management of resident. The current study suggests administering medicine to residents in aged care settings is difficult and has potentially serious medical, professional and economic consequences. Limitations to staff knowledge of contemporary diabetes care and medications potentially place residents with diabetes at risk of receiving less than optimal diabetes care. Providing evidence-based guidelines about diabetes care in residential care settings is essential to achieve acceptable outcomes and increase the quality of life for residents in public aged care. Continuing education programs in diabetes care specifically related to medication must be provided to all health professionals and encompass scope of practice. © 2013 John Wiley & Sons Ltd.
Caring for women wanting a vaginal birth after previous caesarean section: A qualitative study of the experiences of midwives and obstetricians.

PubMed

Foureur, Maralyn; Turkmani, Sabera; Clack, Danielle C; Davis, Deborah L; Mollart, Lyndall; Leiser, Bernadette; Homer, Caroline S E

2017-02-01

One of the greatest contributors to the overall caesarean section rate is elective repeat caesarean section. Decisions around mode of birth are often complex for women and influenced by the views of the doctors and midwives who care for and counsel women. Women may be more likely to choose a repeat elective caesarean section (CS) if their health care providers lack skills and confidence in supporting vaginal birth after caesarean section (VBAC). To explore the views and experiences of providers in caring for women considering VBAC, in particular the decision-making processes and the communication of risk and safety to women. A descriptive interpretive method was utilised. Four focus groups with doctors and midwives were conducted. The central themes were: 'developing trust', 'navigating the system' and 'optimising support'. The impact of past professional experiences; the critical importance of continuity of carer and positive relationships; the ability to weigh up risks versus benefits; and the language used were all important elements. The role of policy and guidelines on providing standardised care for women who had a previous CS was also highlighted. Midwives and doctors in this study were positively oriented towards assisting and supporting women to attempt a VBAC. Care providers considered that women who have experienced a prior CS need access to midwifery continuity of care with a focus on support, information-sharing and effective communication. Copyright © 2016 Australian College of Midwives. Published by Elsevier Ltd. All rights reserved.
A Marxian interpretation of the growth and development of coronary care technology.

PubMed Central

Waitzkin, H

1979-01-01

Cost containment efforts will fail if they continue to ignore the structural relationships between health care costs and private profit in capitalist society. The recent history of coronary care shows that apparent irrationalities of health policy make sense from the standpoint of capitalist profit structure. Coronary care units (CCUs) gained wide acceptance, despite high costs. Studies of CCU effectiveness, using random controlled trials and epidemiologic techniques, do not show a consistent advantage of CCUs over non-intensive ward care or simple rest at home. From a Marxian perspective, the proliferation of CCUs and similar innovations is a complex historical process that includes initiatives by industrial corporations, cooperation by clinical investigators at academic medical centers, support by private philanthropies linked to corporate interests, intervention by state agencies, and changes in the health care labor force. Cost-effective methodology obscures the profit motive as a basic source of high costs and ineffective practices. Health-policy alternatives curtailing corporate involvement in medicine would reduce costs by restricting profit. PMID:116553
The Productive Ward program™: a longitudinal multilevel study of nurse perceived practice environment, burnout, and nurse-reported quality of care and job outcomes.

PubMed

Van Bogaert, Peter; Van heusden, Danny; Somers, Annemie; Tegenbos, Muriel; Wouters, Kristien; Van der Straeten, Johnny; Van Aken, Paul; Havens, Donna Sullivan

2014-09-01

The objective of this study was to investigate the impact of The Productive Ward-Releasing Time to Care™ program implemented in a hospital transformation process on nurse perception related to practice environment, burnout, quality of care, and job outcomes. To address the continuously evolving complex challenges of patient care, high-performance nursing care is necessary. A longitudinal survey design was used to conduct a study in a 600-bed acute care university hospital with 3 measurement periods: T0: base line in 2006, T1 in 2011, and T2 in 2013. As part of the hospital transformation process, the productive ward program was introduced between T1 and T2. Relevant impact on nurse-physician relations, nurse management, hospital management-organizational support, nurse-reported quality of care, and job outcomes were identified. Hospital strategies and policies should be aligned with daily practices so that engaged and committed staff can promote excellent outcomes.
A telemedicine health care delivery system

NASA Technical Reports Server (NTRS)

Sanders, Jay H.

1991-01-01

The Interactive Telemedicine Systems (ITS) system was specifically developed to address the ever widening gap between our medical care expertise and our medical care delivery system. The frustrating reality is that as our knowledge of how to diagnose and treat medical conditions has continued to advance, the system to deliver that care has remained in an embryonic stage. This has resulted in millions of people being denied their most basic health care needs. Telemedicine utilizes an interactive video system integrated with biomedical telemetry that allows a physician at a base station specialty medical complex or teaching hospital to examine and treat a patient at multiple satellite locations, such as rural hospitals, ambulatory health centers, correctional institutions, facilities caring for the elderly, community hospital emergency departments, or international health facilities. Based on the interactive nature of the system design, the consulting physician at the base station can do a complete history and physical examination, as if the patient at the satellite site was sitting in the physician's office. This system is described.
The promise of Lean in health care.

PubMed

Toussaint, John S; Berry, Leonard L

2013-01-01

An urgent need in American health care is improving quality and efficiency while controlling costs. One promising management approach implemented by some leading health care institutions is Lean, a quality improvement philosophy and set of principles originated by the Toyota Motor Company. Health care cases reveal that Lean is as applicable in complex knowledge work as it is in assembly-line manufacturing. When well executed, Lean transforms how an organization works and creates an insatiable quest for improvement. In this article, we define Lean and present 6 principles that constitute the essential dynamic of Lean management: attitude of continuous improvement, value creation, unity of purpose, respect for front-line workers, visual tracking, and flexible regimentation. Health care case studies illustrate each principle. The goal of this article is to provide a template for health care leaders to use in considering the implementation of the Lean management system or in assessing the current state of implementation in their organizations. Copyright © 2013 Mayo Foundation for Medical Education and Research. Published by Elsevier Inc. All rights reserved.
Wearable Contact Lens Biosensors for Continuous Glucose Monitoring Using Smartphones.

PubMed

Elsherif, Mohamed; Hassan, Mohammed Umair; Yetisen, Ali K; Butt, Haider

2018-05-17

Low-cost, robust, and reusable continuous glucose monitoring systems that can provide quantitative measurements at point-of-care settings is an unmet medical need. Optical glucose sensors require complex and time-consuming fabrication processes, and their readouts are not practical for quantitative analyses. Here, a wearable contact lens optical sensor was created for the continuous quantification of glucose at physiological conditions, simplifying the fabrication process and facilitating smartphone readouts. A photonic microstructure having a periodicity of 1.6 μm was printed on a glucose-selective hydrogel film functionalized with phenylboronic acid. Upon binding with glucose, the microstructure volume swelled, which modulated the periodicity constant. The resulting change in the Bragg diffraction modulated the space between zero- and first-order spots. A correlation was established between the periodicity constant and glucose concentration within 0-50 mM. The sensitivity of the sensor was 12 nm mM -1 , and the saturation response time was less than 30 min. The sensor was integrated with commercial contact lenses and utilized for continuous glucose monitoring using smartphone camera readouts. The reflected power of the first-order diffraction was measured via a smartphone application and correlated to the glucose concentrations. A short response time of 3 s and a saturation time of 4 min was achieved in the continuous monitoring mode. Glucose-sensitive photonic microstructures may have applications in point-of-care continuous monitoring devices and diagnostics at home settings.
Development of a new continuous process for mixing of complex non-Newtonian fluids

NASA Astrophysics Data System (ADS)

Migliozzi, Simona; Mazzei, Luca; Sochon, Bob; Angeli, Panagiota; Thames Multiphase Team; Coral Project Collaboration

2017-11-01

Design of new continuous mixing operations poses many challenges, especially when dealing with highly viscous non-Newtonian fluids. Knowledge of complex rheological behaviour of the working mixture is crucial for development of an efficient process. In this work, we investigate the mixing performance of two different static mixers and the effects of the mixture rheology on the manufacturing of novel non-aqueous-based oral care products using experimental and computational fluid dynamic methods. The two liquid phases employed, i.e. a carbomer suspension in polyethylene glycol and glycerol, start to form a gel when they mix. We studied the structure evolution of the liquid mixture using time-resolved rheometry and we obtained viscosity rheograms at different phase ratios from pressure drop measurements in a customized mini-channel. The numerical results and rheological model were validated with experimental measurements carried out in a specifically designed setup. EPSRS-CORAL.
Eyes on the prize: reflections on the impact of the evolving digital ecology on the librarian as expert intermediary and knowledge coach, 1969–2009*

PubMed Central

Homan, J. Michael

2010-01-01

Objective: The 2009 Janet Doe Lecture reflects on the continuing value and increasing return on investment of librarian-mediated services in the constantly evolving digital ecology and complex knowledge environment of the health sciences. Setting: The interrelationship of knowledge, decision making based on knowledge, technology used to access and retrieve knowledge, and the important linkage roles of expert librarian intermediaries is examined. Methodology: Professional experiences from 1969 to 2009, occurring during a time of unprecedented changes in the digital ecology of librarianship, are the base on which the evolving role and value of librarians as knowledge coaches and expert intermediaries are examined. Conclusion: Librarian-mediated services linking knowledge and critical decision making in health care have become more valuable than ever as technology continues to reshape an increasingly complex knowledge environment. PMID:20098655
Feasibility of a Team Approach to Complex Congenital Heart Defect Neurodevelopmental Follow-Up: Early Experience of a Combined Cardiology/Neonatal Intensive Care Unit Follow-Up Program.

PubMed

Chorna, Olena; Baldwin, H Scott; Neumaier, Jamie; Gogliotti, Shirley; Powers, Deborah; Mouvery, Amanda; Bichell, David; Maitre, Nathalie L

2016-07-01

Infants with complex congenital heart disease are at high risk for poor neurodevelopmental outcomes. However, implementation of dedicated congenital heart disease follow-up programs presents important infrastructure, personnel, and resource challenges. We present the development, implementation, and retrospective review of 1- and 2-year outcomes of a Complex Congenital Heart Defect Neurodevelopmental Follow-Up program. This program was a synergistic approach between the Pediatric Cardiology, Cardiothoracic Surgery, Pediatric Intensive Care, and Neonatal Intensive Care Unit Follow-Up teams to provide a feasible and responsible utilization of existing infrastructure and personnel, to develop and implement a program dedicated to children with congenital heart disease. Trained developmental testers administered the Ages and Stages Questionnaire-3 over the phone to the parents of all referred children at least once between 6 and 12 months' corrected age. At 18 months' corrected age, all children were scheduled in the Neonatal Intensive-Care Unit Follow-Up Clinic for a visit with standardized neurological exams, Bayley III, multidisciplinary therapy evaluations and continued follow-up. Of the 132 patients identified in the Cardiothoracic Surgery database and at discharge from the hospital, a total number of 106 infants were reviewed. A genetic syndrome was identified in 23.4% of the population. Neuroimaging abnormalities were identified in 21.7% of the cohort with 12.8% having visibly severe insults. As a result, 23 (26.7%) received first-time referrals for early intervention services, 16 (13.8%) received referrals for new services in addition to their existing ones. We concluded that utilization of existing resources in collaboration with established programs can ensure targeted neurodevelopmental follow-up for all children with complex congenital heart disease. © 2016 American Heart Association, Inc.
Australian diagnosis related groups: Drivers of complexity adjustment.

PubMed

Jackson, Terri; Dimitropoulos, Vera; Madden, Richard; Gillett, Steve

2015-11-01

In undertaking a major revision to the Australian Refined Diagnosis Related Group (ARDRG) classification, we set out to contrast Australia's approach to using data on additional (not principal) diagnoses with major international approaches in splitting base or Adjacent Diagnosis Related Groups (ADRGs). Comparative policy analysis/narrative review of peer-reviewed and grey literature on international approaches to use of additional (secondary) diagnoses in the development of Australian and international DRG systems. European and US approaches to characterise complexity of inpatient care are well-documented, providing useful points of comparison with Australia's. Australia, with good data sources, has continued to refine its national DRG classification using increasingly sophisticated approaches. Hospital funders in Australia and in other systems are often under pressure from provider groups to expand classifications to reflect clinical complexity. DRG development in most healthcare systems reviewed here reflects four critical factors: these socio-political factors, the quality and depth of the coded data available to characterise the mix of cases in a healthcare system, the size of the underlying population, and the intended scope and use of the classification. Australia's relatively small national population has constrained the size of its DRG classifications, and development has been concentrated on inpatient care in public hospitals. Development of casemix classifications in health care is driven by both technical and socio-political factors. Use of additional diagnoses to adjust for patient complexity and cost needs to respond to these in each casemix application. Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.
42 CFR 441.60 - Continuing care.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 42 Public Health 4 2010-10-01 2010-10-01 false Continuing care. 441.60 Section 441.60 Public... Periodic Screening, Diagnosis, and Treatment (EPSDT) of Individuals Under Age 21 § 441.60 Continuing care. (a) Continuing care provider. For purposes of this subpart, a continuing care provider means a...
The Role of the Advanced Practice Nurse in Geriatric Oncology Care.

PubMed

Morgan, Brianna; Tarbi, Elise

2016-02-01

To describe how the Advanced Practice Nurse (APN) is uniquely suited to meet the needs of older adults throughout the continuum of cancer, to explore the progress that APNs have made in gero-oncology care, and make suggestions for future directions. Google Scholar, PubMed, and CINAHL. Search terms included: "gero-oncology," "geriatric oncology," "Advanced Practice Nurse," "Nurse Practitioner," "older adult," "elderly," and "cancer." Over the last decade, APNs have made advances in caring for older adults with cancer by playing a role in prevention, screening, and diagnosis; through evidence-based gero-oncology care during cancer treatment; and in designing tailored survivorship care models. APNs must combat ageism in treatment choice for older adults, standardize comprehensive geriatric assessments, and focus on providing person-centered care, specifically during care transitions. APNs are well-positioned to help understand the complex relationship between risk factors, geriatric syndromes, and frailty and translate research into practice. Palliative care must expand beyond specialty providers and shift toward APNs with a focus on early advanced care planning. Finally, APNs should continue to establish multidisciplinary survivorship models across care settings, with a focus on primary care. Copyright © 2015 Elsevier Inc. All rights reserved.
Making the invisible, visible.

PubMed

Warner, H K

2000-01-01

Special needs children experience all the difficulties experienced by any child admitted to hospital although these are hugely magnified. Parents continue to carry the burden of care, even after hospital admission, when their child has complex needs. Nurses need to remember that these children have all the needs of any child in addition to needs specific to their disability. Nurses should focus what the child can do, rather than what they cannot do.
Efficiency of specialist rehabilitation in reducing dependency and costs of continuing care for adults with complex acquired brain injuries

PubMed Central

Turner‐Stokes, L; Paul, S; Williams, H

2006-01-01

Objectives To examine functional outcomes from a rehabilitation programme and to compare two methods for evaluating cost efficiency of rehabilitation in patients with severe complex disability. Subjects and setting Two hundred and ninety seven consecutive admissions to a specialist inpatient rehabilitation unit following severe acquired brain injury. Methods Retrospective analysis of routinely collected data, including the Functional Independence Measure (FIM), Barthel Index, and Northwick Park Dependency Score and Care Needs Assessment (NPDS/NPCNA), which provides a generic estimation of dependency, care hours. and weekly cost of continuing care in the community. Patients were analysed in three groups according to dependency on admission: “low” (NPDS<10 (n = 83)); “medium” (NPDS10–24 (n = 112)); “high” (NPDS >24 (n = 102)). Results Mean length of stay (LOS) 112 (SD 66) days. All groups showed significant reduction in dependency between admission and discharge on all measures (paired t tests: p<0.001). Mean reduction in “weekly cost of care” was greatest in the high dependency group at £639 per week (95% CI 488 to 789)), as compared with the medium (£323/week (95% CI 217 to 428)), and low (£111/week (95% CI 42 to 179)) dependency groups. Despite their longer LOS, time taken to offset the initial cost of rehabilitation was only 16.3 months in the high dependency group, compared with 21.5 months (medium dependency) and 38.8 months (low dependency). FIM efficiency (FIM gain/LOS) appeared greatest in the medium dependency group (0.25), compared with the low (0.17) and high (0.16) dependency groups. Conclusions The NPDS/NPCNA detected changes in dependency potentially associated with substantial savings in the cost of ongoing care, especially in high dependency patients. Floor effects in responsiveness of the FIM may lead to underestimation of efficiency of rehabilitation in higher dependency patients. PMID:16614023
Outcomes of clinical decision support (CDS) and correlates of CDS use for home care patients with high medication regimen complexity: A randomized trial

PubMed Central

McDonald, Margaret V.; Feldman, Penny H.; Barrón-Vayá, Yolanda; Peng, Timothy R.; Sridharan, Sridevi; Pezzin, Liliana E.

2017-01-01

Objective To assess the outcomes of a clinical decision support (CDS) intervention designed for home care patients with high medication regimen complexity (MRC) and to examine the correlates of CDS use and its relationship to patient outcomes. Method The intervention randomized nurses upon identification of an eligible patient. The CDS consisted of a computerized algorithm that identified high MRC patients, electronic clinician alerts, and a care management module. Analyses were completed on full intention to treat and intervention group-only samples. Regression-adjusted outcomes were hospitalization, emergency department use and reduction in MRC. Data sources included health records and administrative data. Results Five hundred nurses were randomized with 7,919 of their patients. Approximately 20% of the intervention group was hospitalized versus 21% in the control group; 16.5% of the intervention group had an emergency department visit versus 16.7% in the control group; and 6% in each group dropped below the high MRC threshold. No statistically significant differences were found in the intention to treat analysis. Eighty-two percent of intervention nurses used the CDS but for only 42% of their patients. Among intervention patients, CDS use (versus non-use) was associated with reduced MRC and hospitalization. CDS use was more likely among older nurses, those with higher study-patient caseload and, marginally, among salaried nurses and those with longer tenure. Significant patient characteristics were clinical conditions, payer, episode length, care continuity and race. Conclusion CDS use was limited, thus negating the impact of the intervention overall. The findings on correlates of CDS use and the relationship between CDS use and positive outcomes suggest that CDS use and outcomes could be enhanced by avoiding very short patient lengths of stay, improving continuity of care, increasing reliance on salaried nurses and/or increasing per diem nurses’ incentives to use CDS. PMID:26009977
[Regional protocol for adjusting the therapeutic intensity. Southern Metropolitan Area of Barcelona].

PubMed

Fontecha-Gómez, Benito Jesús; Amblàs-Novellas, Jordi; Betancor-Santana, Évora; Rexach-Cano, Lourdes; Ugarte, Marina Isabel; López-Pérez, Araceli; Planas, Kenneth; Gutiérrez Jiménez, Nuria; Casas Floriano, Rosario; García-Fortea, Cristina; Serrano Bermúdez, Gala; Rotllàn-Terradellas, María; Fernández-Ponce, Daniel

2018-02-20

The identification of patients with advanced and complex chronic diseases, and the fragmentation of care towards the end of life, requires the drawing up a long-term therapeutic plan. This should take into account the values and preferences of the patients, as well as the vital and functional prognosis. Having an adjustment tool for determining the diagnostic and therapeutic effort is helpful in the continuity of care, as well as in decision-making in the transitions and dynamic changes of patients as they approach the end of life process. Copyright © 2018 SEGG. Publicado por Elsevier España, S.L.U. All rights reserved.
Capacity building in pediatric transplant infectious diseases: an international perspective.

PubMed

Danziger-Isakov, Lara; Evans, Helen M; Green, Michael; McCulloch, Mignon; Michaels, Marian G; Posfay-Barbe, Klara M; Verma, Anita; Allen, Upton

2014-12-01

Transplant infectious diseases is a rapidly emerging subspecialty within pediatric infectious diseases reflecting the increasing volumes and complexity of this patient population. Incorporating transplant infectious diseases into the transplant process would provide an opportunity to improve clinical outcome and advocacy as well as expand research. The relationship between transplant physicians and infectious diseases (ID) specialists is one of partnership, collaboration, and mutual continuing professional education. The ID CARE Committee of the International Pediatric Transplant Association (IPTA) views the development and integration of transplant infectious diseases into pediatric transplant care as an international priority. © 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.
Cognitive Support During High-Consequence Episodes of Care in Cardiovascular Surgery.

PubMed

Conboy, Heather M; Avrunin, George S; Clarke, Lori A; Osterweil, Leon J; Christov, Stefan C; Goldman, Julian M; Yule, Steven J; Zenati, Marco A

2017-03-01

Despite significant efforts to reduce preventable adverse events in medical processes, such events continue to occur at unacceptable rates. This paper describes a computer science approach that uses formal process modeling to provide situationally aware monitoring and management support to medical professionals performing complex processes. These process models represent both normative and non-normative situations, and are validated by rigorous automated techniques such as model checking and fault tree analysis, in addition to careful review by experts. Context-aware Smart Checklists are then generated from the models, providing cognitive support during high-consequence surgical episodes. The approach is illustrated with a case study in cardiovascular surgery.
A qualitative follow-up study of diabetes patients' appraisal of an integrated diabetes service in primary care.

PubMed

Burridge, Letitia H; Foster, Michele M; Donald, Maria; Zhang, Jianzhen; Russell, Anthony W; Jackson, Claire L

2017-05-01

As the prevalence of type 2 diabetes continues to escalate, health system reform is seeking better patient outcomes through new models of care that aim to provide the most appropriate care when needed. Patients' experiences of service innovations can shed light on the successes and challenges of implementing change. This paper explores patients' views of a new model of integrated care for patients with type 2 diabetes. A mixed-methods, randomised control trial evaluated a beacon clinic model of care for complex type 2 diabetes led by specialist general practitioners (GPs) in primary care settings in Brisbane, Australia. In this qualitative sub-study conducted between May 2014 and January 2015, 25 consenting participants were re-interviewed after 12 months using semi-structured questions, to explore their experiences of the new model of care. Interview transcripts were analysed thematically. In the first theme, Organised for patient-centred care, patients appraised the structural elements of the clinic. For most, it was an enabling experience which included convenience, flexibility and prompt communication back to the referring GPs. The preferences of a minority were partly realised, as they tried to understand the clinical purpose in comparison with traditional care. The second theme, Positioned as partners in care, revealed the pivotal role of patient-clinician relationships in patients' engagement with advice and self-care. Most found clinicians' collaborative approach engaging and motivating. A small minority with contextual concerns were disappointed with the focus on diabetes and struggled to engage fully with the model. Most participants valued this model of care, which reflects a capacity to manage the variable and complex needs of most patients referred for care. However, multi-level strategies are also needed to enhance patients' engagement with care and the sustainability of integrated diabetes care. © 2016 John Wiley & Sons Ltd.

Palliative care for people with dementia in the terminal phase: a mixed-methods qualitative study to inform service development.

PubMed

van der Steen, Jenny T; Lemos Dekker, Natashe; Gijsberts, Marie-José H E; Vermeulen, Laura H; Mahler, Margje M; The, B Anne-Mei

2017-04-28

When entering the dying phase, the nature of physical, psychosocial and spiritual care needs of people with dementia and their families may change. Our objective was to understand what needs to be in place to develop optimal palliative care services for the terminal phase in the face of a small evidence base. In 2015-2016, we performed a mixed-methods qualitative study in which we (1) analysed the domains and recommendations from the European Association for Palliative Care (EAPC) dementia white paper and identified those with particular relevance for the terminal phase; (2) performed a series of focus group discussions with Dutch family caregivers of people with dementia in variable stages; (3) conducted interviews with experts involved in 15 special forms of terminal care for people with dementia in five countries. The terminal phase was defined as dying but because of the difficulty predicting it, we included advanced dementia. We initially analysed the three parts separately, followed by an integrated analysis of (1)-(3) to inform service development. (1) The EAPC domain of "avoiding overly aggressive, burdensome, or futile treatment" was regarded of particular relevance in the terminal phase, along with a number of recommendations that refer to providing of comfort. (2) Families preferred continuity in care and living arrangements. Despite a recognition that this was a time when they had complex support needs, they found it difficult to accept involvement of a large team of unfamiliar (professional) caregivers. Mostly, terminal care was preferred at the place of residence. (3) The expert interviews identified preferred, successful models in which a representative of a well-trained team has the time, authority and necessary expertise to provide care and education of staff and family to where people are and which ensure continuity of relationships with and around the patient. A mobile team that specializes in palliative care in dementia and supports professional and family caregivers is a promising model. Compared to transfer to a hospice in the last weeks or days, it has the potential to address the priorities of families and patients for continuity of care, relationships and specialist expertise.
Continuity of care to optimize chronic disease management in the community setting: an evidence-based analysis.

PubMed

2013-01-01

This evidence-based analysis reviews relational and management continuity of care. Relational continuity refers to the duration and quality of the relationship between the care provider and the patient. Management continuity ensures that patients receive coherent, complementary, and timely care. There are 4 components of continuity of care: duration, density, dispersion, and sequence. The objective of this evidence-based analysis was to determine if continuity of care is associated with decreased health resource utilization, improved patient outcomes, and patient satisfaction. MEDLINE, EMBASE, CINAHL, the Cochrane Library, and the Centre for Reviews and Dissemination database were searched for studies on continuity of care and chronic disease published from January 2002 until December 2011. Systematic reviews, randomized controlled trials, and observational studies were eligible if they assessed continuity of care in adults and reported health resource utilization, patient outcomes, or patient satisfaction. Eight systematic reviews and 13 observational studies were identified. The reviews concluded that there is an association between continuity of care and outcomes; however, the literature base is weak. The observational studies found that higher continuity of care was frequently associated with fewer hospitalizations and emergency department visits. Three systematic reviews reported that higher continuity of care is associated with improved patient satisfaction, especially among patients with chronic conditions. Most of the studies were retrospective cross-sectional studies of large administrative databases. The databases do not capture information on trust and confidence in the provider, which is a critical component of relational continuity of care. The definitions for the selection of patients from the databases varied across studies. There is low quality evidence that: Higher continuity of care is associated with decreased health service utilization.There is insufficient evidence on the relationship of continuity of care with disease-specific outcomes.There is an association between high continuity of care and patient satisfaction, particularly among patients with chronic diseases.
The health care system is making 'too much noise' to provide family-centred care in neonatal intensive care units: Perspectives of health care providers and hospital administrators.

PubMed

Benzies, Karen M; Shah, Vibhuti; Aziz, Khalid; Lodha, Abhay; Misfeldt, Renée

2018-05-11

To describe the perspectives of health care providers and hospital administrators on their experiences of providing care for infants in Level II neonatal intensive care units and their families. We conducted 36 qualitative interviews with neonatal health care providers and hospital administrators and analysed data using a descriptive interpretive approach. 10 Level II Neonatal Intensive Care Units in a single, integrated health care system in one Canadian province. Three major themes emerged: (1) providing family-centred care, (2) working amidst health care system challenges, and (3) recommending improvements to the health care system. The overarching theme was that the health care system was making 'too much noise' for health care providers and hospital administrators to provide family-centred care in ways that would benefit infants and their families. Recommended improvements included: refining staffing models, enhancing professional development, providing tools to deliver consistent care, recognising parental capacity to be involved in care, strengthening continuity of care, supporting families to be with their infant, and designing family-friendly environments. When implementing family-centred care initiatives, health care providers and hospital administrators need to consider the complexity of providing care in Level II Neonatal Intensive Care Units, and recognise that health care system changes may be necessary to optimise implementation. Copyright © 2018 The Authors. Published by Elsevier Ltd.. All rights reserved.
Children with medical complexity in Canada

PubMed Central

Dewan, Tammie; Cohen, Eyal

2013-01-01

The burden of chronic disease is placing pressure on the Canadian health care system. A small but important chronic disease population is children with medical complexity, defined as individuals with: high family-identified needs; complex chronic disease necessitating specialized care; functional disability; and high health care utilization. These patients present a challenge to community providers who are expected to provide holistic care and manage complex issues, often with a paucity of services and supports. Alternative models of care may address the complex needs of this population. In addition, strategies can be implemented in community practices that may assist with the care of children with medical complexity such as collaborative care, engagement of key workers, focus on goal-directed care and use of care plans. The paediatric community should engage in health care reform discussions focused on chronic disease to ensure that the complex needs of these children are met. PMID:24497777
Fifteen minute consultation: Practical pain management in paediatric palliative care.

PubMed

Harrop, Emily Jane; Brombley, Karen; Boyce, Katherine

2017-10-01

Pain and distress in the paediatric palliative care population can be very difficult to manage. Clinical scenarios range from the acute management of cancer-related pain at the end of life to the ongoing long-term support of children with complex multimodal pain related to progressive neurological conditions. Understanding the child's underlying condition, possible causes of pain and their preferred mode of communication are important to the delivery of holistic care. Modification of environmental factors, basic care consideration and non-pharmacological measures have a large role to play, alongside conventional analgesics. Medication may also need to be delivered by novel routes such as transdermal patches, continuous subcutaneous infusion of multiple drugs or transmucosal breakthrough analgesic doses. Two cases are used to illustrate approaches to these clinical problems. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.
Labor Market Work and Home Care's Unpaid Caregivers: A Systematic Review of Labor Force Participation Rates, Predictors of Labor Market Withdrawal, and Hours of Work

PubMed Central

Lilly, Meredith B; Laporte, Audrey; Coyte, Peter C

2007-01-01

As people continue to age and receive complex health care services at home, concern has arisen about the availability of family caregivers and their ability to combine employment with caregiving. This article evaluates the international research on unpaid caregivers and their labor market choices, highlighting three conclusions: first, caregivers in general are equally as likely to be in the labor force as noncaregivers; second, caregivers are more likely to work fewer hours in the labor market than noncaregivers, particularly if their caring commitments are heavy; and finally, only those heavily involved in caregiving are significantly more likely to withdraw from the labor market than noncaregivers. Policy recommendations are targeting greater access to formal care for “intensive” caregivers and developing workplace policies for employed caregivers. PMID:18070333
[Multimorbidity in general practice and the Ariadne principles. A person-centred approach].

PubMed

Prados-Torres, Alexandra; Del Cura-González, Isabel; Prados-Torres, Juan Daniel; Leiva-Fernández, Francisca; López-Rodríguez, Juan Antonio; Calderón-Larrañaga, Amaia; Muth, Christiane

2017-05-01

Multimorbidity, defined as the coexistence of two or more chronic conditions in one same individual, has negative consequences for people suffering from it and it poses a real challenge for health systems. In primary care, where most of these patients are attended, the clinical management of multimorbidity can be a complex task due, among others, to the high volume of clinical information that needs to be handled, the scarce scientific evidence available to approach multimorbidity, and the need for coordination among multiple health providers to guarantee continuity of care. Moreover, the adequate implementation of the care plan in these patients requires a process of shared decision making between patient and physician. One of the available tools to support this process, which is specifically directed to patients with multimorbidity in primary care, is described in the present article: the Ariadne principles. Copyright © 2017 Elsevier España, S.L.U. All rights reserved.
Creating innovative clinical nurse leader practicum experiences through academic and practice partnerships.

PubMed

Jukkala, Angela; Greenwood, Rebecca; Motes, Terry; Block, Velinda

2013-01-01

The new Clinical Nurse Leader (CNL) nursing role was developed to meet the complex health care needs of patients, families, and health care systems. This article describes the process used by nurse leaders at the University of Alabama at Birmingham School of Nursing and Hospital to develop Model C CNL practicum courses, recruit and prepare clinical preceptors, prepare clinical microsystems for CNL students, and develop additional practice partnerships throughout the region. MANAGEMENT AND OUTCOME: Critical to the success of the CNL role is a dynamic partnership between academic and practice leaders.The partnership allows faculty to develop curricula that are relevant and responsive to the rapidly changing health care system. Clinical leaders become more aware of trends and issues in nursing education. Continued growth and success of the CNL role is largely dependent on the ability of faculty and practice partners to collaborate on innovative educational programs and models of care delivery.
Medical homes: challenges in translating theory into practice.

PubMed

Carrier, Emily; Gourevitch, Marc N; Shah, Nirav R

2009-07-01

The concept of the medical home has existed since the 1960s, but has recently become a focus for discussion and innovation in the health care system. The most prominent definitions of the medical home are those presented by the Patient-Centered Primary Care Collaborative, the National Committee for Quality Assurance, and the Commonwealth Fund. These definitions share: adoption of health information technology and decision support systems, modification of clinical practice patterns, and ensuring continuity of care. Each of these components is a complex undertaking, and there is scant evidence to guide assessment of diverse strategies for achieving their integration into a medical home. Without a shared vocabulary and common definitions, policy-makers seeking to encourage the development of medical homes, providers seeking to improve patient care, and payers seeking to develop appropriate systems of reimbursement will face challenges in evaluating and disseminating the medical home model.
Diagnostic, design and implementation of an integrated model of care in France: a bottom-up process with a continuous leadership

PubMed Central

de Stampa, Matthieu; Vedel, Isabelle; Mauriat, Claire; Bagaragaza, Emmanuel; Routelous, Christelle; Bergman, Howard; Lapointe, Liette; Cassou, Bernard; Ankri, Joel; Henrard, Jean-Claude

2010-01-01

Purpose To present an innovative bottom-up and pragmatic strategy used to implement a new integrated care model in France for community-dwelling elderly people with complex needs. Context Sustaining integrated care is difficult, in large part because of problems encountered securing the participation of health care and social service professionals and, in particular, general practitioners (GPs). Case description In the first step, a diagnostic study was conducted with face-to-face interviews to gather data on current practices from a sample of health and social stakeholders working with elderly people. In the second step, an integrated care model called Coordination Personnes Agées (COPA) was designed by the same major stakeholders in order to define its detailed characteristics based on the local context. In the third step, the model was implemented in two phases: adoption and maintenance. This strategy was carried out by a continuous and flexible leadership throughout the process, initially with a mixed leadership (clinician and researcher) followed by a double one (clinician and managers of services) in the implementation phase. Conclusions The implementation of this bottom-up and pragmatic strategy relied on establishing a collaborative dynamic among health and social stakeholders. This enhanced their involvement throughout the implementation phase, particularly among the GPs, and allowed them to support the change practices and services arrangements.
[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. Copyright © 2013 Elsevier España, S.L. All rights reserved.
Wound care guidelines and formulary for community nurses.

PubMed

Baeyens, T A

2000-03-01

Community nursing is experiencing significant change as a result of developments such as improved technology, care in the community and earlier discharge of patients from hospital. Because of this, increasingly complex clinical care is required in the community, and it has been noted that community nurses are 'under considerable pressure' and show 'evidence of high stress and low morale'. Wound care is one area in which community nurses constantly battle to keep abreast of continual change. Growing product availability and diversity of use, changes in dressing techniques and the ever-increasing costs associated with wound care mean decision-making in wound care is often a complex task. In the Grampian region, a handbook of evidence-based practice guidelines with a product formulary was developed and distributed to all community nurses. The handbook was designed to ease the decision-making process by evaluating evidence-based practice and local preferences to recommend and guide nurses towards effective clinical practice and cost efficiency. All grades of district nurse in the region have been issued with their own copy of the handbook. It is presented in an A5 ring-binder format to make it easy to carry and to facilitate updating using loose-leaf inserts. The use of logos, extra information boxes and colour coding makes it easy for users to find specific areas of interest in the handbook. The success of the handbook has led to debate on the potential for development of a similar resource for use by practice nurses and in local community hospitals.
Provider Experiences with Chronic Care Management (CCM) Services and Fees: A Qualitative Research Study.

PubMed

O'Malley, Ann S; Sarwar, Rumin; Keith, Rosalind; Balke, Patrick; Ma, Sai; McCall, Nancy

2017-12-01

Support for ongoing care management and coordination between office visits for patients with multiple chronic conditions has been inadequate. In January 2015, Medicare introduced the Chronic Care Management (CCM) payment policy, which reimburses providers for CCM activities for Medicare beneficiaries occurring outside of office visits. To explore the experiences, facilitators, and challenges of practices providing CCM services, and their implications going forward. Semi-structured telephone interviews from January to April 2016 with 71 respondents. Sixty billing and non-billing providers and practice staff knowledgeable about their practices' CCM services, and 11 professional society representatives. Practice respondents noted that most patients expressed positive views of CCM services. Practice respondents also perceived several patient benefits, including improved adherence to treatment, access to care team members, satisfaction, care continuity, and care coordination. Facilitators of CCM provision included having an in-practice care manager, patient-centered medical home recognition, experience developing care plans, patient trust in their provider, and supplemental insurance to cover CCM copayments. Most billing practices reported few problems obtaining patients' consent for CCM, though providers felt that CMS could better facilitate consent by marketing CCM's goals to beneficiaries. Barriers reported by professional society representatives and by billing and non-billing providers included inadequacy of CCM payments to cover upfront investments for staffing, workflow modification, and time needed to manage complex patients. Other barriers included inadequate infrastructure for health information exchange with other providers and limited electronic health record capabilities for documenting and updating care plans. Practices owned by hospital systems and large medical groups faced greater bureaucracy in implementing CCM than did smaller, independent practices. Improving providers' experiences with and uptake of CCM will require addressing several challenges, including the upfront investment for CCM set-up and the time required to provide CCM to more complex patients.
Aboriginal experiences of cancer and care coordination: Lessons from the Cancer Data and Aboriginal Disparities (CanDAD) narratives.

PubMed

Reilly, Rachel; Micklem, Jasmine; Yerrell, Paul; Banham, David; Morey, Kim; Stajic, Janet; Eckert, Marion; Lawrence, Monica; Stewart, Harold B; Brown, Alex

2018-04-24

Aboriginal people with cancer experience worse outcomes than other Australians for a range of complex and interrelated reasons. A younger age at diagnosis, higher likelihood of more advanced cancer or cancer type with poorer prognosis, geographic isolation and cultural and language diversity mean that patient pathways are potentially more complex for Aboriginal people with cancer. In addition, variation in the quality and acceptability of care may influence cancer outcomes. This study sought to understand how care coordination influences Aboriginal people's experiences of cancer treatment. Interviews with 29 Aboriginal patients or cancer survivors, 11 carers and 22 service providers were carried out. Interviews were semi-structured and sought to elicit experiences of cancer and the health-care system. The manifest content of the cancer narratives was entered onto a cancer pathway mapping tool and underlying themes were identified inductively. The practice of cancer care coordination was found to address the needs of Aboriginal patients and their families/carers in 4 main areas: "navigating the health system"; "information and communication"; "things to manage at home"; and "cultural safety". The CanDAD findings indicate that, when the need for cancer care coordination is met, it facilitated continuity of care in a range of ways that may potentially improve cancer outcomes. However, the need remains unmet for many. Findings support the importance of dedicated care coordination to enable Aboriginal people to receive adequate and appropriate patient-centred care, so that the unacceptable disparity in cancer outcomes between Aboriginal and non-Aboriginal people can be addressed. © 2018 The Authors. Health Expectations published by John Wiley & Sons Ltd.
Childhood Obesity: Causes, Consequences, and Management.

PubMed

Gurnani, Muskaan; Birken, Catherine; Hamilton, Jill

2015-08-01

One-third of North American children are overweight or obese. Pathologic obesity accounts for only a small percentage of these cases. The vast majority are the result of a complex interaction of genetic and hormonal, nutritional, physical activity, and physical and social environmental factors. Obesity increases the risk for various cardiometabolic, pulmonary, and psychosocial complications for children, which often continues into adulthood. Multidisciplinary care, focusing on family-centered behavior change, is an evidence-based, essential part of the treatment, along with pharmacologic and surgical options for more complex cases. Prevention and early intervention strategies are key to reversing the obesity epidemic. Copyright © 2015 Elsevier Inc. All rights reserved.
Hyperbaric intensive care technology and equipment.

PubMed

Millar, Ian L

2015-03-01

In an emergency, life support can be provided during recompression or hyperbaric oxygen therapy using very basic equipment, provided the equipment is hyperbaric-compatible and the clinicians have appropriate experience. For hyperbaric critical care to be provided safely on a routine basis, however, a great deal of preparation and specific equipment is needed, and relatively few facilities have optimal capabilities at present. The type, size and location of the chamber are very influential factors. Although monoplace chamber critical care is possible, it involves special adaptations and inherent limitations that make it inappropriate for all but specifically experienced teams. A large, purpose-designed chamber co-located with an intensive care unit is ideal. Keeping the critically ill patient on their normal bed significantly improves quality of care where this is possible. The latest hyperbaric ventilators have resolved many of the issues normally associated with hyperbaric ventilation, but at significant cost. Multi-parameter monitoring is relatively simple with advanced portable monitors, or preferably installed units that are of the same type as used elsewhere in the hospital. Whilst end-tidal CO₂ readings are changed by pressure and require interpretation, most other parameters display normally. All normal infusions can be continued, with several examples of syringe drivers and infusion pumps shown to function essentially normally at pressure. Techniques exist for continuous suction drainage and most other aspects of standard critical care. At present, the most complex life support technologies such as haemofiltration, cardiac assist devices and extra-corporeal membrane oxygenation remain incompatible with the hyperbaric environment.
Integration of outpatient infectious diseases clinic pharmacy services and specialty pharmacy services for patients with HIV infection.

PubMed

Gilbert, Elise M; Gerzenshtein, Lana

2016-06-01

The integration of specialty pharmacy services and existing outpatient clinical pharmacy services within an infectious diseases (ID) clinic to optimize the care of patients with human immunodeficiency virus (HIV) infection is described. The management of HIV-infected patients is a highly specialized area of practice, often requiring use of complex medication regimens for reduction of HIV-associated morbidity and mortality prophylaxis and treatment of opportunistic infections, and prevention of HIV transmission. To maximize the effectiveness and safety of treatment with antiretroviral agents and associated pharmacotherapies, an interdisciplinary team is often involved in patient care. At Chicago-based Northwestern Medicine (NM), the outpatient ID clinic has long worked with an interdisciplinary care team including physicians, clinical pharmacists, nurses, and social workers to care for patients with HIV infection. In April 2014, specialty pharmacy services for patients with HIV infection were added to the NM ID clinic's care model to help maintain continuity of care and enhance patient follow-up. The care model includes well-defined roles for clinical pharmacists, pharmacy residents and students on rotation, and licensed pharmacy technicians. Specialty pharmacy services, including medication education, prescription fulfillment, assistance with medication access (e.g., navigation of financial assistance programs, completion of prior-authorization requests), and treatment monitoring, allow for closed-loop medication management of the HIV-infected patient population. Integration of specialty pharmacy services with the interdisciplinary care provided in the outpatient NM ID clinic has enhanced continuity of care for patients with HIV infection in terms of prescription filling, medication counseling, and adherence monitoring. Copyright © 2016 by the American Society of Health-System Pharmacists, Inc. All rights reserved.
Palliative wound care management strategies for palliative patients and their circles of care.

PubMed

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

2015-03-01

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

PubMed

Sibeoni, Jordan; Orri, Massimiliano; Podlipski, Marc-Antoine; Labey, Mathilde; Campredon, Sophie; Gerardin, Priscille; Revah-Levy, Anne

2018-01-01

Anxiety-based school refusal in adolescence is a complex, sometimes difficult to treat disorder that can have serious academic and psychiatric consequences. The objective of this qualitative study was to explore how teens with this problem and their parents experience the psychiatric care received. This qualitative multicenter study took place in France, where we conducted semi-structured interviews with adolescents receiving psychiatric care for anxiety-based school refusal and with their parents. Data collection by purposive sampling continued until we reached theoretical sufficiency. Data analysis was thematic. This study included 20 adolescents aged 12 to 18 years and 21 parents. Two themes emerged from the analysis: (1) the goals of psychiatric care with two sub-themes, " self-transformation " and problem solving ; and, (2) the therapeutic levers identified as effective with two sub-themes: time and space and relationships . Our results show a divergence between parents and teens in their representations of care and especially of its goals. Therapeutic and research implications about the terms of return to school within psychiatric care and also the temporality of care are discussed.
Successful prevention of ventilator-associated pneumonia in an intensive care setting.

PubMed

Marra, Alexandre R; Cal, Ruy Guilherme Rodrigues; Silva, Cláudia Vallone; Caserta, Raquel Afonso; Paes, Angela Tavares; Moura, Denis Faria; dos Santos, Oscar Fernando Pavão; Edmond, Michael B; Durão, Marcelino Souza

2009-10-01

Ventilator-associated pneumonia (VAP) is one of the most common health care-associated infections (HAIs) in critical care settings. Our objective was to examine the effect of a series of interventions, implemented in 3 different periods to reduce the incidence of VAP in an intensive care unit (ICU). A quasiexperimental study was conducted in a medical-surgical ICU. Multiple interventions to optimize VAP prevention were performed during different phases. From March 2001 to December 2002 (phase 1: P1), some Centers for Disease Control and Prevention (CDC) evidence-based practices were implemented. From January 2003 to December 2006 (P2), we intervened in these processes at the same time that performance monitoring was occurring at the bedside, and, from January 2007 to September 2008 (P3), we continued P2 interventions and implemented the Institute for Healthcare Improvement's ventilator bundle plus oral decontamination with chlorhexidine and continuous aspiration of subglottic secretions. The incidence density of VAP in the ICU per 1000 patient-days was 16.4 in phase 1, 15.0 in phase 2, and 10.4 in phase 3, P=.05. Getting to zero VAP was possible only in P3 when compliance with all interventions exceeded 95%. These results suggest that reducing VAP rates to zero is a complex process that involves multiple performance measures and interventions.

Men's Preconception Health: A Primary Health-Care Viewpoint.

PubMed

O'Brien, Anthony Paul; Hurley, John; Linsley, Paul; McNeil, Karen Anne; Fletcher, Richard; Aitken, John Robert

2018-05-01

The purpose of this article is to theoretically explore men's preconception health as a mechanism to enhance fertility, as well as the health and well-being of the subject and his descendants. Premorbid risk factors and behaviors associated with stress, environmental toxins, excessive alcohol consumption, smoking, lack of exercise/obesity, and the use of illicit drugs are all known to affect fecundity. While there are many health clinics available to women, where advice in areas such as postnatal care of the newborn, family planning, and couples fertility is provided, there are few, if any, equivalent health clinics available to men. Additionally, getting men to attend primary health-care services has also been continuously problematic, even in the context of there being a clearly discernible need for treatment. It is argued in this article that an impetus is required to encourage men to focus on and improve their preconception health and to utilize primary health-care services to take action. An assertive men's preconception health outlook can positively influence the conjugal relationship, fathering, male self-esteem, and continued good health. Using the sometimes complex concept of preconception health as a motivating factor for healthy lifestyle adaptation has the potential to improve male fertility outcomes and general health and well-being, as well as the health of future generations.
An innovative model for achieving breast-feeding success in infants with complex surgical anomalies.

PubMed

Edwards, Taryn M; Spatz, Diane L

2010-01-01

This manuscript describes an innovative nurse-driven continuous quality improvement project. Infants born with congenital surgical anomalies face significant challenges within the newborn period and human milk/breast-feeding may not be viewed as a priority. In many hospitals, nurses refer families to lactation consultants for all breast-feeding assistance and support. The Transition to Breast Pathway was developed on the basis of the evidence-based standards and protocols at The Children's Hospital of Philadelphia. The pathway consists of (1) initiation of pumping and maintenance of milk supply, (2) mouth care with human milk, (3) skin-to-skin care, (4) nonnutritive sucking at the breast, (5) transitioning to at breast feeds. A sample of 80 infants were enrolled in this project. Major results of the project are as follows: (1) mother's average milk supply was approximately 603 mL/d, (2) 71% (57/80) of the infants received mouth care with human milk, (3) 48% (38/80) mother/infant dyads performed skin-to-skin care, (4) 60% (35/58) of mother/infant dyads performed nonnutritive sucking at the breast, (5) 100% (58/58) of mother-infant dyads transitioned to breast prior to discharge. This continuous quality improvement project demonstrates that nurses can and should lead the process of transitioning infants to at breast feeds.
American Internal Medicine in the 21st Century

PubMed Central

Huddle, Thomas S; Centor, Robert; Heudebert, Gustavo R

2003-01-01

American internal medicine suffers a confusion of identity as we enter the 21st century. The subspecialties prosper, although unevenly, and retain varying degrees of connection to their internal medicine roots. General internal medicine, identified with primary care since the 1970s, retains an affinity for its traditional consultant-generalist ideal even as primary care further displaces that ideal. We discuss the origins and importance of the consultant-generalist ideal of internal medicine as exemplified by Osler, and its continued appeal in spite of the predominant role played by clinical science and accompanying subspecialism in determining the academic leadership of American internal medicine since the 1920s. Organizing departmental clinical work along subspecialty lines diminished the importance of the consultant-generalist ideal in academic departments of medicine after 1950. General internists, when they joined the divisions of general internal medicine that appeared in departments of medicine in the 1970s, could sometimes emulate Osler in practicing a general medicine of complexity, but often found themselves in a more limited role doing primary care. As we enter the 21st century, managed care threatens what remains of the Oslerian ideal, both in departments of medicine and in clinical practice. Twenty-first century American internists will have to adjust their conditions of work should they continue to aspire to practice Oslerian internal medicine. PMID:12950486
Schizophrenia in the Netherlands: Continuity of Care with Better Quality of Care for Less Medical Costs.

PubMed

van der Lee, Arnold; de Haan, Lieuwe; Beekman, Aartjan

2016-01-01

Patients with schizophrenia need continuous elective medical care which includes psychiatric treatment, antipsychotic medication and somatic health care. The objective of this study is to assess whether continuous elective psychiatric is associated with less health care costs due to less inpatient treatment. Data concerning antipsychotic medication and psychiatric and somatic health care of patients with schizophrenia in the claims data of Agis Health Insurance were collected over 2008-2011 in the Netherlands. Included were 7,392 patients under 70 years of age with schizophrenia in 2008, insured during the whole period. We assessed the relationship between continuous elective psychiatric care and the outcome measures: acute treatment events, psychiatric hospitalization, somatic care and health care costs. Continuous elective psychiatric care was accessed by 73% of the patients during the entire three year follow-up period. These patients received mostly outpatient care and accessed more somatic care, at a total cost of €36,485 in three years, than those without continuous care. In the groups accessing fewer or no years of elective care 34%-68% had inpatient care and acute treatment events, while accessing less somatic care at average total costs of medical care from €33,284 to €64,509. Continuous elective mental and somatic care for 73% of the patients with schizophrenia showed better quality of care at lower costs. Providing continuous elective care to the remaining patients may improve health while reducing acute illness episodes.
Patient-reported care coordination: associations with primary care continuity and specialty care use.

PubMed

Liss, David T; Chubak, Jessica; Anderson, Melissa L; Saunders, Kathleen W; Tuzzio, Leah; Reid, Robert J

2011-01-01

Care coordination is increasingly recognized as a necessary element of high-quality, patient-centered care. This study investigated (1) the association between care coordination and continuity of primary care, and (2) differences in this association by level of specialty care use. We conducted a cross-sectional study of Medicare enrollees with select chronic conditions in an integrated health care delivery system in Washington State. We collected survey information on patient experiences and automated health care utilization data for 1 year preceding survey completion. Coordination was defined by the coordination measure from the short form of the Ambulatory Care Experiences Survey (ACES). Continuity was measured by primary care visit concentration. Patients who had 10 or more specialty care visits were classified as high users. Linear regression was used to estimate the association between coordination and continuity, controlling for potential confounders and clustering within clinicians. We used a continuity-by-specialty interaction term to determine whether the continuity-coordination association was modified by high specialty care use. Among low specialty care users, an increase of 1 standard deviation (SD) in continuity was associated with an increase of 2.71 in the ACES coordination scale (P <.001). In high specialty care users, we observed no association between continuity and reported coordination (P= .77). High use of specialty care may strain the ability of primary care clinicians to coordinate care effectively. Future studies should investigate care coordination interventions that allow for appropriate specialty care referrals without diminishing the ability of primary care physicians to manage overall patient care.
Primary Care Physician Insights Into a Typology of the Complex Patient in Primary Care

PubMed Central

Loeb, Danielle F.; Binswanger, Ingrid A.; Candrian, Carey; Bayliss, Elizabeth A.

2015-01-01

PURPOSE Primary care physicians play unique roles caring for complex patients, often acting as the hub for their care and coordinating care among specialists. To inform the clinical application of new models of care for complex patients, we sought to understand how these physicians conceptualize patient complexity and to develop a corresponding typology. METHODS We conducted qualitative in-depth interviews with internal medicine primary care physicians from 5 clinics associated with a university hospital and a community health hospital. We used systematic nonprobabilistic sampling to achieve an even distribution of sex, years in practice, and type of practice. The interviews were analyzed using a team-based participatory general inductive approach. RESULTS The 15 physicians in this study endorsed a multidimensional concept of patient complexity. The physicians perceived patients to be complex if they had an exacerbating factor—a medical illness, mental illness, socioeconomic challenge, or behavior or trait (or some combination thereof)—that complicated care for chronic medical illnesses. CONCLUSION This perspective of primary care physicians caring for complex patients can help refine models of complexity to design interventions or models of care that improve outcomes for these patients. PMID:26371266
Primary care physician insights into a typology of the complex patient in primary care.

PubMed

Loeb, Danielle F; Binswanger, Ingrid A; Candrian, Carey; Bayliss, Elizabeth A

2015-09-01

Primary care physicians play unique roles caring for complex patients, often acting as the hub for their care and coordinating care among specialists. To inform the clinical application of new models of care for complex patients, we sought to understand how these physicians conceptualize patient complexity and to develop a corresponding typology. We conducted qualitative in-depth interviews with internal medicine primary care physicians from 5 clinics associated with a university hospital and a community health hospital. We used systematic nonprobabilistic sampling to achieve an even distribution of sex, years in practice, and type of practice. The interviews were analyzed using a team-based participatory general inductive approach. The 15 physicians in this study endorsed a multidimensional concept of patient complexity. The physicians perceived patients to be complex if they had an exacerbating factor-a medical illness, mental illness, socioeconomic challenge, or behavior or trait (or some combination thereof)-that complicated care for chronic medical illnesses. This perspective of primary care physicians caring for complex patients can help refine models of complexity to design interventions or models of care that improve outcomes for these patients. © 2015 Annals of Family Medicine, Inc.
"Fighting the system": Families caring for ventilator-dependent children and adults with complex health care needs at home

PubMed Central

2011-01-01

Background An increasing number of individuals with complex health care needs now receive life-long and life-prolonging ventilatory support at home. Family members often take on the role of primary caregivers. The aim of this study was to explore the experiences of families giving advanced care to family members dependent on home mechanical ventilation. Methods Using qualitative research methods, a Grounded Theory influenced approach was used to explore the families' experiences. A total of 15 family members with 11 ventilator-dependent individuals (three children and eight adults) were recruited for 10 in-depth interviews. Results The core category, "fighting the system," became the central theme as family members were asked to describe their experiences. In addition, we identified three subcategories, "lack of competence and continuity", "being indispensable" and "worth fighting for". This study revealed no major differences in the families' experiences that were dependent on whether the ventilator-dependent individual was a child or an adult. Conclusions These findings show that there is a large gap between family members' expectations and what the community health care services are able to provide, even when almost unlimited resources are available. A number of measures are needed to reduce the burden on these family members and to make hospital care at home possible. In the future, the gap between what the health care can potentially provide and what they can provide in real life will rapidly increase. New proposals to limit the extremely costly provision of home mechanical ventilation in Norway will trigger new ethical dilemmas that should be studied further. PMID:21726441
Thriving in chaos: Educating the nurse leaders of the future.

PubMed

Garrison, Deborah R; Morgan, Debra A; Johnson, Jewett G

2004-01-01

Nurse educators are challenged to prepare students to become effective leaders in a time of chaos. The last two decades have heralded many changes that have an impact on health care delivery, including changes in health care financing, the information explosion, the recognition of quality chasms, and the composition of the workforce. Nurses continue to be at the forefront of health care delivery and they must orchestrate care for their patients in an increasingly complex health care system. Our goal is to provide nurse educators with strategies to help students blend leadership and management techniques to lead the new generation of knowledge workers. Educators have the opportunity and the challenge to empower their students to master an eclectic set of management and leadership tools, including the best from historical management strategies and embracing the latest theories of leadership. This article presents thoughts and ideas to ponder as well as strategies to consider and implement as we create the curriculum and the learning environment for our students and the future leaders of our profession.
[The innovative dynamic of the mechanics, electronics and materials subsystem].

PubMed

Maldonado, José; Gadelha, Carlos Augusto Grabois; Costa, Laís Silveira; Vargas, Marco

2012-12-01

The mechanics, electronics and materials subsystem, one of the subsystems of the health care productive complex, encompasses different activities, usually clustered in what is called the medical, hospital and dental equipment and materials industry. This is a strategic area for health care, since it represents a continuous source of changes in care practices, and influences the provision of health care services. It has, moreover, potential for promoting the progress of Brazil's system of innovation and for increasing the competitiveness of the industry as a whole, given that it articulates future technologies. Despite the significant growth of this industry in Brazil in recent years, such equipment and materials have been presenting a growing deficit in the balance of trade. This incompatibility between national health care needs and the productive and innovative basis of the industry points to structural fragilities in the system. Using the framework of political economy, the article aims to discuss the development of this industry in Brazil and its challenges.
Publicly disclosed information about the quality of health care: response of the US public

PubMed Central

Schneider, E; Lieberman, T

2001-01-01

Public disclosure of information about the quality of health plans, hospitals, and doctors continues to be controversial. The US experience of the past decade suggests that sophisticated quality measures and reporting systems that disclose information on quality have improved the process and outcomes of care in limited ways in some settings, but these efforts have not led to the "consumer choice" market envisaged. Important reasons for this failure include limited salience of objective measures to consumers, the complexity of the task of interpretation, and insufficient use of quality results by organised purchasers and insurers to inform contracting and pricing decisions. Nevertheless, public disclosure may motivate quality managers and providers to undertake changes that improve the delivery of care. Efforts to measure and report information about quality should remain public, but may be most effective if they are targeted to the needs of institutional and individual providers of care. Key Words: public disclosure; quality of health care; quality improvement PMID:11389318
[Staffing needs of an intensive care unit in consideration of applicable hygiene guidelines--an exploratory analysis].

PubMed

Kochanek, M; Böll, B; Shimabukuro-Vornhagen, A; Michels, G; Barbara, W; Hansen, D; Hallek, M; Fätkenheuer, G; von Bergwelt-Baildon, M

2015-07-01

The patient burden in intensive care units (ICU) has continually increased worldwide over the past decades. Age, co-morbidities and an increasing complexity of conditions and treatments increase the number of patients who are either colonized or infected with antibiotic-resistant pathogens. To prevent nosocomial infections, hygiene guidelines play an important role. In this paper, we investigate the time needed for nursing of five hypothetical critically ill patients in the intensive care unit. The results show that current staffing is not sufficient under the given hygiene guidelines and that a nurse to patient ratio of one will be necessary to meet the requirements. In a national survey of university hospitals, however, we found that the current nurse to patient ratio is 1: 2.47 in German intensive care units. The apparent staffing shortage is compensated by an extraordinary personal commitment of nurses caring for patients in the ICU. © Georg Thieme Verlag KG Stuttgart · New York.
[Governance in a project addressing care of disabled elderly persons within the regional healthcare system of Tuscany, Italy].

PubMed

Pedace, Claudio; Rosa, Antonella; Francesconi, Paolo; Acampora, Anna; Ricciardi, Walter; Damiani, Gianfranco

2017-01-01

Population aging and the concurrent increase of age-related chronic degenerative diseases and disability are associated with an increased proportion of elderly persons who are dependent in activities of daily living (ADL). ADL-dependent persons need continuous and long-term health and social care according to the "taking charge" rationale, in order to warrant access and continuity of care. A healthcare system needs to respond to the long-term and complex needs, such as those of disabled elderly people, by providing appropriate health and social care services in Primary Care. A Primary Health Care system is organized according to two governance levels have distinct aims but are closely inter-dependent in their operational mechanisms. The system governance is accountable for the community and individual health protection while the delivery governance is accountable for the provision of services in accordance with appropriateness, safety and economic criteria. Delivery governance can be considered "integrated governance" as a synergy exists between two decision-making systems guiding provider choices, which are corporate governance and clinical governance. The aim of this study was to analyse the abovementioned governance levels within the healthcare system in Tuscany (Italy) referring to long-term residential care for disabled elderly people. The case of excessive accesses to emergency departments from different types of Nursing Homes (NH) is used as an example to analyse different levels of responsibility involved in the management of a critical phenomenon. Suggestions for improvement in the different levels of governance for disabled elderly people are provided, in order to support institutional programming activities.
Hospital care following emergency admission: a critical incident case study of the experiences of patients with advanced lung cancer and Chronic Obstructive Pulmonary Disease.

PubMed

Bailey, Cara; Hewison, Alistair; Karasouli, Eleni; Staniszewska, Sophie; Munday, Daniel

2016-08-01

To explore the experiences of patients with advanced Chronic Obstructive Pulmonary Disease (COPD) and lung cancer, their carers and healthcare professionals following emergency admission to acute care hospital. Emergency admissions of people with lung cancer and COPD have increased and there is global concern about the number of patients who die in hospital. The experience of patients with advanced lung cancer and COPD admitted to hospital as an emergency when nearing the end of life has not previously been investigated. Qualitative critical incident case study. Semistructured interviews were conducted with 39 patients (15 with COPD and 24 with lung cancer), 20 informal carers and 50 healthcare professionals, exploring patients' experiences of emergency hospital admission. Interviews took place after admission and following discharge. Participants nominated relatives and healthcare professionals for interview. Data were analysed thematically. Patients were satisfied with their 'emergency' care but not the care they received once their initial symptoms had been stabilised. The poorer quality care they experienced was characterised by a lack of attention to their fundamental needs, lack of involvement of the family, poor communication about care plans and a lack of continuity between primary and secondary care. A conceptual model of 'spectacular' and 'subtacular' trajectories of care was used to relate the findings to the wider context of health care provision. The complex nature of illness for patients with advanced respiratory disease makes emergency hospital admissions likely. Whilst patients (with COPD and lung cancer) were satisfied with care in the acute 'spectacular' phase of their admission, more attention needs to be given to the continuing care needs of patients in the 'subtacular' phase. This is the first study to explore the patient experience of acute care following an emergency admission and identifies where there is potential for care to be improved. © 2016 John Wiley & Sons Ltd.
The Twenty-four Hour Workday: Proceedings of a Symposium on Variations in Work-Sleep Schedules

DTIC Science & Technology

1980-10-01

medical care, transportation facilities, and security); (2) technological (continuous process operations, e.g., steel production, petrochemical refineries...able, has stL-nulated measurement of variations across time series. In the 2 process , it has identified a wide and important range of behavioral and phy...dimensions. However, this is a complex and interdependent process and a comprehensive understanding of work/rest schedules will be ulti- mately dependent
Understanding the dynamics of sustainable change: A 20-year case study of integrated health and social care.

PubMed

Klinga, Charlotte; Hasson, Henna; Andreen Sachs, Magna; Hansson, Johan

2018-06-04

Change initiatives face many challenges, and only a few lead to long-term sustainability. One area in which the challenge of achieving long-term sustainability is particularly noticeable is integrated health and social care. Service integration is crucial for a wide range of patients including people with complex mental health and social care needs. However, previous research has focused on the initiation, resistance and implementation of change, while longitudinal studies remain sparse. The objective of this study was therefore to gain insight into the dynamics of sustainable changes in integrated health and social care through an analysis of local actions that were triggered by a national policy. A retrospective and qualitative case-study research design was used, and data from the model organisation's steering-committee minutes covering 1995-2015 were gathered and analysed. The analysis generated a narrative case description, which was mirrored to the key elements of the Dynamic Sustainability Framework (DSF). The development of inter-sectoral cooperation was characterized by a participatory approach in which a shared structure was created to support cooperation and on-going quality improvement and learning based on the needs of the service user. A key management principle was cooperation, not only on all organisational levels, but also with service users, stakeholder associations and other partner organisations. It was shown that all these parts were interrelated and collectively contributed to the creation of a structure and a culture which supported the development of a dynamic sustainable health and social care. This study provides valuable insights into the dynamics of organizational sustainability and understanding of key managerial actions taken to establish, develop and support integration of health and social care for people with complex mental health needs. The service user involvement and regular reviews of service users' needs were essential in order to tailor services to the needs. Another major finding was the importance of continuously adapting the content of the change to suit its context. Hence, continuous refinement of the change content was found to be more important than designing the change at the pre-implementation stage.
Physician perspectives and compliance with patient advance directives: the role external factors play on physician decision making.

PubMed

Burkle, Christopher M; Mueller, Paul S; Swetz, Keith M; Hook, C Christopher; Keegan, Mark T

2012-11-21

Following passage of the Patient Self Determination Act in 1990, health care institutions that receive Medicare and Medicaid funding are required to inform patients of their right to make their health care preferences known through execution of a living will and/or to appoint a surrogate-decision maker. We evaluated the impact of external factors and perceived patient preferences on physicians' decisions to honor or forgo previously established advance directives (ADs). In addition, physician views regarding legal risk, patients' ability to comprehend complexities involved with their care, and impact of medical costs related to end-of-life care decisions were explored. Attendees of two Mayo Clinic continuing medical education courses were surveyed. Three scenarios based in part on previously court-litigated matters assessed impact of external factors and perceived patient preferences on physician compliance with patient-articulated wishes regarding resuscitation. General questions measured respondents' perception of legal risk, concerns over patient knowledge of idiosyncrasies involved with their care, and impact medical costs may have on compliance with patient preferences. Responses indicating strength of agreement or disagreement with statements were treated as ordinal data and analyzed using the Cochran Armitage trend test. Three hundred eighty-eight of 951 surveys were completed (41% response rate). Eighty percent reported they were likely to honor a patient's AD despite its 5 year age. Fewer than half (41%) would honor the AD of a patient in ventricular fibrillation who had expressed a desire to "pass away in peace." Few (17%) would forgo an AD following a family's request for continued resuscitative treatment. A majority (52%) considered risk of liability to be lower when maintaining someone alive against their wishes than mistakenly failing to provide resuscitative efforts. A large percentage (74%) disagreed that patients could not appreciate complexities surrounding their care while 69% agreed that costs should never impact a physician's decision as to whether to comply with a patient's AD. Our findings highlight the impact, albeit small, external factors have on physician AD compliance. Most respondents based their decision on the clinical situation at hand and interpretation of the patient's initial wishes and preferences expressed by the AD.
Quality of Diabetes Management in Saudi Arabia: A Review of Existing Barriers.

PubMed

Almutairi, Khalid M

2015-12-01

Diabetes mellitus is a complex disorder that requires continuous management and medical care. The purpose of this review is to identify and summarize the barriers that affect diabetes management in Saudi Arabia. Studies that have examined the quality of diabetes management in Saudi Arabia were identified through online and manual literature searches. Two researchers independently searched and assessed for inclusion/exclusion criteria. All studies were screened by a specialist for the significance of the review. Studies that were included were evaluated for relevance, methodological rigor, and credibility by giving a quality score based on Russell and Gregory's criteria. This review presents an overview of the quality of diabetes management and issues and barriers concerning the improvement of diabetes care in Saudi Arabia. The online literature search yielded 11 studies which met the inclusion criteria. Factors affecting the quality of diabetes care can be categorized into patient factors (such as adherence, compliance, attitudes, beliefs, knowledge, financial resources and co-morbidities) and healthcare providers' factors (including beliefs, attitudes and knowledge, patient - provider interaction and communication). The identified barriers, both from patients and healthcare providers, will help healthcare authorities to improve diabetes management in Saudi Arabia. Improvement of health awareness about disease and disease management should be tailored through continuous patient education. Continuous training and seminars will also expand providers' knowledge that will ensure quality and effective diabetes management.
Multimorbidity, clinical decision making and health care delivery in New Zealand Primary care: a qualitative study.

PubMed

Stokes, Tim; Tumilty, Emma; Doolan-Noble, Fiona; Gauld, Robin

2017-04-05

Multimorbidity is a major issue for primary care. We aimed to explore primary care professionals' accounts of managing multimorbidity and its impact on clinical decision making and regional health care delivery. Qualitative interviews with 12 General Practitioners and 4 Primary Care Nurses in New Zealand's Otago region. Thematic analysis was conducted using the constant comparative method. Primary care professionals encountered challenges in providing care to patients with multimorbidity with respect to both clinical decision making and health care delivery. Clinical decision making occurred in time-limited consultations where the challenges of complexity and inadequacy of single disease guidelines were managed through the use of "satisficing" (care deemed satisfactory and sufficient for a given patient) and sequential consultations utilising relational continuity of care. The New Zealand primary care co-payment funding model was seen as a barrier to the delivery of care as it discourages sequential consultations, a problem only partially addressed through the use of the additional capitation based funding stream of Care Plus. Fragmentation of care also occurred within general practice and across the primary/secondary care interface. These findings highlight specific New Zealand barriers to the delivery of primary care to patients living with multimorbidity. There is a need to develop, implement and nationally evaluate a revised version of Care Plus that takes account of these barriers.
Teacher Perspectives on the Practice of Continuity of Care

ERIC Educational Resources Information Center

Longstreth, Sascha; Garrity, Sarah; Ritblatt, Shulamit N.; Olson, Kelsey; Virgilio, Ashley; Dinh, Hilary; Padamada, Shane

2016-01-01

This study aims to address gaps in the literature on continuity of care through focus group interviews with teachers at public early care and education programs in San Diego County, California, USA. To better understand various perspectives on continuity of care, focus groups were conducted at programs that currently practice continuity of care,…

Adverse Childhood Experiences and Young Adult Health Outcomes among Youth Aging Out of Foster Care.

PubMed

Rebbe, Rebecca; Nurius, Paula S; Courtney, Mark E; Ahrens, Kym R

2018-04-27

Former youth in foster care (YFC) are at greater risk of chronic health conditions than their peers. Although research in general population samples has demonstrated a dose-response relationship between adverse childhood experiences (ACEs) and adult health outcomes, few studies have conducted similar analyses in highly stress-exposed populations such as YFC. This paper uses person-centered latent class analysis (LCA) methods to examine the relationship between different profiles of ACE exposures and divergent health trajectories amongst this high-risk population. Data are from longitudinal research that followed transition-age YFC from age 17-26 (N =732). Using three subgroups previously identified by their ACEs histories, Complex, Environmental, and Lower Adversity groups, we applied group mean statistics to test for differences between the groups for physical and sexual health outcomes in young adulthood. In contrast to prior research demonstrating that the Environmental group was at the highest risk of criminal behavior outcomes, for most of the physical and sexual health risk outcomes evaluated in this paper, the Complex Adversity group had the highest risk. This study demonstrates that there are subgroups of YFC which each have a distinct profile of risk in young adulthood, with the Complex group being at highest risk of the physical and sexual health risk outcomes evaluated. Findings strongly suggest the need for targeted strategies to promote screening for ACEs and chronic health conditions, linkage to adult healthcare, and continuity of care for adolescents and young adults in foster care to offset these trajectories. Copyright © 2018. Published by Elsevier Inc.
Case study method and problem-based learning: utilizing the pedagogical model of progressive complexity in nursing education.

PubMed

McMahon, Michelle A; Christopher, Kimberly A

2011-08-19

As the complexity of health care delivery continues to increase, educators are challenged to determine educational best practices to prepare BSN students for the ambiguous clinical practice setting. Integrative, active, and student-centered curricular methods are encouraged to foster student ability to use clinical judgment for problem solving and informed clinical decision making. The proposed pedagogical model of progressive complexity in nursing education suggests gradually introducing students to complex and multi-contextual clinical scenarios through the utilization of case studies and problem-based learning activities, with the intention to transition nursing students into autonomous learners and well-prepared practitioners at the culmination of a nursing program. Exemplar curricular activities are suggested to potentiate student development of a transferable problem solving skill set and a flexible knowledge base to better prepare students for practice in future novel clinical experiences, which is a mutual goal for both educators and students.
A framework for complexity in palliative care: A qualitative study with patients, family carers and professionals.

PubMed

Pask, Sophie; Pinto, Cathryn; Bristowe, Katherine; van Vliet, Liesbeth; Nicholson, Caroline; Evans, Catherine J; George, Rob; Bailey, Katharine; Davies, Joanna M; Guo, Ping; Daveson, Barbara A; Higginson, Irene J; Murtagh, Fliss Em

2018-06-01

Palliative care patients are often described as complex but evidence on complexity is limited. We need to understand complexity, including at individual patient-level, to define specialist palliative care, characterise palliative care populations and meaningfully compare interventions/outcomes. To explore palliative care stakeholders' views on what makes a patient more or less complex and insights on capturing complexity at patient-level. In-depth qualitative interviews, analysed using Framework analysis. Semi-structured interviews across six UK centres with patients, family, professionals, managers and senior leads, purposively sampled by experience, background, location and setting (hospital, hospice and community). 65 participants provided an understanding of complexity, which extended far beyond the commonly used physical, psychological, social and spiritual domains. Complexity included how patients interact with family/professionals, how services' respond to needs and societal perspectives on care. 'Pre-existing', 'cumulative' and 'invisible' complexity are further important dimensions to delivering effective palliative and end-of-life care. The dynamic nature of illness and needs over time was also profoundly influential. Adapting Bronfenbrenner's Ecological Systems Theory, we categorised findings into the microsystem (person, needs and characteristics), chronosystem (dynamic influences of time), mesosystem (interactions with family/health professionals), exosystem (palliative care services/systems) and macrosystem (societal influences). Stakeholders found it acceptable to capture complexity at the patient-level, with perceived benefits for improving palliative care resource allocation. Our conceptual framework encompasses additional elements beyond physical, psychological, social and spiritual domains and advances systematic understanding of complexity within the context of palliative care. This framework helps capture patient-level complexity and target resource provision in specialist palliative care.
Measurement Properties of Questionnaires Measuring Continuity of Care: A Systematic Review

PubMed Central

Uijen, Annemarie A.; Heinst, Claire W.; Schellevis, Francois G.; van den Bosch, Wil J.H.M.; van de Laar, Floris A.; Terwee, Caroline B.; Schers, Henk J.

2012-01-01

Background Continuity of care is widely acknowledged as a core value in family medicine. In this systematic review, we aimed to identify the instruments measuring continuity of care and to assess the quality of their measurement properties. Methods We did a systematic review using the PubMed, Embase and PsycINFO databases, with an extensive search strategy including ‘continuity of care’, ‘coordination of care’, ‘integration of care’, ‘patient centered care’, ‘case management’ and its linguistic variations. We searched from 1995 to October 2011 and included articles describing the development and/or evaluation of the measurement properties of instruments measuring one or more dimensions of continuity of care (1) care from the same provider who knows and follows the patient (personal continuity), (2) communication and cooperation between care providers in one care setting (team continuity), and (3) communication and cooperation between care providers in different care settings (cross-boundary continuity). We assessed the methodological quality of the measurement properties of each instrument using the COSMIN checklist. Results We included 24 articles describing the development and/or evaluation of 21 instruments. Ten instruments measured all three dimensions of continuity of care. Instruments were developed for different groups of patients or providers. For most instruments, three or four of the six measurement properties were assessed (mostly internal consistency, content validity, structural validity and construct validity). Six instruments scored positive on the quality of at least three of six measurement properties. Conclusions Most included instruments have problems with either the number or quality of its assessed measurement properties or the ability to measure all three dimensions of continuity of care. Based on the results of this review, we recommend the use of one of the four most promising instruments, depending on the target population Diabetes Continuity of Care Questionnaire, Alberta Continuity of Services Scale-Mental Health, Heart Continuity of Care Questionnaire, and Nijmegen Continuity Questionnaire. PMID:22860100
Continuity of care from the perspective of users.

PubMed

Mendes, Felismina Rosa P; Gemito, Maria Laurência G Parreirinha; Caldeira, Ermelinda do Carmo; Serra, Isaura da Conceição; Casas-Novas, Maria Vitória

2017-03-01

Continuity of care, in addition to ensuring improvement of the quality of care, contributes to the reduction of health costs. The objective of this study was to analyse the continuity of care in health units in the municipality of Évora (south of Portugal), from the perspective of users. This is across-sectional, exploratory and descriptive study with a quantitative approach, with a sample consisting of 342 users of health units. The instrument was a questionnaire adapted from English and Spanish studies. The results show that elements of continuity were identified in the different dimensions of the continuity of care - relational, management, information and some items of flexible continuity. Longitudinal continuity has the lowest values in nursing care. In conclusion, what stands out positively, and in its different dimensions, is relational continuity, in which most users recommend their family doctor and nurse to family and friends, and flexible continuity, which translates into reduced waiting times to be attended by a doctor or nurse and access to care. What stands out negatively is the weak involvement of the user in care by health professionals, in the dimensions of relational continuity.
Continuity of care through medical records--an explorative study on GPs' management considerations.

PubMed

Schers, Henk; van den Hoogen, Henk; Grol, Richard; van den Bosch, Wil

2006-06-01

The growing complexity of care with more professionals involved is a threat to the delivery of coherent and consistent care. Excellent exchange of information between professionals may be a way to maintain continuity of care. Relevant information to be passed over includes thoughts about future management for individual patients. To explore the nature of GPs' thoughts about future management, and to determine the extent to which such thoughts are actually recorded in medical records. Cross-sectional study of 5741 consultations. Thirty GPs from 17 practices in a region in the eastern part of The Netherlands. The GPs responded to an electronic questionnaire, directly after 200 successive consultations. The questionnaire included items on management considerations, consultation characteristics and personal continuity. We compared the data from the questionnaire to the actual recording of management considerations in the patient records. The GPs had management considerations in 66.4% of the consultations, involving mainly considerations about additional testing (15.5%), adjustment of medication (22.5%), alternative treatment plans (18.6%), possible referral (11.8%) and coping behaviour (18.0%). These considerations were seldom recorded in the electronic patient record; additional testing (3.0%) adjustment of medication (2.9%) and alternative treatment plans (4.1%). Surprisingly however, GPs rarely found that management considerations from earlier consultations were lacking in the medical record. GPs often have thoughts on how to deal with this patient, but hardly ever record such considerations. We recommend the development of tools that facilitate the recording of management considerations in electronic patient records.
Katrina's Legacy: Processes for Patient Disaster Preparation have Improved but Important Gaps Remain

PubMed Central

Icenogle, Marjorie; Eastburn, Sasha; Arrieta, Martha

2016-01-01

Background Ensuring continuity of care for the chronically ill, who are elderly or indigent presents unique challenges after disasters; this population has fewer financial resources, is less likely to evacuate, has limited access to recovery resources, and is significantly dependent on charitable and government-funded institutions for care. This study expands a previous investigation of the extent to which healthcare providers in coastal Mississippi and Alabama have made changes to facilitate continued care to these populations after disasters. Methods Key informants representing healthcare and social services organizations serving health disparate residents of the Mississippi and Alabama Gulf Coast were interviewed regarding disaster preparation planning for the period 2009-2012. Interview transcripts were qualitatively coded and analyzed for emerging themes using Atlas.ti® software. Results Participant organizations have implemented changes to ensure continuity of care for the chronically ill in case of disasters. Changes include patient assistance with pre-disaster preparation and training; evacuation planning and assistance; support to find resources in evacuation destinations; equipping patients with prescription information, diagnoses, treatment plans, and advance medications when a disaster is imminent; multiple methods for patients to communicate with providers; and more mandated medical needs shelters. Patients whose chronic conditions were diagnosed post-Katrina are more likely to underestimate the need to prepare. Further, patients' lack of compliance tends to increase as time passes from disasters. Conclusions Although changes were implemented, results indicate these may be inadequate to completely address patient needs. Thus, additional efforts may be needed, underscoring the complexity of adequate disaster preparation among disparate populations. PMID:27865292
[Stability of home based care arrangements for people with dementia : Development of a consensus definition of stability using expert focus groups].

PubMed

von Kutzleben, Milena; Köhler, Kerstin; Dreyer, Jan; Holle, Bernhard; Roes, Martina

2017-04-01

The majority of people with dementia in Germany live at home. These informal care arrangements, which are mostly coordinated by informal carers, are the backbone of home-based dementia care. Creating and maintaining stability is an underlying theme in informal care; however, a definition of the complex phenomenon of 'stability' in this context is still lacking. The aim was to develop a working definition of stability of home-based care arrangements for people with dementia, which can be applied in current and future research projects at the German Center for Neurodegenerative Diseases in Witten (DZNE Witten) and others. Ensuing from prior research a preliminary version of the definition was formulated. This definition was discussed in a focus group of scientific experts with expertise in dementia research and care (n = 8). After data analysis using content analysis, the definition was revised during a scientific colloquium (n = 18) and a consensus was finally reached. There were four major themes which were considered by the experts as being relevant for the definition of stability: (1) creating and maintaining stability as a continuous adaptation process, (2) a qualitative component of stability, (3) persons with dementia and informal carers as pivotal players and (4) transitions to residential care. The working definition introduced in this article reflects the authors' understanding of the phenomenon of stability of home-based care arrangements for people with dementia. In times of increasing need for evidence-based interventions it is necessary to develop elaborated definitions of complex phenomena in order to be able to systematically evaluate the efficacy of interventions on the basis of a common understanding.
Decision-making in nursing practice: An integrative literature review.

PubMed

Nibbelink, Christine W; Brewer, Barbara B

2018-03-01

To identify and summarise factors and processes related to registered nurses' patient care decision-making in medical-surgical environments. A secondary goal of this literature review was to determine whether medical-surgical decision-making literature included factors that appeared to be similar to concepts and factors in naturalistic decision making (NDM). Decision-making in acute care nursing requires an evaluation of many complex factors. While decision-making research in acute care nursing is prevalent, errors in decision-making continue to lead to poor patient outcomes. Naturalistic decision making may provide a framework for further exploring decision-making in acute care nursing practice. A better understanding of the literature is needed to guide future research to more effectively support acute care nurse decision-making. PubMed and CINAHL databases were searched, and research meeting criteria was included. Data were identified from all included articles, and themes were developed based on these data. Key findings in this review include nursing experience and associated factors; organisation and unit culture influences on decision-making; education; understanding patient status; situation awareness; and autonomy. Acute care nurses employ a variety of decision-making factors and processes and informally identify experienced nurses to be important resources for decision-making. Incorporation of evidence into acute care nursing practice continues to be a struggle for acute care nurses. This review indicates that naturalistic decision making may be applicable to decision-making nursing research. Experienced nurses bring a broad range of previous patient encounters to their practice influencing their intuitive, unconscious processes which facilitates decision-making. Using naturalistic decision making as a conceptual framework to guide research may help with understanding how to better support less experienced nurses' decision-making for enhanced patient outcomes. © 2017 John Wiley & Sons Ltd.
Screening for Cystic Fibrosis-Related Diabetes: Matching Pathophysiology and Addressing Current Challenges.

PubMed

Boudreau, Valérie; Reynaud, Quitterie; Dubois, Catherine Lehoux; Coriati, Adèle; Desjardins, Katherine; Durieu, Isabelle; Rabasa-Lhoret, Rémi

2016-10-01

Nearly 50% of adult patients with cystic fibrosis (CF) have diabetes. The occurrence of CF-related diabetes (CFRD) is preceded and is associated with deterioration of lung function and nutritional status. Microvascular complications can occur, but the main cause of death is respiratory failure rather than cardiovascular causes as in type 1 or type 2 diabetes. Because other methods such as glycated hemoglobin (A1C) levels are less sensitive in patients with CF, the recommended screening test is the oral glucose tolerance test (OGTT) with a 75 g glucose dose. However, OGTT is poorly suited for patients with CF, who are already facing a high disease-care burden, and appropriate CF-glucose cut-off for diagnosis and prognosis are also questioned. Thus, alternative screening methods are compared to the classical test (2-hour OGTT), including shorter OGTTs and continuous glucose monitoring. Moreover, many challenges complicate the screening for diabetes such as the complex medical care time for a patient, which is reflected by low adherence to screening tests. The best screening test should take into account the particularities of CFRD and the complexity of the CF medical care. Copyright © 2016 Canadian Diabetes Association. Published by Elsevier Inc. All rights reserved.
Development of a nursing handoff tool: a web-based application to enhance patient safety.

PubMed

Goldsmith, Denise; Boomhower, Marc; Lancaster, Diane R; Antonelli, Mary; Kenyon, Mary Anne Murphy; Benoit, Angela; Chang, Frank; Dykes, Patricia C

2010-11-13

Dynamic and complex clinical environments present many challenges for effective communication among health care providers. The omission of accurate, timely, easily accessible vital information by health care providers significantly increases risk of patient harm and can have devastating consequences for patient care. An effective nursing handoff supports the standardized transfer of accurate, timely, critical patient information, as well as continuity of care and treatment, resulting in enhanced patient safety. The Brigham and Women's/Faulkner Hospital Healthcare Information Technology Innovation Program (HIP) is supporting the development of a web based nursing handoff tool (NHT). The goal of this project is to develop a "proof of concept" handoff application to be evaluated by nurses on the inpatient intermediate care units. The handoff tool would enable nurses to use existing knowledge of evidence-based handoff methodology in their everyday practice to improve patient care and safety. In this paper, we discuss the results of nursing focus groups designed to identify the current state of handoff practice as well as the functional and data element requirements of a web based Nursing Handoff Tool (NHT).
'Complexity-compatible' policy for integrated care? Lessons from the implementation of Ontario's Health Links.

PubMed

Grudniewicz, Agnes; Tenbensel, Tim; Evans, Jenna M; Steele Gray, Carolyn; Baker, G Ross; Wodchis, Walter P

2018-02-01

Complex adaptive systems (CAS) theory views healthcare as numerous sub-systems characterized by diverse agents that interact, self-organize, and continuously adapt. We apply this complexity science perspective to examine the extent to which CAS theory is a useful lens for designing and implementing health policies. We present the case of Health Links, a "low rules" policy intervention in Ontario, Canada aimed at stimulating the development of voluntary networks of health and social organizations to improve care coordination for the most frequent users of the healthcare system. Our sample consisted of stakeholders from regional governance bodies and organizations partnering in Health Links. Qualitative interview data were coded using the key complexity concepts of sensemaking, self-organization, interconnections, coevolution, and emergence. We found that the complexity-compatible policy design successfully stimulated local dynamics of flexibility, experimentation, and learning and that important mediating factors include leadership, readiness, relationship-building, role clarity, communication, and resources. However, we saw tensions between preferences for flexibility and standardization. Desirable developments occurred only in some settings and failed to flow upward to higher levels, resulting in a piecemeal and patchy landscape. Attention needs to be paid not only to local dynamics and processes, but also to regional and provincial levels to ensure that learning flows to the top and informs decision-making. We conclude that implementation of complexity-compatible policies needs a balance between flexibility and consistency and the right leadership to coordinate the two. Complexity-compatible policy for integrated healthcare is more than simply 'letting a thousand flowers bloom'. Copyright © 2017 Elsevier Ltd. All rights reserved.
Critical Care Nurses' Reasons for Poor Attendance at a Continuous Professional Development Program.

PubMed

Viljoen, Myra; Coetzee, Isabel; Heyns, Tanya

2016-12-01

Society demands competent and safe health care, which obligates professionals to deliver quality patient care using current knowledge and skills. Participation in continuous professional development programs is a way to ensure quality nursing care. Despite the importance of continuous professional development, however, critical care nurse practitioners' attendance rates at these programs is low. To explore critical care nurses' reasons for their unsatisfactory attendance at a continuous professional development program. A nominal group technique was used as a consensus method to involve the critical care nurses and provide them the opportunity to reflect on their experiences and challenges related to the current continuous professional development program for the critical care units. Participants were 14 critical care nurses from 3 critical care units in 1 private hospital. The consensus was that the central theme relating to the unsatisfactory attendance at the continuous professional development program was attitude. In order of importance, the 4 contributing priorities influencing attitude were communication, continuous professional development, time constraints, and financial implications. Attitude relating to attending a continuous professional development program can be changed if critical care nurses are aware of the program's importance and are involved in the planning and implementation of a program that focuses on the nurses' individual learning needs. ©2016 American Association of Critical-Care Nurses.
Advanced physical assessment skills: implementation of a module.

PubMed

Aldridge-Bent, Sharon

2011-02-01

This article aims to explore and examine advanced physical assessment skills and the role of the district nurse. It will particularly highlight district nurses' perceptions of how they may implement skills learnt on a new module introduced into the Community Health Care Nursing degree at a university in London. Physical assessment skills have traditionally been viewed as part of a doctor's role; however, with the advancement of nursing roles, it is argued that it has become a key nursing skill. As Government policy continues to expect health professionals to keep patients in the community who have complex health and social care needs, the role of the district nurse presents as 'best placed' to take on this challenge (Department of Health (DH), 2005a; 2005b). Evaluation of the district nurses' perceptions of their practice is shared here, highlighting some of the challenges that they face. The article will address the complexity of developing a curriculum in response to the DH initiatives and the importance of listening to students on courses.
What do practitioners think? A qualitative study of a shared care mental health and nutrition primary care program

PubMed Central

Paquette-Warren, Jann; Vingilis, Evelyn; Greenslade, Jaimi; Newnam, Sharon

2006-01-01

Abstract Objective To develop an in-depth understanding of a shared care model from primary mental health and nutrition care practitioners with a focus on program goals, strengths, challenges and target population benefits. Design Qualitative method of focus groups. Setting/Participants The study involved fifty-three practitioners from the Hamilton Health Service Organization Mental Health and Nutrition Program located in Hamilton, Ontario, Canada. Method Six focus groups were conducted to obtain the perspective of practitioners belonging to various disciplines or health care teams. A qualitative approach using both an editing and template organization styles was taken followed by a basic content analysis. Main findings Themes revealed accessibility, interdisciplinary care, and complex care as the main goals of the program. Major program strengths included flexibility, communication/collaboration, educational opportunities, access to patient information, continuity of care, and maintenance of practitioner and patient satisfaction. Shared care was described as highly dependent on communication style, skill and expertise, availability, and attitudes toward shared care. Time constraint with respect to collaboration was noted as the main challenge. Conclusion Despite some challenges and variability among practices, the program was perceived as providing better patient care by the most appropriate practitioner in an accessible and comfortable setting. PMID:17041680
Health economics, equity, and efficiency: are we almost there?

PubMed

Ferraz, Marcos Bosi

2015-01-01

Health care is a highly complex, dynamic, and creative sector of the economy. While health economics has to continue its efforts to improve its methods and tools to better inform decisions, the application needs to be aligned with the insights and models of other social sciences disciplines. Decisions may be guided by four concept models based on ethical and distributive justice: libertarian, communitarian, egalitarian, and utilitarian. The societal agreement on one model or a defined mix of models is critical to avoid inequity and unfair decisions in a public and/or private insurance-based health care system. The excess use of methods and tools without fully defining the basic goals and philosophical principles of the health care system and without evaluating the fitness of these measures to reaching these goals may not contribute to an efficient improvement of population health.
Health economics, equity, and efficiency: are we almost there?

PubMed Central

Ferraz, Marcos Bosi

2015-01-01

Health care is a highly complex, dynamic, and creative sector of the economy. While health economics has to continue its efforts to improve its methods and tools to better inform decisions, the application needs to be aligned with the insights and models of other social sciences disciplines. Decisions may be guided by four concept models based on ethical and distributive justice: libertarian, communitarian, egalitarian, and utilitarian. The societal agreement on one model or a defined mix of models is critical to avoid inequity and unfair decisions in a public and/or private insurance-based health care system. The excess use of methods and tools without fully defining the basic goals and philosophical principles of the health care system and without evaluating the fitness of these measures to reaching these goals may not contribute to an efficient improvement of population health. PMID:25709481
Welfare reform: advocacy and intervention in the health care setting.

PubMed Central

Lawton, E; Leiter, K; Todd, J; Smith, L

1999-01-01

Welfare reform has drastically altered the lives of poor families in the US. In its wake, many former recipients are not receiving whatever transitional benefits and other safeguards to which they remain entitled under federal and state laws. Families are losing access to Medicaid and are not receiving the child care assistance or Food Stamps for which they continue to be eligible. Ill-served by stringent time limits and work requirements, lack of child care assistance, and lack of training and educational opportunities for the development of skills that will lead to better jobs, families need help to navigate the complexities of the new welfare system. Boston Medical Center's Department of Pediatrics has instituted a welfare screening project to educate families about their rights under welfare reform and assist them in advocating for themselves and their children. PMID:10670622
[Who makes decisions--the dilemma of decision-making within the framework of job-sharing in a hospital].

PubMed

Voglmayr, Elisabeth; Widder, Joachim

2006-05-01

By means of a case report on a 44-year-old female patient, we show how, with changing personnel and places of care, decisions as well as the kind of decision-making during illness influence the quality of care. The patient was receiving immunosuppressive therapy after kidney transplantation and then suffered from a carcinomatous ovary. At first she refused postoperative chemotherapy, but then returned with a very advanced state of metastatic growth. The lack of continuity, a missing overall interdisciplinary concept of medical case, as well as the failure to document decision processes and the patient's attitude to life and suffering made it difficult for the caring team to accompany her in the last weeks of life. A possible solution to such a complex problem will be the introduction of ethical case deliberation.
Nurses' adherence to the Kangaroo Care Method: support for nursing care management1

PubMed Central

da Silva, Laura Johanson; Leite, Josete Luzia; Scochi, Carmen Gracinda Silvan; da Silva, Leila Rangel; da Silva, Thiago Privado

2015-01-01

OBJECTIVE: construct an explanatory theoretical model about nurses' adherence to the Kangaroo Care Method at the Neonatal Intensive Care Unit, based on the meanings and interactions for care management. METHOD: qualitative research, based on the reference framework of the Grounded Theory. Eight nurses were interviewed at a Neonatal Intensive Care Unit in the city of Rio de Janeiro. The comparative analysis of the data comprised the phases of open, axial and selective coding. A theoretical conditional-causal model was constructed. RESULTS: four main categories emerged that composed the analytic paradigm: Giving one's best to the Kangaroo Method; Working with the complexity of the Kangaroo Method; Finding (de)motivation to apply the Kangaroo Method; and Facing the challenges for the adherence to and application of the Kangaroo Method. CONCLUSIONS: the central phenomenon revealed that each nurse and team professional has a role of multiplying values and practices that may or may not be constructive, potentially influencing the (dis)continuity of the Kangaroo Method at the Neonatal Intensive Care Unit. The findings can be used to outline management strategies that go beyond the courses and training and guarantee the strengthening of the care model. PMID:26155013

76 FR 57637 - TRICARE; Continued Health Care Benefit Program Expansion

Federal Register 2010, 2011, 2012, 2013, 2014

2011-09-16

... TRICARE; Continued Health Care Benefit Program Expansion AGENCY: Office of the Secretary, Department of... Continued Health Care Benefit Program (CHCBP) coverage under certain circumstances that terminate their MHS.... Introduction and Background CHCBP is the program that provides continued health care coverage for eligible...
Predictors of relational continuity in primary care: patient, provider and practice factors

PubMed Central

2013-01-01

Background Continuity is a fundamental tenet of primary care, and highly valued by patients; it may also improve patient outcomes and lower cost of health care. It is thus important to investigate factors that predict higher continuity. However, to date, little is known about the factors that contribute to continuity. The purpose of this study was to analyse practice, provider and patient predictors of continuity of care in a large sample of primary care practices in Ontario, Canada. Another goal was to assess whether there was a difference in the continuity of care provided by different models of primary care. Methods This study is part of the larger a cross-sectional study of 137 primary care practices, their providers and patients. Several performance measures were evaluated; this paper focuses on relational continuity. Four items from the Primary Care Assessment Tool were used to assess relational continuity from the patient’s perspective. Results Multilevel modeling revealed several patient factors that predicted continuity. Older patients and those with chronic disease reported higher continuity, while those who lived in rural areas, had higher education, poorer mental health status, no regular provider, and who were employed reported lower continuity. Providers with more years since graduation had higher patient-reported continuity. Several practice factors predicted lower continuity: number of MDs, nurses, opening on weekends, and having 24 hours a week or less on-call. Analyses that compared continuity across models showed that, in general, Health Service Organizations had better continuity than other models, even when adjusting for patient demographics. Conclusions Some patients with greater health needs experience greater continuity of care. However, the lower continuity reported by those with mental health issues and those who live in rural areas is concerning. Furthermore, our finding that smaller practices have higher continuity suggests that physicians and policy makers need to consider the fact that ‘bigger is not always necessarily better’. PMID:23725212
Predictors of relational continuity in primary care: patient, provider and practice factors.

PubMed

Kristjansson, Elizabeth; Hogg, William; Dahrouge, Simone; Tuna, Meltem; Mayo-Bruinsma, Liesha; Gebremichael, Goshu

2013-05-31

Continuity is a fundamental tenet of primary care, and highly valued by patients; it may also improve patient outcomes and lower cost of health care. It is thus important to investigate factors that predict higher continuity. However, to date, little is known about the factors that contribute to continuity. The purpose of this study was to analyse practice, provider and patient predictors of continuity of care in a large sample of primary care practices in Ontario, Canada. Another goal was to assess whether there was a difference in the continuity of care provided by different models of primary care. This study is part of the larger a cross-sectional study of 137 primary care practices, their providers and patients. Several performance measures were evaluated; this paper focuses on relational continuity. Four items from the Primary Care Assessment Tool were used to assess relational continuity from the patient's perspective. Multilevel modeling revealed several patient factors that predicted continuity. Older patients and those with chronic disease reported higher continuity, while those who lived in rural areas, had higher education, poorer mental health status, no regular provider, and who were employed reported lower continuity. Providers with more years since graduation had higher patient-reported continuity. Several practice factors predicted lower continuity: number of MDs, nurses, opening on weekends, and having 24 hours a week or less on-call. Analyses that compared continuity across models showed that, in general, Health Service Organizations had better continuity than other models, even when adjusting for patient demographics. Some patients with greater health needs experience greater continuity of care. However, the lower continuity reported by those with mental health issues and those who live in rural areas is concerning. Furthermore, our finding that smaller practices have higher continuity suggests that physicians and policy makers need to consider the fact that 'bigger is not always necessarily better'.
Continuity of care for elderly patients with diabetes mellitus, hypertension, asthma, and chronic obstructive pulmonary disease in Korea.

PubMed

Hong, Jae Seok; Kang, Hee Chung; Kim, Jaiyong

2010-09-01

We sought to assess continuity of care for elderly patients in Korea and to examine any association between continuity of care and health outcomes (hospitalization, emergency department visits, health care costs). This was a retrospective cohort study using the Korea National Health Insurance Claims Database. Elderly people, 65-84 yr of age, who were first diagnosed with diabetes mellitus (n=268,220), hypertension (n=858,927), asthma (n=129,550), or chronic obstructive pulmonary disease (COPD, n=131,512) in 2002 were followed up for four years, until 2006. The mean of the Continuity of Care Index was 0.735 for hypertension, 0.709 for diabetes mellitus, 0.700 for COPD, and 0.663 for asthma. As continuity of care increased, in all four diseases, the risks of hospitalization and emergency department visits decreased, as did health care costs. In the Korean health care system, elderly patients with greater continuity of care with health care providers had lower risks of hospital and emergency department use and lower health care costs. In conclusion, policy makers need to develop and try actively the program to improve the continuity of care in elderly patients with chronic diseases.
Organizational strategy, structure, and process.

PubMed

Miles, R E; Snow, C C; Meyer, A D; Coleman, H J

1978-07-01

Organizational adaptation is a topic that has received only limited and fragmented theoretical treatment. Any attempt to examine organizational adaptation is difficult, since the process is highly complex and changeable. The proposed theoretical framework deals with alternative ways in which organizations define their product-market domains (strategy) and construct mechanisms (structures and processes) to pursue these strategies. The framework is based on interpretation of existing literature and continuing studies in four industries (college textbook publishing, electronics, food processing, and health care).
Patients' assessments of the continuity of primary care in Finland: a 15-year follow-up questionnaire survey.

PubMed

Raivio, Risto; Holmberg-Marttila, Doris; Mattila, Kari J

2014-10-01

Continuity of care is an essential aspect of quality in general practice. This study is the first systematic follow-up of Finnish primary care patients' assessments with regard to personal continuity of care. To ascertain whether patient-reported longitudinal personal continuity of care is related to patient characteristics and their consultation experiences, and how this had changed over the study period. A 15-year follow-up questionnaire survey that took place at Tampere University Hospital catchment area, Finland. The survey was conducted among patients attending health centres in the Tampere University Hospital catchment area from 1998 until 2013. From a sample of 363 464 patients, a total of 157 549 responded. The responses of patients who had visited a doctor during the survey weeks (n = 97 468) were analysed. Continuity of care was assessed by asking the question: 'When visiting the health centre, do you usually see the same doctor?'; patients could answer 'yes' or 'no'. Approximately half of the responders had met the same doctor when visiting the healthcare centre. Personal continuity of care decreased by 15 percentage points (from 66% to 51%) during the study years. The sense of continuity was linked to several patients' experiences of the consultation. The most prominent factor contributing to the sense of continuity of care was having a doctor who was specifically appointed (odds ratio 7.28, 95% confidence interval = 6.65 to 7.96). Continuity of care was proven to enhance the experienced quality of primary care. Patients felt that continuity of care was best realised when they could consult a doctor who had been specifically appointed to them. Despite efforts of the authorities, over the past 15 years patient-reported continuity of care has declined in Finland. © British Journal of General Practice 2014.
75 FR 2562 - Publication of Model Notices for Health Care Continuation Coverage Provided Pursuant to the...

Federal Register 2010, 2011, 2012, 2013, 2014

2010-01-15

... Health Care Continuation Coverage Provided Pursuant to the Consolidated Omnibus Budget Reconciliation Act (COBRA) and Other Health Care Continuation Coverage, as Required by the American Recovery and... Availability of the Model Health Care Continuation Coverage Notices Required by ARRA, as amended. SUMMARY: On...
Working in a danger zone: A qualitative study of Taiwanese nurses' work experiences in a negative pressure isolation ward.

PubMed

Chen, Shu-Ling; Chen, Kuei-Ling; Lee, Li-Hung; Yang, Cheng-I

2016-07-01

Hospital nurses are frontline health care workers in controlling the spread of infectious diseases. It is not known if nurses working in negative pressure isolation wards (NPIWs) are better prepared than before to safely care for patients with common infectious diseases. For this qualitative descriptive study, 10 nurses were interviewed in depth about their experiences caring for patients in an NPIW. Tape recordings were transcribed verbatim and analyzed by qualitative content analysis. The following 5 themes were identified: (1) complexity of patient care, (2) dissatisfaction with the quantity and quality of protective equipment, (3) shortage of nursing staff, (4) continued worries about being infected, and (5) sensitivity to self-protection. Our participants' anxiety and uncertainty about being infected in the NPIW were increased by the complexity of patients' health problems and organizational factors. To protect themselves against infection before and during patient care, participants also developed sensitivity to, concepts about, and strategies to improve self-protection. NPIW administrators should pay more attention to nurses' concerns about improving the NPIW working environment, supply good quality protective equipment, and provide appropriate psychologic support and ongoing education to ensure that nurses feel safe while working. This ongoing education should refresh and update nurses' knowledge about disease transmission, therefore decreasing unnecessary anxiety based on misunderstandings about becoming infected. Copyright © 2016 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.
Patients’ experiences with continuity of cancer care in Canada

PubMed Central

Easley, Julie; Miedema, Baukje; Carroll, June C.; O’Brien, Mary Ann; Manca, Donna P.; Grunfeld, Eva

2016-01-01

Abstract Objective To explore patient perspectives on and experiences with the coordination and continuity of cancer care. Design Qualitative study using semistructured telephone interviews. Setting Canada. Participants Thirty-eight breast and colorectal cancer survivors 1 to 4 years after diagnosis. Methods Using a constructivist grounded theory approach, semistructured telephone interviews were conducted with the participants. The interviews were digitally recorded, transcribed verbatim, and proofread. Transcripts were reviewed to create a focused coding scheme that was used to develop categories for participants’ experiences. Main findings Although this study focused on the continuity of cancer care, patients described their experiences with cancer care in general, concentrating predominantly on their relationships with individual health care providers (HCPs). Based on patients’ experiences, several themes were identified as the core components of providing good continuity and well coordinated care. The most important overarching theme was communication, which overlapped with 4 other themes: patient-HCP relationships, the role of HCPs, lack of access to care, and timely and tailored information. Conclusion Patients believed that good communication between HCPs and patients was key to improving the overall continuity of cancer care. Continuity of care is an important theoretical concept in cancer care, but it is not easily recognized by patients. They perceive the cancer care continuum and continuity of care as cancer care in general, which is typically framed by the individual relationships with their HCPs. Future research and interventions need to focus on finding and testing ways to improve communication to enhance continuity of cancer care. PMID:27737982
Patients report better satisfaction with part-time primary care physicians, despite less continuity of care and access.

PubMed

Panattoni, Laura; Stone, Ashley; Chung, Sukyung; Tai-Seale, Ming

2015-03-01

The growing number of primary care physicians (PCPs) reducing their clinical work hours has raised concerns about meeting the future demand for services and fulfilling the continuity and access mandates for patient-centered care. However, the patient's experience of care with part-time physicians is relatively unknown, and may be mediated by continuity and access to care outcomes. We aimed to examine the relationships between a physicians' clinical full-time equivalent (FTE), continuity of care, access to care, and patient satisfaction with the physician. We used a multi-level structural equation estimation, with continuity and access modeled as mediators, for a cross-section in 2010. The study included family medicine (n = 104) and internal medicine (n = 101) physicians in a multi-specialty group practice, along with their patient satisfaction survey responses (n = 12,688). Physician level FTE, continuity of care received by patients, continuity of care provided by physician, and a Press Ganey patient satisfaction with the physician score, on a 0-100 % scale, were measured. Access to care was measured as days to the third next-available appointment. Physician FTE was directly associated with better continuity of care received (0.172% per FTE, p < 0.001), better continuity of care provided (0.108% per FTE, p < 0.001), and better access to care (-0.033 days per FTE, p < 0.01), but worse patient satisfaction scores (-0.080% per FTE, p = 0.03). The continuity of care provided was a significant mediator (0.016% per FTE, p < 0.01) of the relationship between FTE and patient satisfaction; but overall, reduced clinical work hours were associated with better patient satisfaction (-0.053 % per FTE, p = 0.03). These results suggest that PCPs who choose to work fewer clinical hours may have worse continuity and access, but they may provide a better patient experience. Physician workforce planning should consider these care attributes when considering the role of part-time PCPs in practice redesign efforts and initiatives to meet the demand for primary care services.
The Complexity of Primary Care Psychology: Theoretical Foundations.

PubMed

Smit, E H; Derksen, J J L

2015-07-01

How does primary care psychology deal with organized complexity? Has it escaped Newtonian science? Has it, as Weaver (1991) suggests, found a way to 'manage problems with many interrelated factors that cannot be dealt by statistical techniques'? Computer simulations and mathematical models in psychology are ongoing positive developments in the study of complex systems. However, the theoretical development of complex systems in psychology lags behind these advances. In this article we use complexity science to develop a theory on experienced complexity in the daily practice of primary care psychologists. We briefly answer the ontological question of what we see (from the perspective of primary care psychology) as reality, the epistemological question of what we can know, the methodological question of how to act, and the ethical question of what is good care. Following our empirical study, we conclude that complexity science can describe the experienced complexity of the psychologist and offer room for personalized client-centered care. Complexity science is slowly filling the gap between the dominant reductionist theory and complex daily practice.
An "All Teach, All Learn" Approach to Research Capacity Strengthening in Indigenous Primary Health Care Continuous Quality Improvement.

PubMed

McPhail-Bell, Karen; Matthews, Veronica; Bainbridge, Roxanne; Redman-MacLaren, Michelle Louise; Askew, Deborah; Ramanathan, Shanthi; Bailie, Jodie; Bailie, Ross

2018-01-01

In Australia, Indigenous people experience poor access to health care and the highest rates of morbidity and mortality of any population group. Despite modest improvements in recent years, concerns remains that Indigenous people have been over-researched without corresponding health improvements. Embedding Indigenous leadership, participation, and priorities in health research is an essential strategy for meaningful change for Indigenous people. To centralize Indigenous perspectives in research processes, a transformative shift away from traditional approaches that have benefited researchers and non-Indigenous agendas is required. This shift must involve concomitant strengthening of the research capacity of Indigenous and non-Indigenous researchers and research translators-all must teach and all must learn. However, there is limited evidence about how to strengthen systems and stakeholder capacity to participate in and lead continuous quality improvement (CQI) research in Indigenous primary health care, to the benefit of Indigenous people. This paper describes the collaborative development of, and principles underpinning, a research capacity strengthening (RCS) model in a national Indigenous primary health care CQI research network. The development process identified the need to address power imbalances, cultural contexts, relationships, systems requirements and existing knowledge, skills, and experience of all parties. Taking a strengths-based perspective, we harnessed existing knowledge, skills and experiences; hence our emphasis on capacity "strengthening". New insights are provided into the complex processes of RCS within the context of CQI in Indigenous primary health care.
An “All Teach, All Learn” Approach to Research Capacity Strengthening in Indigenous Primary Health Care Continuous Quality Improvement

PubMed Central

McPhail-Bell, Karen; Matthews, Veronica; Bainbridge, Roxanne; Redman-MacLaren, Michelle Louise; Askew, Deborah; Ramanathan, Shanthi; Bailie, Jodie; Bailie, Ross; Matthews, Veronica

2018-01-01

In Australia, Indigenous people experience poor access to health care and the highest rates of morbidity and mortality of any population group. Despite modest improvements in recent years, concerns remains that Indigenous people have been over-researched without corresponding health improvements. Embedding Indigenous leadership, participation, and priorities in health research is an essential strategy for meaningful change for Indigenous people. To centralize Indigenous perspectives in research processes, a transformative shift away from traditional approaches that have benefited researchers and non-Indigenous agendas is required. This shift must involve concomitant strengthening of the research capacity of Indigenous and non-Indigenous researchers and research translators—all must teach and all must learn. However, there is limited evidence about how to strengthen systems and stakeholder capacity to participate in and lead continuous quality improvement (CQI) research in Indigenous primary health care, to the benefit of Indigenous people. This paper describes the collaborative development of, and principles underpinning, a research capacity strengthening (RCS) model in a national Indigenous primary health care CQI research network. The development process identified the need to address power imbalances, cultural contexts, relationships, systems requirements and existing knowledge, skills, and experience of all parties. Taking a strengths-based perspective, we harnessed existing knowledge, skills and experiences; hence our emphasis on capacity “strengthening”. New insights are provided into the complex processes of RCS within the context of CQI in Indigenous primary health care. PMID:29761095
Using Systems Thinking to Advance Global Health Engagement in Education and Practice.

PubMed

Phillips, Janet M; Stalter, Ann M

2018-04-01

The integration of global health into nursing practice within complex systems requires a strategic approach. The System-Level Awareness Model (SAM) can be used to guide the process of enhancing systems thinking for global health. The purpose of this article is to explain the SAM and how to use it for integrating systems thinking into nursing education in academic, professional development, and continuing education settings to promote global health across the nursing continuum. Tips are provided on how to teach systems thinking for global health in nursing education and practice, consistent with continuing education national learning competencies for health care professionals. J Contin Educ Nurs. 2018;49(4):154-156. Copyright 2018, SLACK Incorporated.
The Coming Primary Care Revolution.

PubMed

Ellner, Andrew L; Phillips, Russell S

2017-04-01

The United States has the most expensive, technologically advanced, and sub-specialized healthcare system in the world, yet it has worse population health status than any other high-income country. Rising healthcare costs, high rates of waste, the continued trend towards chronic non-communicable disease, and the growth of new market entrants that compete with primary care services have set the stage for fundamental change in all of healthcare, driven by a revolution in primary care. We believe that the coming primary care revolution ought to be guided by the following design principles: 1) Payment must adequately support primary care and reward value, including non-visit-based care. 2) Relationships will serve as the bedrock of value in primary care, and will increasingly be fostered by teams, improved clinical operations, and technology, with patients and non-physicians assuming an ever-increasing role in most aspects of healthcare. 3) Generalist physicians will increasingly focus on high-acuity and high-complexity presentations, and primary care teams will increasingly manage conditions that specialists managed in the past. 4) Primary care will refocus on whole-person care, and address health behaviors as well as vision, hearing, dental, and social services. Design based on these principles should lead to higher-value healthcare, but will require new approaches to workforce training.
Improving the quality of transition and transfer of care in young adults with congenital heart disease.

PubMed

Everitt, Ian K; Gerardin, Jennifer F; Rodriguez, Fred H; Book, Wendy M

2017-05-01

The transition and transfer from pediatric to adult care is becoming increasingly important as improvements in the diagnosis and management of congenital heart disease allow patients to live longer. Transition is a complex and continuous process that requires careful planning. Inadequate transition has adverse effects on patients, their families and healthcare delivery systems. Currently, significant gaps exist in patient care as adolescents transfer to adult care and there are little data to drive the informed management of transition and transfer of care in adolescent congenital heart disease patients. Appropriate congenital heart disease care has been shown to decrease mortality in the adult population. This paper reviews the transition and transfer of care processes and outlines current congenital heart disease specific guidelines in the United States and compares these recommendations to Canadian and European guidelines. It then reviews perceived and real barriers to successful transition and identifies predictors of success during transfer to adult congenital heart disease care. Lastly, it explores how disease-specific markers of outcomes and quality indicators are being utilized to guide transition and transfer of care in other chronic childhood illnesses, and identifies existing knowledge gaps and structural impediments to improving the management of transition and transfer among congenital heart disease patients. © 2017 Wiley Periodicals, Inc.
Inequities In Health Care Needs For Children With Medical Complexity

PubMed Central

Kuo, Dennis; Goudie, Anthony; Cohen, Eyal; Houtrow, Amy; Agrawal, Rishi; Carle, Adam C.; Wells, Nora

2015-01-01

Children with special health care needs are believed to be susceptible to inequities in health and health care access. Within the group with special needs, there is a smaller group of children with medical complexity: children who require medical services beyond what is typically required by children with special health care needs. We describe health care inequities for the children with medical complexity compared to children with special health care needs but without medical complexity, based on a secondary analysis of the 2005–06 and 2009–10 National Survey of Children with Special Health Care Needs. The survey examines the prevalence, health care service use, and needs of children and youth with special care needs, as reported by their families. The inequities we examined were those based on race or ethnicity, primary language in the household, insurance type, and poverty status. We found that children with medical complexity were twice as likely to have at least one unmet need, compared to children without medical complexity. Among the children with medical complexity, uninsured status was associated with more unmet needs than privately insured status. We conclude that medical complexity itself can be a primary determinant of unmet needs. PMID:25489038
Managerial and environmental factors in the continuity of mental health care across institutions.

PubMed

Greenberg, Greg A; Rosenheck, Robert A

2003-04-01

The authors examined the association of continuity of care with factors assumed to be under the control of health care administrators and environmental factors not under managerial control. The authors used a facility-level administrative data set for 139 Department of Veterans Affairs medical centers over a six-year period and supplemental data on environmental factors to conduct two types of analysis. First, simple correlations were used to examine bivariate associations between eight continuity-of-care measures and nine measures of the institutional environment and the social context. Second, to control for potential autocorrelation, multivariate hierarchical linear models with all nine independent measures were created. The strongest predictors of continuity of care were per capita outpatient expenditure and the degree of emphasis on outpatient care as measured by the percentage of all mental health expenditures devoted to outpatient care. The former was significantly associated with greater continuity of care on six of eight measures and the latter on seven of eight measures. The environmental factor of social capital (the degree of civic involvement and trust at the state level) was associated with greater continuity of care on five measures. The degree to which non-VA mental health services were funded in a state was unexpectedly found to be positively associated with greater continuity of care. In multivariate analysis using hierarchical linear modeling, significant relationships with continuity of care remained for per capita outpatient expenditures, overall outpatient emphasis, and social capital, but not for non-VA mental health funding. A linear term representing the year was positively and significantly associated with six of the eight examined continuity-of-care measures, indicating improvement in continuity of care for the period under study, although the explanation for this trend over time is unclear. Several factors potentially under managerial control are associated with increased mental health continuity of care.
Family medicine patients who use retail clinics have lower continuity of care.

PubMed

Rohrer, James E; Angstman, Kurt B; Garrison, Gregory M; Maxson, Julie A; Furst, Joseph W

2013-04-01

The purpose of this study was to compare continuity of care for family medicine patients using retail medicine clinics to continuity for patients not using retail clinics. Retail medicine clinics have become popular in some markets. However, their impact on continuity of care has not been studied. Electronic medical records of adult primary care patients seen in a large group practice in Minnesota in 2011 were analyzed for this study. Two randomly chosen groups of patients were selected (N = 400): those using 1 of 3 retail walk-in clinics staffed by nurse practitioners in addition to standard office care and a comparison group that only used standard office care. Continuity was measured as the percentage of visits that involved the primary care provider. We also compared patients who made zero visits to their primary care providers with those who made some visits to their primary care providers. Continuity of care was lower for patients who used retail clinics than for patients who did not use retail clinics (0.17 vs 0.44, mean difference 0.27). The percentage of patients who made zero visits to their primary care providers was 54.5 for users of retail clinics versus 31.0 for those who did not use retail clinics. Continuity of care should be monitored as retail medicine continues to expand.
Machine learning and new vital signs monitoring in civilian en route care: A systematic review of the literature and future implications for the military.

PubMed

Liu, Nehemiah T; Salinas, Jose

2016-11-01

Although air transport medical services are today an integral part of trauma systems in most developed countries, to date, there are no reviews on recent innovations in civilian en route care. The purpose of this systematic review was to identify potential machine learning and new vital signs monitoring technologies in civilian en route care that could help close civilian and military capability gaps in monitoring and the early detection and treatment of various trauma injuries. MEDLINE, the Cochrane Database of Systematic Reviews, and citation review of relevant primary and review articles were searched for studies involving civilian en route care, air medical transport, and technologies from January 2005 to November 2015. Data were abstracted on study design, population, year, sponsors, innovation category, details of technologies, and outcomes. Thirteen observational studies involving civilian medical transport met inclusion criteria. Studies either focused on machine learning and software algorithms (n = 5), new vital signs monitoring (n = 6), or both (n = 2). Innovations involved continuous digital acquisition of physiologic data and parameter extraction. Importantly, all studies (n = 13) demonstrated improved outcomes where applicable and potential use during civilian and military en route care. However, almost all studies required further validation in prospective and/or randomized controlled trials. Potential machine learning technologies and monitoring of novel vital signs such as heart rate variability and complexity in civilian en route care could help enhance en route care for our nation's war fighters. In a complex global environment, they could potentially fill capability gaps such as monitoring and the early detection and treatment of various trauma injuries. However, the impact of these innovations and technologies will require further validation before widespread acceptance and prehospital use. Systematic review, level V.

Trauma patient discharge and care transition experiences: Identifying opportunities for quality improvement in trauma centres.

PubMed

Gotlib Conn, Lesley; Zwaiman, Ashley; DasGupta, Tracey; Hales, Brigette; Watamaniuk, Aaron; Nathens, Avery B

2018-01-01

Challenges delivering quality care are especially salient during hospital discharge and care transitions. Severely injured patients discharged from a trauma centre will go either home, to rehabilitation or another acute care hospital with complex management needs. This purpose of this study was to explore the experiences of trauma patients and families treated in a regional academic trauma centre to better understand and improve their discharge and care transition experiences. A qualitative study using inductive thematic analysis was conducted between March and October 2016. Telephone interviews were conducted with trauma patients and/or a family member after discharge from the trauma centre. Data collection and analysis were completed inductively and iteratively consistent with a qualitative approach. Twenty-four interviews included 19 patients and 7 family members. Participants' experiences drew attention to discharge and transfer processes that either (1) Fostered quality discharge or (2) Impeded quality discharge. Fostering quality discharge was ward staff preparation efforts; establishing effective care continuity; and, adequate emotional support. Impeding discharge quality was perceived pressure to leave the hospital; imposed transfer decisions; and, sub-optimal communication and coordination around discharge. Patient-provider communication was viewed to be driven by system, rather than patient need. Inter-facility information gaps raised concern about receiving facilities' ability to care for injured patients. The quality of trauma patient discharge and transition experiences is undermined by system- and ward-level processes that compete, rather than align, in producing high quality patient-centred discharge. Local improvement solutions focused on modifiable factors within the trauma centre include patient-oriented discharge education and patient navigation; however, these approaches alone may be insufficient to enhance patient experiences. Trauma patients encounter complex barriers to quality discharge that likely require a comprehensive, multimodal intervention. Copyright © 2017 Elsevier Ltd. All rights reserved.
Aligning population-based care management with chronic disease complexity.

PubMed

Hewner, Sharon; Seo, Jin Young; Gothard, Sandra E; Johnson, Barbara J

2014-01-01

Risk-stratified care management requires knowledge of the complexity of chronic disease and comorbidity, information that is often not readily available in the primary care setting. The purpose of this article was to describe a population-based approach to risk-stratified care management that could be applied in primary care. Three populations (Medicaid, Medicare, and privately insured) at a regional health plan were divided into risk-stratified cohorts based on chronic disease and complexity, and utilization was compared before and after the implementation of population-specific care management teams of nurses. Risk-stratified care management was associated with reductions in hospitalization rates in all three populations, but the opportunities to avoid admissions were different. Knowledge of population complexity is critical to the development of risk-stratified care management in primary care, and a complexity matrix can help nurses identify gaps in care and align interventions to cohort and population needs. Copyright © 2014 Elsevier Inc. All rights reserved.
[Complex automatic data processing in multi-profile hospitals].

PubMed

Dovzhenko, Iu M; Panov, G D

1990-01-01

The computerization of data processing in multi-disciplinary hospitals is the key factor in raising the quality of medical care provided to the population, intensifying the work of the personnel, improving the curative and diagnostic process and the use of resources. Even a small experience in complex computerization at the Botkin Hospital indicates that due to the use of the automated system the quality of data processing in being improved, a high level of patients' examination is being provided, a speedy training of young specialists is being achieved, conditions are being created for continuing education of physicians through the analysis of their own activity. At big hospitals a complex solution of administrative and curative diagnostic tasks on the basis of general hospital network of display connection and general hospital data bank is the most prospective form of computerization.
Nurse training with simulation: an innovative approach to teach complex microsurgery patient care.

PubMed

Flurry, Mitchell; Brooke, Sebastian; Micholetti, Brett; Natoli, Noel; Moyer, Kurtis; Mnich, Stephanie; Potochny, John

2012-10-01

Simulation has become an integral part of education at all levels within the medical field. The ability to allow personnel to practice and learn in a safe and controlled environment makes it a valuable tool for initial training and continued competence verification. An area of specific interest to the reconstructive microsurgeon is assurance that the nursing staff has adequate training and experience to provide optimum care for microsurgery patients. Plastic surgeons in institutions where few microsurgeries are performed face challenges teaching nurses how to care for these complex patients. Because no standard exists to educate microsurgery nurses, learning often happens by chance on-the-job encounters. Outcomes, therefore, may be affected by poor handoffs between inexperienced personnel. Our objective is to create a course that augments such random clinical experience and teaches the knowledge and skills necessary for successful microsurgery through simulated patient scenarios. Quality care reviews at our institution served as the foundation to develop an accredited nursing course providing clinical training for the care of microsurgery patients. The course combined lectures on microsurgery, pharmacology, and flap monitoring as well as simulated operating room, surgical intensive care unit, postanesthesia care unit, Trauma Bay, and Floor scenarios. Evaluation of participants included precourse examination, postcourse examination, and a 6-month follow-up. Average test scores were 72% precourse and 92% postcourse. Educational value, effectiveness of lectures and simulation, and overall course quality was rated very high or high by 86% of respondents; 0% respondents rated it as low. Six-month follow-up test score average was 88%. Learning to care for microsurgery patients should not be left to chance patient encounters on the job. Simulation provides a safe, reproducible, and controlled clinical experience. Our results show that simulation is a highly rated and effective way to teach nurses microsurgery patient care. Simulated patient care training should be considered to augment the clinical experience in hospitals where microsurgery is performed.
Bridging the Gap between Health and Social Care for Rare Diseases: Key Issues and Innovative Solutions.

PubMed

Castro, Raquel; Senecat, Juliette; de Chalendar, Myriam; Vajda, Ildikó; Dan, Dorica; Boncz, Béata

2017-01-01

Bridging the gaps between health and social care for rare diseases is not only necessary but crucial to increase the life expectancy, quality of life and autonomy of people living with a rare disease, supporting them in the full realisation of their fundamental human rights.The complexity of rare diseases, their strong relation to disability and the current unmet social and daily life needs of people living with a rare disease must not be underestimated and require urgent attention from all stakeholders involved in care provision, from healthcare to social and community services.The Commission Expert Group Recommendations to Support the Incorporation of Rare Diseases into Social Services and Policies, adopted unanimously in April 2016, by the representatives of European Member States and the other rare disease stakeholders, clearly set the tone for the need to promote measures that facilitate multidisciplinary, holistic, continuous, person-centred and participative care provision to people living with rare diseases.These recommendations, sided by other recent policy developments at European and national levels, represent an important policy step into approaching rare diseases' complex challenges in regards to holistic care provision.Innovative approaches aiming at bridging the gap between health, social and community service and support providers are currently being developed and tested in different European countries: standards of care, networks of expertise, case management services, one-stop-shop services, amongst others.These ongoing pilot approaches, presented in this chapter, have the power to inspire future policies and the effective and efficient implementation of holistic care pathways for people living with a rare disease, bringing about significant changes for patients, carers, care providers, competent authorities and the society at large.Nonetheless, the challenges to fully address this issue remain numerous and other key issues will also need to be taken into account when moving forward with the implementation of measures that aim at bridging the gaps between care providers and providing holistic care to people living with a rare disease.
Primary care providers' experiences caring for complex patients in primary care: a qualitative study.

PubMed

Loeb, Danielle F; Bayliss, Elizabeth A; Candrian, Carey; deGruy, Frank V; Binswanger, Ingrid A

2016-03-22

Complex patients are increasingly common in primary care and often have poor clinical outcomes. Healthcare system barriers to effective care for complex patients have been previously described, but less is known about the potential impact and meaning of caring for complex patients on a daily basis for primary care providers (PCPs). Our objective was to describe PCPs' experiences providing care for complex patients, including their experiences of health system barriers and facilitators and their strategies to enhance provision of effective care. Using a general inductive approach, our qualitative research study was guided by an interpretive epistemology, or way of knowing. Our method for understanding included semi-structured in-depth interviews with internal medicine PCPs from two university-based and three community health clinics. We developed an interview guide, which included questions on PCPs' experiences, perceived system barriers and facilitators, and strategies to improve their ability to effectively treat complex patients. To focus interviews on real cases, providers were asked to bring de-identified clinical notes from patients they considered complex to the interview. Interview transcripts were coded and analyzed to develop categories from the raw data, which were then conceptualized into broad themes after team-based discussion. PCPs (N = 15) described complex patients with multidimensional needs, such as socio-economic, medical, and mental health. A vision of optimal care emerged from the data, which included coordinating care, preventing hospitalizations, and developing patient trust. PCPs relied on professional values and individual care strategies to overcome local and system barriers. Team based approaches were endorsed to improve the management of complex patients. Given the barriers to effective care described by PCPs, individual PCP efforts alone are unlikely to meet the needs of complex patients. To fulfill PCP's expressed concepts of optimal care, implementation of effective systemic approaches should be considered.
Project ECHO: A Telementoring Network Model for Continuing Professional Development.

PubMed

Arora, Sanjeev; Kalishman, Summers G; Thornton, Karla A; Komaromy, Miriam S; Katzman, Joanna G; Struminger, Bruce B; Rayburn, William F

2017-01-01

A major challenge with current systems of CME is the inability to translate the explosive growth in health care knowledge into daily practice. Project ECHO (Extension for Community Healthcare Outcomes) is a telementoring network designed for continuing professional development (CPD) and improving patient outcomes. The purpose of this article was to describe how the model has complied with recommendations from several authoritative reports about redesigning and enhancing CPD. This model links primary care clinicians through a knowledge network with an interprofessional team of specialists from an academic medical center who provide telementoring and ongoing education enabling community clinicians to treat patients with a variety of complex conditions. Knowledge and skills are shared during weekly condition-specific videoconferences. The model exemplifies learning as described in the seven levels of CPD by Moore (participation, satisfaction, learning, competence, performance, patient, and community health). The model is also aligned with recommendations from four national reports intended to redesign knowledge transfer in improving health care. Efforts in learning sessions focus on information that is relevant to practice, focus on evidence, education methodology, tailoring of recommendations to individual needs and community resources, and interprofessionalism. Project ECHO serves as a telementoring network model of CPD that aligns with current best practice recommendations for CME. This transformative initiative has the potential to serve as a leading model for larger scale CPD, nationally and globally, to enhance access to care, improve quality, and reduce cost.
Gaps, disconnections, and discontinuities--the role of information exchange in the delivery of quality long-term care.

PubMed

Georgiou, Andrew; Marks, Anne; Braithwaite, Jeffrey; Westbrook, Johanna Irene

2013-10-01

The smart use of information and communication technologies (ICT) is widely seen as a means of enhancing the quality of aged care services. One of the barriers to ICT diffusion in aged care is the failure to cater for the complex and interdisciplinary requirements of the aged care environment. The aim of this qualitative study was to identify the layers of information exchange and communication and produce a conceptual model that can help to inform decisions related to the design, implementation, and sustainability of ICT. A qualitative study conducted in 2010 within seven Australian residential aged care facilities. It included 11 focus groups involving 47 staff and 54 individual interviews and observation sessions. The analysis of work processes identified key information exchange components related to the type of information (residential, clinical, and administrative) that is collected, stored, and communicated. This information relies on a diverse number of internal and external communication channels that are important for the organization of care. The findings highlight potential areas of communication dysfunction as a consequence of structural holes, fragmentation, or disconnections that can adversely affect the continuity and coordination of care, its safety, and quality.
The Experience of Psychiatric Care of Adolescents with Anxiety-based School Refusal and of their Parents: A Qualitative Study

PubMed Central

Sibeoni, Jordan; Orri, Massimiliano; Podlipski, Marc-Antoine; Labey, Mathilde; Campredon, Sophie; Gerardin, Priscille; Revah-Levy, Anne

2018-01-01

Objective Anxiety-based school refusal in adolescence is a complex, sometimes difficult to treat disorder that can have serious academic and psychiatric consequences. The objective of this qualitative study was to explore how teens with this problem and their parents experience the psychiatric care received. Methods This qualitative multicenter study took place in France, where we conducted semi-structured interviews with adolescents receiving psychiatric care for anxiety-based school refusal and with their parents. Data collection by purposive sampling continued until we reached theoretical sufficiency. Data analysis was thematic. Results This study included 20 adolescents aged 12 to 18 years and 21 parents. Two themes emerged from the analysis: (1) the goals of psychiatric care with two sub-themes, “self-transformation” and problem solving; and, (2) the therapeutic levers identified as effective with two sub-themes: time and space and relationships. Conclusion Our results show a divergence between parents and teens in their representations of care and especially of its goals. Therapeutic and research implications about the terms of return to school within psychiatric care and also the temporality of care are discussed. PMID:29375632
Facing the challenges and building solutions in clinical psychiatric nursing in Iran: a qualitative study.

PubMed

Zarea, Kourosh; Nikbakht-Nasrabadi, Alireza; Abbaszadeh, Abbas; Mohammadpour, Ali

2012-10-01

Psychiatric nurses play an important role in the process of caring for mentally ill patients and are continually faced with the numerous challenges and complex issues related to this field. This study aimed to understand the perspectives of psychiatric nurses regarding the issues they face while providing care and examine the possible solutions for improvement of inpatient care in clinical settings. The study adopted a qualitative approach that utilized a content analysis of audio taped, semi-structured interviews that had been conducted with 24 nurses. Two main themes emerged from the data. The first, Challenges in Providing Care within Psychiatric Wards, had the following subthemes: Politics and Rules of Organization, Safety and Security Issues, Uncertainty about the Role, Lack of Trained Staff, and Sociocultural Issues. The second theme, Solutions for Improving Psychiatric Care, had the subthemes of Empowerment across four domains: Psychiatric Nurses, Mentally Ill Patients and their Families, The Psychiatric Mental Health System, and the Cultural Context. The results indicated that if nurses are expected to provide optimal nursing care within a psychiatric ward, then there is a need for a stable and responsible organizational structure, skilled psychiatric nurses, and community-based care along with an anti-stigma program.
Perceptions of Ambulatory Workflow Changes in an Academic Primary Care Setting.

PubMed

Hanak, Michael A; McDevitt, Colleen; Dunham, Daniel P

As health care moves to a value-based system, the need for team-based models of care becomes increasingly important to adequately address the growing number of clinical quality metrics required of health care providers. Finding ways to better engage certified medical assistants (CMAs) in the process allows providers to focus on more complex tasks while improving the efficiency of each office visit. Although the roles and responsibilities for CMAs across the specialties can vary widely, standardizing the work can be a helpful step in scaling best practices across an institution. This article presents the results of a survey that evaluated various components of a CMA workflow in adult primary care practices within an academic medical center. Although the survey identified improved engagement and satisfaction with standardized changes overall, it also showed time constraints and provider discretion forcing unplanned modifications. Reviewing and reconciling medications seemed to be the most challenging for CMA staff, leading us to reconsider their involvement in this aspect of each visit. It will be important to continue innovating and testing team-based care models to keep up with the demands of a quality-based health care system.
EPA guidance on building trust in mental health services.

PubMed

Gaebel, W; Muijen, M; Baumann, A E; Bhugra, D; Wasserman, D; van der Gaag, R J; Heun, R; Zielasek, J

2014-02-01

To advance mental health care use by developing recommendations to increase trust from the general public and patients, those who have been in contact with services, those who have never been in contact and those who care for their families in the mental health care system. We performed a systematic literature search and the retrieved documents were evaluated by two independent reviewers. Evidence tables were generated and recommendations were developed in an expert and stakeholder consensus process. We developed five recommendations which may increase trust in mental health care services and advance mental health care service utilization. Trust is a mutual, complex, multidimensional and dynamic interrelationship of a multitude of factors. Its components may vary between individuals and over time. They may include, among others, age, place of residence, ethnicity, culture, experiences as a service user, and type of disorder. For mental health care services, issues of knowledge about mental health services, confidentiality, continuity of treatment, dignity, safety and avoidance of stigma and coercion are central elements to increase trust. Evidence-based recommendations to increase mutual trust of service users and psychiatrists have been developed and may help to increase mental health care service utilization. Copyright © 2014 Elsevier Masson SAS. All rights reserved.
General practitioners' experiences as nursing home medical consultants.

PubMed

Kirsebom, Marie; Hedström, Mariann; Pöder, Ulrika; Wadensten, Barbro

2017-03-01

To describe general practitioners' experiences of being the principal physician responsible for a nursing home. Fifteen general practitioners assigned to a nursing home participated in semi-structured qualitative interviews. Data were analysed using systematic text condensation. Medical assessment is the main duty of general practitioners. Advance care planning together with residents and family members facilitates future decisions on medical treatment and end-of-life care. Registered Nurses' continuity and competence are perceived as crucial to the quality of care, but inadequate staffing, lack of medical equipment and less-than-optimal IT systems for electronic healthcare records are impediments to patient safety. The study highlights the importance of advance care planning together with residents and family members in facilitating future decisions on medical treatment and end-of-life care. To meet the increasing demands for more complex medical treatment at nursing homes and to provide high-quality palliative care, there would seem to be a need to increase Registered Nurses' staffing and acquire more advanced medical equipment, as well as to create better possibilities for Registered Nurses and general practitioners to access each other's healthcare record systems. © 2016 Nordic College of Caring Science.
Infection Control in Limited Resources Countries: Challenges and Priorities.

PubMed

Vilar-Compte, Diana; Camacho-Ortiz, Adrián; Ponce-de-León, Samuel

2017-05-01

The purpose of this article is to review the current status of health care-related infections (HCRI) in low- and middle-income countries (LMIC). HCRI in LMIC are being recognized as an important health problem globally. Despite important efforts, complex medical and non-medical problems prevail. The HCRI burden in LMIC is bigger than in developed countries, with prevalence between 5.7 and 19.1%. The impact on patients, their families, and the hospital systems is high, but has been largely underestimated. During the last 30 years, some progress has been made, with an increased awareness from the medical community and some very successful programs; however, there is a huge gap for improvement and success. In many health care facilities, there is a need of functional surveillance programs, continuous supply of antiseptics, safe water supply, personal protective equipment, essential antibiotics to treat infections, appropriate number of health care personnel trained in infection control, and appropriate health care infrastructure and political commitment.
Cross-disciplinary research in cancer: an opportunity to narrow the knowledge–practice gap

PubMed Central

Urquhart, R.; Grunfeld, E.; Jackson, L.; Sargeant, J.; Porter, G.A.

2013-01-01

Health services researchers have consistently identified a gap between what is identified as “best practice” and what actually happens in clinical care. Despite nearly two decades of a growing evidence-based practice movement, narrowing the knowledge–practice gap continues to be a slow, complex, and poorly understood process. Here, we contend that cross-disciplinary research is increasingly relevant and important to reducing that gap, particularly research that encompasses the notion of transdisciplinarity, wherein multiple academic disciplines and non-academic individuals and groups are integrated into the research process. The assimilation of diverse perspectives, research approaches, and types of knowledge is potentially effective in helping research teams tackle real-world patient care issues, create more practice-based evidence, and translate the results to clinical and community care settings. The goals of this paper are to present and discuss cross-disciplinary approaches to health research and to provide two examples of how engaging in such research may optimize the use of research in cancer care. PMID:24311951
Cross-disciplinary research in cancer: an opportunity to narrow the knowledge-practice gap.

PubMed

Urquhart, R; Grunfeld, E; Jackson, L; Sargeant, J; Porter, G A

2013-12-01

Health services researchers have consistently identified a gap between what is identified as "best practice" and what actually happens in clinical care. Despite nearly two decades of a growing evidence-based practice movement, narrowing the knowledge-practice gap continues to be a slow, complex, and poorly understood process. Here, we contend that cross-disciplinary research is increasingly relevant and important to reducing that gap, particularly research that encompasses the notion of transdisciplinarity, wherein multiple academic disciplines and non-academic individuals and groups are integrated into the research process. The assimilation of diverse perspectives, research approaches, and types of knowledge is potentially effective in helping research teams tackle real-world patient care issues, create more practice-based evidence, and translate the results to clinical and community care settings. The goals of this paper are to present and discuss cross-disciplinary approaches to health research and to provide two examples of how engaging in such research may optimize the use of research in cancer care.
Practical management of anticoagulation in patients with atrial fibrillation.

PubMed

Kovacs, Richard J; Flaker, Greg C; Saxonhouse, Sherry J; Doherty, John U; Birtcher, Kim K; Cuker, Adam; Davidson, Bruce L; Giugliano, Robert P; Granger, Christopher B; Jaffer, Amir K; Mehta, Bella H; Nutescu, Edith; Williams, Kim A

2015-04-07

Anticoagulation for atrial fibrillation has become more complex due to the introduction of new anticoagulant agents, the number and kinds of patients requiring therapy, and the interactions of those patients in the matrix of care. The management of anticoagulation has become a "team sport" involving multiple specialties in multiple sites of care. The American College of Cardiology, through the College's Anticoagulation Initiative, convened a roundtable of experts from multiple specialties to discuss topics important to the management of patients requiring anticoagulation and to make expert recommendations on issues such as the initiation and interruption of anticoagulation, quality of anticoagulation care, management of major and minor bleeding, and treatment of special populations. The attendees continued to work toward consensus on these topics, and present the key findings of this roundtable in a state-of- the-art review focusing on the practical aspects of anticoagulation care for the patient with atrial fibrillation. Copyright © 2015 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.
American Indian family caregivers' experiences with helping elders.

PubMed

Jervis, Lori L; Boland, Mathew E; Fickenscher, Alexandra

2010-12-01

In recent years, a vast literature has accumulated on the negative effects on family caregivers of providing care to elders, while relatively little research has explored caregiving as a positive experience. Only a handful of studies have examined any aspect of informal caregiving among American Indians. This mixed methods study explores the negative and positive aspects of providing elder care among 19 northern plains American Indian family members. These caregivers described low levels of burden and high levels of reward, attributable to cultural attitudes toward elders and caregiving, collective care provision, strong reciprocal relationships with elders, enjoyment of elders, and relatively low levels of care provision. Caregiving manifested as part of a complex exchange of assistance rather than a unidirectional provision of assistance from the family member to the elder. That caregiving emerged as such an overwhelmingly positive experience in a community faced with poverty, alcohol disorders, trauma, and cultural traumatization is testimony to the important roles that elders often continue to play in these communities.
Action learning across the decades.

PubMed

Eason, Ken

2017-05-02

Purpose The purpose of this paper is to explore how action learning concepts were used in two healthcare projects undertaken many decades apart. The specific purpose in both cases was to examine how action learning can contribute to shared learning across key stakeholders in a complex socio-technical system. In each case study, action learning supported joint design programmes and the sharing of perspectives about the complex system under investigation. Design/methodology/approach Two action learning projects are described: first, the Hospital Internal Communications (HIC) project led by Reg Revans in the 1960s. Senior staff in ten London hospitals formed action learning teams to address communication issues. Second, in the Better Outcomes for People with Learning Disabilities: Transforming Care (BOLDTC) project, videoconferencing equipment enabled people with learning disabilities to increase their opportunities to communicate. A mutual learning process was established to enable stakeholders to explore the potential of the technical system to improve individual care. Findings The HIC project demonstrated the importance of evidence being shared between team members and that action had to engage the larger healthcare system outside the hospital. The BOLDTC project confirmed the continuing relevance of action learning to healthcare today. Mutual learning was achieved between health and social care specialists and technologists. Originality/value This work draws together the socio-technical systems tradition (considering both social and technical issues in organisations) and action learning to demonstrate that complex systems development needs to be undertaken as a learning process in which action provides the fuel for learning and design.
Structuring Community Care using Multi-Agent Systems

NASA Astrophysics Data System (ADS)

Beer, Martin D.

Community care is a complex operation that requires the interaction of large numbers of dedicated individuals, managed by an equally wide range of organisations. They are also by their nature highly mobile and flexible, moving between clients in whatever order person receiving care is that they receive what they expect regularly, reliably and when they expect to receive it. Current systems are heavily provider focused on providing the scheduled care with as high apparent cost effectiveness as possible. Unfortunately, the lack of focus on the client often leads to inflexibility with expensive services being provided when they are not needed, large scale duplication of effort or inadequate flexibility to change the care regime to meet changing circumstances. Add to this the problems associated with the lack of integration of emergency and routing care and the extensive support given by friends and family and many opportunities exist to improve both the levels of support and the efficiency of care. The move towards Individual Care Plans requires much closer monitoring to ensure that the care specified for each individual is actually delivered and when linked with smart home technology in conjunction with appropriate sensors allows a much richer range of services to be offered which can be customised to meet the needs of each individual, giving them the assurance to continue to live independently.

Meeting the policy agenda, part 1: the role of the modern district nurse.

PubMed

Dickson, Caroline A W; Gough, Helen; Bain, Heather

2011-10-01

The challenges posed by the current context of health and social care offer opportunities for different models of care delivery. District nursing has evolved, and continues to evolve to meet these challenges. The traditional reactive role of district nursing has developed as contemporary practice expects district nurses to meet both planned and unplanned care required by practice populations. Modern anticipatory care approaches to care are being adopted, while care and case management is being facilitated and delivered to patients and families with complex health and social care needs. Additionally, district nurses are recognizing the need to further develop management and leadership skills as the teams delivering care consist of a skill mix of nurses and other disciplines. They are also charged with evidencing the impact of what they do and influencing care delivery at every level of healthcare organizations. This first paper of two will explore the current UK policy context and ways in which district nursing services within each country are changing to meet the challenges posed. A second article will argue the need to ensure the district nursing workforce is underpinned by robust educational standards that ensure protection of the public. The influences of education and development from professional and organizational perspectives will be examined.
Improving the Quality of Home Health Care for Children With Medical Complexity.

PubMed

Nageswaran, Savithri; Golden, Shannon L

2017-08-01

The objectives of this study are to describe the quality of home health care services for children with medical complexity, identify barriers to delivering optimal home health care, and discuss potential solutions to improve home health care delivery. In this qualitative study, we conducted 20 semistructured in-depth interviews with primary caregivers of children with medical complexity, and 4 focus groups with 18 home health nurses. During an iterative analysis process, we identified themes related to quality of home health care. There is substantial variability between home health nurses in the delivery of home health care to children. Lack of skills in nurses is common and has serious negative health consequences for children with medical complexity, including hospitalizations, emergency room visits, and need for medical procedures. Inadequate home health care also contributes to caregiver burden. A major barrier to delivering optimal home health care is the lack of training of home health nurses in pediatric care and technology use. Potential solutions for improving care include home health agencies training nurses in the care of children with medical complexity, support for nurses in clinical problem solving, and reimbursement for training nurses in pediatric home care. Caregiver-level interventions includes preparation of caregivers about: providing medical care for their children at home and addressing problems with home health care services. There are problems in the quality of home health care delivered to children with medical complexity. Training nurses in the care of children with medical complexity and preparing caregivers about home care could improve home health care quality. Copyright © 2017 Academic Pediatric Association. Published by Elsevier Inc. All rights reserved.
Learning about systems-based practice in the informal curriculum: a case study in an academic pediatric continuity clinic.

PubMed

Balmer, Dorene; Ruzek, Sheryl; Ludwig, Stephen; Giardino, Angelo P

2007-01-01

Pediatric residents learn about systems-based practice (SBP) explicitly in the formal curriculum and implicitly in the informal curriculum as they engage in practice alongside physician faculty. Recent studies describe innovative ways to address SBP in the formal curriculum for SBP, but the informal curriculum has not been explored. We examined what, and how, third-year pediatric residents learn about SBP in the informal curriculum at one continuity clinic, and to consider how this learning aligns with the formal curriculum. A case study involving 10 third-year pediatric residents and 10 continuity preceptors was conducted at one continuity clinic, housed in a community-based, pediatric primary care center. Data were derived from 5 months (100 hours) of direct observation in the precepting room at the case clinic, semistructured interviews with residents (before and after observation) and with preceptors (after observation). Interview transcripts and notes from observation were inductively coded and analyzed for major themes. Two themes emerged in the informal curriculum. Residents perceived "our system," the academic health system in which they trained and practiced as separate and distinct from the "real system," the larger, societal context of health care. Residents also understood SBP as a commitment to helping individual patients and families navigate the complexities of "our system," dealing with issues that concerned them. Residents learn important lessons about SBP in the informal curriculum in continuity clinic. These lessons may reinforce some elements of the competency-based formal curriculum for SBP, but challenge others.
What does 'complex' mean in palliative care? Triangulating qualitative findings from 3 settings.

PubMed

Carduff, Emma; Johnston, Sarah; Winstanley, Catherine; Morrish, Jamie; Murray, Scott A; Spiller, Juliet; Finucane, Anne

2018-01-04

Complex need for patients with a terminal illness distinguishes those who would benefit from specialist palliative care from those who could be cared for by non-specialists. However, the nature of this complexity is not well defined or understood. This study describes how health professionals, from three distinct settings in the United Kingdom, understand complex need in palliative care. Semi-structured qualitative interviews were conducted with professionals in primary care, hospital and hospice settings. Thirty-four professionals including doctors, nurses and allied health professionals were recruited in total. Data collected in each setting were thematically analysed and a workshop was convened to compare and contrast findings across settings. The interaction between diverse multi-dimensional aspects of need, existing co-morbidities, intractable symptoms and complicated social and psychological issues increased perceived complexity. Poor communication between patients and their clinicians contributed to complexity. Professionals in primary and acute care described themselves as 'generalists' and felt they lacked confidence and skill in identifying and caring for complex patients and time for professional development in palliative care. Complexity in the context of palliative care can be inherent to the patient or perceived by health professionals. Lack of confidence, time constraints and bed pressures contribute to perceived complexity, but are amenable to change by training in identifying, prognosticating for, and communicating with patients approaching the end of life.
Associates of Engagement in Adult-Oriented Follow-Up Care for Childhood Cancer Survivors.

PubMed

Szalda, Dava; Piece, Lisa; Brumley, Lauren; Li, Yimei; Schapira, Marilyn M; Wasik, Monika; Hobbie, Wendy L; Ginsberg, Jill P; Schwartz, Lisa A

2017-02-01

Understanding how to predict appropriate uptake of adult-oriented medical care is important for adult patients with pediatric-onset chronic health conditions with continued health vulnerability. We examined associates of engagement in adult survivors of childhood cancer following transfer to adult-oriented care. Adult survivors of childhood cancer (N = 80), within 1-5 years post transfer from pediatric to adult-oriented follow-up care, completed assessments of engagement with recommended adult-oriented follow-up care and psychosocial and transition readiness measures. Measures were validated with adolescent and young adults and/or intended to measure readiness to transition to adult care. Earlier age at diagnosis, parental involvement in health care decision-making, higher motivation, and increased comfort speaking to providers about health concerns were significantly associated with attendance at adult-oriented follow-up care visits. Associates of engagement in adult care are complex, representing social-ecological variables. Current measures of transition readiness or adolescent and young adult health-related measures may not adequately capture the associates of engagement in care or identify targets of intervention to promote successful transfer of care. Identifying patients at risk for loss to follow-up will be useful to design interventions for young adult survivors of childhood cancer and other young adults with pediatric-onset chronic conditions who require ongoing adult-oriented care. Copyright © 2016 Society for Adolescent Health and Medicine. Published by Elsevier Inc. All rights reserved.
Which features of primary care affect unscheduled secondary care use? A systematic review

PubMed Central

Huntley, Alyson; Lasserson, Daniel; Wye, Lesley; Morris, Richard; Checkland, Kath; England, Helen; Salisbury, Chris; Purdy, Sarah

2014-01-01

Objectives To conduct a systematic review to identify studies that describe factors and interventions at primary care practice level that impact on levels of utilisation of unscheduled secondary care. Setting Observational studies at primary care practice level. Participants Studies included people of any age of either sex living in Organisation for Economic Co-operation and Development (OECD) countries with any health condition. Primary and secondary outcome measures The primary outcome measure was unscheduled secondary care as measured by emergency department attendance and emergency hospital admissions. Results 48 papers were identified describing potential influencing features on emergency department visits (n=24 studies) and emergency admissions (n=22 studies). Patient factors associated with both outcomes were increased age, reduced socioeconomic status, lower educational attainment, chronic disease and multimorbidity. Features of primary care affecting unscheduled secondary care were more complex. Being able to see the same healthcare professional reduced unscheduled secondary care. Generally, better access was associated with reduced unscheduled care in the USA. Proximity to healthcare provision influenced patterns of use. Evidence relating to quality of care was limited and mixed. Conclusions The majority of research was from different healthcare systems and limited in the extent to which it can inform policy. However, there is evidence that continuity of care is associated with reduced emergency department attendance and emergency hospital admissions. PMID:24860000
Toward population management in an integrated care model.

PubMed

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

2013-04-01

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

PubMed

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

2013-01-01

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

PubMed

Cockings, Jerome G L; Cook, David A; Iqbal, Rehana K

2006-02-01

A health care system is a complex adaptive system. The effect of a single intervention, incorporated into a complex clinical environment, may be different from that expected. A national database such as the Intensive Care National Audit & Research Centre (ICNARC) Case Mix Programme in the UK represents a centralised monitoring, surveillance and reporting system for retrospective quality and comparative audit. This can be supplemented with real-time process monitoring at a local level for continuous process improvement, allowing early detection of the impact of both unplanned and deliberately imposed changes in the clinical environment. Demographic and UK Acute Physiology and Chronic Health Evaluation II (APACHE II) data were prospectively collected on all patients admitted to a UK regional hospital between 1 January 2003 and 30 June 2004 in accordance with the ICNARC Case Mix Programme. We present a cumulative expected minus observed (E-O) plot and the risk-adjusted p chart as methods of continuous process monitoring. We describe the construction and interpretation of these charts and show how they can be used to detect planned or unplanned organisational process changes affecting mortality outcomes. Five hundred and eighty-nine adult patients were included. The overall death rate was 0.78 of predicted. Calibration showed excess survival in ranges above 30% risk of death. The E-O plot confirmed a survival above that predicted. Small transient variations were seen in the slope that could represent random effects, or real but transient changes in the quality of care. The risk-adjusted p chart showed several observations below the 2 SD control limits of the expected mortality rate. These plots provide rapid analysis of risk-adjusted performance suitable for local application and interpretation. The E-O chart provided rapid easily visible feedback of changes in risk-adjusted mortality, while the risk-adjusted p chart allowed statistical evaluation. Local analysis of risk-adjusted mortality data with an E-O plot and a risk-adjusted p chart is feasible and allows the rapid detection of changes in risk-adjusted outcome of intensive care patients. This complements the centralised national database, which is more archival and comparative in nature.
Quality of care assessment in geriatric evaluation and management units: construction of a chart review tool for a tracer condition.

PubMed

Kergoat, Marie-Jeanne; Leclerc, Bernard-Simon; Leduc, Nicole; Latour, Judith; Berg, Katherine; Bolduc, Aline

2009-07-29

The number of elderly people requiring hospital care is growing, so, quality and assessment of care for elders are emerging and complex areas of research. Very few validated and reliable instruments exist for the assessment of quality of acute care in this field. This study's objective was to create such a tool for Geriatric Evaluation and Management Units (GEMUs). The methodology involved a reliability and feasibility study of a retrospective chart review on 934 older inpatients admitted in 49 GEMUs during the year 2002-2003 for fall-related trauma as a tracer condition. Pertinent indicators for a chart abstraction tool, the Geriatric Care Tool (GCT), were developed and validated according to five dimensions: access to care, comprehensiveness, continuity of care, patient-centred care and appropriateness. Consensus methods were used to develop the content. Participants were experts representing eight main health care professions involved in GEMUs from 19 different sites. Items associated with high quality of care at each step of the multidisciplinary management of patients admitted due to falls were identified. The GCT was tested for intra- and inter-rater reliability using 30 medical charts reviewed by each of three independent and blinded trained nurses. Kappa and agreement measures between pairs of chart reviewers were computed on an item-by-item basis. Three quarters of 169 items identifying the process of care, from the case history to discharge planning, demonstrated good agreement (kappa greater than 0.40 and agreement over 70%). Indicators for the appropriateness of care showed less reliability. Content validity and reliability results, as well as the feasibility of the process, suggest that the chart abstraction tool can gather standardized and pertinent clinical information for further evaluating quality of care in GEMU using admission due to falls as a tracer condition. However, the GCT should be evaluated in other models of acute geriatric units and new strategies should be developed to improve reliability of peer assessments in characterizing the quality of care for elderly patients with complex conditions.
Health care organizations as complex systems: new perspectives on design and management.

PubMed

McDaniel, Reuben R; Driebe, Dean J; Lanham, Holly Jordan

2013-01-01

We discuss the impact of complexity science on the design and management of health care organizations over the past decade. We provide an overview of complexity science issues and their impact on thinking about health care systems, particularly with the rising importance of information systems. We also present a complexity science perspective on current issues in today's health care organizations and suggest ways that this perspective might help in approaching these issues. We review selected research, focusing on work in which we participated, to identify specific examples of applications of complexity science. We then take a look at information systems in health care organizations from a complexity viewpoint. Complexity science is a fundamentally different way of understanding nature and has influenced the thinking of scholars and practitioners as they have attempted to understand health care organizations. Many scholars study health care organizations as complex adaptive systems and through this perspective develop new management strategies. Most important, perhaps, is the understanding that attention to relationships and interdependencies is critical for developing effective management strategies. Increased understanding of complexity science can enhance the ability of researchers and practitioners to develop new ways of understanding and improving health care organizations. This analysis opens new vistas for scholars and practitioners attempting to understand health care organizations as complex adaptive systems. The analysis holds value for those already familiar with this approach as well as those who may not be as familiar.
Inequities in health care needs for children with medical complexity.

PubMed

Kuo, Dennis Z; Goudie, Anthony; Cohen, Eyal; Houtrow, Amy; Agrawal, Rishi; Carle, Adam C; Wells, Nora

2014-12-01

Children with special health care needs are believed to be susceptible to inequities in health and health care access. Within the group with special needs, there is a smaller group of children with medical complexity: children who require medical services beyond what is typically required by children with special health care needs. We describe health care inequities for the children with medical complexity compared to children with special health care needs but without medical complexity, based on a secondary analysis of data from the 2005-06 and 2009-10 National Survey of Children with Special Health Care Needs. The survey examines the prevalence, health care service use, and needs of children and youth with special care needs, as reported by their families. The inequities we examined were those based on race/ethnicity, primary language in the household, insurance type, and poverty status. We found that children with medical complexity were twice as likely to have at least one unmet need, compared to children without medical complexity. Among the children with medical complexity, unmet need was not associated with primary language, income level, or having Medicaid. We conclude that medical complexity itself can be a primary determinant of unmet needs. Project HOPE—The People-to-People Health Foundation, Inc.
Community Care for People with Complex Care Needs: Bridging the Gap between Health and Social Care

PubMed Central

Ho, Julia W.; Hans, Parminder Kaur; Nelson, Michelle LA

2017-01-01

Introduction: A growing number of people are living with complex care needs characterized by multimorbidity, mental health challenges and social deprivation. Required is the integration of health and social care, beyond traditional health care services to address social determinants. This study investigates key care components to support complex patients and their families in the community. Methods: Expert panel focus groups with 24 care providers, working in health and social care sectors across Toronto, Ontario, Canada were conducted. Patient vignettes illustrating significant health and social care needs were presented to participants. The vignettes prompted discussions on i) how best to meet complex care needs in the community and ii) the barriers to delivering care to this population. Results: Categories to support care needs of complex patients and their families included i) relationships as the foundation for care, ii) desired processes and structures of care, and iii) barriers and workarounds for desired care. Discussion and Conclusions: Meeting the needs of the population who require health and social care requires time to develop authentic relationships, broadening the membership of the care team, communicating across sectors, co-locating health and social care, and addressing the barriers that prevent providers from engaging in these required practices. PMID:28970760
Katrina's Legacy: Processes for Patient Disaster Preparation Have Improved but Important Gaps Remain.

PubMed

Icenogle, Marjorie; Eastburn, Sasha; Arrieta, Martha

2016-11-01

Ensuring continuity of care for patients with chronic illness, who are elderly or indigent presents unique challenges after disasters; this population has fewer financial resources, is less likely to evacuate, has limited access to recovery resources and is significantly dependent on charitable and government-funded institutions for care. This study expands a previous investigation of the extent to which healthcare providers in coastal Mississippi and Alabama have made changes to facilitate continued care to these populations after disasters. Key informants representing healthcare and social services organizations serving health-disparate residents of the Mississippi and Alabama Gulf Coast were interviewed regarding disaster preparation planning for the period of 2009-2012. Interview transcripts were qualitatively coded and analyzed for emerging themes using ATLAS.ti software. Participant organizations have implemented changes to ensure continuity of care for patients with chronic illness in case of disasters. Changes include patient assistance with predisaster preparation and training; evacuation planning and assistance; support to find resources in evacuation destinations; equipping patients with prescription information, diagnoses, treatment plans and advance medications when a disaster is imminent; multiple methods for patients to communicate with providers and more mandated medical needs shelters. Patients whose chronic conditions were diagnosed post-Katrina are more likely to underestimate the need to prepare. Further, patients' lack of compliance tends to increase as time passes from disasters. Although changes were implemented, results indicate that these may be inadequate to completely address patient needs. Thus, additional efforts may be needed, underscoring the complexity of adequate disaster preparation among disparate populations. Copyright © 2016 Southern Society for Clinical Investigation. Published by Elsevier Inc. All rights reserved.
Scaling up ART adherence clubs in the public sector health system in the Western Cape, South Africa: a study of the institutionalisation of a pilot innovation.

PubMed

MacGregor, Hayley; McKenzie, Andrew; Jacobs, Tanya; Ullauri, Angelica

2018-04-25

In 2011, a decision was made to scale up a pilot innovation involving 'adherence clubs' as a form of differentiated care for HIV positive people in the public sector antiretroviral therapy programme in the Western Cape Province of South Africa. In 2016 we were involved in the qualitative aspect of an evaluation of the adherence club model, the overall objective of which was to assess the health outcomes for patients accessing clubs through epidemiological analysis, and to conduct a health systems analysis to evaluate how the model of care performed at scale. In this paper we adopt a complex adaptive systems lens to analyse planned organisational change through intervention in a state health system. We explore the challenges associated with taking to scale a pilot that began as a relatively simple innovation by a non-governmental organisation. Our analysis reveals how a programme initially representing a simple, unitary system in terms of management and clinical governance had evolved into a complex, differentiated care system. An innovation that was assessed as an excellent idea and received political backing, worked well whilst supported on a small scale. However, as scaling up progressed, challenges have emerged at the same time as support has waned. We identified a 'tipping point' at which the system was more likely to fail, as vulnerabilities magnified and the capacity for adaptation was exceeded. Yet the study also revealed the impressive capacity that a health system can have for catalysing novel approaches. We argue that innovation in largescale, complex programmes in health systems is a continuous process that requires ongoing support and attention to new innovation as challenges emerge. Rapid scaling up is also likely to require recourse to further resources, and a culture of iterative learning to address emerging challenges and mitigate complex system errors. These are necessary steps to the future success of adherence clubs as a cornerstone of differentiated care. Further research is needed to assess the equity and quality outcomes of a differentiated care model and to ensure the inclusive distribution of the benefits to all categories of people living with HIV.
The spectrum of medical errors: when patients sue

PubMed Central

Kels, Barry D; Grant-Kels, Jane M

2012-01-01

Inarguably medical errors constitute a serious, dangerous, and expensive problem for the twenty-first-century US health care system. This review examines the incidence, nature, and complexity of alleged medical negligence and medical malpractice. The authors hope this will constitute a road map to medical providers so that they can better understand the present climate and hopefully avoid the “Scylla and Charybdis” of medical errors and medical malpractice. Despite some documented success in reducing medical errors, adverse events and medical errors continue to represent an indelible stain upon the practice, reputation, and success of the US health care industry. In that regard, what may be required to successfully attack the unacceptably high severity and volume of medical errors is a locally directed and organized initiative sponsored by individual health care organizations that is coordinated, supported, and guided by state and federal governmental and nongovernmental agencies. PMID:22924008
Quality of care in family planning services in Morocco.

PubMed

Brown, L; Tyane, M; Bertrand, J; Lauro, D; Abou-ouakil, M; deMaria, L

1995-01-01

This study was conducted to heighten awareness of quality of care as a programmatic issue in the Moroccan governmental family planning program and to test modified Situation Analysis instruments for measuring quality of care. Data were collected from 50 service-delivery points in five provinces to measure six elements of quality in accordance with the Bruce/Jain framework. A procedure for calculating quality-indicator scores is presented. Although facilities varied by province and within provinces, most had the equipment and supplies needed to deliver services; service personnel were trained and regularly supervised; the service-delivery points scored well on mechanisms to ensure continuity of use. Notable shortcomings included a dearth of materials for counseling and a widespread unavailability of the Ovrette pill. This study raises issues regarding the complexity of measuring quality, the ownership of results, and the appropriateness of a centralized study of quality in a decentralized program.
Optimizing learning in healthcare: how Island Health is evolving to learn at the speed of change.

PubMed

Gottfredson, Conrad; Stroud, Carol; Jackson, Mary; Stevenson, R Lynn; Archer, Jana

2014-01-01

Healthcare organizations are challenged with constrained resources and increasing service demands by an aging population with complex care needs. Exponential growth in competency requirements also challenges staff's ability to provide quality patient care. How can a healthcare organization support its staff to learn "at or above the speed of change" while continuing to provide the quality patient care? Island Health is addressing this challenge by transforming its traditional education model into an innovative, evidence-based learning and performance support approach. Implementation of the methodology is yielding several lessons learned, both for the internal Learning and Performance Support team, and for what it takes to bring a new way of doing business into an organization. A key result is that this approach is enabling the organization to be more responsive in helping staff gain and maintain competencies.
Systems for the management of respiratory disease in primary care - an international series: Australia.

PubMed

Glasgow, Nicholas

2008-03-01

Australia has a complex health system with policy and funding responsibilities divided across federal and state/territory boundaries and service provision split between public and private providers. General practice is largely funded through the federal government. Other primary health care services are provided by state/territory public entities and private allied health practitioners. Indigenous health services are specifically funded by the federal government through a series of Aboriginal Community Controlled Organisations. NATIONAL POLICY AND MODELS: The dominant primary health care model is federally-funded private "small business" general practices. Medicare reimbursement items have incrementally changed over the last decade to include increasing support for chronic disease care with both generic and disease specific items as incentives. Asthma has received a large amount of national policy attention. Other respiratory diseases have not had similar policy emphasis. Australia has a high prevalence of asthma. Respiratory-related encounters in general practice, including acute and chronic respiratory illness and influenza immunisations, account for 20.6% of general practice activity. Lung cancer is a rare disease in general practice. Tuberculosis is uncommon and most often found in people born outside of Australia. Aboriginal and Torres Strait Islanders have higher rates of asthma, smoking and tuberculosis. Access to care is positively influenced by substantial public funding underpinning both the private and public sectors through Medicare. Access to general practice care is negatively influenced by workforce shortages, the ongoing demands of acute care, and the incremental way in which system redesign is occurring in general practice. Most general practice operates from privately-owned rooms. The Australian Government requires general practice facilities to be accredited against certain standards in order for the practice to receive income from a number of government programs. These standards require GPs to have ready access to spirometry, but do not require every practice to have a spirometer. The initial assessment and management of acute respiratory illnesses currently seen in primary health care settings will continue, but for this to occur the sector may have to adapt traditional workforce roles because of workforce shortages. In the longer term, climate change and migration patterns may result in changes in the epidemiology of regions and populations. The health system will continue to reform incrementally in order to deliver improved chronic disease care, including care of people with asthma and COPD. The incoming Labor Government's National Primary Health Care Strategy provides the high level policy opportunity to drive reform. Australia's complex primary health care system is incrementally changing from one of exclusive acute- and episodic-care orientation in both the public and private sectors to a system that delivers effective anticipatory chronic disease care as well. From a national policy perspective, asthma has received most attention. COPD and possibly other respiratory diseases may now receive focus.
Addressing Low Literacy and Health Literacy in Clinical Oncology Practice

PubMed Central

Garcia, Sofia F.; Hahn, Elizabeth A.; Jacobs, Elizabeth A.

2011-01-01

Low functional literacy and low health literacy continue to be under-recognized and are associated with poorer patient health outcomes. Health literacy is a dynamic state influenced by how well a healthcare system delivers information and services that match patients’ abilities, needs and preferences. Oncology care poses considerable health literacy demands on patients who are expected to process high stakes information about complex multidisciplinary treatment over lengths of time. Much of the information provided to patients in clinical care and research is beyond their literacy levels. In this paper, we provide an overview of currently available guidelines and resources to improve how the needs of patients with diverse literacy skills are met by cancer care providers and clinics. We present recommendations for health literacy assessment in clinical practice and ways to enhance the usability of health information and services by improving written materials and verbal communication, incorporating multimedia and culturally appropriate approaches, and promoting health literacy in cancer care settings. The paper also includes a list of additional resources that can be used to develop and implement health literacy initiatives in cancer care clinics. PMID:20464884

Comparative study of the Aristotle Comprehensive Complexity and the Risk Adjustment in Congenital Heart Surgery scores.

PubMed

Bojan, Mirela; Gerelli, Sébastien; Gioanni, Simone; Pouard, Philippe; Vouhé, Pascal

2011-09-01

The Aristotle Comprehensive Complexity (ACC) and the Risk Adjustment in Congenital Heart Surgery (RACHS-1) scores have been proposed for complexity adjustment in the analysis of outcome after congenital heart surgery. Previous studies found RACHS-1 to be a better predictor of outcome than the Aristotle Basic Complexity score. We compared the ability to predict operative mortality and morbidity between ACC, the latest update of the Aristotle method and RACHS-1. Morbidity was assessed by length of intensive care unit stay. We retrospectively enrolled patients undergoing congenital heart surgery. We modeled each score as a continuous variable, mortality as a binary variable, and length of stay as a censored variable. We compared performance between mortality and morbidity models using likelihood ratio tests for nested models and paired concordance statistics. Among all 1,384 patients enrolled, 30-day mortality rate was 3.5% and median length of intensive care unit stay was 3 days. Both scores strongly related to mortality, but ACC made better prediction than RACHS-1; c-indexes 0.87 (0.84, 0.91) vs 0.75 (0.65, 0.82). Both scores related to overall length of stay only during the first postoperative week, but ACC made better predictions than RACHS-1; U statistic=0.22, p<0.001. No significant difference was noted after adjusting RACHS-1 models on age, prematurity, and major extracardiac abnormalities. The ACC was a better predictor of operative mortality and length of intensive care unit stay than RACHS-1. In order to achieve similar performance, regression models including RACHS-1 need to be further adjusted on age, prematurity, and major extracardiac abnormalities. Copyright © 2011 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.
Medical condition and care of undocumented migrants in ambulatory clinics in Tel Aviv, Israel: assessing unmet needs.

PubMed

Mor, Zohar; Raveh, Yuval; Lurie, Ido; Leventhal, Alex; Gamzu, Roni; Davidovitch, Nadav; Benari, Orel; Grotto, Itamar

2017-07-14

Approximately 150,000 undocumented migrants (UM) who are medically uninsured reside in Israel, including ~50,000 originating from the horn of Africa (MHA). Free medical-care is provided by two walk-in clinics in Tel-Aviv. This study aims to compare the medical complaints of UM from different origins, define their community health needs and assess gaps between medical needs and available services. This cross-sectional study included a random sample of 610 UM aged 18-64 years, who were treated in these community clinics between 2008 and 2011. The study compared UM who had complex medical conditions which necessitated referral to more equipped medical settings with UM having mild/simple medical conditions, who were treated at the clinics. MHA were younger, unemployed and more commonly males compared with UM originating from other countries. MHA also had longer referral-delays and visited the clinics less frequently. UM with complex medical conditions were more commonly females, had chronic diseases and demonstrated longer referral-delays than those who had mild/simple medical conditions. The latter more commonly presented with complained of respiratory, muscular and skeletal discomfort. In multivariate analysis, the variables which predicted complex medical conditions included female gender, chronic illnes and self-referral to the clinics. The ambulatory clinics were capable of responding to mild/simple medical conditions. Yet, the health needs of women and migrants suffering from complex medical conditions and chronic diseases necessitated referrals to secondary/tertiary medical settings, while jeopardizing the continuity of care. The health gaps can be addressed by a more holistic social approach, which includes integration of UM in universal health insurance.
Bad Mothers and Monstrous Sons: Autistic Adults, Lifelong Dependency, and Sensationalized Narratives of Care.

PubMed

Allen, Holly

2017-03-01

Sensationalized representations of autistic families in film and other media frequently feature violent encounters between mothers and sons. This essay analyzes two media stories and three films that suggest how limited-and therefore misleading-popular representations of the autism family are. Except for one of the films, these representations blame the problem of adult autistic dependency on either monstrous autism or bad mothering. Doing so elides collective social responsibility for autism care and denies the reality that autistic adults continue to have complex dependency needs that families cannot always meet. Narratives that sensationalize youth and adults with autism or scapegoat their maternal caregivers also diminish opportunities for social inclusion and for autistic people to live fully and dependently.
Predictors of posttraumatic stress symptoms among runaway youth utilizing two service sectors.

PubMed

Thompson, Sanna J; Maccio, Elaine M; Desselle, Sherry K; Zittel-Palamara, Kimberly

2007-08-01

Youth who run away often experience situations that produce symptoms of traumatic distress. This exploratory study assessed predictors of trauma symptomatology among runaway youth who had been admitted to youth emergency shelter services or juvenile detention. Findings demonstrated high levels of trauma-related symptoms for both groups. Worry about family, greater runaway episodes, and living with a father who abused alcohol/drugs significantly predicted higher posttraumatic stress symptoms in detained youth, whereas only worry about family relationships predicted higher trauma symptom scores among youth in emergency shelter care. Findings suggest distressful family life may induce complex emotional responses in youth. Although services to runaway youth must continue to focus on safe, short-term residential care, trauma issues must be acknowledged.
Enabling new graduate midwives to work in midwifery continuity of care models: A conceptual model for implementation.

PubMed

Cummins, Allison M; Catling, Christine; Homer, Caroline S E

2017-12-04

High-level evidence demonstrates midwifery continuity of care is beneficial for women and babies. Women have limited access to midwifery continuity of care models in Australia. One of the factors limiting women's access is recruiting enough midwives to work in continuity. Our research found that newly graduated midwives felt well prepared to work in midwifery led continuity of care models, were well supported to work in the models and the main driver to employing them was a need to staff the models. However limited opportunities exist for new graduate midwives to work in midwifery continuity of care. The aim of this paper therefore is to describe a conceptual model developed to enable new graduate midwives to work in midwifery continuity of care models. The findings from a qualitative study were synthesised with the existing literature to develop a conceptual model that enables new graduate midwives to work in midwifery continuity of care. The model contains the essential elements to enable new graduate midwives to work in midwifery continuity of care models. Each of the essential elements discussed are to assist midwifery managers, educators and new graduates to facilitate the organisational changes required to accommodate new graduates. The conceptual model is useful to show maternity services how to enable new graduate midwives to work in midwifery continuity of care models. Copyright © 2017 Australian College of Midwives. Published by Elsevier Ltd. All rights reserved.
Identifying primary care patient safety research priorities in the UK: a James Lind Alliance Priority Setting Partnership

PubMed Central

Stocks, Susan Jill; Alam, Rahul; Taylor, Sian; Rolfe, Carly; Glover, Steven William; Whitcombe, Joanne; Campbell, Stephen M

2018-01-01

Objectives To identify the top 10 unanswered research questions for primary care patient safety research. Design A modified nominal group technique. Setting UK. Participants Anyone with experience of primary care including: patients, carers and healthcare professionals. 341 patients and 86 healthcare professionals submitted questions. Main outcomes A top 10, and top 30, future research questions for primary care patient safety. Results 443 research questions were submitted by 341 patients and 86 healthcare professionals, through a national survey. After checking for relevance and rephrasing, a total of 173 questions were collated into themes. The themes were largely focused on communication, team and system working, interfaces across primary and secondary care, medication, self-management support and technology. The questions were then prioritised through a national survey, the top 30 questions were taken forward to the final prioritisation workshop. The top 10 research questions focused on the most vulnerable in society, holistic whole-person care, safer communication and coordination between care providers, work intensity, continuity of care, suicide risk, complex care at home and confidentiality. Conclusions This study was the first national prioritisation exercise to identify patient and healthcare professional priorities for primary care patient safety research. The research priorities identified a range of important gaps in the existing evidence to inform everyday practice to address primary care patient safety. PMID:29490970
Effectiveness of a transitional home care program in reducing acute hospital utilization: a quasi-experimental study.

PubMed

Low, Lian Leng; Vasanwala, Farhad Fakhrudin; Ng, Lee Beng; Chen, Cynthia; Lee, Kheng Hock; Tan, Shu Yun

2015-03-14

Improving healthcare utilization is essential as health systems around the world grapple with the escalating demands for acute hospital resources. Evidence suggests that transitional care programs are effective to improve utilization of healthcare. However, the evidence for transitional care programs that enhance the home medical care model and provide multi-disciplinary patient-centered care is not well established. We evaluated if a transitional home care program operated by the Singapore General Hospital was effective in reducing acute hospital utilization. We performed a quasi-experimental study using a pre-post design to evaluate the effectiveness of a transitional home care program in reducing hospital admissions and emergency department attendances of medically complex patients enrolled into the program in a tertiary hospital in Singapore. Patients received a comprehensive needs assessment performed by the physician and a nurse case manager in the home setting, followed by an individualized care plan that included medical and nursing care, patient education and coordination of care with hospital specialists and community services. Primary study outcomes were emergency department attendances and hospital admissions to all hospitals. These were extracted from hospital administrative data and national health records. Wilcoxon Signed Ranks Test was used for assess differences in pre and post continuous data. Overall, 262 patients were enrolled into the program and 259 were analyzed. Patients had a 51.6% and 52.8% reduction in hospital admissions in the three-month and six-month post enrollment, respectively. Similarly, a 47.1% and 48.2% reduction was observed for emergency department attendances in the three and six months post enrollment, respectively. The average difference in per patient hospital bed days in the pre- and post-enrollment periods were 12.05 days and 20.03 days at the 3-month and 6-month periods, respectively. Patients enrolled in the transitional home care program had significantly lower acute hospital utilization through the reduction of emergency department attendances and hospital admissions. A comprehensive assessment of patients' medical and social needs in the home setting and formulation of an individualized care plan optimized post-discharge care for medically complex patients.
Improving Care for Children With Complex Needs

ClinicalTrials.gov

2017-10-10

Medically Complex Children; Care Coordination; Case Manager; Care Manager; Collaborative Care; Disease Management; Patient Care Team or Organization; Managed Care; Children With Chronic Conditions; Children With Special Health Care Needs; Shared Care Plan; Patient Care Plan; Health Care and Resource Utilization; Adherence to Care; Functional Status and Productivity; Health Related Quality of Life; Satisfaction With Care; Care Coordinator; Family Experience of Care; Quality Health Care
Factors in Maintaining a Stable Patient-Physician Relationship among Individuals with Schizophrenia.

PubMed

Huang, Hsin-Hui; Chen, Chuan-Yu; Tsay, Jen-Huoy; Chou, Yiing-Jenq; Huang, Nicole

2017-07-01

This study aimed to determine whether adequate continuity of care (COC) existed among individuals with schizophrenia, and what the associated determinants were. The National Health Insurance Research Database of Taiwan was used to identify individuals with newly diagnosed schizophrenia from 2000 to 2009. Two outcome indicators were first derived to conduct the continuity assessment based on the usual provider continuity (UPC) index and the continuity of care index (COCI). The average scores of the UPC and COCI were 0.78 and 0.67, respectively. Patients who have been hospitalized, with lower income, and unemployed had significantly poorer continuity of care. In addition, patients were cared for by higher caseload physicians, treated at mental health specialty institutions, and at hospital outpatient settings also experienced significantly poorer continuity. Patients cared for by middle-aged physicians, psychiatrists, and treated at private institutions had significantly better continuity of mental health care.
Continuity of Care and Health Care Utilization in Older Adults With Dementia in Fee-for-Service Medicare.

PubMed

Amjad, Halima; Carmichael, Donald; Austin, Andrea M; Chang, Chiang-Hua; Bynum, Julie P W

2016-09-01

Poor continuity of care may contribute to high health care spending and adverse patient outcomes in dementia. To examine the association between medical clinician continuity and health care utilization, testing, and spending in older adults with dementia. This was a study of an observational retrospective cohort from the 2012 national sample in fee-for-service Medicare, conducted from July to December 2015, using inverse probability weighted analysis. A total of 1 416 369 continuously enrolled, community-dwelling, fee-for-service Medicare beneficiaries 65 years or older with a claims-based dementia diagnosis and at least 4 ambulatory visits in 2012 were included. Continuity of care score measured on patient visits across physicians over 12 months. A higher continuity score is assigned to visit patterns in which a larger share of the patient's total visits are with fewer clinicians. Score range from 0 to 1 was examined in low-, medium-, and high-continuity tertiles. Outcomes include all-cause hospitalization, ambulatory care sensitive condition hospitalization, emergency department visit, imaging, and laboratory testing (computed tomographic [CT] scan of the head, chest radiography, urinalysis, and urine culture), and health care spending (overall, hospital and skilled nursing facility, and physician). Beneficiaries with dementia who had lower levels of continuity of care were younger, had a higher income, and had more comorbid medical conditions. Almost 50% of patients had at least 1 hospitalization and emergency department visit during the year. Utilization was lower with increasing level of continuity. Specifically comparing the highest- vs lowest-continuity groups, annual rates per beneficiary of hospitalization (0.83 vs 0.88), emergency department visits (0.84 vs 0.99), CT scan of the head (0.71 vs 0.83), urinalysis (0.72 vs 1.09), and health care spending (total spending, $22 004 vs $24 371) were higher with lower continuity even after accounting for sociodemographic factors and comorbidity burden (P < .001 for all comparisons). The rate of ambulatory care sensitive condition hospitalization was similar across continuity groups. Among older fee-for-service Medicare beneficiaries with a dementia diagnosis, lower continuity of care is associated with higher rates of hospitalization, emergency department visits, testing, and health care spending. Further research into these relationships, including potentially relevant clinical, clinician, and systems factors, can inform whether improving continuity of care in this population may benefit patients and the wider health system.
Clinician burnout and satisfaction with resources in caring for complex patients.

PubMed

Whitebird, Robin R; Solberg, Leif I; Crain, A Lauren; Rossom, Rebecca C; Beck, Arne; Neely, Claire; Dreskin, Mark; Coleman, Karen J

To describe primary care clinicians' self-reported satisfaction, burnout and barriers for treating complex patients. We conducted a survey of 1554 primary care clinicians in 172 primary care clinics in 18 health care systems across 8 states prior to the implementation of a collaborative model of care for patients with depression and diabetes and/or cardiovascular disease. Of the clinicians who responded to the survey (n=709; 46%), we found that a substantial minority (31%) were experiencing burnout that was associated with lower career satisfaction (P<.0001) and lower satisfaction with resources to treat complex patients (P<.0001). Less than 50% of clinicians rated their ability to treat complex patients as very good to excellent with 21% rating their ability as fair to poor. The majority of clinicians (72%) thought that a collaborative model of care would be very helpful for treating complex patients. Burnout remains a problem for primary care clinicians and is associated with low job satisfaction and low satisfaction with resources to treat complex patients. A collaborative care model for patients with mental and physical health problems may provide the resources needed to improve the quality of care for these patients. Copyright © 2016 Elsevier Inc. All rights reserved.
Glossary of access to health care and related concepts for low- and middle-income countries (LMICs): a critical review of international literature.

PubMed

Cabieses, Baltica; Bird, Philippa

2014-01-01

Access to health care is a multidimensional and complex concept. Achieving equitable access to care is an important goal for all countries, but particularly challenging in Low- and Middle-Income Countries (LMICs). Despite wide use of the concept of access, it continues to be defined and measured in very different ways. This glossary is a structured overview of key definitions for concepts related to access to health care, with special focus on the interpretation for LMICs. It aims to help people with interest in health service delivery to draw an overview and provide some pointers for further reading in both conceptual and empirical advances in access to health care in LMICs. This document is structured in five sections. The first introduces a general description of the concept of access to health care and its relevance to LMICs, the second displays the search conducted on access to health care for LMICs and the framework used for presentation of glossary terms, the third describes theoretical models most frequently used in the past when looking at access to health care in LMICs, the fourth is the list of terms, and the final section is a discussion of the most salient aspects of this critical review.
Implementing Information and Communication Technology to Support Community Aged Care Service Integration: Lessons from an Australian Aged Care Provider.

PubMed

Douglas, Heather E; Georgiou, Andrew; Tariq, Amina; Prgomet, Mirela; Warland, Andrew; Armour, Pauline; Westbrook, Johanna I

2017-04-10

There is limited evidence of the benefits of information and communication technology (ICT) to support integrated aged care services. We undertook a case study to describe carelink+, a centralised client service management ICT system implemented by a large aged and community care service provider, Uniting. We sought to explicate the care-related information exchange processes associated with carelink+ and identify lessons for organisations attempting to use ICT to support service integration. Our case study included seventeen interviews and eleven observation sessions with a purposive sample of staff within the organisation. Inductive analysis was used to develop a model of ICT-supported information exchange. Management staff described the integrated care model designed to underpin carelink+. Frontline staff described complex information exchange processes supporting coordination of client services. Mismatches between the data quality and the functions carelink+ was designed to support necessitated the evolution of new work processes associated with the system. There is value in explicitly modelling the work processes that emerge as a consequence of ICT. Continuous evaluation of the match between ICT and work processes will help aged care organisations to achieve higher levels of ICT maturity that support their efforts to provide integrated care to clients.
Implementing Information and Communication Technology to Support Community Aged Care Service Integration: Lessons from an Australian Aged Care Provider

PubMed Central

Georgiou, Andrew; Tariq, Amina; Prgomet, Mirela; Warland, Andrew; Armour, Pauline; Westbrook, Johanna I

2017-01-01

Introduction: There is limited evidence of the benefits of information and communication technology (ICT) to support integrated aged care services. Objectives: We undertook a case study to describe carelink+, a centralised client service management ICT system implemented by a large aged and community care service provider, Uniting. We sought to explicate the care-related information exchange processes associated with carelink+ and identify lessons for organisations attempting to use ICT to support service integration. Methods: Our case study included seventeen interviews and eleven observation sessions with a purposive sample of staff within the organisation. Inductive analysis was used to develop a model of ICT-supported information exchange. Results: Management staff described the integrated care model designed to underpin carelink+. Frontline staff described complex information exchange processes supporting coordination of client services. Mismatches between the data quality and the functions carelink+ was designed to support necessitated the evolution of new work processes associated with the system. Conclusions: There is value in explicitly modelling the work processes that emerge as a consequence of ICT. Continuous evaluation of the match between ICT and work processes will help aged care organisations to achieve higher levels of ICT maturity that support their efforts to provide integrated care to clients. PMID:29042851
Impact Of Health Care Delivery System Innovations On Total Cost Of Care.

PubMed

Smith, Kevin W; Bir, Anupa; Freeman, Nikki L B; Koethe, Benjamin C; Cohen, Julia; Day, Timothy J

2017-03-01

Using delivery system innovations to advance health care reform continues to be of widespread interest. However, it is difficult to generalize about the success of specific types of innovations, since they have been examined in only a few studies. To gain a broader perspective, we analyzed the results of forty-three ambulatory care programs funded by the first round of the Center for Medicare and Medicaid Innovation's Health Care Innovations Awards. The innovations' impacts on total cost of care were estimated by independent evaluators using multivariable difference-in-differences models. Through the first two years, most of the innovations did not show a significant effect on total cost of care. Using meta-regression, we assessed the effects on costs of five common components of these innovations. Innovations that used health information technology or community health workers achieved the greatest cost savings. Savings were also relatively large in programs that targeted clinically fragile patients-clinically complex populations at risk for disease progression. While the magnitude of these effects was often substantial, none achieved conventional levels of significance in our analyses. Meta-analyses of a larger number of delivery system innovations are needed to more clearly establish their potential for patient care cost savings. Project HOPE—The People-to-People Health Foundation, Inc.
Intense parenting: a qualitative study detailing the experiences of parenting children with complex care needs.

PubMed

Woodgate, Roberta L; Edwards, Marie; Ripat, Jacquie D; Borton, Barbara; Rempel, Gina

2015-11-26

Increased numbers of children with chronic illnesses and/or disabilities who have complex care needs are living at home. Along with the transfer of care to the home setting, parents assume the primary responsibility of their child's complex care needs. Accordingly, it becomes even more important to understand the evolving roles and challenges faced by parents of children with complex care needs in order to better support them. The aim of this paper is to present research findings that add to our understanding of the roles parents assume in parenting their children with complex care needs. To arrive at a detailed and accurate understanding of families' perspectives and experiences, the qualitative research design of ethnography was used. In total, 68 parents from 40 families were recruited. Data collection strategies included ethnographic methods of interviewing and photovoice. Several levels of analysis generated a sociocultural theme with subthemes representing how parents experienced raising children with complex care needs within the context of their life situations. Intense parenting as the overarching theme refers to the extra efforts parents had to commit to in raising their children with complex care needs. Parenting was described as labour-intensive, requiring a readiness to provide care at any time. This left parents with minimal time for addressing any needs and tasks not associated with caring for their child. The main theme is supported by four sub-themes: 1) the good parent; 2) more than a nurse; 3) there's just not enough; 4) it takes a toll on the health of parents. Overall, parents of children with complex care needs take on more roles as well as work more intensely at these roles than parents of healthy children. This, in turn, has led to the need for additional supports and resources for parents. However, to date, parents of children with complex care needs are still lacking adequate services and supports necessary to help them in their role of intense parenting. The findings sensitize professionals to the issues confronted by parents caring for children with complex care needs. Implications for further research and clinical practice are discussed.
[Critical care nurse learning of continuous renal replacement therapy: the efficacy of a self-learning manual].

PubMed

Huang, Yi-Chen; Hsu, Li-Ling

2011-02-01

Many nurses have difficulty learning to use the complex, non-traditional, and regularly-updated critical care equipment. Failure to use such equipment properly can seriously compromise treatment and endanger patient health and lives. New self-learning materials for novice nurses are necessary to provide essential and effective guidance as a part of formal nursing training. Such materials can enhance the capabilities of critical care nurses and, thus, improve the general quality of critical care. The purpose of this research was to develop a continuous renal replacement therapy (CRRT)-themed self-learning manual that would provide easily absorbed and understood knowledge in an easy-to-carry format for ICU nursing staff. This study also investigated CCRT skill learning efficacy. This study adopted a quasi-experimental design with pretests and posttests. Purposive sampling generated a sample of 66 critical care nurses currently working at one hospital in Taipei City. Participants submitted a completed self-assessment survey that rated their command of continuous renal replacement therapy before and after the self-learning manual intervention. Survey data were analyzed using SPSS Version 17.0 for Windows. The two major findings derived from the study included: (1) The mean response score from the self-assessment survey filled out after the intervention was 91.06 and 79.75 (SD = 9.49 and 11.65), respectively, for experimental and control groups. Such demonstrated significant difference. (2) The mean posttest score after the intervention for the experimental group was 91.06 ± 9.49. This represents a significant increase of 10.35 ± 10.35 over their mean pretest score (80.71 ± 11.82). The experimental group showed other significant differences in terms of the CRRT self-assessment survey posttest. Self-learning manuals may be introduced in nursing education as useful aids and catalysts to achieve more effective and satisfying learning experiences.
Case management directors: how to manage in a transition-focused world: part 1.

PubMed

Bankston-White, Cheri; Birmingham, Jackie

2015-01-01

Case management directors are in a dynamic position to affect the transition of care for patients across the continuum, work with all levels of providers, and support the financial well-being of a hospital. Most importantly, they can drive good patient outcomes. Although the position is critical on many different levels, there is little to help guide a new director in attending to all the "moving parts" of such a complex role. The purpose of this two-part article is to provide case management directors, particularly new ones, with a framework for understanding and fulfilling their role.We have divided the guide into seven tracks of responsibility. Part 1 discusses the first four tracks: (1) staffing and human resources, (2) compliance and accreditation, (3) discharge planning, and (4) utilization review and revenue cycle. Part 2 addresses (5) internal departmental relationships (organizational), (6) external relationships (Community agency), and (7) quality and program outcomes. The information is most meaningful to those case management directors who work in either stand-alone hospitals or integrated health systems, and have frontline case managers reporting to them. Case management directors would benefit from further research and documentation of "best practices" related to their role, particularly in the areas of leadership and management. New directors would benefit from mentoring and networking with one another. As new regulations and models of care bring increased emphasis and focus to transitions of care, the role of the case management director continues to evolve, growing in importance and complexity. The growing financial impact of readmissions also brings added scrutiny and increased pressure to get the transitions of care right the first time.To operate most effectively, case management directors must understand the full range of their responsibilities and impact. They must find opportunities for themselves and their departments to learn and stay current as the regulatory environment continues to change. Providing a list of functions for which they are responsible, practical strategies for carrying them out, and places to go for help and information can help hospital case management directors operate with the confidence and knowledge they need to influence the quality and safety of patient care for the entire care team and to provide the best possible interactions with patients and family members.
Case Management Directors

PubMed Central

Bankston-White, Cheri; Birmingham, Jackie

2015-01-01

Purpose and Objectives: Case management directors are in a dynamic position to affect the transition of care for patients across the continuum, work with all levels of providers, and support the financial well-being of a hospital. Most importantly, they can drive good patient outcomes. Although the position is critical on many different levels, there is little to help guide a new director in attending to all the “moving parts” of such a complex role. The purpose of this two-part article is to provide case management directors, particularly new ones, with a framework for understanding and fulfilling their role. We have divided the guide into seven tracks of responsibility. Part 1 discusses the first four tracks: (1) staffing and human resources, (2) compliance and accreditation, (3) discharge planning, and (4) utilization review and revenue cycle. Part 2 addresses (5) internal departmental relationships (organizational), (6) external relationships (Community agency), and (7) quality and program outcomes. Primary Practice Setting: The information is most meaningful to those case management directors who work in either stand-alone hospitals or integrated health systems, and have frontline case managers reporting to them. Findings/Conclusions: Case management directors would benefit from further research and documentation of “best practices” related to their role, particularly in the areas of leadership and management. New directors would benefit from mentoring and networking with one another. Implications for Case Management: As new regulations and models of care bring increased emphasis and focus to transitions of care, the role of the case management director continues to evolve, growing in importance and complexity. The growing financial impact of readmissions also brings added scrutiny and increased pressure to get the transitions of care right the first time. To operate most effectively, case management directors must understand the full range of their responsibilities and impact. They must find opportunities for themselves and their departments to learn and stay current as the regulatory environment continues to change. Providing a list of functions for which they are responsible, practical strategies for carrying them out, and places to go for help and information can help hospital case management directors operate with the confidence and knowledge they need to influence the quality and safety of patient care for the entire care team and to provide the best possible interactions with patients and family members. PMID:25629731
[Development and evaluation of an e-learning program for mothers of premature infants].

PubMed

Lee, Nae-Young; Kim, Young-Hae

2008-02-01

It has been attempted to support mother of premature infants by providing information of premature infant care using e-learning because premature infants need continuous care from birth to after discharge. The e-Learning Program for mother of premature was developed with Xpert, Namo web editor, Adobe Photoshop, and PowerPoint and applied for 4 weeks from 4 to 30 September 2006. 1) We found that the contents of information which premature infants' need when being in the hospital and after discharge were the definition of a premature infant, orientation of NICU, care of premature infants, care of premature infants' common diseases, the connection of healthcare resources, exchange of information, and the management of rearing stress. 2) The program content consisted of cause of premature birth, comparison to full-term baby, physiology character, orientation of NICU, common health problems, follow up care, infection control, feeding, normal development physically and mentally, weaning method, and vaccination. Considering the results, this program for mother of premature is a useful means to provide premature-care information to mothers. This information can be readily accessible and can be varied and complex enough to be able to help mothers to the information and assistance they require.

How to help depressed older people living in residential care: a multifaceted shared-care intervention for late-life depression.

PubMed

Llewellyn-Jones, R H; Baikie, K A; Castell, S; Andrews, C L; Baikie, A; Pond, C D; Willcock, S M; Snowdon, J; Tennant, C C

2001-12-01

To describe a population-based, multifaceted shared-care intervention for late-life depression in residential care as a new model of geriatric practice, to outline its development and implementation, and to describe the lessons learned during the implementation process. A large continuing-care retirement community in Sydney, Australia, providing three levels of care (independent living units, assisted-living complexes, and nursing homes). The intervention was implemented for the entire non-nursing home population (residents in independent and assisted living: N = 1,466) of the facility and their health care providers. Of the 1,036 residents whowere eligible and agreed to be interviewed, 281 (27.1%) were classified as depressed according to the Geriatric Depression Scale. INTERVENTION DESCRIPTION: The intervention included: (a) multidisciplinary collaboration between primary care physicians, facility health care providers, and the local psychogeriatric service; (b) training for primary care physicians and other facility health care providers about detecting and managing depression; and (c) depression-related health education/promotion programs for residents. The intervention was widely accepted by residents and their health care providers, and was sustained and enhanced by the facility after the completion of the study. It is possible to implement and sustain a multifaceted shared-care intervention for late-life depression in a residential care facility where local psychogeriatric services are scarce, staff-to-resident ratios are low, and the needs of depressed residents are substantial.
It Takes Two to Tango: Customization and Standardization as Colluding Logics in Healthcare

PubMed Central

Greenfield, David; Eljiz, Kathy; Butler-Henderson, Kerryn

2018-01-01

The healthcare context is characterized with new developments, technologies, ideas and expectations that are continually reshaping the frontline of care delivery. Mannion and Exworthy identify two key factors driving this complexity, ‘standardization’ and ‘customization,’ and their apparent resulting paradox to be negotiated by healthcare professionals, managers and policy makers. However, while they present a compelling argument an alternative viewpoint exists. An analysis is presented that shows instead of being ‘competing’ logics in healthcare, standardization and customization are long standing ‘colluding’ logics. Mannion and Exworthy’s call for further sustained work to understand this complex, contested space is endorsed, noting that it is critical to inform future debates and service decisions. PMID:29524942
The meaning of living with uncertainty for people with motor neurone disease.

PubMed

Harris, Denise Andrea; Jack, Kirsten; Wibberley, Christopher

2018-03-08

To explore the meaning of living with uncertainty for people diagnosed with motor neurone disease (MND). Motor neurone disease is a progressive neurodegenerative condition resulting in multiple needs, arising from the complex nature of the disease trajectory. People with MND are often required to make decisions for symptom management and end-of-life care. Research into the lived experience of MND has previously highlighted the following: the shock of receiving such a diagnosis and prognosis; subsequent concerns relating to the future and loss; and the existential suffering for a person with MND. The lived experiences of MND accentuate the devastating nature of the disease, and this can impact upon how people respond to care. Hermeneutic (interpretive) phenomenology: suitable for studying lifeworld experiences. Life story interviews were conducted with four participants and subjected to interpretive analysis. Three phases of the MND illness trajectory emerged: "body failing prematurely and searching for answers," "body deterioration and responses to care" and "body nearing its end and needing to talk." These phases highlight the phenomenon under study, all relating to uncertainty for people living with MND. This study showed that people with MND are living with uncertainty and other concerns throughout their illness trajectory. People are having to turn to palliative care professionals who are more able to meet their concerns than those caring for other aspects of their disease. Motor neurone disease is a complex disease, and it is important that professionals continue to provide holistic care throughout the illness trajectory. The identification of three distinct phases of the MND illness trajectory will help nurses and other professionals to better understand the meaning of uncertainty and other concerns for people with MND. © 2018 John Wiley & Sons Ltd.
A novel low-complexity digital filter design for wearable ECG devices

PubMed Central

Mehrnia, Alireza

2017-01-01

Wearable and implantable Electrocardiograph (ECG) devices are becoming prevailing tools for continuous real-time personal health monitoring. The ECG signal can be contaminated by various types of noise and artifacts (e.g., powerline interference, baseline wandering) that must be removed or suppressed for accurate ECG signal processing. Limited device size, power consumption and cost are critical issues that need to be carefully considered when designing any portable health monitoring device, including a battery-powered ECG device. This work presents a novel low-complexity noise suppression reconfigurable finite impulse response (FIR) filter structure for wearable ECG and heart monitoring devices. The design relies on a recently introduced optimally-factored FIR filter method. The new filter structure and several of its useful features are presented in detail. We also studied the hardware complexity of the proposed structure and compared it with the state-of-the-art. The results showed that the new ECG filter has a lower hardware complexity relative to the state-of-the-art ECG filters. PMID:28384272
A novel low-complexity digital filter design for wearable ECG devices.

PubMed

Asgari, Shadnaz; Mehrnia, Alireza

2017-01-01

Wearable and implantable Electrocardiograph (ECG) devices are becoming prevailing tools for continuous real-time personal health monitoring. The ECG signal can be contaminated by various types of noise and artifacts (e.g., powerline interference, baseline wandering) that must be removed or suppressed for accurate ECG signal processing. Limited device size, power consumption and cost are critical issues that need to be carefully considered when designing any portable health monitoring device, including a battery-powered ECG device. This work presents a novel low-complexity noise suppression reconfigurable finite impulse response (FIR) filter structure for wearable ECG and heart monitoring devices. The design relies on a recently introduced optimally-factored FIR filter method. The new filter structure and several of its useful features are presented in detail. We also studied the hardware complexity of the proposed structure and compared it with the state-of-the-art. The results showed that the new ECG filter has a lower hardware complexity relative to the state-of-the-art ECG filters.
Sustainability at the Edge of Chaos: Its Limits and Possibilities in Public Health

PubMed Central

Hudson, Christopher G.; Vissing, Yvonne M.

2013-01-01

This paper critically reviews the expanding literature on applications of sustainability to healthcare policy and planning. It argues that the concept has been overgeneralized and has become a buzzword masking disparate agendas. It ignores the insights of the newest generation of systems theory on complex systems on the ubiquity of far-from-equilibrium conditions. Yet, a central meaning often ascribed to sustainability is the level continuation of healthcare programs and their institutionalization. Sustainability is only coherent in health care when it is more narrowly delimited to involve public health and treated as only one of several evaluative criteria that informs not only the continuation of programs but more often their expansion or contraction as needs dynamically change. PMID:24058914
The Future of General Internal Medicine

PubMed Central

Larson, Eric B; Fihn, Stephan D; Kirk, Lynne M; Levin, Wendy; Loge, Ronald V; Reynolds, Eileen; Sandy, Lewis; Schroeder, Steven; Wenger, Neil; Williams, Mark

2004-01-01

The Society of General Internal Medicine asked a task force to redefine the domain of general internal medicine. The task force believes that the chaos and dysfunction that characterize today's medical care, and the challenges facing general internal medicine, should spur innovation. These are our recommendations: while remaining true to its core values and competencies, general internal medicine should stay both broad and deep—ranging from uncomplicated primary care to continuous care of patients with multiple, complex, chronic diseases. Postgraduate and continuing education should develop mastery. Wherever they practice, general internists should be able to lead teams and be responsible for the care their teams give, embrace changes in information systems, and aim to provide most of the care their patients require. Current financing of physician services, especially fee-for-service, must be changed to recognize the value of services performed outside the traditional face-to-face visit and give practitioners incentives to improve quality and efficiency, and provide comprehensive, ongoing care. General internal medicine residency training should be reformed to provide both broad and deep medical knowledge, as well as mastery of informatics, management, and team leadership. General internal medicine residents should have options to tailor their final 1 to 2 years to fit their practice goals, often earning a certificate of added qualification (CAQ) in special generalist fields. Research will expand to include practice and operations management, developing more effective shared decision making and transparent medical records, and promoting the close personal connection that both doctors and patients want. We believe these changes constitute a paradigm shift that can benefit patients and the public and reenergize general internal medicine. PMID:14748863
[Audit and feedback, and continuous quality improvement strategies to improve the quality of care for type 2 diabetes: a systematic review of literature].

PubMed

Vecchi, Simona; Agabiti, Nera; Mitrova, Susanna; Cacciani, Laura; Amato, Laura; Davoli, Marina; Bargagli, Anna Maria

2016-01-01

we analysed evidence on effective interventions to improve the quality of care and management in patients with diabetes type 2. This review focuses particularly on audit and feedback intervention, targeted to healthcare providers, and continuous quality improvement (CQI) involving health professionals and health care systems, respectively. we searched The Cochrane Library, PubMed, and EMBASE (search period: January 2005-December 2015) to identify systematic reviews (SR) and randomized controlled trials (RCTs) considering patients' outcomes and process measures as quality indicators in diabetes care. Selection of studies and data extraction were carried out independently by two reviewers. Methodological quality of individual studies was assessed using the checklist «Assessment of methodological quality of systematic review» (AMSTAR) and the Cochrane's tool, respectively. We produced summaries of results for each study design. the search process resulted in 810 citations. One SR and 7 RCTs that compared any intervention in which audit and feedback and CQI was a component vs. other interventions were selected. The SR found that audit and feedback activity was associated with improvements of glycaemic (mean difference: 0.26; 95%CI 0.08;0.44) and cholesterol control (mean difference: 0.03; 95%CI -0.04;0.10). CQI interventions were not associated with an improvement of quality of diabetes care. The RCTs considered in this review compared a broad range of interventions including feedback as unique activity or as part of more complex strategies. The methodological quality was generally poor in all the included trials. the available evidence suggests that audit and feedback and CQI improve quality of care in diabetic patients, although the effect is small and heterogeneous among process and outcomes indicators.
Integrative care for pediatric patients with pain.

PubMed

Young, Lari; Kemper, Kathi J

2013-07-01

Although pediatric patients with chronic pain often turn to complementary therapies, little is known about patients who seek academic integrative pediatric care. The study design comprised abstraction of intake forms and physician records from new patients whose primary concern was pain. The study setting was an academic pediatric clinic between January 2010 and December 2011. Of the 110 new patients, 49 (45%) had a primary concern about headache (20), abdominal pain (18), or musculoskeletal pain (11). The average age was 13±4 years, and 37% were male. Patients reported an average pain level of 6±3 on a 10-point scale, and most reported more than one kind of pain; parents had an average of 7±3 health concerns per child, including fatigue (47%), mood or anxiety (45%), constipation/diarrhea (41%), and/or sleep problems (35%). Most patients (57%) were referred by specialists; 71% were taking prescription medications; and 53% were taking one or more dietary supplements at intake. Of those tested, most (61%) had suboptimal vitamin D levels. All families wanted additional counseling about diet (76%), exercise (66%), sleep (58%), and/or stress management (81%). In addition to encouraging continued medical care (100%) and referral to other medical specialists (16%), frequent advice included continuing or initiating dietary supplements such as vitamins/minerals (80%), omega-3 fatty acids (67%), and probiotics (31%). Stress-reducing recommendations included biofeedback (33%), gratitude journals (16%), and yoga/t'ai chi (8%). Other referrals included acupuncture (24%) and massage (20%). Patients who have chronic pain and who present to an integrative clinic frequently have complex conditions and care. They are interested in promoting a healthy lifestyle, reducing stress, and using selected complementary therapies. Patients with chronic pain who seek integrative care may benefit from the kind of coordinated, integrated, comprehensive care provided in a medical home.
Family medicine outpatient encounters are more complex than those of cardiology and psychiatry.

PubMed

Katerndahl, David; Wood, Robert; Jaén, Carlos Roberto

2011-01-01

comparison studies suggest that the guideline-concordant care provided for specific medical conditions is less optimal in primary care compared with cardiology and psychiatry settings. The purpose of this study is to estimate the relative complexity of patient encounters in general/family practice, cardiology, and psychiatry settings. secondary analysis of the 2000 National Ambulatory Medical Care Survey data for ambulatory patients seen in general/family practice, cardiology, and psychiatry settings was performed. The complexity for each variable was estimated as the quantity weighted by variability and diversity. there is minimal difference in the unadjusted input and total encounter complexity of general/family practice and cardiology; psychiatry's input is less complex. Cardiology encounters involved more input quantitatively, but the diversity of general/family practice input eliminated the difference. Cardiology also involved more complex output. However, when the duration of visit is factored in, the complexity of care provided per hour in general/family practice is 33% more relative to cardiology and 5 times more relative to psychiatry. care during family physician visits is more complex per hour than the care during visits to cardiologists or psychiatrists. This may account for a lower rate of completion of process items measured for quality of care.
North Carolina's direct care workforce development journey: the case of the North Carolina New Organizational Vision Award Partner Team.

PubMed

Brannon, S Diane; Kemper, Peter; Barry, Theresa

2009-01-01

Better Jobs Better Care was a five-state direct care workforce demonstration designed to change policy and management practices that influence recruitment and retention of direct care workers, problems that continue to challenge providers. One of the projects, the North Carolina Partner Team, developed a unified approach in which skilled nursing, home care, and assisted living providers could be rewarded for meeting standards of workplace excellence. This case study documents the complex adaptive system agents and processes that coalesced to result in legislation recognizing the North Carolina New Organizational Vision Award. We used a holistic, single-case study design. Qualitative data from project work plans and progress reports as well as notes from interviews with key stakeholders and observation of meetings were coded into a simple rubric consisting of characteristics of complex adaptive systems. Key system agents in the state set the stage for the successful multistakeholder coalition. These included leadership by the North Carolina Department of Health and Human Services and a several year effort to develop a unifying vision for workforce development. Grant resources were used to facilitate both content and process work. Structure was allowed to emerge as needed. The coalition's own development is shown to have changed the context from which it was derived. An inclusive and iterative process produced detailed standards and measures for the voluntary recognition process. With effective facilitation, the interests of the multiple stakeholders coalesced into a policy response that encourages practice changes. Implications for managing change-oriented coalitions are discussed.
Relationship Between Continuity of Care and Diabetes Control: Evidence From the Third National Health and Nutrition Examination Survey

PubMed Central

Mainous, Arch G.; Koopman, Richelle J.; Gill, James M.; Baker, Richard; Pearson, William S.

2004-01-01

Objectives. We examined the relationship between continuity of care and diabetes control. Methods. We analyzed data on 1400 adults with diabetes who took part in the Third National Health and Nutrition Examination Survey. We examined the relationship of continuity of care with glycemic, blood pressure, and lipid control. Results. Continuity of care was associated with both acceptable and optimal levels of glycemic control. Continuity was not associated with blood pressure or lipid control. There was no difference between having a usual site but no usual provider and having a usual provider in any of the investigated outcomes. Conclusions. Continuity of care is associated with better glycemic control among people with diabetes. Our results do not support a benefit of having a usual provider above having a usual site of care. PMID:14713700
Finance issue brief: continuity of care: year end report-2003.

PubMed

MacEachern, Lillian

2003-12-31

When a health care provider leaves or is terminated by a managed care plan, how long can patients continue to receive covered treatment from that provider for a life-threatening condition, pregnancy, disability or other circumstance that requires continuous medical care? Lawmakers in 36 states have answered that question.
78 FR 58291 - TRICARE; Fiscal Year 2014 Continued Health Care Benefit Program Premium Update

Federal Register 2010, 2011, 2012, 2013, 2014

2013-09-23

... DEPARTMENT OF DEFENSE Office of the Secretary TRICARE; Fiscal Year 2014 Continued Health Care... Health Care Benefit Program Premiums for Fiscal Year 2014. SUMMARY: This notice provides the updated Continued Health Care Benefit Program Premiums for Fiscal Year 2014. DATES: The Fiscal Year 2014 rates...
Continuing education for staff in long-term care facilities: corporate philosophies and approaches.

PubMed

Ross, M M; Carswell, A; Dalziel, W B; Aminzadeh, F

2001-01-01

The purpose of this study was to determine corporate philosophies of continuing education and approaches to meeting the learning needs of staff who strive to provide for the increasingly challenging care requirements of seniors who reside in long-term care facilities. In-depth interviews lasting approximately 1 hour were conducted with key informants at the administrative level from nine long-term care facilities. Content analysis revealed a commitment to continuing education for staff. While recognizing the importance of organizational responsibility for continuing education, administrators placed emphasis on the individual responsibility of staff. Learning needs were identified as affective, managerial, and physical in nature. Challenges to providing continuing education programs were derived from a general lack of fiscal and human resources. A variety of measures was suggested as important to supporting the continuing learning of staff. Implications of this study point to the need for long-term care facilities to incorporate into their strategic plans measures of ensuring continuing education as a basis for the ongoing competence and development of staff. In addition, there is a need for collaboration between long-term care facilities and other institutions of a long-term care, acute care, and educational nature in the development of strategies to operationalize a philosophy of continuing learning as a basis for the provision of optimal care to residents.
Patients' experiences of continuity in the care of type 2 diabetes: a focus group study in primary care

PubMed Central

Alazri, Mohammed H; Neal, Richard D; Heywood, Phil; Leese, Brenda

2006-01-01

Background Continuity of care is fundamental to general practice and type 2 diabetes is a common chronic disease with major health and social impacts. Nevertheless continuity, as experienced by patients with type 2 diabetes, remains a neglected area. Aim To explore perceptions and experiences of continuity of care in general practice from the perspectives of patients with type 2 diabetes, focusing on the advantages and disadvantages of different types of continuity. Design of study Focus groups with patients. Setting Seven practices with different organisational structures in Leeds, UK. Method Seventy-nine patients with type 2 diabetes were recruited. Focus group interviews were conducted with 79 patients with type 2 diabetes from seven practices in Leeds, UK. Results Patients experienced three different types of continuity: relational (or longitudinal) continuity, cross-boundary (or team) continuity, and continuity of information. Patients' perceptions of continuity were influenced by several factors including a personal relationship between themselves and their healthcare professional, their own beliefs and behaviours, presence of diabetes, and the systems and structures of general practices. Patients identified the advantages and disadvantages of two types of continuity. Relational or longitudinal continuity was important in providing psychosocial care, but with a risk of misdiagnosis. The advantages of cross-boundary or team continuity were to provide physical care, whereas the main disadvantages were the absence of personal care and patient confusion. Conclusion Perceptions of continuity by patients with type 2 diabetes were influenced by several factors; they perceived several advantages and disadvantages associated with different types of continuity. Patients might expect certain healthcare benefits by following certain types of continuity. PMID:16834874
Using Continuous Glucose Monitoring Data and Detrended Fluctuation Analysis to Determine Patient Condition

PubMed Central

Thomas, Felicity; Signal, Matthew; Chase, J. Geoffrey

2015-01-01

Patients admitted to critical care often experience dysglycemia and high levels of insulin resistance, various intensive insulin therapy protocols and methods have attempted to safely normalize blood glucose (BG) levels. Continuous glucose monitoring (CGM) devices allow glycemic dynamics to be captured much more frequently (every 2-5 minutes) than traditional measures of blood glucose and have begun to be used in critical care patients and neonates to help monitor dysglycemia. In an attempt to obtain a better insight relating biomedical signals and patient status, some researchers have turned toward advanced time series analysis methods. In particular, Detrended Fluctuation Analysis (DFA) has been a topic of many recent studies in to glycemic dynamics. DFA investigates the “complexity” of a signal, how one point in time changes relative to its neighboring points, and DFA has been applied to signals like the inter-beat-interval of human heartbeat to differentiate healthy and pathological conditions. Analyzing the glucose metabolic system with such signal processing tools as DFA has been enabled by the emergence of high quality CGM devices. However, there are several inconsistencies within the published work applying DFA to CGM signals. Therefore, this article presents a review and a “how-to” tutorial of DFA, and in particular its application to CGM signals to ensure the methods used to determine complexity are used correctly and so that any relationship between complexity and patient outcome is robust. PMID:26134835
PHARMACEUTICALS AND PERSONAL CARE PRODUCTS ...

EPA Pesticide Factsheets

The occurrence of pharmaceuticals and personal care products (PPCPs) as trace environmental pollutants is a multifaceted issue whose scope of concerns continues to expand. PPCPs comprise thousands of distinct chemicals from numerous therapeutic and consumer classes. They typically occur as trace environmental pollutants (primarily in surface but also in ground waters) as a result of their widespread, continuous, combined usage in a broad range of human and veterinary therapeutic activities and practices. With respect to the risk-assessment paradigm, the growing body of published work has focused primarily on the origin and occurrence of these substances. Comparatively less is known about human and ecological exposure, and even less about the documented or potential hazards associated with trace exposure to these anthropogenic substances, many of which are highly bioactive and perpetually present in many aquatic locales. The continually growing, worldwide importance of freshwater resources underscores the need for ensuring that any aggregate or cumulative impacts on water supplies and resultant potential for human or ecological exposure be minimized.Of the many facets involved in this complex issue, that of sources/origins and environmental occurrence is the better understood end of the larger spectrum. The potential for adverse ecological or human health effects (especially from long-term, combined exposure to multiple xenobiotics at low concentrations) is the
PHARMACEUTICALS AND PERSONAL CARE PRODUCTS ...

EPA Pesticide Factsheets

The occurrence of pharmaceuticals and personal care products (PPCPs) as trace environmental pollutants is a multifaceted issue whose scope of concerns continues to expand. PPCPs comprise thousands of distinct chemicals from numerous therapeutic and consumer classes. They typically occur as trace environmental pollutants (primarily in surface but also in ground waters) as a result of their widespread, continuous, combined usage in a broad range of human and veterinary therapeutic activities and practices. With respect to the risk-assessment paradigm, the growing body of published work has focused primarily on the origin and occurrence of these substances. Comparatively less is known about human and ecological exposure, and even less about the documented or potential hazards associated with trace exposure to these anthropogenic substances, many of which are highly bioactive and perpetually present in many aquatic locales. The continually growing, worldwide importance of freshwater resources underscores the need for ensuring that any aggregate or cumulative impacts on water supplies and resultant potential for human or ecological exposure be minimized.Of the many facets involved in this complex issue, that of sources/origins and environmental occurrence is the better understood end of the larger spectrum. The potential for adverse ecological or human health effects (especially from long-term, combined exposure to multiple xenobiotics at low concentrations) is the l
Taxonomy for complexity theory in the context of maternity care.

PubMed

Nieuwenhuijze, Marianne; Downe, Soo; Gottfreðsdóttir, Helga; Rijnders, Marlies; du Preez, Antoinette; Vaz Rebelo, Piedade

2015-09-01

The linear focus of 'normal science' is unable to adequately take account of the complex interactions that direct health care systems. There is a turn towards complexity theory as a more appropriate framework for understanding system behaviour. However, a comprehensive taxonomy for complexity theory in the context of health care is lacking. This paper aims to build a taxonomy based on the key complexity theory components that have been used in publications on complexity theory and health care, and to explore their explanatory power for health care system behaviour, specifically for maternity care. A search strategy was devised in PubMed and 31 papers were identified as relevant for the taxonomy. The final taxonomy for complexity theory included and defined 11 components. The use of waterbirth and the impact of the Term Breech trial showed that each of the components of our taxonomy has utility in helping to understand how these techniques became widely adopted. It is not just the components themselves that characterise a complex system but also the dynamics between them. Copyright © 2015 Elsevier Ltd. All rights reserved.

'I've put diabetes completely on the shelf till the mental stuff is in place'. How patients with doctor-assessed impaired self-care perceive disease, self-care, and support from general practitioners. A qualitative study.

PubMed

Kristensen, Mads Aage Toft; Guassora, Ann Dorrit; Arreskov, Anne Beiter; Waldorff, Frans Boch; Hølge-Hazelton, Bibi

2018-06-22

This paper investigated patients' experiences of disease and self-care as well as perceptions of the general practitioner's role in supporting patients with impaired self-care ability. Qualitative interviews with 13 patients with type 2 diabetes, concurrent chronic diseases, and impaired self-care ability assessed by a general practitioner. We analyzed our data using systematic text condensation. The shifting perspectives model of chronic illness formed the theoretical background for the study. Although most patients experienced challenges in adhering to recommended self-care activities, many had developed additional, personal self-care routines that increased wellbeing. Some patients were conscious of self-care trade-offs, including patients with concurrent mental disorders who were much more attentive to their mental disorder than their somatic diseases. Patients' perspectives on diseases could shift over time and were dominated by emotional considerations such as insisting on leading a normal life or struggling with limitations caused by disease. Most patients found support in the ongoing relationship with the same general practitioner, who was valued as a companion or appreciated as a trustworthy health informant. Patient experiences of self-care may collide with what general practitioners find appropriate in a medical regimen. Health professionals should be aware of patients' prominent and shifting considerations about the emotional aspects of disease. Patients valued the general practitioner's role in self-care support, primarily through the long-term doctor-patient relationship. Therefore, relational continuity should be prioritized in chronic care, especially for patients with impaired self-care ability who often have a highly complex disease burden and situational context. Key points Little is known about the perspectives of disease and self-care in patients with a doctor-assessed impaired ability of self-care. • Although patients knew the prescribed regimen they often prioritized self-care routines that increased well-being at the cost of medical recommendations. • Shifting emotional aspects were prominent in patients' considerations of disease and sustained GPs' use of a patient-centred clinical method when discussing self-care. • Relational continuity with general practitioners was a highly valued support and should be prioritized for patients with impaired self-care.
The importance of social and collaborative learning for online continuing medical education (OCME): directions for future development and research.

PubMed

Sandars, John; Kokotailo, Patricia; Singh, Gurmit

2012-01-01

There is an increasing use of online continuing medical education (OCME), but the potential use of social and collaborative learning to change professional performance and improve patient care has yet to be fully realised. The integration of the main themes from the presentations and comments from participants at a symposium at AMEE 2011. Sociological perspectives on change in professional performance highlight the need for social and collaborative learning in OCME so that learners can share information (explicit knowledge) and opinion (tacit knowledge). The educational topic should be relevant to the complexity of professional practice and use iterative cycles of implementation and critical reflection in social networks so that proposed solutions can be tested in actual practice. The challenge of developing effective online discussions for collaborative learning is recognised. The provision of OCME requires a shift in both policy and practice to emphasise the importance of social and collaborative learning. Further research is recommended, especially to evaluate the implementation and impact of social and collaborative learning for OCME on patient care and the use of newer Web 2.0 approaches.
Sedation for routine gastrointestinal endoscopic procedures: a review on efficacy, safety, efficiency, cost and satisfaction

PubMed Central

2017-01-01

Most gastrointestinal endoscopic procedures are now performed with sedation. Moderate sedation using benzodiazepines and opioids continue to be widely used, but propofol sedation is becoming more popular because its unique pharmacokinetic properties make endoscopy almost painless, with a very predictable and rapid recovery process. There is controversy as to whether propofol should be administered only by anesthesia professionals (monitored anesthesia care) or whether properly trained non-anesthesia personnel can use propofol safely via the modalities of nurse-administered propofol sedation, computer-assisted propofol sedation or nurse-administered continuous propofol sedation. The deployment of non-anesthesia administered propofol sedation for low-risk procedures allows for optimal allocation of scarce anesthesia resources, which can be more appropriately used for more complex cases. This can address some of the current shortages in anesthesia provider supply, and can potentially reduce overall health care costs without sacrificing sedation quality. This review will discuss efficacy, safety, efficiency, cost and satisfaction issues with various modes of sedation for non-advanced, non-emergent endoscopic procedures, mainly esophagogastroduodenoscopy and colonoscopy. PMID:29142513
The high cost of the international aging prisoner crisis: well-being as the common denominator for action.

PubMed

Maschi, Tina; Viola, Deborah; Sun, Fei

2013-08-01

The aging prisoner crisis continues to gain international attention as the high human, social, and economic costs of warehousing older adults with complex physical, mental health, and social care needs in prison continues to rise. According to the United Nations, older adults and the serious and terminally ill are considered special needs populations subject to special international health and social practice and policy considerations. We argue that older adults in prison have unique individual and social developmental needs that result from life course exposure to cumulative risk factors compounded by prison conditions that accelerate their aging. We position these factors in a social context model of human development and well-being and present a review of international human rights guidelines that pertain to promoting health and well-being to those aging in custody. The study concludes with promising practices and recommendations of their potential to reduce the high direct and indirect economic costs associated with mass confinement of older adults, many of whom need specialized long-term care that global correctional systems are inadequately equipped to provide.
Clinical implications of drug abuse epidemiology.

PubMed

Schulden, Jeffrey D; Lopez, Marsha F; Compton, Wilson M

2012-06-01

Research on the epidemiology of illicit drug use disorders provides continued critical insights into the distribution and determinants of drug use and drug use disorders in the United States. This research serves as a foundation for understanding the etiology of these disorders, helping to disentangle the complex interrelationship of developmental, genetic, and environmental risk and protective factors. Building on an understanding of this research in substance abuse epidemiology, it is important for clinicians to understand the unique trends in drug use in the overall communities that they serve and the unique risk factors for given individuals. The generally high prevalence of substance use disorders, along with their high comorbidity with other psychiatric disorders and with the HIV epidemic, make prevention, evaluation, and referral for treatment for drug abuse an important part of routine clinical practice in a range of clinical settings, including primary care, psychiatric, and emergency department settings. Ongoing efforts to ensure insurance coverage parity for the treatment of mental health and substance use disorders offer the promise of continued improvements in the integration and availability of such services in the broader US health care system.
'I'll continue as long as I can, and die when I can't help it': a qualitative exploration of the views of end-of-life care by those affected by head and neck cancer (HNC).

PubMed

O'Sullivan, E M; Higginson, I J

2016-03-01

Evidence currently suggests that many people would prefer to die at home. However, optimal end-of-life homecare depends on the patient's ability to express their care preferences, prognostic awareness, complexity of care, concordance of patient/carer preferences and availability of appropriate services/support. This study explores Irish Head and Neck Cancer (HNC) patient and caregivers' views on end-of-life care (EoLC), an area hitherto little studied. Qualitative data were collected using semistructured, one-to-one interviews with HNC patients with therapeutic experience and their nearest caregivers (n=10, 7 patients, 3 carers). Interview topic guide was developed from the PRISMA EoLC survey. Thematic content analysis was employed to interpret findings. Thematic analysis identified five broad EoLC themes: prognostication, decision making, preferred focus of care/advanced care planning (ACP), preferred place of care/death, perceived barriers/supports to home death. Participants were very willing to discuss most aspects of EoLC, exhibiting no signs of distress. Patients were reluctant to discuss preferred focus-of-care and ACP. This seemed linked to an overly optimistic view of aggressive medical intervention. While carers favoured full patient involvement in decision making, patients were divided between wanting autonomy and those preferring a more passive approach. All expressed a preference for homecare, and most felt they would ideally prefer to die at home. However, decision making was considered a complex process intertwined with risks, responsibilities and commitments to others. Carer burden and symptom control were major concerns. Normalising discussions on EoLC may benefit those affected by HNC. However, in HNC, this needs to be done alongside discussions regarding potentially life-extending treatment, symptom management and support. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/
Development, modelling, and pilot testing of a complex intervention to support end-of-life care provided by Danish general practitioners.

PubMed

Winthereik, Anna Kirstine; Neergaard, Mette Asbjoern; Jensen, Anders Bonde; Vedsted, Peter

2018-06-20

Most patients in end-of-life with life-threatening diseases prefer to be cared for and die at home. Nevertheless, the majority die in hospitals. GPs have a pivotal role in providing end-of-life care at patients' home, and their involvement in the palliative trajectory enhances the patient's possibility to stay at home. The aim of this study was to develop and pilot-test an intervention consisting of continuing medical education (CME) and electronic decision support (EDS) to support end-of-life care in general practice. We developed an intervention in line with the first phases of the guidelines for complex interventions drawn up by the Medical Research Council. Phase 1 involved the development of the intervention including identification of key barriers to provision of end-of-life care for GPs and of facilitators of change. Furthermore the actual modelling of two components: CME meeting and EDS. Phase 2 focused on pilot-testing and intervention assessment by process evaluation. In phase 1 lack of identification of patients at the end of life and limited palliative knowledge among GPs were identified as barriers. The CME meeting and the EDS were developed. The CME meeting was a four-hour educational meeting performed by GPs and specialists in palliative care. The EDS consisted of two parts: a pop-up window for each patient with palliative needs and a list of all patients with palliative needs in the practice. The pilot testing in phase 2 showed that the CME meeting was performed as intended and 120 (14%) of the GPs in the region attended. The EDS was integrated in existing electronic records but was shut down early for external reasons; 50 (5%) GPs signed up. The pilot-testing demonstrated a need to strengthen the implementation as attending rate was low in the current set-up. We developed a complex intervention to support GPs in providing end-of-life care. The pilot-test showed general acceptance of the CME meetings. The EDS was shut down early and needs further evaluation before examining the whole intervention in a larger study, where evaluation could be based on patient-related outcomes and impact on end-of-life care. Clinicaltrials.gov ( NCT02050256 ) January 30, 2014.
42 CFR 438.208 - Coordination and continuity of care.

Code of Federal Regulations, 2014 CFR

2014-10-01

... 42 Public Health 4 2014-10-01 2014-10-01 false Coordination and continuity of care. 438.208... Improvement Access Standards § 438.208 Coordination and continuity of care. (a) Basic requirement—(1) General... individual with special health care needs, as specified in paragraph (c) of this section. (3) Exception for...
42 CFR 438.208 - Coordination and continuity of care.

Code of Federal Regulations, 2012 CFR

2012-10-01

... 42 Public Health 4 2012-10-01 2012-10-01 false Coordination and continuity of care. 438.208... Improvement Access Standards § 438.208 Coordination and continuity of care. (a) Basic requirement—(1) General... individual with special health care needs, as specified in paragraph (c) of this section. (3) Exception for...
42 CFR 438.208 - Coordination and continuity of care.

Code of Federal Regulations, 2011 CFR

2011-10-01

... 42 Public Health 4 2011-10-01 2011-10-01 false Coordination and continuity of care. 438.208... Improvement Access Standards § 438.208 Coordination and continuity of care. (a) Basic requirement—(1) General... individual with special health care needs, as specified in paragraph (c) of this section. (3) Exception for...
Transitioning adolescent and young adults with chronic disease and/or disabilities from paediatric to adult care services - an integrative review.

PubMed

Zhou, Huaqiong; Roberts, Pamela; Dhaliwal, Satvinder; Della, Phillip

2016-11-01

This paper aims to provide an updated comprehensive review of the research-based evidence related to the transitions of care process for adolescents and young adults with chronic illness/disabilities since 2010. Transitioning adolescent and young adults with chronic disease and/or disabilities to adult care services is a complex process, which requires coordination and continuity of health care. The quality of the transition process not only impacts on special health care needs of the patients, but also their psychosocial development. Inconsistent evidence was found regarding the process of transitioning adolescent and young adults. An integrative review was conducted using a five-stage process: problem identification, literature search, data evaluation, data analysis and presentation. A search was carried out using the EBSCOhost, Embase, MEDLINE, PsycINFO, and AustHealth, from 2010 to 31 October 2014. The key search terms were (adolescent or young adult) AND (chronic disease or long-term illness/conditions or disability) AND (transition to adult care or continuity of patient care or transfer or transition). A total of 5719 records were initially identified. After applying the inclusion criteria a final 61 studies were included. Six main categories derived from the data synthesis process are Timing of transition; Perceptions of the transition; Preparation for the transition; Patients' outcomes post-transition; Barriers to the transition; and Facilitating factors to the transition. A further 15 subcategories also surfaced. In the last five years, there has been improvement in health outcomes of adolescent and young adults post-transition by applying a structured multidisciplinary transition programme, especially for patients with cystic fibrosis and diabetes. However, overall patients' outcomes after being transited to adult health care services, if recorded, have remained poor both physically and psychosocially. An accurate tracking mechanism needs to be established by stakeholders as a formal channel to monitor patients' outcomes post- transition. © 2016 The Authors. Journal of Clinical Nursing Published by John Wiley & Sons Ltd.
Commentary: quality of care and cost containment are the hospital-based ambulatory surgery challenges for the future.

PubMed

Frezza, E E; Girnys, R P; Silich, R J; Coppa, G F

2000-01-01

Cost containment and quality of care represent the most important objectives of all health care professionals. Because of its progressive growth over the past decade, ambulatory surgery has become an area where these 2 issues need to be addressed. The goal of this paper is to discuss the economic and quality of care challenges faced by hospitals as they strive to become competitive in the 21st century. The quality of care in ambulatory surgery has been improving because of multidisciplinary activities. Hospitals tend to hire the staff on the basis of their expertise in certain areas, and those personnel do not have to cover other hospital roles. Moreover, the hospital staff is able to seek information at any time from coworkers in other areas of specialty. Ambulatory surgery in a hospital offers advantages, such as multiple operating rooms, multiple skilled health care providers, and the ability to stay overnight if needed. The consolidation of supplies makes it easier to contract for a better price. Aggressive contract negotiations and implementation of cost-effective and cost-efficient strategies are the keys to success in the future. Quality improvement (QI) initiatives and quality of care (QC) indicators need to be developed to address various problems in the ambulatory surgery setting such as unnecessary admissions, inadequate staffing, efficient operating room (OR) utilization, quality of care, and assessment outcome. These initiatives should be addressed at regular meetings where opportunities to improve the ambulatory services are discussed. The number of ambulatory surgery procedures performed each year will continue to increase, although perhaps not at the rate we experienced in the past. Procedures that once were performed in an inpatient setting can now be accomplished on an outpatient basis or even in the physician's office. We will continue to see this shift of volume as technologic advancements and anesthetic agents allow more complex procedures to be performed on an outpatient basis.
Treating alcoholism as a chronic disease: approaches to long-term continuing care.

PubMed

McKay, James R; Hiller-Sturmhofel, Susanne

2011-01-01

For many patients, alcohol and other drug (AOD) use disorders are chronic, recurring conditions involving multiple cycles of treatment, abstinence, and relapse. To disrupt this cycle, treatment can include continuing care to reduce the risk of relapse. The most commonly used treatment approach is initial intensive inpatient or outpatient care based on 12-step principles, followed by continuing care involving self-help groups, 12-step group counseling, or individual therapy. Although these programs can be effective, many patients drop out of initial treatment or do not complete continuing care. Thus, researchers and clinicians have begun to develop alternative approaches to enhance treatment retention in both initial and continuing care. One focus of these efforts has been the design of extended treatment models. These approaches increasingly blur the distinction between initial and continuing care and aim to prolong treatment participation by providing a continuum of care. Other researchers have focused on developing alternative treatment strategies (e.g., telephone-based interventions) that go beyond traditional settings and adaptive treatment algorithms that may improve outcomes for clients who do not respond well to traditional approaches.
[Complexity of care and organizational effectiveness: a survey among medical care units in nine Lombardy region hospitals].

PubMed

Pasquali, Sara; Capitoni, Enrica; Tiraboschi, Giuseppina; Alborghetti, Adriana; De Luca, Giuseppe; Di Mauro, Stefania

2017-01-01

Eleven medical care units of nine Lombardy Region hospitals organized by levels of care model or by the traditional departmental model have been analyzed, in order to evaluate if methods for complexity of patient-care evaluation represent an index factor of nursing organizational effectiveness. Survey with nine Nurses in managerial position was conducted between Nov. 2013-Jan. 2014. The following factors have been described: context and nursing care model, staffing, complexity evaluation, patient satisfaction, staff well-being. Data were processed through Microsoft Excel. Among Units analysed ,all Units in levels of care and one organized by the departmental model systematically evaluate nursing complexity. Registered Nurses (RN) and Health Care Assistants (HCA) are on average numerically higher in Units that measure complexity (0.55/ 0.49 RN, 0.38/0.23 HCA - ratio per bed). Adopted measures in relation to changes in complexity are:rewarding systems, supporting interventions, such as moving personnel within different Units or additional required working hours; reduction in number of beds is adopted when no other solution is available. Patient satisfaction is evaluated through Customer Satisfaction questionnaires. Turnover, stress and rate of absenteeism data are not available in all Units. Complexity evaluation through appropriate methods is carried out in all hospitals organized in levels of care with personalized nursing care models, though complexity is detected with different methods. No significant differences in applied managerial strategies are present. Patient's satisfaction is evaluated everywhere. Data on staffing wellbeing is scarcely available. Coordinated regional actions are recommended in order to gather comparable data for research, improve decision making and effectiveness of Nursing care.
[Perceptions about continuous training of Chilean health care teachers].

PubMed

Pérez V, Cristhian; Fasce H, Eduardo; Coloma N, Katherine; Vaccarezza G, Giulietta; Ortega B, Javiera

2013-06-01

Continuous training of teachers, in discipline and pedagogical topics, is a key step to improve the quality of educational processes. To report the perception of Chilean teachers of undergraduate health care programs, about continuous training activities. Twenty teachers working at different undergraduate health care programs in Chile were interviewed. Maximum variation and theoretical sampling methods were used to select the sample. Data was analyzed by open coding, according to the Grounded Theory guidelines. Nine categories emerged from data analysis: Access to continuous training, meaning of training in discipline, activities of continuous training in discipline, meaning of continuous training in pedagogy, kinds of continuous training in pedagogy, quality of continuous training in pedagogy, ideal of continuous training in pedagogy, outcomes of continuous training in pedagogy and needs for continuous training in pedagogy. Teachers of health care programs prefer to participate in contextualized training activities. Also, they emphasize their need of training in evaluation and teaching strategies.
Lessons from a Successful Implementation of a Computerized Provider Order Entry System

PubMed Central

Jacobs, Brian R.; Hallstrom, Craig K.; Hart, Kim Ward; Mahoney, Daniela; Lykowski, Gayle

2007-01-01

OBJECTIVES The electronic health record (EHR) can improve patient safety, care efficiency, cost effectiveness and regulatory compliance. Cincinnati Children's Hospital Medical Center (CCHMC) has successfully implemented an Integrating Clinical Information System (ICIS) that includes Computerized Provider Order Entry (CPOE). This review describes some of the unanticipated challenges and solutions identified during the implementation of ICIS. METHODS Data for this paper was derived from user-generated feedback within the ICIS. Feedback reports were reviewed and placed into categories based on root cause of the issue. Recurring issues or problems which led to potential or actual patient injury are included. RESULTS Nine distinct challenges were identified: 1) Deterioration in communication; 2) Excessive system alerts to users; 3) Unrecognized discontinuation of medications; 4) Unintended loss of orders; 5) Loss of orders during implementation; 6) Amplification of errors; 7) Unintentional generation of patient care orders by system analysts; 8) Persistence of specific patient care order instructions; 9) Verbal orders entered under the incorrect clinician. CONCLUSIONS Unanticipated challenges are expected when implementing EHRs. The implementation plan for any EHR should include methods to identify, evaluate and repair problems quickly. While continued challenges with this complex system are expected, we believe that the EHR will continue to facilitate improved patient care and safety. The lessons learned at CCHMC will permit other institutions to avoid some of these challenges and design robust processes to detect and respond to problems in a timely fashion to ensure implementation success. PMID:23055847
The future of anesthesiology: implications of the changing healthcare environment.

PubMed

Prielipp, Richard C; Cohen, Neal H

2016-04-01

Anesthesiology is at a crossroad, particularly in the USA. We explore the changing and future roles for anesthesiologists, including the implication of new models of care such as the perioperative surgical home, changes in payment methodology, and the impact other refinements in healthcare delivery will have on practice opportunities and training requirements for anesthesiologists. The advances in the practice of anesthesiology are having a significant impact on patient care, allowing a more diverse and complex patient population to benefit from the knowledge, skills and expertise of anesthesiologists. Expanded clinical opportunities, increased utilization of technology and expansion in telemedicine will provide the foundation to care for more patients in diverse settings and to better monitor patients remotely while ensuring immediate intervention as needed. Although the roles of anesthesiologists have been diverse, the scope of practice varies from one country to another. The changing healthcare needs in the USA in particular are creating new opportunities for American anesthesiologists to define expanded roles in healthcare delivery. To fulfill these evolving needs of patients and health systems, resident training, ongoing education and methods to ensure continued competency must incorporate new approaches of education and continued certification to ensure that each anesthesiologist has the full breadth and depth of clinical skills needed to support patient and health system needs. The scope of anesthesia practice has expanded globally, providing anesthesiologists, particularly those in the USA, with unique new opportunities to assume a broader role in perioperative care of surgical patients.
Identifying and Coordinating Care for Complex Patients

PubMed Central

Rudin, Robert S.; Gidengil, Courtney A.; Predmore, Zachary; Schneider, Eric C.; Sorace, James; Hornstein, Rachel

2017-01-01

Abstract In the United States, a relatively small proportion of complex patients---defined as having multiple comorbidities, high risk for poor outcomes, and high cost---incur most of the nation's health care costs. Improved care coordination and management of complex patients could reduce costs while increasing quality of care. However, care coordination efforts face multiple challenges, such as segmenting populations of complex patients to better match their needs with the design of specific interventions, understanding how to reduce spending, and integrating care coordination programs into providers' care delivery processes. Innovative uses of analytics and health information technology (HIT) may address these challenges. Rudin and colleagues at RAND completed a literature review and held discussions with subject matter experts, reaching the conclusion that analytics and HIT are being used in innovative ways to coordinate care for complex patients but that the capabilities are limited, evidence of their effectiveness is lacking, and challenges are substantial, and important foundational work is still needed. PMID:28845354
An exploration of the midwifery continuity of care program at one Australian University as a symbiotic clinical education model.

PubMed

Sweet, Linda P; Glover, Pauline

2013-03-01

This discussion paper analyses a midwifery Continuity of Care program at an Australian University with the symbiotic clinical education model, to identify strengths and weakness, and identify ways in which this new pedagogical approach can be improved. In 2002 a major change in Australian midwifery curricula was the introduction of a pedagogical innovation known as the Continuity of Care experience. This innovation contributes a significant portion of clinical experience for midwifery students. It is intended as a way to give midwifery students the opportunity to provide continuity of care in partnership with women, through their pregnancy and childbirth, thus imitating a model of continuity of care and continuity of carer. A qualitative study was conducted in 2008/9 as part of an Australian Learning and Teaching Council Associate Fellowship. Evidence and findings from this project (reported elsewhere) are used in this paper to illustrate the evaluation of midwifery Continuity of Care experience program at an Australian university with the symbiotic clinical education model. Strengths of the current Continuity of Care experience are the strong focus on relationships between midwifery students and women, and early clinical exposure to professional practice. Improved facilitation through the development of stronger relationships with clinicians will improve learning, and result in improved access to authentic supported learning and increased provision of formative feedback. This paper presents a timely review of the Continuity of Care experience for midwifery student learning and highlights the potential of applying the symbiotic clinical education model to enhance learning. Applying the symbiotic clinical education framework to evidence gathered about the Continuity of Care experience in Australian midwifery education highlights strengths and weaknesses which may be used to guide curricula and pedagogical improvements. Copyright © 2011 Elsevier Ltd. All rights reserved.
Provider continuity in family medicine: does it make a difference for total health care costs?

PubMed

De Maeseneer, Jan M; De Prins, Lutgarde; Gosset, Christiane; Heyerick, Jozef

2003-01-01

International comparisons of health care systems have shown a relationship at the macro level between a well-structured primary health care plan and lower total health care costs. The objective of this study was to assess whether provider continuity with a family physician is related to lower health care costs using the individual patient as the unit of analysis. We undertook a study of a stratified sample of patients (age, sex, region, insurance company) for which 2 cohorts were constructed based on the patients' utilization pattern of family medicine (provider continuity or not). Patient utilization patterns were observed for 2 years. The setting was the Belgian health care system. The participants were 4,134 members of the 2 largest health insurance companies in 2 regions (Aalst and Liège). The main outcome measures were the total health care costs of patients with and without provider continuity with a family physician, controlling for variables known to influence health care utilization (need factors, predisposing factors, enabling factors). Bivariate analyses showed that patients who were visiting the same family physician had a lower total cost for medical care. A multivariate linear regression showed that provider continuity with a family physician was one of the most important explanatory variables related to the total health care cost. Provider continuity with a family physician is related to lower total health care costs. This finding brings evidence to the debate on the importance of structured primary health care (with high continuity for family practice) for a cost-effective health policy.

Which features of primary care affect unscheduled secondary care use? A systematic review.

PubMed

Huntley, Alyson; Lasserson, Daniel; Wye, Lesley; Morris, Richard; Checkland, Kath; England, Helen; Salisbury, Chris; Purdy, Sarah

2014-05-23

To conduct a systematic review to identify studies that describe factors and interventions at primary care practice level that impact on levels of utilisation of unscheduled secondary care. Observational studies at primary care practice level. Studies included people of any age of either sex living in Organisation for Economic Co-operation and Development (OECD) countries with any health condition. The primary outcome measure was unscheduled secondary care as measured by emergency department attendance and emergency hospital admissions. 48 papers were identified describing potential influencing features on emergency department visits (n=24 studies) and emergency admissions (n=22 studies). Patient factors associated with both outcomes were increased age, reduced socioeconomic status, lower educational attainment, chronic disease and multimorbidity. Features of primary care affecting unscheduled secondary care were more complex. Being able to see the same healthcare professional reduced unscheduled secondary care. Generally, better access was associated with reduced unscheduled care in the USA. Proximity to healthcare provision influenced patterns of use. Evidence relating to quality of care was limited and mixed. The majority of research was from different healthcare systems and limited in the extent to which it can inform policy. However, there is evidence that continuity of care is associated with reduced emergency department attendance and emergency hospital admissions. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.
Relationship-centered health care as a Lean intervention.

PubMed

Dunsford, Jennifer; Reimer, Laura E

2017-12-01

Continuous improvement efforts, recognized in much literature as Lean management techniques have been used in efforts to improve efficiency in democratic health care contexts for some time to varying degrees of success. The complexity of the health care system is magnified by the sheer number of processes and sub processes required to deliver value within a bureaucratic environment, while maintaining some level of compassionate and personalized care. There is inherent tension between what is required to be efficient and what is required to be caring and this conflict presses against Lean practice at the level of delivery.Administration and care intersect at the point of the patient's experience. In order to achieve the dual goals of improved value and lower costs, the application of Lean thinking for meaningful health care reform must acknowledge the fundamental dichotomy between the impersonal tasks required to provide health services, and human interactions. Meaningful health care reform requires an acknowledgement of this distinction, currently not recognized in literature. While administrative process improvements are necessary, they are insufficient to achieve a sustainable and caring health care system. Lean thinking must be applied differently for administrative processes and patient care encounters, because these are fundamentally different processes. In this way, Lean principles will effectively contribute to sustainable health system improvements. © The Author 2017. Published by Oxford University Press in association with the International Society for Quality in Health Care. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.
[Primary care in maternal-child health].

PubMed

Pedreira Massa, J L

1986-07-01

The theoretical and methodological elements of primary health care (PHC) include a philosophy of work and an epistemological focus toward the processes of health and illness, as well as a practical medical anthropological knowledge of the culture-specific aspects of disease. The work methodology of PHC requires care of the individual as a bio-psycho-socio-affective being integrated into a particular environment; none of the aspects of being should be neglected or given priority. Care should also be integrated in the sense of providing preventive health care as well as curative and rehabilitative services, in all phases from training of health personnel to record keeping. The primary health care team is multidisciplinary in constitution and interdisciplinary in function. PHC assumes that health care will be accessible to users and that continuity of care will be provided. The need for community participation in all phases of health care has been reiterated in several international health declarations. A well-functioning PHC system will require new types of pre- and postgraduate health education in a changing social and professional system and continuing education under adequate supervision for health workers. Research capability for identifying community health problems, a rigorous evaluation system, and epidemiologic surveillance are also needed. All of these elements are applicable to the field of maternal and child health as well as to PHC. The most appropriate place to intervene in order to correct existing imbalances in access to health care for mothers and children is in the PHC system. Examples of areas that should be stressed include vaccinations, nutrition, psychomotor development, early diagnosis and treatment for handicapped children, prevention of childhood accidents, school health and absenteeism, all aspects of health education, adoption and alternatives to abandonment of children, alcoholism and addiction, adolescent pregnancy and family planning, dental health, and mental problems. Trained primary care pediatricians working within the community as part of the PHC system will be required to confront and solve complex health problems. The training needed does not signify a new speciality or subspeciality, but rather a training methodology and a new type of professional practice.
Occupational therapy in Australian acute hospitals: A modified practice.

PubMed

Britton, Lauren; Rosenwax, Lorna; McNamara, Beverley

2016-08-01

Ongoing changes to health-care funding Australia wide continue to influence how occupational therapists practise in acute hospitals. This study describes the practice challenges experienced by Western Australian acute care occupational therapists. Then, it explores if and how acute care occupational therapists are modifying their practice in response to these practice changes. This study used a qualitative grounded theory approach. Semi-structured interviews were completed with 13 purposively selected acute care occupational therapists from four Western Australian metropolitan hospitals. Data were analysed using a constant comparative method to provide detailed descriptions of acute care occupational therapy practice and to generate theory. Five conceptual categories were developed. The first two addressed practice challenges: pragmatic organisational influences on client care and establishing a professional identity within the multidisciplinary team. Three categories related to therapist responses are as follows: becoming the client advocate, being the facilitator and applying clinical reasoning. Finally, modified practice was identified as the core category which explains the process whereby acute care occupational therapists are ensuring they remain relevant and authentic in the acute care context. Western Australian acute care occupational therapists are practising in a highly complex health context that presents many challenges. They are responding by using a modified form of practice that ensures occupational therapy skills remain relevant within the narrow confines of this health setting. © 2016 Occupational Therapy Australia.
Clinical dashboards: impact on workflow, care quality, and patient safety.

PubMed

Egan, Marie

2006-01-01

There is a vast array of technical data that is continuously generated within the intensive care unit environment. In addition to physiological monitors, there is information being captured by the ventilator, intravenous infusion pumps, medication dispensing units, and even the patient's bed. The ability to retrieve and synchronize data is essential for both clinical documentation and real-time problem solving for individual patients and the intensive care unit population as a whole. Technical advances that permit the integration of all relevant data into a singular display or "dashboard" may improve staff efficiency, accelerate decisions, streamline workflow processes, and reduce oversights and errors in clinical practice. Critical care nurses must coordinate all aspects of care for one or more patients. Clinical data are constantly being retrieved, documented, analyzed, and communicated to others, all within the daily routine of nursing care. In addition, many bedside monitors and devices have alarms systems that must be evaluated throughout the workday, and actions taken on the basis of the patient's condition and other data. It is obvious that the complexity within such care processes presents many potential opportunities for overlooking important details. The capability to systematically and logically link physiological monitors and other selected data sets into a cohesive dashboard system holds tremendous promise for improving care quality, patient safety, and clinical outcomes in the intensive care unit.
[Creation of a complete organised care network allowing facilitated access to ophthalmological care for patients living in socially "at-risk" situations, feasibility study].

PubMed

Terrier de la Chaise, S; Criton, A; Berrod, J-P; Boivin, J-M

2017-09-01

Currently, renouncement to healthcare by socially "at-risk" patients continues to increase and access to ophthalmological care is complex. The main objective of this study is to test the feasibility of a complete organised care network allowing facilitated access to ophthalmological care for patients living in socially "at-risk" situations. A prospective interventional study was conducted within four social housing infrastructures to screen for vision problems in the "at-risk" socially population in question. Partnering with the ophthalmological department of the CHRU de Nancy, an interventional and supportive care trial for the affected population was conducted with the assistance of social workers, nursing aides, opticians, and the author. Ten screening sessions were conducted between December 2015 and April 2016 allowing a vision exam of sixty-five patients living in social housing. Twenty-five patients benefited from specialised care within a three-month time frame provided by the ophthalmological department, of which nineteen patients received corrective lenses. The remaining six patients received other types of ophthalmological care. The study allowed to demonstrate that the cooperation of willing actors makes it possible to improve access to visual healthcare for patients living in socially "at-risk" situations, in particular in the frame of ophthalmological care, often taking second place in a general medical consultation. Copyright © 2017 Elsevier Masson SAS. All rights reserved.
[Regional geriatric care concept in the District of Lippe : Structural effects and network formation in the case management-based model project].

PubMed

Şahin, Charlotte; Iseringhausen, Olaf; Hower, Kira; Liebe, Constanze; Rethmeier-Hanke, Anja; Wedmann, Bernd

2018-04-01

Regional planning of healthcare requires special consideration for the complex needs of elderly, multimorbid people living in a domestic environment. In the District of Lippe, a hospital (Klinikum Lippe) and network of ambulatory care physicians (Ärztenetz Lippe) developed and tested a geriatric care network based on case management for geriatric patients living in a domestic environment. The establishment of the geriatric care network (e.g. promoting networking acceptance and implementation) was formatively evaluated, e. g. with qualitative methods. Data were acquired by guideline-based interviews with experts and analyzed by qualitative content analysis according to Mayring. Structural effects included forming a cross-sectoral and interdisciplinary network for a functioning care network and a geriatric care pathway. The practical work of case managers (CM) is essential for communication with patients, family members and care providers as well as integrating providers into the network. A critical factor was working together with general practitioners and the close cooperation with the hospital's department of geriatric. The quality of care is improved because of exchange of information between sectors and continuity in the course of care. In the District of Lippe the quality of care was improved and structures of care were integrated by the network according to the needs of the target group. The integrative perspective was achieved in particular by the geriatric care pathway and integration of providers into the communication and care process; however, the scope of this care model could not be extended into routine care due to the rigid and subdivided health care system.
Cross-continuum Care Continuity: Achieving Seamless Care and Managing Comorbidities.

PubMed

Boston-Fleischhauer, Carol; Rose, Robert; Hartwig, Laurie

As healthcare systems continue to design care models responsive to payment changes and the assumption of clinical and financial risk, the need exists for a comprehensive approach to address cross-continuum care transitions. This article will highlight key learnings from the Nurse Executive Center's research on achieving care continuity. The business case for developing a cross-continuum care transition strategy will be discussed, as well as systemic enablers for the achievement of seamless care. A case study example of 1 system's solution for supporting the multiple comorbid patient population as part of its cross-continuum care transition strategy will be examined.
[Governance of tertiary referral hospitals in the Democratic Republic of the Congo: a critical interpretive synthesis of the literature].

PubMed

Karemere, H; Kahindo, J B; Ribesse, N; Macq, J

2013-01-01

Because hospitals are complex enterprises requiring adaptive systems, it is appropriate to apply the theory and terminology of governance or even better adaptive governance to the interpretation of their management. This study focused on understanding hospital governance in Logo, Bunia, and Katana, three hospitals in two regions of the eastern DRC, which has been characterized by intermittent armed conflict since 1996. In such a context of war and continuous insecurity, how can governance be interpreted for hospitals required to adapt to a constantly changing environment to be able to continue to provide health care? A critical interpretive synthesis of the literature, identified by searching for keywords related to governance. The concepts of governance, adaptive governance, performance, leadership, and complex adaptive system concepts are defined. The interpretation of the concepts helps us to better understand (1) the hospital as a complex adaptive system, (2) the governance of tertiary referral hospitals, (3) analysis of hospital performance, and (4) leadership for good governance of these hospitals. The interpretation of these concepts raises several questions about their application to the eastern DRC. Conclusion. This critical interpretive synthesis opens the door to a new way of exploring tertiary hospitals and their governance in the eastern DRC.
Chinese midwives' experience of providing continuity of care to labouring women.

PubMed

Gu, Chunyi; Zhang, Zheng; Ding, Yan

2011-04-01

to explore and describe Chinese midwives' experience of providing one-to-one continuity of care to labouring women. a qualitative study using a phenomenological approach. Data were collected using open-ended, tape-recorded interviews. The analysis of the transcribed texts included searching for themes sorted into clusters for a final expression of the essential structure of the phenomenon. Obstetrics and gynaecology hospital of Fudan University, Shanghai, China. 12 midwives, providing one-to-one continuity of care to labouring women. two main categories were identified: (1) midwives' feelings on providing continuity of care, and (2) impact of on-call system on midwives providing continuity of care. Key themes emerged from each main category: (1) 'playing important roles in labour care', 'gaining a sense of self-achievement', 'falling into exhaustion and frustration' and 'coping with caring work'; and (2) 'on-call syndrome', 'affecting personal lives' and 'managing on-call shift'. The midwives experienced mixed feelings of being with women and expressed their adaptation to being on-call, which was the essence of this study. They played important roles in caring for women, gained a sense of self-achievement and developed suitable coping strategies. However, they also indicated the impact of the on-call system upon them in the process of providing continuity of care. midwives have gained both positive and negative experiences when providing continuity of care to labouring women. The positive aspects may facilitate other professional midwives working in a similar role, whereas the negative aspects may inform them of learning to live with this situation, and may also have implications for managers to develop new approaches to the organisation and provision of continuity of care to support midwives' practice, and to fully utilise 'flexibility' under an on-call system. Copyright © 2009 Elsevier Ltd. All rights reserved.
Continuity of Care, Caregiver-Child Interactions, and Toddler Social Competence and Problem Behaviors

ERIC Educational Resources Information Center

Ruprecht, Karen; Elicker, James; Choi, Ji Young

2016-01-01

Research Findings: Continuity of care is a recommended practice in child care intended to promote secure and supportive relationships between infants and toddlers and their caregivers. Toddlers (N = 115) between 12 and 24 months were observed in 30 continuity and 29 noncontinuity classrooms. The average duration of care for toddlers with…
Understanding Users in the ‘Field’ of Medications

PubMed Central

Ballantyne, Peri J.

2016-01-01

The numbers of medicinal drugs available for human consumption have increased rapidly in the past several decades, and physician prescribing practices reflect the growing reliance on medicines in health care. However, the nature of medicines-as-technology makes problematic taken-for-granted relationships among actors involved in the delivery, or who are the recipients of medicines-reliant health care. In this article, I situate the medicine user in the ‘field’ of medications—where interests, actions and outcomes are continually negotiated among and between the various players—physicians, pharmacists, government regulatory bodies, the pharmaceutical industry and users of medicines. The objective of the paper is to illuminate the complex context in which the medicine-user—the target of the pharmacy profession’s service to the public—accesses and uses medicines. PMID:28970392
The consumer health gap: are we innovating for the future or simply addressing the past?

PubMed

Cafazzo, Joseph A

2014-01-01

The pace of adoption of consumer health solutions appears to be slow, despite some documented success. Reasons why the health system is not embracing this success are complex but not entirely unexpected. The barriers continue to be more a reflection of the state of our health system itself than of the patients who are demanding more involvement in the management of their care. The solution may lie in our willingness to be bolder in our vision for our future health system: for consumer health solutions to drive our focus on the management of chronic illness and self-care. The investments we make will require a measured prioritizing of the patient over the provider in building the health information technology systems of tomorrow.
Structured Coaching Programs to Develop Staff.

PubMed

Dyess, Susan MacLeod; Sherman, Rose; Opalinski, Andra; Eggenberger, Terry

2017-08-01

Health care environments are complex and chaotic, therein challenging patients and professionals to attain satisfaction, well-being, and exceptional outcomes. These chaotic environments increase the stress and burnout of professionals and reduce the likelihood of optimizing success in many dimensions. Coaching is evolving as a professional skill that may influence the optimization of the health care environment. This article reflects on three coaching programs: Gallup Strengths-Based Coaching, Dartmouth Microsystem Coaching, and Health and Wellness Nurse Coaching. Each approach is presented, processes and outcomes are considered, and implications for educators are offered. Continuing education departments may recognize various coaching approaches as opportunities to support staff professionals achieve not only the triple aim, but also the quadruple aim. J Contin Educ Nurs. 2017;48(8):373-378. Copyright 2017, SLACK Incorporated.
42 CFR 456.380 - Individual written plan of care.

Code of Federal Regulations, 2012 CFR

2012-10-01

... SERVICES (CONTINUED) MEDICAL ASSISTANCE PROGRAMS UTILIZATION CONTROL Utilization Control: Intermediate Care Facilities Plan of Care § 456.380 Individual written plan of care. (a) Before admission to an ICF or before... designed to meet the objectives of the plan of care; (5) Plans for continuing care, including review and...
42 CFR 456.380 - Individual written plan of care.

Code of Federal Regulations, 2014 CFR

2014-10-01

... SERVICES (CONTINUED) MEDICAL ASSISTANCE PROGRAMS UTILIZATION CONTROL Utilization Control: Intermediate Care Facilities Plan of Care § 456.380 Individual written plan of care. (a) Before admission to an ICF or before... designed to meet the objectives of the plan of care; (5) Plans for continuing care, including review and...
42 CFR 456.380 - Individual written plan of care.

Code of Federal Regulations, 2013 CFR

2013-10-01

... SERVICES (CONTINUED) MEDICAL ASSISTANCE PROGRAMS UTILIZATION CONTROL Utilization Control: Intermediate Care Facilities Plan of Care § 456.380 Individual written plan of care. (a) Before admission to an ICF or before... designed to meet the objectives of the plan of care; (5) Plans for continuing care, including review and...
Weaning from mechanical ventilation: factors that influence intensive care nurses' decision-making.

PubMed

Tingsvik, Catarina; Johansson, Karin; Mårtensson, Jan

2015-01-01

The aim of the study was to describe the factors that influence intensive care nurses' decision-making when weaning patients from mechanical ventilation. Patients with failing vital function may require respiratory support. Weaning from mechanical ventilation is a process in which the intensive care nurse participates in both planning and implementation. A qualitative approach was used. The data were collected by means of semi-structured interviews with 22 intensive care nurses. The interviews were transcribed and analysed using qualitative content analysis. One theme emerged: 'A complex nursing situation where the patient receives attention and which is influenced by the current care culture'. There was consensus that the overall assessment of the patient made by the intensive care nurse was the main factor that influenced the decision-making process. This assessment was a continuous process consisting of three factors: the patient's perspective as well as her/his physical and mental state. On the other hand, there was a lack of consensus about what other factors influenced the decision-making process. These factors included the care culture constituted by the characteristics of the team, the intensive care nurses' professional skills, personalities and ability to be present. The individual overall assessment of the patient enabled nursing care from a holistic perspective. Furthermore, the weaning process can be more effective and potential suffering reduced by creating awareness of the care culture's impact on the decision-making process. © 2014 British Association of Critical Care Nurses.
Identifying primary care patient safety research priorities in the UK: a James Lind Alliance Priority Setting Partnership.

PubMed

Morris, Rebecca Lauren; Stocks, Susan Jill; Alam, Rahul; Taylor, Sian; Rolfe, Carly; Glover, Steven William; Whitcombe, Joanne; Campbell, Stephen M

2018-02-28

To identify the top 10 unanswered research questions for primary care patient safety research. A modified nominal group technique. UK. Anyone with experience of primary care including: patients, carers and healthcare professionals. 341 patients and 86 healthcare professionals submitted questions. A top 10, and top 30, future research questions for primary care patient safety. 443 research questions were submitted by 341 patients and 86 healthcare professionals, through a national survey. After checking for relevance and rephrasing, a total of 173 questions were collated into themes. The themes were largely focused on communication, team and system working, interfaces across primary and secondary care, medication, self-management support and technology. The questions were then prioritised through a national survey, the top 30 questions were taken forward to the final prioritisation workshop. The top 10 research questions focused on the most vulnerable in society, holistic whole-person care, safer communication and coordination between care providers, work intensity, continuity of care, suicide risk, complex care at home and confidentiality. This study was the first national prioritisation exercise to identify patient and healthcare professional priorities for primary care patient safety research. The research priorities identified a range of important gaps in the existing evidence to inform everyday practice to address primary care patient safety. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.
Mental health of survivors of 1984 Bhopal disaster: A continuing challenge

PubMed Central

Murthy, R. Srinivasa

2014-01-01

Bhopal disaster is an important milestone in Indian Industrial Psychiatry. The disaster was not only the biggest industrial disaster but also one in which complex forces have joined hands to demy the mental health needs of the population. Though the biggest general population epidemiological study over 5 years was carried out to understand the mental health impact of the disaster, the findings of this study did not get reflected in mental health care for the population. Furthermore, the needed longitudinal studies and evaluation of the interventions were not undertaken. There was no sharing of information with the survivors about the impact of the disaster on their health and well-being and sharing of skills for self-care. A result of these factors is the extreme degree of dissatisfaction in the population. Looking back, it would have met the needs of the Bhopal population, if the mental health services were community based and reaching the population, rather than the clinic-based approaches, there was a wide range of services, especially rehabilitation, continuous research into the changing mental health needs of the population and the effectiveness of interventions and most importantly, there was a continuous dialogue with the population and sharing of information with the general population. These are the tasks for the immediate future to reorganize the focus of mental health initiatives in Bhopal. Many lessons can be learnt from the Bhopal disaster and the continuing tragedy for the population. PMID:25788796

Interprofessional Training: Not Optional in Good Medical Education.

PubMed

Burcher, Paul

2016-09-01

Interprofessional education is a vital part of medical education, and students should not be permitted to exempt themselves from it. Physicians are part of a team, and the importance of teamwork will only increase as physician shortages continue and medical care becomes more complex. To learn to be good physicians in this emerging environment, students must appreciate the skills, strengths, and vocabularies of other professions. It is shortsighted to think that the best educators of future physicians can only be other physicians. © 2016 American Medical Association. All Rights Reserved.
Factitious Disorders and Cardiothoracic Surgery: The Ongoing Multidisciplinary Challenges of a Complex Case

PubMed Central

Firstenberg, Michael S.; Sirak, John H.; Sun, Benjamin; Kasick, David P.

2009-01-01

Chronic factitious disorder, Munchausen's syndrome, can be challenging to manage—particularly when complaints and symptoms suggest medical or surgical emergencies. We present a patient whose problems have spanned many years and a great distance. Hopefully, with a greater awareness of this disease, as this patient continues to seek health care in many different hospitals, the implications of timely access to information, good histories and physical exams, and an index of suspicion can assist in potentially avoiding unnecessary, expensive, and invasive evaluations. PMID:20029640
[Integration of nursing in science and technology policies].

PubMed

Rocha, Semíramis Melani Melo; Ogata, Márcia Niituma; Arantes, Cássia Irene Spinelli

2003-01-01

Brazilian nursing is included in the national science and technology system, as part of the health knowledge area. Its scientific production is reknown but is yet to strengthen its position. Among the strategies to be used, we can emphasize: study different ways to promote a closer relationship between university and services; create or intensify interfacing between clinical and academic nurses; promote strategic research for the use of technological innovations, continuing education of human resources, and implement studies on Nursing care while integrating skills required by complex technological systems and intersubjectivity, acting in a therapeutic way.
Safety-I, Safety-II and Resilience Engineering.

PubMed

Patterson, Mary; Deutsch, Ellen S

2015-12-01

In the quest to continually improve the health care delivered to patients, it is important to understand "what went wrong," also known as Safety-I, when there are undesired outcomes, but it is also important to understand, and optimize "what went right," also known as Safety-II. The difference between Safety-I and Safety-II are philosophical as well as pragmatic. Improving health care delivery involves understanding that health care delivery is a complex adaptive system; components of that system impact, and are impacted by, the actions of other components of the system. Challenges to optimal care include regular, irregular and unexampled threats. This article addresses the dangers of brittleness and miscalibration, as well as the value of adaptive capacity and margin. These qualities can, respectively, detract from or contribute to the emergence of organizational resilience. Resilience is characterized by the ability to monitor, react, anticipate, and learn. Finally, this article celebrates the importance of humans, who make use of system capabilities and proactively mitigate the effects of system limitations to contribute to successful outcomes. Copyright © 2015 Mosby, Inc. All rights reserved.
Infusing Social Justice in Undergraduate Nursing Education: Fostering Praxis Through Simulation.

PubMed

Caldwell, Robyn; Cochran, Courtney

Forensic clinical experiences are often inconsistent in undergraduate nursing education. Nursing students are not included in the process of forensic evidence collection, often because of the sensitive nature of the situation. Unfortunately, nursing students are forced to rely on theoretical knowledge provided by the nurse educator to understand the complexities of forensic nursing care. Nursing students must be able to identify and provide appropriate nursing care for individuals in all forensic situations. Comprehensive clinical laboratory experiences should be provided through active teaching-learning strategies, which replicate nursing care of the forensic patient. Simulated patient experiences provide a unique opportunity to explore the sensitive nature of sexual trauma in a safe learning environment. This strategy facilitates the application of theoretical forensic principles by utilizing live actors or high-fidelity manikins in laboratory settings. The application of theory to each simulated patient infuses conceptual knowledge at the point of care. Change in social consciousness begins at the bedside. The moral imperative of nursing continues to be the preparation of socially responsible, professional nurses who strive to end social injustices.
The evolution of breast cancer navigation and survivorship care.

PubMed

Shockney, Lillie D

2015-01-01

Over the last several decades, breast screening, diagnosis, and treatment have evolved. With that evolutionary process, so have the complexities of oncology care, especially from the perspective of more fragmented care occurring. The majority of breast care is outpatient based. The need for patient navigation has heightened as this fragmentation and financial issues set before the oncologist and the patient continue to occur and in many situations increase. Without effective navigation, breast patients can fall through the cracks and not get diagnosed as early as possible, or not receive all appropriate treatment they need. We are also seeing a steady increase in the actual number of breast cancer patients being diagnosed and surviving long term. Unfortunately simultaneous to this happen there is also a growing shortage of oncology specialists in the USA. This results in a need to transition survivors back to their community physicians after the completion of their acute treatment, and to do so in an organized, anticipated manner that prepares the survivor and her PCP and gynecologist, the tools they all need for effective cancer survivorship management. © 2014 Wiley Periodicals, Inc.
[Factor analysis and internal consistency of pedagogical practices questionnaire among health care teachers].

PubMed

Pérez V, Cristhian; Vaccarezza G, Giulietta; Aguilar A, César; Coloma N, Katherine; Salgado F, Horacio; Baquedano R, Marjorie; Chavarría R, Carla; Bastías V, Nancy

2016-06-01

Teaching practice is one of the most complex topics of the training process in medicine and other health care careers. The Teaching Practices Questionnaire (TPQ) evaluates teaching skills. To assess the factor structure and internal consistency of the Spanish version of the TPP among health care teachers. The TPQ was answered by 315 university teachers from 13 of the 15 administrative Chilean regions, who were selected through a non-probabilistic volunteer sampling. The internal consistency of TPP factors was calculated and the correlation between them was analyzed. Six factors were identified: Student-centered teaching, Teaching planning, Assessment process, Dialogue relationship, Teacher-centered teaching and Use of technological resources. They had Cronbach alphas ranging from 0.60 to 0.85. The factorial structure of TPQ differentiates the most important functions of teaching. It also shows a theoretical consistency and a practical relevance to perform a diagnosis and continuous evaluation of teaching practices. Additionally, it has an adequate internal consistency. Thus, TPQ is valid and reliable to evaluate pedagogical practices in health care careers.
The use of indicators to improve the quality of intensive care: theoretical aspects and experiences from the Dutch intensive care registry.

PubMed

van der Voort, P H J; van der Veer, S N; de Vos, M L G

2012-10-01

In the concept of total quality management that was originally developed in industry, the use of quality indicators is essential. The implementation of quality indicators in the intensive care unit to improve the quality of care is a complex process. This process can be described in seven subsequent steps of an indicator-based quality improvement (IBQI) cycle. With this IBQI cycle, a continuous quality improvement can be achieved with the use of indicator data in a benchmark setting. After the development of evidence-based indicators, a sense of urgency has to be created, registration should start, raw data must be analysed, feedback must be given, and interpretation and conclusions must be made, followed by a quality improvement plan. The last step is the implementation of changes that needs a sense of urgency, and this completes the IBQI cycle. Barriers and facilitators are found in each step. They should be identified and addressed in a multifaceted quality improvement strategy. © 2012 The Authors. Acta Anaesthesiologica Scandinavica © 2012 The Acta Anaesthesiologica Scandinavica Foundation.
Integrated Transitions of Care for Patients With Rare Pulmonary Diseases.

PubMed

Moreo, Kathleen; Lattimer, Cheri; Lett, James E; Heggen-Peay, Cherilyn L; Simone, Laura

Many continuing education (CE) resources are available to support case management professionals in developing competencies in transitions of care (TOC) that apply generally across disease areas. However, CE programs and tools are lacking for advanced TOC competencies in specific disease areas. This article describes 2 projects in which leading TOC, case management, and CE organizations collaborated to develop CE-accredited interdisciplinary pathways for promoting safe and effective TOC for patients with rare pulmonary diseases, including pulmonary arterial hypertension (PAH) and idiopathic pulmonary fibrosis (IPF). The interdisciplinary pathways apply to PAH and IPF case management practice and TOC across settings that include community-based primary care and specialty care, PAH or IPF centers of expertise, acute care and post-acute settings, long-term care, rehabilitation and skilled nursing facilities, and patients' homes. Both PAH and IPF are chronic, progressive respiratory diseases that are associated with severe morbidity and mortality, along with high health care costs. Because they are relatively rare diseases with nonspecific symptoms and many comorbidities, PAH and IPF are difficult to diagnose. Early diagnosis, referral to centers of expertise, and aggressive treatment initiation are essential for slowing disease progression and maintaining quality of life and function. Both the rarity and complexity of PAH and IPF pose unique challenges to ensuring effective and safe TOC. Expert consensus and evidence-based approaches to meeting these challenges, and thereby improving PAH and IPF patient outcomes, are presented in the 2 interdisciplinary TOC pathways that are described in this article. In coordinating care for patients with complex pulmonary diseases such as PAH and IPF, case managers across practice settings can play key roles in improving workflow processes and communication, transition planning, coordinating TOC with centers of expertise, coordinating care and TOC for patients with comorbidities, providing patient and caregiver education, promoting engagement between patients and the team, advancing the care plan, and improving ongoing adherence to treatment in order to maximize the patient's pulmonary function. Details regarding these interprofessional roles and responsibilities are provided in the full interdisciplinary TOC pathways for PAH and IPF.
Continuity of care in community midwifery.

PubMed

Bowers, John; Cheyne, Helen; Mould, Gillian; Page, Miranda

2015-06-01

Continuity of care is often critical in delivering high quality health care. However, it is difficult to achieve in community health care where shift patterns and a need to minimise travelling time can reduce the scope for allocating staff to patients. Community midwifery is one example of such a challenge in the National Health Service where postnatal care typically involves a series of home visits. Ideally mothers would receive all of their antenatal and postnatal care from the same midwife. Minimising the number of staff-handovers helps ensure a better relationship between mothers and midwives, and provides more opportunity for staff to identify emerging problems over a series of home visits. This study examines the allocation and routing of midwives in the community using a variant of a multiple travelling salesmen problem algorithm incorporating staff preferences to explore trade-offs between travel time and continuity of care. This algorithm was integrated in a simulation to assess the additional effect of staff availability due to shift patterns and part-time working. The results indicate that continuity of care can be achieved with relatively small increases in travel time. However, shift patterns are problematic: perfect continuity of care is impractical but if there is a degree of flexibility in the visit schedule, reasonable continuity is feasible.
Looking at childhood obesity through the lens of Baumrind's parenting typologies.

PubMed

Luther, Brenda

2007-01-01

Obesity is becoming the leading negative health outcome for the current generation of children to a greater degree than for any previous generation. Pediatric orthopaedic nurses encounter many patients and families with concerns about obesity and need the ability to promote parenting capacity in order to detect, prevent, or treat childhood obesity. Parenting is a complex process with numerous two-way interactions between the parent and child. Pediatric orthopaedic nurses affect parenting capacity daily as they care for families in all care settings. Many family researchers use Baumrind's parenting typologies (styles) and their correlations to child health outcomes in research. Understanding Baumrind's theories can help pediatric orthopaedic nurses understand the mechanisms parents use to affect the health outcomes related to the obesity of their children. Baumrind's is one parenting theory that can help demonstrate how parental behaviors and practices affect a child's self-concept and self-care development and ultimately a child's health promotion beliefs and practices related to obesity prevention and care that continue into adulthood. Nurses can use reviews of literature and application to practice of parenting styles to expand their repertoire of parent guidance and anticipatory teaching directed to the prevention and care of childhood obesity.
Intestinal Rehabilitation Programs in the Management of Pediatric Intestinal Failure and Short Bowel Syndrome.

PubMed

Merritt, Russell J; Cohran, Valeria; Raphael, Bram P; Sentongo, Timothy; Volpert, Diana; Warner, Brad W; Goday, Praveen S

2017-11-01

Intestinal failure is a rare, debilitating condition that presents both acute and chronic medical management challenges. The condition is incompatible with life in the absence of the safe application of specialized and individualized medical therapy that includes surgery, medical equipment, nutritional products, and standard nursing care. Intestinal rehabilitation programs are best suited to provide such complex care with the goal of achieving enteral autonomy and oral feeding with or without intestinal transplantation. These programs almost all include pediatric surgeons, pediatric gastroenterologists, specialized nurses, and dietitians; many also include a variety of other medical and allied medical specialists. Intestinal rehabilitation programs provide integrated interdisciplinary care, more discussion of patient management by involved specialists, continuity of care through various treatment interventions, close follow-up of outpatients, improved patient and family education, earlier treatment of complications, and learning from the accumulated patient databases. Quality assurance and research collaboration among centers are also goals of many of these programs. The combined and coordinated talents and skills of multiple types of health care practitioners have the potential to ameliorate the impact of intestinal failure and improve health outcomes and quality of life.
[Advocating for the Inclusion of Psychologists in Family Health Teams in Ontario, Canada].

PubMed

Grenier, Jean; Chomienne, Marie-Hélène; Gaboury, Isabelle

Objectives This article advocates in favor of increasing the accessibility of psychological services in primary health care by focusing more specifically on the relevance of including psychologists in family health teams in primary care in Ontario.Methods The authors present their advocacy from two levels of information: 1) the main results of a demonstration project funded by the Primary Health Care Transition Fund (PHCTF) in which psychologists were integrated into family practices; and 2) experiences and general observations drawn from the combined experiences of the authors from the last decade regarding the inclusion of psychologists in primary care.Results Main results from the demonstration project: 1) highly prevalent mental illnesses (anxiety & mood disorders) are amenable to psychological interventions; 2) psychologists and family physicians are natural and complementary allies in primary care; 3) the cost of integrating psychologists to provide psychological interventions can be off-set by a reduction in physicians' mental health billing. Main observations drawn from authors' combined experiences in primary care: 1) relatively few psychologists work in family health teams in Ontario; 2) most non-pharmacological mental health interventions in primary care involve generic counselling, problem solving, educational groups, and linking to community resources; 3) lack of understanding of the difference between evidence-based psychological treatments and generic counselling; 4) many multidisciplinary clinics unfortunately benefit from only one type of non-medical mental health professional as part of their team to see all cases, independent of the level of complexity on the patient's side, and independent of the level of expertise or supervised training on the provider side; 5) multidisciplinary teams in primary care need various mental health professionals to cover for a wide range of presenting problems and levels of complexity/co-morbidities.Conclusion Our demonstration project combined with our continued clinical experience in primary care is consistent with the scientific literature on the topic of psychological services in primary care. Common mental health problems are highly prevalent. Societal costs are high. Accurate diagnosis is crucial. There are psychological treatments proven to work, and that are cost-effective. We can build on existing multidisciplinary teams and structures in place and also innovate by finding creative mechanisms linking the public and private sectors such as in the Australian primary care system. Interdisciplinary teams should integrate a judicious mix of pertinent skills with the right balance of varying levels of competencies to efficiently address varying levels of problem complexities and co-morbidities. At the moment, there is a gap to be filled in multidisciplinary primary care teams and psychologists are already extensively trained and available to fill this gap.
The experiences of new graduate midwives working in midwifery continuity of care models in Australia.

PubMed

Cummins, Allison M; Denney-Wilson, E; Homer, C S E

2015-04-01

midwifery continuity of care has been shown to be beneficial to women through reducing interventions and other maternal and neonatal morbidity. In Australia, numerous government reports recognise the importance of midwifery models of care that provide continuity. Given the benefits, midwives, including new graduate midwives, should have the opportunity to work in these models of care. Historically, new graduates have been required to have a number of years׳ experience before they are able to work in these models of care although a small number have been able to move into these models as new graduates. to explore the experiences of the new graduate midwives who have worked in midwifery continuity of care, in particular, the support they received; and, to establish the facilitators and barriers to the expansion of new graduate positions in midwifery continuity of care models. a qualitative descriptive study was undertaken framed by the concept of continuity of care. the new graduate midwives valued the relationship with the women and with the group of midwives they worked alongside. The ability to develop trusting relationships, consolidate skills and knowledge, be supported by the group and finally feeling prepared to work in midwifery continuity of care from their degree were all sub-themes. All of these factors led to the participants feeling as though they were 'becoming a real midwife'. this is the first study to demonstrate that new graduate midwives value working in midwifery continuity of care - they felt well prepared to work in this way from their degree and were supported by midwives they worked alongside. The participants reported having more confidence to practice when they have a relationship with the woman, as occurs in these models. Copyright © 2015 Elsevier Ltd. All rights reserved.
Using mixed methods to develop and evaluate complex interventions in palliative care research.

PubMed

Farquhar, Morag C; Ewing, Gail; Booth, Sara

2011-12-01

there is increasing interest in combining qualitative and quantitative research methods to provide comprehensiveness and greater knowledge yield. Mixed methods are valuable in the development and evaluation of complex interventions. They are therefore particularly valuable in palliative care research where the majority of interventions are complex, and the identification of outcomes particularly challenging. this paper aims to introduce the role of mixed methods in the development and evaluation of complex interventions in palliative care, and how they may be used in palliative care research. the paper defines mixed methods and outlines why and how mixed methods are used to develop and evaluate complex interventions, with a pragmatic focus on design and data collection issues and data analysis. Useful texts are signposted and illustrative examples provided of mixed method studies in palliative care, including a detailed worked example of the development and evaluation of a complex intervention in palliative care for breathlessness. Key challenges to conducting mixed methods in palliative care research are identified in relation to data collection, data integration in analysis, costs and dissemination and how these might be addressed. the development and evaluation of complex interventions in palliative care benefit from the application of mixed methods. Mixed methods enable better understanding of whether and how an intervention works (or does not work) and inform the design of subsequent studies. However, they can be challenging: mixed method studies in palliative care will benefit from working with agreed protocols, multidisciplinary teams and engaging staff with appropriate skill sets.
Continuing Care and Trauma in Women Offenders’ Substance Use, Psychiatric Status, and Self-Efficacy Outcomes

PubMed Central

Saxena, Preeta; Grella, Christine E.; Messina, Nena P.

2015-01-01

Using secondary data analysis of 3 separate trauma-informed treatment programs for women offenders, we examine outcomes between those who received both prison and community-based substance abuse treatment (i.e., continuing care; n = 85) and those who received either prison or community aftercare treatment (n = 108). We further account for differences in trauma exposure to examine whether continuing care moderates this effect on substance use, psychiatric severity, and self-efficacy outcomes at follow-up. The main effect models of continuing care showed a significant association with high psychiatric status and did not yield significant associations with substance use or self-efficacy. However, the interaction between trauma history and continuing care showed significant effects on all 3 outcomes. Findings support the importance of a continuing care treatment model for women offenders exposed to multiple forms of traumatic events, and provide evidence of the effectiveness of integrating trauma-informed treatment into women’s substance abuse treatment. PMID:26924891
From quantum physics to digital communication: Single sideband continuous phase modulation

NASA Astrophysics Data System (ADS)

Farès, Haïfa; Christian Glattli, D.; Louët, Yves; Palicot, Jacques; Moy, Christophe; Roulleau, Preden

2018-01-01

In the present paper, we propose a new frequency-shift keying continuous phase modulation (FSK-CPM) scheme having, by essence, the interesting feature of single-sideband (SSB) spectrum providing a very compact frequency occupation. First, the original principle, inspired from quantum physics (levitons), is presented. Besides, we address the problem of low-complexity coherent detection of this new waveform, based on orthonormal wave functions used to perform matched filtering for efficient demodulation. Consequently, this shows that the proposed modulation can operate using existing digital communication technology, since only well-known operations are performed (e.g., filtering, integration). This SSB property can be exploited to allow large bit rates transmissions at low carrier frequency without caring about image frequency degradation effects typical of ordinary double-sideband signals. xml:lang="fr"
Personal care assistants' experiences of caring for people on home mechanical ventilation.

PubMed

Israelsson-Skogsberg, Åsa; Lindahl, Berit

2017-03-01

The aim of this study was to describe personal care assistants' (PCA) experiences of working with a ventilator-assisted person at home. Data were collected from fifteen audiotaped semistructured interviews with PCAs supporting a child or adult using home mechanical ventilation (HMV). Thirteen women and two men participated; their working experience with HMV users ranged from one to 17 years (median 6 years). Data were subjected to qualitative content analysis in an inductive and interpretive manner. Five categories emerged from the data: Being part of a complex work situation; Taking on a multidimensional responsibility; Caring carried out in someone's home; Creating boundaries in an environment with indistinct limits; and Being close to another's body and soul. The participants felt very close to the person they worked with, both physically and emotionally. They had a great responsibility and therefore a commensurate need for support, guidance and a well-functioning organisation around the HMV user. There is international consensus that advanced home care will continue to expand and personal care assistance is key in this development. We suggest that one way to move forward for PCAs working with HMV users is to create multiprofessional teams led by a key-person who coordinates the individual needs. More research is needed within this area from a broad perspective including the HMV-assisted persons, relatives, personal care assistants and management organisations. © 2016 Nordic College of Caring Science.
Enhancing the contribution of research to health care policy-making: a case study of the Dutch Health Care Performance Report.

PubMed

Hegger, Ingrid; Marks, Lisanne K; Janssen, Susan W J; Schuit, Albertine J; van Oers, Hans A M

2016-01-01

The Dutch Health Care Performance Report, issued by the National Institute of Public Health and the Environment, aims to monitor health care performance in The Netherlands. Both the National Institute and the Ministry of Health wish to increase the contribution of the Report to health care policy-making. Our aim was to identify ways to achieve that. We used contribution mapping as a theoretical framework that recognizes alignment of research as crucial to managing contributions to policy-making. To investigate which areas need alignment efforts by researchers and/or policy-makers, we interviewed National Institute researchers and policy-makers from the Ministry of Health and assessed the process for developing the 2010 Report. We identified six areas where alignment is specifically relevant for enhancing the contributions of future versions of the Dutch Health Care Performance Report: well-balanced information for different ministerial directorates; backstage work; double role actors; reports of other knowledge institutes; data collection/generation and presentation forms. The contribution of health care performance reporting to policy-making is complex and requires continuous alignment efforts between researchers and policy-makers. These efforts should form an inseparable part of health care performance reporting and although this demands considerable resources, it is worth considering since it may pay back in better contributions to policy-making. © The Author(s) 2015.
[Complexity of care: meanings and interpretation].

PubMed

Cologna, Marina; Zanolli, Daniela; Saiani, Luisa

2010-01-01

Although the concept of complexity of care is widely used and discussed, its meaning is blurred and its characteristics are not well defined. To identify the words used to define the concept of complexity in the literature and its meaning. A literature search was performed on the following databases: Pubmed, Medline, Ebsco, Cinahl and Cochrane. No temporal limits were set; publications written in English and Italian were included. Several terms are used to define the concept of complexity, often interchangeably notwithstanding their different meaning. Three main concepts were identified: nursing intensity that includes the concepts of dependency, severity and complexity of patients care; nursing workload that comprises the concept of nursing intensity and all the activities not patient-related; and the patient acuity that includes the severity of illness and the caring intensity. A common definition is needed to be able to use the concept of complexity of care to allocate nursing resources.

Practical ethical theory for nurses responding to complexity in care.

PubMed

Fairchild, Roseanne Moody

2010-05-01

In the context of health care system complexity, nurses need responsive leadership and organizational support to maintain intrinsic motivation, moral sensitivity and a caring stance in the delivery of patient care. The current complexity of nurses' work environment promotes decreases in work motivation and moral satisfaction, thus creating motivational and ethical dissonance in practice. These and other work-related factors increase emotional stress and burnout for nurses, prompting both new and seasoned nurse professionals to leave their current position, or even the profession. This article presents a theoretical conceptual model for professional nurses to review and make sense of the ethical reasoning skills needed to maintain a caring stance in relation to the competing values that must coexist among nurses, health care administrators, patients and families in the context of the complex health care work environments in which nurses are expected to practice. A model, Nurses' Ethical Reasoning Skills, is presented as a framework for nurses' thinking through and problem solving ethical issues in clinical practice in the context of complexity in health care.
Validation of 2 New Measures of Continuity of Care Based on Year-to-Year Follow-up With Known Providers of Health Care

PubMed Central

Tousignant, Pierre; Diop, Mamadou; Fournier, Michel; Roy, Yves; Haggerty, Jeannie; Hogg, William; Beaulieu, Marie-Dominique

2014-01-01

PURPOSE In a primary care context favoring group practices, we assessed the validity of 2 new continuity measures (both versions of known provider continuity, KPC) that capture the concentration of care over time from multiple physicians (multiple provider continuity, KPC-MP) or from the physician seen most often (personal provider continuity, KPC-PP). METHODS Patients with diabetes or cardiovascular disease (N = 765) were approached in the waiting rooms of 28 primary care clinics in 3 regions of the province of Quebec, Canada; answered a survey questionnaire measuring relational continuity, interpersonal communication, coordination within the clinic, coordination with specialists, and overall coordination; and gave permission for their medical records to be reviewed and their medical services utilization data for the previous 2 years to be accessed to measure KPC. Using generalized linear mixed models, we assessed the association between KPC and the patients’ responses. RESULTS Among the 5 different patient-reported measures or their combination, KPC-MP was significantly related with overall coordination of care: for high continuity, the odds ratio (OR) = 2.02 (95% CI, 1.33–3.07), and for moderate continuity, OR = 1.61 (95% CI, 1.06–2.46). KPC-MP was also related with the combined continuity score: for high continuity, OR = 1.52 (95% CI, 1.11–2.09), and for moderate continuity, OR = 1.48 (95% CI, 1.10–2.00). KPC-PP was not significantly associated with any of the survey measures. CONCLUSIONS The KPC-MP measure, based on readily available administrative data, is associated with patient-perceived overall coordination of care among multiple physicians. KPC measures are potentially a valuable and low-cost way to follow the effects of changes favoring group practice on continuity of care for entire populations. They are easy to replicate over time and across jurisdictions. PMID:25384820
Medicaid's Complex Goals: Challenges for Managed Care and Behavioral Health

PubMed Central

Gold, Marsha; Mittler, Jessica

2000-01-01

The Medicaid program has become increasingly complex as policymakers use it to address various policy objectives, leading to structural tensions that surface with Medicaid managed care. In this article, we illustrate this complexity by focusing on the experience of three States with behavioral health carveouts—Maryland, Oregon, and Tennessee. Converting to Medicaid managed care forces policymakers to confront Medicaid's competing policy objectives, multiplicity of stakeholders, and diverse patients, many with complex needs. Emerging Medicaid managed care systems typically represent compromises in which existing inequities and fragmentation are reconfigured rather than eliminated. PMID:12500322
Does transport time help explain the high trauma mortality rates in rural areas? New and traditional predictors assessed by new and traditional statistical methods

PubMed Central

Røislien, Jo; Lossius, Hans Morten; Kristiansen, Thomas

2015-01-01

Background Trauma is a leading global cause of death. Trauma mortality rates are higher in rural areas, constituting a challenge for quality and equality in trauma care. The aim of the study was to explore population density and transport time to hospital care as possible predictors of geographical differences in mortality rates, and to what extent choice of statistical method might affect the analytical results and accompanying clinical conclusions. Methods Using data from the Norwegian Cause of Death registry, deaths from external causes 1998–2007 were analysed. Norway consists of 434 municipalities, and municipality population density and travel time to hospital care were entered as predictors of municipality mortality rates in univariate and multiple regression models of increasing model complexity. We fitted linear regression models with continuous and categorised predictors, as well as piecewise linear and generalised additive models (GAMs). Models were compared using Akaike's information criterion (AIC). Results Population density was an independent predictor of trauma mortality rates, while the contribution of transport time to hospital care was highly dependent on choice of statistical model. A multiple GAM or piecewise linear model was superior, and similar, in terms of AIC. However, while transport time was statistically significant in multiple models with piecewise linear or categorised predictors, it was not in GAM or standard linear regression. Conclusions Population density is an independent predictor of trauma mortality rates. The added explanatory value of transport time to hospital care is marginal and model-dependent, highlighting the importance of exploring several statistical models when studying complex associations in observational data. PMID:25972600
Post-fine-needle aspiration biopsy communication and the integrated and standardized cytopathology report.

PubMed

Pitman, Martha B; Black-Schaffer, W Stephen

2017-06-01

Communication between cytopathologists and patients and their care team is a critical component of accurate and timely patient management. The most important single means of communication for the cytopathologist is through the cytopathology report. Implementation of standardized terminology schemes and structured, templated reporting facilitates the ability of the cytopathologist to provide a comprehensive and integrated report. Cytopathology has been among the pathology subspecialties that have led the way in developing standardized reporting, beginning with the 1954 Papanicolaou classification scheme for cervical-vaginal cytology and continuing through the Bethesda systems for gynecological cytology and several nongynecological cytology systems. The effective reporting of cytopathology necessarily becomes more complex as it addresses increasingly sophisticated management options, requiring the integration of information from a broader range of sources. In addition to the complexity of information inputs, a wider spectrum of consumers of these reports is emerging, from patients themselves to primary care providers to subspecialized disease management experts. Both these factors require that the reporting cytopathologist provide the integration and interpretation necessary to translate diverse forms of information into meaningful and actionable reports that will inform the care team while enabling the patient to meaningfully participate in his or her own care. To achieve such broad and focused communications will require first the development of standardized and integrated reports and ultimately the involvement of cytopathologists in the development of the clinical informatics needed to treat all these items of information as structured data elements with flexible reporting operators to address the full range of patient and patient care needs. Cancer Cytopathol 2017;125(6 suppl):486-93. © 2017 American Cancer Society. © 2017 American Cancer Society.
Treatment issues for children with epilepsy transitioning to adult care.

PubMed

Nabbout, Rima; Camfield, Carol S; Andrade, Danielle M; Arzimanoglou, Alexis; Chiron, Catherine; Cramer, Joyce A; French, Jacqueline A; Kossoff, Eric; Mula, Marco; Camfield, Peter R

2017-04-01

This is the third of three papers that summarize the second symposium on Transition in Epilepsies held in Paris in June 2016. This paper focuses on treatment issues that arise during the course of childhood epilepsy and make the process of transition to adult care more complicated. Some AEDs used during childhood, such as stiripentol, vigabatrin, and cannabidiol, are unfamiliar to adult epilepsy specialists. In addition, new drugs are being developed for treatment of specific childhood onset epilepsy syndromes and have no indication yet for adults. The ketogenic diet may be effective during childhood but is difficult to continue in adult care. Regional adult epilepsy diet clinics could be helpful. Polytherapy is common for patients transitioning to adult care. Although these complex AED regimes are difficult, they are often possible to simplify. AEDs used in childhood may need to be reconsidered in adulthood. Rescue medications to stop prolonged seizures and clusters of seizures are in wide home use in children and can be continued in adulthood. Adherence/compliance is notoriously difficult for adolescents, but there are simple clinical approaches that should be helpful. Mental health issues including depression and anxiety are not always diagnosed and treated in children and young adults even though effective treatments are available. Attention deficit hyperactivity disorder and aggressive behavior disorders may interfere with transition and successful adulthood but these can be treated. For the majority, the adult social outcome of children with epilepsy is unsatisfactory with few proven interventions. The interface between pediatric and adult care for children with epilepsy is becoming increasingly complicated with a need for more comprehensive transition programs and adult epileptologists who are knowledgeable about special treatments that benefit this group of patients. Copyright © 2016 Elsevier Inc. All rights reserved.
The 'wayfinding' experience of family carers who learn to manage technical health procedures at home: a grounded theory study.

PubMed

McDonald, Janet; McKinlay, Eileen; Keeling, Sally; Levack, William

2017-12-01

With more care taking place in the home, family carers play an important role in supporting patients. Some family carers undertake technical health procedures generally managed by health professionals in hospital settings (e.g. managing a tracheostomy or enteral feeding). To explore how family carers learn to manage technical health procedures in order to help health professionals better understand and support this process. A grounded theory study using data from interviews with 26 New Zealand family carers who managed technical health procedures including nasogastric or gastrostomy feeding, stoma care, urinary catheterisation, tracheostomy management, intravenous therapy, diabetes management and complex wound dressings. Most (20 participants) were caring for their child and the remaining six for their spouse, parent or grandparent. Following grounded theory methods, each interview was coded soon after completion. Additional data were compared with existing material, and as analysis proceeded, initial codes were grouped into higher order concepts until a core concept was developed. Interviewing continued until no new ideas emerged and concepts were well defined. The core concept of 'wayfinding' indicates that the learning process for family carers is active, individualised and multi-influenced, developing over time as a response to lived experience. Health professional support was concentrated on the initial phase of carers' training, reducing and becoming more reactive as carers took responsibility for day-to-day management. Wayfinding involves self-navigation by carers, in contrast to patient navigator models which provide continuing professional assistance to patients receiving cancer or chronic care services. Wayfinding by carers raises questions about how carers should be best supported in their initial and ongoing learning as the management of these procedures changes over time. © 2017 Nordic College of Caring Science.
The virtual practice: using the residents' continuity clinic to teach practice management and systems-based practice.

PubMed

Perez, Jose A; Faust, Cheryl; Kenyon, Angie

2009-09-01

Education in systems-based practice is a required component of all postgraduate medical education programs in the United States. Competency in this area requires that trainees have an understanding of the health care system sufficient to provide optimal care to patients. Most trainees in residency programs have little understanding of the complexities and challenges of present-day practice in the current system of care and consider themselves unprepared to undertake this activity following completion of training. Training in practice management in residency programs has not been emphasized as an important component of systems-based practice. Historically, practice management training in residency programs has been done using a fully didactic model, and residents have expressed a desire to learn this skill by becoming more directly involved in the operations and management of a practice. The patient visit touches many aspects of the health care system, including clinic operations, insurance, quality, and finances. At our institution, we used the residents' continuity clinic practices as a vehicle to provide education in practice management and systems-based practice by creating a curriculum that included the residents' perceived gaps in knowledge regarding going into practice. This is known as the virtual practice. This curriculum is taught using data obtained from residents' practice to illustrate concepts in many areas, including primary practice operations, malpractice insurance, financial benchmarks, and career planning. Resident self-assessed knowledge of these areas increased after participating in the curriculum, and resident testimonials indicate satisfaction with the project. In addition, residents have become engaged and interested in how their effort translates into performance and how they participate in the health care system.
RFID Continuance Usage Intention in Health Care Industry.

PubMed

Iranmanesh, Mohammad; Zailani, Suhaiza; Nikbin, Davoud

Radio-frequency identification (RFID) has been proved to be an effective tool both for improving operational efficiency and for gaining competitive advantage in the health care industry despite its relatively low-usage rate in hospitals. The sustained use of RFID by health care professionals will promote its development in the long term. This study evaluates the acceptance continuance of RFID among health care professionals through technology continuance theory (TCT). Data were collected from 178 medical professionals in Malaysia and were then analyzed using the partial least squares technique. The analysis showed that the TCT model provided not only a thorough understanding of the continuance behavior of health care professionals toward RFID but also the attitudes, satisfaction, and perceived usefulness of professionals toward it. The results of this study are expected to assist policy makers and managers in the health care industry in implementing the RFID technology in hospitals by understanding the determinants of continuance of RFID usage intention.
How Community Organizations Promote Continuity of Care for Young People with Mental Health Problems

PubMed Central

Polgar, By Michael F.; Cabassa, Leopoldo J.; Morrissey, Joseph P.

2014-01-01

Young people between the ages of 16 and 25 who experience mental health problems experience transitions and need help from a variety of organizations. Organizations promote continuity of care by assisting young adults with developmental, service, and systemic transitions. Providers offer specific services to help transitions and also form cooperative relationships with other community organizations. Results from a survey of 100 service providers in one community describe organizational attributes and practices which are associated with continuity of care in a regional system for young adults. Data analyses show that full-service organizations which practice cultural competence offer more specific services that foster continuity of care. Larger, full-service organizations are also more likely to have more extensive and collaborative inter-organizational networks that help young adults continue care over time within the regional system of care. PMID:24833485
Palliative care for people with advanced liver disease: A feasibility trial of a supportive care liver nurse specialist.

PubMed

Kimbell, Barbara; Murray, Scott A; Byrne, Heidi; Baird, Andrea; Hayes, Peter C; MacGilchrist, Alastair; Finucane, Anne; Brookes Young, Patricia; O'Carroll, Ronan E; Weir, Christopher J; Kendall, Marilyn; Boyd, Kirsty

2018-05-01

Liver disease is an increasing cause of death worldwide but palliative care is largely absent for these patients. We conducted a feasibility trial of a complex intervention delivered by a supportive care liver nurse specialist to improve care coordination, anticipatory care planning and quality of life for people with advanced liver disease and their carers. Patients received a 6-month intervention (alongside usual care) from a specially trained liver nurse specialist. The nurse supported patients/carers to live as well as possible with the condition and acted as a resource to facilitate care by community professionals. A mixed-method evaluation was conducted. Case note analysis and questionnaires examined resource use, care planning processes and quality-of-life outcomes over time. Interviews with patients, carers and professionals explored acceptability, effectiveness, feasibility and the intervention. Patients with advanced liver disease who had an unplanned hospital admission with decompensated cirrhosis were recruited from an inpatient liver unit. The intervention was delivered to patients once they had returned home. We recruited 47 patients, 27 family carers and 13 case-linked professionals. The intervention was acceptable to all participants. They welcomed access to additional expert advice, support and continuity of care. The intervention greatly increased the number of electronic summary care plans shared by primary care and hospitals. The Palliative care Outcome Scale and EuroQol-5D-5L questionnaire were suitable outcome measurement tools. This nurse-led intervention proved acceptable and feasible. We have refined the recruitment processes and outcome measures for a future randomised controlled trial.
Exploring dental student participation in interdisciplinary care team conferences in long-term care.

PubMed

Huynh, Jeremy; Donnelly, Leeann R; Brondani, Mario A

2017-06-01

The purpose of this study was to explore how the participation of dental hygiene students in interdisciplinary care conferences conducted in long-term care (LTC) facilities influenced the staff's awareness of oral health, the student's provision of care as well as the student's ability to work on an interdisciplinary team. Oral health in LTC continues to be poor despite many educational and clinical interventions. The care of a frail elder requires an interdisciplinary team approach, yet dental professionals are often absent from these teams. As an educational intervention, dental hygiene students, in addition to providing clinical care to residents and education to staff in a LTC facility, have been participating in interdisciplinary care conferences for 4 years. Nine LTC facility staff and eight students participated in two focus groups and five personal interviews to discuss their experiences of the care conferences. Narratives were transcribed verbatim and thematic analysis was conducted. Four major themes emerged that described the essence of the experience of involving dental professionals within interdisciplinary care conference: (i) addressing oral health, (ii) reciprocal learning, (iii) dealing with complexity and (iv) impact of collaborative care. Overall, students found the educational intervention to be worthwhile that allowed for the development of interdisciplinary skills and a greater understanding of dental geriatrics. The dental support in care conferences was welcomed by the staff as it facilitated a new way of exchanging knowledge and experiences so that a more holistic approach to care could be undertaken by all. © 2017 John Wiley & Sons A/S and The Gerodontology Association. Published by John Wiley & Sons Ltd.
Caring as emancipatory nursing praxis: the theory of relational caring complexity.

PubMed

Ray, Marilyn A; Turkel, Marian C

2014-01-01

In the culture of health care, nurses are challenged to understand their values and beliefs as humanistic within complex technical and economically driven bureaucratic systems. This article outlines the language of social justice and human rights and the advance of a Theory of Relational Caring Complexity, which offers insights into caring as emancipatory nursing praxis. Recommendations provide knowledge of the struggle to balance economics, technology, and caring. As nurses practice from a value-driven, philosophical, and ethical social justice framework, they will find "their voice" and realize the full potential that the power of caring has on patient and organizational outcomes.
Minimally disruptive medicine: the evidence and conceptual progress supporting a new era of healthcare.

PubMed

Abu Dabrh, A M; Gallacher, K; Boehmer, K R; Hargraves, I G; Mair, F S

2015-01-01

Patients with chronic conditions or multimorbidity, and often their caregivers, have to adjust their lives and mobilise their capacity (ability) to respond to the workload (demands) imposed by treatments and the care of their conditions. There is a continuous and complex interaction between workload and capacity. When capacity proves insufficient to address the treatment workload, creating a burden, patients may place a lower priority on other aspects of their lives, or reduce engagement with healthcare. Guidelines usually focus on disease-centred outcomes without consideration of limited capacity or demanding workload (burden) from treatment regimens. It seems reasonable to consider that healthcare needs reshaping so that care that pursues goals important to patients as well as those suggested by evidence-based medicine. This can be achieved by using shared decision approaches guided by the expertise of clinicians to deliver optimal care while minimising the burden of treatment on patients, their caregivers, and the healthcare system. What we need is minimally disruptive medicine.
Regional Decentralisation in the Greek Health Care System: Rhetoric and Reality

PubMed Central

Athanasiadis, Athanasios; Kostopoulou, Stella; Philalithis, Anastas

2015-01-01

Decentralisation is a complex, yet basic feature of health care systems in many countries entailing the transfer of authority or dispersal of power in public planning, management and decision making from higher to lower levels of government. This paper describes the attempts made in Greece from 1923 until today to decentralise its highly centralised health care system, drawing on a thorough documentary analysis of legislative acts and official reports regarding regional health policy. The analysis shows that, although decentralisation has been attempted on several occasions, in the end it was abandoned every time. The first ever implementation of a decentralised system of governance in 2001 was also curtailed, resulting in only minor decentralisation of authority and real powers. It is suggested that decentralisation has been impeded by many factors, especially obstruction by opposition from key interest groups, absence of policy continuity between governments, the inability to tackle the bureaucratic and highly centralised system and lack of political will. PMID:26153163
Association of the Social Determinants of Health With Quality of Primary Care.

PubMed

Katz, Alan; Chateau, Dan; Enns, Jennifer E; Valdivia, Jeff; Taylor, Carole; Walld, Randy; McCulloch, Scott

2018-05-01

In primary care, there is increasing recognition of the difficulty of treating patients' immediate health concerns when their overall well-being is shaped by underlying social determinants of health. We assessed the association of social complexity factors with the quality of care patients received in primary care settings. Eleven social complexity factors were defined using administrative data on poverty, mental health, newcomer status, and justice system involvement from the Manitoba Population Research Data Repository. We measured the distribution of these factors among primary care patients who made at least 3 visits during 2010-2013 to clinicians in Manitoba, Canada. Using generalized linear mixed modeling, we measured 26 primary care indicators to compare the quality of care received by patients with 0 to 5 or more social complexity factors. Among 626,264 primary care patients, 54% were living with at least 1 social complexity factor, and 4% were living with 5 or more. Social complexity factors were strongly associated with poorer outcomes with respect to primary care indicators for prevention (eg, breast cancer screening; odds ratio [OR] = 0.77; 99% CI, 0.73-0.81), chronic disease management (eg, diabetes management; OR = 0.86; 99% CI, 0.79-0.92), geriatric care (eg, benzodiazepine prescriptions; OR = 1.63; 99% CI, 1.48-1.80), and use of health services (eg, ambulatory visits; OR = 1.09; 99% CI, 1.08-1.09). Linking health and social data demonstrates how social determinants are associated with primary care service provision. Our findings provide insight into the social needs of primary care populations, and may support the development of focused interventions to address social complexity in primary care. © 2018 Annals of Family Medicine, Inc.
An analytics approach to designing patient centered medical homes.

PubMed

Ajorlou, Saeede; Shams, Issac; Yang, Kai

2015-03-01

Recently the patient centered medical home (PCMH) model has become a popular team based approach focused on delivering more streamlined care to patients. In current practices of medical homes, a clinical based prediction frame is recommended because it can help match the portfolio capacity of PCMH teams with the actual load generated by a set of patients. Without such balances in clinical supply and demand, issues such as excessive under and over utilization of physicians, long waiting time for receiving the appropriate treatment, and non-continuity of care will eliminate many advantages of the medical home strategy. In this paper, by using the hierarchical generalized linear model with multivariate responses, we develop a clinical workload prediction model for care portfolio demands in a Bayesian framework. The model allows for heterogeneous variances and unstructured covariance matrices for nested random effects that arise through complex hierarchical care systems. We show that using a multivariate approach substantially enhances the precision of workload predictions at both primary and non primary care levels. We also demonstrate that care demands depend not only on patient demographics but also on other utilization factors, such as length of stay. Our analyses of a recent data from Veteran Health Administration further indicate that risk adjustment for patient health conditions can considerably improve the prediction power of the model.
[Challenges and barriers in the promotion of quality in health care services].

PubMed

Brezis, Mayer; Cohen, Matan J; Frankel, Meir; Chinitz, David

2012-03-01

The promotion of quality and safety in health care faces many challenges and barriers including lack of cooperation by physicians. Complexity and uncertainty in measuring quality raise methodological difficulties. Lack of sufficient awareness about these limitations, also among those who measure quality, contributes to physicians lack of interest, suspicion and mistrust. Strategic issues associated with quality assessment in the Israeli health care system derive from lack of regulation and evasiveness about the accountability of executives and governing bodies regarding the quality of the services provided to patients in hospitals and clinics. Some of these challenges relate to the intrusion of market forces into the world of medicine without needed adaptations, so that reimbursement is often conveniently linked to the quantity of services and not to their quality. Efficiency, which characterizes competitive markets, is not easily translated in the clinical world where empathy, listening skills, and capability of explaining are critical physician attributes. This clinical world values giving beyond monetary compensation, and cooperation between institutions--rather than competition--all crucial for the continuity of patient's care. The interface between economics and health care calls for creative thinking, with a novel definition for the social value of medical and nursing care according to their quality and not their quantity.
Specification of an integrated information architecture for a mobile teleoperated robot for home telecare.

PubMed

Iannuzzi, David; Grant, Andrew; Corriveau, Hélène; Boissy, Patrick; Michaud, Francois

2016-12-01

The objective of this study was to design effectively integrated information architecture for a mobile teleoperated robot in remote assistance to the delivery of home health care. Three role classes were identified related to the deployment of a telerobot, namely, engineer, technology integrator, and health professional. Patients and natural caregivers were indirectly considered, this being a component of future field studies. Interviewing representatives of each class provided the functions, and information content and flows for each function. Interview transcripts enabled the formulation of UML (Universal Modeling Language) diagrams for feedback from participants. The proposed information architecture was validated with a use-case scenario. The integrated information architecture incorporates progressive design, ergonomic integration, and the home care needs from medical specialist, nursing, physiotherapy, occupational therapy, and social worker care perspectives. The integrated architecture iterative process promoted insight among participants. The use-case scenario evaluation showed the design's robustness. Complex innovation such as a telerobot must coherently mesh with health-care service delivery needs. The deployment of integrated information architecture bridging development, with specialist and home care applications, is necessary for home care technology innovation. It enables continuing evolution of robot and novel health information design in the same integrated architecture, while accounting for patient ecological need.
A critical pathway for the frail elderly cardiac patient.

PubMed

Wit, Mirjam; Schaap, Annet; Umans, Victor

2011-12-01

The medical community needs to better respond to the predictable complexities associated with admission of frail and elderly cardiac patients who may need specific attention and care programs. The nurse practitioner can play an important role to continue and coordinate nursing and medical care. We propose a new critical pathway designed to improve cardiac and nursing care for frail elderly cardiac patients admitted with heart failure or atrial fibrillation. The critical pathway is developed by the nurse practitioner who will act as a pathway coordinator and take care of the medical care of these patients in a teaching hospital setting. This critical pathway is applied to all patients aged >75 years who are admitted for heart failure or atrial fibrillation. The pathway implementation identified 5 important socio-medical parameters that may account for a delayed length of stay, even in patients without a complicated medical situation: delirium and fall prevention, nutritional awareness, fluid restriction efforts, and information optimization of patients and spouses. We developed a critical care pathway for the frail elderly patients who are admitted for heart failure or atrial fibrillation. In doing so, we have been able to change the medical and social management of these patients at a general cardiology ward in a teaching hospital.

Owning solutions: a collaborative model to improve quality in hospital care for Aboriginal Australians.

PubMed

Durey, Angela; Wynaden, Dianne; Thompson, Sandra C; Davidson, Patricia M; Bessarab, Dawn; Katzenellenbogen, Judith M

2012-06-01

Well-documented health disparities between Aboriginal and Torres Strait Islander (hereafter referred to as Aboriginal) and non-Aboriginal Australians are underpinned by complex historical and social factors. The effects of colonisation including racism continue to impact negatively on Aboriginal health outcomes, despite being under-recognised and under-reported. Many Aboriginal people find hospitals unwelcoming and are reluctant to attend for diagnosis and treatment, particularly with few Aboriginal health professionals employed on these facilities. In this paper, scientific literature and reports on Aboriginal health-care, methodology and cross-cultural education are reviewed to inform a collaborative model of hospital-based organisational change. The paper proposes a collaborative model of care to improve health service delivery by building capacity in Aboriginal and non-Aboriginal personnel by recruiting more Aboriginal health professionals, increasing knowledge and skills to establish good relationships between non-Aboriginal care providers and Aboriginal patients and their families, delivering quality care that is respectful of culture and improving Aboriginal health outcomes. A key element of model design, implementation and evaluation is critical reflection on barriers and facilitators to providing respectful and culturally safe quality care at systemic, interpersonal and patient/family-centred levels. Nurses are central to addressing the current state of inequity and are pivotal change agents within the proposed model. © 2011 Blackwell Publishing Ltd.
Addressing Structural Barriers to HIV Care among Triply Diagnosed Adults: Project Bridge Oakland.

PubMed

Powers, Christina; Comfort, Megan; Lopez, Andrea M; Kral, Alex H; Murdoch, Owen; Lorvick, Jennifer

2017-05-01

People who are "triply diagnosed" with HIV, mental health issues, and substance-related disorders face tremendous barriers connecting to and remaining in HIV care. Authors of this article implemented Project Bridge Oakland (PBO), an intervention based on harm reduction and trauma-informed care, to help maintain continuity of care for triply diagnosed adults through cycles of criminal justice involvement. From August 2011 to December 2014, a clinical social worker and an HIV physician provided intensive case management for 19 clients living in Oakland, California. By working with clients across a multitude of community, clinic, and correctional spaces while maintaining a low threshold for services, the social worker was able to engage a severely marginalized population in HIV care. This article details the PBO strategies for assisting with a wide range of services needed for community stabilization, navigating criminal justice involvement, and establishing a therapeutic relationship through mundane practices such as eating and waiting for appointments. This article illustrates how programs aimed at stabilizing triply diagnosed clients in the community and connecting them to HIV care require coordination among providers, outreach to engage clients, ample time to work with them, and flexibility to account for the complexities of their day-to-day lives and experiences. © 2017 National Association of Social Workers.
Using standardized patient encounters to teach longitudinal continuity of care in a family medicine clerkship.

PubMed

Vest, Bonnie M; Lynch, Abigail; McGuigan, Denise; Servoss, Timothy; Zinnerstrom, Karen; Symons, Andrew B

2016-08-17

Despite demonstrated benefits of continuity of care, longitudinal care experiences are difficult to provide to medical students. A series of standardized patient encounters was developed as an innovative curricular element to address this gap in training for medical students in a family medicine clerkship. The objective of this paper is to describe the development and implementation of the curriculum, evaluate the effectiveness of the curriculum for increasing student confidence around continuity of care and chronic disease management, and explore student opinions of the value of the experience. The encounters simulate continuity of care in typical family medicine practice over four standardized patient visits, providing students with experience in longitudinal relationships, ongoing management of chronic and acute conditions, lifestyle counseling, and the use of an electronic medical record. Perceptions of the curriculum were obtained using a pre-post survey asking students to self-rate experience and confidence in continuity relationships, chronic disease management, and lifestyle counseling. Students were also asked about the overall effectiveness of the encounters for simulating family practice and continuity of care. Open-ended comments were gathered through weekly reflection papers submitted by the students. Of 138 third-year medical students, 137 completed the pre-survey, 126 completed the post-survey, and 125 (91%) completed both the pre- and the post-survey. Evaluation results demonstrated that students highly valued the experience. Complete confidence data for 116 students demonstrated increased confidence pre-post (t(115) = 14.92, p < .001) in managing chronic disease and establishing relationships. Open-ended comments reflected how the experience fostered appreciation for the significance of patient-doctor relationships and continuity of care. This curriculum offers a promising approach to providing students with continuity of care experience. The model addresses a general lack of training in continuity of care in medical schools and provides a standardized method for teaching chronic disease management and continuity relationships.
Care coordination experiences of people with disabilities enrolled in medicaid managed care.

PubMed

Bowers, Anne; Owen, Randall; Heller, Tamar

2017-10-01

To understand the impact of experience and contacts with care coordinators on Medicaid Managed Care (MMC) enrollees with disabilities. Primary data was collected from a random sample of 6000 out of the 100,000 people with disabilities enrolled in one state's mandatory MMC program. Surveys were conducted through the mail, telephone, and Internet; 1041 surveys were completed. The sample used for analysis included 442 MMC enrollees who received care coordination. Regression analyses were conducted with the outcomes of number of unmet health care needs and enrollee appraisal of the health services they received. Race, age, gender, and disability variables controlled for demographic differences, and the independent variables included enrollee experience with a care coordinator (coordinator knowledge of enrollee medical history and whether the coordinator took into account enrollee wishes and input) and frequency of contact with a care coordinator. Positive enrollee experiences with care coordinators significantly related to more positive enrollee health service appraisals and fewer unmet health care needs; frequency of contact did not have any significant impacts. People with mental health disabilities and intellectual/developmental disabilities had significantly lower health service appraisals. People with mental health disabilities had significantly more unmet needs. Quality of care coordination, but not frequency of contact alone, is associated with better health outcomes for MMC enrollees. Implications for rehabilitation Care coordination is a core component of managed care and facilitates effective healthcare management for people with complex chronic conditions and disabilities. Better experiences with care coordinators is related to fewer unmet healthcare needs and more positive health care service appraisals for Medicaid managed care enrollees. The continuous development of person-centered care coordination strategies and training programs emphasizing quality relationships between coordinators and consumers should be prioritized.
An outbreak of Burkholderia cepacia complex in the paediatric unit of a tertiary care hospital.

PubMed

Mali, Swapna; Dash, Lona; Gautam, Vikas; Shastri, Jayanthi; Kumar, Sunil

2017-01-01

Burkholderia cepacia complex (Bcc) has emerged as a serious nosocomial pathogen worldwide especially in patients with indwelling catheters and cystic fibrosis. Bcc is a common contaminant of pharmaceutical products. We describe an outbreak of Bcc bacteraemia amongst children admitted in Paediatric Intensive Care Unit (PICU) and paediatric ward at a tertiary care hospital, Mumbai, in Western India. Blood culture samples from paediatric patients yielded growth of non-fermenting, oxidase positive, motile, Gram negative bacilli (NFGNB) (76/909) over a period of 8 months. Based on conventional biochemical tests and antimicrobial susceptibility testing, these isolates were provisionally identified as Bcc. The increased, repeated and continued isolation of Bcc alerted the possibility of an outbreak confined to PICU and paediatric ward. Active surveillance was undertaken to trace the source and contain the outbreak. Isolates were subjected to recA polymerase chain reaction (PCR) and Expanded multilocus sequence typing (EMLST). Surveillance revealed the presence of Bcc on the upper surface of rubber stopper of sealed multidose amikacin vials. Isolates from blood culture and rubber stoppers were confirmed as Bcc by recA PCR. EMLST revealed that these isolates shared an identical novel sequence type 824 proving clonality. Timely interventions instituted led to control of the outbreak. This study highlights the importance of identification and molecular characterization of Bcc to establish its role in infection and outbreak.
How to improve healthcare? Identify, nurture and embed individuals and teams with "deep smarts".

PubMed

Eljiz, Kathy; Greenfield, David; Molineux, John; Sloan, Terry

2018-03-19

Purpose Unlocking and transferring skills and capabilities in individuals to the teams they work within, and across, is the key to positive organisational development and improved patient care. Using the "deep smarts" model, the purpose of this paper is to examine these issues. Design/methodology/approach The "deep smarts" model is described, reviewed and proposed as a way of transferring knowledge and capabilities within healthcare organisations. Findings Effective healthcare delivery is achieved through, and continues to require, integrative care involving numerous, dispersed service providers. In the space of overlapping organisational boundaries, there is a need for "deep smarts" people who act as "boundary spanners". These are critical integrative, networking roles employing clinical, organisational and people skills across multiple settings. Research limitations/implications Studies evaluating the barriers and enablers to the application of the deep smarts model and 13 knowledge development strategies proposed are required. Such future research will empirically and contemporary ground our understanding of organisational development in modern complex healthcare settings. Practical implications An organisation with "deep smarts" people - in managerial, auxiliary and clinical positions - has a greater capacity for integration and achieving improved patient-centred care. Originality/value In total, 13 developmental strategies, to transfer individual capabilities into organisational capability, are proposed. These strategies are applicable to different contexts and challenges faced by individuals and teams in complex healthcare organisations.
COPD self-management supportive care: chaos and complexity theory.

PubMed

Cornforth, Amber

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

PubMed

Volpe, F J

1994-09-01

Continuity of health care is a goal to be achieved. Most are for it. Many claim to provide it. But how do we know we have it? What are the key features of continuity? While dictionaries do not define the phrase "continuity of health care," we do find definitions of "continuity." The Oxford English Dictionary, Second Edition, includes in its definitions: "the state or quality of being uninterrupted in sequence or succession, or in essence or idea; connectedness, coherence, unbroken..." Stedman's Medical Dictionary includes: "absence of interruption, a succession of parts intimately united..." These definitions stress an uninterrupted succession and include the concept that there needs to be a connection to the parts. Without that connection, continuity, in health care delivery or elsewhere, does not exist.
Parent Perspective on Care Coordination Services for Their Child with Medical Complexity

PubMed Central

Cady, Rhonda G.; Belew, John L.

2017-01-01

The overarching goal of care coordination is communication and co-management across settings. Children with medical complexity require care from multiple services and providers, and the many benefits of care coordination on health and patient experience outcomes have been documented. Despite these findings, parents still report their greatest challenge is communication gaps. When this occurs, parents assume responsibility for aggregating and sharing health information across providers and settings. A new primary-specialty care coordination partnership model for children with medical complexity works to address these challenges and bridge communication gaps. During the first year of the new partnership, parents participated in focus groups to better understand how they perceive communication and collaboration between the providers and services delivering care for their medically complex child. Our findings from these sessions reflect the current literature and highlight additional challenges of rural families, as seen from the perspective of the parents. We found that parents appreciate when professional care coordination is provided, but this is often the exception and not the norm. Additionally, parents feel that the local health system’s inability to care for their medically complex child results in unnecessary trips to urban-based specialty care. These gaps require a system-level approach to care coordination and, consequently, new paradigms for delivery are urgently needed. PMID:28587274
Parent Perspective on Care Coordination Services for Their Child with Medical Complexity.

PubMed

Cady, Rhonda G; Belew, John L

2017-06-06

The overarching goal of care coordination is communication and co-management across settings. Children with medical complexity require care from multiple services and providers, and the many benefits of care coordination on health and patient experience outcomes have been documented. Despite these findings, parents still report their greatest challenge is communication gaps. When this occurs, parents assume responsibility for aggregating and sharing health information across providers and settings. A new primary-specialty care coordination partnership model for children with medical complexity works to address these challenges and bridge communication gaps. During the first year of the new partnership, parents participated in focus groups to better understand how they perceive communication and collaboration between the providers and services delivering care for their medically complex child. Our findings from these sessions reflect the current literature and highlight additional challenges of rural families, as seen from the perspective of the parents. We found that parents appreciate when professional care coordination is provided, but this is often the exception and not the norm. Additionally, parents feel that the local health system's inability to care for their medically complex child results in unnecessary trips to urban-based specialty care. These gaps require a system-level approach to care coordination and, consequently, new paradigms for delivery are urgently needed.
New resources to address antibiotic resistance are just a click away

PubMed Central

Dowd-Schmidtke, C; Tremblay, G; Gale-Rowe, M; Dodds, J; Finley, R

2014-01-01

Antibiotic resistance is a complex issue with multiple causes, and there are many roles to play in addressing it. As part of its response, the Public Health Agency of Canada is launching a pilot antibiotic awareness campaign for Canadian families and health care professionals. Coinciding with Antibiotic Awareness Week, starting on November 17, 2014, the goal of this campaign is to improve knowledge and awareness of antibiotic resistance in Canada. To achieve this, the Agency has developed a suite of resources for both Canadian families and health care providers featuring a variety of key messages explaining antibiotic resistance, why it is important, and how to reduce the risks associated with it. Resources for Canadian families include an online informational video, an educational brochure, and infographics for both adults and children. Resources for health care professionals include two online Continuing Medical Education Modules, a letter that physicians can sign and provide to parents explaining why an antibiotic was not prescribed, and two webinars to present trends in antimicrobial resistance (AMR) and antimicrobial use. Health professionals will also receive an electronic postcard and a bilingual campaign poster. Promoting the campaign messages and using these campaign resources will support health professionals in discussions about antibiotic resistance with their patients or clients, and in their continuing efforts to be part of the solution in addressing this important global health challenge.
New resources to address antibiotic resistance are just a click away.

PubMed

Dowd-Schmidtke, C; Tremblay, G; Gale-Rowe, M; Dodds, J; Finley, R

2014-11-07

Antibiotic resistance is a complex issue with multiple causes, and there are many roles to play in addressing it. As part of its response, the Public Health Agency of Canada is launching a pilot antibiotic awareness campaign for Canadian families and health care professionals. Coinciding with Antibiotic Awareness Week, starting on November 17, 2014, the goal of this campaign is to improve knowledge and awareness of antibiotic resistance in Canada. To achieve this, the Agency has developed a suite of resources for both Canadian families and health care providers featuring a variety of key messages explaining antibiotic resistance, why it is important, and how to reduce the risks associated with it. Resources for Canadian families include an online informational video, an educational brochure, and infographics for both adults and children. Resources for health care professionals include two online Continuing Medical Education Modules, a letter that physicians can sign and provide to parents explaining why an antibiotic was not prescribed, and two webinars to present trends in antimicrobial resistance (AMR) and antimicrobial use. Health professionals will also receive an electronic postcard and a bilingual campaign poster. Promoting the campaign messages and using these campaign resources will support health professionals in discussions about antibiotic resistance with their patients or clients, and in their continuing efforts to be part of the solution in addressing this important global health challenge.
42 CFR 438.208 - Coordination and continuity of care.

Code of Federal Regulations, 2013 CFR

2013-10-01

... MCO must meet the primary care coordination, identification, assessment, and treatment planning... enrollees. (b) Primary care and coordination of health care services for all MCO, PIHP, and PAHP enrollees... 42 Public Health 4 2013-10-01 2013-10-01 false Coordination and continuity of care. 438.208...
Continuing Care Retirement Communities: An Analysis of Financial Viability and Health Care Coverage.

ERIC Educational Resources Information Center

Ruchlin, Hirsch S.

1988-01-01

Calculated financial ratios for 109 Continuing Care Retirement Communities (CCRCs). Noted problems with regard to asset productivity, profitability, and equity levels. Found that a risk-spreading charge structure for financing health care needs appeared to exist among CCRCs providing a full-care contract. (Author/ABL)
The emotional and professional wellbeing of Australian midwives: A comparison between those providing continuity of midwifery care and those not providing continuity.

PubMed

Fenwick, Jennifer; Sidebotham, Mary; Gamble, Jenny; Creedy, Debra K

2018-02-01

Continuity of midwifery care contributes to significant positive outcomes for women and babies. There is a perception that providing continuity of care may negatively impact on the wellbeing and professional lives of midwives. To compare the emotional and professional wellbeing as well as satisfaction with time off and work-life balance of midwives providing continuity of care with midwives not providing continuity. Online survey. Measures included; Copenhagen Burnout Inventory (CBI); Depression, Anxiety and Stress Scale-21; and Perceptions of Empowerment in Midwifery Scale (PEMS-Revised). The sample (n=862) was divided into two groups; midwives working in continuity (n=214) and those not working in continuity (n=648). Mann Whitney U tests were used to compare the groups. The continuity group had significantly lower scores on each of the burnout subscales (CBI Personal p=.002; CBI Work p<.001; CBI Client p<.001) and Anxiety (p=.007) and Depression (p=.004) sub-scales. Midwives providing continuity reported significantly higher scores on the PEMs Autonomy/Empowerment subscale (p<.001) and the Skills and Resources subscale (p=.002). There was no difference between the groups in terms of satisfaction with time off and work-life balance. Our results indicate that providing continuity of midwifery care is also beneficial for midwives. Conversely, midwives working in shift-based models providing fragmented care are at greater risk of psychological distress. Maternity service managers should feel confident that re-orientating care to align with the evidence is likely to improve workforce wellbeing and is a sustainable way forward. Copyright © 2017 Australian College of Midwives. Published by Elsevier Ltd. All rights reserved.
Discharge summary for medically complex infants transitioning to primary care.

PubMed

Peacock, Jennifer J

2014-01-01

Improvements in the care of the premature infant and advancements in technology are increasing life expectancy of infants with medical conditions once considered lethal; these infants are at risk of becoming a medically complex infant. Complex infants have a significant existing problem list, are on several medications, and receive medical care by several specialists. Deficits in communication and information transfer at the time of discharge remain problematic for this population. A questionnaire was developed for primary care providers (PCPs) to explore the effectiveness of the current discharge summary because it is related to effective communication when assuming the care of a new patient with medical complexity. PCPs assuming the care of these infants agree that an evidence-based tool, in the form of a specialized summary for this population, would be of value.
Change in Oregon Maternity Care Workforce after Malpractice Premium Subsidy Implementation

PubMed Central

Smits, Ariel K; King, Valerie J; Rdesinski, Rebecca E; Dodson, Lisa G; Saultz, John W

2009-01-01

Objectives (1) To determine the proportion of maternity care providers who continue to deliver babies in Oregon; (2) to determine the important factors relating to the decision to discontinue maternity care services; and (3) to examine how the rural liability subsidy is affecting rural maternity care providers' ability to provide maternity care services. Study Design We surveyed all obstetrical care providers in Oregon in 2002 and 2006. Survey data, supplemented with state administrative data, were analyzed for changes in provision of maternity care, reasons for stopping maternity care, and effect of the malpractice premium subsidy on practice. Principal Findings Only 36.6% of responding clinicians qualified to deliver babies were actually providing maternity care in Oregon in 2006, significantly lower than the proportion (47.8%) found in 2002. Cost of malpractice premiums remains the most frequently cited reason for stopping maternity care, followed by lifestyle issues. Receipt of the malpractice subsidy was not associated with continuing any maternity services. Conclusions Oregon continues to lose maternity care providers. A state program subsidizing the liability premiums of rural maternity care providers does not appear effective at keeping rural providers delivering babies. Other policies to encourage continuation of maternity care need to be considered. PMID:19500166
Application of personalized medicine to chronic disease: a feasibility assessment

PubMed Central

2013-01-01

Personalized Medicine has the potential to improve health outcomes and reduce the cost of care; however its adoption has been slow in Canada. Bridgepoint Health is a complex continuous care provider striving to reduce the burden of polypharmacy in chronic patients. The main goal of the study was to explore the feasibility of utilizing personalized medicine in the treatment of chronic complex patients as a preliminary institutional health technology assessment. We analyzed stroke treatment optimization as a clinical indication that could serve as a “proof of concept” for the widespread implementation of pharmacogenetics. The objectives of the study were three-fold: 1. Review current practice in medication administration for stroke treatment at Bridgepoint Health 2. Critically analyze evidence that pharmacogenetic testing could (or could not) enhance drug selection and treatment efficacy for stroke patients; 3. Assess the cost-benefit potential of a pharmacogenetic intervention for stroke. Review current practice in medication administration for stroke treatment at Bridgepoint Health Critically analyze evidence that pharmacogenetic testing could (or could not) enhance drug selection and treatment efficacy for stroke patients; Assess the cost-benefit potential of a pharmacogenetic intervention for stroke. We conducted a review of stroke treatment practices at Bridgepoint Health, scanned the literature for drug-gene and drug-outcome interactions, and evaluated the potential consequences of pharmacogenetic testing using the ACCE model. There is a substantial body of evidence suggesting that pharmacogenetic stratification of stroke treatment can improve patient outcomes in the long-term, and provide substantial efficiencies for the healthcare system in the short-term. Specifically, pharmacogenetic stratification of antiplatelet and anticoagulant therapies for stroke patients may have a major impact on the risk of disease recurrence, and thus should be explored further for clinical application. Bridgepoint Health, and other healthcare institutions taking this path, should consider launching pilot projects to assess the practical impact of pharmacogenetics to optimize treatment for chronic continuous care. PMID:24351097
Preparing your intensive care unit to respond in crisis: considerations for critical care clinicians.

PubMed

Daugherty, Elizabeth L; Rubinson, Lewis

2011-11-01

In recent years, healthcare disaster planning has grown from its early place as an occasional consideration within the manuals of emergency medical services and emergency department managers to a rapidly growing field, which considers continuity of function, surge capability, and process changes across the spectrum of healthcare delivery. A detailed examination of critical care disaster planning was undertaken in 2007 by the Task Force for Mass Critical Care of the American College of Chest Physicians Critical Care Collaborative Initiative. We summarize the Task Force recommendations and available updated information to answer a fundamental question for critical care disaster planners: What is a prepared intensive care unit and how do I ensure my unit's readiness? Database searches and review of relevant published literature. Preparedness is essential for successful response, but because intensive care units face many competing priorities, without defining "preparedness for what," the task can seem overwhelming. Intensive care unit disaster planners should, therefore, along with the entire hospital, participate in a hospital or regionwide planning process to 1) identify critical care response vulnerabilities; and 2) clarify the hazards for which their community is most at risk. The process should inform a comprehensive written preparedness plan targeting the most worrisome scenarios and including specific guidance on 1) optimal use of space, equipment, and staffing for delivery of critical care to significantly increased patient volumes; 2) allocation of resources for provision of essential critical care services under conditions of absolute scarcity; 3) intensive care unit evacuation; and 4) redundant internal communication systems and means for timely data collection. Critical care disaster planners have a complex, challenging task. Experienced planners will agree that no disaster response is perfect, but careful planning will enable the prepared intensive care unit to respond effectively in times of crisis.
Naturalness as an ethical stance: idea(l)s and practices of care in western herbal medicine in the UK.

PubMed

Nissen, Nina

2015-01-01

An association of non-biomedical healthcare with appeals to nature and naturalness, and an invocation of a rhetoric of gentleness, goodness, purity and moral power has been noted previously, and some scholars argue that nature has taken on a meaning broadly opposed to the rational scientific order of modernity. Drawing on an ethnographic study of women's practice and use of western herbal medicine (WHM) in the UK, the intertwining of the perceived naturalness of WHM with distinct care practices points to a further avenue for exploration. To examine patients' and herbalists' discourses of the naturalness of WHM and associated idea(l)s and practices of care, understandings of nature and a feminist ethics of care are utilized as analytical frameworks. The analysis presented suggests that, through WHM, patients and herbalists become embedded in a complex spatio-temporal wholeness and web of care that intertwines past, present and future, self and others, and local and global concerns. In the emerging 'ordinary ethics of care', naturalness constitutes a sign of goodness and of a shared humanity within the organic world, while care, underpinned by idea(l)s of natural and holistic care practices, links human and non-human others. Thus, the naturalness of WHM, as perceived by some patients and herbalists, engages and blends with a continually unfolding field of relationships in the lifeworld(s), where care practices, caring relations and collective wellbeing may constitute an ethical stance that raises deeper questions about the significance of relationality, the values of care/caring and the mutual involvement of nature and human being(s).

Resident continuity of care experience in a Canadian general surgery training program

PubMed Central

Sidhu, Ravindar S.; Walker, G. Ross

Objectives To provide baseline data on resident continuity of care experience, to describe the effect of ambulatory centre surgery on continuity of care, to analyse continuity of care by level of resident training and to assess a resident-run preadmission clinic’s effect on continuity of care. Design Data were prospectively collected for 4 weeks. All patients who underwent a general surgical procedure were included if a resident was present at operation. Setting The Division of General Surgery, Queen’s University, Kingston, Ont. Outcome measures Preoperative, operative and inhospital postoperative involvement of each resident with each case was recorded. Results Residents assessed preoperatively (before entering the operating room) 52% of patients overall, 20% of patients at the ambulatory centre and 83% of patients who required emergency surgery. Of patients assessed by the chief resident, 94% were assessed preoperatively compared with 32% of patients assessed by other residents ( p < 0.001). Of the admitted patients, 40% had complete resident continuity of care (preoperative, operative and postoperative). There was no statistical difference between this rate and that for emergency, chief-resident and non-chief-resident subgroups. Of the eligible patients, 58% were seen preoperatively by the resident on the preadmission clinic service compared with 54% on other services ( p > 0.1). Conclusions This study serves as a reference for the continuity of care experience in Canadian surgical programs. Residents assessed only 52% of patients preoperatively, and only 40% of patients had complete continuity of care. Factors such as ambulatory surgery and junior level of training negatively affected continuity experience. Such factors must be taken into account in planning surgical education. PMID:10526519
An evaluation of data quality in Canada's Continuing Care Reporting System (CCRS): secondary analyses of Ontario data submitted between 1996 and 2011.

PubMed

Hirdes, John P; Poss, Jeff W; Caldarelli, Hilary; Fries, Brant E; Morris, John N; Teare, Gary F; Reidel, Kristen; Jutan, Norma

2013-02-26

Evidence informed decision making in health policy development and clinical practice depends on the availability of valid and reliable data. The introduction of interRAI assessment systems in many countries has provided valuable new information that can be used to support case mix based payment systems, quality monitoring, outcome measurement and care planning. The Continuing Care Reporting System (CCRS) managed by the Canadian Institute for Health Information has served as a data repository supporting national implementation of the Resident Assessment Instrument (RAI 2.0) in Canada for more than 15 years. The present paper aims to evaluate data quality for the CCRS using an approach that may be generalizable to comparable data holdings internationally. Data from the RAI 2.0 implementation in Complex Continuing Care (CCC) hospitals/units and Long Term Care (LTC) homes in Ontario were analyzed using various statistical techniques that provide evidence for trends in validity, reliability, and population attributes. Time series comparisons included evaluations of scale reliability, patterns of associations between items and scales that provide evidence about convergent validity, and measures of changes in population characteristics over time. Data quality with respect to reliability, validity, completeness and freedom from logical coding errors was consistently high for the CCRS in both CCC and LTC settings. The addition of logic checks further improved data quality in both settings. The only notable change of concern was a substantial inflation in the percentage of long term care home residents qualifying for the Special Rehabilitation level of the Resource Utilization Groups (RUG-III) case mix system after the adoption of that system as part of the payment system for LTC. The CCRS provides a robust, high quality data source that may be used to inform policy, clinical practice and service delivery in Ontario. Only one area of concern was noted, and the statistical techniques employed here may be readily used to target organizations with data quality problems in that (or any other) area. There was also evidence that data quality was good in both CCC and LTC settings from the outset of implementation, meaning data may be used from the entire time series. The methods employed here may continue to be used to monitor data quality in this province over time and they provide a benchmark for comparisons with other jurisdictions implementing the RAI 2.0 in similar populations.
Genetic discoveries and nursing implications for complex disease prevention and management.

PubMed

Frazier, Lorraine; Meininger, Janet; Halsey Lea, Dale; Boerwinkle, Eric

2004-01-01

The purpose of this article is to examine the management of patients with complex diseases, in light of recent genetic discoveries, and to explore how these genetic discoveries will impact nursing practice and nursing research. The nursing science processes discussed are not comprehensive of all nursing practice but, instead, are concentrated in areas where genetics will have the greatest influence. Advances in genetic science will revolutionize our approach to patients and to health care in the prevention, diagnosis, and treatment of disease, raising many issues for nursing research and practice. As the scope of genetics expands to encompass multifactorial disease processes, a continuing reexamination of the knowledge base is required for nursing practice, with incorporation of genetic knowledge into the repertoire of every nurse, and with advanced knowledge for nurses who select specialty roles in the genetics area. This article explores the impact of this revolution on nursing science and practice as well as the opportunities for nursing science and practice to participate fully in this revolution. Because of the high proportion of the population at risk for complex diseases and because nurses are occupied every day in the prevention, assessment, treatment, and therapeutic intervention of patients with such diseases in practice and research, there is great opportunity for nurses to improve health care through the application (nursing practice) and discovery (nursing research) of genetic knowledge.
Complex home care: Part 2- family annual income, insurance premium, and out-of-pocket expenses.

PubMed

Piamjariyakul, Ubolrat; Yadrich, Donna Macan; Ross, Vicki M; Smith, Carol E; Clements, Faye; Williams, Arthur R

2010-01-01

Annual costs paid by families for intravenous infusion of home parenteral nutrition (HPN) health insurance premiums, deductibles, co-payments for health services, and the wide range of out-of-pocket home health care expenses are significant. The costs of managing complex chronic care at home cannot be completely understood until all out-of-pocket costs have been defined, described, and tabulated. Non-reimbursed and out-of-pocket costs paid by families over years for complex chronic care negatively impact the financial stability of families. National health care reform must take into account the long-term financial burdens of families caring for those with complex home care. Any changes that may increase the out-of-pocket costs or health insurance costs to these families can also have a negative long-term impact on society when greater numbers of patients declare bankruptcy or qualify for medical disability.
Development of an Inter-Service Complex Wound and Limb Salvage Center within the DoD (Briefing charts)

DTIC Science & Technology

2010-10-15

CWLSC Patient Growth: 2008-2010  Complex soft-tissue wound management in austere settings  NPWT/VAC application and management  Ostomy , fistula, and...acute and chronic wounds Complex Wound Limb Salvage Program WRAMC/NNMC Inpatient Care Wound and Ostomy NNMC and WRAMC Outpatient Care 2 Clinics...Standardization Ostomy Wound care Skin Care Cleansers Research / EBP Pressure ulcer protocol CPG development Wound education research grant WRNMMC
[Patient-related complexity in nursing care - Collective case studies in the acute care hospital].

PubMed

Gurtner, Caroline; Spirig, Rebecca; Staudacher, Diana; Huber, Evelyn

2018-06-04

Patient-related complexity in nursing care - Collective case studies in the acute care hospital Abstract. Patient-related complexity of nursing is defined by the three characteristics "instability", "uncertainty", and "variability". Complexity increased in the past years, due to reduced hospital length of stay and a growing number of patients with chronic and multiple diseases. We investigated the phenomenon of patient-related complexity from the point of view of nurses and clinical nurse specialists in an acute care hospital. In the context of a collective case study design, nurses and clinical nurse specialists assessed the complexity of nursing situations with a questionnaire. Subsequently, we interviewed nurses and clinical nurse specialists about their evaluation of patient-related complexity. In a within-case-analysis we summarized data inductively to create case narratives. By means of a cross-case-analysis we compared the cases with regard to deductively derived characteristics. The four cases exemplarily showed that the degree of complexity depends on the controllability and predictability of clinical problems. Additionally, complexity increases or decreases, according to patients' individual resources. Complex patient situations demand professional expertise, experience, communicative competencies and the ability for reflection. Beginner nurses would benefit from support and advice by experienced nurses to develop these skills.
The role of nursing team continuity in the treatment of very-low-birth-weight infants: findings from a pilot study.

PubMed

Miedaner, Felix; Allendorf, Antje; Kuntz, Ludwig; Woopen, Christiane; Roth, Bernhard

2016-05-01

To assess the association between nursing team continuity and quality of care. Research on nurse staffing and its effect on quality of care is investigated to different degrees. However, very few studies have observed whether the continuous deployment of nursing staff is associated with quality of care. This study was conducted in two university neonatal intensive care units (NICUs). We matched nurse schedule data for the NICUs with nursing-sensitive patient outcomes and quality of care, as perceived by parents. We used analysis of variance to analyse differences in nursing team continuity between NICUs and regression analyses to identify associations with the outcome measures. There were considerable differences between units in terms of team continuity of nursing staff. Positive associations were found between team continuity and a higher rate of non-invasive respiratory support as well as parents' perceptions of how well they knew their nurse. The findings show remarkable differences in staff assignment in the different NICUs. In addition to appropriate staffing levels, scheduling nursing teams continuously would appear to play a role in influencing treatment quality. This paper emphasises the importance of carefully considered staff scheduling decisions. © 2015 John Wiley & Sons Ltd.
Perioperative considerations for neurosurgical procedures in the gravid patient: Continuing Professional Development.

PubMed

Chowdhury, Tumul; Chowdhury, Meenakshi; Schaller, Bernhard; Cappellani, Ronald B; Daya, Jayesh

2013-11-01

The complexity of neurosurgical procedures and their interactions with maternal and fetal physiologies are key factors in determining the overall maternal and fetal outcome. The literature and guidelines provide only partial information regarding the standard of care in these cases. The purpose of this Continuing Professional Development module is to review the issues related to common neurosurgical conditions and their optimal anesthetic management. The most common neurosurgical conditions found in pregnancy include brain tumours, cerebrovascular diseases, spinal pathologies, and neurotrauma. Though rare, these conditions and related procedures may affect maternal and fetal outcome. Maternal considerations should be given priority in cases of emergent surgeries irrespective of trimester. In the early first trimester, risk of fetal loss and congenital malformation are substantial; hence, proper counselling should be given to the mother with special emphasis on therapeutic abortion. When indicated, anticonvulsants should be started as early as possible and continued throughout pregnancy. Surgical procedures can be performed with relative safety during the second trimester and early third trimester. After 34 weeks, delivery seems to be the first choice, and the role of regional anesthesia in this situation should be carefully planned after proper review of neurosurgical pathology and maternal condition. During acute neurological deterioration, however, Cesarean delivery under general anesthesia should be anticipated. A multidisciplinary approach with good communication amongst all team members certainly plays a crucial role for successful management of such cases.
How unique is continuity of care? A review of continuity and related concepts.

PubMed

Uijen, Annemarie A; Schers, Henk J; Schellevis, François G; van den Bosch, Wil J H M

2012-06-01

The concept of 'continuity of care' has changed over time and seems to be entangled with other care concepts, for example coordination and integration of care. These concepts may overlap, and differences between them often remain unclear. In order to clarify the confusion of tongues and to identify core values of these patient-centred concepts, we provide a historical overview of continuity of care and four related concepts: coordination of care, integration of care, patient-centred care and case management. We identified and reviewed articles including a definition of one of these concepts by performing an extensive literature search in PubMed. In addition, we checked the definition of these concepts in the Oxford English Dictionary. Definitions of continuity, coordination, integration, patient-centred care and case management vary over time. These concepts show both great entanglement and also demonstrate differences. Three major common themes could be identified within these concepts: personal relationship between patient and care provider, communication between providers and cooperation between providers. Most definitions of the concepts are formulated from the patient's perspective. The identified themes appear to be core elements of care to patients. Thus, it may be valuable to develop an instrument to measure these three common themes universally. In the patient-centred medical home, such an instrument might turn out to be an important quality measure, which will enable researchers and policy makers to compare care settings and practices and to evaluate new care interventions from the patient perspective.
Telemedicine broadening access to care for complex cases.

PubMed

Jue, Joshua S; Spector, Sydney A; Spector, Seth A

2017-12-01

Surgical and nonsurgical specialists are highly centralized, making access to high-quality care difficult for many Americans. We explored the feasibility, benefits, preliminary outcomes, and patient satisfaction with a new type of health visit, in which a surgical oncologist used video telecommunication to manage and treat complex cancer diseases, including patients with severe comorbidities. Patients visited local VA medical centers throughout Florida to engage in video telecommunication visits with a centralized surgical oncologist in Miami, who directed their oncology treatment. The average length of stay and rate of unplanned readmission were calculated within each organ. The total mileage saved was calculated by subtracting the distance between the patient's home address and the local VA from the distance between the patient's home address and the Miami VA. Travel costs were determined by the VA's reimbursement of $0.415/mile for health-related travel and reimbursement of $150.00 for an overnight hotel stay. A Likert scale with both positively and negatively keyed questions was used to assess patient satisfaction. In 24 mo, seven unplanned readmissions occurred among 195 operations. Patients experienced an 80.7% reduction in travel distance and saved a total of 213,007.58 miles by visiting their local VA instead of the Miami VA. Survey results indicate that 86% of patients believed that the telemedicine program made medical care more accessible. The Specialist-Directed Telemedicine Model can save patients substantial time and money by not traveling to centralized areas, while delivering greater continuity of care and patient satisfaction. Copyright © 2017 Elsevier Inc. All rights reserved.
The ReACH Collaborative--improving quality home care.

PubMed

Boyce, Patricia Simino; Pace, Karen B; Lauder, Bonnie; Solomon, Debra A

2007-08-01

Research on quality of care has shown that vigorous leadership, clear goals, and compatible incentive systems are critical factors in influencing successful change (Institute of Medicine, 2001). Quality improvement is a complex process, and clinical quality improvement applications are more likely to be effective in organizations that are ready for change and have strong leaders, who are committed to creating and reinforcing a work environment that supports quality goals (Shortell, 1998). Key leadership roles include providing clear and sustained direction, articulating a coherent set of values and incentives to guide group and individual activities, aligning and integrating improvement efforts into organizational priorities, obtaining or freeing up resources to implement improvement activities, and creating a culture of "continuous improvement" that encourages and rewards the pursuit and achievement of shared quality aims (Institute of Medicine, 2001, 70-71). In summary, home health care is a significant and growing sector of the health care system that provides care to millions of vulnerable patients. There seems little doubt that home health agencies want to focus on quality of care issues and provide optimal care to home-based patients. Furthermore, there is a growing awareness of the value for adapting innovative, effective models for improving the culture of home care practice. This awareness stems from the notion that some agencies see quality improvement activities as a way for them to distinguish themselves not only to regulators and customers, but also to meet the cultural and transformational needs to remain viable in a constantly evolving and competitive health care industry.
[Coordinated organization of symptoms management and support in all the stages of cancer disease: putting in place pluridisciplinary structures of supportive oncological care].

PubMed

Krakowski, I; Chardot, C; Bey, P; Guillemin, F; Philip, T

2001-03-01

The organization of the management of pain and other symptoms all along the cancer disease, of psychological support and palliative care is a complex question that does not correspond to any perfectly established model, both in France and abroad. Different structures are implied in there care and coexist with an insufficient coordination: cancerology structures, structures of chronic pain management, structures of psycho-oncology, structures of palliative care. Some other assistances are more or less isolated inside the hospital: nutritional support, social assistance, action against tobacco and other addictions, volunteer work. Because of the evolution of practices and mentalities over the last ten years, the highlights of evident interfaces and complementary activities, the notions of "continuous care" and "integrated care" inside conventional departments, the budgetary and organizational restraints, it is now possible to propose a model of hospital structure adapted to the problem of supportive care. The creation is proposed from preexisting structures, consultations, units, departments of supportive oncological care according to the size of the institution. The structure should comply with some specifications, sometimes regulations, and to coordinate at best different competencies in the interest of the patients and medical teams : pain and symptoms management (of which palliative care is an important part), psycho-oncology, rehabilitation (functional rehabilitation, nutrition, social work, fights against addictions). A pooling of technology settings is one of its interest. The model can be applied in other domains than cancerology and in most health institutions.
Health reform in Mexico: the promotion of inequality.

PubMed

Laurell, A C

2001-01-01

The Mexican health reform can be understood only in the context of neoliberal structural adjustment, and it reveals some of the basic characteristics of similar reforms in the Latin American region. The strategy to transform the predominantly public health care system into a market-driven system has been a complex process with a hidden agenda to avoid political resistance. The compulsory social security system is the key sector in opening health care to private insurance companies, health maintenance organizations, and hospital enterprises mainly from abroad. Despite the government's commitment to universal coverage, equity, efficiency, and quality, the empirical data analyzed in this article do not confirm compliance with these objectives. Although an alternative health policy that gradually grants the constitutional right to health would be feasible, the new democratically elected government will continue the previous regressive health reform.
Baby on the move: issues in neonatal transport.

PubMed

Teasdale, Debra; Hamilton, Catherine

2008-02-01

The 2003 review of UK neonatal services led to wide-ranging changes including the centralisation of intensive care into level 3 units, the geographical organisation of neonatal care into 'networks', and the setting up of dedicated network transport teams. Despite these changes, neonatal transport continues to be problematic. Approaches to neonatal transportation are not yet standardised and this presents logistical problems for staff. Risks need to be considered and managed effectively to ensure safety for all involved. Although algorithms are in use for general stabilisation of the neonates, more guidance is required for effective stabilisation and management of infants with complex/surgical conditions. Staff involved in transport need to understand how neonatal physiology may be altered during transportation. They should also consider the legal implications of neonatal transport which are likely to remain unclear until the law is challenged in some way.
A Model for Integrating Ambulatory Surgery Centers Into an Academic Health System Using a Novel Ambulatory Surgery Coordinating Council.

PubMed

Ishii, Lisa; Pronovost, Peter J; Demski, Renee; Wylie, Gill; Zenilman, Michael

2016-06-01

An increasing volume of ambulatory surgeries has led to an increase in the number of ambulatory surgery centers (ASCs). Some academic health systems have aligned with ASCs to create a more integrated care delivery system. Yet, these centers are diverse in many areas, including specialty types, ownership models, management, physician employment, and regulatory oversight. Academic health systems then face challenges in integrating these ASCs into their organizations. Johns Hopkins Medicine created the Ambulatory Surgery Coordinating Council in 2014 to manage, standardize, and promote peer learning among its eight ASCs. The Armstrong Institute for Patient Safety and Quality provided support and a model for this organization through its quality management infrastructure. The physician-led council defined a mission and created goals to identify best practices, uniformly provide the highest-quality patient-centered care, and continuously improve patient outcomes and experience across ASCs. Council members built trust and agreed on a standardized patient safety and quality dashboard to report measures that include regulatory, care process, patient experience, and outcomes data. The council addressed unintentional outcomes and process variation across the system and agreed to standard approaches to optimize quality. Council members also developed a process for identifying future goals, standardizing care practices and electronic medical record documentation, and creating quality and safety policies. The early success of the council supports the continuation of the Armstrong Institute model for physician-led quality management. Other academic health systems can learn from this model as they integrate ASCs into their complex organizations.
Assessment for Systems Learning: A Holistic Assessment Framework to Support Decision Making Across the Medical Education Continuum.

PubMed

Bowe, Constance M; Armstrong, Elizabeth

2017-05-01

Viewing health care from a systems perspective-that is, "a collection of different things which, working together, produce a result not achievable by the things alone"-raises awareness of the complex interrelationships involved in meeting society's goals for accessible, cost-effective, high-quality health care. This perspective also emphasizes the far-reaching consequences of changes in one sector of a system on other components' performance. Medical education promotes this holistic view of health care in its curricula and competency requirements for graduation at the undergraduate and graduate training levels. But how completely does medical education apply a systems lens to itself?The continuum of medical training has undergone a series of changes that have moved it more closely to a systems organizational model. Competency assessment criteria have been expanded and more explicitly defined for learners at all levels of training. Outcomes data, in multiple domains, are monitored by external reviewers for program accreditation. However, translating increasing amounts of individual outcomes into actionable intelligence for decision making poses a formidable information management challenge.Assessment in systems is designed to impart a "big picture" of overall system performance through the synthesis, analysis, and interpretation of outcomes data to provide actionable information for continuous systems improvement, innovation, and long-term planning. A systems-based framework is presented for use across the medical education continuum to facilitate timely improvements in individual curriculum components, continuous improvement in overall program performance, and program decision making on changes required to better address society's health care needs.
Mediators of Telephone-Based Continuing Care for Alcohol and Cocaine Dependence

ERIC Educational Resources Information Center

Mensinger, Janell Lynn; Lynch, Kevin G.; Tenhave, Thomas R.; McKay, James R.

2007-01-01

A previous randomized trial with 224 alcohol and/or cocaine addicts who had completed an initial phase of treatment indicated that 12 weeks of telephone-based continuing care yielded higher abstinence rates over 24 months than did group counseling continuing care. The current study examined mediators of this treatment effect. Results suggested…
77 FR 56631 - TRICARE, Formerly Known as the Civilian Health and Medical Program of the Uniformed Services...

Federal Register 2010, 2011, 2012, 2013, 2014

2012-09-13

... Medical Program of the Uniformed Services; Fiscal Year 2013 Continued Health Care Benefit Program Premium Update AGENCY: Office of the Secretary, DoD. ACTION: Notice of updated continued health care benefit program premiums for fiscal year 2013. SUMMARY: This notice provides the updated Continued Health Care...
Attitudes and Preferences of Pennsylvania Primary Care Physicians Regarding Continuing Medical Education.

ERIC Educational Resources Information Center

Mansfield, Phyllis; And Others

Primary care physicians in Pennsylvania were asked to give their attitudes and preferences regarding continuing medical education (CME) in an effort to expand and develop physician-oriented CME programs for the Hershey Continuing Education department at Penn State. A 32-item questionnaire was mailed to 952 primary care physicians practicing in…
5 CFR 792.200 - What are the benefits of the child care subsidy program law?

Code of Federal Regulations, 2010 CFR

2010-01-01

... (CONTINUED) CIVIL SERVICE REGULATIONS (CONTINUED) FEDERAL EMPLOYEES' HEALTH AND COUNSELING PROGRAMS Agency... at Federal child care centers, non-Federal child care centers, and in family child care homes for... 5 Administrative Personnel 2 2010-01-01 2010-01-01 false What are the benefits of the child care...

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