Sample records for managed care model
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Terra, Sandra M
2007-01-01
This research seeks to determine whether there is adequate evidence-based justification for selection of one acute care case management model over another. Acute Inpatient Hospital. This article presents a systematic review of published case management literature, resulting in classification specific to terms of level of evidence. This review examines the best available evidence in an effort to select an acute care case management model. Although no single case management model can be identified as preferred, it is clear that adequate evidence-based literature exists to acknowledge key factors driving the acute care model and to form a foundation for the efficacy of hospital case management practice. Although no single case management model can be identified as preferred, this systematic review demonstrates that adequate evidence-based literature exists to acknowledge key factors driving the acute care model and forming a foundation for the efficacy of hospital case management practice. Distinctive aspects of case management frameworks can be used to guide the development of an acute care case management model. The study illustrates: * The effectiveness of case management when there is direct patient contact by the case manager regardless of disease condition: not only does the quality of care increase but also length of stay (LOS) decreases, care is defragmented, and both patient and physician satisfaction can increase. * The preferred case management models result in measurable outcomes that can directly relate to, and demonstrate alignment with, organizational strategy. * Acute care management programs reduce cost and LOS, and improve outcomes. * An integrated case management program that includes social workers, as well as nursing, is the most effective acute care management model. * The successful case management model will recognize physicians, as well as patients, as valued customers with whom partnership can positively affect financial outcomes in terms of reduction in LOS, improvement in quality, and delivery of care.
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Applying business management models in health care.
Trisolini, Michael G
2002-01-01
Most health care management training programmes and textbooks focus on only one or two models or conceptual frameworks, but the increasing complexity of health care organizations and their environments worldwide means that a broader perspective is needed. This paper reviews five management models developed for business organizations and analyses issues related to their application in health care. Three older, more 'traditional' models are first presented. These include the functional areas model, the tasks model and the roles model. Each is shown to provide a valuable perspective, but to have limitations if used in isolation. Two newer, more 'innovative' models are next discussed. These include total quality management (TQM) and reengineering. They have shown potential for enabling dramatic improvements in quality and cost, but have also been found to be more difficult to implement. A series of 'lessons learned' are presented to illustrate key success factors for applying them in health care organizations. In sum, each of the five models is shown to provide a useful perspective for health care management. Health care managers should gain experience and training with a broader set of business management models.
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Kanchense, Jane Handina Murigwa
2006-08-01
The primary health care model of public health has been implemented in many countries around the globe since the Declaration of Alma Ata in 1978, without pilot testing the primary health care model. Therefore, many public health researchers have sought methods of improving primary health care by creating evidence-based models. Many of these researchers recognize the role of behavioral models in public health. These offshoots of primary health care include the ecological, care, central human capabilities, and the SPECIES models. Holistic self-management education and support is a capacity-building philosophy that ensures active involvement of consumers of health care in the planning and implementation and evaluation of health care services. It helps consumers of health care to achieve the desired improved quality of health and life in managing and sustaining their health at the grassroots level. The care model addresses disease management ideals of the in the original primary health care model. The SPECIES model addresses those aspects of the primary health care model that include the cultural and social factors, as well as individual health education and support in the original primary health care model. The ecological model offers an improvement of the socioeconomic ideal in the original primary health care model. Improving the health of individuals will prevent illness, thereby reducing health care costs and lessening the current strain on an overburdened health care system in Zimbabwe. Holistic self-management education and support links health care delivery systems with social processes. It is a best practices model that could better serve Zimbabwean girls and women by contributing positively to the national challenges in health care, thereby meeting the Zimbabwean primary health care and safe motherhood goals. It is here recommended that holistic self-management education and support must be pilot tested before being adopted as the most appropriate model for ensuring population health.
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A new model for care population management.
Williams, Jeni
2013-03-01
Steps toward building a population management model of care should include: Identifying the population that would be cared for through a population management initiative. Conducting an actuarial analysis for this population, reviewing historical utilization and cost data and projecting changes in utilization. Investing in data infrastructure that supports the exchange of data among providers and with payers. Determining potential exposure to downside risk and organizational capacity to assume this risk. Experimenting with payment models and care delivery approaches Hiring care coordinators to manage care for high-risk patients.
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Health care managers' views on and approaches to implementing models for improving care processes.
Andreasson, Jörgen; Eriksson, Andrea; Dellve, Lotta
2016-03-01
To develop a deeper understanding of health-care managers' views on and approaches to the implementation of models for improving care processes. In health care, there are difficulties in implementing models for improving care processes that have been decided on by upper management. Leadership approaches to this implementation can affect the outcome. In-depth interviews with first- and second-line managers in Swedish hospitals were conducted and analysed using grounded theory. 'Coaching for participation' emerged as a central theme for managers in handling top-down initiated process development. The vertical approach in this coaching addresses how managers attempt to sustain unit integrity through adapting and translating orders from top management. The horizontal approach in the coaching refers to managers' strategies for motivating and engaging their employees in implementation work. Implementation models for improving care processes require a coaching leadership built on close manager-employee interaction, mindfulness regarding the pace of change at the unit level, managers with the competence to share responsibility with their teams and engaged employees with the competence to share responsibility for improving the care processes, and organisational structures that support process-oriented work. Implications for nursing management are the importance of giving nurse managers knowledge of change management. © 2015 John Wiley & Sons Ltd.
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Managed care. Shifts health care from an altruistic model to a business framework.
Kersbergen, A L
2000-01-01
The term managed care, as used throughout the scientific and lay literature, has become a generic label without a clear, universally accepted definition. The many definitions and descriptions of managed care are usually directly related to the model under discussion. Nevertheless, as nurse educators attempt to align curricula with the evolving health care environment, it is imperative that students gain an understanding of the concept of managed care and the skills needed to practice in the managed care environment. Schools of nursing must prepare students to deal with the consequences of managed care, namely, the changing base of power, conflicts, and ethical dilemmas across settings. The drive to control health care costs in the 1990s brought about unprecedented change for nurses. Regardless of the strategies implemented in the name of managing care, the evolving health care environment has changed where and how nurses practice. To aid faculty in the revision of the nursing curriculum, an attempt was made to arrive at an empirically based definition of managed care that will provide a conceptual foundation for future research and theoretical discussions. Other goals were to identify consequences of managed care across disciplines and models implemented in the name of managing care, and to identify skills needed by nurses today.
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Integrated care management: aligning medical call centers and nurse triage services.
Kastens, J M
1998-01-01
Successful integrated delivery systems must aggressively design new approaches to managing patient care. Implementing a comprehensive care management model to coordinate patient care across the continuum is essential to improving patient care and reducing costs. The practice of telephone nursing and the need for experienced registered nurses to staff medical call centers, nurse triage centers, and outbound telemanagement is expanding as the penetration of full-risk capitated managed care contracts are signed. As health systems design their new care delivery approaches and care management models, medical call centers will be an integral approach to managing demand for services, chronic illnesses, and prevention strategies.
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Lipschitz, Jessica M; Benzer, Justin K; Miller, Christopher; Easley, Siena R; Leyson, Jenniffer; Post, Edward P; Burgess, James F
2017-10-10
The collaborative care model is an evidence-based practice for treatment of depression in which designated care managers provide clinical services, often by telephone. However, the collaborative care model is infrequently adopted in the Department of Veterans Affairs (VA). Almost all VA medical centers have adopted a co-located or embedded approach to integrating mental health care for primary care patients. Some VA medical centers have also adopted a telephone-based collaborative care model where depression care managers support patient education, patient activation, and monitoring of adherence and progress over time. This study evaluated two research questions: (1) What does a dedicated care manager offer in addition to an embedded-only model? (2) What are the barriers to implementing a dedicated depression care manager? This study involved 15 qualitative, multi-disciplinary, key informant interviews at two VA medical centers where reimbursement options were the same- both with embedded mental health staff, but one with a depression care manager. Participant interviews were recorded and transcribed. Thematic analysis was used to identify descriptive and analytical themes. Findings suggested that some of the core functions of depression care management are provided as part of embedded-only mental health care. However, formal structural attention to care management may improve the reliability of care management functions, in particular monitoring of progress over time. Barriers to optimal implementation were identified at both sites. Themes from the care management site included finding assertive care managers to hire, cross-discipline integration and collaboration, and primary care provider burden. Themes from interviews at the embedded site included difficulty getting care management on leaders' agendas amidst competing priorities and logistics (staffing and space). Providers and administrators see depression care management as a valuable healthcare service that improves patient care. Barriers to implementation may be addressed by team-building interventions to improve cross-discipline integration and communication. Findings from this study are limited in scope to the VA healthcare system. Future investigation of whether alternative barriers exist in implementation of depression care management programs in non-VA hospital systems, where reimbursement rates may be a more prominent concern, would be valuable.
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A multilevel modelling approach to analysis of patient costs under managed care.
Carey, K
2000-07-01
The growth of the managed care model of health care delivery in the USA has led to broadened interest in the performance of health care providers. This paper uses multilevel modelling to analyse the effects of managed care penetration on patient level costs for a sample of 24 medical centres operated by the Veterans Health Administration (VHA). The appropriateness of a two level approach to this problem over ordinary least squares (OLS) is demonstrated. Results indicate a modicum of difference in institutions' performance after controlling for patient effects. Facilities more heavily penetrated by the managed care model may be more effective at controlling costs of their sicker patients. Copyright 2000 John Wiley & Sons, Ltd.
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ERIC Educational Resources Information Center
Kastner, Theodore A.; Walsh, Kevin K.
2006-01-01
Lack of sufficient accessible community-based health care services for individuals with developmental disabilities has led to disparities in health outcomes and an overreliance on expensive models of care delivered in hospitals and other safety net or state-subsidized providers. A functioning community-based primary health care model, with an…
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van Mierlo, Lisa D; MacNeil-Vroomen, Janet; Meiland, Franka J M; Joling, Karlijn J; Bosmans, Judith E; Dröes, Rose Marie; Moll van Charante, Eric P; de Rooij, Sophia E J A; van Hout, Hein P J
2016-12-01
Different forms of case management for dementia have emerged over the past few years. In the COMPAS study (Collaborative dementia care for patients and caregivers study), two prominent Dutch case management forms were studied: the linkage and the integrated care form. Evaluation of the (cost)effectiveness of two dementia case management forms compared to usual care as well as factors that facilitated or impeded their implementation. A mixed methods design with a) a prospective, observational controlled cohort study with 2 years follow-up among 521 dyads of people with dementia and their primary informal caregiver with and without case management; b) interviews with 22 stakeholders on facilitating and impeding factors of the implementation and continuity of the two case management models. Outcome measures were severity and frequency of behavioural problems (NPI) for the person with dementia and mental health complaints (GHQ-12) for the informal caregiver, total met and unmet care needs (CANE) and quality adjusted life years (QALYs). Outcomes showed a better quality of life of informal caregivers in the integrated model compared to the linkage model. Caregivers in the control group reported more care needs than those in both case management groups. The independence of the case management provider in the integrated model facilitated the implementation, while the rivalry between multiple providers in the linkage model impeded the implementation. The costs of care were lower in the linkage model (minus 22 %) and integrated care model (minus 33 %) compared to the control group. The integrated care form was (very) cost-effective in comparison with the linkage form or no case management. The integrated care form is easy to implement.
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Granata, Randy L; Hamilton, Karen
2015-01-01
Acute care nurse case managers are charged with compliance oversight, managing throughput, and ensuring safe care transitions. Leveraging the roles of nurse case managers and social workers during care transitions translates into improved fiscal performance under the Affordable Care Act. This article aims to equip leaders in the field of case management with tools to facilitate the alignment of case management systems with hospital pay-for-performance measures. A quality improvement project was implemented at a hospital in south Alabama to examine the question: for acute care case managers, what is the effect of key performance indictors using an at-risk compensation model in comparison to past nonincentive models on hospital readmissions, lengths of stay, and patient satisfaction surrounding the discharge process. Inpatient acute care hospital. The implementation of an at-risk compensation model using key performance indicators, Lean Six Sigma methodology, and Creative Health Care Management's Relationship-Based Care framework demonstrated reduced length of stay, hospital readmissions, and improved patient experiences. Regulatory changes and new models of reimbursement in the acute care environment have created the perfect storm for case management leaders. Hospital fiscal performance is dependent on effective case management processes and the ability to optimize scarce resources. The quality improvement project aimed to further align case management systems and structures with hospital pay-for-performance measures. Tools for change were presented to assist leaders with the change acceleration process.
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MacNeil Vroomen, Janet; Van Mierlo, Lisa D; van de Ven, Peter M; Bosmans, Judith E; van den Dungen, Pim; Meiland, Franka J M; Dröes, Rose-Marie; Moll van Charante, Eric P; van der Horst, Henriëtte E; de Rooij, Sophia E; van Hout, Hein P J
2012-05-28
Dementia care in the Netherlands is shifting from fragmented, ad hoc care to more coordinated and personalised care. Case management contributes to this shift. The linkage model and a combination of intensive case management and joint agency care models were selected based on their emerging prominence in the Netherlands. It is unclear if these different forms of case management are more effective than usual care in improving or preserving the functioning and well-being at the patient and caregiver level and at the societal cost. The objective of this article is to describe the design of a study comparing these two case management care models against usual care. Clinical and cost outcomes are investigated while care processes and the facilitators and barriers for implementation of these models are considered. Mixed methods include a prospective, observational, controlled, cohort study among persons with dementia and their primary informal caregiver in regions of the Netherlands with and without case management including a qualitative process evaluation. Inclusion criteria for the cohort study are: community-dwelling individuals with a dementia diagnosis who are not terminally-ill or anticipate admission to a nursing home within 6 months and with an informal caregiver who speaks fluent Dutch. Person with dementia-informal caregiver dyads are followed for two years. The primary outcome measure is the Neuropsychiatric Inventory for the people with dementia and the General Health Questionnaire for their caregivers. Secondary outcomes include: quality of life and needs assessment in both persons with dementia and caregivers, activity of daily living, competence of care, and number of crises. Costs are measured from a societal perspective using cost diaries. Process indicators measure the quality of care from the participant's perspective. The qualitative study uses purposive sampling methods to ensure a wide variation of respondents. Semi-structured interviews with stakeholders based on the theoretical model of adaptive implementation are planned. This study provides relevant insights into care processes, description of two case management models along with clinical and economic data from persons with dementia and caregivers to clarify important differences in two case management care models compared to usual care.
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2012-01-01
Background Dementia care in the Netherlands is shifting from fragmented, ad hoc care to more coordinated and personalised care. Case management contributes to this shift. The linkage model and a combination of intensive case management and joint agency care models were selected based on their emerging prominence in the Netherlands. It is unclear if these different forms of case management are more effective than usual care in improving or preserving the functioning and well-being at the patient and caregiver level and at the societal cost. The objective of this article is to describe the design of a study comparing these two case management care models against usual care. Clinical and cost outcomes are investigated while care processes and the facilitators and barriers for implementation of these models are considered. Design Mixed methods include a prospective, observational, controlled, cohort study among persons with dementia and their primary informal caregiver in regions of the Netherlands with and without case management including a qualitative process evaluation. Inclusion criteria for the cohort study are: community-dwelling individuals with a dementia diagnosis who are not terminally-ill or anticipate admission to a nursing home within 6 months and with an informal caregiver who speaks fluent Dutch. Person with dementia-informal caregiver dyads are followed for two years. The primary outcome measure is the Neuropsychiatric Inventory for the people with dementia and the General Health Questionnaire for their caregivers. Secondary outcomes include: quality of life and needs assessment in both persons with dementia and caregivers, activity of daily living, competence of care, and number of crises. Costs are measured from a societal perspective using cost diaries. Process indicators measure the quality of care from the participant’s perspective. The qualitative study uses purposive sampling methods to ensure a wide variation of respondents. Semi-structured interviews with stakeholders based on the theoretical model of adaptive implementation are planned. Discussion This study provides relevant insights into care processes, description of two case management models along with clinical and economic data from persons with dementia and caregivers to clarify important differences in two case management care models compared to usual care. PMID:22640695
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On the Scene: Developing a Nurse Care Coordinator Role at City of Hope.
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.
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Groves, Kevin S
2011-01-01
: Difficult economic conditions and powerful workforce trends pose significant challenges to managing talent in health care organizations. Although robust research evidence supports the many benefits of maintaining a strong commitment to talent management practices despite these challenges, many organizations compound the problem by resorting to workforce reductions and limiting or eliminating investments in talent management. : This study examines how nationwide health care systems address these challenges through best practice talent management systems. Addressing important gaps in talent management theory and practice, this study develops a best practice model of talent management that is grounded in the contextual challenges facing health care practitioners. : Utilizing a qualitative case study that examined 15 nationwide health care systems, data were collected through semistructured interviews with 30 executives and document analysis of talent management program materials submitted by each organization. : Exemplary health care organizations employ a multiphased talent management system composed of six sequential phases and associated success factors that drive effective implementation. Based on these findings, a model of talent management best practices in health care organizations is presented. : Health care practitioners may utilize the best practice model to assess and enhance their respective talent management systems by establishing the business case for talent management, defining, identifying, and developing high-potential leaders, carefully communicating high-potential designations, and evaluating talent management outcomes.
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ERIC Educational Resources Information Center
Kastner, Theodore A.; Walsh, Kevin K.; Criscione, Teri
1997-01-01
Presents a general model of the structure and functioning of managed care and describes elements (provider networks, fiscal elements, risk estimation, case-mix, management information systems, practice parameters, and quality improvement) critical to people with developmental disabilities. Managed care demonstration projects and a hypothetical…
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Entrepreneurship management in health services: an integrative model.
Guo, Kristina L
2006-01-01
This research develops an integrated systems model of entrepreneurship management as a method for achieving health care organizational survival and growth. Specifically, it analyzes current health care environment challenges, identifies roles of managers and discusses organizational theories that are relevant to the health care environment, outlines the role of entrepreneurship in health care, and describes the entrepreneurial manager in the entrepreneurial management process to produce desirable organizational outcomes. The study concludes that as current health care environment continues to show intense competition, entrepreneurial managers are responsible for creating innovations, managing change, investing in resources, and recognizing opportunities in the environment to increase organizational viability.
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The Chronic Care Model as vehicle for the development of disease management in Europe
Spreeuwenberg, Cor
2008-01-01
The Chronic Care Model (Wagner, WHO) aims to improve the functioning and clinical situation of chronic patients by focussing on the patient, the practice team and the conditions that determine the functioning of the team. The patient is the most important actor who must be stimulated proactively by a competent, integrated practice team. Six interdependent conditional components are essential: health care organisation, delivery system design, community resources and policies, self-management support systems, decision support and clinical information systems. While the Chronic Care Model focuses on quality and effectiveness of care, disease management programmes underline more the efficiency of care. These programmes apply industrial management principles in health care. Information about process, structure and outcome is gathered and used systematically and human and material sources are used efficiently. There is evidence that the approaches of the Chronic Care Model and disease management can be integrated. Both approaches underline the need of information and focus on the patient as the main actor to improve and that a balance can be found between effectiveness and efficiency. Ideas will be given how the Chronic Care Model can be used as a framework for the development of a European way of disease management for people with a chronic condition.
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Hsieh, Pei-Lun; Chen, Ching-Min
2016-08-01
Longer average life expectancies have caused the rapid growth of the elderly as a percentage of Taiwan's population and, as a result of the number of elders with chronic diseases and disability. Providing continuing-care services in community settings for elderly with multiple chronic conditions has become an urgent need. To review the nurse-led care models that are currently practiced among elders with chronic disease in the community and to further examine the effectiveness and essential components of these models using a systematic review method. Twelve original articles on chronic disease-care planning for the elderly or on nurse-led care management interventions that were published between 2000 and 2015 in any of five electronic databases: MEDLINE, PubMed, CINAHL (Cumulative Index to Nursing and Allied Health Literature) Plus with Full Text, Cochrane Library, and CEPS (Chinese Electronic Periodicals Service）were selected and analyzed systematically. Four types of nurse-led community care models, including primary healthcare, secondary prevention care, cross-boundary models, and case management, were identified. Chronic disease-care planning, case management, and disease self-management were found to be the essential components of the services that were provided. The care models used systematic processes to conduct assessment, planning, implementation, coordination, and follow-up activities as well as to deliver services and to evaluate disease status. The results revealed that providing continuing-care services through the nurse-led community chronic disease-care model and cross-boundary model enhanced the ability of the elderly to self-manage their chronic diseases, improved healthcare referrals, provided holistic care, and maximized resource utilization efficacy. The present study cross-referenced all reviewed articles in terms of target clients, content, intervention, measurements, and outcome indicators. Study results may be referenced in future implementations of nurse-led community care models as well as in future research.
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van Hout, H P J; Macneil Vroomen, J L; Van Mierlo, L D; Meiland, F J M; Moll van Charante, E P; Joling, K J; van den Dungen, P; Dröes, R M; van der Horst, H E; de Rooij, S E J A
2014-04-01
Dementia care in The Netherlands is shifting from fragmented, ad hoc care to more coordinated and personalized care. Case management contributes to this shift. The linkage model and a combination of intensive case management and joint agency care models were selected based on their emerging prominence in The Netherlands. It is unclear if these different forms of case management are more effective than usual care in improving or preserving the functioning and well-being at the patient and caregiver level and at the societal cost. The objective of this article is to describe the design of a study comparing these two case management care models against usual care. Clinical and cost outcomes are investigated while care processes and the facilitators and barriers for implementation of these models are considered. Mixed methods include a prospective, observational, controlled, cohort study among persons with dementia and their primary informal caregiver in regions of The Netherlands with and without case management including a qualitative process evaluation. Community-dwelling individuals with a dementia diagnosis with an informal caregiver are included. The primary outcome measure is the Neuropsychiatric Inventory for the people with dementia and the General Health Questionnaire for their caregivers. Costs are measured from a societal perspective. Semi-structured interviews with stakeholders based on the theoretical model of adaptive implementation are planned. 521 pairs of persons with dementia and their primary informal caregiver were included and are followed over two years. In the linked model substantially more impeding factors for implementation were identified compared with the model. This article describes the design of an evaluation study of two case management models along with clinical and economic data from persons with dementia and caregivers. The impeding and facilitating factors differed substantially between the two models. Further results on cost-effectiveness are expected by the beginning of 2015. This is a Dutch adaptation of MacNeil Vroomen et al., Comparing Dutch case management care models for people with dementia and their caregivers: The design of the COMPAS study.
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Chisholm, Anna; Nelson, Pauline A; Pearce, Christina J; Keyworth, Chris; Griffiths, Christopher E M; Cordingley, Lis; Bundy, Christine
2016-02-01
Individuals' illness representations, including beliefs about psoriasis (a complex immune-mediated condition), and their emotional responses to the condition guide self-management behaviour. It is also plausible that health care providers' illness representations guide their own management of psoriasis. Patients commonly report poor health care experiences related to psoriasis, and the role of health care providers' beliefs, emotions, as well as their knowledge, experiences and behaviours ('personal models') in this is unexplored. This study aimed explore health care providers' personal models of psoriasis. Qualitative analysis of 23 semi-structured interviews with health care professionals providing care for psoriasis patients was performed. Purposive sampling achieved maximum variation regarding participant discipline, level of experience, gender and age. The self-regulatory/common sense model informed data collection and initial data analysis. Principles of framework analysis were used to generate predetermined and emergent key issues related to practitioners' personal models. Three types of personal model emerged. Sophisticated-Linear Model: 70% of practitioners recognized psoriasis as a complex condition but managed it as a skin condition. Mixed Model: 17% of practitioners recognized/managed some elements of psoriasis as complex and some as a skin condition. Sophisticated-Sophisticated Model: 13% recognized and managed psoriasis as a complex condition. Across the data set, five themes emerged illustrating key patterns underpinning these different models including (1) Recognising complexity, (2) Putting skin first, (3) Taking on the complexities of psoriasis with the patient, (4) Aiming for clearance, and (5) Affective experiences within psoriasis consultations. Health care providers recognized psoriasis as a complex condition but commonly reported managing psoriasis as a simple skin condition. Providers' beliefs and management approaches varied in the extent to which they were consistent with one another; and their emotional experiences during consultations may vary depending upon their personal model. Findings could inform future dermatology training programmes by highlighting the role of health care providers' illness representations in clinical management of the condition. What is already known on this subject? Health behaviour is predicted by underlying beliefs and emotions associated with an illness and its treatment. Few studies have examined health care providers' beliefs and emotions about the illnesses they manage in clinical practice. Many patients are dissatisfied with dermatology consultations and wish to be treated holistically. What does this study add? Qualitative exploration of health care providers' beliefs/emotions revealed their personal models of psoriasis. Providers' personal models of psoriasis vary in coherence and are often skin rather than whole person focused. Further investigation of health care providers' models of psoriasis and their impact on health outcomes is needed. © 2015 The British Psychological Society.
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Soroka, Mort; Reis, Lesley; Krumholz, David; Krasner, Mel; Portello, Joan
2003-11-01
Eye care services, though accounting for only a small fraction of healthcare costs, encompass a unique spectrum of professional staffing options that can enhance efficiency and decrease costs within staff model managed care organizations. This study was designed to describe and assess alternative staffing arrangements and cost implications for the delivery of eye care services by optometrists, ophthalmologists, and primary care physicians within staff model managed care organizations. The clinical records of individual patients--rather than administrative and billing files--at three managed care organizations are the principal source of information. Clinical auditors extracted data on ambulatory eye care services provided for conjunctivitis, corneal abrasion/erosion, cataract, diabetic retinopathy, glaucoma, and macular degeneration. Our findings document the substantial role optometrists play in the delivery of eye care, whether they provide the care independently or in collaboration with an ophthalmologist. The levels of remuneration for optometrists are roughly one third to one half the annual rate for ophthalmologists. Staffing arrangements that use optometrists to the full extent of their professional training can provide significant cost savings. The cost-effectiveness of using the services of optometrists capable of delivering high-quality eye care can be demonstrated. Potential cost savings for staff model managed care organizations may accrue if the roles, functions, and availability of eye providers are adjusted.
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2001-04-12
Comparison of Oversight Models in Managed Care 1 Running Head: Comparison of Oversight Models in Managed Care A Comparison of the Audit and...TITLE AND SUBTITLE A Comparison of the Audit and Accreditation Tools Used By The Health Care Financing Administration, The Texas Department of...Comparison of Oversight Models in Managed Care 5 A Comparison of the Audit and Accreditation Tools Used By The Health Care Financing
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Culture Change in Long Term Care Services: Eden-Greenhouse-Aging in the Community
ERIC Educational Resources Information Center
Brune, Kendall
2011-01-01
To discuss the relationship between residents and the management team, we must first review the transition from a medical model to a social model of care that is sweeping across America. Long-term care (LTC) management models were developed for a very autocratic and hierarchical style of management based in the 1960s. Those facilities were built…
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Testing the Theory of Self-care Management for sickle cell disease.
Jenerette, Coretta M; Murdaugh, Carolyn
2008-08-01
Factors predicting health outcomes in persons with sickle cell disease (SCD) were investigated within the framework of the theory of self-care management for SCD, which proposes that vulnerability factors negatively affect health care outcomes and self-care management resources and positively mediate the relationship between vulnerability factors and health care outcomes. A cross-sectional descriptive design was used to test the model with a sample of 232 African American adults with SCD. Results supported the negative effect of vulnerability factors on health outcomes. The overall model was supported, however, self-care management resources did not mediate the relationship between vulnerability and health care outcomes. The findings provide support for interventions to increase self-care management resources to improve health care outcomes. 2008 Wiley Periodicals, Inc
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Ciccone, Marco Matteo; Aquilino, Ambrogio; Cortese, Francesca; Scicchitano, Pietro; Sassara, Marco; Mola, Ernesto; Rollo, Rodolfo; Caldarola, Pasquale; Giorgino, Francesco; Pomo, Vincenzo; Bux, Francesco
2010-05-06
Project Leonardo represented a feasibility study to evaluate the impact of a disease and care management (D&CM) model and of the introduction of "care manager" nurses, trained in this specialized role, into the primary health care system. Thirty care managers were placed into the offices of 83 general practitioners and family physicians in the Apulia Region of Italy with the purpose of creating a strong cooperative and collaborative "team" consisting of physicians, care managers, specialists, and patients. The central aim of the health team collaboration was to empower 1,160 patients living with cardiovascular disease (CVD), diabetes, heart failure, and/or at risk of cardiovascular disease (CVD risk) to take a more active role in their health. With the support of dedicated software for data collection and care management decision making, Project Leonardo implemented guidelines and recommendations for each condition aimed to improve patient health outcomes and promote appropriate resource utilization. Results show that Leonardo was feasible and highly effective in increasing patient health knowledge, self-management skills, and readiness to make changes in health behaviors. Patient skill-building and ongoing monitoring by the health care team of diagnostic tests and services as well as treatment paths helped promote confidence and enhance safety of chronic patient management at home. Physicians, care managers, and patients showed unanimous agreement regarding the positive impact on patient health and self-management, and attributed the outcomes to the strong "partnership" between the care manager and the patient and the collaboration between the physician and the care manager. Future studies should consider the possibility of incorporating a patient empowerment model which considers the patient as the most important member of the health team and care managers as key health care collaborators able to enhance and support services to patients provided by physicians in the primary health care system.
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Simulation modeling for the health care manager.
Kennedy, Michael H
2009-01-01
This article addresses the use of simulation software to solve administrative problems faced by health care managers. Spreadsheet add-ins, process simulation software, and discrete event simulation software are available at a range of costs and complexity. All use the Monte Carlo method to realistically integrate probability distributions into models of the health care environment. Problems typically addressed by health care simulation modeling are facility planning, resource allocation, staffing, patient flow and wait time, routing and transportation, supply chain management, and process improvement.
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Integrating disease management into the outpatient delivery system during and after managed care.
Villagra, Victor G
2004-01-01
Managed care introduced disease management as a replacement strategy to utilization management. The focus changed from influencing treatment decisions to supporting self-care and compliance. Disease management rendered operational many elements of the chronic care model, but it did so outside the delivery system, thus escaping the financial limitations, cultural barriers, and inertia inherent in effecting radical change from within. Medical management "after managed care" should include the functional and structural integration of disease management with primary care clinics. Such integration would supply the infrastructure that primary care physicians need to coordinate the care of chronically ill patients more effectively.
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Fagnan, Lyle J; Dorr, David A; Davis, Melinda; McGinnis, Paul; Mahler, Jo; King, Molly McCarthy; Michaels, LeAnn
2011-01-01
This study sought to understand the acceptability and feasibility of office-based nurse care management in medium to large rural primary care practices. A qualitative assessment of Care Management Plus (a focused medical home model for complex patients) implementation was conducted using semistructured interviews with 4 staff cohorts. Cohorts included clinician champions, clinician partners, practice administrators, and nurse care managers. Seven key implementation attributes were: a proven care coordination program; adequate staffing; practice buy-in; adequate time; measurement; practice facilitation; and functional information technology. Although staff was positive about the care coordination concept, model acceptability was varied and additional study is required to determine sustainability.
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Askari, Marjan; Westerhof, Richard; Eslami, Saied; Medlock, Stephanie; de Rooij, Sophia E; Abu-Hanna, Ameen
2013-10-01
To propose a combined disease management and process modeling approach for evaluating and improving care processes, and demonstrate its usability and usefulness in a real-world fall management case study. We identified essential disease management related concepts and mapped them into explicit questions meant to expose areas for improvement in the respective care processes. We applied the disease management oriented questions to a process model of a comprehensive real world fall prevention and treatment program covering primary and secondary care. We relied on interviews and observations to complete the process models, which were captured in UML activity diagrams. A preliminary evaluation of the usability of our approach by gauging the experience of the modeler and an external validator was conducted, and the usefulness of the method was evaluated by gathering feedback from stakeholders at an invitational conference of 75 attendees. The process model of the fall management program was organized around the clinical tasks of case finding, risk profiling, decision making, coordination and interventions. Applying the disease management questions to the process models exposed weaknesses in the process including: absence of program ownership, under-detection of falls in primary care, and lack of efficient communication among stakeholders due to missing awareness about other stakeholders' workflow. The modelers experienced the approach as usable and the attendees of the invitational conference found the analysis results to be valid. The proposed disease management view of process modeling was usable and useful for systematically identifying areas of improvement in a fall management program. Although specifically applied to fall management, we believe our case study is characteristic of various disease management settings, suggesting the wider applicability of the approach. Copyright © 2013 Elsevier Ireland Ltd. All rights reserved.
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Wu, Shinyi; Ell, Kathleen; Gross-Schulman, Sandra G; Sklaroff, Laura Myerchin; Katon, Wayne J; Nezu, Art M; Lee, Pey-Jiuan; Vidyanti, Irene; Chou, Chih-Ping; Guterman, Jeffrey J
2014-03-01
Health disparities in minority populations are well recognized. Hispanics and Latinos constitute the largest ethnic minority group in the United States; a significant proportion receives their care via a safety net. The prevalence of diabetes mellitus and comorbid depression is high among this group, but the uptake of evidence-based collaborative depression care management has been suboptimal. The study design and baseline characteristics of the enrolled sample in the Diabetes-Depression Care-management Adoption Trial (DCAT) establishes a quasi-experimental comparative effectiveness research clinical trial aimed at accelerating the adoption of collaborative depression care in safety net clinics. The study was conducted in collaboration with the Los Angeles County Department of Health Services at eight county-operated clinics. DCAT has enrolled 1406 low-income, predominantly Hispanic/Latino patients with diabetes to test a translational model of depression care management. This three-group study compares usual care with a collaborative care team support model and a technology-facilitated depression care model that provides automated telephonic depression screening and monitoring tailored to patient conditions and preferences. Call results are integrated into a diabetes disease management registry that delivers provider notifications, generates tasks, and issues critical alerts. All subjects receive comprehensive assessments at baseline, 6, 12, and 18 months by independent English-Spanish bilingual interviewers. Study outcomes include depression outcomes, treatment adherence, satisfaction, acceptance of assessment and monitoring technology, social and economic stress reduction, diabetes self-care management, health care utilization, and care management model cost and cost-effectiveness comparisons. DCAT's goal is to optimize depression screening, treatment, follow-up, outcomes, and cost savings to reduce health disparities. Copyright © 2013 Elsevier Inc. All rights reserved.
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Medicare managed care. How physicians can make it better.
Roggin, G M
1997-12-01
The federal government is attempting to control anticipated, increased Medicare health care costs by providing the senior population with incentives to encourage their movement into managed care programs. For-profit corporate HMOs that currently dominate the managed care arena are coming under increased competitive pressure at a time when their perception of profiteering is undergoing increased public scrutiny. If physicians are to take advantage of this window of opportunity and successfully enter the Medicare managed care marketplace, they must identify the major deficiencies existing in the current model, and fashion a new product that divests itself of the profit orientation of current corporate HMOs. A nonprofit version of a highly integrated, multispecialty provider service organization (PSO) provides an appropriate model to effectively compete with the corporate HMO. The ideal physician-controlled managed care model must: develop a responsive policy board structure; create practice guidelines that decrease variation in physician practice; achieve an appropriate balance between primary and specialty medical care; and adopt a quality-assurance program that effectively addresses both process and outcome data.
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Sun, Wen; Yu, Lin; Liu, Shiliang; Chen, Yanhong; Chen, Juanjuan; Wen, Shi Wu; Chen, Dunjin
2018-03-01
Online-to-offline is a new model for emergent medical service with the ability to connect care providers with patients on instant basis. This study aims to evaluate maternal and neonatal outcomes in patients with placenta accreta spectrum managed by an online-to-offline care model. Starting from January 1, 2015, management of patients with placenta accreta spectrum was changed from standard care model into an online-to-offline care model through "Wechat" in Guangzhou Medical Centre for Critical Obstetrical Care. This study compared maternal and neonatal outcomes in patients affected by placenta accreta spectrum between 2015 (online-to-offline model) and 2014 (standard care model). A total of 209 cases of placenta accrete spectrum were treated in our center in 2015 and 218 such cases were treated in 2014. Patients treated in 2015 had lower rate of hysterectomy (14.83% versus 20.64%) and shorter hospital stay (7 days versus 8 days). The average interval from admission to emergency cesarean section for critically ill patients was 38.5 min in 2015 versus 50.7 min in 2014. Patients affected by placenta accreta spectrum managed by online-to-offline care model have reduced risk of hysterectomy, shorter hospital stay, and shorter response time from admission to emergency cesarean section. Copyright © 2018 Elsevier B.V. All rights reserved.
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Nurse managed occupational health services: a primary care model in practice.
Childre, F
1997-10-01
1. Managed care focus on delivering health care which values prevention, early intervention, continuity of care, commitment to quality care, and outcomes, as well as client satisfaction. Occupational health nurses routinely integrate these values into their practice. 2. An on-site model of primary health care delivery, incorporating the fundamentals of occupational health nursing, can bring significant savings to the organization in health related costs. 3. Case management may provide the greatest potential for growth in occupational health nursing. It is a method that can be used together with managed care to maximize quality health care services. 4. Viewing health related costs as an investment as opposed to part of a benefit plan, influences employees to make positive choices. It also impacts the delivery of health care services on a systematic, global level, which affects total health care costs.
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ERIC Educational Resources Information Center
Burgio, Louis D.; Burgio, Kathryn L.
1990-01-01
Asserts that, if long-term care is to progress from custodial model to therapeutic model of rehabilitation, role of nursing assistants must be redesigned. Reviews current methods of institutional staff training and management and proposes model for geriatric, long-term care facilities. Discusses organizational resistance and offers suggestions for…
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Fromer, Len
2011-01-01
Current primary care patterns for chronic obstructive pulmonary disease (COPD) focus on reactive care for acute exacerbations, often neglecting ongoing COPD management to the detriment of patient experience and outcomes. Proactive diagnosis and ongoing multifactorial COPD management, comprising smoking cessation, influenza and pneumonia vaccinations, pulmonary rehabilitation, and symptomatic and maintenance pharmacotherapy according to severity, can significantly improve a patient's health-related quality of life, reduce exacerbations and their consequences, and alleviate the functional, utilization, and financial burden of COPD. Redesign of primary care according to principles of the chronic care model, which is implemented in the patient-centered medical home, can shift COPD management from acute rescue to proactive maintenance. The chronic care model and patient-centered medical home combine delivery system redesign, clinical information systems, decision support, and self-management support within a practice, linked with health care organization and community resources beyond the practice. COPD care programs implementing two or more chronic care model components effectively reduce emergency room and inpatient utilization. This review guides primary care practices in improving COPD care workflows, highlighting the contributions of multidisciplinary collaborative team care, care coordination, and patient engagement. Each primary care practice can devise a COPD care workflow addressing risk awareness, spirometric diagnosis, guideline-based treatment and rehabilitation, and self-management support, to improve patient outcomes in COPD.
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Managing Chronic Disease in Ontario Primary Care: The Impact of Organizational Factors
Russell, Grant M.; Dahrouge, Simone; Hogg, William; Geneau, Robert; Muldoon, Laura; Tuna, Meltem
2009-01-01
PURPOSE New approaches to chronic disease management emphasize the need to improve the delivery of primary care services to meet the needs of chronically ill patients. This study (1) assessed whether chronic disease management differed among 4 models of primary health care delivery and (2) identified which practice organizational factors were independently associated with high-quality care. METHODS We undertook a cross-sectional survey with nested qualitative case studies (2 practices per model) in 137 randomly selected primary care practices from 4 delivery models in Ontario Canada: fee for service, capitation, blended payment, and community health centers (CHCs). Practice and clinician surveys were based on the Primary Care Assessment Tool. A chart audit assessed evidence-based care delivery for patients with diabetes, congestive heart failure, and coronary artery disease. Intermediate outcomes were calculated for patients with diabetes and hypertension. Multiple linear regression identified those organizational factors independently associated with chronic disease management. RESULTS Chronic disease management was superior in CHCs. Clinicians in CHCs found it easier than those in the other models to promote high-quality care through longer consultations and interprofessional collaboration. Across the whole sample and independent of model, high-quality chronic disease management was associated with the presence of a nurse-practitioner. It was also associated with lower patient-family physician ratios and when practices had 4 or fewer full-time-equivalent family physicians. CONCLUSIONS The study adds to the literature supporting the value of nurse-practitioners within primary care teams and validates the contributions of Ontario’s CHCs. Our observation that quality of care decreased in larger, busier practices suggests that moves toward larger practices and greater patient-physician ratios may have unanticipated negative effects on processes of care quality. PMID:19597168
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Beyond usual care: the economic consequences of expanding treatment options in early pregnancy loss.
Dalton, Vanessa K; Liang, Angela; Hutton, David W; Zochowski, Melissa K; Fendrick, A Mark
2015-02-01
The objective of this study was to estimate the economic consequences of expanding options for early pregnancy loss (EPL) treatment beyond expectant management and operating room surgical evacuation (usual care). We constructed a decision model using a hypothetical cohort of women undergoing EPL management within a 30 day horizon. Treatment options under the usual care arm include expectant management and surgical uterine evacuation in an operating room (OR). Treatment options under the expanded care arm included all evidence-based safe and effective treatment options for EPL: expectant management, misoprostol treatment, surgical uterine evacuation in an office setting, and surgical uterine evacuation in an OR. Probabilities of entering various treatment pathways were based on previously published observational studies. The cost per case was US $241.29 lower for women undergoing treatment in the expanded care model as compared with the usual care model (US $1033.29 per case vs US $1274.58 per case, expanded care and usual care, respectively). The model was the most sensitive to the failure rate of the expectant management arm, the cost of the OR surgical procedure, the proportion of women undergoing an OR surgical procedure under usual care, and the additional cost per patient associated with implementing and using the expanded care model. This study demonstrates that expanding women's treatment options for EPL beyond what is typically available can result in lower direct medical expenditures. Copyright © 2015 Elsevier Inc. All rights reserved.
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The Case for Chronic Disease Management for Addiction
Saitz, Richard; Larson, Mary Jo; LaBelle, Colleen; Richardson, Jessica; Samet, Jeffrey H.
2009-01-01
Chronic disease (care) management (CDM) is a patient-centered model of care that involves longitudinal care delivery; integrated, and coordinated primary medical and specialty care; patient and clinician education; explicit evidence-based care plans; and expert care availability. The model, incorporating mental health and specialty addiction care, holds promise for improving care for patients with substance dependence who often receive no care or fragmented ineffective care. We describe a CDM model for substance dependence and discuss a conceptual framework, the extensive current evidence for component elements, and a promising strategy to reorganize primary and specialty health care to facilitate access for people with substance dependence. The CDM model goes beyond integrated case management by a professional, colocation of services, and integrated medical and addiction care—elements that individually can improve outcomes. Supporting evidence is presented that: 1) substance dependence is a chronic disease requiring longitudinal care, although most patients with addictions receive no treatment (eg, detoxification only) or short-term interventions, and 2) for other chronic diseases requiring longitudinal care (eg, diabetes, congestive heart failure), CDM has been proven effective. PMID:19809579
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Kowinsky, Amy; Greenhouse, Pamela K; Zombek, Victoria L; Rader, Sandra L; Reidy, Margaret E
2009-09-01
In many hospitals, addressing increasing financial and regulatory requirements has resulted in a decline in care managers' time spent communicating directly with patients, families, and healthcare providers. The authors discuss the redesign of a hospital care management model that increased the time care managers spend with patients, families, and other care professionals, while patient satisfaction increased, labor cost remained neutral, length of stay decreased, and the payment denial rate remained among the country's lowest.
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The Effect of Nurse Practitioner Co-Management on the Care of Geriatric Conditions
Reuben, David B.; Ganz, David A.; Roth, Carol P.; McCreath, Heather E.; Ramirez, Karina D.; Wenger, Neil S.
2013-01-01
Background/Objectives The quality of care for geriatric conditions remains poor. The Assessing Care of Vulnerable Elders (ACOVE)-2 model (case finding, delegation of data collection, structured visit notes, physician and patient education, and linkage to community resources) improves the quality of care for geriatric conditions when implemented by primary care physicians (PCPs) or by nurse practitioners (NPs) co-managing care with an academic geriatrician. However, it is unclear whether community-based PCP-NP co-management can achieve similar results. Design Case study. Setting Two community-based primary care practices. Participants Patients > 75 years who screened positive for at least one condition: falls, urinary incontinence (UI), dementia, and depression. Intervention The ACOVE-2 model augmented by NP co-management of conditions. Measurements Quality of care by medical record review using ACOVE-3 quality indicators (QIs). Patients receiving co-management were compared with those who received PCP care alone in the same practices. Results Of 1084 screened patients, 658 (61%) screened positive for > 1 condition; 485 of these patients were randomly selected for chart review and triggered a mean of 7 QIs. A NP saw approximately half (49%) for co-management. Overall, patients received 57% of recommended care. Quality scores for all conditions (falls: 80% versus 34%; UI: 66% versus 19%; dementia: 59% versus 38%) except depression (63% versus 60%) were higher for patients seen by a NP. In analyses adjusted for gender, age of patient, number of conditions, site, and a NP estimate of medical management style, NP co-management remained significantly associated with receiving recommended care (p<0.001), as did the NP estimate of medical management style (p=0.02). Conclusion Compared to usual care using the ACOVE-2 model, NP co-management is associated with better quality of care for geriatric conditions in community-based primary care. PMID:23772723
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Exporting the Buyers Health Care Action Group Purchasing Model: Lessons from Other Communities
Christianson, Jon B; Feldman, Roger
2005-01-01
When first implemented in Minneapolis and St. Paul, Minnesota, the Buyers Health Care Action Group's (BHCAG) purchasing approach received considerable attention as an employer-managed, consumer-driven health care model embodying many of the principles of managed competition. First BHCAG and, later, a for-profit management company attempted to export this model to other communities. Their efforts were met with resistance from local hospitals and, in many cases, apathy by employers who were expected to be supportive. This experience underscores several difficulties that appear to be inherent in implementing purchasing models based on competing care systems. It also, once again, suggests caution in drawing lessons from community-level experiments in purchasing health care. PMID:15787957
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Porteous, Terry; Wyke, Sally; Hannaford, Philip; Bond, Christine
2015-02-01
To explore whether Andersen's Behavioral Model of Health Services Use can aid understanding of self-care behaviour and inform development of interventions to promote self-care for minor illness. Qualitative interviews were conducted with 24 Scottish participants about their experience and management of minor symptoms normally associated with analgesic use. Synthesised data from the interviews were mapped onto the Behavioral Model. All factors identified as influencing decisions about how to manage the symptoms discussed, mapped onto at least one domain of Andersen's model. Individual characteristics including beliefs, need factors and available resources were associated with health behaviour, including self-care. Outcomes such as perceived health status and consumer satisfaction from previous experience of managing symptoms also appeared to feed back into health behaviour. The Behavioral Model seems relevant to self-care as well as formal health services. Additional work is needed to explore applicability of the Behavioral Model to different types of symptoms, different modalities of self-care and in countries with different health care systems. Future quantitative studies should establish the relative importance of factors influencing the actions people take to manage minor symptoms to inform future interventions aimed at optimising self-care behaviour. © 2014 Royal Pharmaceutical Society.
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McGivney, Melissa Somma; Meyer, Susan M; Duncan-Hewitt, Wendy; Hall, Deanne L; Goode, Jean-Venable R; Smith, Randall B
2007-01-01
To delineate the relationship, including similarities and differences, between medication therapy management (MTM) and contemporary pharmacist-provided services, including patient counseling, disease management, and pharmaceutical care, to facilitate the continued evolution of commonly used language and a standard of practice across geographic areas and practice environments. Incorporation of MTM services into the array of Medicare-funded services affords an opportunity for pharmacists to develop direct patient care services in the community. Defining the role of MTM within the scope of pharmacist-provided patient care activities, including patient counseling, disease management, and all currently provided pharmacy services is essential to the delineation of a viable and sustainable practice model for pharmacists. The definitions of each of these services are offered, as well as comparisons and contrasts of the individual services. In addition to Medicare-eligible patients, MTM services are appropriate for anyone with medication-related needs. MTM is offered as an all-encompassing model that incorporates the philosophy of pharmaceutical care, techniques of patient counseling, and disease management in an environment that facilitates the direct collaboration of patients, pharmacists, and other health professionals. Defining the role of MTM within the current patient care models, including patient counseling, disease management, and all who provide pharmacy services, is essential in delineating a viable and sustainable practice model for pharmacists.
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Change management in health care.
Campbell, Robert James
2008-01-01
This article introduces health care managers to the theories and philosophies of John Kotter and William Bridges, 2 leaders in the evolving field of change management. For Kotter, change has both an emotional and situational component, and methods for managing each are expressed in his 8-step model (developing urgency, building a guiding team, creating a vision, communicating for buy-in, enabling action, creating short-term wins, don't let up, and making it stick). Bridges deals with change at a more granular, individual level, suggesting that change within a health care organization means that individuals must transition from one identity to a new identity when they are involved in a process of change. According to Bridges, transitions occur in 3 steps: endings, the neutral zone, and beginnings. The major steps and important concepts within the models of each are addressed, and examples are provided to demonstrate how health care managers can actualize the models within their health care organizations.
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Williams, Brent C; Paik, Jamie L; Haley, Laura L; Grammatico, Gina M
2014-01-01
Although evidence of effectiveness is limited, care management based outside primary care practices or hospitals is receiving increased attention. The University of Michigan (UM) Complex Care Management Program (CCMP) provides care management for uninsured and underinsured, high-utilizing patients in multiple primary care practices. To inform development of optimal care management models, we describe the CCMP model and characteristics and health care utilization patterns of its patients. Of a consecutive series of 49 patients enrolled at CCMP in 2011, the mean (SD) age was 48 (+/- 14); 23 (47%) were women; and 29 (59%) were White. Twenty-eight (57%) had two or more chronic medical conditions, 39 (80%) had one or more psychiatric condition, 28 (57%) had a substance abuse disorder, and 11 (22%) were homeless. Through phone, e-mail, and face-to-face contact with patients and primary care providers (PCPs), care managers coordinated health and social services and facilitated access to medical and mental health care. Patients had a mean (SD) number of hospitalizations and emergency room (ER) visits in 6 months prior to enrollment of2.2 (2.5) and 4.2 (4.3), respectively, with a nonstatistically significant decrease in hospitalizations, hospital days, and emergency room visits in 6 months following enrollment in CCMP. Centralized care management support for primary care practices engages high-utilizing patients with complex medical and behavioral conditions in care management that would be difficult to provide through individual practices and may decrease health care utilization by these patients.
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Quality management in home care: models for today's practice.
Verhey, M P
1996-01-01
In less than a decade, home care providers have been a part of two major transitions in health care delivery. First, because of the advent of managed care and a shift from inpatient to community-based services, home care service delivery systems have experienced tremendous growth. Second, the principles and practices of total quality management and continuous quality improvement have permeated the organization, administration, and practice of home health care. Based on the work of Deming, Juran, and Crosby, the basic tenets of the new quality management philosophy involve a focus on the following five key areas: (1) systems and processes rather than individual performance; (2) involvement, collaboration, and empowerment; (3) internal and external "customers"; (4) data and measurement; and (5) standards, guidelines, and outcomes of care. Home care providers are among those in the forefront who are developing and implementing programs that integrate these foci into the delivery of quality home care services. This article provides a summary of current home care programs that address these five key areas of quality management philosophy and provide models for innovative quality management practice in home care. For further information about each program, readers are referred to the original reports in the home care and quality management journal literature, as cited herein.
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Bleich, Sara N.; Sherrod, Cheryl; Chiang, Anne; Boyd, Cynthia; Wolff, Jennifer; DuGoff, Eva; Salzberg, Claudia; Anderson, Keely; Leff, Bruce
2015-01-01
Introduction Finding ways to provide better and less expensive health care for people with multiple chronic conditions or disability is a pressing concern. The purpose of this systematic review was to evaluate different approaches for caring for this high-need and high-cost population. Methods We searched Medline for articles published from May 31, 2008, through June 10, 2014, for relevant studies. Articles were considered eligible for this review if they met the following criteria: included people with multiple chronic conditions (behavioral or mental health) or disabilities (2 or more); addressed 1 or more of clinical outcomes, health care use and spending, or patient satisfaction; and compared results from an intervention group with a comparison group or baseline measurements. We extracted information on program characteristics, participant characteristics, and significant (positive and negative) clinical findings, patient satisfaction, and health care use outcomes. For each outcome, the number of significant and positive results was tabulated. Results Twenty-seven studies were included across 5 models of care. Of the 3 studies reporting patient satisfaction outcomes, 2 reported significant improvements; both were randomized controlled trials (RCTs). Of the 14 studies reporting clinical outcomes, 12 reported improvements (8 were RCTs). Of the 13 studies reporting health care use and spending outcomes, 12 reported significant improvements (2 were RCTs). Two models of care — care and case management and disease management — reported improvements in all 3 outcomes. For care and case management models, most improvements were related to health care use. For the disease management models, most improvements were related to clinical outcomes. Conclusions Care and case management as well as disease management may be promising models of care for people with multiple chronic conditions or disabilities. More research and consistent methods are needed to understand the most appropriate care for these high-need and high-cost patients. PMID:26564013
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Bleich, Sara N; Sherrod, Cheryl; Chiang, Anne; Boyd, Cynthia; Wolff, Jennifer; DuGoff, Eva; Chang, Eva; Salzberg, Claudia; Anderson, Keely; Leff, Bruce; Anderson, Gerard
2015-11-12
Finding ways to provide better and less expensive health care for people with multiple chronic conditions or disability is a pressing concern. The purpose of this systematic review was to evaluate different approaches for caring for this high-need and high-cost population. We searched Medline for articles published from May 31, 2008, through June 10, 2014, for relevant studies. Articles were considered eligible for this review if they met the following criteria: included people with multiple chronic conditions (behavioral or mental health) or disabilities (2 or more); addressed 1 or more of clinical outcomes, health care use and spending, or patient satisfaction; and compared results from an intervention group with a comparison group or baseline measurements. We extracted information on program characteristics, participant characteristics, and significant (positive and negative) clinical findings, patient satisfaction, and health care use outcomes. For each outcome, the number of significant and positive results was tabulated. Twenty-seven studies were included across 5 models of care. Of the 3 studies reporting patient satisfaction outcomes, 2 reported significant improvements; both were randomized controlled trials (RCTs). Of the 14 studies reporting clinical outcomes, 12 reported improvements (8 were RCTs). Of the 13 studies reporting health care use and spending outcomes, 12 reported significant improvements (2 were RCTs). Two models of care - care and case management and disease management - reported improvements in all 3 outcomes. For care and case management models, most improvements were related to health care use. For the disease management models, most improvements were related to clinical outcomes. Care and case management as well as disease management may be promising models of care for people with multiple chronic conditions or disabilities. More research and consistent methods are needed to understand the most appropriate care for these high-need and high-cost patients.
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Delon, Sandra; Mackinnon, Blair
2009-01-01
Alberta's integrated approach to chronic disease management programming embraces client-centred care, supports self-management and facilitates care across the continuum. This paper presents strategies implemented through collaboration with primary care to improve care of individuals with chronic conditions, evaluation evidence supporting success and lessons learned from the Alberta perspective.
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Garman, Andrew N; McAlearney, Ann Scheck; Harrison, Michael I; Song, Paula H; McHugh, Megan
2011-01-01
: Although management practices are recognized as important factors in improving health care quality and efficiency, most research thus far has focused on individual practices, ignoring or underspecifying the contexts within which these practices are operating. Research from other industries, which has increasingly focused on systems rather than individual practices, has yielded results that may benefit health services management. : Our goal was to develop a conceptual model on the basis of prior research from health care as well as other industries that could be used to inform important contextual considerations within health care. : Using theoretical frameworks from A. Donabedian (1966), P. M. Wright, T. M. Gardner, and L. M. Moynihan (2003), and B. Schneider, D. B. Smith, and H. W. Goldstein (2000) and review methods adapted from R. Pawson (2006b), we reviewed relevant research from peer-reviewed and other industry-relevant sources to inform our model. The model we developed was then reviewed with a panel of practitioners, including experts in quality and human resource management, to assess the applicability of the model to health care settings. : The resulting conceptual model identified four practice bundles, comprising 14 management practices as well as nine factors influencing adoption and perceived sustainability of these practices. The mechanisms by which these practices influence care outcomes are illustrated using the example of hospital-acquired infections. In addition, limitations of the current evidence base are discussed, and an agenda for future research in health care settings is outlined. : Results may help practitioners better conceptualize management practices as part of a broader system of work practices. This may, in turn, help practitioners to prioritize management improvement efforts more systematically.
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Cramm, Jane Murray; Nieboer, Anna Petra
2012-11-01
Disease management programs based on the Chronic Care Model are expected to improve the quality of chronic care delivery. However, evidence to date for such improvement and how it is achieved is scarce. In 2010 and again in 2011, we surveyed professionals in twenty-two primary care practices in the Netherlands that had implemented the Chronic Care Model of disease management beginning in 2009. The responses showed that, over time, chronic illness care delivery improved to advanced levels. The gains were attributed primarily to improved relational coordination-that is, raising the quality of communication and task integration among professionals from diverse disciplines who share common objectives. These findings may have implications for other disease management efforts by collaborative care teams, in that they suggest that diverse health care professionals must be strongly connected to provide effective, holistic care.
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Comprehensive nursing case management. An advanced practice model.
Taylor, P
1999-01-01
Under managed care and capitated reimbursement systems, case management is a core strategy for providing high-quality, cost-effective care by decreasing fragmentation, enhancing quality, ensuring efficient use of resources, and containing costs. Although case management is used in various areas of the healthcare arena, it suffers from a lack of consensus regarding its definition, essential components, and appropriate application. The purpose of this paper is to examine the components and limitations of existing case management models, outline the competencies of an effective case manager, and present a model of advanced practice nursing case management that focuses on a continuum of care that integrates medical and psychosocial resources to promote optimal clinical fiscal outcomes and enables patients to work as partners with the healthcare team in facilitating and maintaining their physical and emotional well-being.
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Alkema, Gretchen E; Wilber, Kathleen H; Shannon, George R; Allen, Douglas
2007-08-01
This analysis evaluated mortality over 24 months for Medicare managed care members who participated in the Care Advocate Program (CA Program) designed to link those with high health care utilization to home- and community-based services. Secondary data from the CA Program, part of the California HealthCare Foundation's Elders in Managed Care Initiative. Randomized-control trial in which participants (N=781) were randomly assigned to intent-to-treat (ITT) and control groups. ITT group received telephonic social care management and 12 months of follow-up. Various multivariate analyses were used to evaluate mortality risk throughout multiple study periods controlling for sociodemographic characteristics, health status, and health care utilization. Older adults (65+) enrolled in a Medicare managed care plan who had high health care utilization in the previous year. ITT group had a significantly lower odds of mortality throughout the study (OR=0.55; p=.005) and during the care management intervention (OR=0.45; p=.006), whereas differential risk in the postintervention period was not statistically significant. Other significant predictors of mortality were age, gender, three chronic conditions (cancer, heart disease, and kidney disease), and emergency room utilization. Findings suggest that the care advocate model of social care management affected mortality while the program was in progress, but not after completion of the intervention phase. Key model elements accounted for the findings, which include individualized targeting, assessment, and monitoring; consumer choice, control, and participant self-management; and bridging medical and social service delivery systems through direct linkages and communication.
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The evaluation of the National Long Term Care Demonstration. 4. Case management under channeling.
Phillips, B R; Kemper, P; Applebaum, R A
1988-01-01
The channeling demonstration involved provision of comprehensive case management and direct service expansion. This article considers the former. Under both models, comprehensive case management was implemented largely as intended; moreover, channeling substantially increased the receipt of comprehensive care management. However, channeling was not a pure test of the effect of comprehensive case management: roughly 10-20 percent of control group members received comparable case management services. This was particularly the case for the financial control model. Thus, the demonstration was not a test of case management compared to no case management; rather, it compared channeling case management to the existing community care system, which already was providing comprehensive case management to some of the population eligible for channeling. PMID:3130331
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Venturato, Lorraine; Drew, Liz
2010-06-01
Contemporary health care environments are increasingly challenged by issues associated with the recruitment and retention of qualified nursing staff. This challenge is particularly felt by residential aged care providers, with registered nurse (RN) numbers already limited and resident acuity rapidly rising. As a result, aged care service providers are increasingly exploring creative and alternative models of care. This article details exploratory research into a pre-existing, alternative model of care in a medium sized, regional residential aged care facility. Research findings suggest that the model of care is complex and multi-faceted and is an example of an integrated model of care. As a result of the implementation of this model of care a number of shifts have occurred in the practice experiences and clinical culture within this facility. Results suggest that the main benefits of this model are: (1) increased opportunities for RNs to engage in clinical leadership and proactive care management; (2) improved management and communication in relation to work processes and practices; and (3) enhanced recruitment and retention of both RNs and care workers.
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A nurse led model of chronic disease care - an interim report.
Eley, Diann S; Del Mar, Chris B; Patterson, Elizabeth; Synnott, Robyn L; Baker, Peter G; Hegney, Desley
2008-12-01
Chronic condition management in general practice is projected to account for 50% of all consultations by 2051. General practices under present workforce conditions will be unable to meet this demand. Nurse led collaborative care models of chronic disease management have been successful overseas and are proposed as one solution. This article provides an interim report on a prospective randomised trial to investigate the acceptability, cost effectiveness and feasibility of a nurse led model of care for chronic conditions in Australian general practice. A qualitative study focused on the impact of this model of care through the perceptions of practice staff from one urban and one regional practice in Queensland, and one Victorian rural practice. Primary benefits of the collaborative care model focused on increased efficiency and communication between practice staff and patients. The increased degree of patient self responsibility was noted by all and highlights the motivational aspect of chronic disease management.
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The modern CIO: forging a new role in the managed care era.
Griffin, J
1997-05-01
The advent of managed care has helped forge new roles for healthcare professionals. Competitive pressures, the profile of the member community, and provider network design drive healthcare delivery via the managed care model. Careful analysis and design of the managed care model charts the success or failure of the health care delivery system--usually an integrated delivery system (IDS). Therefore, those healthcare organizations that have chosen to get on the managed care bandwagon must re-invent themselves, both culturally and technologically. The chief information officer (CIO) leads this technological revolution. To work effectively, the technological infrastructure of the IDS must be closely in line with enterprise goals and objectives. In the managed care environment the old information system (IS) approach of supporting the operational needs of individual departments simply will not work. The CIO's new role will be to master the concept of managed care to ensure that enterprise-wide needs for operational, clinical, and financial information are met, and that IS and enterprise goals are aligned. CIOs who have an intuitive grasp of the managed care environment--although their numbers are growing as managed care mushrooms--make up a minority group. They are a special breed with clearly definable qualities such as business savvy and an affinity for big-picture thinking. To an IDS, a CIO with these qualities is a rare gem indeed. This article introduces Don Winschel, the associate administrator and CIO of Johnson City Medical Center (Johnson City, TN) as an example of one such modern CIO.
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Disease management projects and the Chronic Care Model in action: baseline qualitative research
2012-01-01
Background Disease management programs, especially those based on the Chronic Care Model (CCM), are increasingly common in the Netherlands. While disease management programs have been well-researched quantitatively and economically, less qualitative research has been done. The overall aim of the study is to explore how disease management programs are implemented within primary care settings in the Netherlands; this paper focuses on the early development and implementation stages of five disease management programs in the primary care setting, based on interviews with project leadership teams. Methods Eleven semi-structured interviews were conducted at the five selected sites with sixteen professionals interviewed; all project directors and managers were interviewed. The interviews focused on each project’s chosen chronic illness (diabetes, eating disorders, COPD, multi-morbidity, CVRM) and project plan, barriers to development and implementation, the project leaders’ action and reactions, as well as their roles and responsibilities, and disease management strategies. Analysis was inductive and interpretive, based on the content of the interviews. After analysis, the results of this research on disease management programs and the Chronic Care Model are viewed from a traveling technology framework. Results This analysis uncovered four themes that can be mapped to disease management and the Chronic Care Model: (1) changing the health care system, (2) patient-centered care, (3) technological systems and barriers, and (4) integrating projects into the larger system. Project leaders discussed the paths, both direct and indirect, for transforming the health care system to one that addresses chronic illness. Patient-centered care was highlighted as needed and a paradigm shift for many. Challenges with technological systems were pervasive. Project leaders managed the expenses of a traveling technology, including the social, financial, and administration involved. Conclusions At the sites, project leaders served as travel guides, assisting and overseeing the programs as they traveled from the global plans to local actions. Project leaders, while hypothetically in control of the programs, in fact shared control of the traveling of the programs with patients, clinicians, and outside consultants. From this work, we can learn what roadblocks and expenses occur while a technology travels, from a project leader’s point of view. PMID:22578251
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Disease management projects and the Chronic Care Model in action: baseline qualitative research.
Walters, Bethany Hipple; Adams, Samantha A; Nieboer, Anna P; Bal, Roland
2012-05-11
Disease management programs, especially those based on the Chronic Care Model (CCM), are increasingly common in The Netherlands. While disease management programs have been well-researched quantitatively and economically, less qualitative research has been done. The overall aim of the study is to explore how disease management programs are implemented within primary care settings in The Netherlands; this paper focuses on the early development and implementation stages of five disease management programs in the primary care setting, based on interviews with project leadership teams. Eleven semi-structured interviews were conducted at the five selected sites with sixteen professionals interviewed; all project directors and managers were interviewed. The interviews focused on each project's chosen chronic illness (diabetes, eating disorders, COPD, multi-morbidity, CVRM) and project plan, barriers to development and implementation, the project leaders' action and reactions, as well as their roles and responsibilities, and disease management strategies. Analysis was inductive and interpretive, based on the content of the interviews. After analysis, the results of this research on disease management programs and the Chronic Care Model are viewed from a traveling technology framework. This analysis uncovered four themes that can be mapped to disease management and the Chronic Care Model: (1) changing the health care system, (2) patient-centered care, (3) technological systems and barriers, and (4) integrating projects into the larger system. Project leaders discussed the paths, both direct and indirect, for transforming the health care system to one that addresses chronic illness. Patient-centered care was highlighted as needed and a paradigm shift for many. Challenges with technological systems were pervasive. Project leaders managed the expenses of a traveling technology, including the social, financial, and administration involved. At the sites, project leaders served as travel guides, assisting and overseeing the programs as they traveled from the global plans to local actions. Project leaders, while hypothetically in control of the programs, in fact shared control of the traveling of the programs with patients, clinicians, and outside consultants. From this work, we can learn what roadblocks and expenses occur while a technology travels, from a project leader's point of view.
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Self-Management: Enabling and empowering patients living with cancer as a chronic illness
McCorkle, Ruth; Ercolano, Elizabeth; Lazenby, Mark; Schulman-Green, Dena; Schilling, Lynne S.; Lorig, Kate; Wagner, Edward H.
2010-01-01
With recent improvements in early detection, diagnosis and treatment of cancer, people with cancer are living longer, and their cancer may be managed as a chronic illness. Cancer as a chronic illness places new demands on patients and families to manage their own care, and it challenges old paradigms that oncology's work is done after treatment. As a chronic illness, however, cancer care occurs on a continuum that stretches from prevention to the end of life, with early detection, diagnosis, treatment, and survivorship in between. In this paper, we review self-management interventions that enable patients and families to participate in managing their care along this continuum. We review randomized controlled trials of self-management interventions with cancer patients and families in the treatment, survivorship, and end-of-life phases of the cancer-care continuum. We also present the Chronic Care Model as a model of care that oncology practices can use to enable and empower patients and families to engage in self-management. We conclude that, the need for a common language by which to speak about self-management and a common set of self-management actions for cancer care notwithstanding, oncology practices can now build strong relationships with their patients and formulate mutually-agreed upon care plans that enable and empower patients to care for themselves in the way they prefer. PMID:21205833
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Health care units and human resources management trends.
André, Adriana Maria; Ciampone, Maria Helena Trench; Santelle, Odete
2013-02-01
To identify factors producing new trends in basic health care unit management and changes in management models. This was a prospective study with ten health care unit managers and ten specialists in the field of Health in São Paulo, Southeastern Brazil, in 2010. The Delphi methodology was adopted. There were four stages of data collection, three quantitative and the fourth qualitative. The first three rounds dealt with changing trends in management models, manager profiles and required competencies, and the Mann-Whitney test was used in the analysis. The fourth round took the form of a panel of those involved, using thematic analysis. The main factors which are driving change in basic health care units were identified, as were changes in management models. There was consensus that this process is influenced by the difficulties in managing teams and by politics. The managers were found to be up-to-date with trends in the wider context, with the arrival of social health organizations, but they are not yet anticipating these within the institutions. Not only the content, but the professional development aspect of training courses in this area should be reviewed. Selection and recruitment, training and assessment of these professionals should be guided by these competencies aligned to the health service mission, vision, values and management models.
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Value-based resource management: a model for best value nursing care.
Caspers, Barbara A; Pickard, Beth
2013-01-01
With the health care environment shifting to a value-based payment system, Catholic Health Initiatives nursing leadership spearheaded an initiative with 14 hospitals to establish best nursing care at a lower cost. The implementation of technology-enabled business processes at point of care led to a new model for best value nursing care: Value-Based Resource Management. The new model integrates clinical patient data from the electronic medical record and embeds the new information in care team workflows for actionable real-time decision support and predictive forecasting. The participating hospitals reported increased patient satisfaction and cost savings in the reduction of overtime and improvement in length of stay management. New data generated by the initiative on nursing hours and cost by patient and by population (Medicare severity diagnosis-related groups), and patient health status outcomes across the acute care continuum expanded business intelligence for a value-based population health system.
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Transitions of Care Model Inclusive of Unplanned Care Improves the Patient Experience
Cox, Jon; Teague, Stephanie; Beck, Eric
2016-01-01
A major emphasis in health care is creating an experience whereby patients receive the right care at the right time from the right provider in the right setting at the right cost. Over the past several decades, there has been considerable effort in the area of medical management, with prior authorization, gatekeeper utilization management regimens, and other techniques designed to guide patients and caregivers into desired treatment pathways. Alternatively, the concept of demand management may be employed to achieve these desired outcomes by giving patients meaningful, expanded choices beyond traditional acute-care settings. The implementation of a novel, patient-centered, unplanned care delivery model is described along with illustrative case studies. PMID:28725828
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Diabetes Management at School: Application of the Healthy Learner Model
ERIC Educational Resources Information Center
Bobo, Nichole; Kaup, Tara; McCarty, Patricia; Carlson, Jessie Parker
2011-01-01
Every child with diabetes deserves a school nurse with the capacity to effectively manage the disease at school. The school nurse needs knowledge and skills to confidently provide care and communicate with health care providers and families. The Healthy Learner Model for Chronic Condition Management provided a framework to eliminate the disjointed…
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Thota, Anilkrishna B; Sipe, Theresa Ann; Byard, Guthrie J; Zometa, Carlos S; Hahn, Robert A; McKnight-Eily, Lela R; Chapman, Daniel P; Abraido-Lanza, Ana F; Pearson, Jane L; Anderson, Clinton W; Gelenberg, Alan J; Hennessy, Kevin D; Duffy, Farifteh F; Vernon-Smiley, Mary E; Nease, Donald E; Williams, Samantha P
2012-05-01
To improve the quality of depression management, collaborative care models have been developed from the Chronic Care Model over the past 20 years. Collaborative care is a multicomponent, healthcare system-level intervention that uses case managers to link primary care providers, patients, and mental health specialists. In addition to case management support, primary care providers receive consultation and decision support from mental health specialists (i.e., psychiatrists and psychologists). This collaboration is designed to (1) improve routine screening and diagnosis of depressive disorders; (2) increase provider use of evidence-based protocols for the proactive management of diagnosed depressive disorders; and (3) improve clinical and community support for active client/patient engagement in treatment goal-setting and self-management. A team of subject matter experts in mental health, representing various agencies and institutions, conceptualized and conducted a systematic review and meta-analysis on collaborative care for improving the management of depressive disorders. This team worked under the guidance of the Community Preventive Services Task Force, a nonfederal, independent, volunteer body of public health and prevention experts. Community Guide systematic review methods were used to identify, evaluate, and analyze available evidence. An earlier systematic review with 37 RCTs of collaborative care studies published through 2004 found evidence of effectiveness of these models in improving depression outcomes. An additional 32 studies of collaborative care models conducted between 2004 and 2009 were found for this current review and analyzed. The results from the meta-analyses suggest robust evidence of effectiveness of collaborative care in improving depression symptoms (standardized mean difference [SMD]=0.34); adherence to treatment (OR=2.22); response to treatment (OR=1.78); remission of symptoms (OR=1.74); recovery from symptoms (OR=1.75); quality of life/functional status (SMD=0.12); and satisfaction with care (SMD=0.39) for patients diagnosed with depression (all effect estimates were significant). Collaborative care models are effective in achieving clinically meaningful improvements in depression outcomes and public health benefits in a wide range of populations, settings, and organizations. Collaborative care interventions provide a supportive network of professionals and peers for patients with depression, especially at the primary care level. Published by Elsevier Inc.
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Dziedzic, Krysia S; Allen, Kelli D
2018-01-01
Abstract A number of controversies and challenges exist for the management of OA in health care. This paper describes the challenges and gaps in OA care, particularly in relation to population health management, complex interventions and outcomes. It sets this in the context of competing health priorities and multimorbidity, access to high quality conservative care, non-pharmacological therapies, resource limitations and models of care. The overuse of some therapies and neglect of others are discussed, as well as the potential for self-management. The roles of patient and public involvement and the healthcare team are highlighted in enhancing best care for OA and providing solutions for closing the evidence-to-practice gap. Implementation of models of care offer one solution to the challenges and progress of such implementation is described. Areas for further research are highlighted. PMID:29684219
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Kearns, Patrick
2017-10-01
PURPOSE: Health services research evaluates redesign models for primary care. Care management is one alternative. Evaluation includes resource utilization as a criterion. Compare the impact of care-manager teams on resource utilization. The comparison includes entire panes of patients and the subset of patients with diabetes. DESIGN: Randomized, prospective, cohort study comparing change in utilization rates between groups, pre- and post-intervention. METHODOLOGY: Ten primary care physician panels in a safety-net setting. Ten physicians were randomized to either a care-management approach (Group 1) or a traditional approach (Group 2). Care managers focused on diabetes and the cardiovascular cluster of diseases. Analysis compared rates of hospitalization, 30-day readmission, emergency room visits, and urgent care visits. Analysis compared baseline rates to annual rates after a yearlong run-in for entire panels and the subset of patients with diabetes. RESULTS: Resource utilization showed no statistically significant change between baseline and Year 3 (P=.79). Emergency room visits and hospital readmission increased for both groups (P=.90), while hospital admissions and urgent care visits decreased (P=.73). Similarly, utilization was not significantly different for patients with diabetes (P=.69). CONCLUSIONS: A care-management team approach failed to improve resource utilization rates by entire panels and the subset of diabetic patients compared to traditional care. This reinforces the need for further evidentiary support for the care-management model's hypothesis in the safety net.
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Maniya, Omar Z; Mather, Richard C; Attarian, David E; Mistry, Bipin; Chopra, Aneesh; Strickland, Matt; Schulman, Kevin A
2017-11-01
The Medicare program has initiated Comprehensive Care for Joint Replacement (CJR), a bundled payment mandate for lower extremity joint replacements. We sought to determine the degree to which hospitals will invest in care redesign in response to CJR, and to project its economic impacts. We defined 4 potential hospital management strategies to address CJR: no action, light care management, heavy care management, and heavy care management with contracting. For each of 798 hospitals included in CJR, we used hospital-specific volume, cost, and quality data to determine the hospital's economically dominant strategy. We aggregated data to assess the percentage of hospitals pursuing each strategy; savings to the health care system; and costs and percentages of CJR-derived revenues gained or lost for Medicare, hospitals, and postacute care facilities. In the model, 83.1% of hospitals (range 55.0%-100.0%) were expected to take no action in response to CJR, and 16.1% of hospitals (range 0.0%-45.0%) were expected to pursue heavy care management with contracting. Overall, CJR is projected to reduce health care expenditures by 0.5% (range 0.0%-4.1%) or $14 million (range $0-$119 million). Medicare is expected to save 2.2% (range 2.2%-2.2%), hospitals are projected to lose 3.7% (range 4.7% loss to 3.8% gain), and postacute care facilities are expected to lose 6.5% (range 0.0%-12.8%). Hospital administrative costs are projected to increase by $63 million (range $0-$148 million). CJR is projected to have a negligible impact on total health care expenditures for lower extremity joint replacements. Further research will be required to assess the actual care management strategies adopted by CJR hospitals. Copyright © 2017 Elsevier Inc. All rights reserved.
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PCMHs, ACOs, and medication management: lessons learned from early research partnerships.
Schnur, Evan S; Adams, Alex J; Klepser, Donald G; Doucette, William R; Scott, David M
2014-02-01
The Patient Protection and Affordable Care Act has greatly accelerated the formation of team-based models of care delivery, primarily accountable care organizations (ACOs) and patient-centered medical homes (PCMHs). Many have written about the need to incorporate medication management services into these systems in order to improve care and reduce total health care costs. Two primary ways of doing so have emerged: (1) an embedded model, whereby pharmacists are employed directly by a physician practice, or (2) a "virtual care team" model, whereby a PCMH or ACO develops an arrangement with external pharmacists in community settings to provide coordinated services.
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IGEA--a chronic disease management project for people with diabetes.
Maggini, Marina
2009-01-01
Chronic diseases can be prevented and controlled using available knowledge. Moreover, the solutions are not only effective but can be highly cost-effective. Chronic care model and disease management have emerged, in the last decades, as new models of care delivery. The two models share the objective of improving the quality of care for people with chronic diseases while optimizing health care expenditure. In Italy, within the National Prevention Plan, the Italian Centre for Disease Prevention and Control of the Ministry of Health, and the Istituto Superiore di Sanità (ISS) are developing the IGEA project, which defines a comprehensive strategy for implementing a chronic disease management intervention for people with diabetes.
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Ricci-Cabello, Ignacio; Stevens, Sarah; Dalton, Andrew R H; Griffiths, Robert I; Campbell, John L; Valderas, Jose M
2018-02-01
To study the relationships between the different domains of quality of primary health care for the evaluation of health system performance and for informing policy decision making. A total of 137 quality indicators collected from 7,607 English practices between 2011 and 2012. Cross-sectional study at the practice level. Indicators were allocated to subdomains of processes of care ("quality assurance," "education and training," "medicine management," "access," "clinical management," and "patient-centered care"), health outcomes ("intermediate outcomes" and "patient-reported health status"), and patient satisfaction. The relationships between the subdomains were hypothesized in a conceptual model and subsequently tested using structural equation modeling. The model supported two independent paths. In the first path, "access" was associated with "patient-centered care" (β = 0.63), which in turn was strongly associated with "patient satisfaction" (β = 0.88). In the second path, "education and training" was associated with "clinical management" (β = 0.32), which in turn was associated with "intermediate outcomes" (β = 0.69). "Patient-reported health status" was weakly associated with "patient-centered care" (β = -0.05) and "patient satisfaction" (β = 0.09), and not associated with "clinical management" or "intermediate outcomes." This is the first empirical model to simultaneously provide evidence on the independence of intermediate health care outcomes, patient satisfaction, and health status. The explanatory paths via technical quality clinical management and patient centeredness offer specific opportunities for the development of quality improvement initiatives. © Health Research and Educational Trust.
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Saini, B; Krass, I; Smith, L; Bosnic-Anticevich, S; Armour, C
2011-01-01
Asthma is one of the most common chronic conditions affecting the Australian population. Amongst primary healthcare professionals, pharmacists are the most accessible and this places pharmacists in an excellent position to play a role in the management of asthma. Globally, trials of many community pharmacy-based asthma care models have provided evidence that pharmacist delivered interventions can improve clinical, humanistic and economic outcomes for asthma patients. In Australia, a decade of coordinated research efforts, in various aspects of asthma care, has culminated in the implementation trial of the Pharmacy Asthma Management Service (PAMS), a comprehensive disease management model.There has been research investigating asthma medication adherence through data mining, ways in which usual asthma care can be improved. Our research has focused on self-management education, inhaler technique interventions, spirometry trials, interprofessional models of care, and regional trials addressing the particular needs of rural communities. We have determined that inhaler technique education is a necessity and should be repeated if correct technique is to be maintained. We have identified this effectiveness of health promotion and health education, conducted within and outside the confines of the pharmacy, in public for a and settings such as schools, and established that this outreach role is particularly well received and increases the opportunity for people with asthma to engage in their asthma management.Our research has identified that asthma patients have needs which pharmacists delivering specialized models of care, can address. There is a lot of evidence for the effectiveness of asthma care by pharmacists, the future must involve integration of this role into primary care.
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Brink-Huis, Anita; van Achterberg, Theo; Schoonhoven, Lisette
2008-08-01
This paper reports a review of the literature conducted to identify organisation models in cancer pain management that contain integrated care processes and describe their effectiveness. Pain is experienced by 30-50% of cancer patients receiving treatment and by 70-90% of those with advanced disease. Efforts to improve pain management have been made through the development and dissemination of clinical guidelines. Early improvements in pain management were focussed on just one or two single processes such as pain assessment and patient education. Little is known about organisational models with multiple integrated processes throughout the course of the disease trajectory and concerning all stages of the care process. Systematic review. The review involved a systematic search of the literature, published between 1986-2006. Subject-specific keywords used to describe patients, disease, pain management interventions and integrated care processes, relevant for this review were selected using the thesaurus of the databases. Institutional models, clinical pathways and consultation services are three alternative models for the integration of care processes in cancer pain management. A clinical pathway is a comprehensive institutionalisation model, whereas a pain consultation service is a 'stand-alone' model that can be integrated in a clinical pathway. Positive patient and process outcomes have been described for all three models, although the level of evidence is generally low. Evaluation of the quality of pain management must involve standardised measurements of both patient and process outcomes. We recommend the development of policies for referrals to a pain consultation service. These policies can be integrated within a clinical pathway. To evaluate the effectiveness of pain management models standardised outcome measures are needed.
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da Silva Etges, Ana Paula Beck; Grenon, Veronique; de Souza, Joana Siqueira; Kliemann Neto, Francisco José; Felix, Elaine Aparecida
2018-05-14
In recent years, health care organizations have looked to enterprise risk management (ERM) for novel systems to obtain more accurate data on which to base risk strategies. This study proposes a conceptual ERM framework specifically designed for health care organizations. We explore how hospitals in the United States and Brazil are structuring and implementing ERM processes within their management structure. This study incorporates interviews with 15 chief risk officers (8 from the United States and 7 from Brazil) with qualitative data analysis using NVivo (QSR International software). The interviews confirm that adopting ERM for health care organizations has gained momentum and become a priority, and that the demand for risk economic assessment orientation is common among health care risk managers. We propose an ERM model for health care (Economic Enterprise Risk Management in Health Care) divided into four maturity levels and complemented by an implementation timeline. The model is accompanied by guidelines to orient the gradual implementation of ERM, including orientation to perform risk economic assessment. Copyright © 2018. Published by Elsevier Inc.
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Consumer-directed health care: implications for health care organizations and managers.
Guo, Kristina L
2010-01-01
This article uses a pyramid model to illustrate the key components of consumer-directed health care. Consumer-directed health care is considered the essential strategy needed to lower health care costs and is valuable for making significant strides in health care reform. Consumer-directed health care presents new challenges and opportunities for all health care stakeholders and their managers. The viability of the health system depends on the success of managers to respond rapidly and with precision to changes in the system; thus, new and modified roles of managers are necessary to successfully sustain consumerism efforts to control costs while maintaining access and quality.
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1991-07-25
will cause a restructuring of the health care delivery system to nore closely reAmble civilian managed care models. •Manged Care There is no single ...health care system throxjh the PCP ( single arrow). The RCP decides if thre is need for care beyond the PCPs scope of practice and coordinates for the...availability, * 0 Family Practice 31 Arm MTFs must met the needs of the client, or patient, to ensure the sucess of any program. This is exaipllfied
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Wolfe, Charles DA; McKevitt, Christopher
2014-01-01
Objectives: Self-management is widely promoted but evidence of effectiveness is limited. Policy encourages health care professionals to support people with long-term conditions to learn self-management skills, yet little is known about the extent to which both parties share a common understanding of self-management. Thus, we compared health care professional and lay understandings of self-management of long-term conditions. Methods: Systematic review and narrative synthesis of qualitative studies identified from relevant electronic databases, hand-searching of references lists, citation tracking and recommendations by experts. Results: In total, 55 studies were included and quality was assessed using a brief quality assessment tool. Three conceptual themes, each with two subthemes were generated: traditional and shifting models of the professional–patient relationship (self-management as a tool to promote compliance; different expectations of responsibility); quality of relationship between health care professional and lay person (self-management as a collaborative partnership; self-management as tailored support) and putting self-management into everyday practice (the lived experience of self-management; self-management as a social practice). Conclusion: Self-management was conceptualised by health care professionals as incorporating both a biomedical model of compliance and individual responsibility. Lay people understood self-management in wider terms, reflecting biomedical, psychological and social domains and different expectations of responsibility. In different ways, both deviated from the dominant model of self-management underpinned by the concept of self-efficacy. Different understandings help to explain how self-management is practised and may help to account for limited evidence of effectiveness of self-management interventions. PMID:26770733
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Hudak, R P; Jacoby, I; Meyer, G S; Potter, A L; Hooper, T I; Krakauer, H
1997-01-01
This article describes a training model that focuses on health care management by applying epidemiologic methods to assess and improve the quality of clinical practice. The model's uniqueness is its focus on integrating clinical evidence-based decision making with fundamental principles of resource management to achieve attainable, cost-effective, high-quality health outcomes. The target students are current and prospective clinical and administrative executives who must optimize decision making at the clinical and managerial levels of health care organizations.
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General practitioners in partnership with management: an organisational model for debate.
Starey, N; Bosanquet, N; Griffiths, J
1993-01-01
The role of general practitioners is changing and expanding. Doctors have more control over the treatment received by their patients but remain largely unaccountable to the public and management. This article proposes an organisational model for integrating primary and secondary care which retains the advantages of fund-holding while giving management control over overall strategy. It proposes that general practitioners control funds for all primary and secondary care. Secondary care will be contracted through a joint team of managers and an elected general practice executive committee. A new health care purchasing authority will contract for primary services with individual practices or primary care provider units. General practitioners will have local contracts reflecting their desire to provide an expanded range of services and the needs of the community. PMID:8461651
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Kilbourne, Amy M; Nord, Kristina M; Kyle, Julia; Van Poppelen, Celeste; Goodrich, David E; Kim, Hyungjin Myra; Eisenberg, Daniel; Un, Hyong; Bauer, Mark S
2014-01-01
Mood disorders represent the most expensive mental disorders for employer-based commercial health plans. Collaborative care models are effective in treating chronic physical and mental illnesses at little to no net healthcare cost, but to date have primarily been implemented by larger healthcare organizations in facility-based models. The majority of practices providing commercially insured care are far too small to implement such models. Health plan-level collaborative care treatment can address this unmet need. The goal of this study is to implement at the national commercial health plan level a collaborative care model to improve outcomes for persons with mood disorders. A randomized controlled trial of a collaborative care model versus usual care will be conducted among beneficiaries of a large national health plan from across the country seen by primary care or behavioral health practices. At discharge 344 patients identified by health plan claims as hospitalized for unipolar depression or bipolar disorder will be randomized to receive collaborative care (patient phone-based self-management support, care management, and guideline dissemination to practices delivered by a plan-level care manager) or usual care from their provider. Primary outcomes are changes in mood symptoms and mental health-related quality of life at 12 months. Secondary outcomes include rehospitalization, receipt of guideline-concordant care, and work productivity. This study will determine whether a collaborative care model for mood disorders delivered at the national health plan level improves outcomes compared to usual care, and will inform a business case for collaborative care models for these settings that can reach patients wherever they receive treatment. ClinicalTrials.gov Identifier: NCT02041962; registered January 3, 2014.
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Sustaining self-management in diabetes mellitus.
Mitchell-Brown, Fay
2014-01-01
Successful management of diabetes depends on the individual's ability to manage and control symptoms. Self-management of diabetes is believed to play a significant role in achieving positive outcomes for patients. Adherence to self-management behaviors supports high-quality care, which reduces and delays disease complications, resulting in improved quality of life. Because self-management is so important to diabetes management and involves a lifelong commitment for all patients, health care providers should actively promote ways to maintain and sustain behavior change that support adherence to self-management. A social ecological model of behavior change (McLeroy, Bibeau, Steckler, & Glanz, 1988) helps practitioners provide evidence-based care and optimizes patients' clinical outcomes. This model supports self-management behaviors through multiple interacting interventions that can help sustain behavior change. Diabetes is a complex chronic disease; successful management must use multiple-level interventions.
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A methodology model for quality management in a general hospital.
Stern, Z; Naveh, E
1997-01-01
A reappraisal is made of the relevance of industrial modes of quality management to the issues of medical care. Analysis of the nature of medical care, which differentiates it from the supplier-client relationships of industry, presents the main intrinsic characteristics, which create problems in application of the industrial quality management approaches to medical care. Several examples are the complexity of the relationship between the medical action and the result obtained, the client's nonacceptance of economic profitability as a value in his medical care, and customer satisfaction biased by variable standards of knowledge. The real problems unique to hospitals are addressed, and a methodology model for their quality management is offered. Included is a sample of indicator vectors, measurements of quality care, cost of medical care, quality of service, and human resources. These are based on the trilogy of planning quality, quality control, and improving quality. The conclusions confirm the inadequacy of industrial quality management approaches for medical institutions and recommend investment in formulation of appropriate concepts.
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Coye, Molly Joel; Haselkorn, Ateret; DeMello, Steven
2009-01-01
Remote patient management (RPM) is a transformative technology that improves chronic care management while reducing net spending for chronic disease. Broadly deployed within the Veterans Health Administration and in many small trials elsewhere, RPM has been shown to support patient self-management, shift responsibilities to non-clinical providers, and reduce the use of emergency department and hospital services. Because transformative technologies offer major opportunities to advance national goals of improved quality and efficiency in health care, it is important to understand their evolution, the experiences of early adopters, and the business models that may support their deployment.
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Administrative decision making: a stepwise method.
Oetjen, Reid M; Oetjen, Dawn M; Rotarius, Timothy
2008-01-01
Today's health care organizations face tremendous challenges and fierce competition. These pressures impact the decisions that managers must execute on any given day, not to mention the ever-present constraints of time, personnel, competencies, and finances. The importance of making quality and informed decisions cannot be underestimated. Traditional decision making methods are inadequate for today's larger, more complex health care organizations and the rapidly changing health care environment. As a result, today's health care managers and their teams need new approaches to making decisions for their organizations. This article examines the managerial decision making process and offers a model that can be used as a decision making template to help managers successfully navigate the choppy health care seas. The administrative decision making model will enable health care managers and other key decision makers to avoid the common pitfalls of poor decision making and guide their organizations to success.
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Storkholm, Marie Höjriis; Mazzocato, Pamela; Savage, Mairi; Savage, Carl
2017-01-31
The "Triple Aim" - provision of a better care experience and improved population health at a lower cost - may be theoretically sound, but paradoxical in practice as it forces together the logics of management and medicine. The aim of this study was to explore how staff and managers understand the change imperative inherent to the Triple Aim and the mental models underlying their understanding. This qualitative study builds on thirty semi-structured interviews conducted with managers, nurses, midwives, medical secretaries, and physicians at a department of Gynecology and Obstetrics in Denmark who successfully cut costs through staff and bed reductions and, from what we can ascertain, maintained care quality. Mental models were articulated from a content analysis of the interviews. Staff and managers identified with the different dimensions of the Triple Aim along classic professional divides, i.e. nurses and midwives focused on patient experience, physicians on health outcomes, and manager on all three. Underlying these, we found four mental models. The understanding of change was guided by a Professional ethos (inner drive to improve care) and a Socio-political discourse (external requirement to become more efficient) mental model. The understanding of economics was guided by a You-get-what-you-pay-for and by a More-bang-for-the-buck mental model. A complex interplay could be discerned between all four, which led staff to see the Triple Aim as a dilemma between quality and economics and a threat to clinical care and quality, whereas managers saw it as a paradox that invited improvement efforts. Despite these differences, managers chose a change strategy in line with staff mental models. The practical challenges inherent to the Triple Aim may be symptomatic of the interactions between the different mental models that guide staff and managers' understanding and choice of change strategies. Pursuit of quality improvement in the face of financial constraints (the essence of the Triple Aim) may be facilitated through conscious exploration of these empirically identified mental models. Managers might do well to translate the socio-political discourse into a change process that resonates with the mental models held by staff.
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The development and implementation of the Chronic Care Management Programme in Counties Manukau.
Wellingham, John; Tracey, Jocelyn; Rea, Harold; Gribben, Barry
2003-02-21
To develop an effective and efficient process for the seamless delivery of care for targeted patients with specific chronic diseases. To reduce inexplicable variation and maximise use of available resources by implementing evidence-based care processes. To develop a programme that is acceptable and applicable to the Counties Manukau region. A model for the management of people with chronic diseases was developed. Model components and potential interventions were piloted. For each disease project, a return on investment was calculated and external evaluation was undertaken. The initial model was subsequently modified and individual disease projects aligned to it. The final Chronic Care Management model, agreed in September 2001, described a single common process. Key components were the targeting of high risk patients, organisation of cost effective interventions into a system of care, and an integrated care server acting as a data warehouse with a rules engine, providing flags and reminders. Return on investment analysis suggested potential savings for each disease component from $277 to $980 per person per annum. For selected chronic diseases, introduction of an integrated chronic care management programme, based on internationally accepted best practice processes and interventions can make significant savings, reducing morbidity and improving the efficiency of health delivery in the Counties Manukau region.
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Grimsrud, Anna; Kaplan, Richard; Bekker, Linda-Gail; Myer, Landon
2014-09-01
Models of care utilizing task shifting and decentralization are needed to support growing ART programmes. We compared patient outcomes between a doctor-managed clinic and a nurse-managed down-referral site in Cape Town, South Africa. Analysis included all adults who initiated ART between 2002 and 2011 within a large public sector ART service. Stable patients were eligible for down-referral. Outcomes [mortality, loss to follow-up (LTFU), virologic failure] were compared under different models of care using proportional hazards models with time-dependent covariates. Five thousand seven hundred and forty-six patients initiated ART and over 5 years 41% (n = 2341) were down-referred; the median time on ART before down-referral was 1.6 years (interquartile range, 0.9-2.6). The nurse-managed down-referral site reported lower crude rates of mortality, LTFU and virologic failure compared with the doctor-managed clinic. After adjustment, there was no difference in the risk of mortality or virologic failure by model of care. However, patients who were down-referred were more likely to be LTFU than those retained at the doctor-managed site (adjusted hazard ratio, 1.36; 95% CI, 1.09-1.69). Increased levels of LTFU in the nurse-managed vs. doctor-managed service were observed in subgroups of male patients, those with advanced disease at initiation and those who started ART in the early years of the programme. Reorganization of ART maintenance by down-referral to nurse-managed services is associated with programme outcomes similar to those achieved using doctor-driven primary care services. Further research is necessary to identify optimal models of care to support long-term retention of patients on ART in resource-limited settings. © 2014 John Wiley & Sons Ltd.
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Ong, Stephanie W; Jassal, Sarbjit V; Porter, Eveline; Logan, Alexander G; Miller, Judith A
2013-01-01
New healthcare delivery models are needed to enhance the patient experience and improve quality of care for individuals with chronic conditions such as kidney disease. One potential avenue is to implement self-management strategies. There is growing evidence that self-management interventions help optimize various aspects of chronic disease management. With the increasing use of information technology (IT) in health care, chronic disease management programs are incorporating IT solutions to support patient self-management practices. IT solutions have the ability to promote key principles of self-management, namely education, empowerment, and collaboration. Positive clinical outcomes have been demonstrated for a number of chronic conditions when IT solutions were incorporated into self-management programs. There is a paucity of evidence for self-management in chronic kidney disease (CKD) patients. Furthermore, IT strategies have not been tested in this patient population to the same extent as other chronic conditions (e.g., diabetes, hypertension). Therefore, it is currently unknown if IT strategies will promote self-management behaviors and lead to improvements in overall patient care. We designed and developed an IT solution called My KidneyCare Centre to support self-management strategies for patients with CKD. In this review, we discuss the rationale and vision of incorporating an electronic self-management tool to support the care of patients with CKD. © 2013 Wiley Periodicals, Inc.
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Embedding care management in the medical home: a case study.
Daaleman, Timothy P; Hay, Sherry; Prentice, Amy; Gwynne, Mark D
2014-04-01
Care managers are playing increasingly significant roles in the redesign of primary care and in the evolution of patient-centered medical homes (PCMHs), yet their adoption within day-to-day practice remains uneven and approaches for implementation have been minimally reported. We introduce a strategy for incorporating care management into the operations of a PCMH and assess the preliminary effectiveness of this approach. A case study of the University of North Carolina at Chapel Hill Family Medicine Center used an organizational model of innovation implementation to guide the parameters of implementation and evaluation. Two sources were used to determine the effectiveness of the implementation strategy: data elements from the care management informatics system in the health record and electronic survey data from the Family Medicine Center providers and care staff. A majority of physicians (75%) and support staff (82%) reported interactions with the care manager, primarily via face-to-face, telephone, or electronic means, primarily for facilitating referrals for behavioral health services and assistance with financial and social and community-based resources. Trend line suggests an absolute decrease of 8 emergency department visits per month for recipients of care management services and an absolute decrease of 7.5 inpatient admissions per month during the initial 2-year implementation period. An organizational model of innovation implementation is a potentially effective approach to guide the process of incorporating care management services into the structure and workflows of PCMHs.
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Smith, Marie; Cannon-Breland, Michelle L; Spiggle, Susan
2014-01-01
Health care reform initiatives are examining new care delivery models and payment reform alternatives such as medical homes, health homes, community-based care transitions teams, medical neighborhoods and accountable care organizations (ACOs). Of particular interest is the extent to which pharmacists are integrated in team-based health care reform initiatives and the related perspectives of consumers, physicians, and payers. To assess the current knowledge of consumers and physicians about pharmacist training/expertise and capacity to provide primary care medication management services in a shared resource network; determine factors that will facilitate/limit consumer interest in having pharmacists as a member of a community-based "health care team;" determine factors that will facilitate/limit physician utilization of pharmacists for medication management services; and determine factors that will facilitate/limit payer reimbursement models for medication management services using a shared resource pharmacist network model. This project used qualitative research methods to assess the perceptions of consumers, primary care physicians, and payers on pharmacist-provided medication management services using a shared resource network of pharmacists. Focus groups were conducted with primary care physicians and consumers, while semi-structured discussions were conducted with a public and private payer. Most consumers viewed pharmacists in traditional dispensing roles and were unaware of the direct patient care responsibilities of pharmacists as part of community-based health teams. Physicians noted several chronic disease states where clinically-trained pharmacists could collaborate as health care team members yet had uncertainties about integrating pharmacists into their practice workflow and payment sources for pharmacist services. Payers were interested in having credentialed pharmacists provide medication management services if the services improved quality of patient care and/or prevented adverse drug events, and the services were cost neutral (at a minimum). It was difficult for most consumers and physicians to envision pharmacists practicing in non-dispensing roles. The pharmacy profession must disseminate the existing body of evidence on pharmacists as care providers of medication management services and the related impact on clinical outcomes, patient safety, and cost savings to external audiences. Without such, new pharmacist practice models may have limited acceptance by consumers, primary care physicians, and payers. Copyright © 2014 Elsevier Inc. All rights reserved.
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Length of Stay and Inpatient Costs Under Medicaid Managed Care in Florida
Park, Jungwon
2015-01-01
This study examines the patterns of length of stay (LOS) and inpatient costs for both Medicaid managed care and nonmanaged care patients using data from Medicaid patients aged 18 to 64 years who were discharged from hospitals in Florida between 2006 and 2012. This study used pooled cross-sectional multilevel modeling. The results show that the type of Medicaid program in which patients were enrolled was significantly related to the hospital LOS and inpatient costs. Medicaid managed care patients had 7% shorter LOSs and a 1.9% lower inpatient cost than did Medicaid fee-for-service (FFS) patients. Medicaid managed care patients had shorter LOSs in the Medicaid managed care market with high competition. High managed care penetration generates a cost-decreasing spillover to Medicaid FFS patients. PMID:26472718
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Chronic disease management: improving care for people with osteoarthritis.
Brand, Caroline A; Ackerman, Ilana N; Tropea, Joanne
2014-02-01
Chronic disease management (CDM) service models are being developed for many conditions; however, there is limited evidence to support their effectiveness in osteoarthritis (OA). A systematic review was undertaken to examine effectiveness, cost effectiveness and barriers to the use of osteoarthritis-chronic disease management (OA-CDM) service models. Thirteen eligible studies (eight randomised controlled trial (RCTs)) were identified. The majority focussed on delivery system design (n = 9) and/or providing self-management support (SMS) (n = 8). Overall, reported model effectiveness varied, and where positive impacts on process or health outcomes were observed, they were of small to moderate effect. There was no information about cost effectiveness. There is some evidence to support the use of collaborative care/multidisciplinary case management models in primary and community care and evidence-based pathways/standardisation of care in hospital settings. Multiple barriers were identified. Future research should focus on identifying the effective components of multi-faceted interventions and evaluating cost-effectiveness to support clinical and policy decision-making. Copyright © 2014 Elsevier Ltd. All rights reserved.
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Foundation Care: A Treatment Model for Nonambulatory Profoundly Mentally Retarded Persons.
ERIC Educational Resources Information Center
LaMendola, Walter F.; And Others
1987-01-01
Two institutional treatment models--Intermediate Care Facilities and Foundation Care--were compared with 30 profoundly mentally retarded adults. The Foundation Care model (which emphasized habilitation through health, nurturance, stimulation, and play) demonstrated more resident-oriented management practices and used more tactile modalities and…
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Kucan, John; Bryant, Ernest; Dimick, Alan; Sundance, Paula; Cope, Nathan; Richards, Reginald; Anderson, Chris
2010-01-01
The new standard for successful burn care encompasses both patient survival and the burn patient's long-term quality of life. To provide optimal long-term recovery from catastrophic injuries, including catastrophic burns, an outcome-based model using a new technology called systematic care management (SCM) has been developed. SCM provides a highly organized system of management throughout the spectrum of care that provides access to outcome data, consistent oversight, broader access to expert providers, appropriate allocation of resources, and greater understanding of total costs. Data from a population of 209 workers' compensation catastrophic burn cases with a mean TBSA of 27.9% who were managed under the SCM model of care were analyzed. The data include treatment type, cost, return to work, and outcomes achieved. Mean duration of management to achieve all guaranteed outcomes was 20 months. Of the 209 injured workers, 152 (72.7%) achieved sufficient recovery to be released to return to work, of which 97 (46.8%) were both released and competitively employed. Assessment of 10 domains of functional independence indicated that 47.2% of injured workers required total assistance at initiation of SCM. However, at termination of SCM, 84% of those injured workers were fully independent in the 10 functional activities. When compared with other burn research outcome data, the results support the value of the SCM model of care.
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The chronic care model versus disease management programs: a transaction cost analysis approach.
Leeman, Jennifer; Mark, Barbara
2006-01-01
The present article applies transaction cost analysis as a framework for better understanding health plans' decisions to improve chronic illness management by using disease management programs versus redesigning care within physician practices.
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Zafar, Waleed; Mojtabai, Ramin
2011-07-01
Chronic care model (CCM) envisages a multicomponent systematic remodeling of ambulatory care to improve chronic diseases management. Application of CCM in primary care management of depression has traditionally lagged behind the application of this model in management of other common chronic illnesses. In past research, the use of CCM has been operationalized by measuring the use of evidence-based organized care management processes (CMPs). To compare the use of CMPs in treatment of depression with the use of these processes in treatment of diabetes and asthma and to examine practice-level correlates of this use. Using data from the 2008 Health Tracking Physician Survey, a nationally representative sample of physicians in the United States, we compared the use of 5 different CMPs: written guidelines in English and other languages for self-management, availability of staff to educate patients about self-management, availability of nurse care managers for care coordination, and group meetings of patients with staff. We further examined the association of practice-level characteristics with the use of the 5 CMPs for management of depression. CMPs were more commonly used for management of diabetes and asthma than for depression. The use of CMPs for depression was more common in health maintenance organizations [adjusted odds ratios (AOR) ranging from 2.45 to 5.98 for different CMPs], in practices that provided physicians with feedback regarding quality of care to patients (AOR range, 1.42 to 1.69), and in practices with greater use of clinical information technology (AOR range, 1.06 to 1.11). The application of CMPs in management of depression continues to lag behind other common chronic conditions. Feedbacks on quality of care and expanded use of information technology may improve application of CMPs for depression care in general medical settings.
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Bower, Peter; Macdonald, Wendy; Harkness, Elaine; Gask, Linda; Kendrick, Tony; Valderas, Jose M; Dickens, Chris; Blakeman, Tom; Sibbald, Bonnie
2011-10-01
Primary care professionals often manage patients with multiple long-term health conditions, but managing multimorbidity is challenging given time and resource constraints and interactions between conditions. To explore GP and nurse perceptions of multimorbidity and the influence on service organization and clinical decision making. A qualitative interview study with primary care professionals in practices in Greater Manchester, U.K. Interviews were conducted with 15 GPs and 10 practice nurses. Primary care professionals identified tensions between delivering care to meet quality targets and fulfilling the patient's agenda, tensions which are exacerbated in multimorbidity. They were aware of the inconvenience suffered by patients through attendance at multiple clinic appointments when care was structured around individual conditions. They reported difficulties managing patients with multimorbidity in limited consultation time, which led to adoption of an 'additive-sequential' decision-making model which dealt with problems in priority order until consultation resources were exhausted, when further management was deferred. Other challenges included the need for patients to co-ordinate their care, the difficulties of self-management support in multimorbidity and problems of making sense of the relationships between physical and mental health. Doctor and nurse accounts included limited consideration of multimorbidity in terms of the interactions between conditions or synergies between management of different conditions. Primary care professionals identify a number of challenges in care for multimorbidity and adopt a particular model of decision making to deliver care for multiple individual conditions. However, they did not describe specific decision making around managing multimorbidity per se.
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Value-based formulas for purchasing. Loyalty renaissance: the rebirth of loyalty in health care.
Jepson, S
1997-01-01
As more consumers join managed care organizations, the personal bond between patient and physician or medical group has been transformed into an economic relationship driven chiefly by the price of health care services. Managed care organizations now face the same pressures as the airline and retail industries: To gain and retain client loyalty through product differentiation and consistently high levels of service. How do managed health care plans create and maintain loyalty among their members? What is the value proposition that consumers will respond to in this era of managed care? Discussion will focus on the consumer as the critical variable in the economic model of a health care system and how the consumer will impact the continued evolution of managed care.
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Alden, Dana L; Do, Mai Hoa; Bhawuk, Dharm
2004-12-01
Health-care managers are increasingly interested in client perceptions of clinic service quality and satisfaction. While tremendous progress has occurred, additional perspectives on the conceptualization, modeling and measurement of these constructs may further assist health-care managers seeking to provide high-quality care. To that end, this study draws on theories from business and health to develop an integrated model featuring antecedents to and consequences of reproductive health-care client satisfaction. In addition to developing a new model, this study contributes by testing how well Western-based theories of client satisfaction hold in a developing, Asian country. Applied to urban, reproductive health clinic users in Hanoi, Vietnam, test results suggest that hypothesized antecedents such as pre-visit expectations, perceived clinic performance and how much performance exceeds expectations impact client satisfaction. However, the relative importance of these predictors appears to vary depending on a client's level of service-related experience. Finally, higher levels of client satisfaction are positively related to future clinic use intentions. This study demonstrates the value of: (1) incorporating theoretical perspectives from multiple disciplines to model processes underlying health-care satisfaction and (2) field testing those models before implementation. It also furthers research designed to provide health-care managers with actionable measures of the complex processes related to their clients' satisfaction.
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Harrison, Samantha L; Goldstein, Roger; Desveaux, Laura; Tulloch, Verity; Brooks, Dina
2014-01-01
Though the guidelines for the optimal management of chronic obstructive pulmonary disease (COPD) following an acute exacerbation (AE) are well established, issues associated with poor adherence to nonpharmacological interventions such as self-management advice and pulmonary rehabilitation will impact on hospital readmission rates and health care costs. Systems developed for clinically stable patients with COPD may not be sufficient for those who are post-exacerbation. A redesign of the manner in which such interventions are delivered to patients following an AECOPD is necessary. Addressing two or more components of the chronic care model is effective in reducing health care utilization in patients with COPD, with self-management support contributing a key role. By refining self-management support to incorporate the identification and treatment of psychological symptoms and by providing health care professionals adequate time and training to deliver respiratory-specific advice and self-management strategies, adherence to nonpharmacological therapies following an AE may be enhanced. Furthermore, following up patients in their own homes allows for the tailoring of advice and for the delivery of consistent health care messages which may enable knowledge to be retained. By refining the delivery of nonpharmacological therapies following an AECOPD according to components of the chronic care model, adherence may be improved, resulting in better disease management and possibly reducing health care utilization.
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Primary immunodeficiency disease: a model for case management of chronic diseases.
Burton, Janet; Murphy, Elyse; Riley, Patty
2010-01-01
Patient-centered chronic care management is a new model for the management of rare chronic diseases such as primary immunodeficiency disease (PIDD). This approach emphasizes helping patients become experts on the management of their disease as informed, involved, and interactive partners in healthcare decisions with providers. Because only a few patients are affected by rare illnesses, these patients are forced to become knowledgeable about their disease and therapies and to seek treatment from a healthcare team, which includes physicians and nurse specialists who are equipped to manage the complexity of the disease and its comorbidities. Importantly, therapy for PIDD can be self-administered at home, which has encouraged the transition toward a proactive stance that is at the heart of patient-centered chronic care management. We discuss the evolution of therapy, the issues with the disease, and challenges with its management within the framework of other chronic disease management programs. Suggestions and rationale to move case management of PIDD forward are presented with the intent that sharing our experiences will improve process and better manage outcomes in this patient population. The patient-centered model for the management of PIDD is applicable to the primary care settings, where nurse case managers assist patients through education, support them and their families, and facilitate access to community resources in an approach, which has been described as "guided care." The model also applies specifically to immunology centers where patients receive treatment or instruction on its self-administration at home. Patient-centered management of PIDD, with its emphasis on full involvement of patients in their treatment, has the potential to improve compliance with treatment, and thus patient outcomes, as well as patients' quality of life. The patient-centered model expands the traditional model of chronic disease management, which relies on evidence-based medicine, provider expertise, clinical information systems, and patient education. This approach supports patient self-management with strategies that empower and prepare them for their role as expert patients.
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Federal Nursing Service Award. Impact of TriCare/managed care on total force readiness.
Ray, M A; Turkel, M C
2001-04-01
Mission readiness is dependent on a healthy total force and the response of military medical and nursing services. Managed care has become the norm in U.S. health care, including the Department of Defense Military Health System. Cost management, health maintenance organizations, and other health plans are defined as "managed care," an aggressive cost-control effort by health care purchasers and insurers to limit health care spending and services and advance a market-oriented, profit-driven system. The impact of managed care on mission readiness and retention of active and reserve personnel is and will continue to be profound. The purpose of this research was to conduct a qualitative, phenomenological study (life experiences) of TriCare/managed care to explore the impact and the meaning of the experience on total force mission readiness of the U.S. Air Force and how managed care has changed nursing practice. The results reveal the significance of the impact of TriCare/managed care on total force readiness by identifying, through themes, meta-themes, and a representative model, the negative effect that economics is having on active duty and reserve force health and well-being.
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Primary Care-Based Memory Clinics: Expanding Capacity for Dementia Care.
Lee, Linda; Hillier, Loretta M; Heckman, George; Gagnon, Micheline; Borrie, Michael J; Stolee, Paul; Harvey, David
2014-09-01
The implementation in Ontario of 15 primary-care-based interprofessional memory clinics represented a unique model of team-based case management aimed at increasing capacity for dementia care at the primary-care level. Each clinic tracked referrals; in a subset of clinics, charts were audited by geriatricians, clinic members were interviewed, and patients, caregivers, and referring physicians completed satisfaction surveys. Across all clinics, 582 patients were assessed, and 8.9 per cent were referred to a specialist. Patients and caregivers were very satisfied with the care received, as were referring family physicians, who reported increased capacity to manage dementia. Geriatricians' chart audits revealed a high level of agreement with diagnosis and management. This study demonstrated acceptability, feasibility, and preliminary effectiveness of the primary-care memory clinic model. Led by specially trained family physicians, it provided timely access to high-quality collaborative dementia care, impacting health service utilization by more-efficient use of scarce geriatric specialist resources.
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Xenakis, Nancy
2015-10-01
In July 2012, The Mount Sinai Medical Center was selected by the Centers for Medicare and Medicaid to join the first cohort of Accountable Care Organizations (ACOs) in this country under its Medicare Shared Savings Program. A critical component of an ACO is care coordination of patients, which is a complex concept, intertwined with other concepts related to quality, delivery and organization of health care. This article provides an overview of the development, structure and functionality of Mount Sinai Care, the ACO of The Mount Sinai Health System, and how it was the beginning of its work in population health management. It describes the important role of social work leadership in the development and operation of its care coordination model. The model's successes and challenges and recommendations for future development of care coordination and population health management are outlined.
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E-documentation as a process management tool for nursing care in hospitals.
Rajkovic, Uros; Sustersic, Olga; Rajkovic, Vladislav
2009-01-01
Appropriate documentation plays a key role in process management in nursing care. It includes holistic data management based on patient's data along the clinical path with regard to nursing care. We developed an e-documentation model that follows the process method of work in nursing care. It assesses the patient's status on the basis of Henderson's theoretical model of 14 basic living activities and is aligned with internationally recognized nursing classifications. E-documentation development requires reengineering of existing documentation and facilitates process reengineering. A prototype solution of an e-nursing documentation, already being in testing process at University medical centres in Ljubljana and Maribor, will be described.
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Care management for Type 2 diabetes in the United States: a systematic review and meta-analysis.
Egginton, Jason S; Ridgeway, Jennifer L; Shah, Nilay D; Balasubramaniam, Saranya; Emmanuel, Joann R; Prokop, Larry J; Montori, Victor M; Murad, Mohammad Hassan
2012-03-22
This systematic review and meta-analysis aims at assessing the composition and performance of care management models evaluated in the last decade and their impact on patient important outcomes. A comprehensive literature search of electronic bibliographic databases was performed to identify care management trials in type 2 diabetes. Random effects meta-analysis was used when feasible to pool outcome measures. Fifty-two studies were eligible. Most commonly reported were surrogate outcomes (such as HbA1c and LDL), followed by process measures (clinic visit or testing frequency). Less frequently reported were quality of life, patient satisfaction, self-care, and healthcare utilization. Most care management modalities were carved out from primary care. Meta-analysis demonstrated a statistically significant but trivial reduction of HbA1c (weighted difference in means -0.21%, 95% confidence interval -0.40 to -0.03, p < .03) and LDL-cholesterol (weighted difference in means -3.38 mg/dL, 95% confidence interval -6.27 to -0.49, p < .02). Most care management programs for patients with type 2 diabetes are 'carved-out', accomplish limited effects on metabolic outcomes, and have unknown effects on patient important outcomes. Comparative effectiveness research of different models of care management is needed to inform the design of medical homes for patients with chronic conditions.
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Arnold, K C
2011-11-01
Nurse practitioners (NPs) are advanced practice nurses who have increased responsibility,such as prescribing authority. In the NP-led model, the NP is the primary care provider for clinic patients and takes on an autonomous role in patient management. In some states, NP-led clinics are required to have a supervising or collaborating physician. There is evidence that NP-led and physician-led primary care is comparable for multiple health outcomes. The NP-led model emphasizes the strong interaction between health care provider and patient. Challenges of NP-led care include physician resistance, legal restrictions, inaccessibility and cost of malpractice insurance, and limited payouts from insurance companies
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Quality of care provided in a special needs plan using a nurse care manager model.
Wenger, Neil S; Roth, Carol P; Martin, David; Nickels, Lorraine; Beckman, Robin; Kamberg, Caren; Mach, John; Ganz, David A
2011-10-01
To comprehensively evaluate the quality of care provided in special needs plans (SNPs; Medicare Advantage plans that aim to provide specialized care for complex older adults) and specifically the nurse care management model in the community setting. We adapted 107 process-of-care quality measures across 12 conditions from the Assessing Care of Vulnerable Elders set to obtain a clinically detailed evaluation of the quality of care received by complex older enrollees in a dual eligible Evercare SNP. We abstracted 13 months of primary care medical records to delineate quality of care provided by physicians and whether there was value added from the nurse care manager model. Dual eligible Evercare SNP located in central Florida. Two-hundred thirty-one vulnerable older enrollees in the SNP who had complex disease. Based on physician medical records alone, the 231 high-risk participants (mean age 77, 67% women) received recommended care for 53% of 5,569 evaluated clinical circumstances, ranging from 12% for end-of-life care to 78% for diabetes mellitus. In fewer than 40% of these clinical circumstances was recommended care provided for dementia, falls, and urinary incontinence. In a second analysis accounting for care provided by both the Evercare nurse and the physician, recommended care was provided to patients in 69% of the 5,684 evaluated clinical circumstances. Comprehensive quality measurement applied to vulnerable older adults enrolled in one mature SNP showed that the Evercare nurse model addresses important deficits in physician care for geriatric conditions. Such measurement should be applied to other SNP models and to compare SNP care with that for complex, older, fee-for-service Medicare cohorts. © 2011, Copyright the Authors Journal compilation © 2011, The American Geriatrics Society.
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Sunde, Synnøve; Walstad, Rolf Aksel; Bentsen, Signe Berit; Lunde, Solfrid J; Wangen, Eva Marie; Rustøen, Tone; Henriksen, Anne Hildur
2014-09-01
Adherence to guidelines for managing stable chronic obstructive pulmonary disease (COPD) and its exacerbations is inadequate among healthcare workers and patients. An appropriate care model would meet patient needs, enhance their coping with COPD and improve their quality of life (QOL). This study aims to present the 'COPD-Home' as an integrated care model for patients with severe or very severe COPD. One principle of the COPD-Home model is that hospital treatment should lead to follow up in the patient's home. The model also includes education, improved coordination of levels of care, improved accessibility and a management plan. One of the main elements of the COPD-Home model is the clear role of the home-care nurse. Model development is based on earlier research and clinical experience. It comprises: (i) education provided through an education programme for patients and involved nurses, (ii) joint visits and telephone checks, (iii) a call centre for support and communication with a general practitioner and (iv) an individualised self-management plan including home monitoring and a plan for pharmacological and nonpharmacological interventions. The COPD-Home model attempts to cultivate competences and behaviours of patients and community nurses that better accord with guidelines for interventions. The next step in its development will be to evaluate its ability to assist both healthcare workers and planners to improve the management of COPD, reduce exacerbations and improve QOL and coping among patients with COPD. © 2013 Nordic College of Caring Science.
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Levine, Stuart; Unützer, Jürgen; Yip, Judy Y; Hoffing, Marc; Leung, Moon; Fan, Ming-Yu; Lin, Elizabeth H B; Grypma, Lydia; Katon, Wayne; Harpole, Linda H; Langston, Christopher A
2005-01-01
This study describes physicians' satisfaction with care for patients with depression before and after the implementation of a primary care-based collaborative care program. Project Improving Mood, Promoting Access to Collaborative Treatment for late-life depression (IMPACT) is a multisite, randomized controlled trial comparing a primary care-based collaborative disease management program for late-life depression with care as usual. A total of 450 primary care physicians at 18 participating clinics participated in a satisfaction survey before and 12 months after IMPACT initiation. The preintervention survey focused on physicians' satisfaction with current mental health resources and ability to provide depression care. The postintervention survey repeated these and added questions about physician's experience with the IMPACT collaborative care model. Before intervention, about half (54%) of the participating physicians were satisfied with resources to treat patients with depression. After intervention, more than 90% reported the intervention as helpful in treating patients with depression and 82% felt that the intervention improved patients' clinical outcomes. Participating physicians identified proactive patient follow-up and patient education as the most helpful components of the IMPACT model. Physicians perceived a substantial need for improving depression treatment in primary care. They were very satisfied with the IMPACT collaborative care model for treating depressed older adults and felt that similar care management models would also be helpful for treating other chronic medical illnesses.
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The importance of human resources management in health care: a global context.
Kabene, Stefane M; Orchard, Carole; Howard, John M; Soriano, Mark A; Leduc, Raymond
2006-07-27
This paper addresses the health care system from a global perspective and the importance of human resources management (HRM) in improving overall patient health outcomes and delivery of health care services. We explored the published literature and collected data through secondary sources. Various key success factors emerge that clearly affect health care practices and human resources management. This paper will reveal how human resources management is essential to any health care system and how it can improve health care models. Challenges in the health care systems in Canada, the United States of America and various developing countries are examined, with suggestions for ways to overcome these problems through the proper implementation of human resources management practices. Comparing and contrasting selected countries allowed a deeper understanding of the practical and crucial role of human resources management in health care. Proper management of human resources is critical in providing a high quality of health care. A refocus on human resources management in health care and more research are needed to develop new policies. Effective human resources management strategies are greatly needed to achieve better outcomes from and access to health care around the world.
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The importance of human resources management in health care: a global context
Kabene, Stefane M; Orchard, Carole; Howard, John M; Soriano, Mark A; Leduc, Raymond
2006-01-01
Background This paper addresses the health care system from a global perspective and the importance of human resources management (HRM) in improving overall patient health outcomes and delivery of health care services. Methods We explored the published literature and collected data through secondary sources. Results Various key success factors emerge that clearly affect health care practices and human resources management. This paper will reveal how human resources management is essential to any health care system and how it can improve health care models. Challenges in the health care systems in Canada, the United States of America and various developing countries are examined, with suggestions for ways to overcome these problems through the proper implementation of human resources management practices. Comparing and contrasting selected countries allowed a deeper understanding of the practical and crucial role of human resources management in health care. Conclusion Proper management of human resources is critical in providing a high quality of health care. A refocus on human resources management in health care and more research are needed to develop new policies. Effective human resources management strategies are greatly needed to achieve better outcomes from and access to health care around the world. PMID:16872531
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Development of a diabetes care management curriculum in a family practice residency program.
Nuovo, Jim; Balsbaugh, Thomas; Barton, Sue; Davidson, Ellen; Fox-Garcia, Jane; Gandolfo, Angela; Levich, Bridget; Seibles, Joann
2004-01-01
Improving the quality of care for patients with chronic illness has become a high priority. Implementing training programs in disease management (DM) so the next generation of physicians can manage chronic illness more effectively is challenging. Residency training programs have no specific mandate to implement DM training. Additional barriers at the training facility include: 1) lack of a population-based perspective for service delivery; 2) weak support for self-management of illness; 3) incomplete implementation due to physician resistance or inertia; and 4) few incentives to change practices and behaviors. In order to overcome these barriers, training programs must take the initiative to implement DM training that addresses each of these issues. We report the implementation of a chronic illness management curriculum based on the Improving Chronic Illness Care (ICIC) Model. Features of this process included both patient care and learner objectives. These were: development of a multidisciplinary diabetes DM team; development of a patient registry; development of diabetes teaching clinics in the family practice center (nutrition, general management classes, and one-on-one teaching); development of a group visit model; and training the residents in the elements of the ICIC Model, ie, the community, the health system, self-management support, delivery system design, decision support, and clinical information systems. Barriers to implementing these curricular changes were: the development of a patient registry; buy-in from faculty, residents, clinic leadership, staff, and patients for the chronic care model; the ability to bill for services and maintain clinical productivity; and support from the health system key stakeholders for sustainability. Unique features of each training site will dictate differences in emphasis and structure; however, the core principles of the ICIC Model in enhancing self-management may be generalized to all sites.
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Increasing the involvement of specialist physicians in chronic disease management.
Taylor, Dylan; Lahey, Michele
2008-01-01
The Capital Health (CH) region in Alberta serves the population of the Edmonton area as well as a large referral population in western Canada. CH is responsible for the delivery of the spectrum of patient care, from inpatient to outpatient services. Growth in outpatient care, in particular, has led to the development of several ambulatory care facilities from which the delivery of care to several populations with a chronic disease will be coordinated. The traditional model of care delivery is unsuited to the management of chronic diseases. Physicians must be part of the planning and implementation of new models if they are to be successful and sustainable. The concept of integration into a delivery team is not well understood or practised. This is not conducive to the integration of specialist physicians into multidisciplinary teams in ambulatory care that serves the needs of patients from a large geographic area. Chronic disease management using the Chronic Care Model has proven to be an effective method of delivering care to this wide population. Specialist physicians have not always taken advantage of opportunities to be involved in the planning and development of such new health care projects. In CH, physician integration in the planning, development and implementation of this new model has proven vital to its success. We based our strategy for change on Wagner's Chronic Care Model. This involved eight steps, the first four of which have been completed and the fifth and sixth are underway. Five factors contributed to the successful integration of specialist physicians in chronic disease management: collaboration between disciplines and organizations; creating patient-centred services; organizational commitments; strong clinical leadership; and early involvement of clinicians.
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Treiger, Teresa M; Fink-Samnick, Ellen
2014-01-01
The purpose of the third of this 3-article series is to provide context and justification for a new paradigm of case management built upon a value-driven foundation that * improves the patient's experience of health care delivery, * provides consistency in approach applicable across health care populations, and * optimizes the potential for return on investment. Applicable to all health care sectors where case management is practiced. In moving forward the one fact that rings true is there will be constant change in our industry. As the health care terrain shifts and new influences continually surface, there will be consequences for case management practice. These impacts require nimble clinical professionals in possession of recognized and firmly established competencies. They must be agile to frame (and reframe) their professional practice to facilitate the best possible outcomes for their patients. Case managers can choose to be Gumby or Pokey. This is exactly why the definition of a competency-based case management model's time has come, one sufficiently fluid to fit into any setting of care. The practice of case management transcends the vast array of representative professional disciplines and educational levels. A majority of current models are driven by business priorities rather than the competencies critical to successful practice and quality patient outcomes. This results in a fragmented professional case management identity. While there is inherent value in what each discipline brings to the table, this advanced model unifies behind case management's unique, strengths-based identity instead of continuing to align within traditional divisions (e.g., discipline, work setting, population served). This model fosters case management's expanding career advancement opportunities, including a reflective clinical ladder.
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Brand, Caroline; Hunter, David; Hinman, Rana; March, Lyn; Osborne, Richard; Bennell, Kim
2011-05-01
There is strong rationale for improving care for people with chronic conditions, including osteoarthritis (OA). Successful implementation of healthcare reform requires new concepts and directions that are strongly supported by policy, new models of care (service redesign) and changes in day-to-day practice (healthcare provider and patient practice). In this paper we discuss the extent to which policy about management of OA of the hip and knee has been translated into new service models in Australia. A structured search of government and other key health websites in Australia was performed to identify policy, funding initiatives and new services models for managing OA of the hip and knee. This search was supported by a literature review. Musculoskeletal conditions were designated a National Health Priority in Australia in 2002. Under the Better Arthritis and Osteoporosis Care initiative, Australia has developed a national policy for OA care and national evidence-based clinical practice guidelines for management of OA of the hip and knee. Only two well-described examples of new chronic disease management service models, the Osteoarthritis Clinical Pathway (OACP) model and the Osteoarthritis Hip and Knee Service (OAHKS) were identified. Primarily focused within acute care public hospital settings, these have been shown to be feasible and acceptable but have limited data on clinical impact and cost-effectiveness. While policy is extant, implementation has not been systematic and comprehensive. Clinicians have evidence-based recommendations for OA management but are poorly supported by service models to deliver these effectively and efficiently. © 2011 The Authors. International Journal of Rheumatic Diseases © 2011 Asia Pacific League of Associations for Rheumatology and Blackwell Publishing Asia Pty Ltd.
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Length of Stay and Inpatient Costs Under Medicaid Managed Care in Florida.
Park, Jungwon
2015-01-01
This study examines the patterns of length of stay (LOS) and inpatient costs for both Medicaid managed care and nonmanaged care patients using data from Medicaid patients aged 18 to 64 years who were discharged from hospitals in Florida between 2006 and 2012. This study used pooled cross-sectional multilevel modeling. The results show that the type of Medicaid program in which patients were enrolled was significantly related to the hospital LOS and inpatient costs. Medicaid managed care patients had 7% shorter LOSs and a 1.9% lower inpatient cost than did Medicaid fee-for-service (FFS) patients. Medicaid managed care patients had shorter LOSs in the Medicaid managed care market with high competition. High managed care penetration generates a cost-decreasing spillover to Medicaid FFS patients. © The Author(s) 2015.
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Stokes, Jonathan; Panagioti, Maria; Alam, Rahul; Checkland, Kath; Cheraghi-Sohi, Sudeh; Bower, Peter
2015-01-01
An ageing population with multimorbidity is putting pressure on health systems. A popular method of managing this pressure is identification of patients in primary care 'at-risk' of hospitalisation, and delivering case management to improve outcomes and avoid admissions. However, the effectiveness of this model has not been subjected to rigorous quantitative synthesis. We carried out a systematic review and meta-analysis of the effectiveness of case management for 'at-risk' patients in primary care. Six bibliographic databases were searched using terms for 'case management', 'primary care', and a methodology filter (Cochrane EPOC group). Effectiveness compared to usual care was measured across a number of relevant outcomes: Health--self-assessed health status, mortality; Cost--total cost of care, healthcare utilisation (primary and non-specialist care and secondary care separately), and; Satisfaction--patient satisfaction. We conducted secondary subgroup analyses to assess whether effectiveness was moderated by the particular model of case management, context, and study design. A total of 15,327 titles and abstracts were screened, 36 unique studies were included. Meta-analyses showed no significant differences in total cost, mortality, utilisation of primary or secondary care. A very small significant effect favouring case management was found for self-reported health status in the short-term (0.07, 95% CI 0.00 to 0.14). A small significant effect favouring case management was found for patient satisfaction in the short- (0.26, 0.16 to 0.36) and long-term (0.35, 0.04 to 0.66). Secondary subgroup analyses suggested the effectiveness of case management may be increased when delivered by a multidisciplinary team, when a social worker was involved, and when delivered in a setting rated as low in initial 'strength' of primary care. This was the first meta-analytic review which examined the effects of case management on a wide range of outcomes and considered also the effects of key moderators. Current results do not support case management as an effective model, especially concerning reduction of secondary care use or total costs. We consider reasons for lack of effect and highlight key research questions for the future. The review protocol is available as part of the PROSPERO database (registration number: CRD42014010824).
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The Home Independence Program with non-health professionals as care managers: an evaluation.
Lewin, Gill; Concanen, Karyn; Youens, David
2016-01-01
The Home Independence Program (HIP), an Australian restorative home care/reablement service for older adults, has been shown to be effective in reducing functional dependency and increasing functional mobility, confidence in everyday activities, and quality of life. These gains were found to translate into a reduced need for ongoing care services and reduced health and aged care costs over time. Despite these positive outcomes, few Australian home care agencies have adopted the service model - a key reason being that few Australian providers employ health professionals, who act as care managers under the HIP service model. A call for proposals from Health Workforce Australia for projects to expand the scope of practice of health/aged care staff then provided the opportunity to develop, implement, and evaluate a service delivery model, in which nonprofessionals replaced the health professionals as Care Managers in the HIP service. Seventy older people who received the HIP Coordinator (HIPC) service participated in the outcomes evaluation. On a range of personal outcome measures, the group showed statistically significant improvement at 3 and 12 months compared to baseline. On each outcome, the improvement observed was larger than that observed in a previous trial in which the service was delivered by health professionals. However, differences in the timing of data collection between the two studies mean that a direct comparison cannot be made. Clients in both studies showed a similarly reduced need for ongoing home care services at both follow-up points. The outcomes achieved by HIPC, with non-health professionals as Care Managers, were positive and can be considered to compare favorably with the outcomes achieved in HIP when health professionals take the Care Manager role. These findings will be of interest to managers of home care services and to policy makers interested in reducing the long-term care needs of older community dwelling individuals.
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Boorsma, Marijke; van Hout, Hein PJ; Frijters, Dinnus H; Ribbe, Miel W; Nijpels, Giel
2008-01-01
Background The objective of this article is to describe the design of a study to evaluate the clinical and economic effects of a Disease Management model on functional health, quality of care and quality of life of persons living in homes for the elderly. Methods This study concerns a cluster randomized controlled clinical trial among five intervention homes and five usual care homes in the North-West of the Netherlands with a total of over 500 residents. All persons who are not terminally ill, are able to be interviewed and sign informed consent are included. For cognitively impaired persons family proxies will be approached to provide outcome information. The Disease Management Model consists of several elements: (1) Trained staff carries out a multidimensional assessment of the patients functional health and care needs with the interRAI Long Term Care Facilities instrument (LTCF). Computerization of the LTCF produces immediate identification of problem areas and thereby guides individualized care planning. (2) The assessment outcomes are discussed in a Multidisciplinary Meeting (MM) with the nurse, primary care physician, nursing home physician and Psychotherapist and if necessary other members of the care team. The MM presents individualized care plans to manage or treat modifiable disabilities and risk factors. (3) Consultation by an nursing home physician and psychotherapist is offered to the frailest residents at risk for nursing home admission (according to the interRAI LTCF). Outcome measures are Quality of Care indicators (LTCF based), Quality Adjusted Life Years (Euroqol), Functional health (SF12, COOP-WONCA), Disability (GARS), Patients care satisfaction (QUOTE), hospital and nursing home days and mortality, health care utilization and costs. Discussion This design is unique because no earlier studies were performed to evaluate the effects and costs of this Disease Management Model for disabled persons in homes for the elderly on functional health and quality of care. Trail registration number ISRCTN11076857 PMID:18606020
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Boorsma, Marijke; van Hout, Hein P J; Frijters, Dinnus H; Ribbe, Miel W; Nijpels, Giel
2008-07-07
The objective of this article is to describe the design of a study to evaluate the clinical and economic effects of a Disease Management model on functional health, quality of care and quality of life of persons living in homes for the elderly. This study concerns a cluster randomized controlled clinical trial among five intervention homes and five usual care homes in the North-West of the Netherlands with a total of over 500 residents. All persons who are not terminally ill, are able to be interviewed and sign informed consent are included. For cognitively impaired persons family proxies will be approached to provide outcome information. The Disease Management Model consists of several elements: (1) Trained staff carries out a multidimensional assessment of the patients functional health and care needs with the interRAI Long Term Care Facilities instrument (LTCF). Computerization of the LTCF produces immediate identification of problem areas and thereby guides individualized care planning. (2) The assessment outcomes are discussed in a Multidisciplinary Meeting (MM) with the nurse, primary care physician, nursing home physician and Psychotherapist and if necessary other members of the care team. The MM presents individualized care plans to manage or treat modifiable disabilities and risk factors. (3) Consultation by an nursing home physician and psychotherapist is offered to the frailest residents at risk for nursing home admission (according to the interRAI LTCF). Outcome measures are Quality of Care indicators (LTCF based), Quality Adjusted Life Years (Euroqol), Functional health (SF12, COOP-WONCA), Disability (GARS), Patients care satisfaction (QUOTE), hospital and nursing home days and mortality, health care utilization and costs. This design is unique because no earlier studies were performed to evaluate the effects and costs of this Disease Management Model for disabled persons in homes for the elderly on functional health and quality of care. TRAIL REGISTRATION NUMBER: ISRCTN11076857.
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Preserving community in health care.
Emanuel, E J; Emanuel, L L
1997-02-01
There are two prominent trends in health care today: first, increasing demands for accountabilty, and second, increasing provision of care through managed care organizations. These trends promote the question: What form of account-ability is appropriate to managed care plans? Accountability is the process by which a party justifies its actions and policies. Components of accountability include parties that can be held or hold others accountable, domains and content areas being assessed, and procedures of assessment. Traditionally, the professional model of accountability has operated in medical care. In this model, physicians establish the standards of accountability and hold each other accountable through professional organizations. This form of accountability seems outdated and inapplicable to managed care plans. The alternatives are the economic and the political models of accountability. In the economic model, medicine becomes more like a commodity, and "exit" (consumers changing providers for reasons of cost and quality) is the dominant procedure of accountability. In the political model, medicine becomes more like a community good, and "voice" (citizens communicating their views in public forums or on policy committees, or in elections for representatives) is the dominant procedure of accountability. The economic model's advantages affirm American individualism, make minimal demands on consumers, and use a powerful incentive, money. Its disadvantages undermine health care as a nonmarket good, undermine individual autonomy, undermine good medical practice, impose significant demands on consumers to be informed, sustain differentials of power, and use indirect procedures of accountability. The political model's advantages affirm health care as a matter of justice, permit selecting domains other than price and quality for accountability, reinforce good medical practice, and equalize power between patients and physicians. Its disadvantages include inefficiency in decision making, capture by extremists or experts, intractable value conflicts, fragmentation of community, and oppression of minorities. The political model is the model we should endorse. Its disadvantages can be minimized by proper institutional design. In addition, recent research on managed care plans suggests that the political model may be the best for a competitive marketplace because it can ensure that tough allocation decisions are addressed and improve health through changes in nonmedical aspects of community life.
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Schlette, Sophia; Lisac, Melanie; Wagner, Ed; Gensichen, Jochen
2009-01-01
The Bellagio Model for Population-oriented Primary Care is an evidence-informed framework to assess accessible care for sick, vulnerable, and healthy people. The model was developed in spring 2008 by a multidisciplinary group of 24 experts from nine countries. The purpose of their gathering was to determine success factors for effective 21st century primary care based on state-of-the-art research findings, models, and empirical experience, and to assist with its implementation in practice, management, and health policy. Against the backdrop of "partialization", fragmentation in open health care systems, and the growing numbers of chronically ill or fragile people or those in need of any other kind of care, today's health care systems do not provide the much needed anchor point for continuing coordination and assistance prior, during and following an episode of illness. The Bellagio Model consists of ten key elements, which can make a substantial contribution to identify and overcome current gaps in primary care by using a synergetic approach. These elements are Shared Leadership, Public Trust, Horizontal and Vertical Integration, Networking of Professionals, Standardized Measurement, Research and Development, Payment Mix, Infrastructure, Programmes for Practice Improvement, and Population-oriented Management. All of these elements, which have been identified as being equally necessary, are also alike in that they involve all those responsible for health care: providers, managers, and policymakers.
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Patients' experiences in different models of community health centers in southern China.
Wang, Harry H X; Wong, Samuel Y S; Wong, Martin C S; Wei, Xiao Lin; Wang, Jia Ji; Li, Donald K T; Tang, Jin Ling; Gao, Gemma Y; Griffiths, Sian M
2013-01-01
Current health care reforms in China have an overall goal of strengthening primary care through the establishment and expansion of primary care networks based on community health centers (CHCs). Implementation in urban areas has led to the emergence of different models of ownership and management. The objective of this study was to evaluate the primary care experiences of patients in the Pearl River Delta as measured by the Primary Care Assessment Tool (PCAT) and the relationships with ownership and management in the 3 different models we describe. This cross-sectional study was conducted on-site at CHCs in 3 cities within the Pearl River Delta, China, using a multistage cluster sampling method. A validated Mandarin Chinese version of the PCAT-Adult Edition (short version) was adopted to collect information from adult patients regarding their experiences with primary care sources. PCAT scores for individual primary care attributes and total primary care assessment scores were assessed with respect to sociodemographic characteristics, health characteristics, and health care service utilization across 3 primary care models. One thousand four hundred forty (1,440) primary care patients responded to the survey, for an overall response rate of 86.1%. Respondents gave government-owned and -managed CHCs the highest overall PCAT scores when compared with CHCs either managed by hospitals (95.18 vs 90.81; P = .005) or owned by private and social entities (95.18 vs 90.69; P =.007) as a result of better first-contact care (better first-contact utilization) and coordination of care (better service coordination and information system). Factors that were positively and significantly associated with higher overall assessment scores included the presence of a chronic condition (P <.001), having medical insurance (P = .006), and a self-reported good health status (P <.001). This study suggests that government-owned and -managed CHCs may be able to provide better first-contact care in terms of utilization and coordination of care, and may be better at solving the problem of underutilization of the CHCs as the first-contact point of care, one key problem facing the reforms in China.
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Aging and orthopedics: how a lifespan development model can inform practice and research.
Gautreau, Sylvia; Gould, Odette N; Forsythe, Michael E
2016-08-01
Orthopedic surgical care, like all health care today, is in flux owing to an aging population and to chronic medical conditions leading to an increased number of people with illnesses that need to be managed over the lifespan. The result is an ongoing shift from curing acute illnesses to the management and care of chronic illness and conditions. Theoretical models that provide a useful and feasible vision for the future of health care and health care research are needed. This review discusses how the lifespan development model used in some disciplines within the behavioural sciences can be seen as an extension of the biopsychosocial model. We posit that the lifespan development model provides useful perspectives for both orthopedic care and research. We present key concepts and recommendations, and we discuss how the lifespan development model can contribute to new and evolving perspectives on orthopedic outcomes and to new directions for research. We also offer practical guidelines on how to implement the model in orthopedic practice.
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The development and evaluation of a nursing information system for caring clinical in-patient.
Fang, Yu-Wen; Li, Chih-Ping; Wang, Mei-Hua
2015-01-01
The research aimed to develop a nursing information system in order to simplify the admission procedure for caring clinical in-patient, enhance the efficiency of medical information documentation. Therefore, by correctly delivering patients’ health records, and providing continues care, patient safety and care quality would be effectively improved. The study method was to apply Spiral Model development system to compose a nursing information team. By using strategies of data collection, working environment observation, applying use-case modeling, and conferences of Joint Application Design (JAD) to complete the system requirement analysis and design. The Admission Care Management Information System (ACMIS) mainly included: (1) Admission nursing management information system. (2) Inter-shift meeting information management system. (3) The linkage of drug management system and physical examination record system. The framework contained qualitative and quantitative components that provided both formative and summative elements of the evaluation. System evaluation was to apply information success model, and developed questionnaire of consisting nurses’ acceptance and satisfaction. The results of questionnaires were users’ satisfaction, the perceived self-involvement, age and information quality were positively to personal and organizational effectiveness. According to the results of this study, the Admission Care Management Information System was practical to simplifying clinic working procedure and effective in communicating and documenting admission medical information.
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Pathologists' roles in clinical utilization management. A financing model for managed care.
Zhao, J J; Liberman, A
2000-03-01
In ancillary or laboratory utilization management, the roles of pathologists have not been explored fully in managed care systems. Two possible reasons may account for this: pathologists' potential contributions have not been defined clearly, and effective measurement of and reasonable compensation for the pathologist's contribution remains vague. The responsibilities of pathologists in clinical practice may include clinical pathology and laboratory services (which have long been well-defined and are compensated according to a resource-based relative value system-based coding system), laboratory administration, clinical utilization management, and clinical research. Although laboratory administration services have been compensated with mechanisms such as percentage of total service revenue or fixed salary, the involvement of pathologists seems less today than in the past, owing to increased clinical workload and time constraints in an expanding managed care environment, especially in community hospital settings. The lack of financial incentives or appropriate compensation mechanisms for the services likely accounts for the current situation. Furthermore, the importance of pathologist-driven utilization management in laboratory services lacks recognition among hospital administrators, managed care executives, and pathologists themselves, despite its potential benefits for reducing cost and enhancing quality of care. We propose a financial compensation model for such services and summarize its advantages.
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Olaison, Anna
2017-02-01
Elder care has undergone a marketization in recent years in which various models for care management have been introduced with the aim of making assessments efficient. This article investigates the effects the care management model has on resource allocation for home care when handling the requests of older persons in the needs assessment process. Sixteen tape-recorded assessment conversations with associated case-file texts were analyzed through discourse analysis. The results show that a managerialist thinking has had a partial impact on the assessment process where the documentation requirements have entailed bureaucratization in terms of the transfer that occurs from talk to text. The findings from the study nevertheless indicate that the assessment conversations have clear elements of an individual-centred perspective in which there is room for a care rational dialogue. This constitutes a welfare policy dilemma today. Providing for older people's requests should be on the basis of quality and an individual-centred perspective and care management has had a contrary effect in which focus is directed instead towards needs assessment and bureaucratic processes.
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Kiefer, Stephan; Schäfer, Michael; Bransch, Marco; Brimmers, Peter; Bartolomé, Diego; Baños, Janie; Orr, James; Jones, Dave; Jara, Maximilian; Stockmann, Martin
2014-01-01
A personal health system platform for the management of patients with chronic liver disease that incorporates a novel approach to integrate decision support and guidance through care pathways for patients and their doctors is presented in this paper. The personal health system incorporates an integrated decision support engine that guides patients and doctors through the management of the disease by issuing tasks and providing recommendations to both the care team and the patient and by controlling the execution of a Care Flow Plan based on the results of tasks and the monitored health status of the patient. This Care Flow Plan represents a formal, business process based model of disease management designed off-line by domain experts on the basis of clinical guidelines, knowledge of care pathways and an organisational model for integrated, patient-centred care. In this way, remote monitoring and treatment are dynamically adapted to the patient's actual condition and clinical symptoms and allow flexible delivery of care with close integration of specialists, therapists and care-givers.
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Models of home care services for persons with dementia: a narrative review.
Low, Lee-Fay; Fletcher, Jennifer
2015-10-01
Worldwide trends of increasing dementia prevalence, have put economic and workforce pressures to shifting care for persons with dementia from residential care to home care. We reviewed the effects of the four dominant models of home care delivery on outcomes for community-dwelling persons with dementia. These models are: case management, integrated care, consumer directed care, and restorative care. This narrative review describes benefits and possible drawbacks for persons with dementia outcomes and elements that comprise successful programs. Case management for persons with dementia may increase use of community-based services and delay nursing home admission. Integrated care is associated with greater client satisfaction, increased use of community based services, and reduced hospital days however the clinical impacts on persons with dementia and their carers are not known. Consumer directed care increases satisfaction with care and service usage, but had little effect on clinical outcomes. Restorative models of home care have been shown to improve function and quality of life however these trials have excluded persons with dementia, with the exception of a pilot study. There has been a little research into models of home care for people with dementia, and no head-to-head comparison of the different models. Research to inform evidence-based policy and service delivery for people with dementia needs to evaluate both the impact of different models on outcomes, and investigate how to best deliver these models to maximize outcomes.
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The future of capitation: the physician role in managing change in practice.
Goodson, J D; Bierman, A S; Fein, O; Rask, K; Rich, E C; Selker, H P
2001-04-01
Capitation-based reimbursement significantly influences the practice of medicine. As physicians, we need to assure that payment models do not jeopardize the care we provide when we accept higher levels of personal financial risk. In this paper, we review the literature relevant to capitation, consider the interaction of financial incentives with physician and medical risk, and conclude that primary care physicians need to work to assure that capitated systems incorporate checks and balances which protect both patients and providers. We offer the following proposals for individuals and groups considering capitated contracts: (1) reimbursement for primary care physicians should recognize both individual patient encounters and the administrative work of patient care management; (2) reimbursement for subspecialists should recognize both access to subspecialty knowledge and expertise as well as patient care encounters, but in some situations, subspecialists may provide the majority of care to individual patients and will be reimbursed as primary care providers; (3) groups of physicians should accept financial risk for patient care only if they have the tools and resources to manage the care; (4) physicians sharing risk for patient care should meet regularly to discuss care and resource management; and (5) physicians must disclose the financial relationships they have with health plans and medical care organizations, and engage patients and communities in discussions about resource allocation. As a payment model, capitation offers opportunities for primary care physicians to influence the future of health care by improving the management of resources at a local level.
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Lean leadership attributes: a systematic review of the literature.
Aij, Kjeld Harald; Teunissen, Maurits
2017-10-09
Purpose Emphasis on quality and reducing costs has led many health-care organizations to reconfigure their management, process, and quality control infrastructures. Many are lean, a management philosophy with roots in manufacturing industries that emphasizes elimination of waste. Successful lean implementation requires systemic change and strong leadership. Despite the importance of leadership to successful lean implementation, few researchers have probed the question of ideal leadership attributes to achieve lean thinking in health care. The purpose of this paper is to provide insight into applicable attributes for lean leaders in health care. Design/methodology/approach The authors systematically reviewed the literature on principles of leadership and, using Dombrowski and Mielke's (2013) conceptual model of lean leadership, developed a parallel theoretical model for lean leadership in health care. Findings This work contributes to the development of a new framework for describing leadership attributes within lean management of health care. Originality/value The summary of attributes can provide a model for health-care leaders to apply lean in their organizations.
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Keisu, Britt-Inger; Öhman, Ann; Enberg, Birgit
2018-03-01
Negative aspects, staff dissatisfaction and problems related to internal organisational factors of working in elderly care are well-known and documented. Much less is known about positive aspects of working in elderly care, and therefore, this study focuses on such positive factors in Swedish elderly care. We combined two theoretical models, the effort-reward imbalance model and the Transformational Leadership Style model. The aim was to estimate the potential associations between employee-perceived transformational leadership style of their managers, and employees' ratings of effort and reward within elderly care work. The article is based on questionnaires distributed at on-site visits to registered nurses, occupational therapists, physiotherapists (high-level education) and assistant nurses (low-level education) in nine Swedish elderly care facilities. In order to grasp the positive factors of work in elderly care, we focused on balance at work, rather than imbalance. We found a significant association between employees' effort-reward balance at work and a transformational leadership style among managers. An association was also found between employees' level of education and their assessments of the first-level managers. We conclude that the first-level manager is an important actor for achieving a good workplace within elderly care, since she/he influences employees' psychosocial working environment. We also conclude that there are differences and inequalities, in terms of well-being, effort and reward at the work place, between those with academic training and those without, in that the former group to a higher degree evaluated their first-level manager to perform a transformational leadership style, which in turn is beneficial for their psychosocial work environment. Consequently, this (re)-produce inequalities in terms of well-being, effort and reward among the employees at the work place. © 2017 Nordic College of Caring Science.
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Aragonès, Enric; Palao, Diego; López-Cortacans, Germán; Caballero, Antonia; Cardoner, Narcís; Casaus, Pilar; Cavero, Myriam; Monreal, José Antonio; Pérez-Sola, Víctor; Cirera, Miquel; Loren, Maite; Bellerino, Eva; Tomé-Pires, Catarina; Palacios, Laura
2017-12-13
Primary care is the principal clinical setting for the management of depression. However, significant shortcomings have been detected in its diagnosis and clinical management, as well as in patient outcomes. We developed the INDI collaborative care model to improve the management of depression in primary care. This intervention has been favorably evaluated in terms of clinical efficacy and cost-effectiveness in a clinical trial. Our aim is to bring this intervention from the scientific context into clinical practice. Objective: To test for the feasibility and impact of a strategy for implementing the INDI model for depression in primary care. A quasi-experiment conducted in primary care. Several areas will be established to implement the new program and other, comparable areas will serve as control group. The study constitutes the preliminary phase preceding generalization of the model in the Catalan public healthcare system. The target population of the intervention are patients with major depression. The implementation strategy will also involve healthcare professionals, primary care centers, as well as management departments and the healthcare organization itself in the geographical areas where the study will be conducted: Camp de Tarragona and Vallès Occidental (Catalonia). The INDI model is a program for improving the management of depression involving clinical, instructional, and organizational interventions including the participation of nurses as care managers, the efficacy and efficiency of which has been proven in a clinical trial. We will design an active implementation strategy for this model based on the PARIHS (Promoting Action on Research Implementation in Health Services) framework. Qualitative and quantitative measures will be used to evaluate variables related to the successful implementation of the model: acceptability, utility, penetration, sustainability, and clinical impact. This project tests the transferability of a healthcare intervention supported by scientific research to clinical practice. If implementation is successful in this experimental phase, we will use the information and experience obtained to propose and plan the generalization of the INDI model for depression in the Catalan healthcare system. We expect the program to benefit patients, the healthcare system, and society. ClinicalTrials.gov identifier: NCT03285659 ; Registered 12th September, 2017.
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van Rensburg, André Janse; Fourie, Pieter
2016-01-01
Mental illness is a well-known challenge to global development, particularly in low-to-middle income countries. A key health systems response to mental illness is different models of integrated health care, especially popular in the South African Development Community (SADC) region. This complex construct is often not well-defined in health policy, hampering implementation efforts. A key development in this vein has been the Rainbow Model of integrated care, a comprehensive framework and taxonomy of integrated care based on the integrative functions of primary care. The purpose of this study was to explore the nature and strategic forms of integrated mental health care in selected SADC countries, specifically how integrated care is outlined in state-driven policies. Health policies from five SADC countries were analysed using the Rainbow Model as framework. Electronic copies of policy documents were transferred into NVivo 10, which aided in the framework analysis on the different types of integrated mental health care promoted in the countries assessed. Several Rainbow Model components were emphasised. Clinical integration strategies (coordination of person-focused care) such as centrality of client needs, case management and continuity were central considerations, while others such as patient education and client satisfaction were largely lacking. Professional integration (inter-professional partnerships) was mentioned in terms of agreements on interdisciplinary collaboration and performance management, while organisational integration (inter-organisational relationships) emerged under the guise of inter-organisational governance, population needs and interest management. Among others, available resources, population management and stakeholder management fed into system integration strategies (horizontally and vertically integrated systems), while functional integration strategies (financial, management and information system functions) included human resource, information and resource management. Normative integration (a common frame of reference) included collective attitude, sense of urgency, and linking cultures, though aspects such as conflict management, quality features of the informal collaboration, and trust were largely lacking. Most countries stressed the importance of integrating mental health on primary healthcare level, though an absence of supporting strategies could prove to bar implementation. Inter-service collaboration emerged as a significant goal, though a lack of (especially) normative integration dimensions could prove to be a key omission. Despite the usefulness of the Rainbow Model, it failed to adequately frame regional governance aspects of integration, as the SADC Secretariat could play an important role in coordinating and supporting the development and strengthening of better mental health systems.
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Li, Haitao; Qian, Dongfu; Griffiths, Sian; Chung, Roger Yat-Nork; Wei, Xiaolin
2015-11-10
There are three major models of primary care providers (Community Health Centers, CHCs) in China, i.e., government managed, hospital managed and privately owned CHCs. We performed a systematic review of structures and health care delivery patterns of the three models of CHCs. Studies from relevant English and Chinese databases for the period of 1997-2011 were searched. Two independent researchers extracted data from the eligible studies using a standardized abstraction form. Methodological quality of included articles was assessed with the Mixed Methods Appraisal Tool (MMAT). A total of 13 studies was included in the final analysis. Compared with the other two models, private CHCs had a smaller health workforce and lower share of government funding in their total revenues. Private CHCs also had fewer training opportunities, were less recognized by health insurance schemes and tended to provide primary care services of poor quality. Hospital managed CHCs attracted patients through their higher quality of clinical care, while private CHCs attracted users through convenience and medical equipment. Our study suggested that government and hospital managed CHCs were more competent and provided better primary care than privately owned CHCs. Further studies are warranted to comprehensively compare performances among different models of CHCs.
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Overbeck, G; Kousgaard, M B; Davidsen, A S
2018-04-01
WHAT IS KNOWN ON THE SUBJECT?: In collaborative care models between psychiatry and general practice, mental health nurses are used as care managers who carry out the treatment of patients with anxiety or depression in general practice and establish a collaborating relationship with the general practitioner. Although the care manager is the key person in the collaborative care model, there is little knowledge about this role and the challenges involved in it. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: Our study shows that before the CMs could start treating patients in a routine collaborative relationship with GPs, they needed to carry out an extensive amount of implementation work. This included solving practical problems of location and logistics, engaging GPs in the intervention, and tailoring collaboration to meet the GP's particular preferences. Implementing the role requires high commitment and an enterprising approach on the part of the care managers. The very experienced mental health nurses of this study had these skills. However, the same expertise cannot be presumed in a disseminated model. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: When introducing new collaborative care interventions, the care manager role should be well defined and be well prepared, especially as regards the arrival of the care manager in general practice, and supported during implementation by a coordinated leadership established in collaboration between hospital psychiatry and representatives from general practice. Introduction In collaborative care models for anxiety and depression, the care manager (CM), often a mental health nurse, has a key role. However, the work and challenges related to this role remain poorly investigated. Aim To explore CMs' experiences of their work and the challenges they face when implementing their role in a collaborative care intervention in the Capital Region of Denmark. Methods Interviews with eight CMs, a group interview with five CMs and a recording of one supervision session were analysed by thematic analysis. Results The CM carried out considerable implementation work. This included finding suitable locations; initiating and sustaining communication with the GPs and maintaining their engagement in the model; adapting to the patient population in general practice; dealing with personal security issues, and developing supportive peer relations and meaningful supervision. Discussion We compare our findings to previous studies of collaborative care and advanced nursing roles in general practice. The importance of organizational leadership to support the CM's bridge-building role is emphasized. Implications for practice The planners of new collaborative care interventions should not only focus on the CM's clinical tasks but also on ensuring the sufficient organizational conditions for carrying out the role. © 2017 John Wiley & Sons Ltd.
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Jacobs, Sally; Hughes, Jane; Challis, David; Stewart, Karen; Weiner, Kate
2006-01-01
Since the community care reforms of the early 1990s, care management in the United Kingdom has become the usual means of arranging services for even the most straightforward of social care needs. This paper presents data from a diary study of care managers' time use, from a sample of social services commissioning organizations representing the most common forms of care management practiced in England at the end of the 20th century. It compares the working practices of care managers in community mental health service settings to the practices of those situated in older people's services. Evidence is provided to suggest that while the former follow a more clinical model of care management, those working with older people take an almost exclusively administrative approach to their work. In addition, the multidisciplinary nature of mental health service teams appears to facilitate a more integrated health and social care approach to care management compared to the approach to older people's services. Further enquiry is needed as to the comparative effectiveness of these different modes of working in each service setting.
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The eHealth Enhanced Chronic Care Model: a theory derivation approach.
Gee, Perry M; Greenwood, Deborah A; Paterniti, Debora A; Ward, Deborah; Miller, Lisa M Soederberg
2015-04-01
Chronic illnesses are significant to individuals and costly to society. When systematically implemented, the well-established and tested Chronic Care Model (CCM) is shown to improve health outcomes for people with chronic conditions. Since the development of the original CCM, tremendous information management, communication, and technology advancements have been established. An opportunity exists to improve the time-honored CCM with clinically efficacious eHealth tools. The first goal of this paper was to review research on eHealth tools that support self-management of chronic disease using the CCM. The second goal was to present a revised model, the eHealth Enhanced Chronic Care Model (eCCM), to show how eHealth tools can be used to increase efficiency of how patients manage their own chronic illnesses. Using Theory Derivation processes, we identified a "parent theory", the Chronic Care Model, and conducted a thorough review of the literature using CINAHL, Medline, OVID, EMBASE PsychINFO, Science Direct, as well as government reports, industry reports, legislation using search terms "CCM or Chronic Care Model" AND "eHealth" or the specific identified components of eHealth. Additionally, "Chronic Illness Self-management support" AND "Technology" AND several identified eHealth tools were also used as search terms. We then used a review of the literature and specific components of the CCM to create the eCCM. We identified 260 papers at the intersection of technology, chronic disease self-management support, the CCM, and eHealth and organized a high-quality subset (n=95) using the components of CCM, self-management support, delivery system design, clinical decision support, and clinical information systems. In general, results showed that eHealth tools make important contributions to chronic care and the CCM but that the model requires modification in several key areas. Specifically, (1) eHealth education is critical for self-care, (2) eHealth support needs to be placed within the context of community and enhanced with the benefits of the eCommunity or virtual communities, and (3) a complete feedback loop is needed to assure productive technology-based interactions between the patient and provider. The revised model, eCCM, offers insight into the role of eHealth tools in self-management support for people with chronic conditions. Additional research and testing of the eCCM are the logical next steps.
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Connected health and integrated care: Toward new models for chronic disease management.
Chouvarda, Ioanna G; Goulis, Dimitrios G; Lambrinoudaki, Irene; Maglaveras, Nicos
2015-09-01
The increasingly aging population in Europe and worldwide brings up the need for the restructuring of healthcare. Technological advancements in electronic health can be a driving force for new health management models, especially in chronic care. In a patient-centered e-health management model, communication and coordination between patient, healthcare professionals in primary care and hospitals can be facilitated, and medical decisions can be made timely and easily communicated. Bringing the right information to the right person at the right time is what connected health aims at, and this may set the basis for the investigation and deployment of the integrated care models. In this framework, an overview of the main technological axes and challenges around connected health technologies in chronic disease management are presented and discussed. A central concept is personal health system for the patient/citizen and three main application areas are identified. The connected health ecosystem is making progress, already shows benefits in (a) new biosensors, (b) data management, (c) data analytics, integration and feedback. Examples are illustrated in each case, while open issues and challenges for further research and development are pinpointed. Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.
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Kang, Xiaofeng; Dennison Himmelfarb, Cheryl R; Li, Zheng; Zhang, Jian; Lv, Rong; Guo, Jinyu
2015-01-01
The Self-care of Heart Failure Index (SCHFI) is an empirically tested instrument for measuring the self-care of patients with heart failure. The aim of this study was to develop a simplified Chinese version of the SCHFI and provide evidence for its construct validity. A total of 182 Chinese with heart failure were surveyed. A 2-step structural equation modeling procedure was applied to test construct validity. Factor analysis showed 3 factors explaining 43% of the variance. Structural equation model confirmed that self-care maintenance, self-care management, and self-care confidence are indeed indicators of self-care, and self-care confidence was a positive and equally strong predictor of self-care maintenance and self-care management. Moreover, self-care scores were correlated with the Partners in Health Scale, indicating satisfactory concurrent validity. The Chinese version of the SCHFI is a theory-based instrument for assessing self-care of Chinese patients with heart failure.
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Bundorf, M Kate; Schulman, Kevin A; Stafford, Judith A; Gaskin, Darrell; Jollis, James G; Escarce, José J
2004-02-01
To examine the effects of market-level managed care activity on the treatment, cost, and outcomes of care for Medicare fee-for-service acute myocardial infarction (AMI) patients. Patients from the Cooperative Cardiovascular Project (CCP), a sample of Medicare beneficiaries discharged from nonfederal acute-care hospitals with a primary discharge diagnosis of AMI from January 1994 to February 1996. We estimated models of patient treatment, costs, and outcomes using ordinary least squares and logistic regression. The independent variables of primary interest were market-area managed care penetration and competition. The models included controls for patient, hospital, and other market area characteristics. We merged the CCP data with Medicare claims and other data sources. The study sample included CCP patients aged 65 and older who were admitted during 1994 and 1995 with a confirmed AMI to a nonrural hospital. Rates of revascularization and cardiac catheterization for Medicare fee-for-service patients with AMI are lower in high-HMO penetration markets than in low-penetration ones. Patients admitted in high-HMO-competition markets, in contrast, are more likely to receive cardiac catheterization for treatment of their AMI and had higher treatment costs than those admitted in low-competition markets. The level of managed care activity in the health care market affects the process of care for Medicare fee-for-service AMI patients. Spillovers from managed care activity to patients with other types of insurance are more likely when managed care organizations have greater market power.
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New model helps find missing link between financial and clinical health care management.
Dasso, E; Wilson, T
2001-01-01
U.S. health care is missing a link between the financial managers and clinical health managers of defined patient populations. Utilization and cost management try to bridge the gap by focusing on restricted access to care or tightly managed provider reimbursement to control costs. But frequently, they do not take clinical outcomes or health status into consideration. Take a look at another method based on the science of epidemiology that brings a more balanced knowledge of the clinical world to financial managers and more financial insight to clinicians.
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Physician involvement in disease management as part of the CCM.
Wallace, Paul J
2005-01-01
Phase I of the voluntary chronic care improvement (CCI-I) under traditional fee-for-service Medicare initiative seeks to extend the benefits of disease management to an elderly population with comorbid chronic medical conditions. Active, sustained involvement of treating physicians, a historical deficit of disease management programs, is a CCI-I program goal. During the last decade, Kaiser Permanente, an integrated health care delivery system with more than 60 years of experience in managing the care of individuals and populations, has applied the chronic care model (CCM) to develop care management strategies for populations of patients with chronic medical conditions. Physician leadership and involvement have been key to successfully incorporating these practices into care. The scope of physician involvement in leading, developing, and delivering chronic illness care management at Kaiser Permanente is described as a basis for identifying opportunities to involve practicing physicians in the CCI-I.
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Physician Involvement in Disease Management as Part of the CCM
Wallace, Paul J.
2005-01-01
Phase I of the voluntary chronic care improvement (CCI-I) under traditional fee-for-service Medicare initiative seeks to extend the benefits of disease management to an elderly population with comorbid chronic medical conditions. Active, sustained involvement of treating physicians, a historical deficit of disease management programs, is a CCI-I program goal. During the last decade, Kaiser Permanente, an integrated health care delivery system with more than 60 years of experience in managing the care of individuals and populations, has applied the chronic care model (CCM) to develop care management strategies for populations of patients with chronic medical conditions. Physician leadership and involvement have been key to successfully incorporating these practices into care. The scope of physician involvement in leading, developing, and delivering chronic illness care management at Kaiser Permanente is described as a basis for identifying opportunities to involve practicing physicians in the CCI-I. PMID:17288075
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METABO: a new paradigm towards diabetes disease management. An innovative business model.
Guillén, Alejandra; Colás, Javier; Fico, Giuseppe; Guillén, Sergio
2011-01-01
Dealing with a chronic disease and, more specifically, with Diabetes Mellitus and other metabolic disorders, represents a great challenge for care givers, patients and the healthcare systems as their treatment requires continuous medical care and patient self management. The engagement of patients in the adoption of healthy lifestyles with a positive impact in the progression of their diseases is fundamental to avoid the appearance of chronic complications or co-morbidities. This paper presents the externalization of the health management of diabetic patients as an alternative to the current models of care for these patients that can help improve the quality of follow up and care delivery and contribute to the sustainability of the healthcare systems.
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Implementation of a care management model for depression at two primary care clinics.
Williams, Mark; Angstman, Kurt; Johnson, Isaac; Katzelnick, David
2011-01-01
The Mayo clinic participated in the Depression Improvement Across Minnesota, Offering a New Direction model at two Mayo Family Clinics, that is, the Rochester Northwest and Northeast sites. Although the Northwest and Northeast clinics demonstrated the best 6-month remission rates in the state during the first year of implementation, they were retrospectively found to differ on several process issues and on measures related to the populations served. Six-month remission rates were significantly better at Northwest clinic; yet, Northeast clinic had more patient contacts. Differences in rates of activation into care management, care management accessibility, and differences in maintaining contact with patients at 6 months may explain some of these results.
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Chen, Hsiao-Mei; Han, Tung-Chen; Chen, Ching-Min
2014-04-01
Population aging has caused significant rises in the prevalence of chronic diseases and the utilization of healthcare services in Taiwan. The current healthcare delivery system is fragmented. Integrating medical services may increase the quality of healthcare, enhance patient and patient family satisfaction with healthcare services, and better contain healthcare costs. This article introduces two continuing care models: discharge planning and case management. Further, the effectiveness and essential components of these two models are analyzed using a systematic review method. Articles included in this systematic review were all original articles on discharge-planning or case-management interventions published between February 1999 and March 2013 in any of 6 electronic databases (Medline, PubMed, Cinahl Plus with full Text, ProQuest, Cochrane Library, CEPS and Center for Chinese Studies electronic databases). Of the 70 articles retrieved, only 7 were randomized controlled trial studies. Three types of continuity-of-care models were identified: discharge planning, case management, and a hybrid of these two. All three models used logical and systematic processes to conduct assessment, planning, implementation, coordination, follow-up, and evaluation activities. Both the discharge planning model and the case management model were positively associated with improved self-care knowledge, reduced length of stay, decreased medical costs, and better quality of life. This study cross-referenced all reviewed articles in terms of target clients, content, intervention schedules, measurements, and outcome indicators. Study results may be referenced in future implementations of continuity-care models and may provide a reference for future research.
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RN Diabetes Virtual Case Management: A New Model for Providing Chronic Care Management.
Brown, Nancy N; Carrara, Barbara E; Watts, Sharon A; Lucatorto, Michelle A
2016-01-01
The U.S. chronic disease health care system has substantial gaps in delivery of services. New models of care change traditional delivery of care and explore new settings for care. This article describes a new model of diabetes chronic care delivery: nurse-delivered care that includes protocol-based insulin titration and patient education delivered solely in a virtual environment. In phase 1, the clinical outcome of time to achievement of glycated hemoglobin (A(1C)) goals (P < .001; 95% confidence interval, 1.68-2.24) was significantly improved by registered nurse (RN) standing order intervention (n = 24) as compared with historical controls (n = 28). In phase 2, patients who were referred to an RN-managed insulin titration protocol with individualized A(1C) goals had a significant (P < .001; 95% confidence interval, 1.680-2.242) reduction in results from a mean of 9.6% at baseline to 7.7% at completion. Average patient age was 66 years, with a mean duration of 11 years diagnosed with diabetes. Safety was demonstrated by the absence of hypoglycemia related to RN protocol adjustment. There were no admissions or emergency room (ER) visits for hypoglycemia. This study demonstrates safety and efficacy of RN virtual chronic disease management for an older population of patients with long-standing diabetes.
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Impact of service delivery model on health care access among HIV-positive women in New York City.
Pillai, Nandini V; Kupprat, Sandra A; Halkitis, Perry N
2009-01-01
As the New York City HIV=AIDS epidemic began generalizing beyond traditionally high-risk groups in the early 1990s, AIDS Service Organizations (ASO) sought to increase access to medical care and broaden service offerings to incorporate the needs of low-income women and their families. Strategies to achieve entry into and retention in medical care included the development of integrated care facilities, case management, and a myriad of supportive service offerings. This study examines a nonrandom sample of 60 HIV-positive women receiving case management and supportive services at New York City ASOs. Over 55% of the women interviewed reported high access to care, 43% reported the ability to access urgent care all of the time and 94% reported high satisfaction with obstetrics=gynecology (OB=GYN) care. This held true across race=ethnicity, income level, medical coverage, and service delivery model.Women who accessed services at integrated care facilities offering onsite medical care and case management=supportive services perceived lower access to medical specialists as compared to those who received services at nonintegrated sites. Data from this analysis indicate that supportive services increase access to and satisfaction with both HIV and non-HIV-related health care. Additionally, women who received services at a medical model agency were more likely to report accessing non-HIV care at a clinic compared to those receiving services at a nonmedical model agencies, these women were more likely to report receiving non-HIV care at a hospital.
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Haas, Sheila A; Vlasses, Frances; Havey, Julia
2016-01-01
There are multiple demands and challenges inherent in establishing staffing models in ambulatory heath care settings today. If health care administrators establish a supportive physical and interpersonal health care environment, and develop high-performing interprofessional teams and staffing models and electronic documentation systems that track performance, patients will have more opportunities to receive safe, high-quality evidence-based care that encourages patient participation in decision making, as well as provision of their care. The health care organization must be aligned and responsive to the community within which it resides, fully invested in population health management, and continuously scanning the environment for competitive, regulatory, and external environmental risks. All of these challenges require highly competent providers willing to change attitudes and culture such as movement toward collaborative practice among the interprofessional team including the patient.
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Joubert, J; Davis, S M; Hankey, G J; Levi, C; Olver, J; Gonzales, G; Donnan, G A
2015-07-01
The majority of strokes, both ischaemic and haemorrhagic, are attributable to a relatively small number of risk factors which are readily manageable in primary care setting. Implementation of best-practice recommendations for risk factor management is calculated to reduce stroke recurrence by around 80%. However, risk factor management in stroke survivors has generally been poor at primary care level. A model of care that supports long-term effective risk factor management is needed. To determine whether the model of Integrated Care for the Reduction of Recurrent Stroke (ICARUSS) will, through promotion of implementation of best-practice recommendations for risk factor management reduce the combined incidence of stroke, myocardial infarction and vascular death in patients with recent stroke or transient ischaemic attack (TIA) of the brain or eye. A prospective, Australian, multicentre, randomized controlled trial. Academic stroke units in Melbourne, Perth and the John Hunter Hospital, New South Wales. 1000 stroke survivors recruited as from March 2007 with a recent (<3 months) stroke (ischaemic or haemorrhagic) or a TIA (brain or eye). Randomization and data collection are performed by means of a central computer generated telephone system (IVRS). Exposure to the ICARUSS model of integrated care or usual care. The composite of stroke, MI or death from any vascular cause, whichever occurs first. Risk factor management in the community, depression, quality of life, disability and dementia. With 1000 patients followed up for a median of one-year, with a recurrence rate of 7-10% per year in patients exposed to usual care, the study will have at least 80% power to detect a significant reduction in primary end-points The ICARUSS study aims to recruit and follow up patients between 2007 and 2013 and demonstrate the effectiveness of exposure to the ICARUSS model in stroke survivors to reduce recurrent stroke or vascular events and promote the implementation of best practice risk factor management at primary care level. © 2015 World Stroke Organization.
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Sanchez, Iris
2011-01-01
The purpose of this study was to implement diabetes self-management education in primary care using the Chronic Care Model and shared medical appointments (SMA) to provide evidence-based interventions to improve process and measure outcomes. A quality improvement project using the Plan-Do-Check-Act cycle was implemented in a primary care setting in South Texas to provide diabetes self-management education for adults. Biological measures were evaluated in 70 patients at initiation of the project and thereafter based on current practice guidelines. The results of the project were consistent with the literature regarding the benefits, sustainability, and viability of SMA. As compared with that in studies presented in the literature, the patient population who participated in SMA had similar outcomes regarding improvement in A1C, self-management skills, and satisfaction. SMA are an innovative system redesign concept with the potential to provide comprehensive and coordinated care for patients with multiple and chronic health conditions while still being an efficient, effective, financially viable, and sustainable program. As the incidence and prevalence of diabetes increase, innovative models of care can meet the growing demand for access and utilization of diabetes self-management education programs. Programs focusing on chronic conditions to improve outcomes can be replicated by health care providers in primary care settings. SMA can increase revenue and productivity, improve disease management, and increase provider and patient satisfaction.
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Attachment Theory and Neuroscience for Care Managers.
Blakely, Thomas J; Dziadosz, Gregory M
2016-09-01
This article describes a model for care managers that is based on attachment theory supplemented by knowledge from neuroscience. Together, attachment theory and basic knowledge from neuroscience provide for both an organizing conceptual framework and a scientific, measureable approach to assessment and planning interventions in a care plan.
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Hudon, Catherine; Fortin, Martin; Haggerty, Jeannie; Loignon, Christine; Lambert, Mireille; Poitras, Marie-Eve
2012-08-01
The objective was to provide a synthesis of the results of the research and discourse lines on main dimensions of patient-centered care in the context of chronic disease management in family medicine, building on Stewart et al.'s model. We developed search strategies for the Medline, Embase, and Cochrane databases, from 1980 to April 2009. All articles addressing patient-centered care in the context of chronic disease management in family medicine were included. A thematic analysis was performed using mixed codification, based on Stewart's model of patient-centered care. Thirty-two articles were included. Six major themes emerged: (1) starting from the patient's situation; (2) legitimizing the illness experience; (3) acknowledging the patient's expertise; (4) offering realistic hope; (5) developing an ongoing partnership; (6) providing advocacy for the patient in the health care system. The context of chronic disease management brings forward new dimensions of patient-centered care such as legitimizing the illness experience, acknowledging patient expertise, offering hope and providing advocacy. Chronic disease management calls for the adaptation of the family physician's role to patients' fluctuating needs. Literature also suggests the involvement of the family physician in care transitions as a component of patient-centered care. Crown Copyright © 2012. Published by Elsevier Ireland Ltd. All rights reserved.
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Collaborating for care: initial experience of embedded case managers across five medical homes.
Treadwell, Janet; Giardino, Angelo
2014-01-01
The purpose of this intervention was to answer the following question: Does an embedded nurse case manager from a health plan performing embedded care coordination and supporting a quality improvement project impact medical home service use, role satisfaction, and per member per month expense? The setting for this study was primary care medical home practices with a minimum of 1,000 lives, contracted with a health plan delivering Medicaid and Children's Health Insurance coverage. Five medical home practice sites were selected for the intervention. The study began with case manager training and project permission in 5 medical homes, followed by implementation of care coordination with health plan clients. The nurse case manager performed care coordination functions for clients and initiated a Lean Six Sigma quality improvement project at the medical home site. The analysis strategy was to compare each medical home with itself before and after the intervention, as well as to obtain satisfaction information from medical home staff and care coordinators. Reductions in expense, as demonstrated by decreased per member per month claim cost, admissions per thousand, and reduced variation in days per thousand, were documented. Quality projects attained significant improvements in 4 out of 5 sites, and practice staff as well as case managers described satisfaction with the embedded nurse case manager role. These findings support medical homes as being an effective delivery model of the Affordable Care Act. Case managers who practice in primary care sites can make a significant difference in patient outcomes and practice efficiencies. Embedded case managers have the ability to impact the population being served through modeling and supporting interprofessional relationships and case management expertise. Use of motivational interviewing, assessment skills, advocacy, and joint care planning engage patients in their own care, whereas quality initiatives bring efficiencies and effectiveness to overall operations. There is need for research to be conducted across a larger number of practice sites and diverse populations to substantiate the effect of embedded case management in medical home.
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The influence of leadership practices and empowerment on Canadian nurse manager outcomes.
Spence Laschinger, Heather K; Wong, Carol A; Grau, Ashley L; Read, Emily A; Pineau Stam, Lisa M
2012-10-01
To examine the influence of senior nurse leadership practices on middle and first-line nurse managers' experiences of empowerment and organizational support and ultimately on their perceptions of patient care quality and turnover intentions. Empowering leadership has played an important role in staff nurse retention but there is limited research to explain the mechanisms by which leadership influences nurse managers' turnover intentions. This study was a secondary analysis of data collected using non-experimental, predictive mailed survey design. Data from 231 middle and 788 first-line Canadian acute care managers was used to test the hypothesized model using path analysis in each group. The results showed an adequate fit of the hypothesized model in both groups but with an added path between leadership practices and support in the middle line group. Transformational leadership practices of senior nurses empower middle- and first-line nurse managers, leading to increased perceptions of organizational support, quality care and decreased intent to leave. Empowered nurse managers at all levels who feel supported by their organizations are more likely to stay in their roles, remain committed to achieving quality patient care and act as influential role models for potential future leaders. © 2011 Blackwell Publishing Ltd.
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DeCaporale-Ryan, Lauren N; Ahmed-Sarwar, Nabila; Upham, Robbyn; Mahler, Karen; Lashway, Katie
2017-06-01
A team-based service delivery model was applied to provide patients with biopsychosocial care following hospital discharge to reduce hospital readmission. Most previous interventions focused on transitions of care occurred in the inpatient setting with attention to predischarge strategies. These interventions have not considered psychosocial stressors, and few have explored management in primary care settings. A 7-week team-based service delivery model was implemented in a family medicine practice emphasizing a biopsychosocial approach. A physician, psychologist, pharmacist, care managers, and interdisciplinary trainees worked with 17 patients following hospital discharge. This comprehensive evaluation assessed patients' mood, cognitive abilities, and self-management of health behaviors. Modifications were made to improve ease of access to outpatient care and to improve patient understanding of the therapeutic plan. This pilot study was conducted to determine the utility of the model. Of 17 patients, 15 individuals avoided readmission at 30- and 90-day intervals. Other substantial benefits were noted, including reduced polypharmacy, engagement in specialty care, and reduction of environmental stressors to improve access to care. The clinic in which this was implemented is currently making efforts to maintain this model of care based on observed success. Although this work only represents a small sample, results are encouraging. This model can be replicated in other primary care settings with specialty clinicians on site. Specifically, approaches that promote a team-based delivery in a primary care setting may support improved patient outcomes and reduced overall systems' costs. Recommendations for research in a clinical setting are also offered. (PsycINFO Database Record (c) 2017 APA, all rights reserved).
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Knowledge Representation and Care Planning for Population Health Management.
Merahn, Steven
2015-01-01
The traditional organizing principles of medical knowledge may be insufficient to allow for problem representations that are relevant to solution development in emerging models of care such as population health management. Operational classification and central management of clinical and quality objectives and associated strategies will allow for productive innovation in care design and better support goal-directed collaboration among patients and their health resource communities.
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Alvarez, Renae; Ginsburg, Jacob; Grabowski, Jessica; Post, Sharon; Rosenberg, Walter
2016-04-01
The hospital experience is taxing and confusing for patients and their families, particularly those with limited economic and social resources. This complexity often leads to disengagement, poor adherence to the plan of care, and high readmission rates. Novel approaches to addressing the complexities of transitional care are emerging as possible solutions. The Bridge Model is a person-centered, social work-led, interdisciplinary transitional care intervention that helps older adults safely transition from the hospital back to their homes and communities. The Bridge Model combines 3 key components-care coordination, case management, and patient engagement-which provide a seamless transition during this stressful time and improve the overall quality of transitional care for older adults, including reducing hospital readmissions. The post Affordable Care Act (ACA) and managed care environment's emphasis on value and quality support further development and expansion of transitional care strategies, such as the Bridge Model, which offer promising avenues to fulfil the triple aim by improving the quality of individual patient care while also impacting population health and controlling per capita costs.
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Cool Heads: Crisis Management for Administrators.
ERIC Educational Resources Information Center
Smiar, Nicholas P.
1992-01-01
Applies risk management models to child care administration. These models have been used by corporations to plan for crisis management. The formation of a crisis management policy and procedure is described, and features of effective communication during crises are outlined. (GLR)
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Organizing integrated care in a university hospital: application of a conceptual framework.
Axelsson, Runo; Axelsson, Susanna Bihari; Gustafsson, Jeppe; Seemann, Janne
2014-04-01
As a result of New Public Management, a number of industrial models of quality management have been implemented in health care, mainly in hospitals. At the same time, the concept of integrated care has been developed within other parts of the health sector. The aim of the article is to discuss the relevance of integrated care for hospitals. The discussion is based on application of a conceptual framework outlining a number of organizational models of integrated care. These models are illustrated in a case study of a Danish university hospital implementing a new organization for improving the patient flows of the hospital. The study of the reorganization is based mainly on qualitative data from individual and focus group interviews. The new organization of the university hospital can be regarded as a matrix structure combining a vertical integration of clinical departments with a horizontal integration of patient flows. This structure has elements of both interprofessional and interorganizational integration. A strong focus on teamwork, meetings and information exchange is combined with elements of case management and co-location. It seems that integrated care can be a relevant concept for a hospital. Although the organizational models may challenge established professional boundaries and financial control systems, this concept can be a more promising way to improve the quality of care than the industrial models that have been imported into health care. This application of the concept may also contribute to widen the field of integrated care.
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Effective Implementation of Collaborative Care for Depression: What is Needed?
Whitebird, Robin R.; Solberg, Leif I.; Jaeckels, Nancy A.; Pietruszewski, Pamela B.; Hadzic, Senka; Unützer, Jürgen; Ohnsorg, Kris A.; Rossom, Rebecca C.; Beck, Arne; Joslyn, Ken; Rubenstein, Lisa V.
2014-01-01
Objective To identify the care model factors that were key for successful implementation of collaborative depression care in a statewide Minnesota primary care initiative. Study Design We used a mixed-methods design incorporating both qualitative data from clinic site visits and quantitative measures of patient activation and 6-month remission rates. Methods Care model factors identified from the site visits were tested for association with rates of activation into the program and remission rates. Results Nine factors were identified as important for successful implementation of collaborative care by the consultants who had trained and interviewed participating clinic teams. Factors correlated with higher patient activation rates were: strong leadership support (0.63), well-defined and implemented care manager roles (0.62), a strong primary care physician champion (0.60), and an on-site and accessible care manager (0.59). However, remission rates at six months were correlated with: an engaged psychiatrist (0.62), not seeing operating costs as a barrier to participation (0.56), and face-to-face communication (warm handoffs) between the care-manager and primary care physician for new patients (0.54). Conclusions Care model factors most important for successful program implementation differ for patient activation into the program versus remission at six months. Knowing which implementation factors are most important for successful implementation will be useful for those interested in adopting this evidence-based approach to improve primary care for patients with depression. PMID:25365745
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2011-01-01
Background Primary care providers play an important role in preventing and managing cardiovascular disease. This study compared the quality of preventive cardiovascular care delivery amongst different primary care models. Methods This is a secondary analysis of a larger randomized control trial, known as the Improved Delivery of Cardiovascular Care (IDOCC) through Outreach Facilitation. Using baseline data collected through IDOCC, we conducted a cross-sectional study of 82 primary care practices from three delivery models in Eastern Ontario, Canada: 43 fee-for-service, 27 blended-capitation and 12 community health centres with salary-based physicians. Medical chart audits from 4,808 patients with or at high risk of developing cardiovascular disease were used to examine each practice's adherence to ten evidence-based processes of care for diabetes, chronic kidney disease, dyslipidemia, hypertension, weight management, and smoking cessation care. Generalized estimating equation models adjusting for age, sex, rurality, number of cardiovascular-related comorbidities, and year of data collection were used to compare guideline adherence amongst the three models. Results The percentage of patients with diabetes that received two hemoglobin A1c tests during the study year was significantly higher in community health centres (69%) than in fee-for-service (45%) practices (Adjusted Odds Ratio (AOR) = 2.4 [95% CI 1.4-4.2], p = 0.001). Blended capitation practices had a significantly higher percentage of patients who had their waistlines monitored than in fee-for-service practices (19% vs. 5%, AOR = 3.7 [1.8-7.8], p = 0.0006), and who were recommended a smoking cessation drug when compared to community health centres (33% vs. 16%, AOR = 2.4 [1.3-4.6], p = 0.007). Overall, quality of diabetes care was higher in community health centres, while smoking cessation care and weight management was higher in the blended-capitation models. Fee-for-service practices had the greatest gaps in care, most noticeably in diabetes care and weight management. Conclusions This study adds to the evidence suggesting that primary care delivery model impacts quality of care. These findings support current Ontario reforms to move away from the traditional fee-for-service practice. Trial Registration ClinicalTrials.gov: NCT00574808 PMID:22008366
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The development of an acute care case manager orientation.
Strzelecki, S; Brobst, R
1997-01-01
The authors describe the development of an inpatient acute care case manager orientation in a community hospital. Benner's application of the Dreyfus model of skill acquisition provides the basis for the orientation program. The candidates for the case manager position were expert clinicians. Because of the role change it was projected that they would function as advanced beginners. It was also predicted that, as the case managers progressed within the role, the educational process would need to be adapted to facilitate progression of skills to the proficient level. Feedback from participants reinforced that the model supported the case manager in the role transition. In addition, the model provided a predictive framework for ongoing educational activities.
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Comparison of three models of ownership of community health centres in China: a qualitative study.
Wei, Xiaolin; Yang, Nan; Gao, Yang; Wong, Samuel Y S; Wong, Martin C S; Wang, Jiaji; Wang, Harry H X; Li, Donald K T; Tang, Jinling; Griffiths, Sian M
2015-07-01
Community health centres are the main form of provision of primary care in China. There are three models: government managed, hospital managed and private. Our aim was to describe and compare primary care under the three ownership models. Four aspects of primary care were studied: services, organization, financing and human resources. Interviews were undertaken with 60 managerial and professional staff in 13 community health centres in the Pearl River Delta region in 2010. Three community health centres were selected in the capital city and two were selected from each of the other five cities. Thematic framework analysis was conducted. Government-managed community health centres received the largest public funding, followed by hospital-managed community health centres, while private community health centres received the least. Private community health centres were the smallest in scale and provided lower quality public health services compared with the other two models. Patient out-of-pocket costs accounted for the majority of the revenue in all models of community health centres despite improved government funding for preventive services. General challenges such as the shortage of public funding, the exclusion of migrants in the funding for preventive services, low capacity in human resources and the separation of clinical and preventive care in community health centres were identified in all three models of community health centres. The ownership and management of a community health centre greatly influence the service it provides. Private community health centres are in a disadvantaged position to deliver high quality clinical and preventive care. © The Author(s) 2015.
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Impact of a comprehensive population health management program on health care costs.
Grossmeier, Jessica; Seaverson, Erin L D; Mangen, David J; Wright, Steven; Dalal, Karl; Phalen, Chris; Gold, Daniel B
2013-06-01
Assess the influence of participation in a population health management (PHM) program on health care costs. A quasi-experimental study relied on logistic and ordinary least squares regression models to compare the costs of program participants with those of nonparticipants, while controlling for differences in health care costs and utilization, demographics, and health status. Propensity score models were developed and analyses were weighted by inverse propensity scores to control for selection bias. Study models yielded an estimated savings of $60.65 per wellness participant per month and $214.66 per disease management participant per month. Program savings were combined to yield an integrated return-on-investment of $3 in savings for every dollar invested. A PHM program yielded a positive return on investment after 2 years of wellness program and 1 year of integrated disease management program launch.
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Stokes, Jonathan; Panagioti, Maria; Alam, Rahul; Checkland, Kath; Cheraghi-Sohi, Sudeh; Bower, Peter
2015-01-01
Background An ageing population with multimorbidity is putting pressure on health systems. A popular method of managing this pressure is identification of patients in primary care ‘at-risk’ of hospitalisation, and delivering case management to improve outcomes and avoid admissions. However, the effectiveness of this model has not been subjected to rigorous quantitative synthesis. Methods and Findings We carried out a systematic review and meta-analysis of the effectiveness of case management for ‘at-risk’ patients in primary care. Six bibliographic databases were searched using terms for ‘case management’, ‘primary care’, and a methodology filter (Cochrane EPOC group). Effectiveness compared to usual care was measured across a number of relevant outcomes: Health – self-assessed health status, mortality; Cost – total cost of care, healthcare utilisation (primary and non-specialist care and secondary care separately), and; Satisfaction – patient satisfaction. We conducted secondary subgroup analyses to assess whether effectiveness was moderated by the particular model of case management, context, and study design. A total of 15,327 titles and abstracts were screened, 36 unique studies were included. Meta-analyses showed no significant differences in total cost, mortality, utilisation of primary or secondary care. A very small significant effect favouring case management was found for self-reported health status in the short-term (0.07, 95% CI 0.00 to 0.14). A small significant effect favouring case management was found for patient satisfaction in the short- (0.26, 0.16 to 0.36) and long-term (0.35, 0.04 to 0.66). Secondary subgroup analyses suggested the effectiveness of case management may be increased when delivered by a multidisciplinary team, when a social worker was involved, and when delivered in a setting rated as low in initial ‘strength’ of primary care. Conclusions This was the first meta-analytic review which examined the effects of case management on a wide range of outcomes and considered also the effects of key moderators. Current results do not support case management as an effective model, especially concerning reduction of secondary care use or total costs. We consider reasons for lack of effect and highlight key research questions for the future. Review Protocol The review protocol is available as part of the PROSPERO database (registration number: CRD42014010824). PMID:26186598
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Building Research Relationships With Managed Care Organizations: Issues and Strategies.
Lein, Catherine; Collins, Clare; Lyles, Judith S; Hillman, Donald; Smith, Robert C
2003-06-01
Managed care is now the dominant form of healthcare in the United States. The need for clinical research about the organization, delivery, and outcomes of primary care services in managed care models is high, yet access to managed care organizations as sites for clinical research may be problematic. The purpose of this article is to describe issues involved in obtaining access to managed care settings for clinical research and practical strategies for successful collaboration using literature review and case description. Three steps for developing collaborative relationships with managed care organizations (MCOs) are presented: 1) assessment of organizational structure, history, and culture; 2) finding common ground; and 3) project implementation. These steps are discussed within the context of MCO systems issues and a relationship-centered approach to communication between researchers and individuals from the MCO. Successful relationships with MCOs for clinical research are possible when careful attention is paid to inclusion of MCOs as collaborators in the development of the research questions and design, and as partners in the research implementation process.
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Nurses' adherence to the Kangaroo Care Method: support for nursing care management1
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
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Mattson-Prince, J
1997-05-01
Two groups of individuals with high level tetraplegia (C1-4) were compared with respect to the model of personal care assistance used. The study was undertaken to determine whether a finite population with severe disability had differences in health status, costs and perceived quality of life, relative to whether they used agencies for their care, or hired, trained and reimbursed care givers independently. A survey, which included demographics as well as portions of RAND-36, LSI-A, PIP, PASI and CHART was used. Telephone interviews were held with 29 individuals who received their care through an agency and 42 who managed care independently. Chi square, 't'-tests, and multiple regression analysis were used to control for potentially confounding group differences. The self-managed group demonstrated significantly better health outcomes, with fewer re-hospitalizations for preventable complications. They experienced better life satisfaction and significantly lower costs. Although those who used an independent model of care-giving received significantly more hours of paid assistance, the average annual cost of care was significantly lower for each individual. In addition to reducing the financial burden on the individual and society, self-managed care seemed to diminish the emotional burden borne by these individuals.
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Baik, Seong-Yi; Crabtree, Benjamin F; Gonzales, Junius J
2013-11-01
Depression is prevalent in primary care (PC) practices and poses a considerable public health burden in the United States. Despite nearly four decades of efforts to improve depression care quality in PC practices, a gap remains between desired treatment outcomes and the reality of how depression care is delivered. This article presents a real-world PC practice model of depression care, elucidating the processes and their influencing conditions. Grounded theory methodology was used for the data collection and analysis to develop a depression care model. Data were collected from 70 individual interviews (60 to 70 min each), three focus group interviews (n = 24, 2 h each), two surveys per clinician, and investigators' field notes on practice environments. Interviews were audiotaped and transcribed for analysis. Surveys and field notes complemented interview data. Seventy primary care clinicians from 52 PC offices in the Midwest: 28 general internists, 28 family physicians, and 14 nurse practitioners. A depression care model was developed that illustrates how real-world conditions infuse complexity into each step of the depression care process. Depression care in PC settings is mediated through clinicians' interactions with patients, practice, and the local community. A clinician's interactional familiarity ("familiarity capital") was a powerful facilitator for depression care. For the recognition of depression, three previously reported processes and three conditions were confirmed. For the management of depression, 13 processes and 11 conditions were identified. Empowering the patient was a parallel process to the management of depression. The clinician's ability to develop and utilize interactional relationships and resources needed to recognize and treat a person with depression is key to depression care in primary care settings. The interactional context of depression care makes empowering the patient central to depression care delivery.
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Crosby, Lori E; Quinn, Charles T; Kalinyak, Karen A
2015-04-01
The lifespan of patients with sickle-cell disease (SCD) continues to increase, and most affected individuals in high-resource countries now live into adulthood. This necessitates a successful transition from pediatric to adult health care. Care for transitioning patients with SCD often falls to primary care providers who may not be fully aware of the many challenges and issues faced by patients and the current management strategies for SCD. In this review, we aim to close the knowledge gap between primary care providers and specialists who treat transitioning patients with SCD. We describe the challenges and issues encountered by these patients, and we propose a biopsychosocial multidisciplinary approach to the management of the identified issues. Examples of this approach, such as transition-focused integrated care models and quality improvement collaboratives, with the potential to improve health outcomes in adulthood are also described.
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The Chronic Care Model and Diabetes Management in US Primary Care Settings: A Systematic Review
Stellefson, Michael; Stopka, Christine
2013-01-01
Introduction The Chronic Care Model (CCM) uses a systematic approach to restructuring medical care to create partnerships between health systems and communities. The objective of this study was to describe how researchers have applied CCM in US primary care settings to provide care for people who have diabetes and to describe outcomes of CCM implementation. Methods We conducted a literature review by using the Cochrane database of systematic reviews, CINAHL, and Health Source: Nursing/Academic Edition and the following search terms: “chronic care model” (and) “diabet*.” We included articles published between January 1999 and October 2011. We summarized details on CCM application and health outcomes for 16 studies. Results The 16 studies included various study designs, including 9 randomized controlled trials, and settings, including academic-affiliated primary care practices and private practices. We found evidence that CCM approaches have been effective in managing diabetes in US primary care settings. Organizational leaders in health care systems initiated system-level reorganizations that improved the coordination of diabetes care. Disease registries and electronic medical records were used to establish patient-centered goals, monitor patient progress, and identify lapses in care. Primary care physicians (PCPs) were trained to deliver evidence-based care, and PCP office–based diabetes self-management education improved patient outcomes. Only 7 studies described strategies for addressing community resources and policies. Conclusion CCM is being used for diabetes care in US primary care settings, and positive outcomes have been reported. Future research on integration of CCM into primary care settings for diabetes management should measure diabetes process indicators, such as self-efficacy for disease management and clinical decision making. PMID:23428085
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Bruggmann, Philip; Litwin, Alain H
2013-08-01
One of the major obstacles to hepatitis C virus (HCV) care in people who inject drugs (PWID) is the lack of treatment settings that are suitably adapted for the needs of this vulnerable population. Nevertheless, HCV treatment has been delivered successfully to PWID through various multidisciplinary models such as community-based clinics, substance abuse treatment clinics, and specialized hospital-based clinics. Models may be integrated in primary care--all under one roof in either addiction care units or general practitioner-based models--or can occur in secondary or tertiary care settings. Additional innovative models include directly observed therapy and peer-based models. A high level of acceptance of the individual life circumstances of PWID rather than rigid exclusion criteria will determine the level of success of any model of HCV management. The impact of highly potent and well-tolerated interferon-free HCV treatment regimens will remain negligible as long as access to therapy cannot be expanded to the most affected risk groups.
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Ecosystem Risk Assessment Using the Comprehensive Assessment of Risk to Ecosystems (CARE) Tool
NASA Astrophysics Data System (ADS)
Battista, W.; Fujita, R.; Karr, K.
2016-12-01
Effective Ecosystem Based Management requires a localized understanding of the health and functioning of a given system as well as of the various factors that may threaten the ongoing ability of the system to support the provision of valued services. Several risk assessment models are available that can provide a scientific basis for understanding these factors and for guiding management action, but these models focus mainly on single species and evaluate only the impacts of fishing in detail. We have developed a new ecosystem risk assessment model - the Comprehensive Assessment of Risk to Ecosystems (CARE) - that allows analysts to consider the cumulative impact of multiple threats, interactions among multiple threats that may result in synergistic or antagonistic impacts, and the impacts of a suite of threats on whole-ecosystem productivity and functioning, as well as on specific ecosystem services. The CARE model was designed to be completed in as little as two hours, and uses local and expert knowledge where data are lacking. The CARE tool can be used to evaluate risks facing a single site; to compare multiple sites for the suitability or necessity of different management options; or to evaluate the effects of a proposed management action aimed at reducing one or more risks. This analysis can help users identify which threats are the most important at a given site, and therefore where limited management resources should be targeted. CARE can be applied to virtually any system, and can be modified as knowledge is gained or to better match different site characteristics. CARE builds on previous ecosystem risk assessment tools to provide a comprehensive assessment of fishing and non-fishing threats that can be used to inform environmental management decisions across a broad range of systems.
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Ecosystem Risk Assessment Using the Comprehensive Assessment of Risk to Ecosystems (CARE) Tool
NASA Astrophysics Data System (ADS)
Battista, W.; Fujita, R.; Karr, K.
2016-02-01
Effective Ecosystem Based Management requires a localized understanding of the health and functioning of a given system as well as of the various factors that may threaten the ongoing ability of the system to support the provision of valued services. Several risk assessment models are available that can provide a scientific basis for understanding these factors and for guiding management action, but these models focus mainly on single species and evaluate only the impacts of fishing in detail. We have developed a new ecosystem risk assessment model - the Comprehensive Assessment of Risk to Ecosystems (CARE) - that allows analysts to consider the cumulative impact of multiple threats, interactions among multiple threats that may result in synergistic or antagonistic impacts, and the impacts of a suite of threats on whole-ecosystem productivity and functioning, as well as on specific ecosystem services. The CARE model was designed to be completed in as little as two hours, and uses local and expert knowledge where data are lacking. The CARE tool can be used to evaluate risks facing a single site; to compare multiple sites for the suitability or necessity of different management options; or to evaluate the effects of a proposed management action aimed at reducing one or more risks. This analysis can help users identify which threats are the most important at a given site, and therefore where limited management resources should be targeted. CARE can be applied to virtually any system, and can be modified as knowledge is gained or to better match different site characteristics. CARE builds on previous ecosystem risk assessment tools to provide a comprehensive assessment of fishing and non-fishing threats that can be used to inform environmental management decisions across a broad range of systems.
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Hall, Martin; Christian, Bradley
2017-10-01
Despite the best efforts and commitment of oral health programs, there is no evidence that the current surgical output-based model of oral health care is delivering better oral health outcomes to the community. In fact, Australian evidence indicates the oral health of the community could be getting worse. It is now well-understood that this traditional surgical model of oral health care will never successfully manage the disease itself. It is proposed that a health-promoting, minimally invasive oral disease management model of care may lead to a sustainable benefit to the oral health status of the individual and community groups. The aim of this paper is to describe such a model of oral health care (MoC) currently being implemented by the North Richmond Community Health Oral Health (NRCH-OH) program in Melbourne, Victoria, Australia; this model may serve as a template for other services to re-orient their healthcare delivery towards health promotion and prevention. The paper describes the guiding principles and theories for the model and also its operational components, which are: pre-engagement while on the waitlist; client engagement at the reception area; the assessment phase; oral health education (high-risk clients only); disease management; and reviews and recall.
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Chronic heart failure management in Australia -- time for general practice centred models of care?
Scott, Ian; Jackson, Claire
2013-05-01
Chronic heart failure (CHF) is an increasingly prevalent problem within ageing populations and accounts for thousands of hospitalisations and deaths annually in Australia. Disease management programs for CHF (CHF-DMPs) aim to optimise care, with the predominant model being cardiologist led, hospital based multidisciplinary clinics with cardiac nurse outreach. However, findings from contemporary observational studies and clinical trials raise uncertainty around the effectiveness and sustainability of traditional CHF-DMPs in real-world clinical practice. To suggest an alternative model of care that involves general practitioners with a special interest in CHF liaising with, and being up-skilled by, specialists within community based, multidisciplinary general practice settings. Preliminary data from trials evaluating primary care based CHF-DMPs are encouraging, and further studies are underway comparing this model of care with traditional hospital based, specialist led CHF-DMPs. Results of studies of similar primary care models targeting diabetes and other chronic diseases suggest potential for its application to CHF.
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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.
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DuBard, C Annette; Jackson, Carlos T
2018-04-01
Care management of high-cost/high-needs patients is an increasingly common strategy to reduce health care costs. A variety of targeting methodologies have emerged to identify patients with high historical or predicted health care utilization, but the more pertinent question for program planners is how to identify those who are most likely to benefit from care management intervention. This paper describes the evolution of complex care management targeting strategies in Community Care of North Carolina's (CCNC) work with the statewide non-dual Medicaid population, culminating in the development of an "Impactability Score" that uses administrative data to predict achievable savings. It describes CCNC's pragmatic approach for estimating intervention effects in a historical cohort of 23,455 individuals, using a control population of 14,839 to determine expected spending at an individual level, against which actual spending could be compared. The actual-to-expected spending difference was then used as the dependent variable in a multivariate model to determine the predictive contribution of a multitude of demographic, clinical, and utilization characteristics. The coefficients from this model yielded the information required to build predictive models for prospective use. Model variables related to medication adherence and historical utilization unexplained by disease burden proved to be more important predictors of impactability than any given diagnosis or event, disease profile, or overall costs of care. Comparison of this approach to alternative targeting strategies (emergency department super-utilizers, inpatient super-utilizers, or patients with highest Hierarchical Condition Category risk scores) suggests a 2- to 3-fold higher return on investment using impactability-based targeting.
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Including as a Care-ful Journey: A Parent's Perspective
ERIC Educational Resources Information Center
Scorgie, Kate; Wilgosh, Lorraine
2009-01-01
The authors argue for the need of a cyclical, rather than a linear, model of family coping and life management when a child has a disability. Longitudinal support for such a cyclical model of family life management is presented, with recognition that parental control of outcome lessens as the young person ages, because the adult world is not…
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A framework for the management of intellectual capital in the health care industry.
Grantham, C E; Nichols, L D; Schonberner, M
1997-01-01
This article proposes a new theoretical model for the effective management of intellectual capital in the health care industry. The evolution of knowledge-based resources as a value-adding characteristic of service industries coupled with mounting environmental pressures on health care necessitates the extension of current models of intellectual capital. Our theoretical model contains an expanded context linking its development to organizational learning theory and extends current theory by proposing a six-term archetype of organizational functioning built on flows of information. Further, our proposal offers a hierarchical dimension to intellectual capital and a method of scientific visualization for the measurement of intellectual capital. In conclusion, we offer some practical suggestions for future development, both for researchers and managers.
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Eley, Diann S; Patterson, Elizabeth; Young, Jacqui; Fahey, Paul P; Del Mar, Chris B; Hegney, Desley G; Synnott, Robyn L; Mahomed, Rosemary; Baker, Peter G; Scuffham, Paul A
2013-01-01
The Australian government's commitment to health service reform has placed general practice at the centre of its agenda to manage chronic disease. Concerns about the capacity of GPs to meet the growing chronic disease burden has stimulated the implementation and testing of new models of care that better utilise practice nurses (PN). This paper reports on a mixed-methods study nested within a larger study that trialled the feasibility and acceptability of a new model of nurse-led chronic disease management in three general practices. Patients over 18 years of age with type 2 diabetes, hypertension or stable ischaemic heart disease were randomised into PN-led or usual GP-led care. Primary outcomes were self-reported quality of life and perceptions of the model's feasibility and acceptability from the perspective of patients and GPs. Over the 12-month study quality of life decreased but the trend between groups was not statistically different. Qualitative data indicate that the PN-led model was acceptable and feasible to GPs and patients. It is possible to extend the scope of PN care to lead the routine clinical management of patients' stable chronic diseases. All GPs identified significant advantages to the model and elected to continue with the PN-led care after our study concluded.
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Models of consumer value cocreation in health care.
Nambisan, Priya; Nambisan, Satish
2009-01-01
In recent years, consumer participation in health care has gained critical importance as health care organizations (HCOs) seek varied avenues to enhance the quality and the value of their offerings. Many large HCOs have established online health communities where health care consumers (patients) can interact with one another to share knowledge and offer emotional support in disease management and care. Importantly, the focus of consumer participation in health care has moved beyond such personal health care management as the potential for consumers to participate in innovation and value creation in varied areas of the health care industry becomes increasingly evident. Realizing such potential, however, will require HCOs to develop a better understanding of the varied types of consumer value cocreation that are enabled by new information and communication technologies such as online health communities and Web 2.0 (social media) technologies. This article seeks to contribute toward such an understanding by offering a concise and coherent theoretical framework to analyze consumer value cocreation in health care. We identify four alternate models of consumer value cocreation-the partnership model, the open-source model, the support-group model, and the diffusion model-and discuss their implications for HCOs. We develop our theoretical framework by drawing on theories and concepts in knowledge creation, innovation management, and online communities. A set of propositions are developed by combining theoretical insights from these areas with real-world examples of consumer value cocreation in health care. The theoretical framework offered here informs on the potential impact of the different models of consumer value cocreation on important organizational variables such as innovation cost and time, service quality, and consumer perceptions of HCO. An understanding of the four models of consumer value cocreation can help HCOs adopt appropriate strategies and practices to embrace consumers as partners in the development and delivery of innovative health care products and services.
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Establishment and outcomes of a model primary care pharmacy service system.
Carmichael, Jannet M; Alvarez, Autumn; Chaput, Ryan; DiMaggio, Jennifer; Magallon, Heather; Mambourg, Scott
2004-03-01
The establishment and outcomes of a model primary care pharmacy service system are described. A primary care pharmacy practice model was established at a government health care facility in March 1996. The original objective was to establish a primary pharmacy practice model that would demonstrate improved patient outcomes and maximize the pharmacist's contributions to drug therapy. Since its inception, many improvements have been realized and supported by advanced computer and automated systems, expanded disease state management practices, and unique practitioner and administrative support. Many outcomes studies have been performed on the pharmacist-initiated and -managed clinics, leading to improved patient care and conveying the quality-conscious and cost-effective role pharmacists can play as independent practitioners in this environment. These activities demonstrate cutting-edge leadership in health-system pharmacy. Redesign has been used to improve consistent access to a medication expert and has significantly improved the quality of patient care while easing physicians' workload without increasing health care costs. A system using pharmacists as independent practitioners to promote primary care has achieved high-quality and cost-effective patient care.
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Toward population management in an integrated care model.
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.
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Toward population management in an integrated care model.
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.
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Holm, Anne Lise; Severinsson, Elisabeth
2012-12-01
Depression is a socially- and physically-disabling condition. The Chronic Care Model (CCM) was developed to promote better management of long-term conditions, such as depression, in primary care settings. The aim of the study was to identify barriers to, and facilitators of, success when implementing the CCM for the management of depression in primary care. A systematic search was conducted in electronic databases from January 2005 to December 2011. Thirteen articles met the inclusion criteria and were reviewed by means of a thematic analysis. The barriers were categorized under two themes: lack of organizational, administrative, and professional ability to change and implement the components of the CCM; and lack of clarity pertaining to the responsibility inherent in the role of care manager (often a nurse) when it comes to promoting the patient's self-management ability. In terms of the facilitators of success, two themes emerged: leadership support and vision, and redesigning the delivery system. When shaping an environment for organizational change, leadership and professionals must work towards a common goal and vision. Such processes require a care manager with a clear role and responsibilities in order for the health-care system to meet the needs of the person with depression. © 2012 The Authors. International Journal of Mental Health Nursing © 2012 Australian College of Mental Health Nurses Inc.
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Feng, Shanshan; Shi, Leiyu; Zeng, Jiazhi; Chen, Wen; Ling, Li
2017-01-01
Objectives In order to improve the quality of services at village clinics (VCs), which are important primary care service providers in rural China, the Chinese government has encouraged the township hospitals to own and manage VCs. There are currently three models of ownership and management of VCs: township hospital-owned and -managed (HVC), village committee-owned and -managed (VVC), and private-owned and -managed (PVC). This study aims to examine the association between these ownership models of VCs and patients' primary care experiences. Methods Villagers were selected by multistage stratified sampling and their experiences with primary care were measured using the Primary Care Assessment Tool—Adult Edition (PCAT-AS). Data were collected through face-to-face interviews and the questionnaires administered by investigators in the cross-sectional study from February to April 2015. The PCAT scores were compared among the three models by covariance analysis, and multiple linear regression was used to analyze factors associated with the PCAT total scores. Results A total of 1491 questionnaires were collected. After controlling for covariates, HVCs reported the highest PCAT scores and satisfaction rate. In terms of the domains, HVC reported the highest scores in the coordination and comprehensiveness domains, while PVC had the highest scores in the first contact-accessibility domain. Multivariate linear regression showed that HVC, married participants, aged 60 and older, satisfied with the services, receiving six or more visits, and those with medical expenditures over 20% of their total family expenditures, were also positively associated with better primary care quality. Conclusions This study demonstrates that villagers receiving medical care at HVCs perceived better primary care than those at PVCs and VVCs. In order to improve the quality of primary care at VCs, it is necessary to increase government subsidies for public service packages, tighten the township hospital's supervision of PVCs and VVCs, and develop performance-based incentive plans to motivate improvements in the accessibility of HVCs. PMID:28056038
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Ramirez, Magaly; Wu, Shinyi; Ryan, Gery; Towfighi, Amytis; Vickrey, Barbara G
2017-05-23
Beta versions of health information technology tools are needed in service delivery models with health care and community partnerships to confirm the key components and to assess the performance of the tools and their impact on users. We developed a care management technology (CMT) for use by community health workers (CHWs) and care managers (CMs) working collaboratively to improve risk factor control among recent stroke survivors. The CMT was expected to enhance the efficiency and effectiveness of the CHW-CM team. The primary objective was to describe the Secondary Stroke Prevention by Uniting Community and Chronic Care Model Teams Early to End Disparities (SUCCEED) CMT and investigate CM and CHW perceptions of the CMT's usefulness and challenges for team-based care management. We conducted qualitative interviews with all users of the beta-version SUCCEED CMT, namely two CMs and three CHWs. They were asked to demonstrate and describe their perceptions of the CMT's ease of use and usefulness for completing predefined key care management activities. They were also probed about their general perceptions of the CMT's information quality, ease of use, usefulness, and impact on CM and CHW roles. Interview transcripts were coded using a priori codes. Coded excerpts were grouped into broader themes and then related in a conceptual model of how the CMT facilitated care management. We also conducted a survey with 14 patients to obtain their perspective on CHW tablet use during CHW-patient interactions. Care managers and community health workers expressed that the CMT helped them keep track of patient interactions and plan their work. It guided CMs in developing and sharing care plans with CHWs. For CHWs, the CMT enabled electronic collection of clinical assessment data, provided decision support, and provided remote access to patients' risk factor values. Long loading times and downtimes due to outages were the most significant challenges encountered. Additional issues included extensive use of free-text responses and manual data transfer from the electronic medical record. Despite these challenges, patients overall did not perceive the tablet as interfering with CHW-patient interactions. Our findings suggest useful functionalities of CMTs supporting health care and community partners in collaborative chronic care management. However, usability issues need to be addressed during the development process. The SUCCEED CMT is an initial step toward the development of effective health information technology tools to support collaborative, team-based models of care and will need to be modified as the evidence base grows. Future research should assess the CMT's effects on team performance. ©Magaly Ramirez, Shinyi Wu, Gery Ryan, Amytis Towfighi, Barbara G Vickrey. Originally published in JMIR Research Protocols (http://www.researchprotocols.org), 23.05.2017.
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Lee, Linda; Heckman, George; McKelvie, Robert; Jong, Philip; D'Elia, Teresa; Hillier, Loretta M
2015-03-01
To explore the barriers to and facilitators of adapting and expanding a primary care memory clinic model to integrate care of additional complex chronic geriatric conditions (heart failure, falls, chronic obstructive pulmonary disease, and frailty) into care processes with the goal of improving outcomes for seniors. Mixed-methods study using quantitative (questionnaires) and qualitative (interviews) methods. Ontario. Family physicians currently working in primary care memory clinic teams and supporting geriatric specialists. Family physicians currently working in memory clinic teams (n = 29) and supporting geriatric specialists(n = 9) were recruited as survey participants. Interviews were conducted with memory clinic lead physicians (n = 16).Statistical analysis was done to assess differences between family physician ratings and geriatric specialist ratings related to the capacity for managing complex chronic geriatric conditions, the role of interprofessional collaboration within primary care, and funding and staffing to support geriatric care. Results from both study methods were compared to identify common findings. Results indicate overall support for expanding the memory clinic model to integrate care for other complex conditions. However, the current primary care structure is challenged to support optimal management of patients with multiple comorbidities, particularly as related to limited funding and staffing resources. Structured training, interprofessional teams, and an active role of geriatric specialists within primary care were identified as important facilitators. The memory clinic model, as applied to other complex chronic geriatric conditions, has the potential to build capacity for high-quality primary care, improve health outcomes,promote efficient use of health care resources, and reduce healthcare costs.
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Interdisciplinary Practice Models for Older Adults With Back Pain: A Qualitative Evaluation.
Salsbury, Stacie A; Goertz, Christine M; Vining, Robert D; Hondras, Maria A; Andresen, Andrew A; Long, Cynthia R; Lyons, Kevin J; Killinger, Lisa Z; Wallace, Robert B
2018-03-19
Older adults seek health care for low back pain from multiple providers who may not coordinate their treatments. This study evaluated the perceived feasibility of a patient-centered practice model for back pain, including facilitators for interprofessional collaboration between family medicine physicians and doctors of chiropractic. This qualitative evaluation was a component of a randomized controlled trial of 3 interdisciplinary models for back pain management: usual medical care; concurrent medical and chiropractic care; and collaborative medical and chiropractic care with interprofessional education, clinical record exchange, and team-based case management. Data collection included clinician interviews, chart abstractions, and fieldnotes analyzed with qualitative content analysis. An organizational-level framework for dissemination of health care interventions identified norms/attitudes, organizational structures and processes, resources, networks-linkages, and change agents that supported model implementation. Clinicians interviewed included 13 family medicine residents and 6 chiropractors. Clinicians were receptive to interprofessional education, noting the experience introduced them to new colleagues and the treatment approaches of the cooperating profession. Clinicians exchanged high volumes of clinical records, but found the logistics cumbersome. Team-based case management enhanced information flow, social support, and interaction between individual patients and the collaborating providers. Older patients were viewed positively as change agents for interprofessional collaboration between these provider groups. Family medicine residents and doctors of chiropractic viewed collaborative care as a useful practice model for older adults with back pain. Health care organizations adopting medical and chiropractic collaboration can tailor this general model to their specific setting to support implementation.
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Chi, Felicia W; Parthasarathy, Sujaya; Mertens, Jennifer R; Weisner, Constance M
2011-10-01
How best to provide ongoing services to patients with substance use disorders to sustain long-term recovery is a significant clinical and policy question that has not been adequately addressed. Analyzing nine years of prospective data for 991 adults who entered substance abuse treatment in a private, nonprofit managed care health plan, this study aimed to examine the components of a continuing care model (primary care, specialty substance abuse treatment, and psychiatric services) and their combined effect on outcomes over nine years after treatment entry. In a longitudinal observational study, follow-up measures included self-reported alcohol and drug use, Addiction Severity Index scores, and service utilization data extracted from the health plan databases. Remission, defined as abstinence or nonproblematic use, was the outcome measure. A mixed-effects logistic random intercept model controlling for time and other covariates found that yearly primary care, and specialty care based on need as measured at the prior time point, were positively associated with remission over time. Persons receiving continuing care (defined as having yearly primary care and specialty substance abuse treatment and psychiatric services when needed) had twice the odds of achieving remission at follow-ups (p<.001) as those without. Continuing care that included both primary care and specialty care management to support ongoing monitoring, self-care, and treatment as needed was important for long-term recovery of patients with substance use disorders.
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O'Donnell, Allison N; Williams, Mark; Kilbourne, Amy M
2013-12-01
The Chronic Care Model (CCM) has been shown to improve medical and psychiatric outcomes for persons with mental disorders in primary care settings, and has been proposed as a model to integrate mental health care in the patient-centered medical home under healthcare reform. However, the CCM has not been widely implemented in primary care settings, primarily because of a lack of a comprehensive reimbursement strategy to compensate providers for day-to-day provision of its core components, including care management and provider decision support. Drawing upon the existing literature and regulatory guidelines, we provide a critical analysis of challenges and opportunities in reimbursing CCM components under the current fee-for-service system, and describe an emerging financial model involving bundled payments to support core CCM components to integrate mental health treatment into primary care settings. Ultimately, for the CCM to be used and sustained over time to integrate physical and mental health care, effective reimbursement models will need to be negotiated across payers and providers. Such payments should provide sufficient support for primary care providers to implement practice redesigns around core CCM components, including care management, measurement-based care, and mental health specialist consultation.
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Proposed model of integrated care to improve health outcomes for individuals with multimorbidities
Sampalli, Tara; Fox, Roy A; Dickson, Robert; Fox, Jonathan
2012-01-01
Multimorbidity is defined as the coexistence of multiple chronic conditions. Individuals with multimorbidity typically present with complex needs and show significant changes in their functional health and quality of life. Multimorbidity in the aging population is well recognized, but there has been limited research on ways to manage the problem effectively. More recent studies have demonstrated a high prevalence of multimorbidity in the younger demographics aged under 65 years. There is a definite need to develop models of care that can manage these individuals effectively and mitigate the impact of illness on individuals and the financial burden to the health care system. An integrated model of care has been developed and implemented in a facility in Nova Scotia that routinely treats individuals with multiple chronic conditions. This care model is designed to address the specific needs of this complex patient population, with integrated and coordinated care modules that meet the needs of the person versus the disease. The results of a pilot evaluation of this care model are also discussed. PMID:23118532
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Eleven Years of Primary Health Care Delivery in an Academic Nursing Center.
ERIC Educational Resources Information Center
Hildebrandt, Eugenie; Baisch, Mary Jo; Lundeen, Sally P.; Bell-Calvin, Jean; Kelber, Sheryl
2003-01-01
Client visits to an academic community nursing center (n=25,495) were coded and analyzed. Results show expansion of nursing practice and services, strong case management, and management of illness care. The usefulness of computerized clinical documentation system and of the Lundeen conceptional model of community nursing care was demonstrated.…
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Quality of integrated chronic disease care in rural South Africa: user and provider perspectives
Klipstein-Grobusch, Kerstin; D’ambruoso, Lucia; Kahn, Kathleen; Tollman, Stephen M; Gómez-Olivé, Francesc Xavier
2017-01-01
The integrated chronic disease management (ICDM) model was introduced as a response to the dual burden of HIV/AIDS and non-communicable diseases (NCDs) in South Africa, one of the first of such efforts by an African Ministry of Health. The aim of the ICDM model is to leverage HIV programme innovations to improve the quality of chronic disease care. There is a dearth of literature on the perspectives of healthcare providers and users on the quality of care in the novel ICDM model. This paper describes the viewpoints of operational managers and patients regarding quality of care in the ICDM model. In 2013, we conducted a case study of the seven PHC facilities in the rural Agincourt sub-district in northeast South Africa. Focus group discussions (n = 8) were used to obtain data from 56 purposively selected patients ≥18 years. In-depth interviews were conducted with operational managers of each facility and the sub-district health manager. Donabedian’s structure, process and outcome theory for service quality evaluation underpinned the conceptual framework in this study. Qualitative data were analysed, with MAXQDA 2 software, to identify 17 a priori dimensions of care and unanticipated themes that emerged during the analysis. The manager and patient narratives showed the inadequacies in structure (malfunctioning blood pressure machines and staff shortage); process (irregular prepacking of drugs); and outcome (long waiting times). There was discordance between managers and patients regarding reasons for long patient waiting time which managers attributed to staff shortage and missed appointments, while patients ascribed it to late arrival of managers to the clinics. Patients reported anti-hypertension drug stock-outs (structure); sub-optimal defaulter-tracing (process); rigid clinic appointment system (process). Emerging themes showed that patients reported HIV stigmatisation in the community due to defaulter-tracing activities of home-based carers, while managers reported treatment of chronic diseases by traditional healers and reduced facility-related HIV stigma because HIV and NCD patients attended the same clinic. Leveraging elements of HIV programmes for NCDs, specifically hypertension management, is yet to be achieved in the study setting in part because of malfunctioning blood pressure machines and anti-hypertension drug stock-outs. This has implications for the nationwide scale up of the ICDM model in South Africa and planning of an integrated chronic disease care in other low- and middle-income countries. PMID:28207046
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Quality of integrated chronic disease care in rural South Africa: user and provider perspectives.
Ameh, Soter; Klipstein-Grobusch, Kerstin; D'ambruoso, Lucia; Kahn, Kathleen; Tollman, Stephen M; Gómez-Olivé, Francesc Xavier
2017-03-01
The integrated chronic disease management (ICDM) model was introduced as a response to the dual burden of HIV/AIDS and non-communicable diseases (NCDs) in South Africa, one of the first of such efforts by an African Ministry of Health. The aim of the ICDM model is to leverage HIV programme innovations to improve the quality of chronic disease care. There is a dearth of literature on the perspectives of healthcare providers and users on the quality of care in the novel ICDM model. This paper describes the viewpoints of operational managers and patients regarding quality of care in the ICDM model. In 2013, we conducted a case study of the seven PHC facilities in the rural Agincourt sub-district in northeast South Africa. Focus group discussions (n = 8) were used to obtain data from 56 purposively selected patients ≥18 years. In-depth interviews were conducted with operational managers of each facility and the sub-district health manager. Donabedian’s structure, process and outcome theory for service quality evaluation underpinned the conceptual framework in this study. Qualitative data were analysed, with MAXQDA 2 software, to identify 17 a priori dimensions of care and unanticipated themes that emerged during the analysis. The manager and patient narratives showed the inadequacies in structure (malfunctioning blood pressure machines and staff shortage); process (irregular prepacking of drugs); and outcome (long waiting times). There was discordance between managers and patients regarding reasons for long patient waiting time which managers attributed to staff shortage and missed appointments, while patients ascribed it to late arrival of managers to the clinics. Patients reported anti-hypertension drug stock-outs (structure); sub-optimal defaulter-tracing (process); rigid clinic appointment system (process). Emerging themes showed that patients reported HIV stigmatisation in the community due to defaulter-tracing activities of home-based carers, while managers reported treatment of chronic diseases by traditional healers and reduced facility-related HIV stigma because HIV and NCD patients attended the same clinic. Leveraging elements of HIV programmes for NCDs, specifically hypertension management, is yet to be achieved in the study setting in part because of malfunctioning blood pressure machines and anti-hypertension drug stock-outs. This has implications for the nationwide scale up of the ICDM model in South Africa and planning of an integrated chronic disease care in other low- and middle-income countries.
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Making capitated Medicare work for women: policy and research challenges.
Bierman, A S; Clancy, C M
2000-01-01
Growth in capitated Medicare has special ramifications for older women who comprise the majority of Medicare beneficiaries. Older women are more likely than men to have chronic conditions that lead to illness and disability, and they often have fewer financial and social resources to cope with these problems. Gender differences in health status have a number of important implications for the financing and delivery of care for older women under both traditional fee-for-service Medicare and capitation. The utilization of effective preventive interventions, new therapeutic interventions for the management of common chronic disorders, and more cost-effective models of chronic disease management could potentially extend the active life expectancy of older women. However, there are financial and delivery system barriers to achieving these objectives. Traditional FFS Medicare has gaps in coverage of care for chronic illness and disability that disproportionately impact women. Managed care potentially offers flexibility to allocate resources creatively, to develop new models of care, and offer enhanced benefits with lower out-of-pocket costs. However, challenges to realizing this potential under Medicare managed care with unique implications for older women include: possible gender bias in capitation payments, risk selection, inadequacy of risk adjustment models, benefit and market instability, and disenrollment patterns.
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Heisler, Michele
2010-06-01
Much of diabetes care needs to be carried out by patients between office visits with their health care providers. Yet, many patients face difficulties carrying out these tasks. In addition, many adults with diabetes cannot count on effective support from their families and friends to help them with their self-management. Peer support programmes are a promising approach to enhance social and emotional support, assist patients in daily management and living with diabetes and promote linkages to clinical care. This background paper provides a brief overview of different approaches to mobilize peer support for diabetes self-management support, discusses evidence to date on the effectiveness of each of these models, highlights logistical and evaluation issues for each model and concludes with a discussion of directions for future research in this area.
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2010-01-01
Much of diabetes care needs to be carried out by patients between office visits with their health care providers. Yet, many patients face difficulties carrying out these tasks. In addition, many adults with diabetes cannot count on effective support from their families and friends to help them with their self-management. Peer support programmes are a promising approach to enhance social and emotional support, assist patients in daily management and living with diabetes and promote linkages to clinical care. This background paper provides a brief overview of different approaches to mobilize peer support for diabetes self-management support, discusses evidence to date on the effectiveness of each of these models, highlights logistical and evaluation issues for each model and concludes with a discussion of directions for future research in this area. PMID:19293400
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A model for ubiquitous care of noncommunicable diseases.
Vianna, Henrique Damasceno; Barbosa, Jorge Luis Victória
2014-09-01
The ubiquitous computing, or ubicomp, is a promising technology to help chronic diseases patients managing activities, offering support to them anytime, anywhere. Hence, ubicomp can aid community and health organizations to continuously communicate with patients and to offer useful resources for their self-management activities. Communication is prioritized in works of ubiquitous health for noncommunicable diseases care, but the management of resources is not commonly employed. We propose the UDuctor, a model for ubiquitous care of noncommunicable diseases. UDuctor focuses the resources offering, without losing self-management and communication supports. We implemented a system and applied it in two practical experiments. First, ten chronic patients tried the system and filled out a questionnaire based on the technology acceptance model. After this initial evaluation, an alpha test was done. The system was used daily for one month and a half by a chronic patient. The results were encouraging and show potential for implementing UDuctor in real-life situations.
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Outcomes of Embedded Care Management in a Family Medicine Residency Patient-Centered Medical Home.
Newman, Robert J; Bikowski, Richard; Nakayama, Kristy; Cunningham, Tina; Acker, Pam; Bradshaw, Dana
2017-01-01
Much attention is devoted nationally to preventing hospital readmissions and emergency department (ED) use, given the high cost of this care. There is a growing body of evidence from the Patient Centered Primary Care Collaborative that a patient-centered medical home (PCMH) model successfully lowers these costs. Our study evaluates a specific intervention in a family medicine residency PCMH to decrease readmissions and ED utilization using an embedded care manager. The Department of Family and Community Medicine at Eastern Virginia Medical School in Norfolk, VA, hired an RN care manager in May of 2013 with a well-defined job description focused on decreasing hospital readmissions and ED usage. Our primary outcomes for the study were number of monthly hospital admissions and readmissions over 23 months and monthly ED visits over 20 months. Readmission rates averaged 22.2% per month in the first year of the intervention and 18.3% in the second year, a statistically significant 3.9% decrease. ED visits averaged 176 per month in the first year and 146 per month in the second year, a statistically significant 17% reduction. Our study adds to the evidence that a PCMH model of care with an embedded RN care manager can favorably lower readmission rates and ED utilization in a family medicine residency practice. Developing a viable business model to support this important work remains a challenge.
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Indonesian heath care and the economic crisis: is managed care the needed reform?
Hotchkiss, D R; Jacobalis, S
1999-03-01
The ramifications of the current economic crisis are being felt throughout Asia, but problems are particularly acute in Indonesia; in the midst of high inflation and unemployment the government is considering expanding managed care reform. In this paper, we discuss the impact of the recent economic crisis on the health sector in Indonesia, and analyze the potential for implementing effective reform following the managed care model. The health sector is discussed, highlighting pre-existing problems in the health care supply environment. The determinants of the economic crisis are summarized, and the broad impacts of the crisis to date on the health sector are assessed. Next the prospects for success of current managed-care reform proposals are examined in some detail: viability of expanded managed care reform measures are assessed in light of the continuing crisis and its likely impacts on the consumers and suppliers of health care. Analysis of the potential impact of the continuing crisis focuses on key participants in health care reform: households, the government, and private health care providers. In conclusion the potential viability of managed care appears poor, given the current economic, political, and institutional conditions and likely future impacts, and suggest some alternative reform measures.
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Coordinated Care Management For Dementia In A Large, Academic Health System
Tan, Zaldy S.; Jennings, Lee; Reuben, David
2014-01-01
Alzheimer’s disease and other dementias are chronic, incurable diseases that require coordinated care that addresses the medical, behavioral, and social aspects of the disease. With funding from the Center for Medicare and Medicaid Innovation (the Innovation Center), we launched a dementia care program in which a nurse practitioner acting as a dementia care manager worked with primary care physicians to develop and implement a dementia care plan that offers training and support to caregivers, manages care transitions, and facilitates access to community-based services. Post-visit surveys showed high levels of caregiver satisfaction. As program enrollment grows, outcomes will be tracked based on the triple aim developed by the Institute for Healthcare Improvement and adopted by the Centers for Medicare and Medicaid Services: better care, better health, and lower cost and utilization. The program, if successful at achieving the triple aim, may serve as a national model for how dementia and other chronic diseases can be managed in partnership with primary care practices. The program may also inform policy and reimbursement decisions for the recently released transitional care management codes and the complex chronic care management codes to be released by Medicare in 2015. PMID:24711323
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Academic psychiatry and managed care: a case study.
Wetzler, S; Schwartz, B J; Sanderson, W; Karasu, T B
1997-08-01
An academic department of psychiatry in New York City eliminated the need for behavioral managed care intermediaries by transforming itself from a fee-for-service system to a system able to engage in full-risk capitation contracts. The first step was to require health maintenance organizations to contract directly with the department. The department formed two legal entities, a behavioral management services organization for utilization management and a behavioral integrated provider association. The authors describe these entities and review the first year of operation, presenting data on enrollees, capitation rates, and service utilization for the first three contracts. The fundamental differences in the treatment model under managed care and under a fee-for-service system are highlighted. The authors conclude that by contracting directly with insurers on a full-risk capitation basis, departments of psychiatry will be better able to face the economic threats posed by the cost constraints inherent in managed care and maintain or re-establish their autonomy as care managers as well as high-quality care providers.
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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.
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Wu, Brian; Jin, Haomiao; Vidyanti, Irene; Lee, Pey-Jiuan; Ell, Kathleen; Wu, Shinyi
2014-08-28
The prevalence of comorbid diabetes and depression is high, especially in low-income Hispanic or Latino patients. The complex mix of factors in safety-net care systems impedes the adoption of evidence-based collaborative depression care and results in persistent disparities in depression outcomes. The Diabetes-Depression Care-Management Adoption Trial examined whether the collaborative depression care model is an effective approach in safety-net clinics to improve clinical care outcomes of depression and diabetes. A sample of 964 patients with diabetes from 5 safety-net clinics were enrolled in a quasi-experimental study that included 2 arms: usual care, in which primary medical providers and staff translated and adopted evidence-based depression care; and supportive care, in which providers of a disease management program delivered protocol-driven depression care. Because the study design established individual treatment centers as separate arms, we calculated propensity scores that interpreted the probability of treatment assignment conditional on observed baseline characteristics. Primary outcomes were 5 depression care outcomes and 7 diabetes care measures. Regression models with propensity score covariate adjustment were applied to analyze 6-month outcomes. Compared with usual care, supportive care significantly decreased Patient Health Questionnaire-9 scores, reduced the number of patients with moderate or severe depression, improved depression remission, increased satisfaction in care for patients with emotional problems, and significantly reduced functional impairment. Implementing collaborative depression care in a diabetes disease management program is a scalable approach to improve depression outcomes and patient care satisfaction among patients with diabetes in a safety-net care system.
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Wu, Brian; Jin, Haomiao; Vidyanti, Irene; Lee, Pey-Jiuan; Ell, Kathleen
2014-01-01
Introduction The prevalence of comorbid diabetes and depression is high, especially in low-income Hispanic or Latino patients. The complex mix of factors in safety-net care systems impedes the adoption of evidence-based collaborative depression care and results in persistent disparities in depression outcomes. The Diabetes–Depression Care-Management Adoption Trial examined whether the collaborative depression care model is an effective approach in safety-net clinics to improve clinical care outcomes of depression and diabetes. Methods A sample of 964 patients with diabetes from 5 safety-net clinics were enrolled in a quasi-experimental study that included 2 arms: usual care, in which primary medical providers and staff translated and adopted evidence-based depression care; and supportive care, in which providers of a disease management program delivered protocol-driven depression care. Because the study design established individual treatment centers as separate arms, we calculated propensity scores that interpreted the probability of treatment assignment conditional on observed baseline characteristics. Primary outcomes were 5 depression care outcomes and 7 diabetes care measures. Regression models with propensity score covariate adjustment were applied to analyze 6-month outcomes. Results Compared with usual care, supportive care significantly decreased Patient Health Questionnaire-9 scores, reduced the number of patients with moderate or severe depression, improved depression remission, increased satisfaction in care for patients with emotional problems, and significantly reduced functional impairment. Conclusion Implementing collaborative depression care in a diabetes disease management program is a scalable approach to improve depression outcomes and patient care satisfaction among patients with diabetes in a safety-net care system. PMID:25167093
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Managed care and the diffusion of intensity-modulated radiotherapy for prostate cancer.
Jacobs, Bruce L; Zhang, Yun; Skolarus, Ted A; Wei, John T; Montie, James E; Schroeck, Florian R; Hollenbeck, Brent K
2012-12-01
To better understand associations between managed care penetration in health care markets and the adoption of intensity-modulated radiotherapy (IMRT). We used Surveillance, Epidemiology, and End Results-Medicare data to identify men diagnosed with prostate cancer between 2001 and 2007 who were treated with radiotherapy (n = 55,162). We categorized managed care penetration in Health Service Areas (HSAs) as low (<3%), intermediate (3%-10%), and high (>10%), and assessed our main outcomes (ie, probability of IMRT adoption, which is the ability of a health care market to deliver IMRT, and IMRT utilization in HSA markets) using a Cox proportional hazards model and Poisson regression model, respectively. Compared with markets with low managed care penetration, populations in highly penetrated HSAs were more racially diverse (25% vs 15% non-white, P <.01), densely populated (2110 vs 145 people/square mile, P <.01), and wealthier (median income, $48,500 vs $31,900, P <.01). The probability of IMRT adoption was greatest in markets with the highest managed care penetration (eg, 0.82 [high] vs 0.72 [low] in 2007, P = .05). Among adopting markets, the use of IMRT increased in all HSA categories. However, relative to markets with low managed care penetration, IMRT use was constrained in markets with the highest penetration (0.69 [high] vs 0.76 [low] in 2007, P <.01). Markets with higher managed care penetration demonstrated a greater propensity for acquiring IMRT technology. However, after adopting IMRT, more highly penetrated markets had roughly 7% slower growth in IMRT use during the study period. These findings provide insight into the implications of delivery system reforms for cancer-related technologies. Copyright © 2012 Elsevier Inc. All rights reserved.
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Asmall, Shaidah
2015-01-01
Background South Africa is facing a complex burden of disease arising from a combination of chronic infectious illness and non-communicable diseases. As the burden of chronic diseases (communicable and non-communicable) increases, providing affordable and effective care to the increasing numbers of chronic patients will be an immense challenge. Methods The framework recommended by the Medical Research Council of the United Kingdom for the development and evaluation of complex health interventions was used to conceptualise the intervention. The breakthrough series was utilised for the implementation process. These two frameworks were embedded within the clinical practice improvement model that served as the overarching framework for the development and implementation of the model. Results The Chronic Care Model was ideally suited to improve the facility component and patient experience; however, the deficiencies in other aspects of the health system building blocks necessitated a hybrid model. An integrated chronic disease management model using a health systems approach was initiated across 42 primary health care facilities. The interventions were implemented in a phased approach using learning sessions and action periods to introduce the planned and targeted changes. Conclusion The implementation of the integrated chronic disease management model is feasible at primary care in South Africa provided that systemic challenges and change management are addressed during the implementation process. PMID:26528101
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Mahomed, Ozayr Haroon; Asmall, Shaidah
2015-01-01
South Africa is facing a complex burden of disease arising from a combination of chronic infectious illness and non-communicable diseases. As the burden of chronic diseases (communicable and non-communicable) increases, providing affordable and effective care to the increasing numbers of chronic patients will be an immense challenge. The framework recommended by the Medical Research Council of the United Kingdom for the development and evaluation of complex health interventions was used to conceptualise the intervention. The breakthrough series was utilised for the implementation process. These two frameworks were embedded within the clinical practice improvement model that served as the overarching framework for the development and implementation of the model. The Chronic Care Model was ideally suited to improve the facility component and patient experience; however, the deficiencies in other aspects of the health system building blocks necessitated a hybrid model. An integrated chronic disease management model using a health systems approach was initiated across 42 primary health care facilities. The interventions were implemented in a phased approach using learning sessions and action periods to introduce the planned and targeted changes. The implementation of the integrated chronic disease management model is feasible at primary care in South Africa provided that systemic challenges and change management are addressed during the implementation process.
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Organizing integrated care in a university hospital: application of a conceptual framework
Axelsson, Runo; Axelsson, Susanna Bihari; Gustafsson, Jeppe; Seemann, Janne
2014-01-01
Background and aim As a result of New Public Management, a number of industrial models of quality management have been implemented in health care, mainly in hospitals. At the same time, the concept of integrated care has been developed within other parts of the health sector. The aim of the article is to discuss the relevance of integrated care for hospitals. Theory and methods The discussion is based on application of a conceptual framework outlining a number of organizational models of integrated care. These models are illustrated in a case study of a Danish university hospital implementing a new organization for improving the patient flows of the hospital. The study of the reorganization is based mainly on qualitative data from individual and focus group interviews. Results The new organization of the university hospital can be regarded as a matrix structure combining a vertical integration of clinical departments with a horizontal integration of patient flows. This structure has elements of both interprofessional and interorganizational integration. A strong focus on teamwork, meetings and information exchange is combined with elements of case management and co-location. Conclusions It seems that integrated care can be a relevant concept for a hospital. Although the organizational models may challenge established professional boundaries and financial control systems, this concept can be a more promising way to improve the quality of care than the industrial models that have been imported into health care. This application of the concept may also contribute to widen the field of integrated care. PMID:24966806
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Theory that explains an Aboriginal perspective of learning to understand and manage diabetes.
Webster, Emma; Johnson, Craig; Kemp, Bernie; Smith, Valerie; Johnson, Monica; Townsend, Billie
2017-02-01
To use grounded theory and participatory research methodology to explain how Aboriginal people learn to understand and manage type 2 diabetes. Aboriginal people with diabetes were invited to participate in one of five focus groups (n=25, male=12, female=13). Focus groups and education sessions were conducted by Aboriginal members of the research team. Focus groups were audio recorded and transcribed, with coding and first level analysis undertaken by all members of the research team. Participants described colonisation and dislocation from Country and family members' experiences with diabetes as significant historical influences which, in conjunction with the model of care experienced and the type of interaction with health services, shaped how they came to understand and manage their diabetes. Patient experience of a model of care alone is not what influences understanding and management of diabetes in Aboriginal people. Implications for Public Health: Health service improvements should focus on understanding past experiences of Aboriginal patients, improving interactions with health services and supporting holistic family centred models of care. Focusing on just the model of care in absence of other improvements is unlikely to deliver health benefits to Aboriginal people. © 2016 The Authors.
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Bolíbar, Ignasi; Plaza, Vicente; Llauger, Mariantònia; Amado, Ester; Antón, Pedro A; Espinosa, Ana; Domínguez, Leandra; Fraga, Mar; Freixas, Montserrat; de la Fuente, Josep A; Liguerre, Iskra; Medrano, Casimira; Peiro, Meritxell; Pou, Mariantònia; Sanchis, Joaquin; Solanes, Ingrid; Valero, Carles; Valverde, Pepi
2009-02-24
The diagnosis and treatment of patients with chronic obstructive pulmonary disease (COPD) in Spain continues to present challenges, and problems are exacerbated when there is a lack of coordinated follow-up between levels of care. This paper sets out the protocol for assessing the impact of an integrated management model for the care of patients with COPD. The new model will be evaluated in terms of 1) improvement in the rational utilization of health-care services and 2) benefits reflected in improved health status and quality of life for patients. A quasi-experimental study of the effectiveness of a COPD management model called COPD PROCESS. The patients in the study cohorts will be residents of neighborhoods served by two referral hospitals in Barcelona, Spain. One area comprises the intervention group (n = 32,248 patients) and the other the control group (n = 32,114 patients). The study will include pre- and post-intervention assessment 18 months after the program goes into effect. Analyses will be on two datasets: clinical and administrative data available for all patients, and clinical assessment information for a cohort of 440 patients sampled randomly from the intervention and control areas. The main endpoints will be the hospitalization rates in the two health-care areas and quality-of-life measures in the two cohorts. The COPD PROCESS model foresees the integrated multidisciplinary management of interventions at different levels of the health-care system through coordinated routine clinical practice. It will put into practice diagnostic and treatment procedures that are based on current evidence, multidisciplinary consensus, and efficient use of available resources. Care pathways in this model are defined in terms of patient characteristics, level of disease severity and the presence or absence of exacerbation. The protocol covers the full range of care from primary prevention to treatment of complex cases.
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Larsson, Lena Gunvor; Bäck-Pettersson, Siv; Kylén, Sven; Marklund, Bertil; Carlström, Eric
2017-01-01
The aim of this study was to investigate primary care managers' perceptions of their capability in providing care planning to patients with complex needs. Care planning is defined as a process where the patient, family and health professionals engage in dialogue about the patient's care needs and plan care interventions together. Semi-structured interviews with 18 primary care managers in western Sweden were conducted using Westrin's theoretical cooperation model. Data were analysed using a qualitative deductive method. Results reveal that the managers' approach to care planning was dominated by non-cooperation and separation. The managers were permeated by uncertainty about the meaning of the task of care planning as such. They did not seem to be familiar with the national legislation stipulating that every healthcare provider must meet patients' need for care interventions and participate in the care planning. To accomplish care planning, the process needs to cross - and overcome - both professional and organisational boundaries. There is also a need for incentives to develop working methods that promote local cooperation in order to facilitate optimal care for patients with complex needs. Copyright © 2016. Published by Elsevier Ireland Ltd.
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Time for chronic disease care and management
Montague, Terrence J; Gogovor, Amédé; Krelenbaum, Marilyn
2007-01-01
To manage the future costs and quality of care, a health strategy must move beyond the individual, acute care model and address the care of older people with chronic, and often multiple, diseases. This strategy must address the issue of care gaps, ie, the differences between best care and usual care. It should also embrace broad partnerships in which providers may be a cross-disciplinary team of nurses, physicians and pharmacists; the patient partners may include all patients in the community with a disease or group of diseases; and the system managers should work with all to seek improved long-term care and share the governance of interventions and resources. This partnership is activated by repeated and widely communicated measurements of actual practices and outcomes, facilitating rapid knowledge gain and translation, including unmasking the invisible wait list of unmeasured care gaps. It drives continuous improvement in practices and outcomes. The time is right for such care models. There is increasing evidence of their clinical and financial benefits. There is a clear and immediate opportunity to evaluate them as part of a health strategy for effective chronic care in our aging society. Things can be better. PMID:17932573
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Time for chronic disease care and management.
Montague, Terrence J; Gogovor, Amédé; Krelenbaum, Marilyn
2007-10-01
To manage the future costs and quality of care, a health strategy must move beyond the individual, acute care model and address the care of older people with chronic, and often multiple, diseases. This strategy must address the issue of care gaps, ie, the differences between best care and usual care. It should also embrace broad partnerships in which providers may be a cross-disciplinary team of nurses, physicians and pharmacists; the patient partners may include all patients in the community with a disease or group of diseases; and the system managers should work with all to seek improved long-term care and share the governance of interventions and resources. This partnership is activated by repeated and widely communicated measurements of actual practices and outcomes, facilitating rapid knowledge gain and translation, including unmasking the invisible wait list of unmeasured care gaps. It drives continuous improvement in practices and outcomes. The time is right for such care models. There is increasing evidence of their clinical and financial benefits. There is a clear and immediate opportunity to evaluate them as part of a health strategy for effective chronic care in our aging society. Things can be better.
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Persson, Sophie Schön; Lindström, Petra Nilsson; Pettersson, Pär; Andersson, Ingemar
2018-05-22
The impact of positive social relationships on the health of municipal employees in the elder care sector in Sweden needs further examination. To explore the association between health and relationships among elderly care employees using a salutogenic perspective. Survey of all employees (n = 997) in special housing, home care and Disabled Support and Services in a Swedish municipality. The questionnaire, which had a salutogenic perspective, included information on self-rated health from the previously validated SHIS (Salutogenic Health Indicator Scale), psychosocial work environment and experiences, social climate, and health-promoting workplace relationships. The response rate was 69% . Results of a multivariable linear regression model showed four significant predictors of health: general work experiences, colleague belongingness and positive relationships with managers and care recipients. In another model, colleague belongingness was significantly related to satisfaction with care recipients, work, length of employment as well as general work experiences and relationships with managers. Strengthening of positive work relationships, not only between workmates but also with managers and care recipients, seems to be an essential area for employee health promotion. Colleague belongingness may be deepened by development of a positive work climate, including satisfactory work experiences, positive manager relationships and a stable work force.
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Fornili, Katherine S
2016-01-01
Part 1 of this two-part series (The Theoretical Basis for Recovery-Oriented Management of Substance Use Disorders in the Primary Care) explored the theoretical foundations for evidence-based substance Screening, Brief Intervention and Referral to Treatment (SBIRT) services. The aim was to produce possible explanations for why traditional SBIRT works well for individuals with unhealthy alcohol use but not as well for individuals who have more serious substance use disorders, including drug use and alcohol/drug dependence. Building on that analysis, through meaningful application of recovery management (RM) concepts within an integrated primary care/behavioral health context, a new, theory-based, recovery-oriented framework for primary care SBIRT is now introduced in Part 2. The proposed SBIRT Plus Recovery Management (SBIRT + RM) model moves traditional SBIRT from its original, limited, and narrow focus only on substance detection, brief intervention, and referral to its rightful, structured placement within a comprehensive, multidimensional, recovery-oriented system of care clinical practice environment. SBIRT+RM describes relevant strategies for improving recovery outcomes for individuals identified through primary care substance screening and defines primary care provider roles and responsibilities for sustained recovery support and long-term recovery maintenance.
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Kitson, Nicole A; Price, Morgan; Lau, Francis Y; Showler, Grey
2013-10-17
Medication errors are a common type of preventable errors in health care causing unnecessary patient harm, hospitalization, and even fatality. Improving communication between providers and between providers and patients is a key aspect of decreasing medication errors and improving patient safety. Medication management requires extensive collaboration and communication across roles and care settings, which can reduce (or contribute to) medication-related errors. Medication management involves key recurrent activities (determine need, prescribe, dispense, administer, and monitor/evaluate) with information communicated within and between each. Despite its importance, there is a lack of conceptual models that explore medication communication specifically across roles and settings. This research seeks to address that gap. The Circle of Care Modeling (CCM) approach was used to build a model of medication communication activities across the circle of care. CCM positions the patient in the centre of his or her own healthcare system; providers and other roles are then modeled around the patient as a web of relationships. Recurrent medication communication activities were mapped to the medication management framework. The research occurred in three iterations, to test and revise the model: Iteration 1 consisted of a literature review and internal team discussion, Iteration 2 consisted of interviews, observation, and a discussion group at a Community Health Centre, and Iteration 3 consisted of interviews and a discussion group in the larger community. Each iteration provided further detail to the Circle of Care medication communication model. Specific medication communication activities were mapped along each communication pathway between roles and to the medication management framework. We could not map all medication communication activities to the medication management framework; we added Coordinate as a separate and distinct recurrent activity. We saw many examples of coordination activities, for instance, Medical Office Assistants acting as a liaison between pharmacists and family physicians to clarify prescription details. Through the use of CCM we were able to unearth tacitly held knowledge to expand our understanding of medication communication. Drawing out the coordination activities could be a missing piece for us to better understand how to streamline and improve multi-step communication processes with a goal of improving patient safety.
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2013-01-01
Background Medication errors are a common type of preventable errors in health care causing unnecessary patient harm, hospitalization, and even fatality. Improving communication between providers and between providers and patients is a key aspect of decreasing medication errors and improving patient safety. Medication management requires extensive collaboration and communication across roles and care settings, which can reduce (or contribute to) medication-related errors. Medication management involves key recurrent activities (determine need, prescribe, dispense, administer, and monitor/evaluate) with information communicated within and between each. Despite its importance, there is a lack of conceptual models that explore medication communication specifically across roles and settings. This research seeks to address that gap. Methods The Circle of Care Modeling (CCM) approach was used to build a model of medication communication activities across the circle of care. CCM positions the patient in the centre of his or her own healthcare system; providers and other roles are then modeled around the patient as a web of relationships. Recurrent medication communication activities were mapped to the medication management framework. The research occurred in three iterations, to test and revise the model: Iteration 1 consisted of a literature review and internal team discussion, Iteration 2 consisted of interviews, observation, and a discussion group at a Community Health Centre, and Iteration 3 consisted of interviews and a discussion group in the larger community. Results Each iteration provided further detail to the Circle of Care medication communication model. Specific medication communication activities were mapped along each communication pathway between roles and to the medication management framework. We could not map all medication communication activities to the medication management framework; we added Coordinate as a separate and distinct recurrent activity. We saw many examples of coordination activities, for instance, Medical Office Assistants acting as a liaison between pharmacists and family physicians to clarify prescription details. Conclusions Through the use of CCM we were able to unearth tacitly held knowledge to expand our understanding of medication communication. Drawing out the coordination activities could be a missing piece for us to better understand how to streamline and improve multi-step communication processes with a goal of improving patient safety. PMID:24134454
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[Job satisfaction of nurses in the clinical management units].
Martínez Lara, Concepción; Praena Fernández, Juan Manuel; Gil García, Eugenia
2013-01-01
Clinical Management Unit (CMU) is currently set in the Andalusian health institutions as the model reference management. This management model aims to make all healthcare professionals a powerful idea: the best performance of health resources is performed to drive clinical practice using the least number of diagnostic and therapeutic resources. The CMU not only aims at saving money, in the Clinical Management Agreement [1] are measured all the dimensions that make up the UGC: research, training, clinical process, the portfolio of services, objectives, financial management and indicators to control and security. The CMU is to transfer more responsibilities to Health Care Professionals, involving them in the management of the Unit. The CMU sets new approaches that directly affect health professionals and presents advantages and disadvantages for the Doctors and the Nurses, involved in achieving excellence in care work. Nurse Practitioners shows expectant before the changes are generated in health institutions and appears a discussion of skills derived from the CMU. Some Nurses believe that the bur, den of care to which they are subjected in public institutions has increased since the onset of the CMU and yet others believe that they are motivated and rewarded for the results obtained with this model of management. In health institutions, some professionals are more motivated than others and this is found in the outcome of health care activity [2]. Given the positive and negative perceptions that arise in the CMU Professional Nurses, it is considered appropriate to focus the objective of this work in the search for factors that influence job satisfaction of nurses in the CMU. There are few studies about the CMU [3] but are absent when linked with nursing, so the pursuit of scientific knowledge related to nursing management model based on Clinical and Quality Care can lead to establish new concepts around the nursing profession, a profession in which major changes are foreseen when the Grade is effective.
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The new organization of the health care delivery system.
Shortell, S M; Hull, K E
1996-01-01
The U.S. health care system is restructuring at a dizzying pace. In many parts of the country, managed care has moved into third-generation models emphasizing capitated payment for enrolled lives and, in the process, turning most providers and institutions into cost centers to be managed rather than generators of revenue. While the full impact of the new managed care models remains to be seen, most evidence to date suggests that it tends to reduce inpatient use, may be associated with greater use of physician services and preventive care, and appears to result in no net differences either positive or negative with regard to quality or outcomes of care in comparison with fee-for-service plans. Some patients, however, tend to be somewhat less satisfied with scheduling of appointments and the amount of time spent with providers. There is no persuasive evidence that managed care lowers the rate of growth in overall health care costs within a given market. Further, managed care performance varies considerably across the country, and the factors influencing managed care performance are not well understood. Organized delivery systems are a somewhat more recent phenomenon representing various forms of ownership and strategic alliances among hospitals, physicians, and insurers designed to provide more cost-effective care to defined populations by achieving desired levels of functional, physician-system, and clinical integration. Early evidence suggests that organized delivery systems that are more integrated have the potential to provide more accessible coordinated care across the continuum, and appear to be associated with higher levels of inpatient productivity, greater total system revenue, greater total system cash flow, and greater total system operating margin than less integrated delivery forms. Some key success factors for developing organized delivery systems have been identified. Important roles are played by organizational culture, information systems, internal incentives, total quality management, physician leadership, and the growth of group practices. This chapter describes the growth and evolution of managed care and organized delivery systems, the research evidence regarding managed care and organized delivery systems, and the likely future organization of the health system in light of recent trends and evidence. It also highlights some of the more important public policy implications of the new health care infrastructure.
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Beyond the rhetoric: what do we mean by a 'model of care'?
Davidson, Patricia; Halcomb, Elizabeth; Hickman, L; Phillips, J; Graham, B
2006-01-01
Contemporary health care systems are constantly challenged to revise traditional methods of health care delivery. These challenges are multifaceted and stem from: (1) novel pharmacological and non-pharmacological treatments; (2) changes in consumer demands and expectations; (3) fiscal and resource constraints; (4) changes in societal demographics in particular the ageing of society; (5) an increasing burden of chronic disease; (6) documentation of limitations in traditional health care delivery; (7) increased emphasis on transparency, accountability, evidence-based practice (EBP) and clinical governance structures; and (8) the increasing cultural diversity of the community. These challenges provoke discussion of potential alternative models of care, with scant reference to defining what constitutes a model of care. This paper aims to define what is meant by the term 'model of care' and document the pragmatic systems and processes necessary to develop, plan, implement and evaluate novel models of care delivery. Searches of electronic databases, the reference lists of published materials, policy documents and the Internet were conducted using key words including 'model*', 'framework*', 'models, theoretical' and 'nursing models, theoretical'. The collated material was then analysed and synthesised into this review. This review determined that in addition to key conceptual and theoretical perspectives, quality improvement theory (eg. collaborative methodology), project management methods and change management theory inform both pragmatic and conceptual elements of a model of care. Crucial elements in changing health care delivery through the development of innovative models of care include the planning, development, implementation, evaluation and assessment of the sustainability of the new model. Regardless of whether change in health care delivery is attempted on a micro basis (eg. ward level) or macro basis (eg. national or state system) in order to achieve sustainable, effective and efficient changes a well-planned, systematic process is essential.
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Vickery, Katherine D; Shippee, Nathan D; Menk, Jeremiah; Owen, Ross; Vock, David M; Bodurtha, Peter; Soderlund, Dana; Hayward, Rodney A; Davis, Matthew M; Connett, John; Linzer, Mark
2018-05-01
Hennepin Health, a Medicaid accountable care organization, began serving early expansion enrollees (very low-income childless adults) in 2012. It uses an integrated care model to address social and behavioral needs. We compared health care utilization in Hennepin Health with other Medicaid managed care in the same area from 2012 to 2014, controlling for demographics, chronic conditions, and enrollment patterns. Homelessness and substance use were higher in Hennepin Health. Overall adjusted results showed Hennepin Health had 52% more emergency department visits and 11% more primary care visits than comparators. Over time, modeling a 6-month exposure to Hennepin Health, emergency department and primary care visits decreased and dental visits increased; hospitalizations decreased nonsignificantly but increased among comparators. Subgroup analysis of high utilizers showed lower hospitalizations in Hennepin Health. Integrated, accountable care under Medicaid expansion showed some desirable trends and subgroup benefits, but overall did not reduce acute health care utilization versus other managed care.
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ERIC Educational Resources Information Center
Allcorn, Seth; Winship, Daniel H.
1996-01-01
A discussion of changes in medical school organization to meet new financial challenges looks at the traditional medical school management model and proposes an alternative, the service line management matrix model. In this model, each institutional mission (teaching, research, patient care) must be managed for its cost-effectiveness. Roles of…
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Frølich, Anne
2012-02-01
The quality of health care services offered to people suffering from chronic diseases often fails to meet standards in Denmark or internationally. The population consisting of people with chronic diseases is large and accounts for about 70% of total health care expenses. Given that resources are limited, it is necessary to identify efficient methods to improve the quality of care. Comparing health care systems is a well-known method for identifying new knowledge regarding, for instance, organisational methods and principles. Kaiser Permanente (KP), an integrated health care delivery system in the U.S., is recognized as providing high-quality chronic care; to some extent, this is due to KP's implementation of the chronic care model (CCM). This model recommends a range of evidence-based management practices that support the implementation of evidence-based medicine. However, it is not clear which management practices in the CCM are most efficient and in what combinations. In addition, financial incentives and public reporting of performance are often considered effective at improving the quality of health care services, but this has not yet been definitively proved. The aim of this dissertation is to describe the effect of determinants, such as organisational structures and management practices including two selected incentives, on the quality of care in chronic diseases. The dissertation is based on four studies with the following purposes: 1) macro- or healthcare system-level identification of organisational structures and principles that affect the quality of health care services, based on a comparison of KP and the Danish health care system; 2) meso- or organisation-level identification of management practices with positive effects on screening rates for hemoglobin A1c and lipid profile in diabetes; 3) evaluation of the effect of the CCM on quality of health care services and continuity of care in a Danish setting; 4) micro- or practice-level evaluation of the effect of financial incentives and public performance reporting on the behaviour of professionals and quality of care. Using secondary data, KP and the Danish health care system were compared in terms of six central dimensions: population, health care professionals, health care organisations, utilization patterns, quality measurements, and costs. Differences existed between the two systems on all dimensions, complicating the interpretation of findings. For instance, observed differences might be due to similar tendencies in the two health care systems that were observed at different times, rather than true structural differences. The expenses in the two health care systems were corrected for differences in the populations served and the purchasing power of currencies. However, no validated methods existed to correct for observed differences in case-mixes of chronic conditions. Data from a population of about half a million patients with diabetes in a large U.S. integrated health care delivery system affiliated with 41 medical centers employing 15 different CCM management practices was the basis for identifying effective management practices. Through the use of statistical modelling, the management practice of provider alerts was identified as most effective for promoting screening for hemoglobin A1c and lipid profile. The CCM was used as a framework for implementing four rehabilitation programs. The model promoted continuity of care and quality of health care services. New management practices were developed in the study, and known practices were further developed. However, the observational nature of the study limited the generalisability of the findings. In a structured literature survey focusing on the effect of financial incentives and public performance reporting on the quality of health care services, few studies documenting an effect were identified. The results varied, and important program aspects or contextual variables were often omitted. A model describing the effects of the two incentives on the conduct of health care professionals and their interaction with the organisations in which they serve was developed. On the macro-level, organisational differences between KP and the Danish health care system related to the primary care sectors, utilization patterns, and the quality of health care services, supporting a hypothesis that KP's focus on primary care is a beneficial form of organisation. On the meso-level, use of the CCM improved quality of health care services, but the effect is complicated and context dependent. The CCM was found to be useful in the Danish health care system, and the model was also further developed in a Danish setting. On the micro-level, quality was improved by financial incentives and disclosure in a complex interplay with other central factors in the work environment of health care professionals.
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Managing diversity in the health care workplace.
Davidhizar, R; Dowd, S; Newman Giger, J
1999-03-01
Cultural diversity is increasing in the United States as increasing numbers of minorities enter the United States from abroad, and cultural diversity is especially prevalent in the health care workplace. In fact, the health care professions are particularly interested in the presence of minorities among caregivers because this often enhances the cultural competence of care delivery. Nevertheless, subtle discrimination can still be found, and managers must be alert that such behavior is not tolerated. Use of the Giger-Davidhizar Cultural Assessment Model can provide managers with information needed to respond to diversity among staff appropriately.
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Implementing practice management strategies to improve patient care: the EPIC project.
Attwell, David; Rogers-Warnock, Leslie; Nemis-White, Joanna
2012-01-01
Healthcare gaps, the difference between usual care and best care, are evident in Canada, particularly with respect to our aging, ailing population. Primary care practitioners are challenged to identify, prevent and close care gaps in their practice environment given the competing demands of informed, litigious patients with complex medical needs, ever-evolving scientific evidence with new treatment recommendations across many disciplines and an enhanced emphasis on quality and accountability in healthcare. Patient-centred health and disease management partnerships using measurement, feedback and communication of practice patterns and outcomes have been shown to narrow care gaps. Practice management strategies such as the use of patient registries and recall systems have also been used to help practitioners better understand, follow and proactively manage populations of patients in their practice. The Enhancing Practice to Improve Care project was initiated to determine the impact of a patient-centred health and disease management partnership using practice management strategies to improve patient care and outcomes for patients with chronic kidney disease (CKD). Forty-four general practices from four regions of British Columbia participated and, indeed, demonstrated that care and outcomes for patients with CKD could be improved via the implementation of practice management strategies in a patient-centred partnership measurement model of health and disease management.
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Lee, Linda; Heckman, George; McKelvie, Robert; Jong, Philip; D’Elia, Teresa; Hillier, Loretta M.
2015-01-01
Abstract Objective To explore the barriers to and facilitators of adapting and expanding a primary care memory clinic model to integrate care of additional complex chronic geriatric conditions (heart failure, falls, chronic obstructive pulmonary disease, and frailty) into care processes with the goal of improving outcomes for seniors. Design Mixed-methods study using quantitative (questionnaires) and qualitative (interviews) methods. Setting Ontario. Participants Family physicians currently working in primary care memory clinic teams and supporting geriatric specialists. Methods Family physicians currently working in memory clinic teams (n = 29) and supporting geriatric specialists (n = 9) were recruited as survey participants. Interviews were conducted with memory clinic lead physicians (n = 16). Statistical analysis was done to assess differences between family physician ratings and geriatric specialist ratings related to the capacity for managing complex chronic geriatric conditions, the role of interprofessional collaboration within primary care, and funding and staffing to support geriatric care. Results from both study methods were compared to identify common findings. Main findings Results indicate overall support for expanding the memory clinic model to integrate care for other complex conditions. However, the current primary care structure is challenged to support optimal management of patients with multiple comorbidities, particularly as related to limited funding and staffing resources. Structured training, interprofessional teams, and an active role of geriatric specialists within primary care were identified as important facilitators. Conclusion The memory clinic model, as applied to other complex chronic geriatric conditions, has the potential to build capacity for high-quality primary care, improve health outcomes, promote efficient use of health care resources, and reduce health care costs. PMID:25932482
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Diabetes Management and Self-Care Education for Hospitalized Patients With Cancer
Leak, Ashley; Davis, Ellen D.; Houchin, Laura B.; Mabrey, Melanie
2009-01-01
Managing diabetes can be a daunting task for patients with cancer. Empowerment-based diabetes education and motivational interviewing are complementary approaches. Oncology nurses may feel unprepared to teach patients and their families about self-care for diabetes, but they provide individualized information on symptom management of cancer throughout hospitalization and at discharge. The essential self-care issues include food, exercise, medication, blood glucose monitoring, prevention, recognition and treatment of hypoglycemia and hyperglycemia, and when and how to get additional medical and educational support. This patient-centered model of diabetes education differs from the older “compliance” model that covers many universal rules for all patients, which are predetermined by the nurse. Informing nurses about their role in care of patients with cancer and diabetes is critical. PMID:19349267
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Review: An Australian model of care for co-morbid diabetes and chronic kidney disease.
Lo, Clement; Zimbudzi, Edward; Teede, Helena; Cass, Alan; Fulcher, Greg; Gallagher, Martin; Kerr, Peter G; Jan, Stephen; Johnson, Greg; Mathew, Tim; Polkinghorne, Kevan; Russell, Grant; Usherwood, Tim; Walker, Rowan; Zoungas, Sophia
2018-02-05
Diabetes and chronic kidney disease (CKD) are two of the most prevalent co-morbid chronic diseases in Australia. The increasing complexity of multi-morbidity, and current gaps in health-care delivery for people with co-morbid diabetes and CKD, emphasise the need for better models of care for this population. Previously, proposed published models of care for co-morbid diabetes and CKD have not been co-designed with stake-holders or formally evaluated. Particular components of health-care shown to be effective in this population are interventions that: are structured, intensive and multifaceted (treating diabetes and multiple cardiovascular risk factors); involve multiple medical disciplines; improve self-management by the patient; and upskill primary health-care. Here we present an integrated patient-centred model of health-care delivery incorporating these components and co-designed with key stake-holders including specialist health professionals, general practitioners and Diabetes and Kidney Health Australia. The development of the model of care was informed by focus groups of patients and health-professionals; and semi-structured interviews of care-givers and health professionals. Other distinctives of this model of care are routine screening for psychological morbidity; patient-support through a phone advice line; and focused primary health-care support in the management of diabetes and CKD. Additionally, the model of care integrates with the patient-centred health-care home currently being rolled out by the Australian Department of Health. This model of care will be evaluated after implementation across two tertiary health services and their primary care catchment areas. Copyright © 2018 John Wiley & Sons, Ltd. This article is protected by copyright. All rights reserved.
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Disease management: definitions, difficulties and future directions.
Pilnick, A.; Dingwall, R.; Starkey, K.
2001-01-01
The last decade has seen a wide range of experiments in health care reform intended to contain costs and promote effectiveness. In the USA, managed care and disease management have been major strategies in this endeavour. It has been argued that their apparent success has strong implications for reform in other countries. However, in this paper we ask whether they are so easily exportable. We explain the concepts involved and set the development of managed care and disease management programmes in the context of the USA. The constituent elements of disease management are identified and discussed. Disease management is considered from the perspectives of the major stakeholders in the United Kingdom, and the differences between the models of health care in the United Kingdom's National Health Service and the USA are noted. A review is presented of evaluations of disease management programmes and of the weaknesses they highlight. The prospects for disease management in Europe are also discussed. PMID:11545333
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Møller, Marlene Christina Rosengaard; Mygind, Anna; Bro, Flemming
2018-05-30
Collaborative care treatment is widely recognized as an effective approach to improve the quality of mental healthcare through enhanced and structured collaboration between general practice and specialized psychiatry. However, studies indicate that the complexity of collaborative care treatment interventions challenge the implementation in real-life general practice settings. Four Danish Collaborative Care Models were launched in 2014 for patients with mild/moderate anxiety and depression. These involved collaboration between general practitioners, care managers and consultant psychiatrists. Taking a multi-practice bottom-up approach, this paper aims to explore the perceived barriers and enablers related to collaborative care for patients with mental health problems and to investigate the actual experiences with a Danish collaborative care model in a single-case study in order to identify enablers and barriers for successful implementation. Combining interviews and observations of usual treatment practices, we conducted a multi-practice study among general practitioners who were not involved in the Danish collaborative care models to explore their perspectives on existing mental health treatment and to investigate (from a bottom-up approach) their perceptions of and need for collaborative care in mental health treatment. Additionally, by combining observations and qualitative interviews, we followed the implementation of a Danish collaborative care model in a single-case study to convey identified barriers and enablers of the collaborative care model. Experienced and perceived enablers of the Danish collaborative care model mainly consisted of a need for new treatment options to deal with mild/moderate anxiety and depression. The model was considered to meet the need for a free fast track to high-quality treatment. Experienced barriers included: poor adaptation of the model to the working conditions and needs in daily general practice, time consumption, unsustainable logistical set-up and unclear care manager role. General practitioners in the multi-practice study considered access to treatment and not collaboration with specialised psychiatry to be essential for this group of patients. The study calls for increased attention to implementation processes and better adaptation of collaborative care models to the clinical reality of general practice. Future interventions should address the treatment needs of specific patient populations and should involve relevant stakeholders in the design and implementation processes.
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Hunter, David J; Hinman, Rana S; Bowden, Jocelyn L; Egerton, Thorlene; Briggs, Andrew M; Bunker, Stephen J; Kasza, Jessica; Forbes, Andrew B; French, Simon D; Pirotta, Marie; Schofield, Deborah J; Zwar, Nicholas A; Bennell, Kim L
2018-04-30
To increase the uptake of key clinical recommendations for non-surgical management of knee osteoarthritis (OA) and improve patient outcomes, we developed a new model of service delivery (PARTNER model) and an intervention to implement the model in the Australian primary care setting. We will evaluate the effectiveness and cost-effectiveness of this model compared to usual general practice care. We will conduct a mixed-methods study, including a two-arm, cluster randomised controlled trial, with quantitative, qualitative and economic evaluations. We will recruit 44 general practices and 572 patients with knee OA in urban and regional practices in Victoria and New South Wales. The interventions will target both general practitioners (GPs) and their patients at the practice level. Practices will be randomised at a 1:1 ratio. Patients will be recruited if they are aged ≥45 years and have experienced knee pain ≥4/10 on a numerical rating scale for more than three months. Outcomes are self-reported, patient-level validated measures with the primary outcomes being change in pain and function at 12 months. Secondary outcomes will be assessed at 6 and 12 months. The implementation intervention will support and provide education to intervention group GPs to deliver effective management for patients with knee OA using tailored online training and electronic medical record support. Participants with knee OA will have an initial GP visit to confirm their diagnosis and receive management according to GP intervention or control group allocation. As part of the intervention group GP management, participants with knee OA will be referred to a centralised multidisciplinary service: the PARTNER Care Support Team (CST). The CST will be trained in behaviour change support and evidence-based knee OA management. They will work with patients to develop a collaborative action plan focussed on key self-management behaviours, and communicate with the patients' GPs. Patients receiving care by intervention group GPs will receive tailored OA educational materials, a leg muscle strengthening program, and access to a weight-loss program as appropriate and agreed. GPs in the control group will receive no additional training and their patients will receive usual care. This project aims to address a major evidence-to-practice gap in primary care management of OA by evaluating a new service delivery model implemented with an intervention targeting GP practice behaviours to improve the health of people with knee OA. Australian New Zealand Clinical Trials Registry: ACTRN12617001595303 , date of registration 1/12/2017.
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Toft-Petersen, A P; Ferrando-Vivas, P; Harrison, D A; Dunn, K; Rowan, K M
2018-05-15
In the UK, a network of specialist centres has been set up to provide critical care for burn patients. However, some burn patients are admitted to general intensive care units. Little is known about the casemix of these patients and how it compares with patients in specialist burn centres. It is not known whether burn-specific or generic risk prediction models perform better when applied to patients managed in intensive care units. We examined admissions for burns in the Case Mix Programme Database from April 2010 to March 2016. The casemix, activity and outcome in general and specialist burn intensive care units were compared and the fit of two burn-specific risk prediction models (revised Baux and Belgian Outcome in Burn Injury models) and one generic model (Intensive Care National Audit and Research Centre model) were compared. Patients in burn intensive care units had more extensive injuries compared with patients in general intensive care units (median (IQR [range]) burn surface area 16 (7-32 [0-98])% vs. 8 (1-18 [0-100])%, respectively) but in-hospital mortality was similar (22.8% vs. 19.0%, respectively). The discrimination and calibration of the generic Intensive Care National Audit and Research Centre model was superior to the revised Baux and Belgian Outcome in Burn Injury burn-specific models for patients managed on both specialist burn and general intensive care units. © 2018 The Association of Anaesthetists of Great Britain and Ireland.
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Putting the process of care into practice.
Houck, S; Baum, N
1997-01-01
"Putting the process of care into practice" provides an interactive, visual model of outpatient resources and processes. It illustrates an episode of care from a fee-for-service as well as managed care perspective. The Care Process Matrix can be used for planning and staffing, as well as retrospectively to assess appropriate resource use within a practice. It identifies effective strategies for reducing the cost per episode of care and optimizing quality while moving from managing costs to managing the care process. Because of an overbuilt health care system, including an oversupply of physicians, success in the future will require redesigning the process of care and a coherent customer service strategy. The growing complexities of practice will require physicians to focus on several key competencies while outsourcing other functions such as billing and contracting.
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van der Heijden, Amber A W A; de Bruijne, Martine C; Feenstra, Talitha L; Dekker, Jacqueline M; Baan, Caroline A; Bosmans, Judith E; Bot, Sandra D M; Donker, Gé A; Nijpels, Giel
2014-06-25
The increasing prevalence of diabetes is associated with increased health care use and costs. Innovations to improve the quality of care, manage the increasing demand for health care and control the growth of health care costs are needed. The aim of this study is to evaluate the care process and costs of managed, protocolized and usual care for type 2 diabetes patients from a societal perspective. In two distinct regions of the Netherlands, both managed and protocolized diabetes care were implemented. Managed care was characterized by centralized organization, coordination, responsibility and centralized annual assessment. Protocolized care had a partly centralized organizational structure. Usual care was characterized by a decentralized organizational structure. Using a quasi-experimental control group pretest-posttest design, the care process (guideline adherence) and costs were compared between managed (n = 253), protocolized (n = 197), and usual care (n = 333). We made a distinction between direct health care costs, direct non-health care costs and indirect costs. Multivariate regression models were used to estimate differences in costs adjusted for confounding factors. Because of the skewed distribution of the costs, bootstrapping methods (5000 replications) with a bias-corrected and accelerated approach were used to estimate 95% confidence intervals (CI) around the differences in costs. Compared to usual and protocolized care, in managed care more patients were treated according to diabetes guidelines. Secondary health care use was higher in patients under usual care compared to managed and protocolized care. Compared to usual care, direct costs were significantly lower in managed care (€-1.181 (95% CI: -2.597 to -334)) while indirect costs were higher (€ 758 (95% CI: -353 to 2.701), although not significant. Direct, indirect and total costs were lower in protocolized care compared to usual care (though not significantly). Compared to usual care, managed care was significantly associated with better process in terms of diabetes care, fewer secondary care consultations and lower health care costs. The same trends were seen for protocolized care, however they were not statistically significant. Current Controlled trials: ISRCTN66124817.
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2014-01-01
Background The increasing prevalence of diabetes is associated with increased health care use and costs. Innovations to improve the quality of care, manage the increasing demand for health care and control the growth of health care costs are needed. The aim of this study is to evaluate the care process and costs of managed, protocolized and usual care for type 2 diabetes patients from a societal perspective. Methods In two distinct regions of the Netherlands, both managed and protocolized diabetes care were implemented. Managed care was characterized by centralized organization, coordination, responsibility and centralized annual assessment. Protocolized care had a partly centralized organizational structure. Usual care was characterized by a decentralized organizational structure. Using a quasi-experimental control group pretest-posttest design, the care process (guideline adherence) and costs were compared between managed (n = 253), protocolized (n = 197), and usual care (n = 333). We made a distinction between direct health care costs, direct non-health care costs and indirect costs. Multivariate regression models were used to estimate differences in costs adjusted for confounding factors. Because of the skewed distribution of the costs, bootstrapping methods (5000 replications) with a bias-corrected and accelerated approach were used to estimate 95% confidence intervals (CI) around the differences in costs. Results Compared to usual and protocolized care, in managed care more patients were treated according to diabetes guidelines. Secondary health care use was higher in patients under usual care compared to managed and protocolized care. Compared to usual care, direct costs were significantly lower in managed care (€-1.181 (95% CI: -2.597 to -334)) while indirect costs were higher (€758 (95% CI: -353 to 2.701), although not significant. Direct, indirect and total costs were lower in protocolized care compared to usual care (though not significantly). Conclusions Compared to usual care, managed care was significantly associated with better process in terms of diabetes care, fewer secondary care consultations and lower health care costs. The same trends were seen for protocolized care, however they were not statistically significant. Trial registration Current Controlled trials: ISRCTN66124817. PMID:24966055
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The eHealth Enhanced Chronic Care Model: A Theory Derivation Approach
Greenwood, Deborah A; Paterniti, Debora A; Ward, Deborah; Miller, Lisa M Soederberg
2015-01-01
Background Chronic illnesses are significant to individuals and costly to society. When systematically implemented, the well-established and tested Chronic Care Model (CCM) is shown to improve health outcomes for people with chronic conditions. Since the development of the original CCM, tremendous information management, communication, and technology advancements have been established. An opportunity exists to improve the time-honored CCM with clinically efficacious eHealth tools. Objective The first goal of this paper was to review research on eHealth tools that support self-management of chronic disease using the CCM. The second goal was to present a revised model, the eHealth Enhanced Chronic Care Model (eCCM), to show how eHealth tools can be used to increase efficiency of how patients manage their own chronic illnesses. Methods Using Theory Derivation processes, we identified a “parent theory”, the Chronic Care Model, and conducted a thorough review of the literature using CINAHL, Medline, OVID, EMBASE PsychINFO, Science Direct, as well as government reports, industry reports, legislation using search terms “CCM or Chronic Care Model” AND “eHealth” or the specific identified components of eHealth. Additionally, “Chronic Illness Self-management support” AND “Technology” AND several identified eHealth tools were also used as search terms. We then used a review of the literature and specific components of the CCM to create the eCCM. Results We identified 260 papers at the intersection of technology, chronic disease self-management support, the CCM, and eHealth and organized a high-quality subset (n=95) using the components of CCM, self-management support, delivery system design, clinical decision support, and clinical information systems. In general, results showed that eHealth tools make important contributions to chronic care and the CCM but that the model requires modification in several key areas. Specifically, (1) eHealth education is critical for self-care, (2) eHealth support needs to be placed within the context of community and enhanced with the benefits of the eCommunity or virtual communities, and (3) a complete feedback loop is needed to assure productive technology-based interactions between the patient and provider. Conclusions The revised model, eCCM, offers insight into the role of eHealth tools in self-management support for people with chronic conditions. Additional research and testing of the eCCM are the logical next steps. PMID:25842005
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Models of community care for severe mental illness: a review of research on case management.
Mueser, K T; Bond, G R; Drake, R E; Resnick, S G
1998-01-01
We describe different models of community care for persons with severe mental illness and review the research literature on case management, including the results of 75 studies. Most research has been conducted on the assertive community treatment (ACT) or intensive case management (ICM) models. Controlled research on ACT and ICM indicates that these models reduce time in the hospital and improve housing stability, especially among patients who are high service users. ACT and ICM appear to have moderate effects on improving symptomatology and quality of life. Most studies suggest little effect of ACT and ICM on social functioning, arrests and time spent in jail, or vocational functioning. Studies on reducing or withdrawing ACT or ICM services suggest some deterioration in gains. Research on other models of community care is inconclusive. We discuss the implications of the findings in terms of the need for specialization of ACT or ICM teams to address social and vocational functioning and substance abuse. We suggest directions for future research on models of community care, including evaluating implementation fidelity, exploring patient predictors of improvement, and evaluating the role of the helping alliance in mediating outcome.
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Comprehensive care improves health outcomes among elderly Taiwanese patients with hip fracture.
Shyu, Yea-Ing L; Liang, Jersey; Tseng, Ming-Yueh; Li, Hsiao-Juan; Wu, Chi-Chuan; Cheng, Huey-Shinn; Yang, Ching-Tzu; Chou, Shih-Wei; Chen, Ching-Yen
2013-02-01
Few studies have investigated the effects of care models that combine interdisciplinary care with nutrition consultation, depression management, and fall prevention in older persons with hip fracture. The purpose of this study was to compare the effects of a comprehensive care program with those of interdisciplinary care and usual care for elderly patients with hip fracture. A randomized experimental trial was used to explore outcomes for 299 elderly patients with hip fracture receiving three treatment care models: interdisciplinary care (n = 101), comprehensive care (n = 99), and usual care (n = 99). Interdisciplinary care included geriatric consultation, continuous rehabilitation, and discharge planning with post-hospital services. Comprehensive care consisted of interdisciplinary care plus nutrition consultation, depression management, and fall prevention. Usual care included only in-hospital rehabilitation without geriatric consultation, in-home rehabilitation, and home environmental assessment. Participants in the comprehensive care group had better self-care ability (odds ratio, OR = 3.19, p < .01) and less risk of depression (OR = 0.48, p < .01) than those who received usual care. The comprehensive care group had less risk of depression (OR = 0.51, p < .05) and of malnutrition (OR = 0.48, p < .05) than the interdisciplinary care group during the first year following discharge. Older persons with hip fracture benefitted more from the comprehensive care program than from interdisciplinary care and usual care. Older persons with hip fracture benefitted more from comprehensive care including interdisciplinary care and nutrition consultation, depression management, and fall prevention than simply interdisciplinary care.
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Organizational and environmental factors associated with nursing home participation in managed care.
Zinn, J S; Mor, V; Castle, N; Intrator, O; Brannon, D
1999-01-01
OBJECTIVE: To develop and test a model, based on resource dependence theory, that identifies the organizational and environmental characteristics associated with nursing home participation in managed care. DATA SOURCES AND STUDY SETTING: Data for statistical analysis derived from a survey of Directors of Nursing in a sample of nursing homes in eight states (n = 308). These data were merged with data from the On-line Survey Certification and Reporting System, the Medicare Managed Care State/County Data File, and the 1995 Area Resource File. STUDY DESIGN: Since the dependent variable is dichotomous, the logistic procedure was used to fit the regression. The analysis was weighted using SUDAAN. FINDINGS: Participation in a provider network, higher proportions of resident care covered by Medicare, providing IV therapy, greater availability of RNs and physical therapists, and Medicare HMO market penetration are associated with a greater likelihood of having a managed care contract. CONCLUSION: As more Medicare recipients enroll in HMOs, nursing home involvement in managed care is likely to increase. Interorganizational linkages enhance the likelihood of managed care participation. Nursing homes interested in managed care should consider upgrading staffing and providing at least some subacute services. PMID:10029508
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Ramli, Anis S; Lakshmanan, Sharmila; Haniff, Jamaiyah; Selvarajah, Sharmini; Tong, Seng F; Bujang, Mohamad-Adam; Abdul-Razak, Suraya; Shafie, Asrul A; Lee, Verna K M; Abdul-Rahman, Thuhairah H; Daud, Maryam H; Ng, Kien K; Ariffin, Farnaza; Abdul-Hamid, Hasidah; Mazapuspavina, Md-Yasin; Mat-Nasir, Nafiza; Miskan, Maizatullifah; Stanley-Ponniah, Jaya P; Ismail, Mastura; Chan, Chun W; Abdul-Rahman, Yong R; Chew, Boon-How; Low, Wilson H H
2014-09-13
Chronic disease management presents enormous challenges to the primary care workforce because of the rising epidemic of cardiovascular risk factors. The chronic care model was proven effective in improving chronic disease outcomes in developed countries, but there is little evidence of its effectiveness in developing countries. The aim of this study was to evaluate the effectiveness of the EMPOWER-PAR intervention (multifaceted chronic disease management strategies based on the chronic care model) in improving outcomes for type 2 diabetes mellitus and hypertension using readily available resources in the Malaysian public primary care setting. This paper presents the study protocol. A pragmatic cluster randomised controlled trial using participatory action research is underway in 10 public primary care clinics in Selangor and Kuala Lumpur, Malaysia. Five clinics were randomly selected to provide the EMPOWER-PAR intervention for 1 year and another five clinics continued with usual care. Each clinic consecutively recruits type 2 diabetes mellitus and hypertension patients fulfilling the inclusion and exclusion criteria over a 2-week period. The EMPOWER-PAR intervention consists of creating/strengthening a multidisciplinary chronic disease management team, training the team to use the Global Cardiovascular Risks Self-Management Booklet to support patient care and reinforcing the use of relevant clinical practice guidelines for management and prescribing. For type 2 diabetes mellitus, the primary outcome is the change in the proportion of patients achieving HbA1c < 6.5%. For hypertension without type 2 diabetes mellitus, the primary outcome is the change in the proportion of patients achieving blood pressure < 140/90 mmHg. Secondary outcomes include the proportion of patients achieving targets for serum lipid profile, body mass index and waist circumference. Other outcome measures include medication adherence levels, process of care and prescribing patterns. Patients' assessment of their chronic disease care and providers' perceptions, attitudes and perceived barriers in care delivery and cost-effectiveness of the intervention are also evaluated. Results from this study will provide objective evidence of the effectiveness and cost-effectiveness of a multifaceted intervention based on the chronic care model in resource-constrained public primary care settings. The evidence should instigate crucial primary care system change in Malaysia. ClinicalTrials.gov NCT01545401.
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Sabatelli, L; Seppälä, U; Sastre, J; Crater, G
Fractional exhaled nitric oxide (FeNO) is a marker for type 2 airway inflammation. The objective of this study was to evaluate the cost-effectiveness and budget impact of FeNO monitoring for management of adult asthma in Spain. A cost-effectiveness analysis model was used to evaluate the effect on costs of adding FeNO monitoring to asthma management. Over a 1-year period, the model estimated the incremental cost per quality-adjusted life year and incremental number of exacerbations avoided when FeNO monitoring was added to standard guideline-driven asthma care compared with standard care alone. Univariate and multivariate sensitivity analyses were applied to explore uncertainty in the model. A budget impact model was used to examine the impact of FeNO monitoring on primary care costs across the Spanish health system. The results showed that adding FeNO to standard asthma care saved €62.53 per patient-year in the adult population and improved quality-adjusted life years by 0.026 per patient-year. The budget impact analysis revealed a potential net yearly saving of €129 million if FeNO monitoring had been used in primary care settings in Spain. The present economic model shows that adding FeNO to the treatment algorithm can considerably reduce costs and improve quality of life when used to manage asthma in combination with current treatment guidelines.
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A qualitative study of GPs' attitudes to self-management of chronic disease
Blakeman, Tom; Macdonald, Wendy; Bower, Peter; Gately, Claire; Chew-Graham, Carolyn
2006-01-01
Background Improving the quality of care for patients living with a chronic illness is a key policy goal. Alongside systems to ensure care is delivered according to evidence-based guidelines, an essential component of these new models of care is the facilitation of self-management. However, changes to the way professionals deliver care is complex, and it is important to understand the key drivers and barriers that may operate in the primary care setting. Aim To explore GPs' perspectives on their involvement in the facilitation of chronic disease self-management. Design of study Qualitative study. Setting General practices located in two primary care trusts in northern England. Method Data were collected through in-depth, semi-structured interviews with a purposive sample of GPs. During analysis, categories of response were organised into themes that relate to Howie's theoretical model for understanding general practice consultations: content, values, context. Results The GPs' responses highlighted tensions and trade-offs regarding their role in facilitating self-management. Although GPs valued increased patient involvement in their health care, this was in conflict with other values concerning professional responsibility. Furthermore, contextual factors also limited the degree to which they could assist in encouraging self-management. Conclusions Providing GPs with training in consultation skills is required in order to encourage the delivery of effective self-management. In addition, the context in which GPs work also needs to be modified for this to be achieved. PMID:16762121
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2012-01-01
Background While strong and consistent evidence supports the role of lifestyle modification in the prevention and management of type 2 diabetes (T2DM), the best strategies for program implementation to support lifestyle modification within primary care remain to be determined. The objective of the study is to evaluate the implementation of an evidence-based self- management program for patients with T2DM within a newly established primary care network (PCN) environment. Method Using a non-randomized design, participants (total N = 110 per group) will be consecutively allocated in bi-monthly blocks to either a 6-month self-management program lead by an Exercise Specialist or to usual care. Our primary outcome is self-reported physical activity and pedometer steps. Discussion The present study will assess whether a diabetes self-management program lead by an Exercise Specialist provided within a newly emerging model of primary care and linked to available community-based resources, can lead to positive changes in self-management behaviours for adults with T2DM. Ultimately, our work will serve as a platform upon which an emerging model of primary care can incorporate effective and efficient chronic disease management practices that are sustainable through partnerships with local community partners. Clinical Trials Registration ClinicalTrials.gov identifier: NCT00991380 PMID:22712881
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Nurse Practitioner-Physician Comanagement: A Theoretical Model to Alleviate Primary Care Strain.
Norful, Allison A; de Jacq, Krystyna; Carlino, Richard; Poghosyan, Lusine
2018-05-01
Various models of care delivery have been investigated to meet the increasing demands in primary care. One proposed model is comanagement of patients by more than 1 primary care clinician. Comanagement has been investigated in acute care with surgical teams and in outpatient settings with primary care physicians and specialists. Because nurse practitioners are increasingly managing patient care as independent clinicians, our study objective was to propose a model of nurse practitioner-physician comanagement. We conducted a literature search using the following key words: comanagement; primary care; nurse practitioner OR advanced practice nurse. From 156 studies, we extracted information about nurse practitioner-physician comanagement antecedents, attributes, and consequences. A systematic review of the findings helped determine effects of nurse practitioner-physician comanagement on patient care. Then, we performed 26 interviews with nurse practitioners and physicians to obtain their perspectives on nurse practitioner-physician comanagement. Results were compiled to create our conceptual nurse practitioner-physician comanagement model. Our model of nurse practitioner-physician comanagement has 3 elements: effective communication; mutual respect and trust; and clinical alignment/shared philosophy of care. Interviews indicated that successful comanagement can alleviate individual workload, prevent burnout, improve patient care quality, and lead to increased patient access to care. Legal and organizational barriers, however, inhibit the ability of nurse practitioners to practice autonomously or with equal care management resources as primary care physicians. Future research should focus on developing instruments to measure and further assess nurse practitioner-physician comanagement in the primary care practice setting. © 2018 Annals of Family Medicine, Inc.
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Disease management improves ESRD outcomes.
Sands, J J
2006-02-01
Renal disease management organizations have reported achieving significant decreases in mortality and hospitalization in conjunction with cost savings, improved patient satisfaction and quality of life. Disease management organizations strive to fill existing gaps in care delivery through the standardized use of risk assessment, predictive modeling, evidence based guidelines and process and outcomes measurement. Patient self-management education and the provision of individual nurse care managers are also key program components. As we more fully measure clinical outcomes and total health-care costs including payments from all insurance and government entities, pharmacy costs and out-of-pocket expenditures, the full implications of disease management can be better defined. The results of this analysis will have a profound influence on United States healthcare policy. At present, current data suggests that the promise of disease management, improved care at reduced cost, can and is being realized in ESRD.
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Polverini, Peter J.
2012-01-01
The emerging concept of prospective health care would shift the focus of health care from disease management to disease prevention and health management. Dentistry has a unique opportunity to embrace this model of prospective and collaborative care and focus on the management of oral health. Academic dentistry must better prepare future dentists to succeed in this new health care environment by providing them with the scientific and technical knowledge required to understand and assess risk and practice disease prevention. Dental schools must consider creating career pathways for enabling future graduates to assume important leadership roles that will advance a prospective oral health care system. PMID:22390456
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Bidwell, Julie T.; Vellone, Ercole; Lyons, Karen S.; D’Agostino, Fabio; Riegel, Barbara; Vela, Raúl Juárez; Hiatt, Shirin O.; Alvaro, Rosaria; Lee, Christopher S.
2015-01-01
Disease self-management is a critical component of maintaining clinical stability for patients with chronic illness. This is particularly evident in the context of heart failure (HF), which is the leading cause of hospitalization for older adults. HF self- management, commonly known as HF self-care, is often performed with the support of informal caregivers. However, little is known about how HF dyads manage the patient’s care together. The purpose of this study was to identify determinants of patient and caregiver contributions to HF self-care maintenance (i.e., daily adherence and symptom monitoring) and management (i.e., appropriate recognition & response to symptoms), utilizing an approach that controls for dyadic interdependence. This was a secondary analysis of cross-sectional data from 364 Italian HF patients and caregivers. Multilevel modeling was used to identify determinants of HF self-care within patient-caregiver dyads. Patients were 76.2 (SD=10.7) years, a slight majority (56.9%) was male, while caregivers were 57.4 (SD=14.6) years, and fewer than half (48.1%) were male. Most caregivers were adult children (48.4%) or spouses (32.7%) of patients. Both patients and caregivers reported low levels of HF maintenance and management behaviors. Several significant individual and dyadic determinants of self-care maintenance and self-care management were identified, including gender, quality of life, comorbid burden, impaired ADLs, cognition, hospitalizations, HF duration, relationship type, relationship quality, and social support. These comprehensive dyadic models assist in elucidating the complex nature of patient-caregiver relationships and their influence on HF self-care, leading to more effective ways to intervene and maximize outcomes. PMID:26355702
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Bidwell, Julie T; Vellone, Ercole; Lyons, Karen S; D'Agostino, Fabio; Riegel, Barbara; Juárez-Vela, Raúl; Hiatt, Shirin O; Alvaro, Rosaria; Lee, Christopher S
2015-10-01
Disease self-management is a critical component of maintaining clinical stability for patients with chronic illness. This is particularly evident in the context of heart failure (HF), which is the leading cause of hospitalization for older adults. HF self-management, commonly known as HF self-care, is often performed with the support of informal caregivers. However, little is known about how a HF dyad manages the patient's care together. The purpose of this study was to identify determinants of patient and caregiver contributions to HF self-care maintenance (daily adherence and symptom monitoring) and management (appropriate recognition and response to symptoms), utilizing an approach that controls for dyadic interdependence. This was a secondary analysis of cross-sectional data from 364 dyads of Italian HF patients and caregivers. Multilevel modeling was used to identify determinants of HF self-care within patient-caregiver dyads. Patients averaged 76.2 (SD = 10.7) years old, and a slight majority (56.9%) was male, whereas caregivers averaged 57.4 (SD = 14.6) years old, and about half (48.1%) were male. Most caregivers were adult children (48.4%) or spouses (32.7%) of patients. Both patients and caregivers reported low levels of HF maintenance and management behaviors. Significant individual and dyadic determinants of self-care maintenance and self-care management included gender, quality of life, comorbid burden, impaired ADLs, cognition, hospitalizations, HF duration, relationship type, relationship quality, and social support. These comprehensive dyadic models assist in elucidating the complex nature of patient-caregiver relationships and their influence on HF self-care, leading to more effective ways to intervene and optimize outcomes. © 2015 Wiley Periodicals, Inc.
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Vallis, Michael
2015-08-01
Self-management and self-management support are concepts very familiar to those of us in diabetes care. These concepts require openness to understanding the behaviours of persons with diabetes broadly, not only behaviours restricted to the biomedical perspective. Understanding the importance of health behaviour change and working within the Expanded Chronic Care Model define the context within which self-management support should occur. The purpose of this perspective is to identify a potential limitation in existing self-management support initiatives. This potential limitation reflects provider issues, not patient issues; that is, true self-management support might require changes by healthcare providers. Specifically, although behavioural interventions within the context of academic research studies are evidence based, behaviour change interventions implemented in general practice settings might prove less effective unless healthcare providers are able to shift from a practice based on the biomedical model to a practice based on the self-management support model. The purpose of this article is to facilitate effective self-management support by encouraging providers to switch from a model of care based on the expert clinician encountering the uninformed help seeker (the biomedical model) to one guided by collaboration grounded in the principles of description, prediction and choice. Key to understanding the value of making this shift are patient-centered communication principles and the tenets of complexity theory. Copyright © 2015 Canadian Diabetes Association. Published by Elsevier Inc. All rights reserved.
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Treiger, Teresa M; Fink-Samnick, Ellen
2013-01-01
The purpose of this second article of a 3-article series is to clarify the competencies for a new paradigm of case management built upon a value-driven foundation that : Applicable to all health care sectors where case management is practiced. In moving forward, the one fact that rings true is that there will be a constant change in our industry. As the health care terrain shifts and new influences continually surface, there will be consequences for case management practice. These impacts require nimble clinical professionals in possession of recognized and firmly established competencies. They must be agile to frame (and reframe) their professional practice to facilitate the best possible outcomes for their patients. Case managers can choose to be Gumby™ or Pokey™. This is exactly the time to define a competency-based case management model, highlighting one sufficiently fluid to fit into any setting of care. The practice of case management transcends the vast array of representative professional disciplines and educational levels. A majority of current models are driven by business priorities rather than the competencies critical to successful practice and quality patient outcomes. This results in a fragmented professional case management identity. Although there is an inherent value in what each discipline brings to the table, this advanced model unifies behind case management's unique, strengths-based identity instead of continuing to align within traditional divisions (e.g., discipline, work setting, population served). This model fosters case management's expanding career advancement opportunities, including a reflective clinical ladder.
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López-Martínez, N; Segú, J L; Vázquez-Castro, J; Brosa, M; Bohigas, L; Comellas, M J; Kalfhaus, L
2017-04-01
Diabetes mellitus affects 13.8% of the adult population in Spain, representing some 8.2% of total Spanish health spending, which may be reduced by optimizing treatment and disease monitoring. Areas covered: This perspective article aims to evaluate the possible clinical and economic outcomes of implementing a theoretical personalized care model in diabetes supported by information and communications technology in Spain vs. conventional care. Moreover, we assessed the value of emminens® eConecta, a solution designed to support the operational implementation of this model, which enables the connection and participation of patients and health professionals, facilitates patient education, decision-making, access to information, and data analysis. We carried out a review of the available evidence, consultations with experts and a clinical and cost estimation. Expert commentary: The experts consulted considered that the proposed model is consistent with Spanish strategies on chronicity, supports the management of chronicity/diabetes, and may improve the most important aspects of disease management. In the literature, this type of care models improved or provided equal disease control compared with conventional care, potentiated self-management strategies and reduced the high use of resources. Cost estimation showed a reduction of -12% in total direct costs and around -34% in the costs of outpatient visits.
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Carpenter, Christopher R; Platts-Mills, Timothy F
2013-02-01
Alternative management methods are essential to ensure high-quality and efficient emergency care for the growing number of geriatric adults worldwide. Protocols to support early condition-specific treatment of older adults with acute severe illness and injury are needed. Improved emergency department care for older adults will require providers to address the influence of other factors on the patient's health. This article describes recent and ongoing efforts to enhance the quality of emergency care for older adults using alternative management approaches spanning the spectrum from prehospital care, through the emergency department, and into evolving inpatient or outpatient processes of care. Copyright © 2013 Elsevier Inc. All rights reserved.
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Healthcare professionals' response to cachexia in advanced cancer: a qualitative study.
Millar, Claire; Reid, Joanne; Porter, Sam
2013-11-01
To explore healthcare professionals' experience, understanding, and perception of the needs of patients with cachexia in advanced cancer. A qualitative approach based on symbolic interactionism. A regional cancer center in a large teaching hospital in the United Kingdom. 34 healthcare professionals who had experience providing care to patients with cachexia in advanced cancer. Data collection consisted of two phases: focus group and semistructured interviews. Interviews were digitally recorded and transcribed verbatim for analysis. This article reports on findings from the second phase of data collection. Analysis revealed that professional approaches to cachexia were influenced by three overarching and interthinking themes: knowledge, culture, and resources. Healthcare professionals commonly recognized the impact of the syndrome; however, for nonpalliative healthcare professionals, a culture of avoidance and an overreliance on the biomedical model of care had considerable influence on the management of cachexia in patients with advanced cancer. Cachexia management in patients with advanced cancer can be difficult and is directed by a variable combination of the influence of knowledge, culture of the clinical area, and available resources. Distinct differences exist in the management of cachexia among palliative and nonpalliative care professionals. This study presented a multiprofessional perspective on the management of cachexia in patients with advanced cancer and revealed that cachexia is a complex and challenging syndrome that needs to be addressed from a holistic model of care. Cachexia management in patients with advanced cancer is complex and challenging and is directed by a combination of variables. An overreliance on the biomedical model of health and illness occurs in the management of cachexia in patients with advanced cancer. Cachexia needs to be addressed from a holistic model of care to reflect the multidimensional needs of patients and their families.
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Kaitani, Toshiko; Nakagami, Gojiro; Iizaka, Shinji; Fukuda, Takashi; Oe, Makoto; Igarashi, Ataru; Mori, Taketoshi; Takemura, Yukie; Mizokami, Yuko; Sugama, Junko; Sanada, Hiromi
2015-01-01
The high prevalence of severe pressure ulcers (PUs) is an important issue that requires to be highlighted in Japan. In a previous study, we devised an advanced PU management protocol to enable early detection of and intervention for deep tissue injury and critical colonization. This protocol was effective for preventing more severe PUs. The present study aimed to compare the cost-effectiveness of the care provided using an advanced PU management protocol, from a medical provider's perspective, implemented by trained wound, ostomy, and continence nurses (WOCNs), with that of conventional care provided by a control group of WOCNs. A Markov model was constructed for a 1-year time horizon to determine the incremental cost-effectiveness ratio of advanced PU management compared with conventional care. The number of quality-adjusted life-years gained, and the cost in Japanese yen (¥) ($US1 = ¥120; 2015) was used as the outcome. Model inputs for clinical probabilities and related costs were based on our previous clinical trial results. Univariate sensitivity analyses were performed. Furthermore, a Bayesian multivariate probability sensitivity analysis was performed using Monte Carlo simulations with advanced PU management. Two different models were created for initial cohort distribution. For both models, the expected effectiveness for the intervention group using advanced PU management techniques was high, with a low expected cost value. The sensitivity analyses suggested that the results were robust. Intervention by WOCNs using advanced PU management techniques was more effective and cost-effective than conventional care. © 2015 by the Wound Healing Society.
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The Oral Health Care Manager in a Patient-Centered Health Facility.
Theile, Cheryl Westphal; Strauss, Shiela M; Northridge, Mary Evelyn; Birenz, Shirley
2016-06-01
The dental hygienist team member has an opportunity to coordinate care within an interprofessional practice as an oral health care manager. Although dental hygienists are currently practicing within interprofessional teams in settings such as pediatric offices, hospitals, nursing homes, schools, and federally qualified health centers, they often still assume traditional responsibilities rather than practicing to the full extent of their training and licenses. This article explains the opportunity for the dental hygiene professional to embrace patient-centered care as an oral health care manager who can facilitate integration of oral and primary care in a variety of health care settings. Based on an innovative model of collaboration between a college of dentistry and a college of nursing, an idea emerged among several faculty members for a new management method for realizing continuity and coordination of comprehensive patient care. Involved faculty members began working on the development of an approach to interprofessional practice with the dental hygienist serving as an oral health care manager who would address both oral health care and a patient's related primary care issues through appropriate referrals and follow-up. This approach is explained in this article, along with the results of several pilot studies that begin to evaluate the feasibility of a dental hygienist as an oral health care manager. A health care provider with management skills and leadership qualities is required to coordinate the interprofessional provision of comprehensive health care. The dental hygienist has the opportunity to lead closer integration of oral and primary care as an oral health care manager, by coordinating the team of providers needed to implement comprehensive, patient-centered care. Copyright © 2016 Elsevier Inc. All rights reserved.
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Building the chronic kidney disease management team.
Spry, Leslie
2008-01-01
The need to be efficient and the demands for performance-based service are changing how nephrologists deliver care. Chronic kidney disease (CKD) occurs in patients with complex medical and social problems. CKD management requires that multidisciplinary professionals provide patient education, disease management, and psychosocial support. To remain cost-efficient, many physicians are training and supervising midlevel practitioners in the delivery of specialized health care. Specialized care that meets present CKD patient needs is best delivered in a CKD clinic. Three models of CKD clinic are identified: (1) anemia management CKD clinic, (2) the basic CKD clinic, and (3) the comprehensive CKD clinic. Each clinic model is based on critical elements of staffing, billable services, and patient-focused health care. Billable services are anemia-management services, physician services that may be provided by midlevel practitioners, and medical nutrition therapy. In some cases, social worker services may be billable. Building a patient-focused clinic that offers CKD management requires planning, familiarity with federal regulations and statutes, and skillful practitioners. Making services cost-efficient and outcome oriented requires careful physician leadership, talented midlevel practitioners, and billing professionals who understand the goals of the CKD clinic. As Medicare payment reforms evolve, a well-organized CKD program can be well poised to meet the requirements of payers and congressional mandates for performance-based purchasing.
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Health care 2020: reengineering health care delivery to combat chronic disease.
Milani, Richard V; Lavie, Carl J
2015-04-01
Chronic disease has become the great epidemic of our times, responsible for 75% of total health care costs and the majority of deaths in the US. Our current delivery model is poorly constructed to manage chronic disease, as evidenced by low adherence to quality indicators and poor control of treatable conditions. New technologies have emerged that can engage patients and offer additional modalities in the treatment of chronic disease. Modifying our delivery model to include team-based care in concert with patient-centered technologies offers great promise in managing the chronic disease epidemic. Copyright © 2015 Elsevier Inc. All rights reserved.
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Kuruvilla, Lisha; Weeks, Greg; Eastman, Peter; George, Johnson
2018-05-01
Pharmacists have a key role to play in optimisation of medication regimens and promotion of medication safety. The role of specialist pharmacists as part of the multidisciplinary palliative care team, especially in the primary care setting, is not widely recognised. To explore the perspectives of stakeholders about the gaps in the current model of community palliative care services in relation to medication management and to assess their opinions pertaining to the role of a specialist palliative care pharmacist in addressing some of those gaps. Qualitative study utilising three focus groups involving 20 stakeholders. Thematic analysis was carried out using a framework approach and interpreted in the context of the Chronic Care Model for improving primary care for patients with chronic illness. Setting was a large regional Australian palliative care service. Participants included palliative care consumers and clinicians specifically patients, caregivers, physicians, nurses and pharmacists. Five major themes emerged from the focus groups: access to resources, medicines and information; shared care; challenges of polypharmacy; informal caregiver needs and potential roles of a palliative care pharmacist. Gaps in access to medicines/resources, training for generalist practitioners, communication between treating teams and lack of support for patients and carers were cited as factors adversely impacting medication management in community-based palliative care. While community-based palliative care is an essential aspect of meeting the health care demands of an ageing society, the current model has several gaps and limitations. An appropriately qualified and skilled pharmacist within the palliative care team may help to address some of the gaps in relation to medication access and appropriateness.
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Pylypchuk, George; Vincent, Lloyd; Wentworth, Joan; Kiss, Alexander; Perkins, Nancy; Hartman, Susan; Ironstand, Laurie; Hoppe, Jacqueline; Tobe, Sheldon W
2008-06-01
To review the DREAM studies and the role of participatory research using a Home and Community Care model in treating First Nations diabetes. Population survey, pilot and prospective randomized trial Review documented history of these studies since inception. Collation of all data from the DREAM studies from 1998 to the present, including interviews with all providers and many of the participants. The DREAM studies were a participatory process providing a needs assessment and became the foundation for this First Nation's Home and Community Care team involvement in providing community-based chronic-disease management. The findings motivated the community to find a process that would lead to needed changes. This participatory research enabled a culturally tailored algorithm of evidence-based management of hypertension and disease management strategies for people with diabetes. These studies demonstrated that in this community the Home and Community Care team could work together with primary care physicians and specialists to prevent the complications of diabetes. The DREAM studies demonstrated in the first controlled trial that with participatory research a systems change is possible; a chronic-disease management model utilizing a trained multidisciplinary Home and Community Care team and informed patients can lead to lower blood pressure in a Canadian First Nations population with diabetes.
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Participative management in health care services.
Muller, M
1995-03-01
The need and demand for the highest-quality management of all health care delivery activities requires a participative management approach. The purpose with this article is to explore the process of participative management, to generate and describe a model for such management, focusing mainly on the process of participative management, and to formulate guidelines for operationalization of the procedure. An exploratory, descriptive and theory-generating research design is pursued. After a brief literature review, inductive reasoning is mainly employed to identify and define central concepts, followed by the formulation of a few applicable statements and guidelines. Participative management is viewed as a process of that constitutes the elements of dynamic interactive decision-making and problem-solving, shared governance, empowerment, organisational transformation, and dynamic communication within the health care organisation. The scientific method of assessment, planning, implementation and evaluation is utilised throughout the process of participative management. A continuum of interactive decision-making and problem-solving is described, the different role-players involved, as well as the levels of interactive decision-making and problem-solving. The most appropriate decision-making strategy should be employed in pro-active and reactive decision-making. Applicable principles and assumptions in each element of participative management is described. It is recommended that this proposed model for participative management be refined by means of a literature control, interactive dialogue with experts and a model case description or participative management, to ensure the trustworthiness of this research.
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Managed care and inpatient mortality in adults: effect of primary payer.
Hines, Anika L; Raetzman, Susan O; Barrett, Marguerite L; Moy, Ernest; Andrews, Roxanne M
2017-02-08
Because managed care is increasingly prevalent in health care finance and delivery, it is important to ascertain its effects on health care quality relative to that of fee-for-service plans. Some stakeholders are concerned that basing gatekeeping, provider selection, and utilization management on cost may lower quality of care. To date, research on this topic has been inconclusive, largely because of variation in research methods and covariates. Patient age has been the only consistently evaluated outcome predictor. This study provides a comprehensive assessment of the association between managed care and inpatient mortality for Medicare and privately insured patients. A cross-sectional design was used to examine the association between managed care and inpatient mortality for four common inpatient conditions. Data from the 2009 Healthcare Cost and Utilization Project State Inpatient Databases for 11 states were linked to data from the American Hospital Association Annual Survey Database. Hospital discharges were categorized as managed care or fee for service. A phased approach to multivariate logistic modeling examined the likelihood of inpatient mortality when adjusting for individual patient and hospital characteristics and for county fixed effects. Results showed different effects of managed care for Medicare and privately insured patients. Privately insured patients in managed care had an advantage over their fee-for-service counterparts in inpatient mortality for acute myocardial infarction, stroke, pneumonia, and congestive heart failure; no such advantage was found for the Medicare managed care population. To the extent that the study showed a protective effect of privately insured managed care, it was driven by individuals aged 65 years and older, who had consistently better outcomes than their non-managed care counterparts. Privately insured patients in managed care plans, especially older adults, had better outcomes than those in fee-for-service plans. Patients in Medicare managed care had outcomes similar to those in Medicare FFS. Additional research is needed to understand the role of patient selection, hospital quality, and differences among county populations in the decreased odds of inpatient mortality among patients in private managed care and to determine why this result does not hold for Medicare.
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Using Computational Approaches to Improve Risk-Stratified Patient Management: Rationale and Methods
Stone, Bryan L; Sakaguchi, Farrant; Sheng, Xiaoming; Murtaugh, Maureen A
2015-01-01
Background Chronic diseases affect 52% of Americans and consume 86% of health care costs. A small portion of patients consume most health care resources and costs. More intensive patient management strategies, such as case management, are usually more effective at improving health outcomes, but are also more expensive. To use limited resources efficiently, risk stratification is commonly used in managing patients with chronic diseases, such as asthma, chronic obstructive pulmonary disease, diabetes, and heart disease. Patients are stratified based on predicted risk with patients at higher risk given more intensive care. The current risk-stratified patient management approach has 3 limitations resulting in many patients not receiving the most appropriate care, unnecessarily increased costs, and suboptimal health outcomes. First, using predictive models for health outcomes and costs is currently the best method for forecasting individual patient’s risk. Yet, accuracy of predictive models remains poor causing many patients to be misstratified. If an existing model were used to identify candidate patients for case management, enrollment would miss more than half of those who would benefit most, but include others unlikely to benefit, wasting limited resources. Existing models have been developed under the assumption that patient characteristics primarily influence outcomes and costs, leaving physician characteristics out of the models. In reality, both characteristics have an impact. Second, existing models usually give neither an explanation why a particular patient is predicted to be at high risk nor suggestions on interventions tailored to the patient’s specific case. As a result, many high-risk patients miss some suitable interventions. Third, thresholds for risk strata are suboptimal and determined heuristically with no quality guarantee. Objective The purpose of this study is to improve risk-stratified patient management so that more patients will receive the most appropriate care. Methods This study will (1) combine patient, physician profile, and environmental variable features to improve prediction accuracy of individual patient health outcomes and costs; (2) develop the first algorithm to explain prediction results and suggest tailored interventions; (3) develop the first algorithm to compute optimal thresholds for risk strata; and (4) conduct simulations to estimate outcomes of risk-stratified patient management for various configurations. The proposed techniques will be demonstrated on a test case of asthma patients. Results We are currently in the process of extracting clinical and administrative data from an integrated health care system’s enterprise data warehouse. We plan to complete this study in approximately 5 years. Conclusions Methods developed in this study will help transform risk-stratified patient management for better clinical outcomes, higher patient satisfaction and quality of life, reduced health care use, and lower costs. PMID:26503357
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Factors associated with integrating self-management support into primary care.
Crespo, Richard; Shrewsberry, Molly
2007-06-01
The purpose of this article is to expand the understanding of self-management support by describing factors that contribute to implementing a comprehensive self-management program in primary care. Four rural health centers in medically underserved areas participated in a study to document the implementation of a self-management program. This program consisted of a social marketing plan and decision-making tools to guide patients in making self-management behavior changes. The stages of change constructs of the transtheoretical model were used to design the social marketing plan. Key informant interviews were conducted at 6-month and 9-month intervals to document the implementation process. A standardized set of questions was used in the interviews. The data from the interviews were analyzed using content analysis techniques. One of the principle findings is that self-management support requires putting a system in place, not just adding a new component to primary care. The health centers that fully implemented the self-management program made an organizational commitment to keep self-management on the agenda in management meetings, clinical staff set the example by adopting self-management behaviors, and patient self-management support was implemented in multiple patient care venues. Primary care centers with limited financial resources are able to integrate self-management support into their system of chronic illness care.
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Healthcare reform: the role of coordinated critical care.
Cerra, F B
1993-03-01
To evaluate and editorialize the evolving role of the discipline of critical care as a healthcare delivery system in the process of healthcare reform. The sources included material from the Federal Office of Management and Budget, Health Care Financing Review, President Bush's Office, Association of American Medical Colleges, and publications of the Society of Critical Care Medicine. Data were selected that the author felt was relevant to the healthcare reform process and its implications for the discipline of critical care. The data were extracted by the author to illustrate the forces behind healthcare reform, the implications for the practice of critical care, and role of critical care as a coordinated (managed) care system in the process of healthcare reform. Healthcare reform has been initiated because of a number of considerations that arise in evaluating the current healthcare delivery system: access, financing, cost, dissatisfactions with the mechanisms of delivery, and political issues. The reform process will occur with or without the involvement of critical care practitioners. Reforms may greatly alter the delivery of critical care services, education, training, and research in critical care. Critical care has evolved into a healthcare delivery system that provides services to patients who need and request them and provides these services in a coordinated (managed) care model. Critical care practitioners must become involved in the healthcare reform process, and critical care services that are effective must be preserved, as must the education, training, and research programs. Critical care as a healthcare delivery system utilizing a coordinated (managed) care model has the potential to provide services to all patients who need them and to deliver them in a manner that is cost effective and recognized as providing added value.
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Workplace empowerment, collaborative work relationships, and job strain in nurse practitioners.
Almost, Joan; Laschinger, Heather K Spence
2002-09-01
To test a theoretical model linking nurse practitioners' (NPs) perceptions of workplace empowerment, collaboration with physicians and managers, and job strain. A predictive, nonexperimental design was used to test a model in a sample of 63 acute care NPs and 54 primary care NPs working in Ontario, Canada. The Conditions of Work Effectiveness Questionnaire, the Collaborative Behaviour Scale--Parts A (physicians) and B (managers), and the Job Content Questionnaire were used to measure the major study variables. The results of this study support the proposition that the extent to which NPs have access to information, support, resources, and opportunities in their work environment has an impact on the extent of collaboration with physicians and managers, and ultimately, the degree of job strain experienced in the work setting. Primary care NPs have significantly higher levels of workplace empowerment, collaboration with managers, and lower levels of job strain than acute care NPs. These findings will benefit NPs and nursing leaders in their efforts to create empowering work environments that enable NPs to provide excellent quality patient care and achieve organizational outcomes.
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EFFECT OF QUALITY CHRONIC DISEASE MANAGEMENT FOR ALCOHOL AND DRUG DEPENDENCE ON ADDICTION OUTCOMES
Kim, Theresa W.; Saitz, Richard; Cheng, Debbie M.; Winter, Michael R; Witas, Julie; Samet, Jeffrey H.
2012-01-01
We examinedthe effect ofthe quality of primary care-basedchronic disease management (CDM)for alcohol and/or other drug (AOD) dependenceonaddiction outcomes.We assessed qualityusing 1)avisit frequencybased measure and 2) a self-reported assessment measuring alignment with the chronic care model. The visit frequency based measure had no significant association with addiction outcomes. Theself-reported measure of care - when care was at a CDM clinic - was associated with lower drug addiction severity.The self-reported assessment of care from any healthcare source (CDM clinic or elsewhere)was associated with lower alcoholaddiction severity and abstinence.These findings suggest that high quality CDM for AOD dependence may improve addiction outcomes.Quality measuresbased upon alignment with the chronic care model may better capture features of effective CDM care than a visitfrequency measure. PMID:22840687
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Social Determinants of Health in Managed Care Payment Formulas.
Ash, Arlene S; Mick, Eric O; Ellis, Randall P; Kiefe, Catarina I; Allison, Jeroan J; Clark, Melissa A
2017-10-01
Managed care payment formulas commonly allocate more money for medically complex populations, but ignore most social determinants of health (SDH). To add SDH variables to a diagnosis-based payment formula that allocates funds to managed care plans and accountable care organizations. Using data from MassHealth, the Massachusetts Medicaid and Children's Health Insurance Program, we estimated regression models predicting Medicaid spending using a diagnosis-based and SDH-expanded model, and compared the accuracy of their cost predictions overall and for vulnerable populations. MassHealth members enrolled for at least 6 months in 2013 in fee-for-service (FFS) programs (n = 357 660) or managed care organizations (MCOs) (n = 524 607). We built cost prediction models from a fee-for-service program. Predictors in the diagnosis-based model are age, sex, and diagnoses from claims. The SDH model adds predictors describing housing instability, behavioral health issues, disability, and neighborhood-level stressors. Overall model explanatory power and overpayments and underpayments for subgroups of interest for all Medicaid-reimbursable expenditures excepting long-term support services (mean annual cost = $5590 per member). We studied 357 660 people who were FFS participants and 524 607 enrolled in MCOs with a combined 806 889 person-years of experience. The FFS program experience included more men (49.6% vs 43.6%), older patients (mean age of 26.1 years vs 21.6 years), and sicker patients (mean morbidity score of 1.16 vs 0.89) than MCOs. Overall, the SDH model performed well, but only slightly better than the diagnosis-based model, explaining most of the spending variation in the managed care population (validated R2 = 62.4) and reducing underpayments for several vulnerable populations. For example, raw costs for the quintile of people living in the most stressed neighborhoods were 9.6% ($537 per member per year) higher than average. Since greater medical morbidity accounts for much of this difference, the diagnosis-based model underpredicts costs for the most stressed quintile by about 2.1% ($130 per member per year). The expanded model eliminates the neighborhood-based underpayment, as well as underpayments of 72% for clients of the Department of Mental Health (observed costs of about $30 000 per year) and of 7% for those with serious mental illness (observed costs of about $16 000 per year). Since October 2016, MassHealth has used an expanded model to allocate payments from a prespecified total budget to managed care organizations according to their enrollees' social and medical risk. Extra payments for socially vulnerable individuals could fund activities, such as housing assistance, that could improve health equity.
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A service model for delivering care closer to home.
Dodd, Joanna; Taylor, Charlotte Elizabeth; Bunyan, Paul; White, Philippa Mary; Thomas, Siân Myra; Upton, Dominic
2011-04-01
Upton Surgery (Worcestershire) has developed a flexible and responsive service model that facilitates multi-agency support for adult patients with complex care needs experiencing an acute health crisis. The purpose of this service is to provide appropriate interventions that avoid unnecessary hospital admissions or, alternatively, provide support to facilitate early discharge from secondary care. Key aspects of this service are the collaborative and proactive identification of patients at risk, rapid creation and deployment of a reactive multi-agency team and follow-up of patients with an appropriate long-term care plan. A small team of dedicated staff (the Complex Care Team) are pivotal to coordinating and delivering this service. Key skills are sophisticated leadership and project management skills, and these have been used sensitively to challenge some traditional roles and boundaries in the interests of providing effective, holistic care for the patient.This is a practical example of early implementation of the principles underlying the Department of Health's (DH) recent Best Practice Guidance, 'Delivering Care Closer to Home' (DH, July 2008) and may provide useful learning points for other general practice surgeries considering implementing similar models. This integrated case management approach has had enthusiastic endorsement from patients and carers. In addition to the enhanced quality of care and experience for the patient, this approach has delivered value for money. Secondary care costs have been reduced by preventing admissions and also by reducing excess bed-days. The savings achieved have justified the ongoing commitment to the service and the staff employed in the Complex Care Team. The success of this service model has been endorsed recently by the 'Customer Care' award by 'Management in Practice'. The Surgery was also awarded the 'Practice of the Year' award for this and a number of other customer-focussed projects.
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Morales-Asencio, Jose M; Martin-Santos, Francisco J; Morilla-Herrera, Juan C; Fernández-Gallego, Magdalena Cuevas; Celdrán-Mañas, Miriam; Navarro-Moya, Francisco J; Rodríguez-Salvador, Maria M; Muñoz-Ronda, Francisco J; Gonzalo-Jiménez, Elena; Carrasco, Almudena Millán
2010-12-02
Chronic diseases account for nearly 60% of deaths around the world. The extent of this silent epidemic has not met determined responses in governments, policies or professionals in order to transform old Health Care Systems, configured for acute diseases. There is a large list of research about alternative models for people with chronic conditions, many of them with an advanced practice nurse as a key provider, as case management. But some methodological concerns raise, above all, the design of the intervention (intensity, frequency, components, etc). General: To develop the first and second phases (theorization and modeling) for designing a multifaceted case-management intervention in people with chronic conditions (COPD and heart failure) and their caregivers. 1) To identify key events in people living with chronic disease and their relation with the Health Care System, from their point of view. 2) To know the coping mechanisms developed by patients and their caregivers along the story with the disease. 3) To know the information processing and its utilization in their interactions with health care providers. 4) To detect potential unmet needs and the ways deployed by patients and their caregivers to resolve them. 5) To obtain a description from patients and caregivers, about their itineraries along the Health Care System, in terms of continuity, accessibility and comprehensiveness of care. 6) To build up a list of promising case-management interventions in patients with Heart Failure and COPD with this information in order to frame it into theoretical models for its reproducibility and conceptualization. 7) To undergo this list to expert judgment to assess its feasibility and pertinence in the Andalusian Health Care. Qualitative research with two phases: For the first five objectives, a qualitative technique with biographic stories will be developed and, for the remaining objectives, an expert consensus through Delphi technique, on the possible interventions yielded from the first phase. The study will be developed in the provinces of Almería, Málaga and Granada in the Southern Spain, from patients included in the Andalusian Health Care Service database with the diagnosis of COPD or Heart Failure, with the collaboration of case manager nurses and general practitioners for the assessment of their suitability to inclusion criteria. Patients and caregivers will be interviewed in their homes or their Health Centers, with their family or their case manager nurse as mediator. First of a series of studies intended to design a case-management service for people with heart failure and COPD, in the Andalusian Health Care System, where case management has been implemented since 2002. Accordingly with the steps of a theoretical model for complex interventions, in this study, theorization and intervention modeling phases will be developed.
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Case management considerations of progressive dementia in a home setting.
Pierce, Mary Ellen
2010-01-01
Nursing theory, research, and best practice guidelines contribute substantially to the field of dementia care. Interventional plans are challenged most by those dementias considered progressive and deteriorative in nature, requiring ongoing reassessment and modification of care practices as the clinical course changes. The purpose of this article is to provide guidelines for case managers in the development of effective, individualized care plans for clients with progressive dementia residing in a home setting. The application of these guidelines is illustrated through the presentation of an actual case. The practice setting is a private home in the Pacific Northwest. Geriatric case management is provided by an RN case manager. Progressive dementia presents challenges to home care. Professional case management using comprehensive, holistic assessment, collaborative approaches, and best practice fundamentals serve to create an effective, individualized plan of care. The increasing geriatric population presents great opportunities for case managers in strategic management for creating successful home care models in clients with progressive dementia. Use of nursing diagnoses, dementia research, and collaborative approaches with families and other medical providers creates a viable alternative for clients with progressive dementia.
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Swinehart, K; Zimmerer, T W; Oswald, S
1995-01-01
Industrial organizations have employed the process of strategic management in their attempts to cope effectively with global competitive pressures, while attempting to build and maintain competitive advantage. With health-care organizations presently trying to cope with an increasingly turbulent environment created by the uncertainty as to pending legislation and anticipated reform, the need for such organizational strategic planning is apparent. Presents and discusses a methodology for adapting a business-oriented model of strategic planning to health care.
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Team-Based Models for End-of-Life Care: An Evidence-Based Analysis
2014-01-01
Background End of life refers to the period when people are living with advanced illness that will not stabilize and from which they will not recover and will eventually die. It is not limited to the period immediately before death. Multiple services are required to support people and their families during this time period. The model of care used to deliver these services can affect the quality of the care they receive. Objectives Our objective was to determine whether an optimal team-based model of care exists for service delivery at end of life. In systematically reviewing such models, we considered their core components: team membership, services offered, modes of patient contact, and setting. Data Sources A literature search was performed on October 14, 2013, using Ovid MEDLINE, Ovid MEDLINE In-Process and Other Non-Indexed Citations, Ovid Embase, EBSCO Cumulative Index to Nursing & Allied Health Literature (CINAHL), and EBM Reviews, for studies published from January 1, 2000, to October 14, 2013. Review Methods Abstracts were reviewed by a single reviewer and full-text articles were obtained that met the inclusion criteria. Studies were included if they evaluated a team model of care compared with usual care in an end-of-life adult population. A team was defined as having at least 2 health care disciplines represented. Studies were limited to English publications. A meta-analysis was completed to obtain pooled effect estimates where data permitted. The GRADE quality of the evidence was evaluated. Results Our literature search located 10 randomized controlled trials which, among them, evaluated the following 6 team-based models of care: hospital, direct contact home, direct contact home, indirect contact comprehensive, indirect contact comprehensive, direct contact comprehensive, direct, and early contact Direct contact is when team members see the patient; indirect contact is when they advise another health care practitioner (e.g., a family doctor) who sees the patient. A “comprehensive” model is one that provides continuity of service across inpatient and outpatient settings, e.g., in hospital and then at home. All teams consisted of a nurse and physician at minimum, at least one of whom had a specialty in end-of-life health care. More than 50% of the teams offered services that included symptom management, psychosocial care, development of patient care plans, end-of-life care planning, and coordination of care. We found moderate-quality evidence that the use of a comprehensive direct contact model initiated up to 9 months before death improved informal caregiver satisfaction and the odds of having a home death, and decreased the odds of dying in a nursing home. We found moderate-quality evidence that the use of a comprehensive, direct, and early (up to 24 months before death) contact model improved patient quality of life, symptom management, and patient satisfaction. We did not find that using a comprehensive team-based model had an impact on hospital admissions or length of stay. We found low-quality evidence that the use of a home team-based model increased the odds of having a home death. Limitations Heterogeneity in data reporting across studies limited the ability to complete a meta-analysis on many of the outcome measures. Missing data was not managed well within the studies. Conclusions Moderate-quality evidence shows that a comprehensive, direct-contact, team-based model of care provides the following benefits for end-of-life patients with an estimated survival of up to 9 months: it improves caregiver satisfaction and increases the odds of dying at home while decreasing the odds of dying in a nursing home. Moderate-quality evidence also shows that improvement in patient quality of life, symptom management, and patient satisfaction occur when end-of-life care via this model is provided early (up to 24 months before death). However, using this model to deliver end-of-life care does not impact hospital admissions or hospital length of stay. Team membership includes at minimum a physician and nurse, with at least one having specialist training and/or experience in end-of-life care. Team services include symptom management, psychosocial care, development of patient care plans, end-of-life care planning, and coordination of care. PMID:26356140
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The role of peer support in diabetes care and self-management.
Brownson, Carol A; Heisler, Michele
2009-03-01
In light of the growing prevalence and healthcare costs of diabetes mellitus, it is critically important for healthcare providers to improve the efficiency and effectiveness of their diabetes care. A key element of effective disease management for diabetes is support for patient self-management. Barriers to care exist for both patients and healthcare systems. As a result, many people with diabetes do not get the care and support needed to successfully manage their diabetes.Disease management approaches that incorporate peer support may be a promising way to help provide self-management support to patients with diabetes. Trained peers provide emotional support, instrumental (tangible or material) support, education, and skills training to those they serve, and outreach and care coordination for provider systems. They play a unique role that complements and supports clinical care.To describe how peers are currently supporting diabetes care, a number of databases were searched for studies describing the roles of peers using relevant key words. This paper reviews current literature that describes the roles and duties of peers in interventions to improve diabetes care, with a focus on their contributions to six essential elements of self-management support: (i) access to regular, high-quality clinical care; (ii) an individualized approach to assessment and treatment; (iii) patient-centered collaborative goal setting; (iv) education and skills training; (v) ongoing follow-up and support; and (vi) linkages to community resources.Peers worked under a variety of titles, which did not define their duties. The scope of their work ranged from assisting health professionals to playing a central role in care. Providing education and follow-up support were the two most common roles. In all but one study, these roles were carried out during face-to-face contact, most frequently in community sites.A growing body of literature supports the value of peer models for diabetes management. Additional research can answer remaining questions related to such issues as cost effectiveness, sustainability, integration of peers into health and social service delivery systems, and recruitment, training, and support of peers. Continuing to develop and evaluate innovative models for more effectively mobilizing and integrating peers into diabetes care has great potential for improving diabetes outcomes worldwide.
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Kaptein, Ad A; Fischer, Maarten J; Scharloo, Margreet
2014-01-01
In this narrative review, we put self-management in the context of a 50-year history of research about how patients with COPD respond to their illness. We review a definition of self-management, and emphasize that self-management should be combined with disease management and the chronic care model in order to be effective. Reviewing the empirical status of self-management in COPD, we conclude that self-management is part and parcel of modern, patient-oriented biopsychosocial care. In pulmonary rehabilitation programs, self-management is instrumental in improving patients' functional status and quality of life. We conclude by emphasizing how studying the way persons with COPD make sense of their illness helps in refining self-management, and thereby patient-reported outcomes in COPD.
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Kaptein, Ad A; Fischer, Maarten J; Scharloo, Margreet
2014-01-01
In this narrative review, we put self-management in the context of a 50-year history of research about how patients with COPD respond to their illness. We review a definition of self-management, and emphasize that self-management should be combined with disease management and the chronic care model in order to be effective. Reviewing the empirical status of self-management in COPD, we conclude that self-management is part and parcel of modern, patient-oriented biopsychosocial care. In pulmonary rehabilitation programs, self-management is instrumental in improving patients’ functional status and quality of life. We conclude by emphasizing how studying the way persons with COPD make sense of their illness helps in refining self-management, and thereby patient-reported outcomes in COPD. PMID:25214777
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Barriers of access to care in a managed competition model: lessons from Colombia.
Vargas, Ingrid; Vázquez, María Luisa; Mogollón-Pérez, Amparo Susana; Unger, Jean-Pierre
2010-10-29
The health sector reform in Colombia, initiated by Law 100 (1993) that introduced a managed competition model, is generally presented as a successful experience of improving access to care through a health insurance regulated market. The study's objective is to improve our understanding of the factors influencing access to the continuum of care in the Colombian managed competition model, from the social actors' point of view. An exploratory, descriptive-interpretative qualitative study was carried out, based on case studies of four healthcare networks in rural and urban areas. Individual semi-structured interviews were conducted to a three stage theoretical sample: I) cases, II) providers and III) informants: insured and uninsured users (35), health professionals (51), administrative personnel (20), and providers' (18) and insurers' (10) managers. Narrative content analysis was conducted; segmented by cases, informant's groups and themes. Access, particularly to secondary care, is perceived as complex due to four groups of obstacles with synergetic effects: segmented insurance design with insufficient services covered; insurers' managed care and purchasing mechanisms; providers' networks structural and organizational limitations; and, poor living conditions. Insurers' and providers' values based on economic profit permeate all factors. Variations became apparent between the two geographical areas and insurance schemes. In the urban areas barriers related to market functioning predominate, whereas in the rural areas structural deficiencies in health services are linked to insufficient public funding. While financial obstacles are dominant in the subsidized regime, in the contributory scheme supply shortage prevails, related to insufficient private investment. The results show how in the Colombian healthcare system structural and organizational barriers to care access, that are common in developing countries, are widened by both the insurers' use of mechanisms that limit the utilization and the public healthcare providers' change of behavior in a competition environment. They provide evidence to question the promotion of the managed competition model in low and middle-income countries.
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Barriers of access to care in a managed competition model: lessons from Colombia
2010-01-01
Background The health sector reform in Colombia, initiated by Law 100 (1993) that introduced a managed competition model, is generally presented as a successful experience of improving access to care through a health insurance regulated market. The study's objective is to improve our understanding of the factors influencing access to the continuum of care in the Colombian managed competition model, from the social actors' point of view. Methods An exploratory, descriptive-interpretative qualitative study was carried out, based on case studies of four healthcare networks in rural and urban areas. Individual semi-structured interviews were conducted to a three stage theoretical sample: I) cases, II) providers and III) informants: insured and uninsured users (35), health professionals (51), administrative personnel (20), and providers' (18) and insurers' (10) managers. Narrative content analysis was conducted; segmented by cases, informant's groups and themes. Results Access, particularly to secondary care, is perceived as complex due to four groups of obstacles with synergetic effects: segmented insurance design with insufficient services covered; insurers' managed care and purchasing mechanisms; providers' networks structural and organizational limitations; and, poor living conditions. Insurers' and providers' values based on economic profit permeate all factors. Variations became apparent between the two geographical areas and insurance schemes. In the urban areas barriers related to market functioning predominate, whereas in the rural areas structural deficiencies in health services are linked to insufficient public funding. While financial obstacles are dominant in the subsidized regime, in the contributory scheme supply shortage prevails, related to insufficient private investment. Conclusions The results show how in the Colombian healthcare system structural and organizational barriers to care access, that are common in developing countries, are widened by both the insurers' use of mechanisms that limit the utilization and the public healthcare providers' change of behavior in a competition environment. They provide evidence to question the promotion of the managed competition model in low and middle-income countries. PMID:21034481
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Development of an asthma disease management program in a children's hospital.
Miller, Kelly; Ward-Smith, Peggy; Cox, Karen; Jones, Erika M; Portnoy, Jay M
2003-11-01
The incidence, morbidity, and mortality of asthma have been increasing at an alarming rate, making asthma the most common chronic illness of childhood. An asthma disease management program was developed to improve the care and management of patients with asthma--a comprehensive health care delivery model that was designed to improve the management of patients with asthma was designed and implemented. The goal of the program was to provide high-quality interventions for those children diagnosed with asthma. The asthma disease management program at Children's Mercy Hospital improved the care received, decreased costs, and improved the quality of life for those children with asthma.
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Organisational capacity and chronic disease care: an Australian general practice perspective.
Proudfoot, Judith; Infante, Fernando; Holton, Christine; Powell-Davies, Gawaine; Bubner, Tanya; Beilby, Justin; Harris, Mark
2007-04-01
Although we are rapidly improving our understanding of how to manage patients with chronic illness in Australian general practice, many patients are still receiving suboptimal care. General practices have limited organisational capacity to provide the structured care that is required for managing chronic conditions: regular monitoring, decision support, patient recall, supporting patient self management, team work, and information management. This requires a shift away from episodic, acute models. Overseas research has shown that areas such as team work, clinical information systems, decision support, linkages and leadership are also important in managing chronic illness, but we do not know which of these are most important in Australia.
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Should there be an expanded role for palliative care in end-stage renal disease?
Kurella Tamura, Manjula; Cohen, Lewis M
2010-11-01
In this review, we outline the rationale for expanding the role of palliative care in end-stage renal disease (ESRD), describe the components of a palliative care model, and identify potential barriers in implementation. Patients receiving chronic dialysis have reduced life expectancy and high rates of chronic pain, depression, cognitive impairment, and physical disability. Delivery of prognostic information and advance care planning are desired by patients, but occur infrequently. Furthermore, although hospice care is associated with improved symptom control and lower healthcare costs at the end of life, it is underutilized by the ESRD population, even among patients who withdraw from dialysis. A palliative care model incorporating communication of prognosis, advance care planning, symptom assessment and management, and timely hospice referral may improve quality of life and quality of dying. Resources and clinical practice guidelines are available to assist practitioners with incorporating palliative care into ESRD management. There is a large unmet need to alleviate the physical, psychosocial, and existential suffering of patients with ESRD. More fully integrating palliative care into ESRD management by improving end-of-life care training, eliminating structural and financial barriers to hospice use, and identifying optimal methods to deliver palliative care are necessary if we are to successfully address the needs of an aging ESRD population.
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2013-01-01
Background Self-management support is a key component of effective chronic care management, yet in practice appears to be the least implemented and most challenging. This study explores whether and how self-management support is integrated into chronic care approaches in 13 European countries. In addition, it investigates the level of and barriers to implementation of support strategies in health care practice. Methods We conducted a review among the 13 participating countries, based on a common data template informed by the Chronic Care Model. Key informants presented a sample of representative chronic care approaches and related self-management support strategies. The cross-country review was complemented by a Dutch case study of health professionals’ views on the implementation of self-management support in practice. Results Self-management support for chronically ill patients remains relatively underdeveloped in Europe. Similarities between countries exist mostly in involved providers (nurses) and settings (primary care). Differences prevail in mode and format of support, and materials used. Support activities focus primarily on patients’ medical and behavioral management, and less on emotional management. According to Dutch providers, self-management support is not (yet) an integral part of daily practice; implementation is hampered by barriers related to, among others, funding, IT and medical culture. Conclusions Although collaborative care for chronic conditions is becoming more important in European health systems, adequate self-management support for patients with chronic disease is far from accomplished in most countries. There is a need for better understanding of how we can encourage both patients and health care providers to engage in productive interactions in daily chronic care practice, which can improve health and social outcomes. PMID:23530744
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Schmidt, Barbara; Wenitong, Mark; Esterman, Adrian; Hoy, Wendy; Segal, Leonie; Taylor, Sean; Preece, Cilla; Sticpewich, Alex; McDermott, Robyn
2012-11-21
Prevalence and incidence of diabetes and other common comorbid conditions (hypertension, coronary heart disease, renal disease and chronic lung disease) are extremely high among Indigenous Australians. Recent measures to improve quality of preventive care in Indigenous community settings, while apparently successful at increasing screening and routine check-up rates, have shown only modest or little improvements in appropriate care such as the introduction of insulin and other scaled-up drug regimens in line with evidence-based guidelines, together with support for risk factor reduction. A new strategy is required to ensure high quality integrated family-centred care is available locally, with continuity and cultural safety, by community-based care coordinators with appropriate system supports. The trial design is open parallel cluster randomised controlled trial. The objective of this pragmatic trial is to test the effectiveness of a model of health service delivery that facilitates integrated community-based, intensive chronic condition management, compared with usual care, in rural and remote Indigenous primary health care services in north Queensland. Participants are Indigenous adults (aged 18-65 years) with poorly controlled diabetes (HbA1c>=8.5) and at least one other chronic condition. The intervention is to employ an Indigenous Health Worker to case manage the care of a maximum caseload of 30 participants. The Indigenous Health Workers receive intensive clinical training initially, and throughout the study, to ensure they are competent to coordinate care for people with chronic conditions. The Indigenous Health Workers, supported by the local primary health care (PHC) team and an Indigenous Clinical Support Team, will manage care, including coordinating access to multidisciplinary team care based on best practice standards. Allocation by cluster to the intervention and control groups is by simple randomisation after participant enrolment. Participants in the control group will receive usual care, and will be wait-listed to receive a revised model of the intervention informed by the data analysis. The primary outcome is reduction in HbA1c measured at 18 months. Implementation fidelity will be monitored and a qualitative investigation (methods to be determined) will aim to identify elements of the model which may influence health outcomes for Indigenous people with chronic conditions. This pragmatic trial will test a culturally-sound family-centred model of care with supported case management by IHWs to improve outcomes for people with complex chronic care needs. This trial is now in the intervention phase. Australian New Zealand Clinical Trials Registry ACTR12610000812099.
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Care Management in Germany and the U.S.: An Expanded Laboratory
Pittman, Patricia M.; Arnold, Sharon B.; Schlette, Sophia
2005-01-01
Germany and the U.S. share a keen interest in exploring the potential of care management programs for the chronically ill. Despite obvious health system differences, in both countries there has been a proliferation of disease management models, initiated by a variety of actors, paid for in different ways, targeting different types of population groups, and encompassing a broad menu of interventions and services. Comparison of three case studies from the U.S. and four from Germany reveals greater differences among models within countries than between them. PMID:17288074
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Lean business model and implementation of a geriatric fracture center.
Kates, Stephen L
2014-05-01
Geriatric hip fracture is a common event associated with high costs of care and often with suboptimal outcomes for the patients. Ideally, a new care model to manage geriatric hip fractures would address both quality and safety of patient care as well as the need for reduced costs of care. The geriatric fracture center model of care is one such model reported to improve both outcomes and quality of care. It is a lean business model applied to medicine. This article describes basic lean business concepts applied to geriatric fracture care and information needed to successfully implement a geriatric fracture center. It is written to assist physicians and surgeons in their efforts to implement an improved care model for their patients. Copyright © 2014 Elsevier Inc. All rights reserved.
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Managed care, vertical integration strategies and hospital performance.
Wang, B B; Wan, T T; Clement, J; Begun, J
2001-09-01
The purpose of this study is to examine the association of managed care with hospital vertical integration strategies, as well as to observe the relationships of different types of vertical integration with hospital efficiency and financial performance. The sample consists of 363 California short-term acute care hospitals in 1994. Linear structure equation modeling is used to test six hypotheses derived from the strategic adaptation model. Several organizational and market factors are controlled statistically. Results suggest that managed care is a driving force for hospital vertical integration. In terms of performance, hospitals that are integrated with physician groups and provide outpatient services (backward integration) have better operating margins, returns on assets, and net cash flows (p < 0.01). These hospitals are not, however, likely to show greater productivity. Forward integration with a long-term-care facility, on the other hand, is positively and significantly related to hospital productivity (p < 0.001). Forward integration is negatively related to financial performance (p < 0.05), however, opposite to the direction hypothesized. Health executives should be responsive to the growth of managed care in their local market and should probably consider providing more backward integrated services rather than forward integrated services in order to improve the hospital's financial performance in today's competitive health care market.
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Training Physicians in Palliative Care.
ERIC Educational Resources Information Center
Muir, J. Cameron; Krammer, Lisa M.; von Gunten, Charles F.
1999-01-01
Describes the elements of a program in hospice and palliative medicine that may serve as a model of an effective system of physician education. Topics for the palliative-care curriculum include hospice medicine, breaking bad news, pain management, the process of dying, and managing personal stress. (JOW)
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Siminerio, Linda; Ruppert, Kristine; Huber, Kimberly; Toledo, Fredrico G S
2014-01-01
The purpose of this study was to examine diabetes-related behavioral and psychosocial outcomes as well as patient satisfaction with the Telemedicine for Reach, Education, Access, and Treatment (TREAT) model. TREAT employs telemedicine services provided by an endocrinologist at an urban area in partnership with a diabetes educator in a rural area, working together with patients and primary care providers (PCPs). Thirty-five patients with type 2 diabetes were referred by PCPs and received glycemic management and education in the TREAT model. A diabetes educator operated the videoconferencing equipment, remained with the patient to receive and review plan communicated by the endocrinologist during the visit, coordinated services, administered surveys, and provided self-management education and support. Empowerment, self-care, diabetes distress, adherence to monitoring, and patient satisfaction were assessed by survey at baseline and follow-up. There was significant improvement in empowerment, self-care (adherence to diet and monitoring), and reduction in diabetes distress. Patients reported high levels of satisfaction. In rural areas, the TREAT model delivers improvements in behavioral and psychosocial outcomes and high patient satisfaction. The TREAT model may be a viable option for rural communities that suffer from a shortage of team-based diabetes specialist and self-management support services. © 2014 The Author(s).
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Results from a national survey on chronic care management by health plans.
Mattke, Soeren; Higgins, Aparna; Brook, Robert
2015-05-01
The growing burden of chronic disease necessitates innovative approaches to help patients and to ensure the sustainability of our healthcare system. Health plans have introduced chronic care management models, but systematic data on the type and prevalence of different approaches are lacking. Our goal was to conduct a systematic examination of chronic care management programs offered by health plans in the commercial market (ie, in products sold to employers and individuals. We undertook a national survey of a representative sample of health plans (70 plans, 36% response rate) and 6 case studies on health plans' programs to improve chronic care in the commercial market. The data underwent descriptive and bivariate analyses. All plans, regardless of size, location, and ownership, offer chronic care management programs, which identify eligible members from claims data and match them to interventions based on overall risk and specific care gaps. Plans then report information on care gaps to providers and offer self-management support to their members. While internal evaluations suggest that the interventions improve care and reduce cost, plans report difficulties in engaging members and providers. To overcome those obstacles, plans are integrating their programs into provider work flow, collaborating with providers on care redesign and leveraging patient support technologies. Our study shows that chronic care management programs have become a standard component of the overall approach used by health plans to manage the health of their members.
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The Norrtaelje model: a unique model for integrated health and social care in Sweden.
Bäck, Monica Andersson; Calltorp, Johan
2015-01-01
Many countries organise and fund health and social care separately. The Norrtaelje model is a Swedish initiative that transformed the funding and organisation of health and social care in order to better integrate care for older people with complex needs. In Norrtaelje model, this transformation made it possible to bringing the team together, to transfer responsibility to different providers, to use care coordinators, and to develop integrated pathways and plans around transitions in and out of hospital and from nursing homes to hospital. The Norrtaelje model operates in the context of the Swedish commitment to universal coverage and public programmes based on tax-funded resources that are pooled and redistributed to citizens on the basis of need. The experience of Norrtaelje model suggests that one way to promote integration of health and social care is to start with a transformation that aligns these two sectors in terms of high level organisation and funding. This transformation then enables the changes in operations and management that can be translated into changes in care delivery. This "top-down" approach must be in-line with national priorities and policies but ultimately is successful only if the culture, resource allocation and management are changed throughout the local system.
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The Trade-Offs of Developing a Case Management Model for Chronically Mentally Ill People.
ERIC Educational Resources Information Center
Belcher, John R.
1993-01-01
Addresses role of case management in care of chronically mentally ill persons. Notes that case management can be effective if designed so that services match client needs and service costs are measured accurately. Contends that profit-maximizing nature of U.S. health care system makes some form of capitation likely in design of case management…
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Care zoning in a psychiatric intensive care unit: strengthening ongoing clinical risk assessment.
Mullen, Antony; Drinkwater, Vincent; Lewin, Terry J
2014-03-01
To implement and evaluate the care zoning model in an eight-bed psychiatric intensive care unit and, specifically, to examine the model's ability to improve the documentation and communication of clinical risk assessment and management. Care zoning guides nurses in assessing clinical risk and planning care within a mental health context. Concerns about the varying quality of clinical risk assessment prompted a trial of the care zoning model in a psychiatric intensive care unit within a regional mental health facility. The care zoning model assigns patients to one of 3 'zones' according to their clinical risk, encouraging nurses to document and implement targeted interventions required to manage those risks. An implementation trial framework was used for this research to refine, implement and evaluate the impact of the model on nurses' clinical practice within the psychiatric intensive care unit, predominantly as a quality improvement initiative. The model was trialled for three months using a pre- and postimplementation staff survey, a pretrial file audit and a weekly file audit. Informal staff feedback was also sought via surveys and regular staff meetings. This trial demonstrated improvement in the quality of mental state documentation, and clinical risk information was identified more accurately. There was limited improvement in the quality of care planning and the documentation of clinical interventions. Nurses' initial concerns over the introduction of the model shifted into overall acceptance and recognition of the benefits. The results of this trial demonstrate that the care zoning model was able to improve the consistency and quality of risk assessment information documented. Care planning and evaluation of associated outcomes showed less improvement. Care zoning remains a highly applicable model for the psychiatric intensive care unit environment and is a useful tool in guiding nurses to carry out routine patient risk assessments. © 2013 John Wiley & Sons Ltd.
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Lane, S J; Sholapur, N S; Yeung, C H T; Iorio, A; Heddle, N M; Sholzberg, M; Pai, M
2016-07-01
Care for persons with haemophilia (PWH) is most commonly delivered through the integrated care model used by Hemophilia Treatment Centers (HTCs). Although this model is widely accepted as the gold standard for the management of haemophilia; there is little evidence comparing different care models. We performed a qualitative study to gain insight into issues related to outcomes, acceptability, equity and feasibility of different care models operating in the US. We used a qualitative descriptive approach with semi-structured interviews. Purposive sampling was used to recruit individuals with experience providing or receiving care for haemophilia in the US through either an integrated care centre, a specialty pharmacy or homecare company, or by a specialist in a non-specialized centre. Persons with haemophilia, parents of PWH aged ≤18, healthcare providers, insurance company representatives and policy developers were invited to participate. Twenty-nine interviews were conducted with participants representing 18 US states. Participants in the study sample had experience receiving or providing care predominantly within an HTC setting. Integrated care at HTCs was highly acceptable to participants, who appreciated the value of specialized, expert care in a multidisciplinary team setting. Equity and feasibility issues were primarily related to health insurance and funding limitations. Additional research is required to document the impact of care on health and psychosocial outcomes and identify effective ways to facilitate equitable access to haemophilia treatment and care. © 2016 John Wiley & Sons Ltd.
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Removing barriers to care among persons with psychiatric symptoms.
Mechanic, David
2002-01-01
Many persons with serious psychiatric conditions who could benefit from available treatments do not receive care, and the barriers are generally understood to be limited knowledge, inadequacies in insurance coverage, and stigma. Sophisticated approaches are needed to realistically eliminate these and other barriers. Public policy should focus on criteria for need for care and encourage interventions that facilitate treatment when it can be helpful. Appropriate insurance coverage is indispensable, and achieving mental health parity will require careful management of care. Policymakers must help to create a trustworthy management structure that is inclusive, that develops and disseminates models of best practice, that encourages evidence-based decision processes, and that ensures continuing dialogue and procedural fairness in managed care decision making.
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Devoe, L D
1997-08-01
Managed care has marched relentlessly through all fields of obstetric care: individual and group practices, proprietary hospitals and academic medical centers, and public health systems. Emphasis on cost containment while preserving high quality has driven the redesign of healthcare delivery. A number of models for providing effective and less expensive obstetric care are now being examined in the USA and abroad. Increased market penetration by managed care will also exert profound and possibly harmful effects on traditional academic teaching institutions. These organizations must adapt to this new environment or face the erosion of physician support and training bases. Ultimately, significant moral and ethical dilemmas will arise when patients' best interests for care are being continually brought into conflict with the physician's need to earn a living.
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Restructuring VA ambulatory care and medical education: the PACE model of primary care.
Cope, D W; Sherman, S; Robbins, A S
1996-07-01
The Veterans Health Administration (VHA) Western Region and associated medical schools formulated a set of recommendations for an improved ambulatory health care delivery system during a 1988 strategic planning conference. As a result, the Department of Veterans Affairs (VA) Medical Center in Sepulveda, California, initiated the Pilot (now Primary) Ambulatory Care and Education (PACE) program in 1990 to implement and evaluate a model program. The PACE program represents a significant departure from traditional VA and non-VA academic medical center care, shifting the focus of care from the inpatient to the outpatient setting. From its inception, the PACE program has used an interdisciplinary team approach with three independent global care firms. Each firm is interdisciplinary in composition, with a matrix management structure that expands role function and empowers team members. Emphasis is on managed primary care, stressing a biopsychosocial approach and cost-effective comprehensive care emphasizing prevention and health maintenance. Information management is provided through a network of personal computers that serve as a front end to the VHA Decentralized Hospital Computer Program (DHCP) mainframe. In addition to providing comprehensive and cost-effective care, the PACE program educates trainees in all health care disciplines, conducts research, and disseminates information about important procedures and outcomes. Undergraduate and graduate trainees from 11 health care disciplines rotate through the PACE program to learn an integrated approach to managed ambulatory care delivery. All trainees are involved in a problem-based approach to learning that emphasizes shared training experiences among health care disciplines. This paper describes the transitional phases of the PACE program (strategic planning, reorganization, and quality improvement) that are relevant for other institutions that are shifting to training programs emphasizing primary and ambulatory care.
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The mapping competences of the nurse Case/Care Manager in the context of Intensive Care.
Alfieri, Emanuela; Ferrini, Anna Chiara; Gianfrancesco, Francesca; Lise, Gianluca; Messana, Giovanni; Tirelli, Lorenzo; Lorenzo, Ana; Sarli, Leopoldo
2017-03-15
Since the recent introduction of the Case/Care Manager's professional figure, it is quite difficult to identify properly his/her own particular features, which could be mainly be found revising mainly in American studies. Therefore, the present study intended to identify the Case/Care Manager's skills and professional profile in an Intensive Care Unit experience, taking into consideration the staff's activities, perception and expectations towards the Case/Care Manager. In particular, it has been compared the experience of an Intensive Care Units where the Case/Care Manager's profile is operational to a different Unit where a Case/Care Manager is not yet in force. a Levati's model was used to map the Case/Care Manager's skills, involving each unit whole working staff, executives and caregivers through semi-structured interviews. It has been taken into consideration the Anaesthesia Unit and Emergency Unit of Cesena's healthcare organisation (AUSL of Romagna) and a Cardiology Intensive Care Unit of Piacenza's healthcare organisation, where the Case/Care Manager's profile has not been experimented yet. Firstly, it a data collection in each healthcare organization has been organised. Subsequently, semi-structured interviews to doctors, unit nurses, caregivers, nurses' coordinators and medical staff have been used to compare each healthcare system. The interviewees' described their expectations in relation to the Case/Care Manager working in a critical area. Then, every data collected during interviews has been organised to map a Case/Care Manager's essential professional profile to work in a critical area together with medical staff. Piacenza's O.U. critical area experience reported a major demand for patients' and patient's families' assistance. On the other hand, the very same aspects seem to have been better achieved in Cesena's O.U., where a Case/Care Manager's recent introduction has actually helped to overcome the void in organising systems. a Case/Care Manager's profile has been drafted on the basis of the comparative analysis conducted. It has been noted how the Case/Care Manager's professional profile can really improve relationships and communications between medical staff and patients, promoting a major unity among the working team. According to the present research, the Case/Care Manager's profile has been proved helpful in positively influencing the team activity and to elicit major satisfaction both in patients and their family.
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Anatomy of health care reform proposals.
Soffel, D; Luft, H S
1993-01-01
The current proliferation of proposals for health care reform makes it difficult to sort out the differences among plans and the likely outcome of different approaches to reform. The current health care system has two basic features. The first, enrollment and eligibility functions, includes how people get into the system and gain coverage for health care services. We describe 4 models, ranging from an individual, voluntary approach to a universal, tax-based model. The second, the provision of health care, includes how physician services are organized, how they are paid for, what mechanisms are in place for quality assurance, and the degree of organization and oversight of the health care system. We describe 7 models of the organization component, including the current fee-for-service system with no national health budget, managed care, salaried providers under a budget, and managed competition with and without a national health budget. These 2 components provide the building blocks for health care plans, presented as a matrix. We also evaluate several reform proposals by how they combine these 2 elements. PMID:8273344
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Ten years of integrated care for the older in France
Somme, Dominique; de Stampa, Matthieu
2011-01-01
Background This paper analyzes progress made toward the integration of the French health care system for the older and chronically ill population. Policies Over the last 10 years, the French health care system has been principally influenced by two competing linkage models that failed to integrate social and health care services: local information and coordination centers, governed by the social field, and the gerontological health networks governed by the health field. In response to this fragmentation, Homes for the Integration and Autonomy for Alzheimer patients (MAIAs) is currently being implemented at experimental sites in the French national Alzheimer plan, using an evidence-based model of integrated care. In addition, the state’s reforms recently created regional health agencies (ARSs) by merging seven strategic institutions to manage the overall delivery of care. Conclusion The French health care system is moving from a linkage-based model to a more integrated care system. We draw some early lessons from these changes, including the importance of national leadership and governance and a change management strategy that uses both top-down and bottom-up approaches to implement these reforms. PMID:22375101
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"They don't want anything to do with you": patient views of primary care management of chronic pain.
Upshur, Carole C; Bacigalupe, Gonzalo; Luckmann, Roger
2010-12-01
Chronic pain is one of the most frequent complaints of patients in primary care, yet both patients and providers report low satisfaction with chronic pain care. This study was designed to explore the views held by a diverse sample of patients with chronic pain complaints about their care experiences to identify ways to improve care. Qualitative analysis of 17 patient focus groups (size 3-7 participants). Groups used structured questions and were tape recorded, transcribed, and coded using qualitative software. Eleven groups were conducted in English, six groups in Spanish. Convenience sample of 72 adult patients (68% female, 44% Latino, mean age=48.1 years) recruited from four diverse primary care practices in Central Massachusetts. Across all 17 groups, and all gender, ethnicity, and age groups, most patients reported suboptimal interactions with their providers when seeking care for chronic pain. Subjects acknowledged feeling disrespected and distrusted, suspected of drug-seeking, and having their symptoms dismissed as trivial and/or not warranting medical care. Patients reported more satisfaction when they felt a provider listened to them, trusted them, was accessible to address pain concerns between visits, and used patient-centered approaches to establish goals and treatment plans. Patients also recommended some management techniques related to the chronic disease management model to improve pain care. Implementing patient-centered approaches in caring for individuals with chronic pain and using principles drawn from the chronic disease management model to improve care systems may improve both patient and provider satisfaction with chronic pain care. Wiley Periodicals, Inc.
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ICT use for information management in healthcare system for chronic disease patient
NASA Astrophysics Data System (ADS)
Wawrzyniak, Zbigniew M.; Lisiecka-Biełanowicz, Mira
2013-10-01
Modern healthcare systems are designed to fulfill needs of the patient, his system environment and other determinants of the treatment with proper support of technical aids. A whole system of care is compatible to the technical solutions and organizational framework based on legal rules. The purpose of this study is to present how can we use Information and Communication Technology (ICT) systemic tools in a new model of patient-oriented care, improving the effectiveness of healthcare for patients with chronic diseases. The study material is the long-term process of healthcare for patients with chronic illness. Basing on the knowledge of the whole circumstances of patient's ecosystem and his needs allow us to build a new ICT model of long term care. The method used is construction, modeling and constant improvement the efficient ICT layer for the patient-centered healthcare model. We present a new constructive approach to systemic process how to use ICT for information management in healthcare system for chronic disease patient. The use of ICT tools in the model for chronic disease can improve all aspects of data management and communication, and the effectiveness of long-term complex healthcare. In conclusion: ICT based model of healthcare can be constructed basing on the interactions of ecosystem's functional parts through information feedback and the provision of services and models as well as the knowledge of the patient itself. Systematic approach to the model of long term healthcare assisted functionally by ICT tools and data management methods will increase the effectiveness of patient care and organizational efficiency.
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Khullar, Dhruv; Rao, Sandhya K; Chaguturu, Sreekanth K; Rajkumar, Rahul
2016-06-01
New healthcare delivery models, including accountable care organizations (ACOs) and patient-centered medical homes, emphasize a more robust role for primary care. However, it is less clear how the roles and responsibilities of subspecialists should change as we enter a new paradigm of alternative payment models. Health systems seeking to better manage population health and control costs will need a clearer understanding of how best to incorporate subspecialty practitioners: What is a subspecialist's role? How does it vary by subspecialty? How should they be compensated? We argue that subspecialist compensation in ACOs and other new care delivery models should recognize the range of ways in which specialists can provide value to patients across a population-which varies depending on the provider's role in a patient's care. Only by more thoughtfully engaging, equipping, and compensating subspecialty practitioners can we achieve reform's central goal of better population health at a lower cost.
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2014-01-01
Background The intent of adopting managed care plans is to improve access to health care services while containing costs. To date, there have been a number of studies that examine the relationship between managed care and access to health care. However, the results from previous studies have been inconsistent. Specifically, previous studies did not demonstrate a clear benefit of Medicaid managed care. In this study we have examine whether Medicaid managed care is associated with the probabilities of preventable hospitalizations. This study also analyzes the spillover effect of Medicaid managed care into Medicaid patients in traditional FFS plans and the interaction effects of other patient- and county-level variables on preventable hospitalizations. Methods The study included 254,321 Medicaid patients who were admitted to short-term general hospital in the 67 counties in Florida. Using 2008 hospital inpatient discharge data for working-age adult Medicaid enrollees (18-64 years) in Florida, we conduct multivariate logistic regression analyses to identify possible factors associated with preventable hospitalizations. The first model includes patient- and county-level variables. Then, we add interaction terms between Medicaid HMO and other variables such as race, rurality, market-level factors, and resource for primary care. Results The results show that Medicaid HMO patients are more likely to be hospitalized for ambulatory care sensitive conditions (ACSCs) (OR = 1.30; CI = 1.21, 1.40). We also find that market structure (i.e., competition) is significantly associated with preventable hospitalizations. However, our study does not support that there are spillover effects of Medicaid managed care on preventable hospitalizations for other Medicaid recipients. We find that interactions between Medicaid managed care and race, rurality and market structure are significant. Conclusions The results of our study show that the Medicaid managed care program in Florida was associated with an increase in potentially preventable hospitalizations for Medicaid enrollees. The results suggest that lower capitation rate has been associated with a greater likelihood of preventable hospitalizations for Medicaid managed care patients. Our findings also indicate that increased competition in the Medicaid managed care market has no clear benefit in Medicaid managed care patients. PMID:24916077
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In Search of Joy in Practice: A Report of 23 High-Functioning Primary Care Practices
Sinsky, Christine A.; Willard-Grace, Rachel; Schutzbank, Andrew M.; Sinsky, Thomas A.; Margolius, David; Bodenheimer, Thomas
2013-01-01
We highlight primary care innovations gathered from high-functioning primary care practices, innovations we believe can facilitate joy in practice and mitigate physician burnout. To do so, we made site visits to 23 high-performing primary care practices and focused on how these practices distribute functions among the team, use technology to their advantage, improve outcomes with data, and make the job of primary care feasible and enjoyable as a life’s vocation. Innovations identified include (1) proactive planned care, with previsit planning and previsit laboratory tests; (2) sharing clinical care among a team, with expanded rooming protocols, standing orders, and panel management; (3) sharing clerical tasks with collaborative documentation (scribing), nonphysician order entry, and streamlined prescription management; (4) improving communication by verbal messaging and in-box management; and (5) improving team functioning through co-location, team meetings, and work flow mapping. Our observations suggest that a shift from a physician-centric model of work distribution and responsibility to a shared-care model, with a higher level of clinical support staff per physician and frequent forums for communication, can result in high-functioning teams, improved professional satisfaction, and greater joy in practice. PMID:23690328
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Jacob, Verughese; Chattopadhyay, Sajal K; Sipe, Theresa Ann; Thota, Anilkrishna B; Byard, Guthrie J; Chapman, Daniel P
2012-05-01
Major depressive disorders are frequently underdiagnosed and undertreated. Collaborative Care models developed from the Chronic Care Model during the past 20 years have improved the quality of depression management in the community, raising intervention cost incrementally above usual care. This paper assesses the economic efficiency of collaborative care for management of depressive disorders by comparing its economic costs and economic benefits to usual care, as informed by a systematic review of the literature. The economic review of collaborative care for management of depressive disorders was conducted in tandem with a review of effectiveness, under the guidance of the Community Preventive Services Task Force, a nonfederal, independent group of public health leaders and experts. Economic review methods developed by the Guide to Community Preventive Services were used by two economists to screen, abstract, adjust, and summarize the economic evidence of collaborative care from societal and other perspectives. An earlier economic review that included eight RCTs was included as part of the evidence. The present economic review expanded the evidence with results from studies published from 1980 to 2009 and included both RCTs and other study designs. In addition to the eight RCTs included in the earlier review, 22 more studies of collaborative care that provided estimates for economic outcomes were identified, 20 of which were evaluations of actual interventions and two of which were based on models. Of seven studies that measured only economic benefits of collaborative care in terms of averted healthcare or productivity loss, four found positive economic benefits due to intervention and three found minimal or no incremental benefit. Of five studies that measured both benefits and costs, three found lower collaborative care cost because of reduced healthcare utilization or enhanced productivity, and one found the same for a subpopulation of the intervention group. One study found that willingness to pay for collaborative care exceeded program costs. Among six cost-utility studies, five found collaborative care was cost effective. In two modeled studies, one showed cost effectiveness based on comparison of $/disability-adjusted life-year to annual per capita income; the other demonstrated cost effectiveness based on the standard threshold of $50,000/quality-adjusted life year, unadjusted for inflation. Finally, six of eight studies in the earlier review reported that interventions were cost effective on the basis of the standard threshold. The evidence indicates that collaborative care for management of depressive disorders provides good economic value. Published by Elsevier Inc.
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Capitated risk-bearing managed care systems could improve end-of-life care.
Lynn, J; Wilkinson, A; Cohn, F; Jones, S B
1998-03-01
Capitated or salaried managed care systems offer an important opportunity to provide high quality, cost-effective end-of-life care. However, capitated healthcare delivery systems have strong incentives to avoid patient populations in need of such care. Care currently provided at the end of life in fee-for-service practice is commonly deficient, with high rates of avoidable pain and other burdens. Only hospice offers a better track record, yet access to hospice is limited, and length of stay is short. Traditional staff- or group-model managed care plans, with their emphasis on prevention, patient education, cost efficiency, service coordination, and integrated provider networks, present a dynamic set of conditions and organizational structures that would support real change. Advantages derived from managed care systems providing quality end-of-life care include coordinated care across delivery sites, interdisciplinary teams, integrated services, and opportunities to develop innovative care programs, service arrays, utilization controls, and accountability for care standards. We propose a special comprehensive system of managed care, which we call MediCaring, for seriously ill persons nearing the end of life. MediCaring would encompass the best elements of palliative care within a managed care structure: comprehensive, supportive, community-based services that meet personal and medical needs, a focus on patient preferences, symptom management, family counseling, and support. Other programs, such as hospice, have shown that continuity and coordinated care, financed through a capitated payment and directed at a special population, are both feasible and effective. There are obstacles to improving care at the end of life. Managed care systems, like most of medical care, have largely ignored the terminally ill patient. Current financing arrangements make it financially undesirable for insurers to recruit or retain the very sick; very ill patients can be costly over a prolonged time. In addition, inertia and habit inhibit change, and there are few criteria by which to judge whether care at the end-of-life is "good." Nevertheless, capitated or salaried managed care systems committed to enhanced end-of-life care seem well positioned to achieve it if payment reimbursements were revised to encourage this end.
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Self-management in palliative medicine.
Davidson, Isobel; Whyte, Fiona; Richardson, Rosemary
2012-12-01
Self-management in the palliative care domain means equipping patients and carers to manage medical aspects of illness, managing life roles and allowing adaptation to the changing dynamics brought on by illness and its progression. As well as dealing with the psychological consequences of living with a life-threatening illness in which the aim is to optimise living. This review will consider the rationale for developing and adopting self-management as a model of care. Health policy currently advocates de-investment in traditional approaches to patient management paralleled with a re-engineering of services towards approaches required to underpin self-management care. However, the literature suggests that patients lack a fundamental knowledge and more importantly an understanding of the progression of their illness or what palliative of hospice care is. As a first step, this issue must be addressed in any self-management intervention. In terms of outcomes evidence continues to emerge that when compared with care self-management imparts sustainable understanding in targeted areas and has the potential to create a preventive spend environment. The role of self-management in palliative care requires further elucidation yet based on the evidence which is predominately gleaned from long-term conditions it would seem sensible if not ethical to educate patients/carers to actively be involved in decision making.
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Is managed care restraining the adoption of technology by hospitals?
Mas, Núria; Seinfeld, Janice
2008-07-01
As health care costs increase, cost-control mechanisms become more widespread and it is crucial to understand their implications for the health care market. This paper examines the effect that managed care activity (based on the aim to control health care expenditure) has on the adoption of technologies by hospitals. We use a hazard rate model to investigate whether higher levels of managed care market share are associated with a decrease on medical technology adoption during the period 1982-1995. We analyze annual data on 5390 US hospitals regarding the adoption of 13 different technologies. Our results are threefold: first, we find that managed care has a negative effect on hospitals' technology acquisition for each of the 13 medical technologies in our study, and its effect is stronger for those technologies diffusing in the 1990s, when the managed care sector is at its largest. If managed care enrollment had remained at its 1984 level, there would be 5.3%, 7.3% and 4.1% more hospitals with diagnostic radiology, radiation therapy and cardiac technologies, respectively. Second, we find that the rise in managed care leads to long-term reductions in medical cost growth. Finally, we take into account that profitability analysis is one of the main dimensions considered by hospitals when deciding about the adoption of new technologies. In order to determine whether managed care affects technologies differently if they have a different cost-reimbursement ratio (CRR), we have created a unique data set with information on the cost-reimbursement for each of the 13 technologies and we find that managed care enrollment has a considerably larger negative effect on the adoption of less profitable technologies.
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Individualising Chronic Care Management by Analysing Patients' Needs - A Mixed Method Approach.
Timpel, P; Lang, C; Wens, J; Contel, J C; Gilis-Januszewska, A; Kemple, K; Schwarz, P E
2017-11-13
Modern health systems are increasingly faced with the challenge to provide effective, affordable and accessible health care for people with chronic conditions. As evidence on the specific unmet needs and their impact on health outcomes is limited, practical research is needed to tailor chronic care to individual needs of patients with diabetes. Qualitative approaches to describe professional and informal caregiving will support understanding the complexity of chronic care. Results are intended to provide practical recommendations to be used for systematic implementation of sustainable chronic care models. A mixed method study was conducted. A standardised survey (n = 92) of experts in chronic care using mail responses to open-ended questions was conducted to analyse existing chronic care programs focusing on effective, problematic and missing components. An expert workshop (n = 22) of professionals and scientists of a European funded research project MANAGE CARE was used to define a limited number of unmet needs and priorities of elderly patients with type 2 diabetes mellitus and comorbidities. This list was validated and ranked using a multilingual online survey (n = 650). Participants of the online survey included patients, health care professionals and other stakeholders from 56 countries. The survey indicated that current care models need to be improved in terms of financial support, case management and the consideration of social care. The expert workshop identified 150 patient needs which were summarised in 13 needs dimensions. The online survey of these pre-defined dimensions revealed that financial issues, education of both patients and professionals, availability of services as well as health promotion are the most important unmet needs for both patients and professionals. The study uncovered competing demands which are not limited to medical conditions. The findings emphasise that future care models need to focus stronger on individual patient needs and promote their active involvement in co-design and implementation. Future research is needed to develop new chronic care models providing evidence-based and practical implications for the regional care setting.
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Allen, Kyle R; Hazelett, Susan E; Radwany, Steven; Ertle, Denise; Fosnight, Susan M; Moore, Pamela S
2012-04-01
Practice guidelines are available for hospice and palliative medicine specialists and geriatricians. However, these guidelines do not adequately address the needs of patients who straddle the 2 specialties: homebound chronically ill patients. The purpose of this article is to describe the theoretical basis for the Promoting Effective Advance Care for Elders (PEACE) randomized pilot study. PEACE is an ongoing 2-group randomized pilot study (n=80) to test an in-home interdisciplinary care management intervention that combines palliative care approaches to symptom management, psychosocial and emotional support, and advance care planning with geriatric medicine approaches to optimizing function and addressing polypharmacy. The population comprises new enrollees into PASSPORT, Ohio's community-based, long-term care Medicaid waiver program. All PASSPORT enrollees have geriatric/palliative care crossover needs because they are nursing home eligible. The intervention is based on Wagner's Chronic Care Model and includes comprehensive interdisciplinary care management for these low-income frail elders with chronic illnesses, uses evidence-based protocols, emphasizes patient activation, and integrates with community-based long-term care and other community agencies. Our model, with its standardized, evidence-based medical and psychosocial intervention protocols, will transport easily to other sites that are interested in optimizing outcomes for community-based, chronically ill older adults. © Mary Ann Liebert, Inc.
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Gallardo-Rincón, Héctor; Saucedo-Martínez, Rodrigo; Mujica-Rosales, Ricardo; Lee, Evan M; Israel, Amy; Torres-Beltran, Braulio; Quijano-González, Úrsula; Atkinson, Elena Rose; Kuri-Morales, Pablo; Tapia-Conyer, Roberto
2017-01-01
The purpose of this study is to evaluate how the benefits of online continuing medical education (CME) provided to health care professionals traveled along a patient "educational chain". In this study, the educational chain begins with the influence that CME can have on the quality of health care, with subsequent influence on patient knowledge, disease self-management, and disease biomarkers. A total of 422 patients with at least one noncommunicable disease (NCD) treated in eight different Mexican public health clinics were followed over 3 years. All clinics were participants in the CASALUD Model, an NCD care model for primary care, where all clinic staff were offered CME. Data were collected through a questionnaire on health care, patient disease knowledge, and self-management behaviors; blood samples and anthropometric measurements were collected to measure patient disease biomarkers. Between 2013 and 2015, the indexes measuring quality of health care, patient health knowledge, and diabetes self-management activities rose moderately but significantly (from 0.54 to 0.64, 0.80 to 0.84, and 0.62 to 0.67, respectively). Performing self-care activities - including owning and using a glucometer and belonging to a disease support group - saw the highest increase (from 0.65 to 0.75). A1C levels increased between 2013 and 2015 from 7.95 to 8.41% (63-68 mmol/mol) ( P <0.001), and blood pressure decreased between 2014 and 2015 from 143.7/76.8 to 137.5/74.4 (systolic/diastolic reported in mmHg) ( P <0.001). The mean levels of other disease biomarkers remained statistically unchanged, despite the improvements seen in the previous "links" of the educational chain. Online CME can effect certain changes in the educational chain linking quality of health care, patient knowledge, and self-management behaviors. However, in order to assure adequate NCD control, the entire health care system must be improved in tandem. Online CME programs, such as CASALUD's, are feasible strategies for impacting changes in disease self-management at a clinic level throughout a country.
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Gallardo-Rincón, Héctor; Saucedo-Martínez, Rodrigo; Mujica-Rosales, Ricardo; Lee, Evan M; Israel, Amy; Torres-Beltran, Braulio; Quijano-González, Úrsula; Atkinson, Elena Rose; Kuri-Morales, Pablo; Tapia-Conyer, Roberto
2017-01-01
Purpose The purpose of this study is to evaluate how the benefits of online continuing medical education (CME) provided to health care professionals traveled along a patient “educational chain”. In this study, the educational chain begins with the influence that CME can have on the quality of health care, with subsequent influence on patient knowledge, disease self-management, and disease biomarkers. Methods A total of 422 patients with at least one noncommunicable disease (NCD) treated in eight different Mexican public health clinics were followed over 3 years. All clinics were participants in the CASALUD Model, an NCD care model for primary care, where all clinic staff were offered CME. Data were collected through a questionnaire on health care, patient disease knowledge, and self-management behaviors; blood samples and anthropometric measurements were collected to measure patient disease biomarkers. Results Between 2013 and 2015, the indexes measuring quality of health care, patient health knowledge, and diabetes self-management activities rose moderately but significantly (from 0.54 to 0.64, 0.80 to 0.84, and 0.62 to 0.67, respectively). Performing self-care activities – including owning and using a glucometer and belonging to a disease support group – saw the highest increase (from 0.65 to 0.75). A1C levels increased between 2013 and 2015 from 7.95 to 8.41% (63–68 mmol/mol) (P<0.001), and blood pressure decreased between 2014 and 2015 from 143.7/76.8 to 137.5/74.4 (systolic/diastolic reported in mmHg) (P<0.001). The mean levels of other disease biomarkers remained statistically unchanged, despite the improvements seen in the previous “links” of the educational chain. Conclusion Online CME can effect certain changes in the educational chain linking quality of health care, patient knowledge, and self-management behaviors. However, in order to assure adequate NCD control, the entire health care system must be improved in tandem. Online CME programs, such as CASALUD’s, are feasible strategies for impacting changes in disease self-management at a clinic level throughout a country. PMID:29089779
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Twelve evidence-based principles for implementing self-management support in primary care.
Battersby, Malcolm; Von Korff, Michael; Schaefer, Judith; Davis, Connie; Ludman, Evette; Greene, Sarah M; Parkerton, Melissa; Wagner, Edward H
2010-12-01
Recommendations to improve self-management support and health outcomes for people with chronic conditions in primary care settings are provided on the basis of expert opinion supported by evidence for practices and processes. Practices and processes that could improve self-management support in primary care were identified through a nominal group process. In a targeted search strategy, reviews and meta-analyses were then identifed using terms from a wide range of chronic conditions and behavioral risk factors in combination with Self-Care, Self-Management, and Primary Care. On the basis of these reviews, evidence-based principles for self-management support were developed. The evidence is organized within the framework of the Chronic Care Model. Evidence-based principles in 12 areas were associated with improved patient self-management and/or health outcomes: (1) brief targeted assessment, (2) evidence-based information to guide shared decision-making, (3) use of a nonjudgmental approach, (4) collaborative priority and goal setting, (5) collaborative problem solving, (6) self-management support by diverse providers, (7) self-management interventions delivered by diverse formats, (8) patient self-efficacy, (9) active followup, (10) guideline-based case management for selected patients, (11) linkages to evidence-based community programs, and (12) multifaceted interventions. A framework is provided for implementing these principles in three phases of the primary care visit: enhanced previsit assessment, a focused clinical encounter, and expanded postvisit options. There is a growing evidence base for how self-management support for chronic conditions can be integrated into routine health care.
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Chiêm, Jean-Christophe; Van Durme, Thérèse; Vandendorpe, Florence; Schmitz, Olivier; Speybroeck, Niko; Cès, Sophie; Macq, Jean
2014-08-01
Various elderly case management projects have been implemented in Belgium. This type of long-term health care intervention involves contextual factors and human interactions. These underlying complex mechanisms can be usefully informed with field experts' knowledge, which are hard to make explicit. However, computer simulation has been suggested as one possible method of overcoming the difficulty of articulating such elicited qualitative views. A simulation model of case management was designed using an agent-based methodology, based on the initial qualitative research material. Variables and rules of interaction were formulated into a simple conceptual framework. This model has been implemented and was used as a support for a structured discussion with experts in case management. The rigorous formulation provided by the agent-based methodology clarified the descriptions of the interventions and the problems encountered regarding: the diverse network topologies of health care actors in the project; the adaptation time required by the intervention; the communication between the health care actors; the institutional context; the organization of the care; and the role of the case manager and his or hers personal ability to interpret the informal demands of the frail older person. The simulation model should be seen primarily as a tool for thinking and learning. A number of insights were gained as part of a valuable cognitive process. Computer simulation supporting field experts' elicitation can lead to better-informed decisions in the organization of complex health care interventions. © 2013 John Wiley & Sons, Ltd.
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Heisler, Michele; Bouknight, Reynard R; Hayward, Rodney A; Smith, Dylan M; Kerr, Eve A
2002-01-01
OBJECTIVE Patients' self-management practices have substantial consequences on morbidity and mortality in diabetes. While the quality of patient-physician relations has been associated with improved health outcomes and functional status, little is known about the impact of different patient-physician interaction styles on patients' diabetes self-management. This study assessed the influence of patients' evaluation of their physicians' participatory decision-making style, rating of physician communication, and reported understanding of diabetes self-care on their self-reported diabetes management. DESIGN We surveyed 2,000 patients receiving diabetes care across 25 Veterans' Affairs facilities. We measured patients' evaluation of provider participatory decision making with a 4-item scale (Provider Participatory Decision-making Style [PDMstyle]; α = 0.96), rating of providers' communication with a 5-item scale (Provider Communication [PCOM]; α = 0.93), understanding of diabetes self-care with an 8-item scale (α = 0.90), and patients' completion of diabetes self-care activities (self-management) in 5 domains (α = 0.68). Using multivariable linear regression, we examined self-management with the independent associations of PDMstyle, PCOM, and Understanding. RESULTS Sixty-six percent of the sample completed the surveys (N = 1,314). Higher ratings in PDMstyle and PCOM were each associated with higher self-management assessments (P < .01 in all models). When modeled together, PCOM remained a significant independent predictor of self-management (standardized β: 0.18; P < .001), but PDMstyle became nonsignificant. Adding Understanding to the model diminished the unique effect of PCOM in predicting self-management (standardized β: 0.10; P = .004). Understanding was strongly and independently associated with self-management (standardized β: 0.25; P < .001). CONCLUSION For these patients, ratings of providers' communication effectiveness were more important than a participatory decision-making style in predicting diabetes self-management. Reported understanding of self-care behaviors was highly predictive of and attenuated the effect of both PDMstyle and PCOM on self-management, raising the possibility that both provider styles enhance self-management through increased patient understanding or self-confidence. PMID:11972720
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Treiger, Teresa M; Fink-Samnick, Ellen
2013-01-01
The purpose of this first of a three-article series is to provide context and justification for a new paradigm of case management built upon a value-driven foundation that Applicable to all health care sectors where case management is practiced. In moving forward, the one fact that rings true is there will be constant change in our industry. As the health care terrain shifts and new influences continually surface, there will be consequences for case management practice. These impacts require nimble clinical professionals in possession of recognized and firmly established competencies. They must be agile to frame (and reframe) their professional practice to facilitate the best possible outcomes for their patients. Case managers can choose to be Gumby or Pokey. This is exactly why the definition of a competency-based case management model's time has come, one sufficiently fluid to fit into any setting of care. The practice of case management transcends the vast array of representative professional disciplines and educational levels. A majority of current models are driven by business priorities rather than by the competencies critical to successful practice and quality patient outcomes. This results in a fragmented professional case management identity. While there is inherent value in what each discipline brings to the table, this advanced model unifies behind case management's unique, strengths-based identity instead of continuing to align within traditional divisions (e.g., discipline, work setting, population served). This model fosters case management's expanding career advancement opportunities, including a reflective clinical ladder.
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Moreo, Kathleen; Moreo, Natalie; Urbano, Frank L; Weeks, Matthew; Greene, Laurence
2014-01-01
Care coordination, traditionally the purview of the case management field, is recognized as a national priority for improving health care delivery and patient outcomes. With reforms of the Affordable Care Act (ACA) of 2010, case managers face new challenges and opportunities in providing care coordination services. The evolving roles of case managers as members of interprofessional care teams will be influenced by new policies that enable physicians to be reimbursed for care coordination. This qualitative study aimed to evaluate case managers' self-assessed readiness for ACA reforms of care coordination and their perceptions of physicians' understanding of case management and ability to lead care coordination efforts in evolving models. Provisions of care coordination in the ACA affect case managers in all practice settings. The majority of this study's participants represented hospital and managed care settings. An invitation to complete an 11-item online survey was sent by e-mail to 8,110 case managers in an opt-in database maintained by a health care continuing education company. Survey questions were designed to assess respondents' (1) self-reported levels of knowledge and preparation for ACA care coordination provisions and (2) beliefs about the readiness and abilities of physicians to administer care coordination services. In addition, demographic data and open-ended comments regarding physicians' roles in conducting care coordination were collected. Over a restricted 9-day period, 834 case managers representing various health care settings responded to the survey. The majority of respondents (63%) indicated that more than 50% of their day is dedicated to performing care coordination activities. However, 80% of all respondents reported being "not at all knowledgeable" or only "somewhat knowledgeable" about the new care coordination provisions in the ACA. Only 8% admitted to being "very prepared" to implement ACA changes. The majority of respondents (68%) perceive their case management departments to be at least "somewhat prepared" to implement necessary changes. Whereas 67% of respondents expect physicians to have at least a "moderate role" in implementing care coordination services, only 12% believe that physicians have more than "some" understanding of the processes of care coordination and case managers' roles. These qualitative study findings suggest that case managers from multiple practice settings perceive a lack of preparedness, knowledge, and understanding among themselves and physicians regarding ACA reforms that may significantly affect the delivery of care coordination services. The findings call for new initiatives in interprofessional education to address the knowledge gaps and enhance understanding of the collaborative roles among case managers and physicians.
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Anderson, D A; Bankston, K; Stindt, J L; Weybright, D W
2000-09-01
Today's managed care environment is forcing hospitals to seek new and innovative ways to deliver a seamless continuum of high-quality care and services to defined populations at lower costs. Many are striving to achieve this goal through the implementation of shared governance models that support point-of-service decision making, interdisciplinary partnerships, and the integration of work across clinical settings and along the service delivery continuum. The authors describe the key processes and strategies used to facilitate the design and successful implementation of an interdisciplinary shared governance model at The University Hospital, Cincinnati, Ohio. Implementation costs and initial benefits obtained over a 2-year period also are identified.
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The impact of non-IPA HMOs on the number of hospitals and hospital capacity.
Chernew, M
1995-01-01
Concentration in the hospital market could limit the success of health care reform strategies that rely on managed care to constrain costs. Hospital market capacity also is important because capacity affects both costs and the degree of price competition. Because managed care plans, particularly non-individual practice association (non-IPA) model HMOs, practice a less hospital-intensive style of care, consolidation and downsizing in the hospital market potentially will accompany managed care growth, influencing the long-run effectiveness of managed care cost-containment strategies. Using Standard Metropolitan Statistical Area (SMSA) data from 1982 and 1987, a 10-percentage point increase in non-IPA HMO market share is estimated to reduce the number of hospitals by about 4%, causing an approximate 5% reduction in the number of hospital beds. No statistically significant relationship is found between non-IPA HMO penetration rates and hospital occupancy rates.
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The Finnish healthcare services lean management.
Hihnala, Susanna; Kettunen, Lilja; Suhonen, Marjo; Tiirinki, Hanna
2018-02-05
Purpose The purpose of this paper is to discuss health services managers' experiences of management in a special health-care unit and development efforts from the point of view of the Lean method. Additionally, the aim is to deepen the knowledge of the managers' work and nature of the Lean method development processes in the workplace. The research focuses on those aspects and results of Lean method that are currently being used in health-care environments. Design/methodology/approach These data were collected through a number of thematic interviews. The participants were nurse managers ( n = 7) and medical managers ( n = 7) who applied Lean management in their work at the University Hospital in the Northern Ostrobothnia Health Care District. The data were analysed with a qualitative content analysis. Findings A common set of values in specialized health-care services, development of activities and challenges for management in the use of the Lean manager development model to improve personal management skills. Practical implications Managers in specialized health-care services can develop and systematically manage with the help of the Lean method. This emphasizes assumptions, from the point of view of management, about systems development when the organization uses the Lean method. The research outcomes originate from specialized health-care settings in Finland in which the Lean method and its associated management principles have been implemented and applied to the delivery of health care. Originality/value The study shows that the research results and in-depth knowledge on Lean method principles can be applied to health-care management and development processes. The research also describes health services managers' experiences of using the Lean method. In the future, these results can be used to improve Lean management skills, identify personal professional competencies and develop skills required in development processes. Also, the research findings can be used in the training of health services managers in the health-care industry worldwide and to help them survive the pressure to change repeatedly.
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Effect of quality chronic disease management for alcohol and drug dependence on addiction outcomes.
Kim, Theresa W; Saitz, Richard; Cheng, Debbie M; Winter, Michael R; Witas, Julie; Samet, Jeffrey H
2012-12-01
We examined the effect of the quality of primary care-based chronic disease management (CDM) for alcohol and/or other drug (AOD) dependence on addiction outcomes. We assessed quality using (1) a visit frequency based measure and (2) a self-reported assessment measuring alignment with the chronic care model. The visit frequency based measure had no significant association with addiction outcomes. The self-reported measure of care-when care was at a CDM clinic-was associated with lower drug addiction severity. The self-reported assessment of care from any healthcare source (CDM clinic or elsewhere) was associated with lower alcohol addiction severity and abstinence. These findings suggest that high quality CDM for AOD dependence may improve addiction outcomes. Quality measures based upon alignment with the chronic care model may better capture features of effective CDM care than a visit frequency measure. Copyright © 2012 Elsevier Inc. All rights reserved.
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Cichosz, Simon Lebech; Johansen, Mette Dencker; Hejlesen, Ole
2015-10-14
Diabetes is one of the top priorities in medical science and health care management, and an abundance of data and information is available on these patients. Whether data stem from statistical models or complex pattern recognition models, they may be fused into predictive models that combine patient information and prognostic outcome results. Such knowledge could be used in clinical decision support, disease surveillance, and public health management to improve patient care. Our aim was to review the literature and give an introduction to predictive models in screening for and the management of prevalent short- and long-term complications in diabetes. Predictive models have been developed for management of diabetes and its complications, and the number of publications on such models has been growing over the past decade. Often multiple logistic or a similar linear regression is used for prediction model development, possibly owing to its transparent functionality. Ultimately, for prediction models to prove useful, they must demonstrate impact, namely, their use must generate better patient outcomes. Although extensive effort has been put in to building these predictive models, there is a remarkable scarcity of impact studies. © 2015 Diabetes Technology Society.
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Yoon, Jean; Chang, Evelyn; Rubenstein, Lisa V; Park, Angel; Zulman, Donna M; Stockdale, Susan; Ong, Michael K; Atkins, David; Schectman, Gordon; Asch, Steven M
2018-06-05
Primary care models that offer comprehensive, accessible care to all patients may provide insufficient resources to meet the needs of patients with complex conditions who have the greatest risk for hospitalization. To assess whether augmenting usual primary care with team-based intensive management lowers utilization and costs for high-risk patients. Randomized quality improvement trial. (ClinicalTrials.gov: NCT03100526). 5 U.S. Department of Veterans Affairs (VA) medical centers. Primary care patients at high risk for hospitalization who had a recent acute care episode. Locally tailored intensive management programs providing care coordination, goals assessment, health coaching, medication reconciliation, and home visits through an interdisciplinary team, including a physician or nurse practitioner, a nurse, and psychosocial experts. Utilization and costs (including intensive management program expenses) 12 months before and after randomization. 2210 patients were randomly assigned, 1105 to intensive management and 1105 to usual care. Patients had a mean age of 63 years and an average of 7 chronic conditions; 90% were men. Of the patients assigned to intensive management, 487 (44%) received intensive outpatient care (that is, ≥3 encounters in person or by telephone) and 204 (18%) received limited intervention. From the pre- to postrandomization periods, mean inpatient costs decreased more for the intensive management than the usual care group (-$2164 [95% CI, -$7916 to $3587]). Outpatient costs increased more for the intensive management than the usual care group ($2636 [CI, $524 to $4748]), driven by greater use of primary care, home care, telephone care, and telehealth. Mean total costs were similar in the 2 groups before and after randomization. Sites took up to several months to contact eligible patients, limiting the time between treatment and outcome assessment. Only VA costs were assessed. High-risk patients with access to an intensive management program received more outpatient care with no increase in total costs. Veterans Health Administration Primary Care Services.
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A model to evaluate quality and effectiveness of disease management.
Lemmens, K M M; Nieboer, A P; van Schayck, C P; Asin, J D; Huijsman, R
2008-12-01
Disease management has emerged as a new strategy to enhance quality of care for patients suffering from chronic conditions, and to control healthcare costs. So far, however, the effects of this strategy remain unclear. Although current models define the concept of disease management, they do not provide a systematic development or an explanatory theory of how disease management affects the outcomes of care. The objective of this paper is to present a framework for valid evaluation of disease-management initiatives. The evaluation model is built on two pillars of disease management: patient-related and professional-directed interventions. The effectiveness of these interventions is thought to be affected by the organisational design of the healthcare system. Disease management requires a multifaceted approach; hence disease-management programme evaluations should focus on the effects of multiple interventions, namely patient-related, professional-directed and organisational interventions. The framework has been built upon the conceptualisation of these disease-management interventions. Analysis of the underlying mechanisms of these interventions revealed that learning and behavioural theories support the core assumptions of disease management. The evaluation model can be used to identify the components of disease-management programmes and the mechanisms behind them, making valid comparison feasible. In addition, this model links the programme interventions to indicators that can be used to evaluate the disease-management programme. Consistent use of this framework will enable comparisons among disease-management programmes and outcomes in evaluation research.
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Partnering with patients to promote holistic diabetes management: changing paradigms.
Lorenzo, Lenora
2013-07-01
To provide a review of best practice for clinical management of diabetes mellitus (DM) for nurse practitioners (NPs) and accelerate incorporation of key findings into current practice. A search was conducted in Pub Med, Ovid, CINAHL, and Cochrane's Database of Systematic Reviews. There are many challenges for DM care identified in the current health system. There is a great need to change care paradigms to engage patients in partnership for enhanced management and self-management in DM. A review of the best practice evidence revealed numerous models of care, strategies, and tools available to enhance diabetes care and promote health and well-being. The primary focus of this article is to engage NP clinicians to incorporate new strategies to augment management and improve clinical outcomes. Incorporation of best practice for DM management may accelerate the paradigm shift to more patient-focused care. Engaged, informed, and activated patients along with clinicians working in partnerships may enhance clinical outcomes. ©2013 The Author ©2013 American Association of Nurse Practitioners.
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Weintraub, William S; Fanari, Zaher; Elliott, Daniel; Ostertag-Stretch, Jennifer; Muther, Ann; Lynahan, Margaret; Kerzner, Roger; Salam, Tabassum; Scherrer, Herbert; Anderson, Sharon; Russo, Carla A; Kolm, Paul; Steinberg, Terri H
2017-07-03
Reducing readmissions and improving metrics of care are a national priority. Supplementing traditional care with care management may improve outcomes. The Bridges program was an initial evaluation of a care management platform (CareLinkHub), supported by information technology (IT) developed to improve the quality and transition of care from hospital to home after percutaneous coronary intervention (PCI) and reduce readmissions. CareLink is comprised of care managers, patient navigators, pharmacists and physicians. Information to guide care management is guided by a middleware layer to gather information, PLR (ColdLight Solutions, LLC) and presented to CareLink staff on a care management platform, Aerial™ (Medecision). An additional analytic engine [Neuron™ (ColdLight Solutions, LLC)] helps, evaluates and guide care. The "Bridges" program enrolled a total of 2054 PCI patients with 2835 admission from April, 1st 2013 through March 1st, 2015. The data of the program was compared with those of 3691 PCI patients with 4414 admissions in the 3years prior to the program. No impact was seen with respect to inpatient and observation readmission, or emergency department visits. Similarly no change was noticed in LDL control. There was minimal improvement in BP control and only in the CTM-3 and SAQ-7 physical limitation scores in the patients' reported outcomes. Patient follow-up with physicians within 1week of discharge improved during the Bridges years. The CareLink hub platform was successfully implemented. Little or no impact on outcome metrics was seen in the short follow-up time. The Bridges program suggests that population health management must be a long-term goal, improving preventive care in the community. Copyright © 2017 Elsevier Inc. All rights reserved.
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Diabetes management using modern information and communication technologies and new care models.
Spanakis, Emmanouil G; Chiarugi, Franco; Kouroubali, Angelina; Spat, Stephan; Beck, Peter; Asanin, Stefan; Rosengren, Peter; Gergely, Tamas; Thestrup, Jesper
2012-10-04
Diabetes, a metabolic disorder, has reached epidemic proportions in developed countries. The disease has two main forms: type 1 and type 2. Disease management entails administration of insulin in combination with careful blood glucose monitoring (type 1) or involves the adjustment of diet and exercise level, the use of oral anti-diabetic drugs, and insulin administration to control blood sugar (type 2). State-of-the-art technologies have the potential to assist healthcare professionals, patients, and informal carers to better manage diabetes insulin therapy, help patients understand their disease, support self-management, and provide a safe environment by monitoring adverse and potentially life-threatening situations with appropriate crisis management. New care models incorporating advanced information and communication technologies have the potential to provide service platforms able to improve health care, personalization, inclusion, and empowerment of the patient, and to support diverse user preferences and needs in different countries. The REACTION project proposes to create a service-oriented architectural platform based on numerous individual services and implementing novel care models that can be deployed in different settings to perform patient monitoring, distributed decision support, health care workflow management, and clinical feedback provision. This paper presents the work performed in the context of the REACTION project focusing on the development of a health care service platform able to support diabetes management in different healthcare regimes, through clinical applications, such as monitoring of vital signs, feedback provision to the point of care, integrative risk assessment, and event and alarm handling. While moving towards the full implementation of the platform, three major areas of research and development have been identified and consequently approached: the first one is related to the glucose sensor technology and wearability, the second is related to the platform architecture, and the third to the implementation of the end-user services. The Glucose Management System, already developed within the REACTION project, is able to monitor a range of parameters from various sources including glucose levels, nutritional intakes, administered drugs, and patient's insulin sensitivity, offering decision support for insulin dosing to professional caregivers on a mobile tablet platform that fulfills the need of the users and supports medical workflow procedures in compliance with the Medical Device Directive requirements. Good control of diabetes, as well as increased emphasis on control of lifestyle factors, may reduce the risk profile of most complications and contribute to health improvement. The REACTION project aims to respond to these challenges by providing integrated, professional, management, and therapy services to diabetic patients in different health care regimes across Europe in an interoperable communication platform.
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Luo, Zhehui; Chen, Qiaoling; Annis, Ann M; Piatt, Gretchen; Green, Lee A; Tao, Min; Holtrop, Jodi Summers
2016-07-01
The real world implementation of chronic care management model varies greatly. One aspect of this variation is the delivery mode. Two contrasting strategies include provider-delivered care management (PDCM) and health plan-delivered care management (HPDCM). We aimed to compare the effectiveness of PDCM vs. HPDCM on improving clinical outcomes for patients with chronic diseases. We used a quasi-experimental two-group pre-post design using the difference-in-differences method. Commercially insured patients, with any of the five chronic diseases-congestive heart failure, chronic obstructive pulmonary disease, coronary heart disease, diabetes, or asthma, who were outreached to and engaged in either PDCM or HPDCM were included in the study. Outreached patients were those who received an attempted or actual contact for enrollment in care management; and engaged patients were those who had one or more care management sessions/encounters with a care manager. Effectiveness measures included blood pressure, low density lipoprotein (LDL), weight loss, and hemoglobin A1c (for diabetic patients only). Primary endpoints were evaluated in the first year of follow-up. A total of 4,000 patients were clustered in 165 practices (31 in PDCM and 134 in HPDCM). The PDCM approach demonstrated a statistically significant improvement in the proportion of outreached patients whose LDL was under control: the proportion of patients with LDL < 100 mg/dL increased by 3 % for the PDCM group (95 % CI: 1 % to 6 %) and 1 % for the HPDCM group (95 % CI: -2 % to 5 %). However, the 2 % difference in these improvements was not statistically significant (95 % CI: -2 % to 6 %). The HPDCM approach showed 3 % [95 % CI: 2 % to 6 %] improvement in overall diabetes care among outreached patients and significant reduction in obesity rates compared to PDCM (4 %, 95 % CI: 0.3 % to 8 %). Both care management delivery modes may be viable options for improving care for patients with chronic diseases. In this commercially insured population, neither PDCM nor HPDCM resulted in substantial improvement in patients' clinical indicators in the first year. Different care management strategies within the provider-delivered programs need further investigation.
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Self-management in heart failure: where have we been and where should we go?
Gardetto, Nancy Jean
2011-01-01
Chronic conditions such as heart failure (HF) place a tremendous strain on patients, their families, the community, and the health care system because there are no real “cures”. Adding to the burden are longer life expectancies and increased numbers of people living with multiple chronic conditions. Today, whether engaging in a health-promoting activity, such as exercise, or living with a chronic disease such as HF, the individual is responsible for actively managing day-to-day activities, a concept referred to as self-management. Self-management emerged as the cornerstone for chronic care models and multidisciplinary disease-management strategies in chronic illness care. Moreover, self-management has been prioritized as a central pathway for improving the quality and effectiveness of most chronic HF care. Adherence to self-management is vital to optimize the treatment outcomes in HF patients, but implementing chronic disease self-management (CDSM) strategies and identifying the difficulties in self-management has proved to be a challenge. Understanding both where we have been and the future direction of self-management in HF care is not only timely, but a crucial aspect of improving long-term outcomes for people with HF and other chronic diseases. PMID:21544247
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The emerging role of faith community nurses in prevention and management of chronic disease.
McGinnis, Sandra L; Zoske, Frances M
2008-08-01
Faith community nursing, formerly known as parish nursing, is one model of care that relies heavily on older registered nurses (RNs) to provide population-based and other nonclinical services in community settings. Faith community nursing provides services not commonly available in the traditional health care system (e.g., community case management, community advocacy, community health education). With appropriate support, this model of nursing could be expanded into other settings within the community and has the potential to draw on the skills of experienced RNs to provide communities with services that address unmet health care needs.
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Fuller, Jeffrey; Oster, Candice; Muir Cochrane, Eimear; Dawson, Suzanne; Lawn, Sharon; Henderson, Julie; O'Kane, Deb; Gerace, Adam; McPhail, Ruth; Sparkes, Deb; Fuller, Michelle; Reed, Richard L
2015-11-11
To test a management model of facilitated reflection on network feedback as a means to engage services in problem solving the delivery of integrated primary mental healthcare to older people. Participatory mixed methods case study evaluating the impact of a network management model using organisational network feedback (through social network analysis, key informant interviews and policy review). A model of facilitated network reflection using network theory and methods. A rural community in South Australia. 32 staff from 24 services and 12 senior service managers from mental health, primary care and social care services. Health and social care organisations identified that they operated in clustered self-managed networks within sectors, with no overarching purposive older people's mental healthcare network. The model of facilitated reflection revealed service goal and role conflicts. These discussions helped local services to identify as a network, and begin the problem-solving communication and referral links. A Governance Group assisted this process. Barriers to integrated servicing through a network included service funding tied to performance of direct care tasks and the lack of a clear lead network administration organisation. A model of facilitated reflection helped organisations to identify as a network, but revealed sensitivity about organisational roles and goals, which demonstrated that conflict should be expected. Networked servicing needed a neutral network administration organisation with cross-sectoral credibility, a mandate and the resources to monitor the network, to deal with conflict, negotiate commitment among the service managers, and provide opportunities for different sectors to meet and problem solve. This requires consistency and sustained intersectoral policies that include strategies and funding to facilitate and maintain health and social care networks in rural communities. 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/
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Li, Haitao; Sun, Ying; Qian, Dongfu
2016-11-30
Policy makers require information regarding performance of different primary care delivery models in managing hypertension, which can be helpful for better hypertension management. This study aims to compare continuity of care among hypertensive patients between Direct Management (DM) Model of community health centers (CHCs) in Wuhan and Loose Collaboration (LC) Model in Nanjing. A cross-sectional questionnaire survey was conducted. Four CHCs in each city were randomly selected as study settings. 386 patients in Nanjing and 396 in Wuhan completed face-to-face interview surveys and were included in the final analysis. The relational continuity and coordination continuity (including both information continuity and management continuity) were measured and analyzed. Binary or multinomial logistic regression models were used for comparison between the two cities. Participants from Nanjing had better relational continuity with primary care providers as compared with those from Wuhan, including more likely to be familiar with a CHC physician (OR = 2.762; 95%CI: 1.878 to 4.061), taken care of by the same CHC physician (OR = 1.846; 95%CI: 1.262 to 2.700), and known well by a CHC physician (OR = 1.762; 95%CI: 1.206 to 2.572). Multinomial logistic regression analyses showed there were significant differences between the two cities in reported frequency of communications between hospital and CHC physicians (P = 0.001), whether hospital and CHC physicians gave same treatment suggestions (P = 0.016), as well as how treatment strategy was formulated (P < 0.001). Participants in Wuhan were less likely than those in Nanjing to consider there was continuum regarding health services provided by hospital and CHC physicians (OR = 3.932; 95%CI: 2.394 to 6.459). Our study shows that continuity of care is better for LC Model in Nanjing than DM Model in Wuhan. Our study suggests there is room for improvement regarding relational and information continuity in both cities.
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Using systems science for population health management in primary care.
Li, Yan; Kong, Nan; Lawley, Mark A; Pagán, José A
2014-10-01
Population health management is becoming increasingly important to organizations managing and providing primary care services given ongoing changes in health care delivery and payment systems. The objective of this study is to show how systems science methodologies could be incorporated into population health management to compare different interventions and improve health outcomes. The New York Academy of Medicine Cardiovascular Health Simulation model (an agent-based model) and data from the Behavioral Risk Factor Surveillance System were used to evaluate a lifestyle program that could be implemented in primary care practice settings. The program targeted Medicare-age adults and focused on improving diet and exercise and reducing weight. The simulation results suggest that there would be significant reductions projected in the proportion of the Medicare-age population with diabetes after the implementation of the proposed lifestyle program for a relatively long term (3 and 5 years). Similar results were found for the subpopulations with high cholesterol, but the proposed intervention would not have a significant effect in the proportion of the population with hypertension over a time period of <5 years. Systems science methodologies can be useful to compare the health outcomes of different interventions. These tools can become an important component of population health management because they can help managers and other decision makers evaluate alternative programs in primary care settings. © The Author(s) 2014.
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Chronic disease management: teaching medical students to incorporate community.
Dent, M Marie; Mathis, Mary W; Outland, Monita; Thomas, McKinley; Industrious, DeShawn
2010-01-01
As a response to the growing prevalence of chronic disease, models of chronic care have emerged as salient approaches to address dynamic health care changes and to manage the burden of suffering of these diseases. Concurrently, there has been a growing call to address chronic disease management within medical school curricula. This article describes the development and evaluation of a curricular intervention designed to prepare students to integrate patient-centered care with an understanding of the patients' community, provide care within rural settings, and experience clinical education specific to chronic disease management. Second-year medical students completed a chronic disease management project as part of a 4-week community visit in rural and/or medically underserved sites. Paired pre- and post-survey data were collected using the Community Oriented Health Care Competency Scale to assess the student's knowledge, intent to practice, and attitudes toward incorporating community-oriented primary care into future practice. Matched pre- and post-project surveys were identified for 170 respondents out of 219 students (77.6% response rate). Post-assessment items were found to be statistically different from measures collected prior to the students' entrance into the community: all knowledge questions indicated significant advancements toward community responsiveness, as did one question related to attitude and three of the intent to practice community-oriented health care questions. Community-based rotations can play a positive role in developing the competencies needed for future practice. The development of curricular opportunities designed to train future physicians on the value of incorporating models of chronic care within rural and underserved communities should remain at the forefront of medical education.
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Developing an active implementation model for a chronic disease management program.
Smidth, Margrethe; Christensen, Morten Bondo; Olesen, Frede; Vedsted, Peter
2013-04-01
Introduction and diffusion of new disease management programs in healthcare is usually slow, but active theory-driven implementation seems to outperform other implementation strategies. However, we have only scarce evidence on the feasibility and real effect of such strategies in complex primary care settings where municipalities, general practitioners and hospitals should work together. The Central Denmark Region recently implemented a disease management program for chronic obstructive pulmonary disease (COPD) which presented an opportunity to test an active implementation model against the usual implementation model. The aim of the present paper is to describe the development of an active implementation model using the Medical Research Council's model for complex interventions and the Chronic Care Model. We used the Medical Research Council's five-stage model for developing complex interventions to design an implementation model for a disease management program for COPD. First, literature on implementing change in general practice was scrutinised and empirical knowledge was assessed for suitability. In phase I, the intervention was developed; and in phases II and III, it was tested in a block- and cluster-randomised study. In phase IV, we evaluated the feasibility for others to use our active implementation model. The Chronic Care Model was identified as a model for designing efficient implementation elements. These elements were combined into a multifaceted intervention, and a timeline for the trial in a randomised study was decided upon in accordance with the five stages in the Medical Research Council's model; this was captured in a PaTPlot, which allowed us to focus on the structure and the timing of the intervention. The implementation strategies identified as efficient were use of the Breakthrough Series, academic detailing, provision of patient material and meetings between providers. The active implementation model was tested in a randomised trial (results reported elsewhere). The combination of the theoretical model for complex interventions and the Chronic Care Model and the chosen specific implementation strategies proved feasible for a practice-based active implementation model for a chronic-disease-management-program for COPD. Using the Medical Research Council's model added transparency to the design phase which further facilitated the process of implementing the program. http://www.clinicaltrials.gov/(NCT01228708).
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Wade, Julia; Holding, Peter N; Bonnington, Susan; Rooshenas, Leila; Lane, J Athene; Salter, C Elizabeth; Tilling, Kate; Speakman, Mark J; Brewster, Simon F; Evans, Simon; Neal, David E; Hamdy, Freddie C; Donovan, Jenny L
2015-09-18
To develop a nurse-led, urologist-supported model of care for men managed by active surveillance or active monitoring (AS/AM) for localised prostate cancer and provide a formative evaluation of its acceptability to patients, clinicians and nurses. Nurse-led care, comprising an explicit nurse-led protocol with support from urologists, was developed as part of the AM arm of the Prostate testing for cancer and Treatment (ProtecT) trial. Interviews and questionnaire surveys of clinicians, nurses and patients assessed acceptability. Nurse-led clinics were established in 9 centres in the ProtecT trial and compared with 3 non-ProtecT urology centres elsewhere in UK. Within ProtecT, 22 men receiving AM nurse-led care were interviewed about experiences of care; 11 urologists and 23 research nurses delivering ProtecT trial care completed a questionnaire about its acceptability; 20 men managed in urology clinics elsewhere in the UK were interviewed about models of AS/AM care; 12 urologists and three specialist nurses working in these clinics were also interviewed about management of AS/AM. Nurse-led care was commended by ProtecT trial participants, who valued the flexibility, accessibility and continuity of the service and felt confident about the quality of care. ProtecT consultant urologists and nurses also rated it highly, identifying continuity of care and resource savings as key attributes. Clinicians and patients outside the ProtecT trial believed that nurse-led care could relieve pressure on urology clinics without compromising patient care. The ProtecT AM nurse-led model of care was acceptable to men with localised prostate cancer and clinical specialists in urology. The protocol is available for implementation; we aim to evaluate its impact on routine clinical practice. NCT02044172; ISRCTN20141297. 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.
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Wade, Julia; Holding, Peter N; Bonnington, Susan; Rooshenas, Leila; Lane, J Athene; Salter, C Elizabeth; Tilling, Kate; Speakman, Mark J; Brewster, Simon F; Evans, Simon; Neal, David E; Hamdy, Freddie C; Donovan, Jenny L
2015-01-01
Objectives To develop a nurse-led, urologist-supported model of care for men managed by active surveillance or active monitoring (AS/AM) for localised prostate cancer and provide a formative evaluation of its acceptability to patients, clinicians and nurses. Nurse-led care, comprising an explicit nurse-led protocol with support from urologists, was developed as part of the AM arm of the Prostate testing for cancer and Treatment (ProtecT) trial. Design Interviews and questionnaire surveys of clinicians, nurses and patients assessed acceptability. Setting Nurse-led clinics were established in 9 centres in the ProtecT trial and compared with 3 non-ProtecT urology centres elsewhere in UK. Participants Within ProtecT, 22 men receiving AM nurse-led care were interviewed about experiences of care; 11 urologists and 23 research nurses delivering ProtecT trial care completed a questionnaire about its acceptability; 20 men managed in urology clinics elsewhere in the UK were interviewed about models of AS/AM care; 12 urologists and three specialist nurses working in these clinics were also interviewed about management of AS/AM. Results Nurse-led care was commended by ProtecT trial participants, who valued the flexibility, accessibility and continuity of the service and felt confident about the quality of care. ProtecT consultant urologists and nurses also rated it highly, identifying continuity of care and resource savings as key attributes. Clinicians and patients outside the ProtecT trial believed that nurse-led care could relieve pressure on urology clinics without compromising patient care. Conclusions The ProtecT AM nurse-led model of care was acceptable to men with localised prostate cancer and clinical specialists in urology. The protocol is available for implementation; we aim to evaluate its impact on routine clinical practice. Trial registration numbers NCT02044172; ISRCTN20141297. PMID:26384727
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Kendall, Claire E; Taljaard, Monica; Younger, Jaime; Hogg, William; Glazier, Richard H; Manuel, Douglas G
2015-01-01
Objectives Physician specialty is often positively associated with disease-specific outcomes and negatively associated with primary care outcomes for people with chronic conditions. People with HIV have increasing comorbidity arising from antiretroviral therapy (ART) related longevity, making HIV a useful condition to examine shared care models. We used a previously described, theoretically developed shared care framework to assess the impact of care delivery on the quality of care provided. Design Retrospective population-based observational study from 1 April 2009 to 31 March 2012. Participants 13 480 patients with HIV and receiving publicly funded healthcare in Ontario were assigned to one of five patterns of care. Outcome measures Cancer screening, ART prescribing and healthcare utilisation across models using adjusted multivariable hierarchical logistic regression analyses. Results Models in which patients had an assigned family physician had higher odds of cancer screening than those in exclusively specialist care (colorectal cancer screening, exclusively primary care adjusted OR (AOR)=3.12, 95% CI (1.90 to 5.13), family physician-dominant co-management AOR=3.39, 95% CI (1.94 to 5.93), specialist-dominant co-management AOR=2.01, 95% CI (1.23 to 3.26)). The odds of having one emergency department visit did not differ among models, although the odds of hospitalisation and HIV-specific hospitalisation were lower among patients who saw exclusively family physicians (AOR=0.23, 95% CI (0.14 to 0.35) and AOR=0.15, 95% CI (0.12 to 0.21)). The odds of antiretroviral prescriptions were lower among models in which patients’ HIV care was provided predominantly by family physicians (exclusively primary care AOR=0.15, 95% CI (0.12 to 0.21), family physician-dominant co-management AOR=0.45, 95% CI (0.32 to 0.64)). Conclusions How care is provided had a potentially important influence on the quality of care delivered. Our key limitation is potential confounding due to the absence of HIV stage measures. PMID:25971708
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Krebs, Erin E; Bair, Matthew J; Carey, Timothy S; Weinberger, Morris
2010-03-01
Researchers and quality improvement advocates sometimes use review of chart-documented pain care processes to assess the quality of pain management. Studies have found that primary care providers frequently fail to document pain assessment and management. To assess documentation of pain care processes in an academic primary care clinic and evaluate the validity of this documentation as a measure of pain care delivered. Prospective observational study. 237 adult patients at a university-affiliated internal medicine clinic who reported any pain in the last week. Immediately after a visit, we asked patients to report the pain treatment they received. Patients completed the Brief Pain Inventory (BPI) to assess pain severity at baseline and 1 month later. We extracted documentation of pain care processes from the medical record and used kappa statistics to assess agreement between documentation and patient report of pain treatment. Using multivariable linear regression, we modeled whether documented or patient-reported pain care predicted change in pain at 1 month. Participants' mean age was 53.7 years, 66% were female, and 74% had chronic pain. Physicians documented pain assessment for 83% of visits. Patients reported receiving pain treatment more often (67%) than was documented by physicians (54%). Agreement between documentation and patient report was moderate for receiving a new pain medication (k = 0.50) and slight for receiving pain management advice (k = 0.13). In multivariable models, documentation of new pain treatment was not associated with change in pain (p = 0.134). In contrast, patient-reported receipt of new pain treatment predicted pain improvement (p = 0.005). Chart documentation underestimated pain care delivered, compared with patient report. Documented pain care processes had no relationship with pain outcomes at 1 month, but patient report of receiving care predicted clinically significant improvement. Chart review measures may not accurately reflect the pain management patients receive in primary care.
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Reichert, Sonja M; Harris, Stewart; Harvey, Betty
2014-06-01
The majority of diabetes care in Canada is provided within the primary healthcare setting. It is delivered in a variety of models ranging from the physician working in a solo fee-for-service practice to an interprofessional team setting with specialist collaboration. To augment diabetes-related health services, the Ontario government has provided substantial funding to support community diabetes education programs. These models and initiatives are improving diabetes outcomes, and continued evolution of these programs can provide even greater outcomes. The St. Joseph's Primary Care Diabetes Support Program (SJHC PCDSP) is an innovative model that incorporates multidisciplinary allied health professionals together with physician support to provide care for more than 3000 patients in London, Ontario, Canada. It embodies the Canadian Diabetes Association (CDA)'s Organizations of Care recommendations to combine patient education and self-management with active medical support at each clinic encounter, all while embodying the tenets of primary care. A brief review of primary healthcare reform is provided to explain how the SJHC PCDSP combines features of current models in a unique format so as to deliver exceptional patient care. By providing a detailed description of the services delivered at the SJHC PCDSP, it is hoped that both specialists and primary care providers consider using and adapting approaches to diabetes management based on this innovative model to optimize their practices. Copyright © 2014 Canadian Diabetes Association. Published by Elsevier Inc. All rights reserved.
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Do competition and managed care improve quality?
Sari, Nazmi
2002-10-01
In recent years, the US health care industry has experienced a rapid growth of managed care, formation of networks, and an integration of hospitals. This paper provides new insights about the quality consequences of this dynamic in US hospital markets. I empirically investigate the impact of managed care and hospital competition on quality using in-hospital complications as quality measures. I use random and fixed effects, and instrumental variable fixed effect models using hospital panel data from up to 16 states in the 1992-1997 period. The paper has two important findings: First, higher managed care penetration increases the quality, when inappropriate utilization, wound infections and adverse/iatrogenic complications are used as quality indicators. For other complication categories, coefficient estimates are statistically insignificant. These findings do not support the straightforward view that increases in managed care penetration are associated with decreases in quality. Second, both higher hospital market share and market concentration are associated with lower quality of care. Hospital mergers have undesirable quality consequences. Appropriate antitrust policies towards mergers should consider not only price and cost but also quality impacts. Copyright 2002 John Wiley & Sons, Ltd.
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German diabetes management programs improve quality of care and curb costs.
Stock, Stephanie; Drabik, Anna; Büscher, Guido; Graf, Christian; Ullrich, Walter; Gerber, Andreas; Lauterbach, Karl W; Lüngen, Markus
2010-12-01
This paper reports the results of a large-scale analysis of a nationwide disease management program in Germany for patients with diabetes mellitus. The German program differs markedly from "classic" disease management in the United States. Although it combines important hallmarks of vendor-based disease management and the Chronic Care Model, the German program is based in primary care practices and carried out by physicians, and it draws on their personal relationships with patients to promote adherence to treatment goals and self-management. After four years of follow-up, overall mortality for patients and drug and hospital costs were all significantly lower for patients who participated in the program compared to other insured patients with similar health profiles who were not in the program. These results suggest that the German disease management program is a successful strategy for improving chronic illness care.
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Authentic leadership and nurses' voice behaviour and perceptions of care quality.
Wong, Carol A; Spence Laschinger, Heather K; Cummings, Greta G
2010-11-01
The purpose of the present study was to test a theoretical model linking authentic leadership with staff nurses' trust in their manager, work engagement, voice behaviour and perceived unit care quality. Authentic leadership is a guide for effective leadership needed to build trust and healthier work environments because there is special attention given to honesty, integrity and high ethical standards in the development of leader-follower relationships. A non-experimental, predictive survey design was used to test the hypothesized model in a random sample of 280 (48% response rate) registered nurses working in acute care hospitals in Ontario. The final model fitted the data acceptably (χ(2)=17.24, d.f.=11, P=0.10, IFI=0.99, CFI=0.99, RMSEA=0.045). Authentic leadership significantly and positively influenced staff nurses' trust in their manager and work engagement which in turn predicted voice behaviour and perceived unit care quality. These findings suggest that authentic leadership and trust in the manager play a role in fostering trust, work engagement, voice behaviour and perceived quality of care. Nursing leaders can improve care quality and workplace conditions by paying attention to facilitating genuine and positive relationships with their staff. © 2010 The Authors. Journal compilation © 2010 Blackwell Publishing Ltd.
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Andrews, Sasha E; Downey, Ann G; Showalter, David Scott; Fitzgerald, Heather; Showalter, Vivian P; Carey, John C; Hulac, Peter
2016-09-01
The medical management of infants with the trisomy 13 and trisomy 18 syndromes is challenging and controversial. Both conditions have high neonatal and infant mortality, and surviving children display significant cognitive and motor disabilities. Currently, there exists a tension in the neonatal and perinatal communities regarding care. One view holds that management should consist solely of comfort care, while another opinion recommends offering medical and surgical intervention in appropriate situations. The purpose of this manuscript is to present a model for the care of fetuses and infants with trisomy 13 and 18 during the prenatal, perinatal, and postnatal periods. Adopting the pathways approach as a framework, we have identified several pertinent decision points, characterizing the goals of care and the resources needed for the decision points at various times. Additionally, we identified themes surrounding parental and professional experiences. The authors propose a care model for trisomy 13 and 18 that uses shared decision making as its foundational principle and the pathways approach as the method. Our model requires further investigation as a strategy for care in order to render it useful in other complex medical situations. © 2016 Wiley Periodicals, Inc. © 2016 Wiley Periodicals, Inc.
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Reforming funding for chronic illness: Medicare-CDM.
Swerissen, Hal; Taylor, Michael J
2008-02-01
Chronic diseases are a major challenge for the Australian health care system in terms of both the provision of quality care and expenditure, and these challenges will only increase in the future. Various programs have been instituted under the Medicare system to provide increased funding for chronic care, but essentially these programs still follow the traditional fee-for-service model. This paper proposes a realignment and extension of current Medicare chronic disease management programs into a framework that provides general practitioners and other health professionals with the necessary "tools" for high quality care planning and ongoing management, and incorporating international models of outcome-linked funding. The integration of social support services with the Medicare system is also a necessary step in providing high quality care for patients with complex needs requiring additional support.
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The development of the Professional Values Model in Nursing.
Kaya, Ayla; Boz, İlkay
2017-01-01
One of the most important criteria for professionalism is accumulation of knowledge that is usable in professional practice. Nursing models and theories are important elements of accumulating nursing knowledge and have a chance to guarantee the ethical professional practice. In recent years, there has been an increase in the use of models in nursing research and newly created terminology has started to be used in nursing. In this study, a new model, termed as the Professional Values Model, developed by the authors was described. Concepts comprising the conceptual framework of the model and relations between the concepts were explained. It is assumed that awareness about concepts of the model will increase not only the patients' satisfaction with nursing care, but also the nurses' job satisfaction and quality of nursing care. Contemporary literature has been reviewed and synthesized to develop this theoretical paper on the Professional Values Model in nursing. Having high values in nursing increases job satisfaction, which results in the improvement of patient care and satisfaction. Also, individual characteristics are effective in the determination of individual needs, priorities, and values. This relation, proved through research about the Professional Values Model, has been explained. With development of these concepts, individuals' satisfaction with care and nurses' job satisfaction will be enhanced, which will increase the quality of nursing care. Most importantly, nurses can take proper decisions about ethical dilemmas and take ethical action when they take these values into consideration when giving care. The Professional Values Model seems suitable for nurse managers and it is expected that testing will improve it. Implementation of the Professional Values Model by nurse managers may increase motivation of nurses they work with. It is suggested that guidance by the Professional Values Model may help in enhancement of motivation efforts of the nurse managers and therefore should be taken into account.
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VanGeest, Jonathan; Weiner, Saul; Johnson, Timothy; Cummins, Deborah
2007-07-01
To develop and test an explanatory model of the impact of managed care on physicians' decisions to manipulate reimbursement rules for patients. A self-administered mailed questionnaire of a national random sample of 1124 practicing physicians in the USA. Structural equation modelling was used. The main outcome measure assessed whether or not physicians had manipulated reimbursement rules (such as exaggerated the severity of patients conditions, changed billing diagnoses, or reported signs or symptoms that the patients did not have) to help patients secure coverage for needed treatment or services. The response rate was 64% (n = 720). Physicians' decisions to manipulate reimbursement rules for patients are directly driven not only by ethical beliefs about gaming the system but also by requests from patients, the perception of insufficient time to deliver care, and the proportion of Medicaid patients. Covert advocacy is also the indirect result of utilization review hassles, primary care specialty, and practice environment. Managed care is not just a set of rules that physicians choose to follow or disobey, but an environment of competing pressures from patients, purchasers, and high workload. Reimbursement manipulation is a response to that environment, rather than simply a reflection of individual physicians' values.
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Beyond inpatient and outpatient care: alternative model for hypertension management.
Ho, P Michael; Rumsfeld, John S
2006-10-19
Hypertension is a major contributor to worldwide cardiovascular mortality, however, only one-third of patients with hypertension have their blood pressure treated to guideline recommended levels. To improve hypertension control, there may need to be a fundamental shift in care delivery, one that is population-based and simultaneously addresses patient, provider and system barriers. One potential approach is home-based disease management, based on the triad of home monitoring, team care, and patient self-care. Although there may be challenges to achieving the vision of home-based disease management, there are tremendous potential benefits of such an approach for reducing the global burden of cardiovascular disease.
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Benefits of information technology-enabled diabetes management.
Bu, Davis; Pan, Eric; Walker, Janice; Adler-Milstein, Julia; Kendrick, David; Hook, Julie M; Cusack, Caitlin M; Bates, David W; Middleton, Blackford
2007-05-01
To determine the financial and clinical benefits of implementing information technology (IT)-enabled disease management systems. A computer model was created to project the impact of IT-enabled disease management on care processes, clinical outcomes, and medical costs for patients with type 2 diabetes aged >25 years in the U.S. Several ITs were modeled (e.g., diabetes registries, computerized decision support, remote monitoring, patient self-management systems, and payer-based systems). Estimates of care process improvements were derived from published literature. Simulations projected outcomes for both payer and provider organizations, scaled to the national level. The primary outcome was medical cost savings, in 2004 U.S. dollars discounted at 5%. Secondary measures include reduction of cardiovascular, cerebrovascular, neuropathy, nephropathy, and retinopathy clinical outcomes. All forms of IT-enabled disease management improved the health of patients with diabetes and reduced health care expenditures. Over 10 years, diabetes registries saved $14.5 billion, computerized decision support saved $10.7 billion, payer-centered technologies saved $7.10 billion, remote monitoring saved $326 million, self-management saved $285 million, and integrated provider-patient systems saved $16.9 billion. IT-enabled diabetes management has the potential to improve care processes, delay diabetes complications, and save health care dollars. Of existing systems, provider-centered technologies such as diabetes registries currently show the most potential for benefit. Fully integrated provider-patient systems would have even greater potential for benefit. These benefits must be weighed against the implementation costs.
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Optimizing the care model for an uncomplicated acute pain episode in sickle cell disease.
Telfer, Paul; Kaya, Banu
2017-12-08
The pathophysiology, clinical presentation, and natural history of acute pain in sickle cell disease are unique and require a disease-centered approach that also applies general principles of acute and chronic pain management. The majority of acute pain episodes are managed at home without the need to access health care. The long-term consequences of poorly treated acute pain include chronic pain, adverse effects of chronic opioid usage, psychological maladjustment, poor quality of life, and excessive health care utilization. There is no standard protocol for management of an acute pain crisis in either the hospital or the community. The assumptions that severe acute pain must be managed in the hospital with parenteral opioids and that strong opioids are needed for home management of pain need to be questioned. Pain management in the emergency department often does not meet acceptable standards, while chronic use of strong opioids is likely to result in opioid-induced hyperalgesia, exacerbation of chronic pain symptoms, and opioid dependency. We suggest that an integrated approach is needed to control the underlying condition, modify psychological responses, optimize social support, and ensure that health care services provide safe, effective, and prompt treatment of acute pain and appropriate management of chronic pain. This integrated approach should begin at an early age and continue through the adolescent, transition, and adult phases of the care model. © 2016 by The American Society of Hematology. All rights reserved.
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The healthy learner model for student chronic condition management--part II: the asthma initiative.
Erickson, Cecelia DuPlessis; Splett, Patricia L; Mullett, Sara Stoltzfus; Jensen, Charlotte; Belseth, Stephanie Bisson
2006-12-01
The Healthy Learner Asthma Initiative (HLAI) was designed as a comprehensive, school-community initiative to improve asthma management and produce healthy learners. National asthma guidelines were translated into components of asthma management in the school setting that defined performance expectations and lead to greater quality and consistency of asthma care. The HLAI incorporated evidence-based practice and introduced the role of the asthma resource nurse. Leadership, capacity building, and strong partnerships among school nurses, students, families, and health care providers were essential to the implementation and sustainability of the HLAI. Professional school nursing and evaluation were defined as key requisites to a successful initiative. Evaluation results indicated positive effects on nursing practice, fewer asthma visits to the health office, and better attendance among students who received asthma care in the school health office. The HLAI provided the basis for development of the Healthy Learner Model for Student Chronic Condition Management.
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Design of a Recommendation System for Adding Support in the Treatment of Chronic Patients.
Torkar, Simon; Benedik, Peter; Rajkovič, Uroš; Šušteršič, Olga; Rajkovič, Vladislav
2016-01-01
Rapid growth of chronic disease cases around the world is adding pressure on healthcare providers to ensure a structured patent follow-up during chronic disease management process. In response to the increasing demand for better chronic disease management and improved health care efficiency, nursing roles have been specialized or enhanced in the primary health care setting. Nurses become key players in chronic disease management process. Study describes a system to help nurses manage the care process of patient with chronic disease. It supports focusing nurse's attention on those resources/solutions that are likely to be most relevant to their particular situation/problem in nursing domain. System is based on multi-relational property graph representing a flexible modeling construct. Graph allows modeling a nursing ontology and the indices that partition domain into an efficient, searchable space where the solution to a problem is seen as abstractly defined traversals through its vertices and edges.
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Finlay, Susanna; Sandall, Jane
2009-10-01
Continuity and advocacy are widely held to be important elements in maternal healthcare, yet they are often lacking from the care women receive. In order to understand this disparity, we draw upon interviews and ethnographic observational findings from The One-to-One Caseload Project, a study exploring the impacts of a caseload model of maternity care within an urban National Health Service provider in Britain. Drawing on Lipsky's (1980) and Prottas's (1979) theories of street-level bureaucracy, this paper attempts to understand how midwives, working on the frontline within caseload and standard care models, manage the competing demands of delivering a personalised service within a bureaucratic organisation. The caseload care model serves as a case study for how a client-centred model of working can assist street-level bureaucrats to manage the administrative pressures of public service organisations and provide their clients with a personalised, responsive service. Nevertheless, despite such benefits, client-centred models of working may have unintended consequences for both health carers and healthcare systems.
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Suter, Paula; Hennessey, Beth; Florez, Donna; Newton Suter, W
2011-01-01
Individuals with chronic obstructive pulmonary disease (COPD) face significant challenges due to frequent distressing dyspnea and deficits related to activities of daily living. Individuals with COPD are often hospitalized frequently for disease exacerbations, negatively impacting quality of life and healthcare expenditure burden. The home-based chronic care model (HBCCM) was designed to address the needs of patients with chronic diseases. This model facilitates the re-design of chronic care delivery within the home health sector by ensuring patient-centered evidence-based care. This HBCCM foundation is Dr. Edward Wagner s chronic care model and has four additional areas of focus: high touch delivery, theory-based self management, specialist oversight and the use of technology. This article will describe this model in detail and outline how model use for patients with COPD can bring value to stakeholders across the health care continuum.
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Improving Health Care Management in Primary Care for Homeless People: A Literature Review.
Jego, Maeva; Abcaya, Julien; Ștefan, Diana-Elena; Calvet-Montredon, Céline; Gentile, Stéphanie
2018-02-10
Homeless people have poorer health status than the general population. They need complex care management, because of associated medical troubles (somatic and psychiatric) and social difficulties. We aimed to describe the main characteristics of the primary care programs that take care of homeless people, and to identify which could be most relevant. We performed a literature review that included articles which described and evaluated primary care programs for homeless people. Most of the programs presented a team-based approach, multidisciplinary and/or integrated care. They often proposed co-located services between somatic health services, mental health services and social support services. They also tried to answer to the specific needs of homeless people. Some characteristics of these programs were associated with significant positive outcomes: tailored primary care organizations, clinic orientation, multidisciplinary team-based models which included primary care physicians and clinic nurses, integration of social support, and engagement in the community's health. Primary health care programs that aimed at taking care of the homeless people should emphasize a multidisciplinary approach and should consider an integrated (mental, somatic and social) care model.
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The Comprehensive Primary Care Initiative: Effects On Spending, Quality, Patients, And Physicians.
Peikes, Deborah; Dale, Stacy; Ghosh, Arkadipta; Taylor, Erin Fries; Swankoski, Kaylyn; O'Malley, Ann S; Day, Timothy J; Duda, Nancy; Singh, Pragya; Anglin, Grace; Sessums, Laura L; Brown, Randall S
2018-06-01
The Comprehensive Primary Care Initiative (CPC), a health care delivery model developed by the Centers for Medicare and Medicaid Services (CMS), tested whether multipayer support of 502 primary care practices across the country would improve primary care delivery, improve care quality, or reduce spending. We evaluated the initiative's effects on care delivery and outcomes for fee-for-service Medicare beneficiaries attributed to initiative practices, relative to those attributed to matched comparison practices. CPC practices reported improvements in primary care delivery, including care management for high-risk patients, enhanced access, and improved coordination of care transitions. The initiative slowed growth in emergency department visits by 2 percent in CPC practices, relative to comparison practices. However, it did not reduce Medicare spending enough to cover care management fees or appreciably improve physician or beneficiary experience or practice performance on a limited set of Medicare claims-based quality measures. As CMS and other payers increasingly use alternative payment models that reward quality and value, CPC provides important lessons about supporting practices in transforming care.
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Hay, Joel W; Lee, Pey-Jiuan; Jin, Haomiao; Guterman, Jeffrey J; Gross-Schulman, Sandra; Ell, Kathleen; Wu, Shinyi
2018-05-01
The Diabetes-Depression Care-Management Adoption Trial is a translational study of safety-net primary care predominantly Hispanic/Latino patients with type 2 diabetes in collaboration with the Los Angeles County Department of Health Services. To evaluate the cost-effectiveness of an information and communication technology (ICT)-facilitated depression care management program. Cost-effectiveness of the ICT-facilitated care (TC) delivery model was evaluated relative to a usual care (UC) and a supported care (SC) model. TC added automated low-intensity periodic depression assessment calls to patients. Patient-reported outcomes included the 12-Item Short Form Health Survey converted into quality-adjusted life-years (QALYs) and the 9-Item Patient Health Questionnaire-calculated depression-free days (DFDs). Costs and outcomes data were collected over a 24-month period (-6 to 0 months baseline, 0 to 18 months study intervention). A sample of 1406 patients (484 in UC, 480 in SC, and 442 in TC) was enrolled in the nonrandomized trial. TC had a significant improvement in DFDs (17.3; P = 0.011) and significantly greater 12-Item Short Form Health Survey utility improvement (2.1%; P = 0.031) compared with UC. Medical costs were statistically significantly lower for TC (-$2328; P = 0.001) relative to UC but not significantly lower than for SC. TC had more than a 50% probability of being cost-effective relative to SC at willingness-to-pay thresholds of more than $50,000/QALY. An ICT-facilitated depression care (TC) delivery model improved QALYs, DFDs, and medical costs. It was cost-effective compared with SC and dominant compared with UC. Copyright © 2017 International Society for Pharmacoeconomics and Outcomes Research (ISPOR). Published by Elsevier Inc. All rights reserved.
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Pediatric Dental Care: Prevention and Management Protocols Based on Caries Risk Assessment
RAMOS-GOMEZ, FRANCISCO J.; CRYSTAL, YASMI O.; NG, MAN WAI; CRALL, JAMES J.; FEATHERSTONE, JOHN D.B.
2012-01-01
Recent increases in caries prevalence in young children, especially among minorities and the economically disadvantaged, highlight the need for early establishment of dental homes and simple, effective infant oral care preventive programs for all children as part of a medical disease prevention management model.1–3 This article presents an updated approach and practical tools for pediatric dental caries management by risk assessment, CAMBRA, in an effort to stimulate greater adoption of infant oral care programs among clinicians and early establishment of dental homes for young children. PMID:21162350
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A transitional care service for elderly chronic disease patients at risk of readmission.
Brand, Caroline A; Jones, Catherine T; Lowe, Adrian J; Nielsen, David A; Roberts, Carol A; King, Bellinda L; Campbell, Donald A
2004-12-13
Multiple hospital admissions, especially those related to chronic disease, represent a particular challenge to the acute health care sector in Australia. To determine whether a nurse-led chronic disease management model of transitional care reduced readmissions to acute care. A quasi-experimental controlled trial. A large tertiary metropolitan teaching hospital. 166 general medical patients aged > or = 65 years with either a history of readmissions to acute care or multiple medical comorbidities. Implementation of a chronic disease management model of transitional care aimed at improving patient management and reducing readmissions to acute care. Readmission rates and emergency department presentation rates at 3-and 6-month follow up. Secondary outcome measures include quality of life, discharge destination, and primary health care service utilisation. There was no difference in readmission rates, emergency department presentation rates, quality of life, discharge destination or primary health care service utilisation. The difficulties inherent in evaluating this type of multifactorial intervention are discussed and consideration is given to patient factors, the difficulty of influencing readmission rates, and local system issues. The outcomes of this study reflect the tension that exists between implementing multifaceted integrated health service programs and attempting to evaluate them within complex and changing environments using robust research methodologies.
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Glurich, Ingrid; Nycz, Gregory; Acharya, Amit
2017-06-01
Escalating prevalence of both diabetes and periodontal disease, two diseases associated with bi-directional exacerbation, has been reported. Periodontal disease represents a modifiable risk factor that may reduce diabetes onset or progression, and integrated models of cross-disciplinary care are needed to establish and manage glycemic control in affected patients. An ad-hoc environmental scan of current literature and media sought to characterize factors impacting status of integrated care models based on review of the existing evidence base in literature and media surrounding: (1) current cross-disciplinary practice patterns, (2) epidemiological updates, (3) status on risk assessment and screening for dysglycemia in the dental setting, (4) status on implementation of quality metrics for oral health, (5) care model pilots, and (6) public health perspectives. The survey revealed: escalating prevalence of diabetes and periodontitis globally; greater emphasis on oral health assessment for diabetic patients in recent medical clinical practice guidelines; high knowledgeability surrounding oral-systemic impacts on diabetes and growing receptivity to medical-dental integration among medical and dental providers; increasing numbers of programs/studies reporting on positive impact of emerging integrated dental-medical care models on diabetic patient healthcare access and health outcomes; a growing evidence base for clinically significant rates of undiagnosed dysglycemia among dental patients reported by point-of-care pilot studies; no current recommendation for population-based screening for dysglycemia in dental settings pending a stronger evidence base; improved definition of true periodontitis prevalence in (pre)/diabetics; emerging recognition of the need for oral health quality indicators and tracking; evidence of persistence in dental access disparity; updated status on barriers to integration. The potential benefit of creating clinically-applicable integrated care models to support holistic management of an escalating diabetic population by targeting modifiable risk factors including periodontitis is being recognized by the health industry. Cross-disciplinary efforts supported by high quality research are needed to mitigate previously- and newly-defined barriers of care integration and expedite development and implementation of integrated care models in various practice settings. Implementation of quality monitoring in the dental setting will support definition of the impact and efficacy of interventional clinical care models on patient outcomes. © 2017 Marshfield Clinic.
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Campos, G W
1998-01-01
This paper describes a new health care management method. A triangular confrontation system was constructed, based on a theoretical review, empirical facts observed from health services, and the researcher's knowledge, jointly analyzed. This new management model was termed 'health-team-focused collegiate management', entailing several original organizational concepts: production unity, matrix-based reference team, collegiate management system, cogovernance, and product/production interface.
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Clinical outcomes of HIV care delivery models in the US: a systematic review.
Kimmel, April D; Martin, Erika G; Galadima, Hadiza; Bono, Rose S; Tehrani, Ali Bonakdar; Cyrus, John W; Henderson, Margaret; Freedberg, Kenneth A; Krist, Alexander H
2016-10-01
With over 1 million people living with HIV, the US faces national challenges in HIV care delivery due to an inadequate HIV specialist workforce and the increasing role of non-communicable chronic diseases in driving morbidity and mortality in HIV-infected patients. Alternative HIV care delivery models, which include substantial roles for advanced practitioners and/or coordination between specialty and primary care settings in managing HIV-infected patients, may address these needs. We aimed to systematically review the evidence on patient-level HIV-specific and primary care health outcomes for HIV-infected adults receiving outpatient care across HIV care delivery models. We identified randomized trials and observational studies from bibliographic and other databases through March 2016. Eligible studies met pre-specified eligibility criteria including on care delivery models and patient-level health outcomes. We considered all available evidence, including non-experimental studies, and evaluated studies for risk of bias. We identified 3605 studies, of which 13 met eligibility criteria. Of the 13 eligible studies, the majority evaluated specialty-based care (9 studies). Across all studies and care delivery models, eligible studies primarily reported mortality and antiretroviral use, with specialty-based care associated with mortality reductions at the clinician and practice levels and with increased antiretroviral initiation or use at the clinician level but not the practice level. Limited and heterogeneous outcomes were reported for other patient-level HIV-specific outcomes (e.g., viral suppression) as well as for primary care health outcomes across all care delivery models. No studies addressed chronic care outcomes related to aging. Limited evidence was available across geographic settings and key populations. As re-design of care delivery in the US continues to evolve, better understanding of patient-level HIV-related and primary care health outcomes, especially across different staffing models and among different patient populations and geographic locations, is urgently needed to improve HIV disease management.
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Liu, Hsin-Yun; Tseng, Ming-Yueh; Li, Hsiao-Juan; Wu, Chi-Chuan; Cheng, Huey-Shinn; Yang, Ching-Tzu; Chou, Shih-Wei; Chen, Ching-Yen; Shyu, Yea-Ing L
2014-06-01
The effects of nutritional management among other intervention components have not been examined for hip-fractured elderly persons with poor nutritional status. Accordingly, this study explored the intervention effects of an in-home program using a comprehensive care model that included a nutrition-management component on recovery of hip-fractured older persons with poor nutritional status at hospital discharge. A secondary analysis of data from a randomized controlled trial with 24-month follow-up. A 3000-bed medical center in northern Taiwan. Subjects were included only if they had "poor nutritional status" at hospital discharge, including those at risk for malnutrition or malnourished. The subsample included 80 subjects with poor nutritional status in the comprehensive care group, 87 in the interdisciplinary care group, and 85 in the usual care group. The 3 care models were usual care, interdisciplinary care, and comprehensive care. Usual care provided no in-home care, interdisciplinary care provided 4 months of in-home rehabilitation, and comprehensive care included management of depressive symptoms, falls, and nutrition as well as 1 year of in-home rehabilitation. Data were collected on nutritional status and physical functions, including range of motion, muscle power, proprioception, balance and functional independence, and analyzed using a generalized estimating equation approach. We also compared patients' baseline characteristics: demographic characteristics, type of surgery, comorbidities, length of hospital stay, cognitive function, and depression. Patients with poor nutritional status who received comprehensive care were 1.67 times (95% confidence interval 1.06-2.61) more likely to recover their nutritional status than those who received interdisciplinary and usual care. Furthermore, the comprehensive care model improved the functional independence and balance of patients who recovered their nutritional status over the first year following discharge, but not of those who had not yet recovered. An in-home program using the comprehensive care model with a nutritional component effectively improved the nutritional status of hip-fractured patients with poor nutrition. This comprehensive care intervention more effectively improved recovery of functional independence and balance for patients with recovered nutritional status. Copyright © 2014 American Medical Directors Association, Inc. Published by Elsevier Inc. All rights reserved.
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Out of Place: Mediating Health and Social Care in Ontario's Long-Term Care Sector
ERIC Educational Resources Information Center
Daly, Tamara
2007-01-01
The paper discusses two reforms in Ontario's long-term care. The first is the commercialization of home care as a result of the implementation of a "managed competition" delivery model. The second is the Ministry of Health and Long-Term Care's privileging of "health care" over "social care" through changes to which…
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[Quality assurance and total quality management in residential home care].
Nübling, R; Schrempp, C; Kress, G; Löschmann, C; Neubart, R; Kuhlmey, A
2004-02-01
Quality, quality assurance, and quality management have been important topics in residential care homes for several years. However, only as a result of reform processes in the German legislation (long-term care insurance, care quality assurance) is a systematic discussion taking place. Furthermore, initiatives and holistic model projects, which deal with the assessment and improvement of service quality, were developed in the field of care for the elderly. The present article gives a critical overview of essential developments. Different comprehensive approaches such as the implementation of quality management systems, nationwide expert-based initiatives, and developments towards professionalizing care are discussed. Empirically based approaches, especially those emphasizing the assessment of outcome quality, are focused on in this work. Overall, the authors conclude that in the past few years comprehensive efforts have been made to improve the quality of care. However, the current situation still requires much work to establish a nationwide launch and implementation of evidence-based quality assurance and quality management.
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Health and social care management for older adults with multimorbidity: a multiperspective approach.
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.
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Jones, Shelley L
2015-08-01
The role of the outreach diabetes case manager in New Brunswick, Canada, was first developed in the Moncton Area of Horizon Health Network in response to a physician-identified gap between patients' diagnoses of diabetes and their attendance at the local diabetes education centre. This model of collaborative interprofessional practice increases support for primary care providers and people living with diabetes in that they are being provided the services of certified diabetes educators who can address knowledge gaps with respect to evidence-based guidelines and best practice, promote advancement of diabetes and chronic-disease management therapies and support adherence to treatment plans and self-management practices. This report chronicles a review of the implementation, expansion and evaluation of the outreach diabetes case manager model in the province of New Brunswick, Canada, along with the rationale for development of the role for registered nurses in other jurisdictions. Crown Copyright © 2015. Published by Elsevier Inc. All rights reserved.
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Weintraub, William S; Elliott, Daniel; Fanari, Zaher; Ostertag-Stretch, Jennifer; Muther, Ann; Lynahan, Margaret; Kerzner, Roger; Salam, Tabassum; Scherrer, Herbert; Anderson, Sharon; Russo, Carla A; Kolm, Paul; Steinberg, Terri H
Reducing readmissions and improving metrics of care are a national priority. Supplementing traditional care with care management may improve outcomes. The Bridges program was an initial evaluation of a care management platform (CareLinkHub), supported by information technology (IT) developed to improve the quality and transition of care from hospital to home after Coronary Artery Bypass Surgery (CABG) and reduce readmissions. CareLink is comprised of care managers, patient navigators, pharmacists and physicians. Information to guide care management is guided by a middleware layer to gather information, PLR (ColdLight Solutions, LLC) and presented to CareLink staff on a care management platform, Aerial™ (Medecision). In addition there is an analytic engine to help evaluate and guide care, Neuron™ (Coldlight Solutions, LLC). The "Bridges" program enrolled a total of 716 CABG patients with 850 admissions from April 2013 through March 2015. The data of the program was compared with those of 1111 CABG patients with 1203 admissions in the 3years prior to the program. No impact was seen with respect to readmissions, Blood Pressure or LDL control. There was no significant improvement in patients' reported outcomes using either the CTM-3 or any of the SAQ-7 scores. Patient follow-up with physicians within 1week of discharge improved during the Bridges years. The CareLink hub platform was successfully implemented. Little or no impact on outcome metrics was seen in the short follow-up time. Copyright © 2017 Elsevier Inc. All rights reserved.
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Phillips, Kelly-Anne; Steel, Emma J; Collins, Ian; Emery, Jon; Pirotta, Marie; Mann, G Bruce; Butow, Phyllis; Hopper, John L; Trainer, Alison; Moreton, Jane; Antoniou, Antonis C; Cuzick, Jack; Keogh, Louise
2016-01-01
To capitalise on advances in breast cancer prevention, all women would need to have their breast cancer risk formally assessed. With ~85% of Australians attending primary care clinics at least once a year, primary care is an opportune location for formal breast cancer risk assessment and management. This study assessed the current practice and needs of primary care clinicians regarding assessment and management of breast cancer risk. Two facilitated focus group discussions were held with 17 primary care clinicians (12 GPs and 5 practice nurses (PNs)) as part of a larger needs assessment. Primary care clinicians viewed assessment and management of cardiovascular risk as an intrinsic, expected part of their role, often triggered by practice software prompts and facilitated by use of an online tool. Conversely, assessment of breast cancer risk was not routine and was generally patient- (not clinician-) initiated, and risk management (apart from routine screening) was considered outside the primary care domain. Clinicians suggested that routine assessment and management of breast cancer risk might be achieved if it were widely endorsed as within the remit of primary care and supported by an online risk-assessment and decision aid tool that was integrated into primary care software. This study identified several key issues that would need to be addressed to facilitate the transition to routine assessment and management of breast cancer risk in primary care, based largely on the model used for cardiovascular disease.
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Making sense of change: patients' views of diabetes and GP-led integrated diabetes care.
Burridge, Letitia H; Foster, Michele M; Donald, Maria; Zhang, Jianzhen; Russell, Anthony W; Jackson, Claire L
2016-02-01
Health system reform is directed towards better management of diabetes. However, change can be difficult, and patients' perspectives are a key aspect of implementing change. This study investigated patients' perceptions and experiences of type 2 diabetes (T2DM), self-care and engagement with GP-led integrated diabetes care. Qualitative interviews were conducted with purposively selected patients with T2DM following their initial medical appointment in the new model of care. Normalization process theory was used to orientate the thematic analysis, to explain the work of implementing change. Two specialist GP-based complex diabetes services in primary care in Brisbane, Australia. Intervention group patients (n = 30) in a randomized controlled trial to evaluate a model of GP-led integrated care for complex T2DM. Participants' experiences and perceptions of diabetes management and a GP-led model of care. Three themes were identified: sensibility of change, 'diabetic life' and diabetes care alliance. The imperative of change made sense, but some participants experienced dissonance between this rational view and their lived reality. Diabetes invaded life, revealing incongruities between participants' values and living with diabetes. They appreciated a flexible and personalized approach to care. Participants responded to advice in ways that seemed rational within the complexities of their life context. Their diabetes partnerships with health professionals coupled providers' biomedical expertise with patients' contextual expertise. Learning to manage relationships with various health professionals adds to patients' diabetes-related work. Providers need to adopt a flexible, interactive approach and foster trust, to enable better diabetes care. © 2015 John Wiley & Sons Ltd.
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Through the Eyes of Nurse Managers in Long-Term Care: Identifying Perceived Competencies and Skills.
Dever, Kathleen H
2018-05-01
Nurse managers (NMs) in long-term care supervise health care services for individuals with high acuity levels and numerous comorbidities. There is minimal research identifying NMs' skills and competencies as unit leaders within the long-term care environment. The current mixed-methods study identified NMs' leadership skills and competencies. Nineteen NMs with ≥5 years' long-term care management experience completed the Nurse Manager Inventory Tool and were individually interviewed. They rated their clinical skills at the competent level and their financial/strategic management skills at the novice level. All other skill categories, including leadership reflective practice, diversity, human resource leadership/management, relationship management, performance improvement, and problem solving, were rated at a competent level. Emergent interview qualitative themes included their visibility on the unit, trial and error learning, a sense of "aloneness" due to the absence of other RNs, NM position being a tough job, need for peer support, role modeling, and importance of supporting the resident through their "final journey." [Journal of Gerontological Nursing, 44(5), 32-38.]. Copyright 2018, SLACK Incorporated.
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Steuten, L M G; Vrijhoef, H J M; Landewé-Cleuren, S; Schaper, N; Van Merode, G G; Spreeuwenberg, C
2007-10-01
To assess the impact of a disease management programme for patients with diabetes mellitus (Type 1 and Type 2) on cost-effectiveness, quality of life and patient self-management. By organizing care in accordance with the principles of disease management, it is aimed to increase quality of care within existing budgets. Single-group, pre-post design with 2-year follow-up in 473 patients. Substantial significant improvements in glycaemic control, health-related quality of life (HRQL) and patient self-management were found. No significant changes were detected in total costs of care. The probability that the disease management programme is cost-effective compared with usual care amounts to 74%, expressed in an average saving of 117 per additional life year at 5% improved HRQL. Introduction of a disease management programme for patients with diabetes is associated with improved intermediate outcomes within existing budgets. Further research should focus on long-term cost-effectiveness, including diabetic complications and mortality, in a controlled setting or by using decision-analytic modelling techniques.
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Beyond profession: nursing leadership in contemporary healthcare.
Sorensen, Roslyn; Iedema, Rick; Severinsson, Elisabeth
2008-07-01
To examine nursing leadership in contemporary health care and its potential contribution to health service organization and management. As the nursing profession repositions itself as an equal partner in health care beside medicine and management, its enhanced nursing standards and clinical knowledge are not leading to a commensurate extension of nursing's power and authority in the organization. An ethnographic study of an ICU in Sydney, Australia, comprising: interviews with unit nursing managers (4); focus groups (3) with less experienced, intermediate and experienced nurses (29 in total); and interviews with senior nurse manager (1). Inter- and intra-professional barriers in the workplace, fragmentation of multidisciplinary clinical systems that collectively deliver care, and clinical and administrative disconnection in resolving organizational problems, prevented nurses articulating a model of intensive and end-of-life care. Professional advocacy skills are needed to overcome barriers and to articulate and operationalize new nursing knowledge and standards if nurses are to enact and embed a leadership role. The profession will need to move beyond a reliance on professional clinical models to become skilled multidisciplinary team members and professional advocates for nurses to take their place as equal partners in health care.
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ERIC Educational Resources Information Center
de Stampa, Matthieu; Vedel, Isabelle; Bergman, Howard; Novella, Jean-Luc; Lechowski, Laurent; Ankri, Joel; Lapointe, Liette
2013-01-01
Purpose: The purpose of the study was to understand better the clinical collaboration process among primary care physicians (PCPs), case managers (CMs), and geriatricians in integrated models of care. Methods: We conducted a qualitative study with semistructured interviews. A purposive sample of 35 PCPs, 7 CMs, and 4 geriatricians was selected in…
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A nurse-led model of chronic disease management in general practice: Patients' perspectives.
Young, Jacqueline; Eley, Diann; Patterson, Elizabeth; Turner, Catherine
2016-12-01
Evidence suggests that current models of chronic disease management within general practice are not effective in meeting the needs of the community. The objective of this article is to examine patients' perceptions of a nurse-led collaborative model of care trialled in three general practices in Australia. This article reports on the second phase of a mixed-methods study in which semi-structured interviews with purposively selected patients were conducted to elicit information about their perceptions of nurse-led care. Three themes emerged from the data - time, ambiance and dimensions of the nurse role. The results suggest that general practice nurses had a positive impact on patients' ability to manage their chronic disease. This infers that there is scope for general practice nurses to expand their role in chronic disease management to assist patients to better self-manage their chronic diseases.
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Ahluwalia, Sangeeta C; Harris, Benjamin J; Lewis, Valerie A; Colla, Carrie H
2018-06-01
To measure the extent to which accountable care organizations (ACOs) have adopted end-of-life (EOL) care planning processes and characterize those ACOs that have established processes related to EOL. This study uses data from three waves (2012-2015) of the National Survey of ACOs. Respondents were 397 ACOs participating in Medicare, Medicaid, and commercial ACO contracts. This is a cross-sectional survey study using multivariate ordered logit regression models. We measured the extent to which the ACO had adopted EOL care planning processes as well as organizational characteristics, including care management, utilization management, health informatics, and shared decision-making capabilities, palliative care, and patient-centered medical home experience. Twenty-one percent of ACOs had few or no EOL care planning processes, 60 percent had some processes, and 19.6 percent had advanced processes. ACOs with a hospital in their system (OR: 3.07; p = .01), and ACOs with advanced care management (OR: 1.43; p = .02), utilization management (OR: 1.58, p = .00), and shared decision-making capabilities (OR: 16.3, p = .000) were more likely to have EOL care planning processes than those with no hospital or few to no capabilities. There remains considerable room for today's ACOs to increase uptake of EOL care planning, possibly by leveraging existing care management, utilization management, and shared decision-making processes. © Health Research and Educational Trust.
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Aged care nurses' job control influence satisfaction and mental health.
Elliott, Kate-Ellen J; Rodwell, John; Martin, Angela J
2017-10-01
Relationships exist between aged care nurses' perceptions of psychosocial work characteristics, job satisfaction and mental health, suggesting these characteristics may be important for the management of aged care services. An expanded demand-control-support model that included justice perceptions was examined to determine its impact on multiple types of psychological and organisational well-being outcomes (i.e. job satisfaction, psychological distress and depression). Data were collected from a sample of 173 aged care nurses using a self-report survey and analysed using hierarchical multiple regression. A significant proportion (27-28%) of the variance in aged care nurses' satisfaction, depression and psychological distress was explained by the psychosocial factors included in the model. Job control had the most consistent impact with direct effects on job satisfaction, psychological distress and depression. Informational justice was associated with both psychological distress and depression. Targeting job control may provide the biggest response for nurse managers in aged care, as it is likely to influence nurses' job satisfaction, psychological distress and depression. Facility managers should implement organisational policies and procedures that promote higher levels of control over how nurses perform their work in order to improve nurse well-being in aged care settings. © 2017 John Wiley & Sons Ltd.
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Kowinsky, Amy M; Shovel, Judith; McLaughlin, Maribeth; Vertacnik, Lisa; Greenhouse, Pamela K; Martin, Susan Christie; Minnier, Tamra E
2012-01-01
Predictable and unpredictable patient care tasks compete for caregiver time and attention, making it difficult for patient care staff to reliably and consistently meet patient needs. We have piloted a redesigned care model that separates the work of patient care technicians based on task predictability and creates role specificity. This care model shows promise in improving the ability of staff to reliably complete tasks in a more consistent and timely manner.
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Kibicho, Jennifer; Owczarzak, Jill
2012-01-01
Reflecting trends in health care delivery, pharmacy practice has shifted from a drug-specific to a patient-centered model of care, aimed at improving the quality of patient care and reducing health care costs. In this article, we outline a theoretical model of patient-centered pharmacy services (PCPS), based on in-depth, qualitative interviews with a purposive sample of 28 pharmacists providing care to HIV-infected patients in specialty, semispecialty, and nonspecialty pharmacy settings. Data analysis was an interactive process informed by pharmacists' interviews and a review of the general literature on patient centered care, including Medication Therapy Management (MTM) services. Our main finding was that the current models of pharmacy services, including MTM, do not capture the range of pharmacy services in excess of mandated drug dispensing services. In this article, we propose a theoretical PCPS model that reflects the actual services pharmacists provide. The model includes five elements: (1) addressing patients as whole, contextualized persons; (2) customizing interventions to unique patient circumstances; (3) empowering patients to take responsibility for their own health care; (4) collaborating with clinical and nonclinical providers to address patient needs; and (5) developing sustained relationships with patients. The overarching goal of PCPS is to empower patients' to take responsibility for their own health care and self-manage their HIV-infection. Our findings provide the foundation for future studies regarding how widespread these practices are in diverse community settings, the validity of the proposed PCPS model, the potential for standardizing pharmacist practices, and the feasibility of a PCPS framework to reimburse pharmacists services.
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A model for community-based pediatric oral heath: implementation of an infant oral care program.
Ramos-Gomez, Francisco J
2014-01-01
The Affordable Care Act (ACA) mandates risk assessments, preventive care, and evaluations based on outcomes. ACA compliance will require easily accessible, cost-effective care models that are flexible and simple to establish. UCLA has developed an Infant Oral Care Program (IOCP) in partnership with community-based organizations that is an intervention model providing culturally competent perinatal and infant oral care for underserved, low-income, and/or minority children aged 0-5 and their caregivers. In collaboration with the Venice Family Clinic's Simms/Mann Health and Wellness Center, UCLA Pediatrics, Women, Infants, and Children (WIC), and Early Head Start and Head Start programs, the IOCP increases family-centered care access and promotes early utilization of dental services in nontraditional, primary care settings. Emphasizing disease prevention, management, and care that is sensitive to cultural, language, and oral health literacy challenges, IOCP patients achieve better oral health maintenance "in health" not in "disease modality". IOCP uses interprofessional education to promote pediatric oral health across multiple disciplines and highlights the necessity for the "age-one visit". This innovative clinical model facilitates early intervention and disease management. It sets a new standard of minimally invasive dental care that is widely available and prevention focused, with high retention rates due to strong collaborations with the community-based organizations serving these vulnerable, high-risk children.
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Ambrosio, Art; Brigger, Matthew T
2014-07-01
(1) To determine the association between socioeconomic status (SES), race/ethnicity, and other demographic risk factors in surgically managed otitis media within a model of universal health care. 2) To determine quality of life (QOL) outcomes of surgically managed otitis media in this model. Tertiary academic medical center. Prospective cohort study. A prospective study was conducted between June 2011 and December 2012 with dependent children of military families. TRICARE provides equal access to care among all beneficiaries regardless of a wide range of annual incomes. Caretakers of children scheduled for bilateral myringotomy and tympanostomy tube (BMT) placement were administered a demographic survey, as well as OM-6 QOL instrument preoperatively and 6 weeks postoperatively. A control group who did not undergo BMT was also administered both the survey and OM-6 for comparison. Two hundred forty patients were enrolled (120 surgical patients and 120 controls). Logistic regression demonstrated age younger than 6 years old (P < .001), day care attendance (P < .001), and non-Hispanic Caucasian race (P = .022) to be associated with surgery. Surgical QOL outcomes demonstrated a significant improvement in otitis media-6 (OM-6) scores after surgical management from 3.00 (95% confidence interval [CI], 2.79-3.20) to 1.35 (95% CI, 1.22-1.47). In a universal health care model serving more than 2 million children, previously reported proxies of low SES as well as minority race/ethnicity were not associated with surgically managed otitis media contrary to reported literature. Caucasian race, young age, and day care attendance were associated with surgery. Surgery improved QOL outcomes 6 weeks postoperatively. © American Academy of Otolaryngology—Head and Neck Surgery Foundation 2014.
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An Application of Business Process Management to Health Care Facilities.
Hassan, Mohsen M D
The purpose of this article is to help health care facility managers and personnel identify significant elements of their facilities to address, and steps and actions to follow, when applying business process management to them. The ABPMP (Association of Business Process Management Professionals) life-cycle model of business process management is adopted, and steps from Lean, business process reengineering, and Six Sigma, and actions from operations management are presented to implement it. Managers of health care facilities can find in business process management a more comprehensive approach to improving their facilities than Lean, Six Sigma, business process reengineering, and ad hoc approaches that does not conflict with them because many of their elements can be included under its umbrella. Furthermore, the suggested application of business process management can guide and relieve them from selecting among these approaches, as well as provide them with specific steps and actions that they can follow. This article fills a gap in the literature by presenting a much needed comprehensive application of business process management to health care facilities that has specific steps and actions for implementation.
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The transprofessional model: blending intents in terminal care of AIDS.
Cherin, D A; Simmons, W J; Hillary, K
1998-01-01
Current terminal care services present dying patients and their families with a dichotomy in service delivery and the intent care between curative treatments and palliative treatments. This arbitrary dichotomy reduces patients' quality of life in many cases and robs patients and families of benefiting from the psychosocial aspects of treatment until the last few weeks of life. This article presents a blended model of care, the Transprofessional Model, in which patients receive both curative and palliative service throughout their care process. The blended intent model differs from traditional home care in that services are provided by a care coordination team composed of nurses and social workers; the traditional model of care is often case managed by a single, registered nurse. The combination of the multi-disciplinary approach to care coordination and training in both curative and palliative services in the Transprofessional Model demonstrates that this blended model of care produces a bio-psychosocial focus to terminal care as compared to a primary focus on curative services present in the traditional model of home care.
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Swiss and Dutch "consumer-driven health care": ideal model or reality?
Okma, Kieke G H; Crivelli, Luca
2013-02-01
This article addresses three topics. First, it reports on the international interest in the health care reforms of Switzerland and The Netherlands in the 1990s and early 2000s that operate under the label "managed competition" or "consumer-driven health care." Second, the article reviews the behavior assumptions that make plausible the case for the model of "managed competition." Third, it analyze the actual reform experience of Switzerland and Holland to assess to what extent they confirm the validity of those assumptions. The article concludes that there is a triple gap in understanding of those topics: a gap between the theoretical model of managed competition and the reforms as implemented in both Switzerland and The Netherlands; second, a gap between the expectations of policy-makers and the results of the reforms, and third, a gap between reform outcomes and the observations of external commentators that have embraced the reforms as the ultimate success of "consumer-driven health care." The article concludes with a discussion of the implications of this "triple gap". Copyright © 2012 Elsevier Ireland Ltd. All rights reserved.
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Moen, Hans; Ginter, Filip; Marsi, Erwin; Peltonen, Laura-Maria; Salakoski, Tapio; Salanterä, Sanna
2015-01-01
Patients' health related information is stored in electronic health records (EHRs) by health service providers. These records include sequential documentation of care episodes in the form of clinical notes. EHRs are used throughout the health care sector by professionals, administrators and patients, primarily for clinical purposes, but also for secondary purposes such as decision support and research. The vast amounts of information in EHR systems complicate information management and increase the risk of information overload. Therefore, clinicians and researchers need new tools to manage the information stored in the EHRs. A common use case is, given a--possibly unfinished--care episode, to retrieve the most similar care episodes among the records. This paper presents several methods for information retrieval, focusing on care episode retrieval, based on textual similarity, where similarity is measured through domain-specific modelling of the distributional semantics of words. Models include variants of random indexing and the semantic neural network model word2vec. Two novel methods are introduced that utilize the ICD-10 codes attached to care episodes to better induce domain-specificity in the semantic model. We report on experimental evaluation of care episode retrieval that circumvents the lack of human judgements regarding episode relevance. Results suggest that several of the methods proposed outperform a state-of-the art search engine (Lucene) on the retrieval task.
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2015-01-01
Patients' health related information is stored in electronic health records (EHRs) by health service providers. These records include sequential documentation of care episodes in the form of clinical notes. EHRs are used throughout the health care sector by professionals, administrators and patients, primarily for clinical purposes, but also for secondary purposes such as decision support and research. The vast amounts of information in EHR systems complicate information management and increase the risk of information overload. Therefore, clinicians and researchers need new tools to manage the information stored in the EHRs. A common use case is, given a - possibly unfinished - care episode, to retrieve the most similar care episodes among the records. This paper presents several methods for information retrieval, focusing on care episode retrieval, based on textual similarity, where similarity is measured through domain-specific modelling of the distributional semantics of words. Models include variants of random indexing and the semantic neural network model word2vec. Two novel methods are introduced that utilize the ICD-10 codes attached to care episodes to better induce domain-specificity in the semantic model. We report on experimental evaluation of care episode retrieval that circumvents the lack of human judgements regarding episode relevance. Results suggest that several of the methods proposed outperform a state-of-the art search engine (Lucene) on the retrieval task. PMID:26099735
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Managed care quality of care and plan choice in New York SCHIP.
Liu, Hangsheng; Phelps, Charles E; Veazie, Peter J; Dick, Andrew W; Klein, Jonathan D; Shone, Laura P; Noyes, Katia; Szilagyi, Peter G
2009-06-01
To examine whether low-income parents of children enrolled in the New York State Children's Health Insurance Program (SCHIP) choose managed care plans with better quality of care. 2001 New York SCHIP evaluation data; 2001 New York State Managed Care Plan Performance Report; 2000 New York State Managed Care Enrollment Report. Each market was defined as a county. A final sample of 2,325 new enrollees was analyzed after excluding those in markets with only one SCHIP plan. Plan quality was measured using seven Consumer Assessment of Health Plans Survey (CAHPS) and three Health Plan Employer Data and Information Set (HEDIS) scores. A conditional logit model was applied with plan and individual/family characteristics as covariates. There were 30 plans in the 45 defined markets. The choice probability increased 2.5 percentage points for each unit increase in the average CAHPS score, and the association was significantly larger in children with special health care needs. However, HEDIS did not show any statistically significant association with plan choice. Low-income parents do choose managed care plans with higher CAHPS scores for their newly enrolled children, suggesting that overall quality could improve over time because of the dynamics of enrollment.
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Ameh, Soter; Gómez-Olivé, Francesc Xavier; Kahn, Kathleen; Tollman, Stephen M; Klipstein-Grobusch, Kerstin
2017-03-23
South Africa faces a complex dual burden of chronic communicable and non-communicable diseases (NCDs). In response, the Integrated Chronic Disease Management (ICDM) model was initiated in primary health care (PHC) facilities in 2011 to leverage the HIV/ART programme to scale-up services for NCDs, achieve optimal patient health outcomes and improve the quality of medical care. However, little is known about the quality of care in the ICDM model. The objectives of this study were to: i) assess patients' and operational managers' satisfaction with the dimensions of ICDM services; and ii) evaluate the quality of care in the ICDM model using Avedis Donabedian's theory of relationships between structure (resources), process (clinical activities) and outcome (desired result of healthcare) constructs as a measure of quality of care. A cross-sectional study was conducted in 2013 in seven PHC facilities in the Bushbuckridge municipality of Mpumalanga Province, north-east South Africa - an area underpinned by a robust Health and Demographic Surveillance System (HDSS). The patient satisfaction questionnaire (PSQ-18), with measures reflecting structure/process/outcome (SPO) constructs, was adapted and administered to 435 chronic disease patients and the operational managers of all seven PHC facilities. The adapted questionnaire contained 17 dimensions of care, including eight dimensions identified as priority areas in the ICDM model - critical drugs, equipment, referral, defaulter tracing, prepacking of medicines, clinic appointments, waiting time, and coherence. A structural equation model was fit to operationalise Donabedian's theory, using unidirectional, mediation, and reciprocal pathways. The mediation pathway showed that the relationships between structure, process and outcome represented quality systems in the ICDM model. Structure correlated with process (0.40) and outcome (0.75). Given structure, process correlated with outcome (0.88). Of the 17 dimensions of care in the ICDM model, three structure (equipment, critical drugs, accessibility), three process (professionalism, friendliness and attendance to patients) and three outcome (competence, confidence and coherence) dimensions reflected their intended constructs. Of the priority dimensions, referrals, defaulter tracing, prepacking of medicines, appointments, and patient waiting time did not reflect their intended constructs. Donabedian's theoretical framework can be used to provide evidence of quality systems in the ICDM model.
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Howard, Steven W; Bernell, Stephanie L; Yoon, Jangho; Luck, Jeff; Ranit, Claire M
2015-02-01
To control Medicaid costs, improve quality, and drive community engagement, the Oregon Health Authority introduced a new system of coordinated care organizations (CCOs). While CCOs resemble traditional Medicaid managed care, they have differences that have been deliberately designed to improve care coordination, increase accountability, and incorporate greater community governance. Reforms include global budgets integrating medical, behavioral, and oral health care and public health functions; risk-adjusted payments rewarding outcomes and evidence-based practice; increased transparency; and greater community engagement. The CCO model faces several implementation challenges. If successful, it will provide improved health care delivery, better health outcomes, and overall savings. Copyright © 2015 by Duke University Press.
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Anderson, G F; Han, K C; Miller, R H; Johns, M E
1997-01-01
OBJECTIVE: To compare three methods of computing the national requirements for otolaryngologists in 1994 and 2010. DATA SOURCES: Three large HMOs, a Delphi panel, the Bureau of Health Professions (BHPr), and published sources. STUDY DESIGN: Three established methods of computing requirements for otolaryngologists were compared: managed care, demand-utilization, and adjusted needs assessment. Under the managed care model, a published method based on reviewing staffing patterns in HMOs was modified to estimate the number of otolaryngologists. We obtained from BHPr estimates of work force projections from their demand model. To estimate the adjusted needs model, we convened a Delphi panel of otolaryngologists using the methodology developed by the Graduate Medical Education National Advisory Committee (GMENAC). DATA COLLECTION/EXTRACTION METHODS: Not applicable. PRINCIPAL FINDINGS: Wide variation in the estimated number of otolaryngologists required occurred across the three methods. Within each model it was possible to alter the requirements for otolaryngologists significantly by changing one or more of the key assumptions. The managed care model has a potential to obtain the most reliable estimates because it reflects actual staffing patterns in institutions that are attempting to use physicians efficiently. CONCLUSIONS: Estimates of work force requirements can vary considerably if one or more assumptions are changed. In order for the managed care approach to be useful for actual decision making concerning the appropriate number of otolaryngologists required, additional research on the methodology used to extrapolate the results to the general population is necessary. PMID:9180613
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Tuot, Delphine S; Leeds, Kiren; Murphy, Elizabeth J; Sarkar, Urmimala; Lyles, Courtney R; Mekonnen, Tekeshe; Chen, Alice H M
2015-12-19
Access to specialty care remains a challenge for primary care providers and patients. Implementation of electronic referral and/or consultation (eCR) systems provides an opportunity for innovations in the delivery of specialty care. We conducted key informant interviews to identify drivers, facilitators, barriers and evaluation metrics of diverse eCR systems to inform widespread implementation of this model of specialty care delivery. Interviews were conducted with leaders of 16 diverse health care delivery organizations between January 2013 and April 2014. A limited snowball sampling approach was used for recruitment. Content analysis was used to examine key informant interview transcripts. Electronic referral systems, which provide referral management and triage by specialists, were developed to enhance tracking and operational efficiency. Electronic consultation systems, which encourage bi-directional communication between primary care and specialist providers facilitating longitudinal virtual co-management, were developed to improve access to specialty expertise. Integrated eCR systems leverage both functionalities to enhance the delivery of coordinated, specialty care at the population level. Elements of successful eCR system implementation included executive and clinician leadership, established funding models for specialist clinician reimbursement, and a commitment to optimizing clinician workflows. eCR systems have great potential to streamline access to and enhance the coordination of specialty care delivery. While different eCR models help solve different organizational challenges, all require institutional investments for successful implementation, such as funding for program management, leadership and clinician incentives.
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Bekelman, David B; Plomondon, Mary E; Sullivan, Mark D; Nelson, Karin; Hattler, Brack; McBryde, Connor; Lehmann, Kenneth G; Potfay, Jonathan; Heidenreich, Paul; Rumsfeld, John S
2013-07-09
Chronic heart failure (HF) disease management programs have reported inconsistent results and have not included comorbid depression management or specifically focused on improving patient-reported outcomes. The Patient Centered Disease Management (PCDM) trial was designed to test the effectiveness of collaborative care disease management in improving health status (symptoms, functioning, and quality of life) in patients with HF who reported poor HF-specific health status. Patients with a HF diagnosis at four VA Medical Centers were identified through population-based sampling. Patients with a Kansas City Cardiomyopathy Questionnaire (KCCQ, a measure of HF-specific health status) score of < 60 (heavy symptom burden and impaired quality of life) were invited to enroll in the PCDM trial. Enrolled patients were randomized to receive usual care or the PCDM intervention, which included: (1) collaborative care management by VA clinicians including a nurse, cardiologist, internist, and psychiatrist, who worked with patients and their primary care providers to provide guideline-concordant care management, (2) home telemonitoring and guided patient self-management support, and (3) screening and treatment for comorbid depression. The primary study outcome is change in overall KCCQ score. Secondary outcomes include depression, medication adherence, guideline-based care, hospitalizations, and mortality. The PCDM trial builds on previous studies of HF disease management by prioritizing patient health status, implementing a collaborative care model of health care delivery, and addressing depression, a key barrier to optimal disease management. The study has been designed as an 'effectiveness trial' to support broader implementation in the healthcare system if it is successful. Unique identifier: NCT00461513.
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Integrating telecare for chronic disease management in the community: What needs to be done?
2011-01-01
Background Telecare could greatly facilitate chronic disease management in the community, but despite government promotion and positive demonstrations its implementation has been limited. This study aimed to identify factors inhibiting the implementation and integration of telecare systems for chronic disease management in the community. Methods Large scale comparative study employing qualitative data collection techniques: semi-structured interviews with key informants, task-groups, and workshops; framework analysis of qualitative data informed by Normalization Process Theory. Drawn from telecare services in community and domestic settings in England and Scotland, 221 participants were included, consisting of health professionals and managers; patients and carers; social care professionals and managers; and service suppliers and manufacturers. Results Key barriers to telecare integration were uncertainties about coherent and sustainable service and business models; lack of coordination across social and primary care boundaries, lack of financial or other incentives to include telecare within primary care services; a lack of a sense of continuity with previous service provision and self-care work undertaken by patients; and general uncertainty about the adequacy of telecare systems. These problems led to poor integration of policy and practice. Conclusion Telecare services may offer a cost effective and safe form of care for some people living with chronic illness. Slow and uneven implementation and integration do not stem from problems of adoption. They result from incomplete understanding of the role of telecare systems and subsequent adaption and embeddedness to context, and uncertainties about the best way to develop, coordinate, and sustain services that assist with chronic disease management. Interventions are therefore needed that (i) reduce uncertainty about the ownership of implementation processes and that lock together health and social care agencies; and (ii) ensure user centred rather than biomedical/service-centred models of care. PMID:21619596
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Integrating telecare for chronic disease management in the community: what needs to be done?
May, Carl R; Finch, Tracy L; Cornford, James; Exley, Catherine; Gately, Claire; Kirk, Sue; Jenkings, K Neil; Osbourne, Janice; Robinson, A Louise; Rogers, Anne; Wilson, Robert; Mair, Frances S
2011-05-27
Telecare could greatly facilitate chronic disease management in the community, but despite government promotion and positive demonstrations its implementation has been limited. This study aimed to identify factors inhibiting the implementation and integration of telecare systems for chronic disease management in the community. Large scale comparative study employing qualitative data collection techniques: semi-structured interviews with key informants, task-groups, and workshops; framework analysis of qualitative data informed by Normalization Process Theory. Drawn from telecare services in community and domestic settings in England and Scotland, 221 participants were included, consisting of health professionals and managers; patients and carers; social care professionals and managers; and service suppliers and manufacturers. Key barriers to telecare integration were uncertainties about coherent and sustainable service and business models; lack of coordination across social and primary care boundaries, lack of financial or other incentives to include telecare within primary care services; a lack of a sense of continuity with previous service provision and self-care work undertaken by patients; and general uncertainty about the adequacy of telecare systems. These problems led to poor integration of policy and practice. Telecare services may offer a cost effective and safe form of care for some people living with chronic illness. Slow and uneven implementation and integration do not stem from problems of adoption. They result from incomplete understanding of the role of telecare systems and subsequent adaption and embeddedness to context, and uncertainties about the best way to develop, coordinate, and sustain services that assist with chronic disease management. Interventions are therefore needed that (i) reduce uncertainty about the ownership of implementation processes and that lock together health and social care agencies; and (ii) ensure user centred rather than biomedical/service-centred models of care.
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Befort, Christie A; VanWormer, Jeffrey J; DeSouza, Cyrus; Ellerbeck, Edward F; Kimminau, Kim S; Greiner, Allen; Gajewski, Byron; Huang, Terry; Perri, Michael G; Fazzino, Tera L; Christifano, Danielle; Eiland, Leslie; Drincic, Andjela
2016-03-01
Obesity disproportionately affects rural residents in the United States, and primary care has the potential to fill a major gap in the provision of weight management services for rural communities. The objective of this cluster-randomized pragmatic trial is to evaluate the comparative effectiveness of three obesity treatment models in rural primary care: the Intensive Behavior Therapy fee-for-service (FFS) model reimbursed by Medicare, a team-based model that recognizes the patient-centered medical home (PCMH) as a preferred delivery approach, and the centralized disease management (DM) model, in which phone-based counseling is provided outside of the primary care practice. We hypothesize that the PCMH and DM treatments will be more effective than FFS in reducing weight at 24 months. Thirty-six practices from the rural Midwestern U.S. are randomized to deliver one of the three interventions to 40 patients (N=1440) age 20 to 75 with a BMI 30-45 kg/m(2). In the FFS arm, primary care providers and their personnel counsel patients to follow evidence-based weight loss guidelines using the Medicare-designated treatment schedule. In the PCMH arm, patients receive a comprehensive weight management intervention delivered locally by practice personnel using a combination of in-person and phone-based group sessions. In the DM arm, the same intervention is delivered remotely by obesity treatment specialists via group conference calls. The primary outcome is weight loss at 24 months. Additional measures include fasting glucose, lipids, quality of life indicators, and implementation process measures. Findings will illuminate effective obesity treatment intervention(s) in rural primary care. Copyright © 2016. Published by Elsevier Inc.
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Francis, Caitlin F; Feyer, Anne-Marie; Smith, Ben J
2007-11-01
The evaluation of the Sharing Health Care Initiative addressed the translation of different models of chronic disease self-management into health and community service contexts in Australia. Across seven projects, four intervention models were adopted: (1) the Stanford Chronic Disease Self Management course; (2) generic disease management planning, training and support; (3) tailored disease management planning, training and support, and; (4) telephone coaching. Targeted recruitment through support groups and patient lists was most successful for reaching high-needs clients. Projects with well developed organisational structures and health system networks demonstrated more effective implementation. Engagement of GPs in recruitment and client support was limited. Future self-management programs will require flexible delivery methods in the primary health care setting, involving practice nurses or the equivalent. After 12 months there was little evidence of potential sustainability, although structures such as consumer resource centres and client support clubs were established in some locations. Only one project was able to use Medicare chronic disease-related items to integrate self-management support into routine general practice. Participants in all projects showed improvements in self-management practices, but those receiving Model 3, flexible and tailored support, and Model 4, telephone coaching, reported the greatest benefits.
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Ercolano, Elizabeth; Grant, Marcia; McCorkle, Ruth; Tallman, Nancy J; Cobb, Martha D; Wendel, Christopher; Krouse, Robert
2016-06-01
Living with an ostomy requires daily site and equipment care, lifestyle changes, emotional management, and social role adjustments. The Chronic Care Ostomy Self-Management Training Program (CCOSMTP) offers an ostomy self-management curriculum, emphasizing problem solving, self-efficacy, cognitive reframing, and goal setting. The qualitative method of content analysis was employed to categorize self-reported goals of ostomates identified during a nurse-led feasibility trial testing the CCOSMTP. Thirty-eight ostomates identified goals at three CCOSMTP sessions. The goals were classified according to the City of Hope Health-Related Qualify of Life Model, a validated multidimensional framework, describing physical, psychological, social, and spiritual ostomy-related effects. Nurse experts coded the goals independently and then collaborated to reach 100% consensus on the goals' classification. A total of 118 goals were identified by 38 participants. Eighty-seven goals were physical, related to the care of the skin, placement of the pouch or bag, and management of leaks; 26 were social goals, which addressed engagement in social or recreational roles and daily activities; and 5 were psychological goals, which were related to confidence and controlling negative thinking. Although the goals of survivors of cancer with an ostomy are variable, physical goals are most common in self-management training.
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Case management redesign in an urban facility.
Almaden, Stefany; Freshman, Brenda; Quaye, Beverly
2011-01-01
To explore strategies for improving patient throughput and to redesign case management processes to facilitate level of care transitions and safe discharges. Large Urban Medical Center in South Los Angeles County, with 384 licensed beds that services poor, underserved communities. Both qualitative and quantitative methods were applied. Combined theoretical frameworks were used for needs assessment, intervention strategies, and change management. Observations, interviews, surveys, and database extraction methods were used. The sample consisted of case management staff members and several other staff from nursing, social work, and emergency department staff. Postintervention measures indicated improvement in reimbursements for services, reduction in length of stay, increased productivity, improved patients' access to care, and avoiding unnecessary readmission or emergency department visits. Effective change management strategies must consider multiple factors that influence daily operations and service delivery. Creating accountability by using performance measures associated with patient transitions is highlighted by the case study results. The authors developed a process model to assist in identifying and tracking outcome measures related to patient throughput, front-end assessments, and effective patient care transitions. This model can be used in future research to further investigate best case management practices.
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Operations research in intensive care unit management: a literature review.
Bai, Jie; Fügener, Andreas; Schoenfelder, Jan; Brunner, Jens O
2018-03-01
The intensive care unit (ICU) is a crucial and expensive resource largely affected by uncertainty and variability. Insufficient ICU capacity causes many negative effects not only in the ICU itself, but also in other connected departments along the patient care path. Operations research/management science (OR/MS) plays an important role in identifying ways to manage ICU capacities efficiently and in ensuring desired levels of service quality. As a consequence, numerous papers on the topic exist. The goal of this paper is to provide the first structured literature review on how OR/MS may support ICU management. We start our review by illustrating the important role the ICU plays in the hospital patient flow. Then we focus on the ICU management problem (single department management problem) and classify the literature from multiple angles, including decision horizons, problem settings, and modeling and solution techniques. Based on the classification logic, research gaps and opportunities are highlighted, e.g., combining bed capacity planning and personnel scheduling, modeling uncertainty with non-homogenous distribution functions, and exploring more efficient solution approaches.
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Co-Leadership - A Management Solution for Integrated Health and Social Care.
Klinga, Charlotte; Hansson, Johan; Hasson, Henna; Sachs, Magna Andreen
2016-05-23
Co-leadership has been identified as one approach to meet the managerial challenges of integrated services, but research on the topic is limited. In the present study, co-leadership, practised by pairs of managers - each manager representing one of the two principal organizations in integrated health and social care services - was explored. To investigate co-leadership in integrated health and social care, identify essential preconditions in fulfilling the management assignment, its operationalization and impact on provision of sustainable integration of health and social care. Interviews with eight managers exercising co-leadership were analysed using directed content analysis. Respondent validation was conducted through additional interviews with the same managers. Key contextual preconditions were an organization-wide model supporting co-leadership and co-location of services. Perception of the management role as a collective activity, continuous communication and lack of prestige were essential personal and interpersonal preconditions. In daily practice, office sharing, being able to give and take and support each other contributed to provision of sustainable integration of health and social care. Co-leadership promoted robust management by providing broader competence, continuous learning and joint responsibility for services. Integrated health and social care services should consider employing co-leadership as a managerial solution to achieve sustainability.
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Co-Leadership – A Management Solution for Integrated Health and Social Care
Hansson, Johan; Hasson, Henna; Sachs, Magna Andreen
2016-01-01
Introduction: Co-leadership has been identified as one approach to meet the managerial challenges of integrated services, but research on the topic is limited. In the present study, co-leadership, practised by pairs of managers – each manager representing one of the two principal organizations in integrated health and social care services – was explored. Aim: To investigate co-leadership in integrated health and social care, identify essential preconditions in fulfilling the management assignment, its operationalization and impact on provision of sustainable integration of health and social care. Method: Interviews with eight managers exercising co-leadership were analysed using directed content analysis. Respondent validation was conducted through additional interviews with the same managers. Results: Key contextual preconditions were an organization-wide model supporting co-leadership and co-location of services. Perception of the management role as a collective activity, continuous communication and lack of prestige were essential personal and interpersonal preconditions. In daily practice, office sharing, being able to give and take and support each other contributed to provision of sustainable integration of health and social care. Conclusion and discussion: Co-leadership promoted robust management by providing broader competence, continuous learning and joint responsibility for services. Integrated health and social care services should consider employing co-leadership as a managerial solution to achieve sustainability. PMID:27616963
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Rodriguez, Salvador; Aziz, Ayesha; Chatwin, Chris
2014-01-01
The use of Health Information Technology (HIT) to improve healthcare service delivery is constantly increasing due to research advances in medical science and information systems. Having a fully automated process solution for a Healthcare Organization (HCO) requires a combination of organizational strategies along with a selection of technologies that facilitate the goal of improving clinical outcomes. HCOs, requires dynamic management of care capability to realize the full potential of HIT. Business Process Management (BPM) is being increasingly adopted to streamline the healthcare service delivery and management processes. Emergency Departments (EDs) provide a case in point, which require multidisciplinary resources and services to deliver effective clinical outcomes. Managed care involves the coordination of a range of services in an ED. Although fully automated processes in emergency care provide a cutting edge example of service delivery, there are many situations that require human interactions with the computerized systems; e.g. Medication Approvals, care transfer, acute patient care. This requires a coordination mechanism for all the resources, computer and human, to work side by side to provide the best care. To ensure evidence-based medical practice in ED, we have designed a Human Task Management service to model the process of coordination of ED resources based on the UK's NICE Clinical guideline for managing the care of acutely ill patients. This functionality is implemented using Java Business process Management (jBPM).
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Schulman-Green, Dena; Jeon, Sangchoon
2017-02-01
We tested the feasibility and acceptability of a psycho-educational self-management intervention, Managing Cancer Care: A Personal Guide (MCC), to improve knowledge of care options (curative, palliative, and hospice care) among a range of breast cancer self-management skills. We conducted a one-group, pre-post-test study among women with non-metastatic breast cancer (n = 105). We gave participants the printed, self-guided, seven-module intervention following enrollment. At baseline and 2 months, we measured knowledge of care options, desired and actual role in self-management, medical communication skills, experience and management of transitions, anxiety, depression, uncertainty, and self-efficacy. We conducted interviews to obtain module ratings and qualitative data on strengths and limitations of MCC. Knowledge of care options (δ = 0.40 (1.11), p = 0.0005) and desired role in self-management (δ = -0.28 (1.08), p = 0.0177) significantly improved. Less skilled medical communicators significantly improved their communication (δ = 3.47, standard deviation = 6.58, p = 0.0449). Multivariate modeling showed that changes in our primary outcomes of medical communication and management of transitions seemed to drive positive changes in our secondary outcomes of anxiety, depression, uncertainty, and self-efficacy. Participants highly rated MCC and reported the importance of understanding care options despite non-metastatic disease. MCC is a feasible and acceptable means of improving knowledge of care options and other aspects of breast cancer self-management. The combination of modules offered in MCC appears to have beneficial interactive effects. We are currently testing MCC more rigorously in a randomized controlled trial to explore mediating and moderating relationships. Copyright © 2015 John Wiley & Sons, Ltd. Copyright © 2015 John Wiley & Sons, Ltd.
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Stewart, C; Bench, S
2018-05-15
Quality improvement (QI) is a way through which health care delivery can be made safer and more effective. Various models of quality improvement methods exist in health care today. These models can help guide and manage the process of introducing changes into clinical practice. The aim of this project was to implement the use of a delirium assessment tool into three adult critical care units within the same hospital using a QI approach. The objective was to improve the identification and management of delirium. Using the Model for Improvement framework, a multidisciplinary working group was established. A delirium assessment tool was introduced via a series of educational initiatives. New local guidelines regarding the use of delirium assessment and management for the multidisciplinary team were also produced. Audit data were collected at 6 weeks and 5 months post-implementation to evaluate compliance with the use of the tool across three critical care units within a single hospital in London. At 6 weeks, in 134 assessment points out of a possible 202, the tool was deemed to be used appropriately, meaning that 60% of patients received timely assessment; 18% of patients were identified as delirious in audit one. Five months later, only 95 assessment points out of a possible 199 were being appropriately assessed (47%); however, a greater number (32%) were identified as delirious. This project emphasizes the complexity of changing practice in a large busy critical care centre. Despite an initial increase in delirium assessment, this was not sustained over time. The use of a QI model highlights the continuous process of embedding changes into clinical practice and the need to use a QI method that can address the challenging nature of modern health care. QI models guide changes in practice. Consideration should be given to the type of QI model used. © 2018 British Association of Critical Care Nurses.
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Care guides: an examination of occupational conflict and role relationships in primary care.
Wholey, Douglas R; White, Katie M; Adair, Richard; Christianson, Jon B; Lee, Suhna; Elumba, Deborah
2013-01-01
Improving the efficiency and effectiveness of primary care treatment of patients with chronic illness is an important goal in reforming the U.S. health care system. Reducing occupational conflicts and creating interdependent primary care teams is crucial for the effective functioning of new models being developed to reorganize chronic care. Occupational conflict, role interdependence, and resistance to change in a proof-of-concept pilot test of one such model that uses a new kind of employee in the primary care office, a "care guide," were analyzed. Care guides are lay individuals who help chronic disease patients and their providers achieve standard health goals. The aim of this study was to examine the development of occupational boundaries, interdependence of care guides and primary care team members, and acceptance by clinic employees of this new kind of health worker. A mixed methods, pilot study was conducted using qualitative analysis; clinic, provider, and patient surveys; administrative data; and multivariate analysis. Qualitative analysis examined the emergence of the care guide role. Administrative data and surveys were used to examine patterns of interdependence between care guides, physicians, team members, and clinic staff; obtain physician evaluations of the care guide role; and evaluate the effect of care guides on patient perceptions of care coordination and follow-up. Evaluation of implementation of the care guide model showed that (a) the care guide scope of practice was clearly defined; (b) interdependent relationships between care guides and providers were formed; (c) relational triads consisting of patient, care guide, and physician were created; (d) patients and providers were supported in managing chronic disease; and (e) resistance to this model among traditional employees was minimized. The feasibility of implementing a new care model for chronic disease management in the primary care setting, identifying factors associated with a positive organizational experience, was shown in this study.
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Multidsciplinary heart failure management and end of life care.
Ryder, Mary; Beattie, James M; O'Hanlon, Rory; McDonald, Kenneth
2011-12-01
There has been much improvement in the treatment of heart failure over the past decade through the implementation of a multidisciplinary team approach to disease management focused on optimizing medication, the application of device-based therapy, surgical intervention and in promoting the education of patients and carers in self-management. This multidisciplinary strategy has now been extended to try and improve the care of those with advanced heart failure in the latter phases of the disease trajectory nearing the end of their lives. A growing consensus has emerged in the literature that confirms the need to extend multidisciplinary management beyond the early targets of reducing heart failure-related mortality and morbidity to address the significant care needs of those who decline due to the often inexorable progression of this syndrome. Multidisciplinary management facilitates the development of a comprehensive care plan that is specifically tailored to accommodate the requirements of individual patients and their families and fosters a collaborative approach to care to optimize symptom management, avoid potential treatments conflicts, and to fulfil their supportive care needs. Partnership working between the three principal clinical disciplines of cardiology, specialist palliative care and general practice is central to this process and promotes coordinated care across hospital, hospice and community-based services. Advanced heart failure management has improved over time; however, the incorporation of a multidisciplinary care model appears to offer significant promise in dealing with complex care needs of heart failure patients towards the end of life. Delivery of this practice requires the development of bespoke care structures that are relevant to the spectrum of healthcare service environments.
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Case Management of Adolescents with Chronic Disease.
ERIC Educational Resources Information Center
Lankard, Bettina A.
This training guide presents a model for optimum delivery of the primary duties, tasks, and steps required in the comprehensive case management of adolescents with chronic disease. Using a team approach to coordinated health care, the guide involves the patient and family as key members of the care team along with the physician, nurse, dietitian,…
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ERIC Educational Resources Information Center
Nie, Youyan; Lau, Shun
2009-01-01
This study examined how classroom management practices--care and behavioral control--were differentially associated with students' engagement, misbehavior, and satisfaction with school, using a large representative sample of 3196 Grade 9 students from 117 classes in Singapore. Results of hierarchical linear modeling showed differential relations.…
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Little, Jeanette R; Pavliscsak, Holly H; Cooper, Mabel R; Goldstein, Lois A; Fonda, Stephanie J
2018-03-01
Research has shown that mobile phones can help with management of numerous health problems. As an adjunct to care management provided to injured service members rehabilitating in their communities, particularly those with mild traumatic brain injury (mTBI), post-traumatic stress (PTS), and/or behavioral health problems, the Army developed a mobile phone application called "mCare." This study examined whether service members who received mCare had higher well-being, were more satisfied with their care, and viewed mCare as a valuable part of their care management as compared with their counterparts who received standard care management alone, and whether those with mTBI, PTS, and/or behavioral health problems benefited differently from mCare. In-processing service members at four community-based warrior transition units were recruited for participation in a 36-wk, randomized, controlled trial and allocated to receive standard care management plus mCare (n = 95) or standard care management alone (n = 87). Participants in the mCare group received daily questionnaires, tips, and appointment reminders. All participants were asked to complete the General Well-being Schedule (GWS) at baseline, 12, 24, and 36 wk, and the Case Management Quality Questionnaire (CMQQ) at 12, 24, and 36 wk. All participants and care managers were approached to complete interviews about the usability/likeability of mCare or standard care management. The analyses tested for group differences in completion of the intervention, graphed means for the GWS and CMQQ by group/subgroup, and statistically compared the longitudinal trends in these outcomes using mixed models in which group, time, and group*time were included as regression variables. The analyses also tallied interview responses and identified thematic quotes. The study protocol was reviewed and approved by the Walter Reed National Military Medical Center's Institutional Review Board. Estimated rate of change in GWS scores was -2.2 (standard error = 1.0; t = -2.1; p = 0.0382). Estimated rate of change in CMQQ scores was -0.8 (standard error = 0.5; t = -1.52; p = 0.1299). Neither change was meaningful. Rates of change in the GWS and CMQQ scores did not differ by group or by behavioral health, mTBI, and PTS subgroups within the groups. The interviews found that 83% of mCare participants liked the communication with their care managers versus 73% of standard care management participants. Participants in both the mCare group and the care managers said that they liked the application's appointment tracking and reminders. Care managers thought mCare was particularly useful for people with mTBI, PTS, and cognitive problems. mCare did not result in differences in general well-being and satisfaction with care management among service members rehabilitating in their communities, some with mTBI, PTS, and/or behavioral health problems. But participants and care managers who used mCare said that they found it useful. Study limitations included the diversity of clinical issues of the participants, greater missing data among mCare participants, and the high baseline quality of care management in the settings observed. The fact that patients and care managers liked mCare, apart from no changes in outcomes, is important because health care is increasingly adopting mobile solutions.
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Crowley, Matthew J; Edelman, David; McAndrew, Ann T; Kistler, Susan; Danus, Susanne; Webb, Jason A; Zanga, Joseph; Sanders, Linda L; Coffman, Cynthia J; Jackson, George L; Bosworth, Hayden B
2016-05-01
Telemedicine-based diabetes management improves outcomes versus clinic care but is seldom implemented by healthcare systems. In order to advance telemedicine-based management as a practical option for veterans with persistent poorly controlled diabetes mellitus (PPDM) despite clinic-based care, we evaluated a comprehensive telemedicine intervention that we specifically designed for delivery using existing Veterans Health Administration (VHA) clinical staffing and equipment. We conducted a 6-month randomized trial among 50 veterans with PPDM; all maintained hemoglobin A1c (HbA1c) levels continuously >9.0% for >1 year despite clinic-based management. Participants received usual care or a telemedicine intervention combining telemonitoring, medication management, self-management support, and depression management; existing VHA clinical staff delivered the intervention. Using linear mixed models, we examined HbA1c, diabetes self-care (measured by the Self-Care Inventory-Revised questionnaire), depression, and blood pressure. At baseline, the model-estimated common HbA1c intercept was 10.5%. By 6 months, estimated HbA1c had improved by 1.3% for intervention participants and 0.3% for usual care (estimated difference, -1.0%, 95% confidence interval [CI], -2.0%, 0.0%; p = 0.050). Intervention participants' diabetes self-care (estimated difference, 7.0; 95% CI, 0.1, 14.0; p = 0.047), systolic blood pressure (-7.7 mm Hg; 95% CI, -14.8, -0.6; p = 0.035), and diastolic blood pressure (-5.6 mm Hg; 95% CI, -9.9, -1.2; p = 0.013) were improved versus usual care by 6 months. Depressive symptoms were similar between groups. A comprehensive telemedicine intervention improved outcomes among veterans with PPDM despite clinic-based care. Because we specifically designed this intervention with scalability in mind, it may represent a practical, real-world strategy to reduce the burden of poor diabetes control among veterans.
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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.
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Managing a work-life balance: the experiences of midwives working in a group practice setting.
Fereday, Jennifer; Oster, Candice
2010-06-01
To explore how a group of midwives achieved a work-life balance working within a caseload model of care with flexible work hours and on-call work. in-depth interviews were conducted and the data were analysed using a data-driven thematic analysis technique. Children, Youth and Women's Health Service (CYWHS) (previously Women's and Children's Hospital), Adelaide, where a midwifery service known as Midwifery Group Practice (MGP) offers a caseload model of care to women within a midwife-managed unit. 17 midwives who were currently working, or had previously worked, in MGP. analysis of the midwives' individual experiences provided insight into how midwives managed the flexible hours and on-call work to achieve a sustainable work-life balance within a caseload model of care. it is important for midwives working in MGP to actively manage the flexibility of their role with time on call. Organisational, team and individual structure influenced how flexibility of hours was managed; however, a period of adjustment was required to achieve this balance. the study findings offer a description of effective, sustainable strategies to manage flexible hours and on-call work that may assist other midwives working in a similar role or considering this type of work setting. Copyright 2008 Elsevier Ltd. All rights reserved.
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Green, Beverly B; Ralston, James D; Fishman, Paul A; Catz, Sheryl L; Cook, Andrea; Carlson, Jim; Tyll, Lynda; Carrell, David; Thompson, Robert S
2008-05-01
Randomized controlled trials have provided unequivocal evidence that treatment of hypertension decreases mortality and major disability from cardiovascular disease; however, blood pressure remains inadequately treated in most affected individuals. This large gap continues despite the facts that more than 90% of adults with hypertension have health insurance, and hypertension is the leading cause of visits to the doctor. New approaches are needed to improve hypertension care. The Electronic Communications and Home Blood Pressure Monitoring (e-BP) study is a three-arm randomized controlled trial designed to determine whether care based on the Chronic Care Model and delivered over the Internet improves hypertension care. The primary study outcomes are systolic, diastolic, and blood pressure control; secondary outcomes are medication adherence, patient self-efficacy, satisfaction and quality of life, and healthcare utilization and costs. Hypertensive patients receiving care at Group Health medical centers are eligible if they have uncontrolled blood pressure on two screening visits and access to the Web and an e-mail address. Study participants are randomly assigned to three intervention groups: (a) usual care; (b) home blood pressure monitoring receipt and proficiency training on its use and the Group Health secure patient website (with secure e-mail access to their healthcare provider, access to a shared medical record, prescription refill and other services); or (c) this plus pharmacist care management (collaborative care management between the patient, the pharmacist, and the patient's physician via a secure patient website and the electronic medical record). We will determine whether a new model of patient-centered care that leverages Web communications, self-monitoring, and collaborative care management improves hypertension control. If this model proves successful and cost-effective, similar interventions could be used to improve the care of large numbers of patients with uncontrolled hypertension.
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Trousselard, Marion; Dutheil, Frédéric; Naughton, Geraldine; Cosserant, Sylvie; Amadon, Sylvie; Dualé, Christian; Schoeffler, Pierre
2016-02-01
The nurse stress literature reports an overwhelming culture of acceptance and expectation of work stressors, ironically linked to the control of the workplace to effectively and proactively manage stress. The stressors involved in delivering "stress management" have been well studied in nursing-related workplaces, especially in acute care settings in accordance with the Karasek Job Demand-Control-Support (JDCS) model. However, little is known about the effects of specificity of an acute care unit and the level of qualifications on stress experienced by nurses. A survey using the JDCS model was conducted among 385 nurses working in three different acute care units (anesthesiology, emergency and intensive care unit) from a university hospital. Specific questions explored variables such as gender, acute care units, level of qualification and working experience. Two hundred questionnaires were returned. A high level of job strain was highlighted without a gender effect and in the absence of isostrain. Nurses from acute care units were located in the high stress quadrant of the JDCS model. Conversely, other nurses were commonly located in the "active" quadrant. Independent of acute care settings, the highest level of education was associated with the highest job strain and the lowest level of control. In an acute care setting, a high level of education was a key factor for high job stress and was associated with a perception of a low control in the workplace, both of which may be predictors of adverse mental health. In particular, the lack of control has been associated with moral distress, a frequently reported characteristic of acute care settings. To enhance the personal and professional outcomes of the advanced registered nurses, strategies for supporting nurses manage daily stressors in acute care are urgently required.
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Fluet, Norman R.; Reis, Michael D.; Stern, Charles H.; Thompson, Alexander W.; Jolly, Gillian A.
2016-01-01
The integration of behavioral health services in primary care has been referred to in many ways, but ultimately refers to common structures and processes. Behavioral health is integrated into primary care because it increases the effectiveness and efficiency of providing care and reduces costs in the care of primary care patients. Reimbursement is one factor, if not the main factor, that determines the level of integration that can be achieved. The federal health reform agenda supports changes that will eventually permit behavioral health to be fully integrated and will allow the health of the population to be the primary target of intervention. In an effort to develop more integrated services at Baylor Scott and White Healthcare, models of integration are reviewed and the advantages and disadvantages of each model are discussed. Recommendations to increase integration include adopting a disease management model with care management, planned guideline-based stepped care, follow-up, and treatment monitoring. Population-based interventions can be completed at the pace of the development of alternative reimbursement methods. The program should be based upon patient-centered medical home standards, and research is needed throughout the program development process. PMID:27034543
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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.
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A heart failure initiative to reduce the length of stay and readmission rates.
White, Sabrina Marie; Hill, Alethea
2014-01-01
The purpose of this pilot was to improve multidisciplinary coordination of care and patient education and foster self-management behaviors. The primary and secondary outcomes achieved from this pilot were to decrease the 30-day readmission rate and heart failure length of stay. The primary practice site was an inpatient medical-surgical nursing unit. The length of stay decreased from 6.05% to 4.42% for heart failure diagnostic-related group 291 as a result of utilizing the model. The length of stay decreased from 3.9% to 3.09%, which was also less than the national rate of 3.8036% for diagnostic-related group 292. In addition, the readmission rate decreased from 23.1% prior to January 2013 to 12.9%. Implementation of standards of care coordination can decrease length of stay, readmission rate, and improve self-management. Implementation of evidence-based heart failure guidelines, improved interdisciplinary coordination of care, patient education, self-management skills, and transitional care at the time of discharge improved overall heart failure outcome measures. Utilizing the longitudinal model of care to transition patients to home aided in evaluating social support, resource allocation and utilization, access to care postdischarge, and interdisciplinary coordination of care. The collaboration between disciplines improved continuity of care, patient compliance to their discharge regimen, and adequate discharge follow-up.
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An Innovative Approach to Health Care Delivery for Patients with Chronic Conditions.
Clarke, Janice L; Bourn, Scott; Skoufalos, Alexis; Beck, Eric H; Castillo, Daniel J
2017-02-01
Although the health care reform movement has brought about positive changes, lingering inefficiencies and communication gaps continue to hamper system-wide progress toward achieving the overarching goal-higher quality health care and improved population health outcomes at a lower cost. The multiple interrelated barriers to improvement are most evident in care for the population of patients with multiple chronic conditions. During transitions of care, the lack of integration among various silos and inadequate communication among providers cause delays in delivering appropriate health care services to these vulnerable patients and their caregivers, diminishing positive health outcomes and driving costs ever higher. Long-entrenched acute care-focused treatment and reimbursement paradigms hamper more effective deployment of existing resources to improve the ongoing care of these patients. New models for care coordination during transitions, longitudinal high-risk care management, and unplanned acute episodic care have been conceived and piloted with promising results. Utilizing existing resources, Mobile Integrated Healthcare is an emerging model focused on closing these care gaps by means of a round-the-clock, technologically sophisticated, physician-led interprofessional team to manage care transitions and chronic care services on-site in patients' homes or workplaces.
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Optimizing cardiothoracic surgery information for a managed care environment.
Denton, T A; Matloff, J M
1995-11-01
The rapid change occurring in American healthcare is a direct response to rising costs. Managed care is the fastest growing model that attempts to control escalating costs through limitations in patient choice, the active use of guidelines, and placing providers at risk. Managed care is an information intensive system, and those providers who use information effectively will be at an advantage in the competitive healthcare marketplace. There are five classes of information that providers must collect to be competitive in a managed care environment: patient satisfaction, medical outcomes, continuous quality improvement, quality of the decision, and financial data. Each of these should be actively used in marketing, assuring the quality of patient care, and maintaining financial stability. Although changes in our healthcare system are occurring rapidly, we need to respond to the marketplace to maintain our viability, but as physicians, we have the singular obligation to maintain the supremacy of the individual patient and the physician-patient relationship.
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Providing and funding breast health services in urban nurse-managed health centers.
Tsai, Pei-Yun; Peterman, Beth; Baisch, Mary Jo; Ji, Eun Sun; Zwiers, Kelly
2014-01-01
Nurse-managed health centers (NMHCs) are an innovative health care delivery model that serves as an important point of health care access for populations at risk for disparities in health outcomes. This article describes the process and outcomes of clinical breast health services in two NMHCs located in a large Midwestern city. Findings indicate that client's knowledge about breast health was increased after they received breast health services from NMHC nurses. Significant positive changes in behavior related to the early detection of breast cancer were found in the study. NMHCs, identified for expansion in the Patient Protection and Affordable Care Act, offer a unique health care services delivery model that promotes access to care and early identification of breast cancer in very low-income and uninsured women. Copyright © 2014 Elsevier Inc. All rights reserved.
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Spoorenberg, Sophie L. W.; Wynia, Klaske; Fokkens, Andrea S.; Slotman, Karin; Kremer, Hubertus P. H.; Reijneveld, Sijmen A.
2015-01-01
Background Integrated care models aim to solve the problem of fragmented and poorly coordinated care in current healthcare systems. These models aim to be patient-centered by providing continuous and coordinated care and by considering the needs and preferences of patients. The objective of this study was to evaluate the opinions and experiences of community-living older adults with regard to integrated care and support, along with the extent to which it meets their health and social needs. Methods Semi-structured interviews were conducted with 23 older adults receiving integrated care and support through “Embrace,” an integrated care model for community-living older adults that is based on the Chronic Care Model and a population health management model. Embrace is currently fully operational in the northern region of the Netherlands. Data analysis was based on the grounded theory approach. Results Responses of participants concerned two focus areas: 1) Experiences with aging, with the themes “Struggling with health,” “Increasing dependency,” “Decreasing social interaction,” “Loss of control,” and “Fears;” and 2) Experiences with Embrace, with the themes “Relationship with the case manager,” “Interactions,” and “Feeling in control, safe, and secure”. The prospect of becoming dependent and losing control was a key concept in the lives of the older adults interviewed. Embrace reinforced the participants’ ability to stay in control, even if they were dependent on others. Furthermore, participants felt safe and secure, in contrast to the fears of increasing dependency within the standard care system. Conclusion The results indicate that integrated care and support provided through Embrace met the health and social needs of older adults, who were coping with the consequences of aging. PMID:26489096
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Spoorenberg, Sophie L W; Wynia, Klaske; Fokkens, Andrea S; Slotman, Karin; Kremer, Hubertus P H; Reijneveld, Sijmen A
2015-01-01
Integrated care models aim to solve the problem of fragmented and poorly coordinated care in current healthcare systems. These models aim to be patient-centered by providing continuous and coordinated care and by considering the needs and preferences of patients. The objective of this study was to evaluate the opinions and experiences of community-living older adults with regard to integrated care and support, along with the extent to which it meets their health and social needs. Semi-structured interviews were conducted with 23 older adults receiving integrated care and support through "Embrace," an integrated care model for community-living older adults that is based on the Chronic Care Model and a population health management model. Embrace is currently fully operational in the northern region of the Netherlands. Data analysis was based on the grounded theory approach. Responses of participants concerned two focus areas: 1) Experiences with aging, with the themes "Struggling with health," "Increasing dependency," "Decreasing social interaction," "Loss of control," and "Fears;" and 2) Experiences with Embrace, with the themes "Relationship with the case manager," "Interactions," and "Feeling in control, safe, and secure". The prospect of becoming dependent and losing control was a key concept in the lives of the older adults interviewed. Embrace reinforced the participants' ability to stay in control, even if they were dependent on others. Furthermore, participants felt safe and secure, in contrast to the fears of increasing dependency within the standard care system. The results indicate that integrated care and support provided through Embrace met the health and social needs of older adults, who were coping with the consequences of aging.
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Building HR capability in health care organizations.
Khatri, Naresh
2006-01-01
The current human resource (HR) management practices in health care are consistent with the industrial model of management. However, health care organizations are not factories. They are highly knowledge-intensive and service-oriented entities and thus require a different set of HR practices and systems to support them. Drawing from the resource-based theory, I argue that HRs are a potent weapon of competitive advantage for health care organizations and propose a five-dimensional conception of HR capability for harnessing HRs in health care organizations. The significant complementarities that exist between HRs and information technologies for delivering safer and better quality of patient care are also discussed.
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Integrating Behavioral Health into Primary Care.
McGough, Peter M; Bauer, Amy M; Collins, Laura; Dugdale, David C
2016-04-01
Depression is one of the more common diagnoses encountered in primary care, and primary care in turn provides the majority of care for patients with depression. Many approaches have been tried in efforts to improve the outcomes of depression management. This article outlines the partnership between the University of Washington (UW) Neighborhood Clinics and the UW Department of Psychiatry in implementing a collaborative care approach to integrating the management of anxiety and depression in the ambulatory primary care setting. This program was built on the chronic care model, which utilizes a team approach to caring for the patient. In addition to the patient and the primary care provider (PCP), the team included a medical social worker (MSW) as care manager and a psychiatrist as team consultant. The MSW would manage a registry of patients with depression at a clinic with several PCPs, contacting the patients on a regular basis to assess their status, and consulting with the psychiatrist on a weekly basis to discuss patients who were not achieving the goals of care. Any recommendation (eg, a change in medication dose or class) made by the psychiatrist was communicated to the PCP, who in turn would work with the patient on the new recommendation. This collaborative care approach resulted in a significant improvement in the number of patients who achieved care plan goals. The authors believe this is an effective method for health systems to integrate mental health services into primary care. (Population Health Management 2016;19:81-87).
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Teaching Wound Care Management: A Model for the Budget Conscious Educator
ERIC Educational Resources Information Center
Berry, David C.
2012-01-01
For the author, the concept of wound care has always been a challenging topic to demonstrate. How to teach the concept without having a student in need of wound care or without having to spend money to buy another simulation manikin/model? The author has recently created a simulation to demonstrate and practice the cleaning, closing, and dressing…
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The importance of health belief models in determining self-care behaviour in diabetes.
Harvey, J N; Lawson, V L
2009-01-01
Patients' self-care behaviours have a major role in diabetes management. Diabetes education provides the required knowledge, but despite this, self-care is often suboptimal. The degree to which patients follow advice as regards the various self-care behaviours is determined by their health beliefs (Illness Representations or Personal Models) of diabetes. Psychometric studies have tried to categorize and measure the beliefs about illness that influence patients to adhere to treatment recommendations in diabetes. Various models have been proposed to explain the relationship between beliefs and behaviour. Leventhal's Self-Regulatory Model, which takes account of the emotional as well as the objective rational response to illness, currently seems to offer the best system for identifying the determinants of patient self-care behaviour. A review of interventions indicates those based on psychological theory offer professionals the best chance of maximizing their patients' contribution to diabetes self-management and achieving improved outcomes, both glycaemic and psychosocial. Studies designed specifically to modify illness representations are now being undertaken. This brief review aims to summarize developments in this area of psychological theory over the last 20 years and the implications for promoting better self-care behaviour in diabetes.
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A systematic review of chronic disease management interventions in primary care.
Reynolds, Rebecca; Dennis, Sarah; Hasan, Iqbal; Slewa, Jan; Chen, Winnie; Tian, David; Bobba, Sangeetha; Zwar, Nicholas
2018-01-09
Primary and community care are key settings for the effective management of long term conditions. We aimed to evaluate the pattern of health outcomes in chronic disease management interventions for adults with physical health problems implemented in primary or community care settings. The methods were based on our previous review published in 2006. We performed database searches for articles published from 2006 to 2014 and conducted a systematic review with narrative synthesis using the Cochrane Effective Practice and Organisation of Care taxonomy to classify interventions and outcomes. The interventions were mapped to Chronic Care Model elements. The pattern of outcomes related to interventions was summarized by frequency of statistically significant improvements in health care provision and patient outcomes. A total of 9589 journal articles were retrieved from database searches and snowballing. After screening and verification, 165 articles that detailed 157 studies were included. There were few studies with Health Care Organization (1.9% of studies) or Community Resources (0.6% of studies) as the primary intervention element. Self-Management Support interventions (45.8% of studies) most frequently resulted in improvements in patient-level outcomes. Delivery System Design interventions (22.6% of studies) showed benefits in both professional and patient-level outcomes for a narrow range of conditions. Decision Support interventions (21.3% of studies) had impact limited to professional-level outcomes, in particular use of medications. The small number of studies of Clinical Information System interventions (8.9%) showed benefits for both professional- and patient-level outcomes. The published literature has expanded substantially since 2006. This review confirms that Self-Management Support is the most frequent Chronic Care Model intervention that is associated with statistically significant improvements, predominately for diabetes and hypertension.
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Oppel, Eva-Maria; Winter, Vera; Schreyögg, Jonas
Patient satisfaction with quality of care is becoming increasingly important in the competitive hospital market. Simultaneously, the growing shortage of clinical staff poses a considerable challenge to ensuring a high quality of care. In this context, a question emerges regarding whether and how human resource management (HRM) might serve as a means to reduce staff shortage problems and to increase patient satisfaction. Although considerable efforts have been devoted to understanding the concepts of patient satisfaction and HRM, little is known about the interrelationships between these concepts or about the link between staff shortage problems and patients' satisfaction with quality of care. The aim of this study was to investigate the relationship between strategic human resource management (SHRM), staff shortage problems, and patients' satisfaction with care. Furthermore, we analyze how the HRM decision to fill short-term vacancies through temporary staffing affects patient satisfaction. We differentiate between physicians and nurses. We develop and empirically test a theoretical model. The data (n = 165) are derived from a survey on SHRM that was sent to 732 German hospitals and from a survey on patient satisfaction that comprises 436,848 patient satisfaction ratings. We use a structural equation modeling approach to test the model. The results indicate that SHRM significantly reduces staff shortage problems for both occupational groups. Having fewer physician shortage problems is significantly associated with higher levels of patient satisfaction, whereas this effect is not significant for nurses. Furthermore, the use of temporary staffing considerably reduces patients' satisfaction with care. Hospital managers are advised to consider the effects of HRM decisions on patients' satisfaction with care. In particular, investments in SHRM targeted at physicians have significantly positive effects on patient satisfaction, whereas the temporary staffing of physicians and nurses should be avoided.
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Levy, C.; Beauchamp, C.
1996-01-01
This poster describes the methods used and working prototype that was developed from an abstraction of the relational model from the VA's hierarchical DHCP database. Overlaying the relational model on DHCP permits multiple user views of the physical data structure, enhances access to the database by providing a link to commercial (SQL based) software, and supports a conceptual managed care data model based on primary and longitudinal patient care. The goal of this work was to create a relational abstraction of the existing hierarchical database; to construct, using SQL data definition language, user views of the database which reflect the clinical conceptual view of DHCP, and to allow the user to work directly with the logical view of the data using GUI based commercial software of their choosing. The workstation is intended to serve as a platform from which a managed care information model could be implemented and evaluated.
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COLLABORATE©, Part IV: Ramping Up Competency-Based Performance Management.
Treiger, Teresa M; Fink-Samnick, Ellen
The purpose of this fourth part of the COLLABORATE© article series provides an expansion and application of previously presented concepts pertaining to the COLLABORATE paradigm of professional case management practice. The model is built upon a value-driven foundation that: PRIMARY PRACTICE SETTING(S):: Applicable to all health care sectors where case management is practiced. As an industry, health care continues to evolve. Terrain shifts and new influences continually surface to challenge professional case management practice. The need for top-performing and nimble professionals who are knowledgeable and proficient in the workplace continues to challenge human resource departments. In addition to care setting knowledge, professional case managers must continually invest in their practice competence toolbox to grow skills and abilities that transcend policies and processes. These individuals demonstrate agility in framing (and reframing) their professional practice to facilitate the best possible outcomes for their clients. Therefore, the continued emphasis on practice competence conveyed through the performance management cycle is an essential ingredient to performance management focused on customer service excellence and organizational improvement. Professional case management transcends professional disciplines, educational levels, and practice settings. Business objectives continue to drive work process and priorities in many practice settings. However, competencies that align with regulatory and accreditation requirements should be the critical driver for consistent, high-quality case management practice. Although there is inherent value in what various disciplines bring to the table, this advanced model unifies behind case management's unique, strengths-based identity instead of continuing to align within traditional divisions (e.g., discipline, work setting, population served). This model fosters case management's expanding career advancement opportunities.
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Panel management, team culture, and worklife experience.
Willard-Grace, Rachel; Dubé, Kate; Hessler, Danielle; O'Brien, Bridget; Earnest, Gillian; Gupta, Reena; Shunk, Rebecca; Grumbach, Kevin
2015-09-01
Burnout and professional dissatisfaction are threats to the primary care workforce. We investigated the relationship between panel management capability, team culture, cynicism, and perceived "do-ability" of primary care among primary care providers (PCPs) and staff in primary care practices. We surveyed 326 PCPs and 142 staff members in 10 county-administered, 6 university-run, and 3 Veterans Affairs primary care clinics in a large urban area in 2013. Predictor variables included capability for performing panel management and perception of team culture. Outcome variables included 2 work experience measures--the Maslach Burnout Inventory cynicism scale and a 1-item measure of the "do-ability" of primary care this year compared with last year. Generalized Estimation Equation (GEE) models were used to account for clustering at the clinic level. Greater panel management capability and higher team culture were associated with lower cynicism among PCPs and staff and higher reported "do-ability" of primary care among PCPs. Panel management capability and team culture interacted to predict the 2 work experience outcomes. Among PCPs and staff reporting high team culture, there was little association between panel management capability and the outcomes, which were uniformly positive. However, there was a strong relationship between greater panel management capability and improved work experience outcomes for PCPs and staff reporting low team culture. Team-based processes of care such as panel management may be an important strategy to protect against cynicism and dissatisfaction in primary care, particularly in settings that are still working to improve their team culture. (c) 2015 APA, all rights reserved).
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2011-01-01
The United States pediatric population with chronic health conditions is expanding. Currently, this demographic comprises 12-18% of the American child and youth population. Affected children often receive fragmented, uncoordinated care. Overall, the American health care delivery system produces modest outcomes for this population. Poor, uninsured and minority children may be at increased risk for inferior coordination of services. Further, the United States health care delivery system is primarily organized for the diagnosis and treatment of acute conditions. For pediatric patients with chronic health conditions, the typical acute problem-oriented visit actually serves as a barrier to care. The biomedical model of patient education prevails, characterized by unilateral transfer of medical information. However, the evidence basis for improvement in disease outcomes supports the use of the chronic care model, initially proposed by Dr. Edward Wagner. Six inter-related elements distinguish the success of the chronic care model, which include self-management support and care coordination by a prepared, proactive team. United States health care lacks a coherent policy direction for the management of high cost chronic conditions, including rheumatic diseases. A fundamental restructure of United States health care delivery must urgently occur which places the patient at the center of care. For the pediatric rheumatology workforce, reimbursement policies and the actions of health plans and insurers are consistent barriers to chronic disease improvement. United States reimbursement policy and overall fragmentation of health care services pose specific challenges for widespread implementation of the chronic care model. Team-based multidisciplinary care, care coordination and self-management are integral to improve outcomes. Pediatric rheumatology demand in the United States far exceeds available workforce supply. This article reviews the career choice decision-making process at each medical trainee level to determine best recruitment strategies. Educational debt is an unexpectedly minor determinant for pediatric residents and subspecialty fellows. A two-year fellowship training option may retain the mandatory scholarship component and attract an increasing number of candidate trainees. Diversity, work-life balance, scheduling flexibility to accommodate part-time employment, and reform of conditions for academic promotion all need to be addressed to ensure future growth of the pediatric rheumatology workforce. PMID:21843335
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Henrickson, Michael
2011-01-01
The United States pediatric population with chronic health conditions is expanding. Currently, this demographic comprises 12-18% of the American child and youth population. Affected children often receive fragmented, uncoordinated care. Overall, the American health care delivery system produces modest outcomes for this population. Poor, uninsured and minority children may be at increased risk for inferior coordination of services. Further, the United States health care delivery system is primarily organized for the diagnosis and treatment of acute conditions. For pediatric patients with chronic health conditions, the typical acute problem-oriented visit actually serves as a barrier to care. The biomedical model of patient education prevails, characterized by unilateral transfer of medical information. However, the evidence basis for improvement in disease outcomes supports the use of the chronic care model, initially proposed by Dr. Edward Wagner. Six inter-related elements distinguish the success of the chronic care model, which include self-management support and care coordination by a prepared, proactive team. United States health care lacks a coherent policy direction for the management of high cost chronic conditions, including rheumatic diseases. A fundamental restructure of United States health care delivery must urgently occur which places the patient at the center of care. For the pediatric rheumatology workforce, reimbursement policies and the actions of health plans and insurers are consistent barriers to chronic disease improvement. United States reimbursement policy and overall fragmentation of health care services pose specific challenges for widespread implementation of the chronic care model. Team-based multidisciplinary care, care coordination and self-management are integral to improve outcomes. Pediatric rheumatology demand in the United States far exceeds available workforce supply. This article reviews the career choice decision-making process at each medical trainee level to determine best recruitment strategies. Educational debt is an unexpectedly minor determinant for pediatric residents and subspecialty fellows. A two-year fellowship training option may retain the mandatory scholarship component and attract an increasing number of candidate trainees. Diversity, work-life balance, scheduling flexibility to accommodate part-time employment, and reform of conditions for academic promotion all need to be addressed to ensure future growth of the pediatric rheumatology workforce.
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Adcock, G B
1999-07-01
Corporate-based nurse managed centers are not the national norm. More prevalent is the use of an occupational health or physician-directed medical model of care. The author describes how a 14-year-old primary care center at a North Carolina computer software company is just "business as usual" when viewed in the context of the company's philosophy, goals, and culture. Included are considerations for nurse practitioners interested in the successful transplantation of this primary care model to other settings.
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Effect of Workplace Weight Management on Health Care Expenditures and Quality of Life.
Michaud, Tzeyu L; Nyman, John A; Jutkowitz, Eric; Su, Dejun; Dowd, Bryan; Abraham, Jean M
2016-11-01
We examined the effectiveness of the weight management program used by the University of Minnesota in reducing health care expenditures and improving quality of life of its employees, and also in reducing their absenteeism during a 3-year intervention. A differences-in-differences regression approach was used to estimate the effect of weight management participation. We further applied ordinary least squares regression models with fixed effects to estimate the effect in an alternative analysis. Participation in the weight management program significantly reduced health care expenditures by $69 per month for employees, spouses, and dependents, and by $73 for employees only. Quality-of-life weights were 0.0045 points higher for participating employees than for nonparticipating ones. No significant effect was found for absenteeism. The workplace weight management used by the University of Minnesota reduced health care expenditures and improved quality of life.
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Lee, Cik Yin; Beanland, Christine; Goeman, Dianne P; Petrie, Neil; Petrie, Barbara; Vise, Felicity; Gray, June
2017-01-01
Objective To develop a collaborative, person-centred model of clinical pharmacy support for community nurses and their medication management clients. Design Co-creation and participatory action research, based on reflection, data collection, interaction and feedback from participants and other stakeholders. Setting A large, non-profit home nursing service in Melbourne, Australia. Participants Older people referred to the home nursing service for medication management, their carers, community nurses, general practitioners (GPs) and pharmacists, a multidisciplinary stakeholder reference group (including consumer representation) and the project team. Data collection and analysis Feedback and reflections from minutes, notes and transcripts from: project team meetings, clinical pharmacists’ reflective diaries and interviews, meetings with community nurses, reference group meetings and interviews and focus groups with 27 older people, 18 carers, 53 nurses, 15 GPs and seven community pharmacists. Results The model was based on best practice medication management standards and designed to address key medication management issues raised by stakeholders. Pharmacist roles included direct client care and indirect care. Direct care included home visits, medication reconciliation, medication review, medication regimen simplification, preparation of medication lists for clients and nurses, liaison and information sharing with prescribers and pharmacies and patient/carer education. Indirect care included providing medicines information and education for nurses and assisting with review and implementation of organisational medication policies and procedures. The model allowed nurses to refer directly to the pharmacist, enabling timely resolution of medication issues. Direct care was provided to 84 older people over a 15-month implementation period. Ongoing feedback and consultation, in line with participatory action research principles, informed the development and refinement of the model and identification of enablers and challenges. Conclusions A collaborative, person-centred clinical pharmacy model that addressed the needs of clients, carers, nurses and other stakeholders was successfully developed. The model is likely to have applicability to home nursing services nationally and internationally. PMID:29102998
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Foxwell, Anessa M; Moyer, Mary E; Casarett, David J; O'Connor, Nina R
2017-10-01
Palliative care programs are experiencing rapid growth, with demand for consults surpassing staffing. Innovative models are needed to equip nonpalliative care providers to manage basic palliative care issues. To develop a novel program of palliative care office hours for hematologic oncology advanced practice providers, and to evaluate its impact on palliative care consult volume and composition. A palliative care nurse practitioner or pharmacist was available for weekday office hours to all inpatient hematologic oncology advanced practice providers at an academic medical center to offer advice on pain, nonpain symptoms, and psychosocial distress. A retrospective study looking at outcome measures after six months of office hour utilization and palliative care consults from the hematologic oncology services. Palliative care office hours had a mean duration of 16 minutes per day (range 5 to 55). A mean of 11 patients were discussed per week (range 4 to 20). Pain, nausea, and anxiety were the issues most frequently raised. Of 299 patients discussed during office hours, 44 (14.7%) subsequently required a full palliative care consult. Overall, palliative care consults from the hematologic oncology services decreased from 19.6% to 10.2% of admissions (87/445 vs. 61/594, p < 0.001) with an increase in consults for goals of care. Office hours are an efficient way to address palliative care needs when demand for palliative care consults exceeds capacity. Office hours may serve an educational function as well, enabling primary teams to manage basic palliative care issues with increasing independence over time.
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Adams, Julie L; Almond, Maria L G; Ringo, Edward J; Shangali, Wahida H; Sikkema, Kathleen J
2012-01-01
Sub-Saharan Africa has the highest HIV prevalence worldwide and depression is highly prevalent among those infected. The negative impact of depression on HIV outcomes highlights the need to identify and treat it in this population. A model for doing this in lower-resourced settings involves task-shifting depression treatment to primary care; however, HIV-infected individuals are often treated in a parallel HIV specialty setting. We adapted a model of task-shifting, measurement-based care (MBC), for an HIV clinic setting and tested its feasibility in Tanzania. MBC involves measuring depressive symptoms at meaningful intervals and adjusting antidepressant medication treatment based on the measure of illness. Twenty adults presenting for care at an outpatient HIV clinic in Tanzania were enrolled and followed by a nurse care manager who measured depressive symptoms at baseline and every 4 weeks for 12 weeks. An algorithm-based decision-support tool was utilized by the care manager to recommend individualized antidepressant medication doses to participants' HIV providers at each visit. Retention was high and fidelity of the care manager to the MBC protocol was exceptional. Follow through of antidepressant prescription dosing recommendations by the prescriber was low. Limited availability of antidepressants was also noted. Despite challenges, baseline depression scores decreased over the 12-week period. Overall, the model of algorithm-based nursing support of prescription decisions was feasible. Future studies should address implementation issues of medication supply and dosing. Further task-shifting to relatively more abundant and lower-skilled health workers, such as nurses' aides, warrants examination.
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Morrin, Louise; Britten, Judith; Davachi, Shahnaz; Knight, Holly
2013-08-01
The most common presentation of chronic disease is multimorbidity. Disease management strategies are similar across most chronic diseases. Given the prevalence of multimorbidity and the commonality in approaches, fragmented single disease management must be replaced with integrated care of the whole person. The Alberta Healthy Living Program, a community-based chronic disease management program, supports adults with, or at risk for, chronic disease to improve their health and well being. Participants gain confidence and skills in how to manage their chronic disease(s) by learning to understand their health condition, make healthy eating choices, exercise safely and cope emotionally. The program includes 3 service pillars: disease-specific and general health patient education, disease-spanning supervised exercise and Better Choices, Better Health(TM) self-management workshops. Services are delivered in the community by an interprofessional team and can be tailored to target specific diverse and vulnerable populations, such as Aboriginal, ethno-cultural and francophone groups and those experiencing homelessness. Programs may be offered as a partnership between Alberta Health Services, primary care and community organizations. Common standards reduce provincial variation in care, yet maintain sufficient flexibility to meet local and diverse needs and achieve equity in care. The model has been implemented successfully in 108 communities across Alberta. This approach is associated with reduced acute care utilization and improved clinical indicators, and achieves efficiencies through an integrated, disease-spanning patient-centred approach. Crown Copyright © 2013. Published by Elsevier Inc. All rights reserved.
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An introductory pharmacy practice experience based on a medication therapy management service model.
Agness, Chanel F; Huynh, Donna; Brandt, Nicole
2011-06-10
To implement and evaluate an introductory pharmacy practice experience (IPPE) based on the medication therapy management (MTM) service model. Patient Care 2 is an IPPE that introduces third-year pharmacy students to the MTM service model. Students interacted with older adults to identify medication-related problems and develop recommendations using core MTM elements. Course outcome evaluations were based on number of documented medication-related problems, recommendations, and student reviews. Fifty-seven older adults participated in the course. Students identified 52 medication-related problems and 66 medical problems, and documented 233 recommendations relating to health maintenance and wellness, pharmacotherapy, referrals, and education. Students reported having adequate experience performing core MTM elements. Patient Care 2 may serve as an experiential learning model for pharmacy schools to teach the core elements of MTM and provide patient care services to the community.
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Neuroscience nursing practice in a new millennium.
Hickey, J V; Minton, M S
1999-09-01
Neuroscience nursing practice in the 21st century is considered from two perspectives: 1) scope of care and roles within a collaborative interdisciplinary model of care; and 2) patient-focused care within the challenging health care system. The implications of illness trends for neuroscience nursing practice are discussed, as are the developing changes in the health care delivery system driven by economics. The article focuses on the futuristic role of disease management in shaping practice and the models for practice which will prevail in this new health care environment.
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Use of a state inpatient forensic system under managed mental health care.
Fisher, William H; Dickey, Barbara; Normand, Sharon-Lise T; Packer, Ira K; Grudzinskas, Albert J; Azeni, Hocine
2002-04-01
One of the goals of managed mental health care has been to lower the use of inpatient psychiatric treatment. In the past, interventions that have limited hospitalization for persons with severe mental illness have led to greater involvement of these individuals with the criminal justice and forensic mental health systems. The authors examined associations between Medicaid managed mental health care in Massachusetts and rates of admission to the inpatient forensic mental health service maintained by the state's mental health department. A total of 7,996 persons who were receiving services from the department before and after the introduction of managed care were studied. A logistic regression model based on generalized estimating equations was used to identify associations between Medicaid beneficiary status and forensic hospitalization before and after the introduction of managed care. The overall rate of forensic hospitalization declined in the study cohort in both periods. However, no significant decline was observed in the risk of forensic hospitalization among Medicaid beneficiaries whose care had become managed. Although the results of this study warrant further exploration, the risk of forensic hospitalization among Medicaid beneficiaries should be considered by policy makers in the design of mental health system interventions.
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Treating Depression in Staff-Model Versus Network-Model Managed Care Organizations
Meredith, Lisa S; Rubenstein, Lisa V; Rost, Kathryn; Ford, Daniel E; Gordon, Nancy; Nutting, Paul; Camp, Patti; Wells, Kenneth B
1999-01-01
OBJECTIVE To compare primary care providers’ depression-related knowledge, attitudes, and practices and to understand how these reports vary for providers in staff or group-model managed care organizations (MCOs) compared with network-model MCOs including independent practice associations and preferred provider organizations. DESIGN Survey of primary care providers’ depression-related practices in 1996. SETTING AND PARTICIPANTS We surveyed 410 providers, from 80 outpatient clinics, in 11 MCOs participating in four studies designed to improve the quality of depression care in primary care. MEASUREMENTS AND MAIN RESULTS We measured knowledge based on depression guidelines, attitudes (beliefs about burden, skill, and barriers) related to depression, and reported behavior. Providers in both types of MCO are equally knowledgeable about treating depression (better knowledge of pharmacologic than psychotherapeutic treatments) and perceive equivalent skills in treating depression. However, compared with network-model providers, staff/group-model providers have stronger beliefs that treating depression is burdensome to their practice. While more staff/group-model providers reported time limitations as a barrier to optimal depression treatment, more network-model providers reported limited access to mental health specialty referral as a barrier. Accordingly, these staff/group-model providers are more likely to treat patients with major depression through referral (51% vs 38%) or to assess but not treat (17% vs 7%), and network-model providers are more likely to prescribe antidepressants (57% vs 6%) as first-line treatment. CONCLUSIONS Whereas the providers from staff/group-model MCOs had greater access to and relied more on referral, the providers from network-model organizations were more likely to treat depression themselves. Given varying attitudes and behaviors, improving primary care for the treatment of depression will require unique strategies beyond enhancing technical knowledge for the two types of MCOs. PMID:9893090
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Qureshi, Babar M; Mansur, Rabiu; Al-Rajhi, Abdulaziz; Lansingh, Van; Eckert, Kristen; Hassan, Kunle; Ravilla, Thulasiraj; Muhit, Mohammad; Khanna, Rohit C; Ismat, Chaudhry
2012-01-01
Since the launching of Global Initiative, VISION 2020 “the Right to Sight” many innovative, practical and unique comprehensive eye care services provision models have evolved targeting the underserved populations in different parts of the World. At places the rapid assessment of the burden of eye diseases in confined areas or utilizing the key informants for identification of eye diseases in the communities are promoted for better planning and evidence based advocacy for getting / allocation of resources for eye care. Similarly for detection and management of diabetes related blindness, retinopathy of prematurity and avoidable blindness at primary level, the major obstacles are confronted in reaching to them in a cost effective manner and then management of the identified patients accordingly. In this regard, the concept of tele-ophthalmology model sounds to be the best solution. Whereas other models on comprehensive eye care services provision have been emphasizing on surgical output through innovative scales of economy that generate income for the program and ensure its sustainability, while guaranteeing treatment of the poorest of the poor. PMID:22944741
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An obesity/cardiometabolic risk reduction disease management program: a population-based approach.
Villagra, Victor G
2009-04-01
Obesity is a critical health concern that has captured the attention of public and private healthcare payers who are interested in controlling costs and mitigating the long-term economic consequences of the obesity epidemic. Population-based approaches to obesity management have been proposed that take advantage of a chronic care model (CCM), including patient self-care, the use of community-based resources, and the realization of care continuity through ongoing communications with patients, information technology, and public policy changes. Payer-sponsored disease management programs represent an important conduit to delivering population-based care founded on similar CCM concepts. Disease management is founded on population-based disease identification, evidence-based care protocols, and collaborative practices between clinicians. While substantial clinician training, technology infrastructure commitments, and financial support at the payer level will be needed for the success of disease management programs in obesity and cardiometabolic risk reduction, these barriers can be overcome with the proper commitment. Disease management programs represent an important tool to combat the growing societal risks of overweight and obesity.
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Role of the registered nurse in primary health care: meeting health care needs in the 21st century.
Smolowitz, Janice; Speakman, Elizabeth; Wojnar, Danuta; Whelan, Ellen-Marie; Ulrich, Suzan; Hayes, Carolyn; Wood, Laura
2015-01-01
There is widespread interest in the redesign of primary health care practice models to increase access to quality health care. Registered nurses (RNs) are well positioned to assume direct care and leadership roles based on their understanding of patient, family, and system priorities. This project identified 16 exemplar primary health care practices that used RNs to the full extent of their scope of practice in team-based care. Interviews were conducted with practice representatives. RN activities were performed within three general contexts: episodic and preventive care, chronic disease management, and practice operations. RNs performed nine general functions in these contexts including telephone triage, assessment and documentation of health status, chronic illness case management, hospital transition management, delegated care for episodic illness, health coaching, medication reconciliation, staff supervision, and quality improvement leadership. These functions improved quality and efficiency and decreased cost. Implications for policy, practice, and RN education are considered. Copyright © 2015 Elsevier Inc. All rights reserved.
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Askew, Deborah A; Jackson, Claire L; Ware, Robert S; Russell, Anthony
2010-05-24
Type 2 Diabetes Mellitus is one of the most disabling chronic conditions worldwide, resulting in significant human, social and economic costs and placing huge demands on health care systems. The Inala Chronic Disease Management Service aims to improve the efficiency and effectiveness of care for patients with type 2 diabetes who have been referred by their general practitioner to a specialist diabetes outpatient clinic. Care is provided by a multidisciplinary, integrated team consisting of an endocrinologist, diabetes nurse educators, General Practitioner Clinical Fellows (general practitioners who have undertaken focussed post-graduate training in complex diabetes care), and allied health personnel (a dietitian, podiatrist and psychologist). Using a geographical control, this evaluation study tests the impact of this model of diabetes care provided by the service on patient outcomes compared to usual care provided at the specialist diabetes outpatient clinic. Data collection at baseline, 6 and 12-months will compare the primary outcome (glycaemic control) and secondary outcomes (serum lipid profile, blood pressure, physical activity, smoking status, quality of life, diabetes self-efficacy and cost-effectiveness). This model of diabetes care combines the patient focus and holistic care valued by the primary care sector with the specialised knowledge and skills of hospital diabetes care. Our study will provide empirical evidence about the clinical effectiveness of this model of care. Australian New Zealand Clinical Trials Registry ACTRN12608000010392.
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Graham, Robert J; McManus, Michael L; Rodday, Angie Mae; Weidner, Ruth Ann; Parsons, Susan K
2018-05-01
To describe program design, costs, and savings implications of a critical care-based care coordination model for medically complex children with chronic respiratory failure. All program activities and resultant clinical outcomes were tracked over 4 years using an adapted version of the Care Coordination Measurement Tool. Patient characteristics, program activity, and acute care resource utilization were prospectively documented in the adapted version of the Care Coordination Measurement Tool and retrospectively cross-validated with hospital billing data. Impact on total costs of care was then estimated based on program outcomes and nationally representative administrative data. Tertiary children's hospital. Critical Care, Anesthesia, Perioperative Extension and Home Ventilation Program enrollees. None. The program provided care for 346 patients and families over the study period. Median age at enrollment was 6 years with more than half deriving secondary respiratory failure from a primary neuromuscular disease. There were 11,960 encounters over the study period, including 1,202 home visits, 673 clinic visits, and 4,970 telephone or telemedicine encounters. Half (n = 5,853) of all encounters involved a physician and 45% included at least one care coordination activity. Overall, we estimated that program interventions were responsible for averting 556 emergency department visits and 107 hospitalizations. Conservative monetization of these alone accounted for annual savings of $1.2-2 million or $407/pt/mo net of program costs. Innovative models, such as extension of critical care services, for high-risk, high-cost patients can result in immediate cost savings. Evaluation of financial implications of comprehensive care for high-risk patients is necessary to complement clinical and patient-centered outcomes for alternative care models. When year-to-year cost variability is high and cost persistence is low, these savings can be estimated from documentation within care coordination management tools. Means of financial sustainability, scalability, and equal access of such care models need to be established.
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Economic organization of medicine and the Committee on the Costs of Medical Care.
Perkins, B B
1998-01-01
Recent strategies in managed care and managed competition illustrate how health care reforms may reproduce the patterns of economic organization of their times. Such a reform approach is not a new development in the United States. The work of the 1927-1932 Committee on the Costs of Medical Care exemplifies an earlier effort that applied forms of economic organization to medical care. The committee tried to restructure medicine along lines consistent with its economic environment while attributing its models variously to science, profession, and business. Like current approaches, the committee's reports defined costs as the major problem and business models of organization as the major solution. The reports recommended expanded financial management and group medicine, which would include growth in self-supporting middle-class services such as fee clinics and middle-rate hospital units. Identifying these elements as corporate practice of medicine, the American Medical Association-based minority dissented from the final report in favor of conserving individual entrepreneurial practice. This continuum in forms of economic organization has limited structural reform strategies in medicine for the remainder of the century. PMID:9807547
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Cloutier, Denise; Cox, Amy; Kampen, Ruth; Kobayashi, Karen; Cook, Heather; Taylor, Deanne; Gaspard, Gina
2016-01-01
Residential, long-term care serves vulnerable older adults in a facility-based environment. A new care delivery model (CDM) designed to promote more equitable care for residents was implemented in a health region in Western Canada. Leaders and managers faced challenges in implementing this model alongside other concurrent changes. This paper explores the question: How did leadership style influence team functioning with the implementation of the CDM? Qualitative data from interviews with leadership personnel (directors and managers, residential care coordinators and clinical nurse educators), and direct care staff (registered nurses, licensed practical nurses, health care aides, and allied health therapists), working in two different facilities comprise the main sources of data for this study. The findings reveal that leaders with a servant leadership style were better able to create and sustain the conditions to support successful model implementation and higher team functioning, compared to a facility in which the leadership style was less inclusive and proactive, and more resistant to the change. Consequently, staff at the second facility experienced a greater sense of overload with the implementation of the CDM. This study concludes that strong leadership is key to facilitating team work and job satisfaction in a context of change. PMID:27417591
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Cloutier, Denise; Cox, Amy; Kampen, Ruth; Kobayashi, Karen; Cook, Heather; Taylor, Deanne; Gaspard, Gina
2016-01-04
Residential, long-term care serves vulnerable older adults in a facility-based environment. A new care delivery model (CDM) designed to promote more equitable care for residents was implemented in a health region in Western Canada. Leaders and managers faced challenges in implementing this model alongside other concurrent changes. This paper explores the question: How did leadership style influence team functioning with the implementation of the CDM? Qualitative data from interviews with leadership personnel (directors and managers, residential care coordinators and clinical nurse educators), and direct care staff (registered nurses, licensed practical nurses, health care aides, and allied health therapists), working in two different facilities comprise the main sources of data for this study. The findings reveal that leaders with a servant leadership style were better able to create and sustain the conditions to support successful model implementation and higher team functioning, compared to a facility in which the leadership style was less inclusive and proactive, and more resistant to the change. Consequently, staff at the second facility experienced a greater sense of overload with the implementation of the CDM. This study concludes that strong leadership is key to facilitating team work and job satisfaction in a context of change.
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Diabetes Care in Malaysia: Problems, New Models, and Solutions.
Hussein, Zanariah; Taher, Sri Wahyu; Gilcharan Singh, Harvinder Kaur; Chee Siew Swee, Winnie
2015-01-01
Diabetes is a major public health concern in Malaysia, and the prevalence of type 2 diabetes (T2D) has escalated to 20.8% in adults above the age of 30, affecting 2.8 million individuals. The burden of managing diabetes falls on primary and tertiary health care providers operating in various settings. This review focuses on the current status of diabetes in Malaysia, including epidemiology, complications, lifestyle, and pharmacologic treatments, as well as the use of technologies in its management and the adoption of the World Health Organization chronic care model in primary care clinics. A narrative review based on local available health care data, publications, and observations from clinic experience. The prevalence of diabetes varies among the major ethnic groups in Malaysia, with Asian Indians having the highest prevalence of T2D, followed by Malays and Chinese. The increase prevalence of overweight and obesity has accompanied the rise in T2D. Multidisciplinary care is available in tertiary and primary care settings with integration of pharmacotherapy, diet, and lifestyle changes. Poor dietary adherence, high consumption of carbohydrates, and sedentary lifestyle are prevalent in patients with T2D. The latest medication options are available with increasing use of intensive insulin regimens, insulin pumps, and continuous glucose monitoring systems for managing glycemic control. A stepwise approach is proposed to expand the chronic care model into an Innovative Care for Chronic Conditions framework to facilitate implementation and realize better outcomes in primary care settings. A comprehensive strategy and approach has been established by the Malaysian government to improve prevention, treatment, and control of diabetes as an urgent response to this growing chronic disease. Copyright © 2015 The Authors. Published by Elsevier Inc. All rights reserved.
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Redesign of a health science centre: reflections on co-leadership.
MacTavish, M; Norton, P
1995-01-01
Since 1988, the Sunnybrook Health Science Centre has been proactive in re-designing its system toward decentralized management, the purpose being to further enhance patient care. This process has involved numerous changes, among which were the establishment of three large clinical units. These clinical units are not defined following the historic medical model, but group patients with similar service and care needs. Subsequently, each of the clinical units defined Patient Service Units (PSUs). The hospital has chosen a co-leadership model for the lead management at each of the unit levels. This paper describes the model for clinical units.
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[Leaders as intermediates between economic incentive models and professional motivation].
Korlén, Sara; Essén, Anna; Lindgren, Peter; Amer-Wåhlin, Isis; von Thiele Schwarz, Ulrica
2018-05-24
The application of economic incentives to providers in health care governance is debated. Advocates argue that it drives efficiency and improvement, opponents claim that it leads to unintended consequences for patients and professionals. Research shows that incentives can increase well-defined activities and targets, but there is a lack of substantial evidence that applications in health care lead to desired outcomes. The motivational literature acknowledges internal sources of motivation as important determinants of behavior, and the literature about professions suggests that professional values of serving patient needs is a key motivator. The management literature identifies the important role of leaders in aligning external demands and rewards to staff preferences, using their own management and leadership skills. Findings in health services research confirm the vital role of leaders for successful implementation and improvement work. In sum, internal motivators and the role of leaders are important to acknowledge also when understanding how economic governance models are put into practice.Our recently published qualitative case study provides empirical examples of how clinical leaders function as intermediaries between a local care choice model, including financial incentives, and the motivation of staff. The strategies deployed by the leaders aimed to align the economic logics of the model to the professional focus on increasing patient value. The main conclusion from these empirical examples, as well as previous research, is that health care managers play a key role in aligning economic incentive models with professional values and in translating such models in to feasible tasks related to the provision of high quality care.
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Katz, Steven J; Hawley, Sarah T; Morrow, Monica; Griggs, Jennifer J; Jagsi, Reshma; Hamilton, Ann S; Graff, John J; Friese, Christopher R; Hofer, Timothy P
2010-01-01
The Institute of Medicine has called for more coordinated cancer care models that correspond to initiatives led by cancer providers and professional organizations. These initiatives parallel those underway to integrate the management of patients with chronic conditions. We developed 5 breast cancer patient and practice management process measures based on the Chronic Care Model. We then performed a survey to evaluate patterns and correlates of these measures among attending surgeons of a population-based sample of patients diagnosed with breast cancer between June 2005 and February 2007 in Los Angeles and Detroit (N = 312; response rate, 75.9%). Surgeon practice specialization varied markedly with about half of the surgeons devoting 15% or less of their total practice to breast cancer, whereas 16.2% of surgeons devoted 50% or more. There was also large variation in the extent of the use of patient and practice management processes with most surgeons reporting low use. Patient and practice management process measures were positively associated with greater levels of surgeon specialization and the presence of a teaching program. Cancer program status was weakly associated with patient and practice management processes. Low uptake of patient and practice management processes among surgeons who treat breast cancer patients may indicate that surgeons are not convinced that these processes matter, or that there are logistical and cost barriers to implementation. More research is needed to understand how large variations in patient and practice management processes might affect the quality of care for patients with breast cancer.
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An architecture model for multiple disease management information systems.
Chen, Lichin; Yu, Hui-Chu; Li, Hao-Chun; Wang, Yi-Van; Chen, Huang-Jen; Wang, I-Ching; Wang, Chiou-Shiang; Peng, Hui-Yu; Hsu, Yu-Ling; Chen, Chi-Huang; Chuang, Lee-Ming; Lee, Hung-Chang; Chung, Yufang; Lai, Feipei
2013-04-01
Disease management is a program which attempts to overcome the fragmentation of healthcare system and improve the quality of care. Many studies have proven the effectiveness of disease management. However, the case managers were spending the majority of time in documentation, coordinating the members of the care team. They need a tool to support them with daily practice and optimizing the inefficient workflow. Several discussions have indicated that information technology plays an important role in the era of disease management. Whereas applications have been developed, it is inefficient to develop information system for each disease management program individually. The aim of this research is to support the work of disease management, reform the inefficient workflow, and propose an architecture model that enhance on the reusability and time saving of information system development. The proposed architecture model had been successfully implemented into two disease management information system, and the result was evaluated through reusability analysis, time consumed analysis, pre- and post-implement workflow analysis, and user questionnaire survey. The reusability of the proposed model was high, less than half of the time was consumed, and the workflow had been improved. The overall user aspect is positive. The supportiveness during daily workflow is high. The system empowers the case managers with better information and leads to better decision making.
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Littauer, Sydney L; Dixon, Dave L; Mishra, Vimal K; Sisson, Evan M; Salgado, Teresa M
2017-01-01
Telemedicine refers to the delivery of clinical services using technology that allows two-way, real time, interactive communication between the patient and the clinician at a distant site. Commonly, telemedicine is used to improve access to general and specialty care for patients in rural areas. This review aims to provide an overview of existing telemedicine models involving the delivery of care by pharmacists via telemedicine (including telemonitoring and video, but excluding follow-up telephone calls) and to highlight the main areas of chronic-disease management where these models have been applied. Studies within the areas of hypertension, diabetes, asthma, anticoagulation and depression were identified, but only two randomized controlled trials with adequate sample size demonstrating the positive impact of telemonitoring combined with pharmacist care in hypertension were identified. The evidence for the impact of pharmacist-based telemedicine models is sparse and weak, with the studies conducted presenting serious threats to internal and external validity. Therefore, no definitive conclusions about the impact of pharmacist-led telemedicine models can be made at this time. In the Unites States, the increasing shortage of primary care providers and specialists represents an opportunity for pharmacists to assume a more prominent role managing patients with chronic disease in the ambulatory care setting. However, lack of reimbursement may pose a barrier to the provision of care by pharmacists using telemedicine.
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Pharmacists providing care in the outpatient setting through telemedicine models: a narrative review
Littauer, Sydney L.
2017-01-01
Telemedicine refers to the delivery of clinical services using technology that allows two-way, real time, interactive communication between the patient and the clinician at a distant site. Commonly, telemedicine is used to improve access to general and specialty care for patients in rural areas. This review aims to provide an overview of existing telemedicine models involving the delivery of care by pharmacists via telemedicine (including telemonitoring and video, but excluding follow-up telephone calls) and to highlight the main areas of chronic-disease management where these models have been applied. Studies within the areas of hypertension, diabetes, asthma, anticoagulation and depression were identified, but only two randomized controlled trials with adequate sample size demonstrating the positive impact of telemonitoring combined with pharmacist care in hypertension were identified. The evidence for the impact of pharmacist-based telemedicine models is sparse and weak, with the studies conducted presenting serious threats to internal and external validity. Therefore, no definitive conclusions about the impact of pharmacist-led telemedicine models can be made at this time. In the Unites States, the increasing shortage of primary care providers and specialists represents an opportunity for pharmacists to assume a more prominent role managing patients with chronic disease in the ambulatory care setting. However, lack of reimbursement may pose a barrier to the provision of care by pharmacists using telemedicine. PMID:29317927
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Carpenter, Christopher R.; Platts-Mills, Timothy F.
2013-01-01
Alternative management methods are essential to ensure high quality and efficient emergency care for the growing number of geriatric adults worldwide. Protocols for case-finding and rapid diagnosis to support early condition-specific treatment for older adults with acute severe illness and injury are needed. Improved emergency department care for older adults will require providers to look beyond the diagnosis to address the influence of other factors on the patient's health: isolation and depression; finances and transportation; and chronic medical conditions and polypharmacy. This review article describes recent and ongoing efforts to enhance the quality of emergency care for older adults using alternative management approaches spanning the spectrum from prehospital care, through the emergency department, and into evolving inpatient or outpatient processes of care. PMID:23177599
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Testing a Model of Diabetes Self-Care Management: A Causal Model Analysis with LISREL.
ERIC Educational Resources Information Center
Nowacek, George A.; And Others
1990-01-01
A diabetes-management model is presented, which includes an attitudinal element and depicts relationships among causal elements. LISREL-VI was used to analyze data from 115 Type-I and 105 Type-II patients. The data did not closely fit the model. Results support the importance of the personal meaning of diabetes. (TJH)
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American Pharmacists Association
... Tools Quality Measures Transitions of Care Chronic Care Management Appointment Based Model OTC Supplement OPIOID Center Nuclear Pharmacy Clinical Guidelines Conducting Research Projects GET INVOLVED Participate House of Delegates APhA-APPM ...
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Tabrizi, Jafar-Sadegh; Farahbakhsh, Mostafa; Shahgoli, Javad; Rahbar, Mohammad Reza; Naghavi-Behzad, Mohammad; Ahadi, Hamid-Reza; Azami-Aghdash, Saber
2015-10-01
Excellence and quality models are comprehensive methods for improving the quality of healthcare. The aim of this study was to design excellence and quality model for training centers of primary health care using Delphi method. In this study, Delphi method was used. First, comprehensive information were collected using literature review. In extracted references, 39 models were identified from 34 countries and related sub-criteria and standards were extracted from 34 models (from primary 39 models). Then primary pattern including 8 criteria, 55 sub-criteria, and 236 standards was developed as a Delphi questionnaire and evaluated in four stages by 9 specialists of health care system in Tabriz and 50 specialists from all around the country. Designed primary model (8 criteria, 55 sub-criteria, and 236 standards) were concluded with 8 criteria, 45 sub-criteria, and 192 standards after 4 stages of evaluations by specialists. Major criteria of the model are leadership, strategic and operational planning, resource management, information analysis, human resources management, process management, costumer results, and functional results, where the top score was assigned as 1000 by specialists. Functional results had the maximum score of 195 whereas planning had the minimum score of 60. Furthermore the most and the least sub-criteria was for leadership with 10 sub-criteria and strategic planning with 3 sub-criteria, respectively. The model that introduced in this research has been designed following 34 reference models of the world. This model could provide a proper frame for managers of health system in improving quality.
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Mittler, Jessica N; Landon, Bruce E; Zaslavsky, Alan M; Cleary, Paul D
2011-10-14
Medicare beneficiaries' awareness of Medicare managed care plans is critical for realizing the potential benefits of coverage choices. To assess the relationships of the number of Medicare risk plans, managed care penetration, and stability of plans in an area with traditional Medicare beneficiaries' awareness of the program. Cross-sectional analysis of Medicare Current Beneficiary Survey data about beneficiaries' awareness and knowledge of Medicare managed care plan availability. Logistic regression models used to assess the relationships between awareness and market characteristics. Traditional Medicare beneficiaries (n = 3,597) who had never been enrolled in Medicare managed care, but had at least one plan available in their area in 2002, and excluding beneficiaries under 65, receiving Medicaid, or with end stage renal disease. Traditional Medicare beneficiaries' knowledge of Medicare managed care plans in general and in their area. Having more Medicare risk plans available was significantly associated with greater awareness, and having an intermediate number of plans (2-4) was significantly associated with more accurate knowledge of Medicare risk plan availability than was having fewer or more plans. Medicare may have more success engaging consumers in choice and capturing the benefits of plan competition by more actively selecting and managing the plan choice set. Public Domain.
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Mittler, Jessica N.; Landon, Bruce E.; Zaslavsky, Alan M.; Cleary, Paul D.
2011-01-01
Background Medicare beneficiaries' awareness of Medicare managed care plans is critical for realizing the potential benefits of coverage choices. Objectives To assess the relationships of the number of Medicare risk plans, managed care penetration, and stability of plans in an area with traditional Medicare beneficiaries' awareness of the program. Research Design Cross-sectional analysis of Medicare Current Beneficiary Survey data about beneficiaries' awareness and knowledge of Medicare managed care plan availability. Logistic regression models used to assess the relationships between awareness and market characteristics. Subjects Traditional Medicare beneficiaries (n = 3,597) who had never been enrolled in Medicare managed care, but had at least one plan available in their area in 2002, and excluding beneficiaries under 65, receiving Medicaid, or with end stage renal disease. Measures Traditional Medicare beneficiaries' knowledge of Medicare managed care plans in general and in their area. Results Having more Medicare risk plans available was significantly associated with greater awareness, and having an intermediate number of plans (2-4) was significantly associated with more accurate knowledge of Medicare risk plan availability than was having fewer or more plans. Conclusions Medicare may have more success engaging consumers in choice and capturing the benefits of plan competition by more actively selecting and managing the plan choice set. PMID:22340776
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ERIC Educational Resources Information Center
Kelehear, D. Zach
2005-01-01
Looking at medical care administration, 14 assistant principals noted that the hospital administrator managed the business of health care, while the chief of staff provided leadership to the doctors and nurses. The assistant principals then posited: Can the organization model found in many hospitals offer any insight into ways that school…
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The impact of health information technology on collaborative chronic care management.
Marchibroda, Janet M
2008-03-01
Chronic disease is a growing problem in the United States. More than 125 million Americans had at least 1 chronic care condition in 2000, and this number is expected to grow to 157 million by the year 2020.1 Some of the challenges associated with current chronic care management approaches can be addressed through the use of health information technology (IT) and health information exchange. To review the current challenges of chronic care management and explore how health IT and health information exchange efforts at the national, state, and local levels can be leveraged to address some of these challenges. Efforts to effectively manage chronic care have been hampered by a number of factors, including a fragmented health care system and the need for more coordination across the health care setting; the lack of interoperable clinical information systems, which would help provide readily available, comprehensive information about the patient to those who deliver care, those who manage care, and those who receive care, and finally, the current predominantly fee-for-service reimbursement system that rewards volume and fragmentation, and does not effectively align incentives with the goals of chronic care management. The introduction of health IT, including electronic health records and health information exchange, holds great promise for addressing many of the barriers to effective chronic care management, by providing important clinical information about the patient when it is needed, and where it is needed, in a timely, secure fashion. Having information from the care delivery process readily available through health IT and health information exchange at the national, state, and local levels supports key components of the chronic care management process, including those related to measurement, clinical decision support, collaboration and coordination, and consumer activation. Those engaged in chronic care management should seek to leverage health IT and health information exchange initiatives particularly at the local levels. Community-based initiatives have built social capital and trust across multiple stakeholders; enabled access to clinical data derived from the care delivery process that only resides locally; and in many cases aligned incentives around the mobilization of clinical information across care settings. All of these elements are critical to the long-term success of chronic care management. While there is good research regarding interdisciplinary care models, more research is still needed to identify policies, practices, and strategies for facilitating and building cooperation among those engaged in chronic care management, and those engaged in multi-stakeholder efforts involved in the exchange of clinical health information electronically.
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Socioeconomic Disparities in the Use of Home Health Services in a Medicare Managed Care Population
Freedman, Vicki A; Rogowski, Jeannette; Wickstrom, Steven L; Adams, John; Marainen, Jonas; Escarce, José J
2004-01-01
Objective To investigate socioeconomic disparities in access to home health visits and durable medical equipment by persons enrolled in two Medicare managed care health plans. Data Sources A telephone survey of 4,613 Medicare managed care enrollees conducted between April and October of 2000 and linked to administrative claims for a subsequent 12-month period. Study Design We estimated a series of logistic regression models to determine which socioeconomic factors were related to home health visits and the use of durable medical equipment (DME) among Medicare managed care enrollees. Principal Findings Controlling for health and demographic differences, Medicare managed care enrollees in the lowest tertile for nonhousing assets had 50 percent greater odds than those in the highest tertile of having one or more home health visits. All else equal, enrollees with less than a high school education had 30 percent lower odds than those who had graduated from high school of using durable medical equipment. Conclusions Medicare managed care enrollees of low socioeconomic status do not appear to have reduced access to home health visits; however, use of durable medical equipment is considerably lower for enrollees with less than a high school education. Physicians and therapists working with Medicare managed care enrollees may want to actively target DME prescriptions to those with educational disadvantages. PMID:15333109
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Monroe, C Douglas; Chin, Karen Y
2013-05-01
The specialty pharmaceuticals market is expanding more rapidly than the traditional pharmaceuticals market. Specialty pharmacy operations have evolved to deliver selected medications and associated clinical services. The growing role of specialty drugs requires new approaches to managing the use of these drugs. The focus, expectations, and emphasis in specialty drug management in an integrated health care delivery system such as Kaiser Permanente (KP) can vary as compared with more conventional health care systems. The KP Specialty Pharmacy (KP-SP) serves KP members across the United States. This descriptive account addresses the impetus for specialty drug management within KP, the use of tools such as an electronic health record (EHR) system and process management software, the KP-SP approach for specialty pharmacy services, and the emphasis on quality measurement of services provided. Kaiser Permanente's integrated system enables KP-SP pharmacists to coordinate the provision of specialty drugs while monitoring laboratory values, physician visits, and most other relevant elements of the patient's therapy. Process management software facilitates the counseling of patients, promotion of adherence, and interventions to resolve clinical, logistic, or pharmacy benefit issues. The integrated EHR affords KP-SP pharmacists advantages for care management that should become available to more health care systems with broadened adoption of EHRs. The KP-SP experience may help to establish models for clinical pharmacy services as health care systems and information systems become more integrated.
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Kuhn, Kurt W.; Cambron, Jerrilyn
2013-01-01
Objective The purpose of this report is to describe chiropractic management, using a brain-based model of care, of a teen who had migraine headaches and several social and learning difficulties. Clinical features A 15-year-old adolescent boy with a chronic history of migraines and more than 10 years of learning and behavioral difficulties, including attention-deficit/hyperactivity disorder, obsessive compulsive disorder, and Tourette syndrome, presented for chiropractic care. Intervention and outcome The patient received spinal manipulation and was given home physical coordination activities that were contralateral to the side of the involved basal ganglia and ipsilateral to the involved cerebellum, along with interactive metronome training. Quantitative changes were noted in neurological soft signs, tests of variables of attention Conners’ Parent Rating Scale, the California Achievement Test, grade point, and reduction of medications. The patient reported qualitative improvements in tics, attention, reading, vision, health, relationships with his peers and his family, and self-esteem. Conclusion The patient with migraine headaches and learning difficulties responded well to the course of chiropractic care. This study suggests that there may be value in a brain-based model of care in the chiropractic management of conditions that are beyond musculoskeletal in nature. PMID:24396330
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Green, Carolyn J; Fortin, Patricia; Maclure, Malcolm; Macgregor, Art; Robinson, Sylvia
2006-12-01
Improvement of chronic disease management in primary care entails monitoring indicators of quality over time and across patients and practices. Informatics tools are needed, yet implementing them remains challenging. To identify critical success factors enabling the translation of clinical and operational knowledge about effective and efficient chronic care management into primary care practice. A prospective case study of positive deviants using key informant interviews, process observation, and document review. A chronic disease management (CDM) collaborative of primary care physicians with documented improvement in adherence to clinical practice guidelines using a web-based patient registry system with CDM guideline-based flow sheet. Thirty community-based physician participants using predominantly paper records, plus a project management team including the physician lead, project manager, evaluator and support team. A critical success factor (CSF) analysis of necessary and sufficient pathways to the translation of knowledge into clinical practice. A web-based CDM 'toolkit' was found to be a direct CSF that allowed this group of physicians to improve their practice by tracking patient care processes using evidence-based clinical practice guideline-based flow sheets. Moreover, the information and communication technology 'factor' was sufficient for success only as part of a set of seven direct CSF components including: health delivery system enhancements, organizational partnerships, funding mechanisms, project management, practice models, and formal knowledge translation practices. Indirect factors that orchestrated success through the direct factor components were also identified. A central insight of this analysis is that a comprehensive quality improvement model was the CSF that drew this set of factors into a functional framework for successful knowledge translation. In complex primary care settings environment where physicians have low adoption rates of electronic tools to support the care of patients with chronic conditions, successful implementation may require a set of interrelated system and technology factors.
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Dodek, Peter M; Wong, Hubert; Jaswal, Danny; Heyland, Daren K; Cook, Deborah J; Rocker, Graeme M; Kutsogiannis, Demetrios J; Dale, Craig; Fowler, Robert; Ayas, Najib T
2012-02-01
The objectives of this study are to describe organizational and safety culture in Canadian intensive care units (ICUs), to correlate culture with the number of beds and physician management model in each ICU, and to correlate organizational culture and safety culture. In this cross-sectional study, surveys of organizational and safety culture were administered to 2374 clinical staff in 23 Canadian tertiary care and community ICUs. For the 1285 completed surveys, scores were calculated for each of 34 domains. Average domain scores for each ICU were correlated with number of ICU beds and with intensivist vs nonintensivist management model. Domain scores for organizational culture were correlated with domain scores for safety culture. Culture domain scores were generally favorable in all ICUs. There were moderately strong positive correlations between number of ICU beds and perceived effectiveness at recruiting/retaining physicians (r = 0.58; P < .01), relative technical quality of care (r = 0.66; P < .01), and medical director budgeting authority (r = 0.46; P = .03), and moderately strong negative correlations with frequency of events reported (r = -0.46; P = .03), and teamwork across hospital units (r = -0.51; P = .01). There were similar patterns for relationships with intensivist management. For most pairs of domains, there were weak correlations between organizational and safety culture. Differences in perceptions between staff in larger and smaller ICUs highlight the importance of teamwork across units in larger ICUs. Copyright © 2012 Elsevier Inc. All rights reserved.
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Multidisciplinary management of chronic heart failure: principles and future trends.
Davidson, Patricia M; Newton, Phillip J; Tankumpuan, Thitipong; Paull, G; Dennison-Himmelfarb, Cheryl
2015-10-01
Globally, the management of chronic heart failure (CHF) challenges health systems. The high burden of disease and the costs associated with hospitalization adversely affect individuals, families, and society. Improved quality, access, efficiency, and equity of CHF care can be achieved by using multidisciplinary care approaches if there is adherence and fidelity to the program's elements. The goal of this article was to summarize evidence and make recommendations for advancing practice, education, research, and policy in the multidisciplinary management of patients with CHF. Essential elements of multidisciplinary management of CHF were identified from meta-analyses and clinical practice guidelines. The study factors were discussed from the perspective of the health care system, providers, patients, and their caregivers. Identified gaps in evidence were used to identify areas for future focus in CHF multidisciplinary management. Although there is high-level evidence (including several meta-analyses) for the efficacy of management programs for CHF, less evidence exists to determine the benefit attributable to individual program components or to identify the specific content of effective components and the manner of their delivery. Health care system, provider, and patient factors influence health care models and the effective management of CHF and require focus and attention. Extrapolating trial findings to clinical practice settings is limited by the heterogeneity of study populations and the implementation of models of intervention beyond academic health centers, where practice environments differ considerably. Ensuring that individual programs are both developed and assessed that consider these factors is integral to ensuring adherence and fidelity with the core dimensions of disease management necessary to optimize patient and organizational outcomes. Recognizing the complexity of the multidisciplinary CHF interventions will be important in advancing the design, implementation, and evaluation of the interventions. Copyright © 2015 Elsevier HS Journals, Inc. All rights reserved.
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2013-01-01
Background Chronic heart failure (HF) disease management programs have reported inconsistent results and have not included comorbid depression management or specifically focused on improving patient-reported outcomes. The Patient Centered Disease Management (PCDM) trial was designed to test the effectiveness of collaborative care disease management in improving health status (symptoms, functioning, and quality of life) in patients with HF who reported poor HF-specific health status. Methods/design Patients with a HF diagnosis at four VA Medical Centers were identified through population-based sampling. Patients with a Kansas City Cardiomyopathy Questionnaire (KCCQ, a measure of HF-specific health status) score of < 60 (heavy symptom burden and impaired quality of life) were invited to enroll in the PCDM trial. Enrolled patients were randomized to receive usual care or the PCDM intervention, which included: (1) collaborative care management by VA clinicians including a nurse, cardiologist, internist, and psychiatrist, who worked with patients and their primary care providers to provide guideline-concordant care management, (2) home telemonitoring and guided patient self-management support, and (3) screening and treatment for comorbid depression. The primary study outcome is change in overall KCCQ score. Secondary outcomes include depression, medication adherence, guideline-based care, hospitalizations, and mortality. Discussion The PCDM trial builds on previous studies of HF disease management by prioritizing patient health status, implementing a collaborative care model of health care delivery, and addressing depression, a key barrier to optimal disease management. The study has been designed as an ‘effectiveness trial’ to support broader implementation in the healthcare system if it is successful. Trial registration Unique identifier: NCT00461513 PMID:23837415
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Improving population management through pharmacist-primary care integration: a pilot study.
Kennedy, Amanda G; Chen, Harry; Corriveau, Michele; MacLean, Charles D
2015-02-01
Pharmacists have unique skills that may benefit primary care practices. The objective of this demonstration project was to determine the impact of integrating pharmacists into patient-centered medical homes, with a focus on population management. Pharmacists were partnered into 5 primary care practices in Vermont 1 day per week to provide direct patient care, population-based medication management, and prescriber education. The main measures included a description of drug therapy problems identified and cost avoidance models. The pharmacists identified 708 drug therapy problems through direct patient care (336/708; 47.5%), population-based strategies (276/708; 38.9%), and education (96/708; 13.6%). Common population-based strategies included adjusting doses and discontinuing unnecessary medications. Pharmacists' recommendations to correct drug therapy problems were accepted by prescribers 86% of the time, when data about acceptance were known. Of the 49 recommendations not accepted, 47/49 (96%) were population-based and 2/49 (4%) were related to direct patient care. The cost avoidance model suggests $2.11 in cost was avoided for every $1.00 spent on a pharmacist ($373,092/$176,690). There was clear value in integrating pharmacists into primary care teams. Their inclusion prevented adverse drug events, avoided costs, and improved patient outcomes. Primary care providers should consider pharmacists well suited to offer direct patient care, population-based management, and prescriber education to their practices. To be successful, pharmacists must have full permission to document findings in the primary care practices' electronic health records. Given that many pharmacist services do not involve billable activities, sustainability requires identifying alternative funding mechanisms that do not rely on a traditional fee-for-service approach.
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Improving Health Care Management in Primary Care for Homeless People: A Literature Review
Abcaya, Julien; Ștefan, Diana-Elena; Calvet-Montredon, Céline; Gentile, Stéphanie
2018-01-01
Background: Homeless people have poorer health status than the general population. They need complex care management, because of associated medical troubles (somatic and psychiatric) and social difficulties. We aimed to describe the main characteristics of the primary care programs that take care of homeless people, and to identify which could be most relevant. Methods: We performed a literature review that included articles which described and evaluated primary care programs for homeless people. Results: Most of the programs presented a team-based approach, multidisciplinary and/or integrated care. They often proposed co-located services between somatic health services, mental health services and social support services. They also tried to answer to the specific needs of homeless people. Some characteristics of these programs were associated with significant positive outcomes: tailored primary care organizations, clinic orientation, multidisciplinary team-based models which included primary care physicians and clinic nurses, integration of social support, and engagement in the community’s health. Conclusions: Primary health care programs that aimed at taking care of the homeless people should emphasize a multidisciplinary approach and should consider an integrated (mental, somatic and social) care model. PMID:29439403
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Kline, Ronald M; Bazell, Carol; Smith, Erin; Schumacher, Heidi; Rajkumar, Rahul; Conway, Patrick H
2015-03-01
Cancer is a medically complex and expensive disease with costs projected to rise further as new treatment options increase and the United States population ages. Studies showing significant regional variation in oncology quality and costs and model tests demonstrating cost savings without adverse outcomes suggest there are opportunities to create a system of oncology care in the US that delivers higher quality care at lower cost. The Centers for Medicare and Medicaid Services (CMS) have designed an episode-based payment model centered around 6 month periods of chemotherapy treatment. Monthly per-patient care management payments will be made to practices to support practice transformation, including additional patient services and specific infrastructure enhancements. Quarterly reporting of quality metrics will drive continuous quality improvement and the adoption of best practices among participants. Practices achieving cost savings will also be eligible for performance-based payments. Savings are expected through improved care coordination and appropriately aligned payment incentives, resulting in decreased avoidable emergency department visits and hospitalizations and more efficient and evidence-based use of imaging, laboratory tests, and therapeutic agents, as well as improved end of life care. New therapies and better supportive care have significantly improved cancer survival in recent decades. This has come at a high cost, with cancer therapy consuming $124 billion in 2010. CMS has designed an episode-based model of oncology care that incorporates elements from several successful model tests. By providing care management and performance based payments in conjunction with quality metrics and a rapid learning environment, it is hoped that this model will demonstrate how oncology care in the US can transform into a high value, high quality system. Copyright © 2015 by American Society of Clinical Oncology.
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Managing the physics of the economics of integrated health care.
Zismer, Daniel K; Werner, Mark J
2012-01-01
The physics metaphor, as applied to the economics (and financial performance) of the integrated health system, seems appropriate when considered together with the nine principles of management framework provided. The nature of the integrated design enhances leaders' management potential as they consider organizational operations and strategy in the markets ahead. One question begged by this argument for the integrated design is the durability, efficiency and ultimate long-term survivability of the more "traditional" community health care delivery models, which, by design, are fragmented, internally competitive and less capital efficient. They also cannot exploit the leverage of teams, optimal access management or the pursuit of revenues made available in many forms. For those who wish to move from the traditional to the more integrated community health system designs (especially those who have not yet started the journey), the path requires: * Sufficient balance sheet capacity to fund the integration process-especially as the model requires physician practice acquisitions and electronic health record implementations * A well-prepared board13, 14 * A functional, durable and sustainable physician services enterprise design * A redesigned organizational and governance structure * Favorable internal financial incentives alignment design * Effective accountable physician leadership * Awareness that the system is not solely a funding strategy for acquired physicians, rather a fully -.. committed clinical and business model, one in which patient-centered integrated care is the core service (and not acute care hospital-based services) A willingness to create and exploit the implied and inherent potential of an integrated design and unified brand Last, it's important to remember that an integrated health system is a tool that creates a "new potential" (a physics metaphor reference, one last time). The design doesn't operate itself. Application of the management principles presented here are necessary as a complete recipe. Leaders of health systems moving toward integration are cautioned to apply the recipe in full. This article ends with two questions. First, if not an integrated model of health care, what's the alternative? Since it seems clear that many of the existing community-based models are excessively fragmented and inefficient, especially in a reforming U.S. health care marketplace, is there a new model that is superior to the integrated models and, if so, what is it and what are its functional principles? The second question: Is there more than one functional form of integration? This article argues for the most integrated form. Others would argue that clinical integration is sufficient,'s and full integration isn't required. The stability, durability and adaptability of the fully integrated models have, arguably, been tested. The lesser integrated models remain to be proven in an unstable health care marketplace seeking higher levels of economic efficiency.
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Menachemi, Nir; Ford, Eric W; Chukmaitov, Askar; Brooks, Robert G
2006-12-01
To estimate the current uses level of ambulatory computerized physician order entry (A-CPOE) among physicians and to examine the relationship of managed care penetration as well as other market and practice characteristics to use of A-CPOE by physicians. This study uses both primary and secondary data sources. The primary data source was a large-scale survey of physicians' use of information technologies in Florida. Secondary data on managed care penetration were obtained from the Florida Agency for Health Care Administration, and other market-level data were extracted from the area resource file. A hierarchical logistic regression model was used to examine the correlation of county-level and practice-level characteristics with physicians' self-reported use of A-CPOE systems. Overall, 1360 physicians (32.4%) indicated use of an A-CPOE system. Findings suggest that 1% more managed care penetration was associated with 2.1% lower use of A-CPOE (P = .003). Additionally, practice size, multispecialty affiliation, and primary care practice were significantly and positively correlated with the use of A-CPOE. Physician age was negatively associated with A-CPOE use. Managed care organizations may experience significant financial savings from A-CPOE use by physicians; however, managed care penetration in a community negatively affects A-CPOE use among physicians in their practices. Further study regarding the causal nature of this association is warranted.
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Results of the Medicare Health Support disease-management pilot program.
McCall, Nancy; Cromwell, Jerry
2011-11-03
In the Medicare Modernization Act of 2003, Congress required the Centers for Medicare and Medicaid Services to test the commercial disease-management model in the Medicare fee-for-service program. The Medicare Health Support Pilot Program was a large, randomized study of eight commercial programs for disease management that used nurse-based call centers. We randomly assigned patients with heart failure, diabetes, or both to the intervention or to usual care (control) and compared them with the use of a difference-in-differences method to evaluate the effects of the commercial programs on the quality of clinical care, acute care utilization, and Medicare expenditures for Medicare fee-for-service beneficiaries. The study included 242,417 patients (163,107 in the intervention group and 79,310 in the control group). The eight commercial disease-management programs did not reduce hospital admissions or emergency room visits, as compared with usual care. We observed only 14 significant improvements in process-of-care measures out of 40 comparisons. These modest improvements came at substantial cost to the Medicare program in fees paid to the disease-management companies ($400 million), with no demonstrable savings in Medicare expenditures. In this large study, commercial disease-management programs using nurse-based call centers achieved only modest improvements in quality-of-care measures, with no demonstrable reduction in the utilization of acute care or the costs of care.
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Stanhope, Victoria; Matejkowski, Jason
2010-08-01
The widespread adoption of assertive community treatment has resulted in a shift from an individual model to a team model of case management. The shift has had implications for individual relationships between case managers and consumers, but still little is known about how these relationships develop in teams. This exploratory mixed methods study looked at how case managers and consumers negotiate individual relationships within a team model. Quantitative methods identified high and low service intensity relationships between consumers and case managers and qualitative methods explored and compared these relationships. Consumers in high service intensity relationships described a preference for certain case managers and the burden of working with multiple people. Case managers invested high service intensity relationships with special therapeutic value, articulated the challenges of coordinating care across the team, and utilized team limit setting techniques. In contrast, low service intensity relationships were more likely to reflect integration with the entire team. Findings suggest that teams need to consider how individual relationships enhance care for their consumers and how to nurture these relationships while maintaining the support necessary for case managers and consumers.
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Improving Quality of Care in Patients with Liver Cirrhosis.
Saberifiroozi, Mehdi
2017-10-01
Liver cirrhosis is a major chronic disease in the field of digestive diseases. It causes more than one million deaths per year. Despite established evidence based guidelines, the adherence to standard of care or quality indicators are variable. Complete adherence to the recommendations of guidelines is less than 50%. To improve the quality of care in patients with cirrhosis, we need a more holistic view. Because of high rate of death due to cardiovascular disease and neoplasms, the care of comorbid conditions and risk factors such as smoking, hypertension, high blood sugar or cholesterol, would be important in addition to the management of primary liver disease. Despite a holistic multidisciplinary approach for this goal, the management of such patients should be patient centered and individualized. The diagnosis of underlying etiology and its appropriate treatment is the most important step. Definition and customizing the quality indicators for quality measure in patients are needed. Because most suggested quality indicators are designed for measuring the quality of care in decompensated liver cirrhosis, we need special quality indicators for compensated and milder forms of chronic liver disease as well. Training the patients for participation in their own management, design of special clinics with dedicated health professionals in a form of chronic disease model, is suggested for improvement of quality of care in this group of patients. Special day care centers by a dedicated gastroenterologist and a trained nurse may be a practical model for better management of such patients.
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Concierge Medicine: A Viable Business Model for (Some) Physicians of the Future?
Paul, David P; Skiba, Michaeline
Concierge medicine is a medical management structure that has been in existence since the 1990s. Essentially, a typical concierge medical practice limits its number of patients and provides highly personalized attention that includes comprehensive annual physicals, same-day appointments, preventive and wellness care, and fast, 24/7 response time. Concierge medicine has become popular among both physicians and patients/consumers who are frustrated by the limitations imposed by managed care organizations. From many physicians' perspectives, concierge medicine offers greater autonomy, the opportunity to return to a more manageable patient load, and the chance to improve their incomes that have declined because of increasingly lowered reimbursements for their services. From many patients'/consumers' perspectives, concierge medicine provides more immediate, convenient, and caring access to their primary care physicians and, regardless of their physician's annual retainer fee, the elimination of third-party insurance coverage costs and hassles. The major criticisms of the concierge medicine model come from some health care policy makers and experts, who believe that concierge medicine is elitist and its widespread implementation will increase the shortage of primary care physicians, which is already projected to become worse because of the Affordable Care Act's individual mandate, which requires everyone to have health insurance.Utilizing these topics as its framework, this article explains why concierge medicine's form of medical management is gaining ground, cites its advantages and disadvantages for stakeholders, and examines some of the issues that will affect its growth.
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Korop, Oleg A; Lenskykh, Sergiy V
2018-01-01
Introduction: Modern changes in the health care system of Ukraine are focused on financial support in providing medical and diagnostic care to the population and are based on deep and consistent structural and functional transformations. They are aimed at providing adequate quality care, which is the main target function and a principal criterion for operation of health care system. The urgency of this problem is increasing in the context of reforming the health care system and global changes in the governmental financial guarantees for the provision of medical services to the population. The aim of the work is to provide theoretical grounds for a structural and functional model of quality assurance of radiation diagnostics at all levels of medical care given to the population under the current health care reform in Ukraine. Materials and methods: The object of the study is organizing the operation of the radiation diagnostic service; the information is based on the actual data on the characteristics of radiation diagnosis at different levels of medical care provision. Methods of systematic approach, system analysis and structural and functional analysis of the operating system of radiation diagnostics are used. Review: The basis of the quality assurance model is the cyclical process, which includes the stages of the problem identifition, planning of its solution, organization of the system for implementation of decisions, monitoring the quality management process of the radiation diagnostics, and factors influencing the quality of the radiation diagnostics service. These factors include the quality of the structure, process, results, organization of management and control of current processes and the results of radiation diagnostics management. Conclusions: The advantages of the proposed model for ensuring the quality of the radiation diagnostics service are its systemacy and complexity, elimination of identified defects and deficiencies, and achievement of profitability through modern redistribution and use of existing resources of the health care system. The results of adequate service quality management activities in radiation diagnostics are the improvement of organizational and economic principles along with legislative regulation, the implementation of a modern system of radiation diagnostics in the state health care at the national and regional levels, the increase of the accessibility, quality and efficiency of the radiation diagnostics service.
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Evidence-based characteristics of nurse-managed health centers for quality and outcomes.
Holt, Jeana; Zabler, Bev; Baisch, Mary Jo
2014-01-01
There are approximately 250 nurse-managed health centers (NMHC) in the United States, but there are few consistent descriptions of their functions and even fewer reports of their outcomes. Because NMHCs have been identified as a unique and effectual health care delivery care model (Patient Protection and Affordable Care Act), a description of their characteristics and a framework for outcome evaluation are required for their continued evolution and expansion. This study identifies the principal characteristics of U.S. NMHCs described in the professional literature through an integrative review and classifies these characteristics through a multistage qualitative analysis in relation to Donabedian's structure-process-outcomes model, a well-established model for evaluating quality in health care. This study yielded an evidence-based definition of NMHCs that is more reflective of current NMHC practice across settings and recognizes the full scope of nursing practice that is considered one solution to the health care crisis in the country. Using the results from this study, NMHCs will be able to structure self-evaluations of quality care and compare their quality related to structure, processes, and outcomes with other primary health care delivery systems. Copyright © 2014 Elsevier Inc. All rights reserved.
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Séror, Ann C
2002-12-01
The Internet and emergent telecommunications infrastructures are transforming the future of health care management. The costs of health care delivery systems, products, and services continue to rise everywhere, but performance of health care delivery is associated with institutional and ideological considerations as well as availability of financial and technological resources. to identify the effects of ideological differences on health care market infrastructures including the Internet and telecommunications technologies by a comparative case analysis of two large health care organizations: the British National Health Service and the California-based Kaiser Permanente health maintenance organization. A qualitative comparative analysis focusing on the British National Health Service and the Kaiser Permanente health maintenance organization to show how system infrastructures vary according to market dynamics dominated by health care institutions ("push") or by consumer demand ("pull"). System control mechanisms may be technologically embedded, institutional, or behavioral. The analysis suggests that telecommunications technologies and the Internet may contribute significantly to health care system performance in a context of ideological diversity. The study offers evidence to validate alternative models of health care governance: the national constitution model, and the enterprise business contract model. This evidence also suggests important questions for health care policy makers as well as researchers in telecommunications, organizational theory, and health care management.
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2002-01-01
Background The Internet and emergent telecommunications infrastructures are transforming the future of health care management. The costs of health care delivery systems, products, and services continue to rise everywhere, but performance of health care delivery is associated with institutional and ideological considerations as well as availability of financial and technological resources. Objective To identify the effects of ideological differences on health care market infrastructures including the Internet and telecommunications technologies by a comparative case analysis of two large health care organizations: the British National Health Service and the California-based Kaiser Permanente health maintenance organization. Methods A qualitative comparative analysis focusing on the British National Health Service and the Kaiser Permanente health maintenance organization to show how system infrastructures vary according to market dynamics dominated by health care institutions ("push") or by consumer demand ("pull"). System control mechanisms may be technologically embedded, institutional, or behavioral. Results The analysis suggests that telecommunications technologies and the Internet may contribute significantly to health care system performance in a context of ideological diversity. Conclusions The study offers evidence to validate alternative models of health care governance: the national constitution model, and the enterprise business contract model. This evidence also suggests important questions for health care policy makers as well as researchers in telecommunications, organizational theory, and health care management. PMID:12554552
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Shared mental models of integrated care: aligning multiple stakeholder perspectives.
Evans, Jenna M; Baker, G Ross
2012-01-01
Health service organizations and professionals are under increasing pressure to work together to deliver integrated patient care. A common understanding of integration strategies may facilitate the delivery of integrated care across inter-organizational and inter-professional boundaries. This paper aims to build a framework for exploring and potentially aligning multiple stakeholder perspectives of systems integration. The authors draw from the literature on shared mental models, strategic management and change, framing, stakeholder management, and systems theory to develop a new construct, Mental Models of Integrated Care (MMIC), which consists of three types of mental models, i.e. integration-task, system-role, and integration-belief. The MMIC construct encompasses many of the known barriers and enablers to integrating care while also providing a comprehensive, theory-based framework of psychological factors that may influence inter-organizational and inter-professional relations. While the existing literature on integration focuses on optimizing structures and processes, the MMIC construct emphasizes the convergence and divergence of stakeholders' knowledge and beliefs, and how these underlying cognitions influence interactions (or lack thereof) across the continuum of care. MMIC may help to: explain what differentiates effective from ineffective integration initiatives; determine system readiness to integrate; diagnose integration problems; and develop interventions for enhancing integrative processes and ultimately the delivery of integrated care. Global interest and ongoing challenges in integrating care underline the need for research on the mental models that characterize the behaviors of actors within health systems; the proposed framework offers a starting point for applying a cognitive perspective to health systems integration.
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Development of an International School Nurse Asthma Care Coordination Model
Garwick, Ann W.; Svavarsdóttir, Erla Kolbrun; Seppelt, Ann M.; Looman, Wendy S.; Anderson, Lori S.; Örlygsdóttir, Brynja
2015-01-01
Aim To identify and compare how school nurses in Reykjavik, Iceland and St. Paul, Minnesota coordinated care for youth with asthma (ages 10–18) and to develop an asthma school nurse care coordination model. Background Little is known about how school nurses coordinate care for youth with asthma in different countries. Design A qualitative descriptive study design using focus group data. Methods Six focus groups with 32 school nurses were conducted in Reykjavik (n=17) and St. Paul (n=15) using the same protocol between September 2008 – January 2009. Descriptive content analytic and constant comparison strategies were used to categorize and compare how school nurses coordinated care, which resulted in the development of an International School Nurse Asthma Care Coordination Model. Findings Participants in both countries spontaneously described a similar asthma care coordination process that involved information gathering, assessing risk for asthma episodes, prioritizing health care needs and anticipating and planning for student needs at the individual and school levels. This process informed how they individualized symptom management, case management and/or asthma education. School nurses played a pivotal part in collaborating with families, school and health care professionals to ensure quality care for youth with asthma. Conclusions Results indicate a high level of complexity in school nurses’ approaches to asthma care coordination that were responsive to the diverse and changing needs of students in school settings. The conceptual model derived provides a framework for investigators to use in examining the asthma care coordination process of school nurses in other geographic locations. PMID:25223389
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Developing an active implementation model for a chronic disease management program
Smidth, Margrethe; Christensen, Morten Bondo; Olesen, Frede; Vedsted, Peter
2013-01-01
Background Introduction and diffusion of new disease management programs in healthcare is usually slow, but active theory-driven implementation seems to outperform other implementation strategies. However, we have only scarce evidence on the feasibility and real effect of such strategies in complex primary care settings where municipalities, general practitioners and hospitals should work together. The Central Denmark Region recently implemented a disease management program for chronic obstructive pulmonary disease (COPD) which presented an opportunity to test an active implementation model against the usual implementation model. The aim of the present paper is to describe the development of an active implementation model using the Medical Research Council’s model for complex interventions and the Chronic Care Model. Methods We used the Medical Research Council’s five-stage model for developing complex interventions to design an implementation model for a disease management program for COPD. First, literature on implementing change in general practice was scrutinised and empirical knowledge was assessed for suitability. In phase I, the intervention was developed; and in phases II and III, it was tested in a block- and cluster-randomised study. In phase IV, we evaluated the feasibility for others to use our active implementation model. Results The Chronic Care Model was identified as a model for designing efficient implementation elements. These elements were combined into a multifaceted intervention, and a timeline for the trial in a randomised study was decided upon in accordance with the five stages in the Medical Research Council’s model; this was captured in a PaTPlot, which allowed us to focus on the structure and the timing of the intervention. The implementation strategies identified as efficient were use of the Breakthrough Series, academic detailing, provision of patient material and meetings between providers. The active implementation model was tested in a randomised trial (results reported elsewhere). Conclusion The combination of the theoretical model for complex interventions and the Chronic Care Model and the chosen specific implementation strategies proved feasible for a practice-based active implementation model for a chronic-disease-management-program for COPD. Using the Medical Research Council’s model added transparency to the design phase which further facilitated the process of implementing the program. Trial registration: http://www.clinicaltrials.gov/(NCT01228708). PMID:23882169
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Managed Care Quality of Care and Plan Choice in New York SCHIP
Liu, Hangsheng; Phelps, Charles E; Veazie, Peter J; Dick, Andrew W; Klein, Jonathan D; Shone, Laura P; Noyes, Katia; Szilagyi, Peter G
2009-01-01
Objective To examine whether low-income parents of children enrolled in the New York State Children's Health Insurance Program (SCHIP) choose managed care plans with better quality of care. Data Sources 2001 New York SCHIP evaluation data; 2001 New York State Managed Care Plan Performance Report; 2000 New York State Managed Care Enrollment Report. Study Design Each market was defined as a county. A final sample of 2,325 new enrollees was analyzed after excluding those in markets with only one SCHIP plan. Plan quality was measured using seven Consumer Assessment of Health Plans Survey (CAHPS) and three Health Plan Employer Data and Information Set (HEDIS) scores. A conditional logit model was applied with plan and individual/family characteristics as covariates. Principle Findings There were 30 plans in the 45 defined markets. The choice probability increased 2.5 percentage points for each unit increase in the average CAHPS score, and the association was significantly larger in children with special health care needs. However, HEDIS did not show any statistically significant association with plan choice. Conclusions Low-income parents do choose managed care plans with higher CAHPS scores for their newly enrolled children, suggesting that overall quality could improve over time because of the dynamics of enrollment. PMID:19208091
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The impact of managed care penetration and hospital quality on efficiency in hospital staffing.
Mobley, Lee R; Magnussen, Jon
2002-01-01
The state of California has recently mandated minimum nurse-staffing ratios, raising concerns about possible affects on hospital efficiency. In this study, we examine how market factors and quality were related to staffing levels in California hospitals in 1995 (prior to implementation of the new law). We are particularly interested in the affect of managed care penetration on this aspect of hospital efficiency because the call to legislative action was predicated on fears that hospitals were reducing staffing below optimal levels in response to managed care pressures. We derive a unique measure of excess staffing in hospitals based on a data envelopment analysis (DEA) production function model, which explicitly includes ancillary care among the inputs and outputs. This careful specification of production is important because ancillary care use has risen relative to daily hospital services, with the spread of managed care and advances in medical technology. We find that market share (adjusted for size) and market concentration are the major determinants of excess staffing while managed care penetration is insignificant. We also find that poor quality (outcomes worse than expected) is associated with less efficient staffing. These findings suggest that the larger, more efficient urban hospitals will be penalized more heavily under binding staffing ratios than smaller, less-urban hospitals.
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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.
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Haji Ali Afzali, Hossein; Gray, Jodi; Beilby, Justin; Holton, Christine; Karnon, Jonathan
2013-12-01
There are few studies investigating the economic value of the Australian practice nurse workforce on the management of chronic conditions. This is particularly important in Australia, where the government needs evidence to inform decisions on whether to maintain or redirect current financial incentives that encourage practices to recruit practice nurses. The objective of this study was to estimate the lifetime costs and quality-adjusted life-years (QALYs) associated with two models of practice nurse involvement in clinical-based activities (high and low level) in the management of type 2 diabetes within the primary care setting. A previously validated state transition model (the United Kingdom Prospective Diabetes Study Outcomes Model) was adapted, which uses baseline prognostic factors (e.g. gender, haemoglobin A1c [HbA1c]) to predict the risk of occurrence of diabetes-related complications (e.g. stroke). The model was populated by data from Australian and UK observational studies. Costs and utility values associated with complications were summed over patients' lifetimes to estimate costs and QALY gains from the perspective of the health care system. All costs were expressed in 2011 Australian dollars (AU$). The base-case analysis assumed a 40-year time horizon with an annual discount rate of 5 %. Relative to low-level involvement of practice nurses in the provision of clinical-based activities, the high-level model was associated with lower mean lifetime costs of management of complications (-AU$8,738; 95 % confidence interval [CI] -AU$12,522 to -AU$4,954), and a greater average gain in QALYs (0.3; 95 % CI 0.2-0.4). A range of sensitivity analyses were performed, in which the high-level model was dominant in all cases. Our results suggest that the high-level model is a dominant management strategy over the low-level model in all modelled scenarios. These findings indicate the need for effective primary care-based incentives to encourage general practices not only to employ practice nurses, but to better integrate them into the provision of clinical services.