A blueprint for community benefit. A CHA-AAHA (Catholic Health Association-American Association of Homes for the Aging) document helps long-term care providers plan for and implement needed services.

PubMed

Forschner, B; Trocchio, J

1993-05-01

A collaborative effort of the Catholic Health Association (CHA) and the American Association of Homes for the Aging, The Social Accountability Program: Continuing the Community Benefit Tradition of Not-for-Profit Homes and Services for the Aging helps long-term care organizations plan and report community benefit activities. The program takes long-term care providers through five sequential tasks: reaffirming commitment to the elderly and others in the community; developing a community service plan; developing and providing community services; reporting community services; and evaluating the community service role. To help organizations reaffirm commitment, the Social Accountability Program presents a process facilities can use to review their historical roots and purposes and evaluate whether current policies and procedures are consistent with the organizational philosophy. Once this step is completed, providers can develop a community service plan by identifying target populations and the services they need. For facilities developing and implementing such services, the program suggests ways of measuring and monitoring them for budgetary purposes. Once they have implemented services, not-for-profit healthcare organizations must account for their impact on the community. The Social Accountability Program lists elements to be included in community service reports. It also provides guidelines for evaluating these services' effectiveness and the organization's overall community benefit role.

Bursar Accounts, Payroll Deduction, and Debt Collection: A Three-Channel Approach to Lost Item Reimbursement

ERIC Educational Resources Information Center

Snowman, Ann MacKay

2005-01-01

In 2003, Penn State Libraries implemented payroll deduction and collection agency programs to gain better control of accounts receivable. The author reports on the implementation processes and first year outcomes of the programs. She recommends careful consideration of several questions before implementing such measures.

Accountable care organizations: impact on pharmacy.

PubMed

Amara, Shilpa; Adamson, Robert T; Lew, Indu; Slonim, Anthony

2014-03-01

The Patient Protection and Affordable Care Act (PPACA) has considerably transformed the approaches being used to deliver health care in the United States. It was enacted to expand health insurance access, improve funding for health professions education, and reform patient care delivery. The traditional fee-for-service payment system has been criticized for overspending and providing substandard quality of care. The Accountable Care Organization (ACO) was developed as a payment reform mechanism to slow rising health care costs and improve quality. Under this concept, networks of clinicians and hospitals share responsibility for a population of patients and are held accountable for the financial and clinical outcomes. Due to high rates of medication misuse, nonadherence to therapeutic medication regimens, and preventable adverse drug events, pharmacists are in an ideal position to manage drug therapy and reduce health care expenditures; as such, they may be valuable assets to the ACO team. This article discusses the role of the pharmacist in the era of ACOs specifically and health care reform globally. It outlines pharmacy-related quality of care measures, medication therapy management (MTM) programs (which may provide the foundation for pharmacist involvement in ACOs), and pharmacist functions in patient-centered medical homes (through which ACO services may be organized). The article concludes with a description of successful ACO models that have incorporated pharmacists into their programs.

Accountability for Community-Based Programs for the Seriously Ill.

PubMed

Teno, Joan M; Montgomery, Russ; Valuck, Tom; Corrigan, Janet; Meier, Diane E; Kelley, Amy; Curtis, J Randall; Engelberg, Ruth

2018-03-01

Innovation is needed to improve care of the seriously ill, and there are important opportunities as we transition from a volume- to value-based payment system. Not all seriously ill are dying; some recover, while others are persistently functionally impaired. While we innovate in service delivery and payment models for the seriously ill, it is important that we concurrently develop accountability that ensures a focus on high-quality care rather than narrowly focusing on cost containment. The Gordon and Betty Moore Foundation convened a meeting of 45 experts to arrive at guiding principles for measurement, create a starter measurement set, specify a proposed definition of the denominator and its refinement, and identify research priorities for future implementation of the accountability system. A series of articles written by experts provided the basis for debate and guidance in formulating a path forward to develop an accountability system for community-based programs for the seriously ill, outlined in this article. As we innovate in existing population-based payment programs such as Medicare Advantage and develop new alternative payment models, it is important and urgent that we develop the foundation for accountability along with actionable measures so that the healthcare system ensures high-quality person- and family-centered care for persons who are seriously ill.

Accountability for Community-Based Programs for the Seriously Ill

PubMed Central

Montgomery, Russ; Valuck, Tom; Corrigan, Janet; Meier, Diane E.; Kelley, Amy; Curtis, J. Randall; Engelberg, Ruth

2018-01-01

Abstract Innovation is needed to improve care of the seriously ill, and there are important opportunities as we transition from a volume- to value-based payment system. Not all seriously ill are dying; some recover, while others are persistently functionally impaired. While we innovate in service delivery and payment models for the seriously ill, it is important that we concurrently develop accountability that ensures a focus on high-quality care rather than narrowly focusing on cost containment. The Gordon and Betty Moore Foundation convened a meeting of 45 experts to arrive at guiding principles for measurement, create a starter measurement set, specify a proposed definition of the denominator and its refinement, and identify research priorities for future implementation of the accountability system. A series of articles written by experts provided the basis for debate and guidance in formulating a path forward to develop an accountability system for community-based programs for the seriously ill, outlined in this article. As we innovate in existing population-based payment programs such as Medicare Advantage and develop new alternative payment models, it is important and urgent that we develop the foundation for accountability along with actionable measures so that the healthcare system ensures high-quality person- and family-centered care for persons who are seriously ill. PMID:29195052

Health care spending accounts: a flexible solution for Canadian employers.

PubMed

Smithies, R; Steeves, L

1996-01-01

Flexible benefits plans have grown more slowly in Canada than in the United States, largely because of certain legal and regulatory considerations. Health care spending accounts (HCSAs) provide a cost-effective way for Canadian employers to address the health care benefit needs of a diverse workforce. A flexible health care spending account is a versatile and cost-effective instrument that can be used by Canadian employers that wish to provide a full range of health care benefits to employees. The health care alternatives available through an HCSA can provide employees with an opportunity to customize and optimize their benefits program. Regulatory requirements that an HCSA must meet in order to qualify for available tax advantages are discussed, as are the range of health care services that may be covered.

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

PubMed Central

Kodner, Dennis L.

2015-01-01

The Massachusetts General Care Management Program (Mass General CMP or CMP) was designed as a federally supported demonstration to test the impact of intensive, practice-based care management on high-cost Medicare fee-for-service (FFS) beneficiaries—primarily older persons—with multiple hospitalisations and multiple chronic conditions. The Massachusetts General Care Management Program operated over a 6-year period in two phases (3 years each). It started during the first phase at Massachusetts General Hospital, a major academic medical centre in Boston, Massachusetts in collaboration with Massachusetts General Physicians Organisation. During the second phase, the programme expanded to two more affiliated sites in and around the Boston area, including a community hospital, as well as incorporated several modifications primarily focused on the management of transitions to post-acute care in skilled nursing facilities. At the close of the demonstration in July 2012, Mass General Massachusetts General Care Management Program became a component of a new Pioneer accountable care organisation (ACO). The Massachusetts General Care Management Program is focused on individuals meeting defined eligibility criteria who are offered care that is integrated by a case manager embedded in a primary care practice. The demonstration project showed substantial cost savings compared to fee-for-service patients served in the traditional Medicare system but no impact on hospital readmissions. The Massachusetts General Care Management Program does not rest upon a “whole systems” approach to integrated care. It is an excellent example of how an innovative care co-ordination programme can be implemented in an existing health-care organisation without making fundamental changes in its underlying structure or the way in which direct patient care services are paid for. The accountable care organisation version of the Massachusetts General Care Management Program includes the staffing structure, standards of practice, collaborative approach to care transitions and information technology tools that were used in the original demonstration project. PMID:26417211

Food Assistance: Efforts To Control Fraud and Abuse in the Child and Adult Care Food Program Should Be Strengthened. United States General Accounting Office Report to Congressional Committees.

ERIC Educational Resources Information Center

Robertson, Robert E.

The Child and Adult Care Food Program provides over $1.5 billion in benefits annually to children and adults in day care. In order to address the longstanding problems of fraud and abuse present in the program, state agencies have been charged with the responsibility for implementing Food and Nutrition Service's (FNS) regulations to prevent and…

Accountable Care Organizations: roles and opportunities for hospitals.

PubMed

Schoenbaum, Stephen C

2011-08-01

Federal health reform has established Medicare Accountable Care Organizations (ACOs) as a new program, and some states and private payers have been independently developing ACO pilot projects. The objective is to hold provider groups accountable for the quality and cost of care to a population. The financial models for providers generally build off of shared savings between the payers and providers or some type of global payment that includes the possibility of partial or full capitation. For ACOs to achieve the same outcomes with lower costs or, better yet, improved outcomes with the same or lower costs, the delivery system will need to become more oriented toward primary care and care coordination than is currently the case. Providers of clinical services, in order to be more effective, efficient, and coordinated, will need to be supported by a variety of shared services, such as off-hours care, easy access to specialties, and information exchanges. These services can be organized by an ACO as a medical neighborhood or community. Hospitals, because they have a management structure, history of developing programs and services, and accessibility 24/7/365, are logical leaders of this enhancement of health care delivery for populations and other providers.

Corporate Financial Assistance for Child Care. The Conference Board Research Bulletin No. 177.

ERIC Educational Resources Information Center

Friedman, Dana

Described are four different corporate initiatives that help employees pay for work-related child care expenses: vouchers, discounts, flexible benefit programs and comprehensive cafeteria plans, and flexible spending accounts with salary reduction. Several other options, such as corporate contributions to community programs, subsidizing on-site…

Affordability, accountability, and accessibility in health care reform: implications for cardiovascular and pulmonary rehabilitation.

PubMed

King, Marjorie L

2013-01-01

Because health care costs in the United States have been growing disproportionately compared to inflation for many years, without a clear connection to improved quality or increased access to care, employers and payers have begun to test new models of health care delivery and payment. These models are linked to the concepts of affordability, accountability, and accessibility and incorporate the premise that there must be shared responsibility for improving meaningful patient outcomes, with attention to the coordination of team-based and patient-centered care, and value for services purchased. This article explores emerging health care delivery and payment models, including expanded access to care related to the Affordable Care Act of 2010, patient-centered medical homes and neighborhoods, accountable and coordinated care organizations, and value-based purchasing and insurance design, with an emphasis on implications for cardiovascular and pulmonary rehabilitation programs and the American Association of Cardiovascular and Pulmonary Rehabilitation.

18. Uniform cost accounting in long-term care.

PubMed

Sorensen, J E

1976-05-01

Uniform cost data are essential for managing health services, establishing billing and reimbursement rates, and measuring effectiveness and impact. Although it is especially difficult in the case of long-term health care to develop standard cost accounting procedures because of the varied configurations of inpatient, intermediate, and ambulatory services, the overall approaches to cost accounting and its content can be made more uniform. With this purpose in mind, a general model of cost accounting is presented for a multilevel program of long-term services, together with a special method for ambulatory services using "hours accounted for" as the basic measure.

75 FR 70165 - Medicare Program; Request for Information Regarding Accountable Care Organizations and the...

Federal Register 2010, 2011, 2012, 2013, 2014

2010-11-17

..., phone 1-800-743-3951. I. Background The Affordable Care Act seeks to improve the quality of health care services and to lower health care costs by encouraging providers to create integrated health care delivery... incentives for health care providers to enhance health care quality and lower costs. One important delivery...

The Role of the School in Children's Out-of-School Time.

ERIC Educational Resources Information Center

Dryfoos, Joy G.

1999-01-01

Reports the prevalence of school-based after-school programs and discusses extracurricular activities, child care, extended-day programs, enrichment programs, and efforts to make the schools community hubs. Outlines implementation challenges to program expansion: governance, space, program quality, funding, and accountability. (SLD)

76 FR 28988 - Medicare Program; Accelerated Development Sessions for Accountable Care Organizations-June 20, 21...

Federal Register 2010, 2011, 2012, 2013, 2014

2011-05-19

... health, and lower growth in health care expenditures. II. Session Participant Information and Agenda... new ways of delivering health care and paying health care providers in ways that can save money for... coordinated care can improve beneficiaries' quality outcomes and reduce the growth of Medicare expenditures...

Peer pressure and public reporting within healthcare setting: improving accountability and health care quality in hospitals.

PubMed

Specchia, Maria Lucia; Veneziano, Maria Assunta; Cadeddu, Chiara; Ferriero, Anna Maria; Capizzi, Silvio; Ricciardi, Walter

2012-01-01

In the last few years, the need of public reporting of health outcomes has acquired a great importance. The public release of performance results could be a tool for improving health care quality and many attempts have been made in order to introduce public reporting programs within the health care context at different levels. It would be necessary to promote the introduction of a standardized set of outcome and performance measures in order to improve quality of health care services and to make health care providers aware of the importance of transparency and accountability.

New Hampshire Nurse Practitioners Take the Lead in Forming an Accountable Care Organization.

PubMed

Wright, Wendy L

In 2012, New Hampshire nurse practitioners (NPs), along with Anthem Blue Cross/Blue Shield, formed the first Patient Centered Shared Savings Program in the nation, composed of patients managed by nurse practitioners employed within NP-owned and operated clinics. In this accountable care organization (ACO), NP-attributed patients were grouped into one risk pool. Data from the ACO and the NP risk pool, now in its third year, have produced compelling statistics. Nurse practitioners participating in this program have met or exceeded the minimum scores for 29 quality metrics along with a demonstrated cost-savings in the first 2 years of the program. Hospitalization rates for NP-managed patients are among the lowest in the state. Cost of care for NP-managed patients is $66.85 less per member per month than the participating physician-managed patients. Data from this ACO provide evidence that NPs provide cost-effective, quality health care and are integral to the formation and sustainability of any ACO.

5th Annual Provider Software Buyer's Guide.

PubMed

1995-03-01

To help long term care providers find new ways to improve quality of care and efficiency, PROVIDER presents the fifth annual listing of software firms marketing computer programs for all areas of long term care operations. On the following five pages, more than 70 software firms display their wares, with programs such as minimum data set and care planning, dietary, accounting and financials, case mix, and medication administration records. The guide also charts compatible hardware, integration ability, telephone numbers, company contacts, and easy-to-use reader service numbers.

The Accreditation Canada Program: A Complementary Tool to Promote Accountability in Canadian Healthcare

PubMed Central

Mitchell, Jonathan I.; Nicklin, Wendy; Macdonald, Bernadette

2014-01-01

Across Canada and internationally, the public and governments at all levels have increasing expectations for quality of care, value for healthcare dollars and accountability. Within this reality, there is increasing recognition of the value of accreditation as a barometer of quality and as a tool to assess and improve accountability and efficiency in healthcare delivery. In this commentary, we show how three key attributes of the Accreditation Canada Qmentum accreditation program – measurement, scalability and currency – promote accountability in healthcare. PMID:25305398

76 FR 50224 - Medicare Program; Accountable Care Organization Accelerated Development Learning Sessions; Center...

Federal Register 2010, 2011, 2012, 2013, 2014

2011-08-12

... individuals, better population health, and lower growth in health care expenditures. The ACO ADLSs were first... amended by the Health Care and Education Reconciliation Act of 2010 (Pub. L. 111-152) (collectively, the... purpose of examining new ways of delivering health care and paying health care providers in ways that can...

76 FR 66931 - Medicare Program; Accountable Care Organization Accelerated Development Learning Sessions; Center...

Federal Register 2010, 2011, 2012, 2013, 2014

2011-10-28

... health care expenditures. The ADLSs were first announced in the May 19, 2011 Federal Register (76 FR... Affordable Care Act (Pub. L. 111-148), as amended by the Health Care and Education Reconciliation Act of 2010... Medicaid Innovation (Innovation Center) for the purpose of examining new ways of delivering health care and...

Accountability among Baccalaureate Nursing Students: Definitions, Perceptions, and Engagement Practices of Accountability

ERIC Educational Resources Information Center

Ort, Jennifer Ann

2016-01-01

To ensure optimal patient care an especially high level of accountability is required when entering the workforce. The purpose of this qualitative study was to explore, describe, and define perceptions of accountability as described by sophomore and senior nursing students in two baccalaureate nursing programs. The research questions aimed to (a)…

Early Education and Care: Overlap Indicates Need To Assess Crosscutting Programs. Report to the Chairman, Subcommittee on Oversight of Government Management, Restructuring and the District of Columbia, U.S. Senate.

ERIC Educational Resources Information Center

Shaul, Marnie S.

In response to Congressional requests reflecting the nationwide attention on early childhood education (ECE) and care, the General Accounting Office assessed the federally funded programs that provide or support ECE and care for children under 5 years. Information was obtained by means of an electronic search of the June 1999 Catalog of Federal…

Evaluating Innovations in Home Care for Performance Accountability.

PubMed

Collister, Barbara; Gutscher, Abram; Ambrogiano, Jana

2016-01-01

Concerns about rising costs and the sustainability of our healthcare system have led to a drive for innovative solutions and accountability for performance. Integrated Home Care, Calgary Zone, Alberta Health Services went beyond traditional accountability measures to use evaluation methodology to measure the progress of complex innovations to its organization structure and service delivery model. This paper focuses on the first two phases of a three-phase evaluation. The results of the first two phases generated learning about innovation adoption and sustainability, and performance accountability at the program-level of a large publicly funded healthcare organization.

An Intersectoral Response to Children with Complex Health Care Needs

ERIC Educational Resources Information Center

Young, Wendy; Earle, Jasmin; Dadebo, Mark

2004-01-01

The purpose of this paper is to stimulate debate on how to define and enact public responsibility to children with complex health care needs and their families. We present a program, developed using the Auditor General's framework for accountability that involves Community Care Access Centres, schools and Saint Elizabeth Health Care, a complex…

76 FR 34712 - Medicare Program; Pioneer Accountable Care Organization Model; Extension of the Submission...

Federal Register 2010, 2011, 2012, 2013, 2014

2011-06-14

...: I. Background We are committed to achieving the three-part aim of better health, better health care... beneficiaries. One potential mechanism for achieving this goal is for CMS to partner with groups of health care... expenditures while enhancing the quality of care available to beneficiaries. Being responsive to the...

Sustaining Reliability on Accountability Measures at The Johns Hopkins Hospital.

PubMed

Pronovost, Peter J; Holzmueller, Christine G; Callender, Tiffany; Demski, Renee; Winner, Laura; Day, Richard; Austin, J Matthew; Berenholtz, Sean M; Miller, Marlene R

2016-02-01

In 2012 Johns Hopkins Medicine leaders challenged their health system to reliably deliver best practice care linked to nationally vetted core measures and achieve The Joint Commission Top Performer on Key Quality Measures ®program recognition and the Delmarva Foundation award. Thus, the Armstrong Institute for Patient Safety and Quality implemented an initiative to ensure that ≥96% of patients received care linked to measures. Nine low-performing process measures were targeted for improvement-eight Joint Commission accountability measures and one Delmarva Foundation core measure. In the initial evaluation at The Johns Hopkins Hospital, all accountability measures for the Top Performer program reached the required ≥95% performance, gaining them recognition by The Joint Commission in 2013. Efforts were made to sustain performance of accountability measures at The Johns Hopkins Hospital. Improvements were sustained through 2014 using the following conceptual framework: declare and communicate goals, create an enabling infrastructure, engage clinicians and connect them in peer learning communities, report transparently, and create accountability systems. One part of the accountability system was for teams to create a sustainability plan, which they presented to senior leaders. To support sustained improvements, Armstrong Institute leaders added a project management office for all externally reported quality measures and concurrent reviewers to audit performance on care processes for certain measure sets. The Johns Hopkins Hospital sustained performance on all accountability measures, and now more than 96% of patients receive recommended care consistent with nationally vetted quality measures. The initiative methods enabled the transition of quality improvement from an isolated project to a way of leading an organization.

76 FR 28196 - Medicare and Medicaid Programs; Opportunities for Alignment Under Medicaid and Medicare

Federal Register 2010, 2011, 2012, 2013, 2014

2011-05-16

... nation's health care expenditures in 2006.\\7\\ Furthermore, dual eligibles account for a..., Federal Coordinated Health Care Office, at (410) 786-8911 or [email protected] . SUPPLEMENTARY... Coordinated Health Care Office (``Medicare-Medicaid Coordination Office'') and charged the new office with...

30 CFR 1229.123 - Standards for audit activities.

Code of Federal Regulations, 2011 CFR

2011-07-01

... professional proficiency for the tasks required, including a knowledge of accounting, auditing, agency... shall maintain an independent attitude and appearance. (iii) Due professional care. Due professional... accordance with the generally accepted program audit standards (including the applicable General Accounting...

GAO audit not apt to find pervasive fraud in CARE Act.

PubMed

1999-12-24

After hearing a series of news reports suggesting financial improprieties in programs run by Ryan White CARE Act recipients, a General Accounting Office (GAO) review of the program was made. A preliminary GAO report found only a few cases of fraud in the administration of funding stemming from the CARE Act, but that the potential for fraud is very real because of the lack of safeguards. These findings are considered important since the House Commerce Committee is expected to conduct oversight hearings into further authorization of the CARE Act early in 2000.

Setting Standards at the Forefront of Delivery System Reform: Aligning Care Coordination Quality Measures for Multiple Chronic Conditions

PubMed Central

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

2015-01-01

The primary study objective is to assess how three major health reform care coordination initiatives (Accountable Care Organizations, Independence at Home, and Community-based Care Transitions) measure concepts critical to care coordination for people with multiple chronic conditions. We find that there are major differences in quality measurement across these three large and politically important programs. Quality measures currently used or proposed for these new health reform-related programs addressing care coordination primarily capture continuity of care. Other key areas of care coordination, such as care transitions, patient-centeredness, and cross-cutting care across multiple conditions are infrequently addressed. The lack of a comprehensive and consistent measure set for care coordination will pose challenges for health care providers and policymakers who seek, respectively, to provide and reward well-coordinated care. In addition, this heterogeneity in measuring care coordination quality will generate new information, but will inhibit comparisons between these care coordination programs. PMID:24004040

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

PubMed

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

2013-01-01

The primary study objective is to assess how three major health reform care coordination initiatives (Accountable Care Organizations, Independence at Home, and Community-Based Care Transitions) measure concepts critical to care coordination for people with multiple chronic conditions. We find that there are major differences in quality measurement across these three large and politically important programs. Quality measures currently used or proposed for these new health reform-related programs addressing care coordination primarily capture continuity of care. Other key areas of care coordination, such as care transitions, patient-centeredness, and cross-cutting care across multiple conditions are infrequently addressed. The lack of a comprehensive and consistent measure set for care coordination will pose challenges for healthcare providers and policy makers who seek, respectively, to provide and reward well-coordinated care. In addition, this heterogeneity in measuring care coordination quality will generate new information, but will inhibit comparisons between these care coordination programs. © 2013 National Association for Healthcare Quality.

Welfare Reform: States' Efforts To Expand Child Care Programs. United States General Accounting Office Report to the Ranking Minority Member, Subcommittee on Children and Families, Committee on Labor and Human Resources, U.S. Senate.

ERIC Educational Resources Information Center

General Accounting Office, Washington, DC. Health, Education, and Human Services Div.

The sweeping changes of welfare reform embodied in the Personal Responsibility and Work Opportunity Reconciliation Act of 1996, and which created the Child Care and Development Block Grant, raise many questions about how states will implement subsidy programs to help an increasing number of low-income families meet their child care needs. At the…

Provider software buyer's guide.

PubMed

1994-03-01

To help long term care providers find new ways to improve quality of care and efficiency, Provider magazine presents the fourth annual listing of software firms marketing computer programs for all areas of nursing facility operations. On the following five pages, more than 80 software firms display their wares, with programs such as minimum data set and care planning, dietary, accounting and financials, case mix, and medication administration records. The guide also charts compatible hardware, integration ability, telephone numbers, company contacts, and easy-to-use reader service numbers.

Provider software buyer's guide.

PubMed

1993-03-01

To help long term care providers find new ways to improve quality of care and efficiency. Provider magazine presents the third annual listing of software firms marketing computer programs for all areas of nursing facility operations. On the following five pages, more than 80 software firms display their wares, with programs such as minimum data set and care planning, dietary, accounting and financials, case mix, and medication administration records. The guide also charts compatible hardware, integration ability, telephone numbers, company contacts, and easy-to-use reader service numbers.

Care coordination for children with special needs in Medicaid: lessons from Medicare.

PubMed

Stewart, Kate A; Bradley, Katharine W V; Zickafoose, Joseph S; Hildrich, Rachel; Ireys, Henry T; Brown, Randall S

2018-04-01

To provide actionable recommendations for improving care coordination programs for children with special healthcare needs (CSHCN) in Medicaid managed care.  Literature review and interviews with stakeholders and policy experts to adapt lessons learned from Medicare care coordination programs for CSHCN in Medicaid managed care. We reviewed syntheses of research on Medicare care coordination programs to identify lessons learned from successful programs. We adapted findings from Medicare to CSHCN in Medicaid based on an environmental scan and discussions with experts. The scan focused on Medicaid financing and eligibility for care coordination and how these intersect with Medicaid managed care. The expert discussions included pediatricians, Medicaid policy experts, Medicaid medical directors, and a former managed care executive, all experienced in care coordination for CSHCN. We found 6 elements that are consistently associated with improved outcomes from Medicare care coordination programs and relevant to CSHCN in Medicaid: 1) identifying and targeting high-risk patients, 2) clearly articulating what outcomes programs are likely to improve, 3) encouraging active engagement between care coordinators and primary care providers, 4) requiring some in-person contact between care coordinators and patients, 5) facilitating information sharing among providers, and 6) supplementing care coordinators' expertise with that of other clinical experts. States and Medicaid managed care organizations have many options for designing effective care coordination programs for CSHCN. Their choices should account for the diversity of conditions among CSHCN, families' capacity to coordinate care, and social determinants of health.

Child Care: How Do Military and Civilian Center Costs Compare? United States General Accounting Office Report to Congressional Requesters.

ERIC Educational Resources Information Center

Fagnoni, Cynthia M.

The Department of Defense's (DOD) child development program has been identified as a model for the rest of the nation. To provide a benchmark cost estimate for Congress as it addresses child care issues, this report identifies the objectives of the military child development program, describes its operation, determines the full costs of DOD…

No Pipe Dream: Achieving Care That Is Accountable for Cost, Quality, and Outcomes.

PubMed

Terrell, Grace E

2016-01-01

The April 2015 passage of the Medicare Access and Children's Health Insurance Program Reauthorization Act is accelerating the move of the US health care industry from traditional fee-for-service provider payments to alternative payment methods that are focused on value rather than volume of services. Medicaid, private employers, and consumer groups are also developing similar payment models. Learning from the experience of the 27 early accountable care organizations in North Carolina, such as Cornerstone Health Care, will help to accelerate the transformation that will be necessary across the health care delivery ecosystem in our state. ©2016 by the North Carolina Institute of Medicine and The Duke Endowment. All rights reserved.

The Interventions to Reduce Acute Care Transfers (INTERACT) quality improvement program: an overview for medical directors and primary care clinicians in long term care.

PubMed

Ouslander, Joseph G; Bonner, Alice; Herndon, Laurie; Shutes, Jill

2014-03-01

Interventions to Reduce Acute Care Transfers (INTERACT) is a publicly available quality improvement program that focuses on improving the identification, evaluation, and management of acute changes in condition of nursing home residents. Effective implementation has been associated with substantial reductions in hospitalization of nursing home residents. Familiarity with and support of program implementation by medical directors and primary care clinicians in the nursing home setting are essential to effectiveness and sustainability of the program over time. In addition to helping nursing homes prevent unnecessary hospitalizations and their related complications and costs, and thereby continuing to be or becoming attractive partners for hospitals, health care systems, managed care plans, and accountable care organizations, effective INTERACT implementation will assist nursing homes in meeting the new requirement for a robust quality assurance performance improvement program, which is being rolled out by the federal government over the next year. Copyright © 2014 American Medical Directors Association, Inc. Published by Elsevier Inc. All rights reserved.

European Long-Term Care Programs: Lessons for Community Living Assistance Services and Supports?

PubMed Central

Nadash, Pamela; Doty, Pamela; Mahoney, Kevin J; von Schwanenflugel, Matthias

2012-01-01

Objective To uncover lessons from abroad for Community Living Assistance Services and Supports (CLASS), a federally run voluntary public long-term care (LTC) insurance program created under the Accountable Care Act of 2010. Data Sources Program administrators and policy researchers from Austria, England, France, Germany, and the Netherlands. Study Design Qualitative methods focused on key parameters of cash for care: how programs set benefit levels; project expenditures; control administrative costs; regulate the use of benefits; and protect workers. Data Collection/Extraction Methods Structured discussions were conducted during an international conference of LTC experts, followed by personal meetings and individual correspondence. Principal Findings Germany's self-financing mandate and tight targeting of benefits have resulted in a solvent program with low premiums. Black markets for care are likely in the absence of regulation; France addresses this via a unique system ensuing legal payment of workers. Conclusions Programs in the five countries studied have lessons, both positive and negative, relevant to CLASS design. PMID:22091672

Toward an Evaluation Strategy for FAP-Day Care.

ERIC Educational Resources Information Center

Datta, Lois-ellin, Ed.

This report presents the findings of an invitational conference sponsored by the Office of Child Development to assess the implications of Family Assistance Plan (FAP) day care provisions from the viewpoint of program evaluation. The first section outlines the features of FAP day care, and the second section identifies accountability issues for…

Funding Instability Reduces the Impact of the Federal Teaching Health Center Graduate Medical Education Program.

PubMed

Kurz, Troy; Liaw, Winston; Wingrove, Peter; Petterson, Stephen; Bazemore, Andrew

2017-01-01

The Teaching Health Center Graduate Medical Education (THCGME) program is a decentralized residency training component of the Affordable Care Act, created to combat critical shortages and maldistribution of primary care physicians. The Accreditation Council of Graduate Medical Education and federal data reveal that the THCGME program accounted for 33% of the net increase in family medicine residency positions between 2011 and 2015. However, amid concerns about the program's stability, the contribution of the THCGME program to the net increase fell to 7% after 2015. © Copyright 2017 by the American Board of Family Medicine.

CARES/LIFE Ceramics Analysis and Reliability Evaluation of Structures Life Prediction Program

NASA Technical Reports Server (NTRS)

Nemeth, Noel N.; Powers, Lynn M.; Janosik, Lesley A.; Gyekenyesi, John P.

2003-01-01

This manual describes the Ceramics Analysis and Reliability Evaluation of Structures Life Prediction (CARES/LIFE) computer program. The program calculates the time-dependent reliability of monolithic ceramic components subjected to thermomechanical and/or proof test loading. CARES/LIFE is an extension of the CARES (Ceramic Analysis and Reliability Evaluation of Structures) computer program. The program uses results from MSC/NASTRAN, ABAQUS, and ANSYS finite element analysis programs to evaluate component reliability due to inherent surface and/or volume type flaws. CARES/LIFE accounts for the phenomenon of subcritical crack growth (SCG) by utilizing the power law, Paris law, or Walker law. The two-parameter Weibull cumulative distribution function is used to characterize the variation in component strength. The effects of multiaxial stresses are modeled by using either the principle of independent action (PIA), the Weibull normal stress averaging method (NSA), or the Batdorf theory. Inert strength and fatigue parameters are estimated from rupture strength data of naturally flawed specimens loaded in static, dynamic, or cyclic fatigue. The probabilistic time-dependent theories used in CARES/LIFE, along with the input and output for CARES/LIFE, are described. Example problems to demonstrate various features of the program are also included.

The measurement of community benefit: issues, options, and questions for further research.

PubMed

Longo, D R

1994-01-01

Community benefit from a conceptual perspective can be traced to the philanthropic and humanitarian spirit that dominated the earliest foundations of the hospital as a social institution. However, the measurement of community benefit is a recent development and one rarely addressed in the literature in any detail. This article outlines the various concepts integral to community benefit measurement that must be taken into account for a program to demonstrate community accountability in an era where hospitals and health care institutions are increasingly required to evaluate and document their value to society. The perspective taken is that of a practicing health care executive. The use of the discussed concepts will assist health care executives and their staff in designing and evaluating programs, and will also assist academics in preparing students for this important professional responsibility.

A curriculum for training quality scholars to improve the health and health care of veterans and the community at large.

PubMed

Splaine, Mark E; Aron, David C; Dittus, Robert S; Kiefe, Catarina I; Landefeld, C Seth; Rosenthal, Gary E; Weeks, William B; Batalden, Paul B

2002-01-01

In 1998, the Veterans Health Administration invested in the creation of the Veterans Administration National Quality Scholars Fellowship Program (VAQS) to train physicians in new ways to improve the quality of health care. We describe the curriculum for this program and the lessons learned from our experience to date. The VAQS Fellowship program has developed a core improvement curriculum to train postresidency physicians in the scholarship, research, and teaching of the improvement of health care. The curriculum covers seven domains of knowledge related to improvement: health care as a process; variation and measurement; customer/beneficiary knowledge; leading, following, and making changes in health care; collaboration; social context and accountability; and developing new, locally useful knowledge. We combine specific knowledge about the improvement of health care with the use of adult learning strategies, interactive video, and development of learner competencies. Our program provides insights for medical education to better prepare physicians to participate in and lead the improvement of health care.

Independent practice associations and physician-hospital organizations can improve care management for smaller practices.

PubMed

Casalino, Lawrence P; Wu, Frances M; Ryan, Andrew M; Copeland, Kennon; Rittenhouse, Diane R; Ramsay, Patricia P; Shortell, Stephen M

2013-08-01

Pay-for-performance, public reporting, and accountable care organization programs place pressures on physicians to use health information technology and organized care management processes to improve the care they provide. But physician practices that are not large may lack the resources and size to implement such processes. We used data from a unique national survey of 1,164 practices with fewer than twenty physicians to provide the first information available on the extent to which independent practice associations (IPAs) and physician-hospital organizations (PHOs) might make it possible for these smaller practices to share resources to improve care. Nearly a quarter of the practices participated in an IPA or a PHO that accounted for a significant proportion of their patients. On average, practices participating in these organizations provided nearly three times as many care management processes for patients with chronic conditions as nonparticipating practices did (10.4 versus 3.8). Half of these processes were provided only by IPAs or PHOs. These organizations may provide a way for small and medium-size practices to systematically improve care and participate in accountable care organizations.

Accountable care organizations may have difficulty avoiding the failures of integrated delivery networks of the 1990s.

PubMed

Burns, Lawton R; Pauly, Mark V

2012-11-01

Accountable care organizations are intended to improve the quality and lower the cost of health care through several mechanisms, such as disease management programs, care coordination, and aligning financial incentives for hospitals and physicians. Providers employed several of these mechanisms in forming the integrated delivery networks of the 1990s. The networks failed, however, because of heavy financial losses stemming from hospitals' purchase of physician practices and their inability to align incentives, garner capitated contracts, and develop the infrastructure to manage risk. Although the current mechanisms underlying accountable care organizations continue to evolve, whether and how they will have an impact on quality and costs remains open to question. Care coordination and information technology are proving more complicated and expensive to implement than anticipated, providers may lack the ability to implement these mechanisms, and primary care providers are in short supply. As in the 1990s, success depends on targeting specific populations, such as people with multiple chronic conditions who need and may benefit from coordinated care.

American surgery and the Affordable Care Act.

PubMed

Stain, Steven C; Hoyt, David B; Hunter, John G; Joyce, Geoffrey; Hiatt, Jonathan R

2014-09-01

The Affordable Care Act (ACA) attempts to change the way we finance and deliver health care by coordinating the delivery of primary, specialty, and hospital services in accountable care organizations. The ways in which accountable care organizations will develop and evolve is unclear; however, the effects on surgeons and their patients will be substantial. High-value care in the ACA emphasizes quality, safety, resource use and appropriateness, and the patient's experience of care. Payment will be linked to these principles. Department chairs overseeing a clinical enterprise in academic medical centers now must add financial and quality measures to the traditional missions of education, research, and clinical service. At a time when surgical training is in dramatic evolution, with work hour limitations for residents and an emphasis on quality, productivity, and increasing oversight of trainees for faculty, residency programs will need to meet the increasing demands of an aging population and newly insured patients under the ACA. The American College of Surgeons, with its century-long commitment to quality improvement, research-based standards, and performance measurement and verification, has begun its Inspiring Quality Campaign, is developing new educational tools, and is preparing proposals for payment reform based on surgeons' participation in quality programs.

76 FR 74067 - Medicare Program; Announcement of a New Application Deadline for the Advance Payment Model

Federal Register 2010, 2011, 2012, 2013, 2014

2011-11-30

.... One potential mechanism for achieving this goal is for CMS to partner with groups of health care... will test whether and how pre-paying a portion of future shared savings could increase participation in... Accountable Care Organization (ACO) through which they work together to coordinate care for a specified group...

Swing-bed services under the Medicare program, 1984-87

PubMed Central

Silverman, Herbert A.

1990-01-01

Under Medicare, swing beds are beds that can be used by small rural hospitals to furnish both acute and post-acute care. The swing-bed program was instituted under the provisions of the Omnibus Reconciliation Act of 1980 (Public Law 96-499). Under Medicare, post-acute care in the hospital would be covered as services equivalent to skilled nursing facility level of care. Data show that the program has had a rapid rate of growth. By 1987, swing beds accounted for 9.7 percent of the admissions to skilled nursing facility services, 6.0 percent of the covered days of care, and 6.2 percent of the reimbursements. Over one-half of the swing-bed services are furnished in the North Central States. PMID:10113275

A Population Intervention to Improve Outcomes in Children With Medical Complexity.

PubMed

Noritz, Garey; Madden, Melissa; Roldan, Dina; Wheeler, T Arthur; Conkol, Kimberly; Brilli, Richard J; Barnard, John; Gleeson, Sean

2017-01-01

Children with medical complexity experience frequent interactions with the medical system and often receive care that is costly, duplicative, and inefficient. The growth of value-based contracting creates incentives for systems to improve their care. This project was designed to improve the health, health care value, and utilization for a population-based cohort of children with neurologic impairment and feeding tubes. A freestanding children's hospital and affiliated accountable care organization jointly developed a quality improvement initiative. Children with a percutaneous feeding tube, a neurologic diagnosis, and Medicaid, were targeted for intervention within a catchment area of >300 000 children receiving Medicaid. Initiatives included standardizing feeding tube management, improving family education, and implementing a care coordination program. Between January 2011 and December 2014, there was an 18.0% decrease (P < .001) in admissions and a 31.9% decrease (P < .001) in the average length of stay for children in the cohort. Total inpatient charges were reduced by $11 764 856. There was an 8.2% increase (P < .001) in the percentage of children with weights between the fifth and 95th percentiles. The care coordination program enrolled 58.3% of the cohort. This population-based initiative to improve the care of children with medical complexity showed promising results, including a reduction in charges while improving weight status and implementing a care coordination program. A concerted institutional initiative, in the context of an accountable care organization, can be part of the solution for improving outcomes and health care value for children with medical complexity. Copyright © 2017 by the American Academy of Pediatrics.

Funding child rearing: child allowance and parental leave.

PubMed

Walker, J R

1996-01-01

This article proposes two financing plans to address what the author identifies as the two primary concerns in the child care field: (1) a child allowance for poor and near-poor households to address the child care problems of low-income families, and (2) a program of voluntary parental leave, available to all parents at child birth or adoption, to ensure the adequacy of infant care. The child allowance plan would cover the first three children in families up to 175% of the poverty level (more than 22 million children) at an annual cost of $45 billion. The author suggests that the allowance could be financed by redirecting funds from existing income support (for example, Aid to Families with Dependent Children), tax credit, and tax deduction programs. Financing the parental leave program would require new revenues, generated by an employee-paid increase in payroll tax totaling 3.5%. Each employee's contributions would create a parental leave account (PLA). Families could use the funds in these accounts to cover the cost of a one-year leave from work after the birth or adoption of a child. If families did not have enough dollars in their accounts to cover the cost of the leave, the federal government would extend a low-interest loan to them, which they would have to pay back. The amount individuals receive through Social Security would be adjusted upward or downward according to the balances in their parental leave accounts at retirement. The author suggests that both proposals would help parents balance work and family obligations and protect parental freedom of choice over the care and upbringing of their children.

Analysis of early accountable care organizations defines patient, structural, cost, and quality-of-care characteristics.

PubMed

Epstein, Arnold M; Jha, Ashish K; Orav, E John; Liebman, Daniel L; Audet, Anne-Marie J; Zezza, Mark A; Guterman, Stuart

2014-01-01

Accountable care organizations (ACOs) have attracted interest from many policy makers and clinical leaders because of their potential to improve the quality of care and reduce costs. Federal ACO programs for Medicare beneficiaries are now up and running, but little information is available about the baseline characteristics of early entrants. In this descriptive study we present data on the structural and market characteristics of these early ACOs and compare ACOs' patient populations, costs, and quality with those of their non-ACO counterparts at baseline. We found that ACO patients were more likely than non-ACO patients to be older than age eighty and had higher incomes. ACO patients were less likely than non-ACO patients to be black, covered by Medicaid, or disabled. The cost of care for ACO patients was slightly lower than that for non-ACO patients. Slightly fewer than half of the ACOs had a participating hospital. Hospitals that were in ACOs were more likely than non-ACO hospitals to be large, teaching, and not-for-profit, although there was little difference in their performance on quality metrics. Our findings can be useful in interpreting the early results from the federal ACO programs and in establishing a baseline to assess the programs' development.

Authorities and Mechanisms for Purchased Care at the Department of Veterans Affairs

PubMed Central

Greenberg, Michael D.; Batka, Caroline; Buttorff, Christine; Dunigan, Molly; Lovejoy, Susan L.; McGovern, Geoffrey; Pace, Nicholas M.; Pillemer, Francesca; Williams, Kayla M.; Apaydin, Eric; Aranibar, Clara; Buenaventura, Maya; Carter, Phillip; Cherney, Samantha; Davis, Lynn E.; Donohue, Amy Grace; Geyer, Lily; Hemler, Joslyn; Roshan, Parisa; Skrabala, Lauren; Simmons, Stephen; Thompson, Joseph; Welch, Jonathan; Hosek, Susan D.; Farmer, Carrie M.

2016-01-01

Abstract The Veterans Access, Choice, and Accountability Act of 2014 addressed the need for access to timely, high-quality health care for veterans. Section 201 of the legislation called for an independent assessment of various aspects of veterans' health care. The RAND Corporation was tasked with an assessment of the authorities and mechanisms by which the Department of Veterans Affairs (VA) pays for health care services from non-VA providers. Purchased care accounted for 10 percent, or around $5.6 billion, of VA's health care budget in fiscal year 2014, and the amount of care purchased from outside VA is growing rapidly. VA purchases non-VA care through an array of programs, each with different payment processes and eligibility requirements for veterans and outside providers. A review and analysis of statutes, regulations, legislation, and literature on VA purchased care, along with interviews with expert stakeholders, a survey of VA medical facilities, and an evaluation of local-level policy documents revealed that VA's purchased care system is complex and decentralized. Inconsistencies in procedures, unclear goals, and a lack of cohesive strategy for purchased care could have ramifications for veterans' access to care. Adding to the complexity of VA's purchased care system is a lack of systematic data collection on access to and quality of care provided through VA's purchased care programs. The analysis also explored concepts of “episodes of care” and their implications for purchased care by VA. PMID:28083425

Computer Bits: Child Care Center Management Software Buying Guide Update.

ERIC Educational Resources Information Center

Neugebauer, Roger

1987-01-01

Compares seven center management programs used for basic financial and data management tasks such as accounting, payroll and attendance records, and mailing lists. Describes three other specialized programs and gives guidelines for selecting the best software for a particular center. (NH)

Shift in U.S. payer responsibility for the acute care of violent injuries after the Affordable Care Act: Implications for prevention.

PubMed

Coupet, Edouard; Karp, David; Wiebe, Douglas J; Kit Delgado, M

2018-03-28

Investment in violence prevention programs is hampered by lack of clearly identifiable stakeholders with a financial stake in prevention. We determined the total annual charges for the acute care of injuries from interpersonal violence and the shift in financial responsibility for these charges after the Medicaid expansion from the Affordable Care Act in 2014. We analyzed all emergency department (ED) visits from 2009 to 2014 with diagnosis codes for violent injury in the Nationwide Emergency Department Sample (NEDS). We used sample weights to estimate total charges with adjusted generalized linear models to estimate charges for the 15% of ED visits with missing charge data. We then calculated the share attributable by payer and determined the difference in proportion by payer from 2013 to 2014. Between 2009 and 2013, the uninsured accounted for 28.2-31.3% of annual charges for the acute care of violent injury, while Medicaid was responsible for a similar amount (29.0-31.0%). In 2014, there were $10.7 billion in total charges for violent injury. Medicaid assumed the greatest share, 39.8% (95% CI: 38.0-41.5%, $3.5-5.1 billion), while the uninsured accounted for 23.6% (95% CI: 22.2-24.9%, $2.0-3.0 billion), and Medicare accounted for 7.8% (95% CI: 7.7-8.0%, $0.7-1.0 billion). After Medicaid expansion, taxpayers are now accountable for nearly half of the $10.7 billion in annual charges for the acute care of violent injury in the U.S. These findings highlight the benefit to state Medicaid programs of preventing interpersonal violence. Published by Elsevier Inc.

The Role of Social Work Leadership: Mount Sinai Care, the Accountable Care Organization, and Population Health Management.

PubMed

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.

How the center for Medicare and Medicaid innovation should test accountable care organizations.

PubMed

Shortell, Stephen M; Casalino, Lawrence P; Fisher, Elliott S

2010-07-01

The Patient Protection and Affordable Care Act establishes a national voluntary program for accountable care organizations (ACOs) by January 2012 under the auspices of the Centers for Medicare and Medicaid Services (CMS). The act also creates a Center for Medicare and Medicaid Innovation in the CMS. We propose that the CMS allow flexibility and tiers in ACOs based on their specific circumstances, such as the degree to which they are or are not fully integrated systems. Further, we propose that the CMS assume responsibility for ACO provisions and develop an ordered system for learning how to create and sustain ACOs. Key steps would include setting specific performance goals, developing skills and tools that facilitate change, establishing measurement and accountability mechanisms, and supporting leadership development.

Measuring Success in Health Care Value-Based Purchasing Programs

PubMed Central

Damberg, Cheryl L.; Sorbero, Melony E.; Lovejoy, Susan L.; Martsolf, Grant R.; Raaen, Laura; Mandel, Daniel

2014-01-01

Abstract Value-based purchasing (VBP) refers to a broad set of performance-based payment strategies that link financial incentives to health care providers' performance on a set of defined measures in an effort to achieve better value. The U.S. Department of Health and Human Services is advancing the implementation of VBP across an array of health care settings in the Medicare program in response to requirements in the 2010 Patient Protection and Affordable Care Act, and policymakers are grappling with many decisions about how best to design and implement VBP programs so that they are successful in achieving stated goals. This article summarizes the current state of knowledge about VBP based on a review of the published literature, a review of publicly available documentation from VBP programs, and discussions with an expert panel composed of VBP program sponsors, health care providers and health systems, and academic researchers with VBP evaluation expertise. Three types of VBP models were the focus of the review: (1) pay-for-performance programs, (2) accountable care organizations, and (3) bundled payment programs. The authors report on VBP program goals and what constitutes success; the evidence on the impact of these programs; factors that characterize high– and low–performing providers in VBP programs; the measures, incentive structures, and benchmarks used by VBP programs; evidence on spillover effects and unintended consequences; and gaps in the knowledge base. PMID:28083347

Health resources management and physician control in a San Francisco, California, hospital.

PubMed Central

Rosenstein, A. H.; Stier, M. M.

1991-01-01

The continued escalation in health care spending has caused money to become an increasingly limited resource, which may eventually affect the ability of health professionals to provide complete health care services. Health care payers have stressed efficiency and the appropriateness of health care measures and are putting greater financial pressures on health professionals by making them more accountable for services provided. Hospitals and physicians must take a more active role in monitoring health care delivery and work together to improve performance efficiency. Efficiency can be gained through a comprehensive program that emphasizes high-quality care and the effective use of health care resources. The Health Resource Management Program is a model for carrying out this function that integrates data analysis and physician input and education. Images PMID:2006564

75 FR 78707 - Medicare Program; First Semi-Annual Meeting of the Advisory Panel on Ambulatory Payment...

Federal Register 2010, 2011, 2012, 2013, 2014

2010-12-16

... hospital payment systems; hospital medical care delivery systems; provider billing and accounting systems; APC groups; Current Procedural Terminology codes; Health Care Common Procedure Coding System (HCPCS) codes; the use of, and payment for, drugs, medical devices, and other services in the outpatient setting...

Cancer Patient Navigator Tasks across the Cancer Care Continuum

PubMed Central

Braun, Kathryn L.; Kagawa-Singer, Marjorie; Holden, Alan E. C.; Burhansstipanov, Linda; Tran, Jacqueline H.; Seals, Brenda F.; Corbie-Smith, Giselle; Tsark, JoAnn U.; Harjo, Lisa; Foo, Mary Anne; Ramirez, Amelie G.

2011-01-01

Cancer patient navigation (PN) programs have been shown to increase access to and utilization of cancer care for poor and underserved individuals. Despite mounting evidence of its value, cancer patient navigation is not universally understood or provided. We describe five PN programs and the range of tasks their navigators provide across the cancer care continuum (education and outreach, screening, diagnosis and staging, treatment, survivorship, and end-of-life). Tasks are organized by their potential to make cancer services understandable, available, accessible, affordable, appropriate, and accountable. Although navigators perform similar tasks across the five programs, their specific approaches reflect differences in community culture, context, program setting, and funding. Task lists can inform the development of programs, job descriptions, training, and evaluation. They also may be useful in the move to certify navigators and establish mechanisms for reimbursement for navigation services. PMID:22423178

Lifetime Reliability Evaluation of Structural Ceramic Parts with the CARES/LIFE Computer Program

NASA Technical Reports Server (NTRS)

Nemeth, Noel N.; Powers, Lynn M.; Janosik, Lesley A.; Gyekenyesi, John P.

1993-01-01

The computer program CARES/LIFE calculates the time-dependent reliability of monolithic ceramic components subjected to thermomechanical and/or proof test loading. This program is an extension of the CARES (Ceramics Analysis and Reliability Evaluation of Structures) computer program. CARES/LIFE accounts for the phenomenon of subcritical crack growth (SCG) by utilizing the power law, Paris law, or Walker equation. The two-parameter Weibull cumulative distribution function is used to characterize the variation in component strength. The effects of multiaxial stresses are modeled using either the principle of independent action (PIA), Weibull's normal stress averaging method (NSA), or Batdorf's theory. Inert strength and fatigue parameters are estimated from rupture strength data of naturally flawed specimens loaded in static, dynamic, or cyclic fatigue. Two example problems demonstrating cyclic fatigue parameter estimation and component reliability analysis with proof testing are included.

Case histories of six consumers and their families in Cash and Counseling.

PubMed

San Antonio, Patricia M; Simon-Rusinowitz, Lori; Loughlin, Dawn; Eckert, J Kevin; Mahoney, Kevin J

2007-02-01

To examine how the lives of consumers and their caregivers were affected by making choices and controlling their own resources with the cash option, this paper focuses on six case studies from the Cash and Counseling Demonstration Program. Twenty-one consumers, caregivers, and state consultants were interviewed about their experiences in the program. The data come from a larger study of over 200 interviews conducted from June 2000 to August 2004. Interview data were analyzed for themes about caregiving and program satisfaction. Cash and Counseling benefited consumers and caregivers by allowing consumers increased continuity and reliability of care, increased ability to set hours of care, more satisfaction with how caregiving is offered and more satisfaction with the quality of care. The cash option allowed consumers to create, schedule, and manage their own model of care. Some consumers faced challenges in the program with paperwork, accounting, worries about receiving care, and some ineffective state consultants who could have been more helpful.

Case Histories of Six Consumers and Their Families in Cash and Counseling

PubMed Central

San Antonio, Patricia M; Simon-Rusinowitz, Lori; Loughlin, Dawn; Eckert, J Kevin; Mahoney, Kevin J

2007-01-01

Objective To examine how the lives of consumers and their caregivers were affected by making choices and controlling their own resources with the cash option, this paper focuses on six case studies from the Cash and Counseling Demonstration Program. Data Sources Twenty-one consumers, caregivers, and state consultants were interviewed about their experiences in the program. Study Design The data come from a larger study of over 200 interviews conducted from June 2000 to August 2004. Interview data were analyzed for themes about caregiving and program satisfaction. Principal Findings Cash and Counseling benefited consumers and caregivers by allowing consumers increased continuity and reliability of care, increased ability to set hours of care, more satisfaction with how caregiving is offered and more satisfaction with the quality of care. Conclusions The cash option allowed consumers to create, schedule, and manage their own model of care. Some consumers faced challenges in the program with paperwork, accounting, worries about receiving care, and some ineffective state consultants who could have been more helpful. PMID:17244296

Bending The Spending Curve By Altering Care Delivery Patterns: The Role Of Care Management Within A Pioneer ACO.

PubMed

Hsu, John; Price, Mary; Vogeli, Christine; Brand, Richard; Chernew, Michael E; Chaguturu, Sreekanth K; Weil, Eric; Ferris, Timothy G

2017-05-01

Accountable care organizations (ACOs) appear to lower medical spending, but there is little information on how they do so. We examined the impact of patient participation in a Pioneer ACO and its care management program on rates of emergency department (ED) visits and hospitalizations and on Medicare spending. We used data for the period 2009-14, exploiting naturally staggered program entry to create concurrent controls to help isolate the program effects. The care management program (the ACO's primary intervention) targeted beneficiaries with elevated but modifiable risks for future spending. ACO participation had a modest effect on spending, in line with previous estimates. Participation in the care management program was associated with substantial reductions in rates for hospitalizations and both all and nonemergency ED visits, as well as Medicare spending, when compared to preparticipation levels and to rates and spending for a concurrent sample of beneficiaries who were eligible for but had not yet started the program. Rates of ED visits and hospitalizations were reduced by 6 percent and 8 percent, respectively, and Medicare spending was reduced by 6 percent. Targeting beneficiaries with modifiable high risks and shifting care away from the ED represent viable mechanisms for altering spending within ACOs. Project HOPE—The People-to-People Health Foundation, Inc.

Understanding Effects of Flexible Spending Accounts on People with Disabilities: The Case of a Consumer-Directed Care Program.

PubMed

Lombe, Margaret; Inoue, Megumi; Mahoney, Kevin; Chu, Yoosun; Putnam, Michelle

2016-01-01

This study set out to explore the saving behavior, barriers, and facilitators along with effects of participating in a consumer-directed care program among people with disabilities in the state of West Virginia (N = 29). Results suggest that respondents were able to save money through the program to enable them to purchase goods and services they needed to enhance their welfare and quality of life. Generally, items saved for fell into 3 broad categories: household equipment, individual functioning, and home modification. Facilitators and barriers to saving were also indicated and so were the benefits of program participation. Program and policy implications are presented.

Assessing program efficiency: a time and motion study of the Mental Health Emergency Care - Rural Access Program in NSW Australia.

PubMed

Saurman, Emily; Lyle, David; Kirby, Sue; Roberts, Russell

2014-07-31

The Mental Health Emergency Care-Rural Access Program (MHEC-RAP) is a telehealth solution providing specialist emergency mental health care to rural and remote communities across western NSW, Australia. This is the first time and motion (T&M) study to examine program efficiency and capacity for a telepsychiatry program. Clinical services are an integral aspect of the program accounting for 6% of all activities and 50% of the time spent conducting program activities, but half of this time is spent completing clinical paperwork. This finding emphasizes the importance of these services to program efficiency and the need to address variability of service provision to impact capacity. Currently, there is no efficiency benchmark for emergency telepsychiatry programs. Findings suggest that MHEC-RAP could increase its activity without affecting program responsiveness. T&M studies not only determine activity and time expenditure, but have a wider application assessing program efficiency by understanding, defining, and calculating capacity. T&M studies can inform future program development of MHEC-RAP and similar telehealth programs, both in Australia and overseas.

The CARE model of social accountability: promoting cultural change.

PubMed

Meili, Ryan; Ganem-Cuenca, Alejandra; Leung, Jannie Wing-sea; Zaleschuk, Donna

2011-09-01

On the 10th anniversary of Health Canada and the Association of Faculties of Medicine of Canada's publication in 2001 of Social Accountability: A Vision for Canadian Medical Schools, the authors review the progress at one Canadian medical school, the College of Medicine at the University of Saskatchewan, in developing a culture of social accountability. They review the changes that have made the medical school more socially accountable and the steps taken to make those changes possible. In response to calls for socially accountable medical schools, the College of Medicine created a Social Accountability Committee to oversee the integration of these principles into the college. The committee developed the CARE model (Clinical activity, Advocacy, Research, Education and training) as a guiding tool for social accountability initiatives toward priority health concerns and as a means of evaluation. Diverse faculty and student committees have emerged as a result and have had far-reaching impacts on the college and communities: from changes in curricula and admissions to community programming and international educational experiences. Although a systematic assessment of the CARE model is needed, early evidence shows that the most significant effects can be found in the cultural shift in the college, most notably among students. The CARE model may serve as an important example for other educational institutions in the development of health practitioners and research that is responsive to the needs of their communities.

An Examination of Potential Career Programs. Special Reports.

ERIC Educational Resources Information Center

Johnson County Community Coll., Overland Park, KS.

Surveys of local employers were conducted by Johnson County Community College to determine the needs for potential career programs as related to job opportunities in the following areas: (1) accounting; (2) advertising and journalism; (3) animal health technology; (4) automotive technology; (5) building construction; (6) child care for…

Development of a Medicaid Behavioral Health Case-Mix Model

ERIC Educational Resources Information Center

Robst, John

2009-01-01

Many Medicaid programs have either fully or partially carved out mental health services. The evaluation of carve-out plans requires a case-mix model that accounts for differing health status across Medicaid managed care plans. This article develops a diagnosis-based case-mix adjustment system specific to Medicaid behavioral health care. Several…

A Preliminary Qualitative Evaluation of the Virginia Gold Quality Improvement Program

ERIC Educational Resources Information Center

Craver, Gerald A.; Burkett, Amy K.

2012-01-01

Certified nursing assistants (CNAs) perform an important role in the long-term care system because they provide the majority of paid care to nursing facility residents. Unfortunately, annual CNA turnover often exceeds 100 percent nationally. Many factors account for this, including stressful working conditions, low pay, and limited benefits. The…

Hennepin Health: a safety-net accountable care organization for the expanded Medicaid population.

PubMed

Sandberg, Shana F; Erikson, Clese; Owen, Ross; Vickery, Katherine D; Shimotsu, Scott T; Linzer, Mark; Garrett, Nancy A; Johnsrud, Kimry A; Soderlund, Dana M; DeCubellis, Jennifer

2014-11-01

Health care payment and delivery models that challenge providers to be accountable for outcomes have fueled interest in community-level partnerships that address the behavioral, social, and economic determinants of health. We describe how Hennepin Health--a county-based safety-net accountable care organization in Minnesota--has forged such a partnership to redesign the health care workforce and improve the coordination of the physical, behavioral, social, and economic dimensions of care for an expanded community of Medicaid beneficiaries. Early outcomes suggest that the program has had an impact in shifting care from hospitals to outpatient settings. For example, emergency department visits decreased 9.1 percent between 2012 and 2013, while outpatient visits increased 3.3 percent. An increasing percentage of patients have received diabetes, vascular, and asthma care at optimal levels. At the same time, Hennepin Health has realized savings and reinvested them in future improvements. Hennepin Health offers lessons for counties, states, and public hospitals grappling with the problem of how to make the best use of public funds in serving expanded Medicaid populations and other communities with high needs. Project HOPE—The People-to-People Health Foundation, Inc.

Child Care: Recent State Policy Changes Affecting the Availability of Assistance for Low-Income Families. Report to the Ranking Minority Member, Subcommittee on Human Resources, Committee on Ways and Means, House of Representatives.

ERIC Educational Resources Information Center

General Accounting Office, Washington, DC.

At Congressional request, the General Accounting Office examined states choices for providing child care assistance to families and states' proposed changes to child care assistance programs for fiscal year 2004. Information was obtained through a survey of child care administrators of the 50 states and the District of Columbia. Findings revealed…

[Management accounting in hospital setting].

PubMed

Brzović, Z; Richter, D; Simunić, S; Bozić, R; Hadjina, N; Piacun, D; Harcet, B

1998-12-01

The periodic income and expenditure accounts produced at the hospital and departmental level enable successful short term management, but, in the long run do not help remove tensions between health care demand and limited resources, nor do they enable optimal medical planning within the limited financial resources. We are trying to estabilish disease category costs based on case mixing according to diagnostic categories (diagnosis related groups, DRG, or health care resource groups, HRG) and calculation of hospital standard product costs, e.g., radiology cost, preoperative nursing cost etc. The average DRG cost is composed of standard product costs plus any costs specific to a diagnostic category. As an example, current costing procedure for hip artheroplasty in the University Hospital Center Zagreb is compared to the management accounting approach based on British Health Care Resource experience. The knowledge of disease category costs based on management accounting requirements facilitates the implementation of medical programs within the given financial resources and devolves managerial responsibility closer to the clinical level where medical decisions take place.

Impact: The Magazine for Innovation and Change in the Helping Professions, Volume 2, Number 3.

ERIC Educational Resources Information Center

Walz, Garry R., Ed.; And Others

This issue of Impact examines a variety of viewpoints, programs, issues, and concerns about accountability of guidance. Three articles are adaptations from speeches presented at the conference on Accountability and Pupil Personnel Work held at Michigan State University in the summer of 1971; they explore the importance of preserving "caring"…

Designing health promotion programs by watching the market.

PubMed

Gelb, B D; Bryant, J M

1992-03-01

More health care providers and payors are beginning to see health promotion programs as a significant tool for attracting patients, reducing costs, or both. To help design programs that take into account the values and lifestyles of the target group, naturalistic observation can be useful. The authors illustrate the approach in a study of pipeline workers that provided input for the design of nutrition and smoking cessation programs.

Pediatric Specialty Care Model for Management of Chronic Respiratory Failure: Cost and Savings Implications and Misalignment With Payment Models.

PubMed

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.

Factors that influence case managers' resource allocation decisions in pediatric home care: an ethnographic study.

PubMed

Fraser, Kimberly D; Estabrooks, Carole; Allen, Marion; Strang, Vicki

2009-03-01

Case managers make decisions that directly affect the amount and type of services home care clients receive and subsequently affect the overall available health care resources of home care programs. A recent systematic review of the literature identified significant knowledge gaps with respect to resource allocation decision-making in home care. Using Spradley's methodology, we designed an ethnographic study of a children's home care program in Western Canada. The sample included 11 case managers and program leaders. Data sources included interviews, card sorts, and participant observation over a 5-month period. Data analyses included open coding, domain, taxonomic, and componential analysis. One of the key findings was a taxonomy of factors that influence case manager resource allocation decisions. The factors were grouped into one of four main categories: system-related, home care program-related, family related, or client-related. Family related factors have not been previously reported as influencing case manager resource allocation decision-making and nor has the team's role been reported as an influencing factor. The findings of this study are examined in light of Daniels and Sabin's Accountability for Reasonableness framework, which may be useful for future knowledge development about micro-level resource allocation theory.

Developing Quality Indicators for Family Support Services in Community Team-Based Mental Health Care

PubMed Central

Olin, S. Serene; Kutash, Krista; Pollock, Michele; Burns, Barbara J.; Kuppinger, Anne; Craig, Nancy; Purdy, Frances; Armusewicz, Kelsey; Wisdom, Jennifer; Hoagwood, Kimberly E.

2013-01-01

Quality indicators for programs integrating parent-delivered family support services for children’s mental health have not been systematically developed. Increasing emphasis on accountability under the Affordable Care Act highlights the importance of quality-benchmarking efforts. Using a modified Delphi approach, quality indicators were developed for both program level and family support specialist level practices. These indicators were pilot tested with 21 community-based mental health programs. Psychometric properties of these indicators are reported; variations in program and family support specialist performance suggest the utility of these indicators as tools to guide policies and practices in organizations that integrate parent-delivered family support service components. PMID:23709287

Medicare program; clarification of Medicare's accrual basis of accounting policy--HCFA. Final rule.

PubMed

1995-06-27

This final rule revises the Medicare regulations to clarify the concept of "accrual basis of accounting" to indicate that expenses must be incurred by a provider of health care services before Medicare will pay its share of those expenses. This rule does not signify a change in policy but, rather, incorporates into the regulations Medicare's longstanding policy regarding the circumstances under which we recognize, for the purposes of program payment, a provider's claim for costs for which it has not actually expended funds during the current cost reporting period.

Physician role change in managed care: a frontline report.

PubMed

Christian, J H

1998-01-01

Dr. Christian, Vice President and Chief Medical Officer of ManagedComp, Inc., describes the company's new managed compensation program in which the physician's role is expanded to include more accountability.

Challenges and opportunities in building a sustainable rural primary care workforce in alignment with the Affordable Care Act: the WWAMI program as a case study.

PubMed

Allen, Suzanne M; Ballweg, Ruth A; Cosgrove, Ellen M; Engle, Kellie A; Robinson, Lawrence R; Rosenblatt, Roger A; Skillman, Susan M; Wenrich, Marjorie D

2013-12-01

The authors examine the potential impact of the Patient Protection and Affordable Care Act (ACA) on a large medical education program in the Northwest United States that builds the primary care workforce for its largely rural region. The 42-year-old Washington, Wyoming, Alaska, Montana, and Idaho (WWAMI) program, hosted by the University of Washington School of Medicine, is one of the nation's most successful models for rural health training. The program has expanded training and retention of primary care health professionals for the region through medical school education, graduate medical education, a physician assistant training program, and support for practicing health professionals.The ACA and resulting accountable care organizations (ACOs) present potential challenges for rural settings and health training programs like WWAMI that focus on building the health workforce for rural and underserved populations. As more Americans acquire health coverage, more health professionals will be needed, especially in primary care. Rural locations may face increased competition for these professionals. Medical schools are expanding their positions to meet the need, but limits on graduate medical education expansion may result in a bottleneck, with insufficient residency positions for graduating students. The development of ACOs may further challenge building a rural workforce by limiting training opportunities for health professionals because of competing demands and concerns about cost, efficiency, and safety associated with training. Medical education programs like WWAMI will need to increase efforts to train primary care physicians and increase their advocacy for student programs and additional graduate medical education for rural constituents.

Relationship marketing in health care.

PubMed

Wagner, H C; Fleming, D; Mangold, W G; LaForge, R W

1994-01-01

Building relationships with patients is critical to the success of many health care organizations. The authors profile the relationship marketing program for a hospital's cardiac center and discuss the key strategic aspects that account for its success: a focus on a specific hospital service, an integrated marketing communication strategy, a specially designed database, and the continuous tracking of results.

76 FR 33306 - Medicare Program; Pioneer Accountable Care Organization Model, Request for Applications; Correction

Federal Register 2010, 2011, 2012, 2013, 2014

2011-06-08

... information posted on our Center for Medicare and Medicaid Innovation (CMMI) Web site and in the Pioneer ACO Application. (For more information see http://innovations.cms.gov/areas-of-focus/seamless-and-coordinated-care... postmarked on or before July 18, 2011.'' Authority: Section 1115A of the Social Security Act. Dated: June 2...

Developing and integrating a practice model for health finance reform into wound healing programs: an examination of the triple aim approach.

PubMed

Flattau, Anna; Thompson, Maureen; Meara, Anne

2013-10-01

Throughout the United States, government and private payers are exploring new payment models such as accountable care organizations and shared savings agreements. These models are widely based on the construct of the Triple Aim, a set of three principles for health services reform: improving population-based outcomes, improving patient care experiences, and reducing costs through better delivery systems. Wound programs may adapt to the new health financing environment by incorporating initiatives known to promote the Triple Aim, such as diabetes amputation reduction and pressure ulcer prevention programs, and by rethinking how health services can best be delivered to meet these new criteria. The existing literature supports that programmatic approaches can improve care, quality, and cost, especially in the field of diabetic foot ulcers. Wound healing programs have opportunities to develop new business plan models that provide quality, cost-efficient care to their patient population and to be leaders in the development of new types of partnerships with payers and health delivery organizations.

Transfer of financial risk and alternative financing solutions.

PubMed

Levitt, Jeffrey C

2004-01-01

The high cost of health care in the United States has created a number of alarming economic and social problems. It has contributed to a greater number of underinsured and uninsured individuals living in the United States, and forced people to either ration or not purchase the care they need. Accumulated medical debt is grossly disproportionate to the US median AGI, and accounted for at least 25 percent of all personal bankruptcies. For patients, a guaranteed loan program specifically for medical procedures and treatments with below market interest rates would help alleviate bankruptcies related to medical debt by lowering payments and extending the loan maturities. A guaranteed loan program would also improve the debt charge-off rate for medical providers that carry patient receivables and reduce the risk of their balance sheets. This might hold or reduce the rate at which health care inflation grows. The health care loan program could model the current student loan programs and produce significant economic and societal benefits.

Toward defining and measuring social accountability in graduate medical education: a stakeholder study.

PubMed

Reddy, Anjani T; Lazreg, Sonia A; Phillips, Robert L; Bazemore, Andrew W; Lucan, Sean C

2013-09-01

Since 1965, Medicare has publically financed graduate medical education (GME) in the United States. Given public financing, various advisory groups have argued that GME should be more socially accountable. Several efforts are underway to develop accountability measures for GME that could be tied to Medicare payments, but it is not clear how to measure or even define social accountability. We explored how GME stakeholders perceive, define, and measure social accountability. Through purposive and snowball sampling, we completed semistructured interviews with 18 GME stakeholders from GME training sites, government agencies, and health care organizations. We analyzed interview field notes and audiorecordings using a flexible, iterative, qualitative group process to identify themes. THREE THEMES EMERGED IN REGARDS TO DEFINING SOCIAL ACCOUNTABILITY: (1) creating a diverse physician workforce to address regional needs and primary care and specialty shortages; (2) ensuring quality in training and care to best serve patients; and (3) providing service to surrounding communities and the general public. All but 1 stakeholder believed GME institutions have a responsibility to be socially accountable. Reported barriers to achieving social accountability included training time constraints, financial limitations, and institutional resistance. Suggestions for measuring social accountability included reviewing graduates' specialties and practice locations, evaluating curricular content, and reviewing program services to surrounding communities. Most stakeholders endorsed the concept of social accountability in GME, suggesting definitions and possible measures that could inform policy makers calls for increased accountability despite recognized barriers.

Strategic Review Process for an Accountable Care Organization and Emerging Accountable Care Best Practices.

PubMed

Conway, Sarah J; Himmelrich, Sarah; Feeser, Scott A; Flynn, John A; Kravet, Steven J; Bailey, Jennifer; Hebert, Lindsay C; Donovan, Susan H; Kachur, Sarah G; Brown, Patricia M C; Baumgartner, William A; Berkowitz, Scott A

2018-02-02

Accountable Care Organizations (ACOs), like other care entities, must be strategic about which initiatives they support in the quest for higher value. This article reviews the current strategic planning process for the Johns Hopkins Medicine Alliance for Patients (JMAP), a Medicare Shared Savings Program Track 1 ACO. It reviews the 3 focus areas for the 2017 strategic review process - (1) optimizing care coordination for complex, at-risk patients, (2) post-acute care, and (3) specialty care integration - reviewing cost savings and quality improvement opportunities, associated best practices from the literature, and opportunities to leverage and advance existing ACO and health system efforts in each area. It then reviews the ultimate selection of priorities for the coming year and early thoughts on implementation. After the robust review process, key stakeholders voted to select interventions targeted at care coordination, post-acute care, and specialty integration including Part B drug and imaging costs. The interventions selected incorporate a mixture of enhancing current ACO initiatives, working collaboratively and synergistically on other health system initiatives, and taking on new projects deemed targeted, cost-effective, and manageable in scope. The annual strategic review has been an essential and iterative process based on performance data and informed by the collective experience of other organizations. The process allows for an evidence-based strategic plan for the ACO in pursuit of the best care for patients.

Durability evaluation of ceramic components using CARES/LIFE

NASA Technical Reports Server (NTRS)

Nemeth, Noel N.; Powers, Lynn M.; Janosik, Lesley A.; Gyekenyesi, John P.

1994-01-01

The computer program CARES/LIFE calculates the time-dependent reliability of monolithic ceramic components subjected to thermomechanical and/or proof test loading. This program is an extension of the CARES (Ceramics Analysis and Reliability Evaluation of Structures) computer program. CARES/LIFE accounts for the phenomenon of subcritical crack growth (SCG) by utilizing the power law, Paris law, or Walker equation. The two-parameter Weibull cumulative distribution function is used to characterize the variation in component strength. The effects of multiaxial stresses are modeled using either the principle of independent action (PIA), the Weibull normal stress averaging method (NSA), or the Batdorf theory. Inert strength and fatigue parameters are estimated from rupture strength data of naturally flawed specimens loaded in static, dynamic, or cyclic fatigue. Application of this design methodology is demonstrated using experimental data from alumina bar and disk flexure specimens which exhibit SCG when exposed to water.

Durability evaluation of ceramic components using CARES/LIFE

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

Nemeth, N.N.; Janosik, L.A.; Gyekenyesi, J.P.

1996-01-01

The computer program CARES/LIFE calculates the time-dependent reliability of monolithic ceramic components subjected to thermomechanical and/or proof test loading. This program is an extension of the CARES (Ceramics Analysis and Reliability Evaluation of Structures) computer program. CARES/LIFE accounts for the phenomenon of subcritical crack growth (SCG) by utilizing the power law, Paris law, or Walker equation. The two-parameter Weibull cumulative distribution function is used to characterize the variation in component strength. The effects of multiaxial stresses are modeled using either the principle of independent action (PIA), the Weibull normal stress averaging method (NSA), or the Batdorf theory. Inert strength andmore » fatigue parameters are estimated from rupture strength data of naturally flawed specimens loaded in static, dynamic, or cyclic fatigue. Application of this design methodology is demonstrated using experimental data from alumina bar and disk flexure specimens, which exhibit SCG when exposed to water.« less

A framework for evaluating the formation, implementation, and performance of accountable care organizations.

PubMed

Fisher, Elliott S; Shortell, Stephen M; Kreindler, Sara A; Van Citters, Aricca D; Larson, Bridget K

2012-11-01

The implementation of accountable care organizations (ACOs), a new health care payment and delivery model designed to improve care and lower costs, is proceeding rapidly. We build on our experience tracking early ACOs to identify the major factors-such as contract characteristics; structure, capabilities, and activities; and local context-that would be likely to influence ACO formation, implementation, and performance. We then propose how an ACO evaluation program could be structured to guide policy makers and payers in improving the design of ACO contracts, while providing insights for providers on approaches to care transformation that are most likely to be successful in different contexts. We also propose key activities to support evaluation of ACOs in the near term, including tracking their formation, developing a set of performance measures across all ACOs and payers, aggregating those performance data, conducting qualitative and quantitative research, and coordinating different evaluation activities.

Time-dependent reliability analysis of ceramic engine components

NASA Technical Reports Server (NTRS)

Nemeth, Noel N.

1993-01-01

The computer program CARES/LIFE calculates the time-dependent reliability of monolithic ceramic components subjected to thermomechanical and/or proof test loading. This program is an extension of the CARES (Ceramics Analysis and Reliability Evaluation of Structures) computer program. CARES/LIFE accounts for the phenomenon of subcritical crack growth (SCG) by utilizing either the power or Paris law relations. The two-parameter Weibull cumulative distribution function is used to characterize the variation in component strength. The effects of multiaxial stresses are modeled using either the principle of independent action (PIA), the Weibull normal stress averaging method (NSA), or the Batdorf theory. Inert strength and fatigue parameters are estimated from rupture strength data of naturally flawed specimens loaded in static, dynamic, or cyclic fatigue. Two example problems demonstrating proof testing and fatigue parameter estimation are given.

Partners for Kids Care Coordination: Lessons From the Field.

PubMed

Weier, Rory Cusack; Gardner, William; Conkol, Kimberly; Pajer, Kathleen; Kelleher, Kelly J

2017-05-01

The goal of this trial was to present a case study of care coordination for children and youth with special health care needs from an exclusively pediatric accountable care organization, and compare precare and postcare data on their use of inpatient and emergency department services. This pre-post comparison of the health care utilization included a subset of 733 children enrolled in Partners for Kids care coordination funded through a delegation arrangement with several Medicaid managed care plans. We compared inpatient admissions, hospital bed days, 30-day hospital readmissions, and emergency department visits during the 6 months before their enrollment in the coordination program versus the 6 months after enrollment. Approximately 16 000 referrals to the Partners for Kids care coordination program were made for an estimated 12 000 children. A total of 3072 unique individual children were enrolled; the most common condition classification was mental, behavioral, and neurodevelopmental disorders (25% of enrolled children). Due to rapid turnover/churn in Medicaid managed care eligibility, the subset of children with continuous enrollment was limited to 733 children. Among this subset, the counts of inpatient admissions, bed days, and 30-day readmissions between the pre-enrollment and post-enrollment period decreased ( P < .05). These results suggest that it is possible for an accountable care organization to reduce inpatient and emergency department utilization. Going forward, the most important tasks of the care coordination team are to overcome obstacles to referral and participation and to develop methods to achieve better measures of patient-reported outcomes. Copyright © 2017 by the American Academy of Pediatrics.

Impact of a New Palliative Care Program on Health System Finances: An Analysis of the Palliative Care Program Inpatient Unit and Consultations at Johns Hopkins Medical Institutions.

PubMed

Isenberg, Sarina R; Lu, Chunhua; McQuade, John; Chan, Kelvin K W; Gill, Natasha; Cardamone, Michael; Torto, Deirdre; Langbaum, Terry; Razzak, Rab; Smith, Thomas J

2017-05-01

Palliative care inpatient units (PCUs) can improve symptoms, family perception of care, and lower per-diem costs compared with usual care. In March 2013, Johns Hopkins Medical Institutions (JHMI) added a PCU to the palliative care (PC) program. We studied the financial impact of the PC program on JHMI from March 2013 to March 2014. This study considered three components of the PC program: PCU, PC consultations, and professional fees. Using 13 months of admissions data, the team calculated the per-day variable cost pre-PCU (ie, in another hospital unit) and after transfer to the PCU. These fees were multiplied by the number of patients transferred to the PCU and by the average length of stay in the PCU. Consultation savings were estimated using established methods. Professional fees assumed a collection rate of 50%. The total positive financial impact of the PC program was $3,488,863.17. There were 153 transfers to the PCU, 60% with cancer, and an average length of stay of 5.11 days. The daily loss pretransfer to the PCU of $1,797.67 was reduced to $1,345.34 in the PCU (-25%). The PCU saved JHMI $353,645.17 in variable costs, or $452.33 per transfer. Cost savings for PC consultations in the hospital, 60% with cancer, were estimated at $2,765,218. $370,000 was collected in professional fees savings. The PCU and PC program had a favorable impact on JHMI while providing expert patient-centered care. As JHMI moves to an accountable care organization model, value-based patient-centered care and increased intensive care unit availability are desirable.

Portfolio theory and cost-effectiveness analysis: a further discussion.

PubMed

Sendi, Pedram; Al, Maiwenn J; Rutten, Frans F H

2004-01-01

Portfolio theory has been suggested as a means to improve the risk-return characteristics of investments in health-care programs through diversification when costs and effects are uncertain. This approach is based on the assumption that the investment proportions are not subject to uncertainty and that the budget can be invested in toto in health-care programs. In the present paper we develop an algorithm that accounts for the fact that investment proportions in health-care programs may be uncertain (due to the uncertainty associated with costs) and limited (due to the size of the programs). The initial budget allocation across programs may therefore be revised at the end of the investment period to cover the extra costs of some programs with the leftover budget of other programs in the portfolio. Once the total budget is equivalent to or exceeds the expected costs of the programs in the portfolio, the initial budget allocation policy does not impact the risk-return characteristics of the combined portfolio, i.e., there is no benefit from diversification anymore. The applicability of portfolio methods to improve the risk-return characteristics of investments in health care is limited to situations where the available budget is much smaller than the expected costs of the programs to be funded.

Implementation of Transition in Care and Relationship Based Care to Reduce Preventable Rehospitalizations.

PubMed

Burt, Susan; Berry, Donna; Quackenbush, Patricia

2015-01-01

Home healthcare agencies are accountable for preventing rehospitalization, yet many struggle to make progress with this metric. The purpose of this article is to share how our organization turned to two frameworks, Transitions in Care and Relationship-Based Care, to prevent unnecessary rehospitalizations. Appreciative inquiry, motivational interviewing, and action plans are used by our Transitional Care Nurses to engage and motivate patients to manage chronic diseases and achieve desirable health outcomes. Implementation of a Transitional Care Program has led our organization to improve the health of our patients and to decrease rehospitalization rates.

Characteristics of the original patient navigation programs to reduce disparities in the diagnosis and treatment of breast cancer.

PubMed

Vargas, Roberto B; Ryan, Gery W; Jackson, Catherine A; Rodriguez, Rian; Freeman, Harold P

2008-07-15

Patient navigation is an intervention developed to reduce disparities in cancer care that is being widely replicated and receiving considerable support for demonstration projects and research to test its effectiveness. In the current study, the authors present an in-depth descriptive analysis of the original patient navigation programs to inform current and future program development. A qualitative multistakeholder case study using interviews and site visits of the first patient navigation site and 2 sites subsequently developed by the leadership of the original site were evaluated. At these sites, patient navigation is a system, as opposed to a person, comprised primarily of navigators and directors that work together to remove barriers and facilitate access in a well-defined course of care; navigators were from the community or were culturally similar to the patient population served but were also paid employees of the clinical care site with detailed knowledge of the clinical course patients must traverse to complete care plans. Directors had administrative authority over the clinical facility and social capital across institutions, and communicated regularly and openly with navigators to implement system level changes to remove barriers to care. Contextual factors such as policies supporting breast cancer care also influenced the implementation of these programs. The first patient navigation programs combined community and culturally sensitive care-coordination with aspects of disease management programs to reduce racial, ethnic, and poverty-driven disparities in care. Future efforts to replicate and evaluate patient navigation should take into account these unique aspects of the original patient navigation programs. (c) 2008 American Cancer Society.

76 FR 19527 - Medicare Program; Medicare Shared Savings Program: Accountable Care Organizations

Federal Register 2010, 2011, 2012, 2013, 2014

2011-04-07

... one of the addresses provided below, no later than 5 p.m. on June 6, 2011. ADDRESSES: In commenting... comments by facsimile (FAX) transmission. You may submit comments in one of four ways (please choose only one of the ways listed): 1. Electronically. You may submit electronic comments on this regulation to...

A Targeted E-Learning Program for Surgical Trainees to Enhance Patient Safety in Preventing Surgical Infection

ERIC Educational Resources Information Center

McHugh, Seamus Mark; Corrigan, Mark; Dimitrov, Borislav; Cowman, Seamus; Tierney, Sean; Humphreys, Hilary; Hill, Arnold

2010-01-01

Introduction: Surgical site infection accounts for 20% of all health care-associated infections (HCAIs); however, a program incorporating the education of surgeons has yet to be established across the specialty. Methods: An audit of surgical practice in infection prevention was carried out in Beaumont Hospital from July to November 2009. An…

The Effects of a Disease Management Program on Self-Reported Health Behaviors and Health Outcomes: Evidence from the "Florida--A Healthy State (FAHS)" Medicaid Program

ERIC Educational Resources Information Center

Morisky, Donald E.; Kominski, Gerald F.; Afifi, Abdelmonem A.; Kotlerman, Jenny B.

2009-01-01

Premature morbidity and mortality from chronic diseases account for a major proportion of expenditures for health care cost in the United States. The purpose of this study was to measure the effects of a disease management program on physiological and behavioral health indicators for Medicaid patients in Florida. A two-year prospective study of…

The cost of cancer care: Part II.

PubMed

Eagle, David

2012-11-01

The rising cost of cancer treatment competes with the availability of effective therapy as a limiting factor in our war on cancer. Specific programs are being developed that have the potential to slow the growth in spending on oncology care. The Affordable Care Act includes provisions for containing healthcare costs, such as accountable care organizations and the Independent Payment Advisory Board. Within oncology, specific programs have emerged, including clinical pathways, episode-of-care based payment arrangements, and the oncology medical home. All models of cost containment have strengths and weaknesses. Outside of the United States, explicit rationing exists' through national health technology assessment organizations. Excessive demands on physicians to limit spending at the bedside could potentially create conflicts with their professional responsibility to patients. While spending for cancer care in the US is high, its "worth" is ultimately a societal decision. Recent economic modeling suggests that we may be achieving value for the money we spend.

Aligning quality and payment for heart failure care: defining the challenges.

PubMed

Havranek, Edward P; Krumholz, Harlan M; Dudley, R Adams; Adams, Kirkwood; Gregory, Douglas; Lampert, Steven; Lindenfeld, Joann; Massie, Barry M; Pina, Ileana; Restaino, Susan; Rich, Michael W; Konstam, Marvin A

2003-08-01

Hospitals may not support programs that improve the quality of care delivered to heart failure patients because these programs lower readmission rates and empty beds, and therefore further diminish already-declining revenues. A conflict between the highest quality of care and financial solvency does not serve the interests of patients, physicians, hospitals, or payers. In principle, resolution of this conflict is simple: reimbursement systems should reward higher quality care. In practice, resolving the conflict is not simple. A recent roundtable discussion sponsored by the Heart Failure Society of America identified 4 major challenges to the design and implementation of reimbursement schemes that promote higher quality care for heart failure: defining quality, accounting for differences in disease severity, crafting novel payment mechanisms, and overcoming professional parochialism. This article describes each of these challenges in turn.

Changes in Low-Value Services in Year 1 of the Medicare Pioneer Accountable Care Organization Program.

PubMed

Schwartz, Aaron L; Chernew, Michael E; Landon, Bruce E; McWilliams, J Michael

2015-11-01

Wasteful practices are widespread in the US health care system. It is unclear if payment models intended to improve health care efficiency, such as the Medicare accountable care organization (ACO) programs, discourage the provision of low-value services. To assess whether the first year of the Medicare Pioneer ACO program was associated with a reduction in use of low-value services. In a difference-in-differences analysis, we compared use of low-value services between Medicare fee-for-service beneficiaries attributed to health care provider groups that entered the Pioneer program (ACO group) and beneficiaries attributed to other health care providers (control group) before (2009-2011) vs after (2012) Pioneer ACO contracts began. Data analysis was conducted from December 1, 2014, to June 27, 2015. Comparisons were adjusted for beneficiaries' sociodemographic and clinical characteristics as well as for geography. We decomposed estimates according to service characteristics (clinical category, price, and sensitivity to patient preferences) and compared estimates between subgroups of ACOs with higher vs lower baseline use of low-value services. Use of, and spending on, 31 services in instances that provide minimal clinical benefit, measured as annual service counts per 100 beneficiaries and price-standardized annual service spending per 100 beneficiaries. During the precontract period, trends in the use of low-value services were similar for the ACO and control groups. The first year of ACO contracts was associated with a differential reduction (95% CI) of 0.8 low-value services per 100 beneficiaries for the ACO group (-1.2 to -0.4; P < .001), corresponding to a 1.9% differential reduction in service quantity (-2.9% to -0.9%) and a 4.5% differential reduction in spending on low-value services (-7.5% to -1.4%; P = .004). Differential reductions were similar for services less sensitive vs more sensitive to patient preferences and for higher- vs lower-priced services. The ACOs with higher than their markets' mean baseline levels of low-value service use experienced greater service reductions (-1.2 services per 100 beneficiaries; -1.7 to -0.7; P < .001) than did ACOs with use below the mean (-0.2 services per 100 beneficiaries, -0.6 to -0.2; P = .41; P = .003 for test of difference between subgroups). During its first year, the Pioneer ACO program was associated with modest reductions in low-value services, with greater reductions for organizations providing more low-value care. Accountable care organization-like risk contracts may be able to discourage use of low-value services even without specifying services to target.

77 FR 55120 - Federal Housing Administration (FHA): Section 232 Healthcare Facility Insurance Program...

Federal Register 2010, 2011, 2012, 2013, 2014

2012-09-07

...In 2010 through 2011, HUD commenced and completed the process of revising regulations applicable to, and closing documents used in, FHA insurance of multifamily rental projects, to reflect current policy and practices in the multifamily mortgage market. This final rule results from a similar process that was initiated in 2011 for revising and updating the regulations governing, and the transactional documents used in, the program for insurance of healthcare facilities under section 232 of the National Housing Act (Section 232 program). HUD's Section 232 program insures mortgage loans to facilitate the construction, substantial rehabilitation, purchase, and refinancing of nursing homes, intermediate care facilities, board and care homes, and assisted-living facilities. This rule revises the Section 232 program regulations to reflect current policy and practices, and improve accountability and strengthen risk management in the Section 232 program.

The patient perspective: utilizing focus groups to inform care coordination for high-risk medicaid populations.

PubMed

Sheff, Alex; Park, Elyse R; Neagle, Mary; Oreskovic, Nicolas M

2017-07-25

Care coordination programs for high-risk, high-cost patients are a critical component of population health management. These programs aim to improve outcomes and reduce costs and have proliferated over the last decade. Some programs, originally designed for Medicare patients, are now transitioning to also serve Medicaid populations. However, there are still gaps in the understanding of what barriers to care Medicaid patients experience, and what supports will be most effective for providing them care coordination. We conducted two focus groups (n = 13) and thematic analyses to assess the outcomes drivers and programmatic preferences of Medicaid patients enrolled in a high-risk care coordination program at a major academic medical center in Boston, MA. Two focus groups identified areas where care coordination efforts were having a positive impact, as well as areas of unmet needs among the Medicaid population. Six themes emerged from the focus groups that clustered in three groupings: In the first group (1) enrollment in an existing medical care coordination programs, and (2) provider communication largely presented as positive accounts of assistance, and good relationships with providers, though participants also pointed to areas where these efforts fell short. In the second group (3) trauma histories, (4) mental health challenges, and (5) executive function difficulties all presented challenges faced by high-risk Medicaid patients that would likely require redress through additional programmatic supports. Finally, in the third group, (6) peer-to-peer support tendencies among patients suggested an untapped resource for care coordination programs. Programs aimed at high-risk Medicaid patients will want to consider programmatic adjustments to attend to patient needs in five areas: (1) provider connection/care coordination, (2) trauma, (3) mental health, (4) executive function/paperwork and coaching support, and (5) peer-to-peer support.

Perceived benefits and proposed solutions for teen pregnancy: qualitative interviews with youth care workers.

PubMed

Boustani, Maya Mroué; Frazier, Stacy L; Hartley, Chelsey; Meinzer, Michael; Hedemann, Erin

2015-01-01

The purpose of this article is to examine youth care workers' perceptions of the specific and unique sexual health needs of youth at risk for foster care. Semistructured interviews were conducted with youth care workers (N = 10) at a shelter for youth in or at risk for foster care. Youth care workers perceive that youth have unique experiences and needs related to sexual health programming and pregnancy prevention. Reflecting a great deal of family dysfunction, 3 themes emerged that revealed perceived benefits of teen pregnancy: youths' effort to prove themselves as adults, opportunity to secure their relationship with a partner, and desire to create an emotional connection with a baby. Lack of knowledge and accumulation of risk factors were viewed as most problematic. Current pregnancy prevention programs assume teen pregnancies are unwanted and emphasize the costs of sexual risk taking. Current findings suggest that sexual health programming for youth in or at risk for foster care should account for 3 perceived benefits of teen pregnancy. New opportunities for improving the reach and effectiveness of intervention for youth in or at risk for foster care are discussed.

CARES/Life Ceramics Durability Evaluation Software Enhanced for Cyclic Fatigue

NASA Technical Reports Server (NTRS)

Nemeth, Noel N.; Powers, Lynn M.; Janosik, Lesley A.

1999-01-01

The CARES/Life computer program predicts the probability of a monolithic ceramic component's failure as a function of time in service. The program has many features and options for materials evaluation and component design. It couples commercial finite element programs--which resolve a component's temperature and stress distribution--to reliability evaluation and fracture mechanics routines for modeling strength-limiting defects. The capability, flexibility, and uniqueness of CARES/Life have attracted many users representing a broad range of interests and has resulted in numerous awards for technological achievements and technology transfer. Recent work with CARES/Life was directed at enhancing the program s capabilities with regards to cyclic fatigue. Only in the last few years have ceramics been recognized to be susceptible to enhanced degradation from cyclic loading. To account for cyclic loads, researchers at the NASA Lewis Research Center developed a crack growth model that combines the Power Law (time-dependent) and the Walker Law (cycle-dependent) crack growth models. This combined model has the characteristics of Power Law behavior (decreased damage) at high R ratios (minimum load/maximum load) and of Walker law behavior (increased damage) at low R ratios. In addition, a parameter estimation methodology for constant-amplitude, steady-state cyclic fatigue experiments was developed using nonlinear least squares and a modified Levenberg-Marquardt algorithm. This methodology is used to give best estimates of parameter values from cyclic fatigue specimen rupture data (usually tensile or flexure bar specimens) for a relatively small number of specimens. Methodology to account for runout data (unfailed specimens over the duration of the experiment) was also included.

Principal-agent theory: a framework for improving health care reform in Tennessee.

PubMed

Sekwat, A

2000-01-01

Using a framework based on principal-agent theory, this study examines problems faced by managed care organizations (MCOs) and major health care providers under the state of Tennessee's current capitation-based managed care programs called TennCare. Based on agency theory, the study proposes a framework to show how an effective collaborative relationship can be forged between the state of Tennessee and participating MCOs which takes into account the major concerns of third-party health care providers. The proposed framework further enhances realization of the state's key health care reform goals which are to control the rising costs of health care delivery and to expand health care coverage to uninsured and underinsured Tennesseans.

Teaching of leprosy: current challenges*

PubMed Central

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

2014-01-01

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

The Affordable Care Act, Accountable Care Organizations, and Mental Health Care for Older Adults: Implications and Opportunities.

PubMed

Bartels, Stephen J; Gill, Lydia; Naslund, John A

2015-01-01

The Patient Protection and Affordable Care Act (ACA) represents the most significant legislative change in the United States health care system in nearly half a century. Key elements of the ACA include reforms aimed at addressing high-cost, complex, vulnerable patient populations. Older adults with mental health disorders are a rapidly growing segment of the population and are among the most challenging subgroups within health care, and they account for a disproportionate amount of costs. What does the ACA mean for geriatric mental health? We address this question by highlighting opportunities for reaching older adults with mental health disorders by leveraging the diverse elements of the ACA. We describe nine relevant initiatives: (1) accountable care organizations, (2) patient-centered medical homes, (3) Medicaid-financed specialty health homes, (4) hospital readmission and health care transitions initiatives, (5) Medicare annual wellness visit, (6) quality standards and associated incentives, (7) support for health information technology and telehealth, (8) Independence at Home and 1915(i) State Plan Home and Community-Based Services program, and (9) Medicare-Medicaid Coordination Office, Center for Medicare and Medicaid Innovation, and the Patient-Centered Outcomes Research Institute. We also consider potential challenges to full implementation of the ACA and discuss novel solutions for advancing geriatric mental health in the context of projected workforce shortages and the opportunities afforded by the ACA.

The Affordable Care Act, Accountable Care Organizations, and Mental Health Care for Older Adults: Implications and Opportunities

PubMed Central

Bartels, Stephen J.; Gill, Lydia; Naslund, John A.

2015-01-01

Abstract The Patient Protection and Affordable Care Act (ACA) represents the most significant legislative change in the United States health care system in nearly half a century. Key elements of the ACA include reforms aimed at addressing high-cost, complex, vulnerable patient populations. Older adults with mental health disorders are a rapidly growing segment of the population and are among the most challenging subgroups within health care, and they account for a disproportionate amount of costs. What does the ACA mean for geriatric mental health? We address this question by highlighting opportunities for reaching older adults with mental health disorders by leveraging the diverse elements of the ACA. We describe nine relevant initiatives: (1) accountable care organizations, (2) patient-centered medical homes, (3) Medicaid-financed specialty health homes, (4) hospital readmission and health care transitions initiatives, (5) Medicare annual wellness visit, (6) quality standards and associated incentives, (7) support for health information technology and telehealth, (8) Independence at Home and 1915(i) State Plan Home and Community-Based Services program, and (9) Medicare-Medicaid Coordination Office, Center for Medicare and Medicaid Innovation, and the Patient-Centered Outcomes Research Institute. We also consider potential challenges to full implementation of the ACA and discuss novel solutions for advancing geriatric mental health in the context of projected workforce shortages and the opportunities afforded by the ACA. PMID:25811340

To evaluate if increased supervision and support of South African Government health workers' home visits improves maternal and child outcomes: study protocol for a randomized control trial.

PubMed

Rotheram-Borus, Mary Jane; Le Roux, Karl; Le Roux, Ingrid M; Christodoulou, Joan; Laurenzi, Christina; Mbewu, Nokwanele; Tomlinson, Mark

2017-08-07

Concurrent epidemics of HIV, depression, alcohol abuse, and partner violence threaten maternal and child health (MCH) in South Africa. Although home visiting has been repeatedly demonstrated efficacious in research evaluations, efficacy disappears when programs are scaled broadly. In this cluster randomized controlled trial (RCT), we examine whether the benefits of ongoing accountability and supervision within an existing government funded and implemented community health workers (CHW) home visiting program ensure the effectiveness of home visiting. In the deeply rural, Eastern Cape of South Africa, CHW will be hired by the government and will be initially trained by the Philani Programme to conduct home visits with all pregnant mothers and their children until the children are 2 years old. Eight clinics will be randomized to receive either (1) the Accountable Care Condition in which additional monitoring and accountability systems that Philani routinely uses are implemented (4 clinics, 16 CHW, 450 households); or (2) a Standard Care Condition of initial Philani training, but with supervision and monitoring being delivered by local government structures and systems (4 clinics, 21 CHW, 450 households). In the Accountable Care Condition areas, the CHW's mobile phone reports, which are time-location stamped, will be monitored and data-informed supervision will be provided, as well as monitoring growth, medical adherence, mental health, and alcohol use outcomes. Interviewers will independently assess outcomes at pregnancy at 3, 6, 15, and 24 months post-birth. The primary outcome will be a composite score of documenting maternal HIV/TB testing, linkage to care, treatment adherence and retention, as well as child physical growth, cognitive functioning, and child behavior and developmental milestones. The proposed cluster RCT will evaluate whether routinely implementing supervision and accountability procedures and monitoring CHWs' over time will improve MCH outcomes over the first 2 years of life. ClinicalTrials.gov registration #NCT02957799 , registered on October 26, 2016.

Geography should not be destiny: focusing HIV/AIDS implementation research and programs on microepidemics in US neighborhoods.

PubMed

Nunn, Amy; Yolken, Annajane; Cutler, Blayne; Trooskin, Stacey; Wilson, Phill; Little, Susan; Mayer, Kenneth

2014-05-01

African Americans and Hispanics are disproportionately affected by the HIV/AIDS epidemic. Within the most heavily affected cities, a few neighborhoods account for a large share of new HIV infections. Addressing racial and economic disparities in HIV infection requires an implementation program and research agenda that assess the impact of HIV prevention interventions focused on increasing HIV testing, treatment, and retention in care in the most heavily affected neighborhoods in urban areas of the United States. Neighborhood-based implementation research should evaluate programs that focus on community mobilization, media campaigns, routine testing, linkage to and retention in care, and block-by-block outreach strategies.

Reduced mortality: the unexpected impact of a telephone-based care management intervention for older adults in managed care.

PubMed

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.

A Direct Experience in a New Accountable Care Organization: Results, Challenges, and the Role of the Neurosurgeon.

PubMed

Kim, Dong H; Lloyd, Christopher; Fernandez, Douglas K; Spielman, Amanda; Bradshaw, David

2017-04-01

The passage of the Affordable Care Act saw the creation of Accountable Care Organizations (ACOs), a new approach to healthcare delivery moving from fee-for-service toward population health. This paper presents a case study of the Memorial Hermann ACO (MHACO), launched in response to the Medicare Shared Savings Program, with goals to align physician and hospital incentives, practice evidence-based medicine, develop care coordination, and increase efficiency. Building blocks included an affiliated primary care network, a clinical integration program (involving shared electronic medical record platforms and quality data reporting), and significant investments in information technology. Presented is the approach taken to form MHACO; the management structure, technology developed, and a 2-year experience. Incorporated in July 2012, the MHACO involved 22 000 Medicare patients. In 2015, Centers for Medicare and Medicaid Services released data showing a composite quality score between 80 and 85 (from a maximum 100) and nearly $53 million in total savings (or 11% of expected expenditure), making MHACO one of the most successful nationally.1 In fewer than 5 years, almost 500 ACOs have developed, and by some estimates, a quarter of Medicare patients are currently enrolled in an ACO. Although ACOs to date have focused on primary care, the future will increasingly involve specialists. At Memorial Hermann, neurosurgeons took an early role in forming collaborative partnerships with the hospital, and started programs that served as precursors to the ACO model. This paper ends with an overview of ACO development, likely changes going forward, and a discussion of the role of specialists in general, and of neurosurgeons in particular. Copyright © 2016 by the Congress of Neurological Surgeons.

Social work role in developing and managing employee assistance programs in health care settings.

PubMed

Foster, Z; Hirsch, S; Zaske, K

1991-01-01

The hospital setting presents special needs for an Employee Assistance Program and special complications for sponsorship, development, and maintenance. What has been learned, how certain problems can be solved or avoided, how responsibility and accountability can be negotiated are presented by a team that has successfully established such a program at a large metropolitan medical center. In addition to successes, some unsolved problems are identified for further study.

The New Jersey Medicaid ACO Demonstration Project: seeking opportunities for better care and lower costs among complex low-income patients.

PubMed

Cantor, Joel C; Chakravarty, Sujoy; Tong, Jian; Yedidia, Michael J; Lontok, Oliver; DeLia, Derek

2014-12-01

A small but growing number of states are turning to accountable care concepts to improve their Medicaid programs. In 2011 New Jersey enacted the Medicaid Accountable Care Organization (ACO) Demonstration Project to offer local provider coalitions the opportunity to share any savings they generate. Impetus came from initiatives in Camden that aim to reduce costs through improved care coordination among hospital high users and that have received considerable media attention and substantial federal and private grant support. Though broadly similar to Medicare and commercial ACOs, the New Jersey demonstration addresses the unique concerns faced by Medicaid populations. Using hospital all-payer billing data, we estimate savings from care improvement efforts among inpatient and emergency department high users in thirteen communities that are candidates for participation in the New Jersey demonstration. We also examine their characteristics to inform Medicaid accountable care strategies. We find substantial variation in the share of high-user hospital patients across the study communities and high rates of avoidable use and costs among these patients. The potential savings among Medicaid enrollees are considerable, particularly if Medicaid ACOs can develop ways to successfully address the high burden of chronic illness and behavioral health conditions prevalent in the prospective demonstration communities. Copyright © 2014 by Duke University Press.

The Hidden Roles That Management Partners Play In Accountable Care Organizations.

PubMed

Lewis, Valerie A; D'Aunno, Thomas; Murray, Genevra F; Shortell, Stephen M; Colla, Carrie H

2018-02-01

Accountable care organizations (ACOs) are often discussed and promoted as driven by physicians, hospitals, and other health care providers. However, because of the flexible nature of ACO contracts, management organizations may also become partners in ACOs. We used data from 2013-15 on 276 ACOs from the National Survey of Accountable Care Organizations to understand the prevalence of nonprovider management partners' involvement in ACOs, the services these partners provide, and the structure of ACOs that have such partners. We found that 37 percent of ACOs reported having a management partner, and two-thirds of these ACOs reported that the partner shared in the financial risks or rewards. Among ACOs with partners, 94 percent had data services provided by the partner, 87 percent received administrative services, 68 percent received educational services, and 66 percent received care coordination services. Half received all four of these services from their partner. ACOs with partners were more heavily primary care than other ACOs. ACOs with and without partners had similar performance on costs and quality in Medicare ACO programs. Our findings suggest that management partners play a central role in many ACOs, perhaps supplying smaller and physician-run ACOs with services or expertise perceived as necessary for ACO success.

Variation in teenage mothers' experiences of child care and other components of welfare reform: selection processes and developmental consequences.

PubMed

Yoshikawa, H; Rosman, E A; Hsueh, J

2001-01-01

Developmental evaluations of the current wave of welfare reform programs present challenges with regard to (1) assessing child outcomes; (2) accounting for heterogeneity among low-income families in both baseline characteristics and involvement in self-sufficiency activities and supports, and (3) development of alternatives to experimental approaches to causal inference. This study (N = 1,079) addresses these challenges by examining effects on 4- to 6-year-old children of different patterns of child care, self-sufficiency activities, and other service utilization indicators among experimental-group mothers in a 16-site welfare reform program. Outcomes in areas of cognitive ability and behavior problems were investigated. The study identified seven subgroups of participants engaging in different patterns of service utilization and activity involvement. A two-stage simultaneous equation methodology was used to account for selection, and effects on child cognitive ability of participation in specific patterns of services and activities were found. For example, children of mothers characterized by high levels of involvement in center-based child care, education, and job training showed higher levels of cognitive ability than children of mothers in groups characterized by high involvement in center-based care and education, or center-based care and job training. In addition, children of mothers in groups with high levels of involvement in any of these activities showed higher levels of cognitive ability than those with low levels of involvement. The bulk of selection effects occurred through site-level differences, rather than family-level socio-economic status or maternal depression indicators. Implications for welfare reform program and policy concerns are discussed.

Child Care: States Exercise Flexibility in Setting Reimbursement Rates and Providing Access for Low-Income Children. Report to Congressional Requesters.

ERIC Educational Resources Information Center

Shaul, Marnie S.

In order to promote low-income parents' job preparation and work efforts, states were given greater flexibility to design programs using federal funds to subsidize child care for low-income families. At Congressional request, this report from the General Accounting Office describes how states set reimbursement rates and calculates the extent to…

An evaluation of a computer based education program for the diagnosis and management of dementia in primary care. An international study of the transcultural adaptations necessary for European dissemination.

PubMed

Degryse, J; De Lepeleire, J; Southgate, L; Vernooij-Dassen, M; Gay, B; Heyrman, J

2009-05-01

The aim of this study is to make an inventory of the changes that are needed to make an interactive computer based training program (ICBT) with a specific educational content, acceptable to professional communities with different linguistic,cultural and health care backgrounds in different European countries. Existing educational software, written in two languages was reviewed by GPs and primary care professionals in three different countries. Reviewers worked through the program using a structured critical reading grid. A 'simple' translation of the program is not sufficient. Minor changes are needed to take account of linguistic differences and medical semantics. Major changes are needed in respect of the existing clinical guidelines in every country related to differences in the existing health care systems. ICTB programs cannot easily be used in different countries and cultures. The development of a structured educational program needs collaboration between educationalists, domain experts, information technology advisers and software engineers. Simple validation of the content by local expert groups will not guarantee the program's exportability. It is essential to involve different national expert groups at every phase of the development process in order to disseminate it in other countries.

Practice Innovation, Health Care Utilization and Costs in a Network of Federally Qualified Health Centers and Hospitals for Medicaid Enrollees.

PubMed

Johnson, Tricia J; Jones, Art; Lulias, Cheryl; Perry, Anthony

2018-06-01

State Medicaid programs need cost-effective strategies to provide high-quality care that is accessible to individuals with low incomes and limited resources. Integrated delivery systems have been formed to provide care across the continuum, but creating a shared vision for improving community health can be challenging. Medical Home Network was created as a network of primary care providers and hospital systems providing care to Medicaid enrollees, guided by the principles of egalitarian governance, practice-level care coordination, real-time electronic alerts, and pay-for-performance incentives. This analysis of health care utilization and costs included 1,189,195 Medicaid enrollees. After implementation of Medical Home Network, a risk-adjusted increase of $9.07 or 4.3% per member per month was found over the 2 years of implementation compared with an increase of $17.25 or 9.3% per member per month, before accounting for the cost of care management fees and other financial incentives, for Medicaid enrollees within the same geographic area with a primary care provider outside of Medical Home Network. After accounting for care coordination fees paid to providers, the net risk-adjusted cost reduction was $11.0 million.

Quality assurance in gerontological and geriatric training programs: the European case.

PubMed

Politynska, Barbara; van Rijsselt, René J T; Lewko, Jolanta; Philp, Ian; Figueiredo, Daniella; De Sousa, Lilliana

2012-01-01

Quality assurance (QA) in gerontological and geriatric education programs is regarded as essential to maintain standards, strengthen accountability, improve readability of qualifications, and facilitate professional mobility. In this article the authors present a summary of international developments in QA and elaborate four international trends, including the pros and cons of QA. Furthermore, the authors focus on accreditation and credit transfer opportunities in vocational and academic education programs for primary care practitioners, including nurses, home care workers, social workers, physiotherapists, and family doctors involved in the care of older people in nine European countries and highlight changes that have occurred over the last decade. Vocational education and professional training in elderly care at the basic and postgraduate specialization level remains extremely diversified, reflecting the lack of standardization for programs outside the higher education sector. The situation is ripe for the implementation of the European Qualifications Framework, which is intended to promote transparency, comparability and portability of qualifications at different levels and the introduction of a credit transfer system for vocational education to be established in 2012.

Cancer Care Ontario and integrated cancer programs: portrait of a performance management system and lessons learned.

PubMed

Cheng, Siu Mee; Thompson, Leslee J

2006-01-01

A performance management system has been implemented by Cancer Care Ontario (CCO). This system allows for the monitoring and management of 11 integrated cancer programs (ICPs) across the Province of Ontario. The system comprises of four elements: reporting frequency, reporting requirements, review meetings and accountability and continuous improvement activities. CCO and the ICPs have recently completed quarterly performance review exercises for the last two quarters of the fiscal year 2004-2005. The purpose of this paper is to address some of the key lessons learned. The paper provides an outline of the CCO performance management system. These lessons included: data must be valid and reliable; performance management requires commitments from both parties in the performance review exercises; streamlining performance reporting is beneficial; technology infrastructure which allows for cohesive management of data is vital for a sustainable performance management system; performance indicators need to stand up to scrutiny by both parties; and providing comparative data across the province is valuable. Critical success factors which would help to ensure a successful performance management system include: corporate engagement from various parts of an organization in the review exercises; desire to focus on performance improvement and avoidance of blaming; and strong data management systems. The performance management system is a practical and sustainable system that allows for performance improvement of cancer care services. It can be a vital tool to enhance accountability within the health care system. The paper demonstrates that the performance management system supports accountability in the cancer care system for Ontario, and reflects the principles of the provincial governments commitment to continuous improvement of healthcare.

Self-care management of Thai Buddhists and Muslims with type 2 diabetes after an empowerment education program.

PubMed

Lundberg, Pranee C; Thrakul, Supunnee

2018-04-23

The aim of the present study was to explore self-care management of Thai Buddhists and Muslims with type 2 diabetes and inadequate blood glucose levels, after they had been subjected to a 6-month diabetes empowerment education program. Twenty-seven participants (male and female) were selected through purposive convenience sampling for an explorative qualitative study. Semistructured focus group interviews with four open-ended questions were used to study the participants' self-care behavior at the beginning and the end of the program, and the data obtained were subjected to content analysis. At the end, one third of the participants had been able to reduce their blood glucose to acceptable levels. Most of the others had achieved reduced but irregular blood glucose levels; however, some did not achieve any reduction. Diet was the most difficult problem, and economic difficulties, incorrect knowledge, and misleading beliefs were barriers. In conclusion, an empowerment education program can substantially improve the outcome of self-care management for many people with type 2 diabetes. In the planning of such programs, barriers should be taken into account. © 2018 John Wiley & Sons Australia, Ltd.

Principles for assessing disease management outcomes.

PubMed

Fitzner, Karen; Sidorov, Jaan; Fetterolf, Don; Wennberg, David; Eisenberg, Edward; Cousins, Michael; Hoffman, Joel; Haughton, John; Charlton, Warwick; Krause, David; Woolf, Allen; Mcdonough, Kenneth; Todd, Warren; Fox, Kathe; Plocher, David; Juster, Iver; Stiefel, Matt; Villagra, Victor; Duncan, Ian

2004-01-01

Disease management (DM) is rapidly becoming an important force in the late 20th and early 21st century as a strategy for managing the chronic illness of large populations. Given the increasing visibility of DM programs, the clinical, economic and financial impact of this support are vital to DM program accountability and its acceptance as a solution to the twin challenges of achieving affordable, quality health care. Measuring and reporting outcomes in DM is difficult. DM programs must adapt to local market conditions and customer desires, which in turn limits generalizability, and still account for the overlapping/interlocking/multifaceted nature of the interventions included in any DM program. The Disease Management Association of America convened a Steering Committee to suggest a preferred approach, not a mandated or standardized approach for DM program evaluation. This paper presents the Steering Committee's "Consensus Statement" and "Guiding Principles" for robust evaluation.

77 FR 43773 - Wireline Competition Bureau Seeks Further Comment on Issues in the Rural Health Care Reform...

Federal Register 2010, 2011, 2012, 2013, 2014

2012-07-26

... and Primary programs in supporting any recommendations for streamlined application procedures. b. Post... ineligible HCPs) by taking into account a variety of healthcare-specific factors. We note that in the Pilot...

The Affordable Care Act and Cancer Care Delivery

PubMed Central

Brooks, Gabriel A.; Hoverman, J. Russell; Colla, Carrie H.

2017-01-01

The Affordable Care Act (ACA) has reformed U.S. health care delivery through insurance coverage expansion, experiments in payment design, and funding for patient-centered clinical and health care delivery research. The impact on cancer care specifically has been far-reaching, with new ACA-related programs that encourage coordinated, patient-centered, cost-effective care. Insurance expansions through private exchanges and Medicaid, along with pre-existing condition clauses, have helped over 20 million Americans gain health care coverage. Accountable care organizations, oncology patient-centered medical homes and the Oncology Care Model—all implemented through the Center for Medicare and Medicaid Innovation—have initiated an accelerating shift toward value-based cancer care. Concurrently, evidence for better cancer outcomes and improved quality of cancer care is starting to accrue in the wake of ACA implementation. PMID:28537961

Early Childhood Programs: Characteristics Affect the Availability of School Readiness Information. Report to the Chairman, Subcommittee on Oversight of Government Management, Restructuring, and the District of Columbia, Committee on Governmental Affairs, U.S. Senate.

ERIC Educational Resources Information Center

Shaul, Marnie S.

At the request of members of Congress, the General Accounting Office: (1) developed a categorization of federal early childhood education and care programs for a better understanding of the federal involvement in achieving school readiness; and (2) determined what is known about the effectiveness of selected programs in contributing to school…

Changing Donor Funding and the Challenges of Integrated HIV Treatment.

PubMed

Nattrass, Nicoli; Hodes, Rebecca; Cluver, Lucie

2016-07-01

Donor financing for HIV prevention and treatment has shifted from supporting disease-specific ("vertical") programs to health systems strengthening ("horizontal") programs intended to integrate all aspects of care. We examine the consequences of shifting resources from three perspectives: first, through a broad analysis of the changing policy context of health care financing; second, through an account of changing priorities for HIV treatment in South Africa; and third, through a description of some clinical consequences that the authors observed in a research study examining adherence to antiretroviral therapy (ART) and sexual health among adolescents. We note that AIDS responses are neither completely vertical nor horizontal but rather increasingly diagonal, as disease-specific protocols operate alongside integrated supply chain management, human resource development, and preventive screening. We conclude that health care programs are better conceived of as networks of policies requiring different degrees of integration into communities. © 2016 American Medical Association. All Rights Reserved. ISSN 2376-6980.

Past, present, and future trends of master's education in nursing.

PubMed

Gerard, Sally O; Kazer, Meredith W; Babington, Lynn; Quell, Theresa T

2014-01-01

Nurses interested in pursuing careers in advanced practice are now being educated at the doctoral level through new doctorate of nursing practice degree programs. In light of this shift, master's programs for advanced practice nurses are in a tenuous position, and it is questionable whether the remaining master's level educational programs are meeting the needs of consumers, health care institutions, and students. Given the great need for clinical leadership in health care, it is essential to reexamine master's nursing education to ensure that educational institutions are meeting the needs of graduate nursing students, consumers, and health care systems. Research supports that the master's-prepared nurse of the future must be proficient in the development and management of accountable care systems using state-of-the-art technology. In addition, interprofessional models show improvement in health care delivery and health outcomes. The current demands in health care that impact nursing education will be discussed, including the movement toward interprofessional education and the broadened expertise, required of master's-prepared nurses working in an era of health care reform. While academic medical centers are actively advancing toward an interprofessional model, the majority of nurses in this country are educated in private and community settings. This article will examine the move toward interprofessional education at a private university, utilizing clinical partnerships to revise the master's program. The goal of this revision is to empower students with the expertise required in today's health care environment to improve the delivery of care. Copyright © 2014 Elsevier Inc. All rights reserved.

Extending the P4P agenda, part 2: how Medicare can reduce waste and improve the care of the chronically ill.

PubMed

Wennberg, John E; Fisher, Elliott S; Skinner, Jonathan S; Bronner, Kristen K

2007-01-01

The care of Americans with severe chronic illnesses is disorganized, unnecessarily costly, and undisciplined by sound clinical science. The federal government should invest in a crash program to improve the scientific basis of managing chronic illness, and the Centers for Medicare and Medicaid Services (CMS) should extend its pay-for-performance (P4P) agenda to ensure that within ten years all Americans with severe chronic illnesses have access to accountable health care organizations providing evidence-based prospective care. This paper recommends a strategy for achieving this goal.

Analysis of the costs and quality of cardiovascular care in oncological monitoring.

PubMed

Costa, Élide Sbardellotto Mariano da; Hyeda, Adriano

2016-11-01

To analyze the health care costs specifically related to cardiovascular diseases, which were spent by patients of a private healthcare provider in southern Brazil, after their diagnosis of cancer. We developed an observational, cross-sectional, retrospective study, with a qualitative-quantitative strategy, through the activity of analytical internal audit of medical accounts. 860 accounts from 2012 to 2015 were analyzed, 73% referred to female users, with average age of 62.38 years, and a total direct cost of BRL 241,103.72. There was prevalence of 37% of breast cancer, 15% of prostate cancer and 9% of colon cancer. In relation to the cardiovascular care, 44% were consultations, 44% were complementary exams, 10% were emergency care, and 3% were hospitalizations. Regarding the health care costs with cardiovascular services, higher costs were in hospitalizations (51%), followed by complementary exams (37%), consultations (8%) and emergency care (4%). The cancer survivors commonly use health care in other specialties such as cardiology, and the main cost refers to hospitalization. It is recommended to invest in prevention (consultation and complementary exam) as well as in programs of chronic disease management to reduce costs and improve the quality of health care.

Early Impact of Medicare Accountable Care Organizations on Inpatient Surgical Spending.

PubMed

Nathan, Hari; Thumma, Jyothi R; Ryan, Andrew M; Dimick, Justin B

2018-05-16

To evaluate whether hospital participation in accountable care organizations (ACOs) is associated with reduced Medicare spending for inpatient surgery. ACOs have proliferated rapidly and now cover more than 32 million Americans. Medicare Shared Savings Program (MSSP) ACOs have shown modest success in reducing medical spending. Whether they have reduced surgical spending remains unknown. We used 100% Medicare claims from 2010 to 2014 for patients aged 65 to 99 years undergoing 6 common elective surgical procedures [abdominal aortic aneurysm (AAA) repair, colectomy, coronary artery bypass grafting (CABG), hip or knee replacement, or lung resection]. We compared total Medicare payments for 30-day surgical episodes, payments for individual components of care (index hospitalization, readmissions, physician services, and postacute care), and clinical outcomes for patients treated at MSSP ACO hospitals versus matched controls at non-ACO hospitals. We accounted for preexisting trends independent of ACO participation using a difference-in-differences approach. Among 341,675 patients at 427 ACO hospitals and 1,024,090 matched controls at 1531 non-ACO hospitals, patient and hospital characteristics were well-balanced. Average baseline payments were similar at ACO versus non-ACO hospitals. ACO participation was not associated with reductions in total Medicare payments [difference-in-differences estimate=-$72, confidence interval (CI95%): -$228 to +$84] or individual components of payments. ACO participation was also not associated with clinical outcomes. Duration of ACO participation did not affect our estimates. Although Medicare ACOs have had success reducing spending for medical care, they have not had similar success with surgical spending. Given that surgical care accounts for 30% of total health care costs, ACOs and policymakers must pay greater attention to reducing surgical expenditures.

Being accountable for care of the poor. CHA's social accountability budget helps facilities keep track of charitable activity.

PubMed

Trocchio, J; Eckels, T

1989-06-01

The Catholic Health Association's social accountability budget is a set of tools to help Catholic healthcare facilities plan for, administer, and report benefits provided to their communities, especially the poor. It defines a full roster of community benefits that a healthcare organization may provide. The benefits fall into three major categories: activities and services, policies and procedures, and community leadership. The social accountability budget also presents guidelines for assessing the facility's existing services, activities, policies, and procedures and discusses how the facility can conduct or be part of a community needs assessment. Information collected through this assessment is used in the planning and budgeting processes. This ensures that uncompensated care and charitable services receive consideration along with traditional planning and budgeting items. Additional guidelines show the facility how to track and measure its services to the community. The final step, often absent from Catholic healthcare facilities' programs, is reporting community benefits.

National Health Expenditures, 19801

PubMed Central

Gibson, Robert M.; Waldo, Daniel R.

1981-01-01

The United States spent an estimated $247 billion for health care in 1980 (Figure 1), an amount equal to 9.4 percent of the Gross National Product (GNP). Highlights of the figures that underlie this estimate include the following: Health care expenditures in 1980 accelerated at a time when the economy as a whole exhibited sluggish growth. The 9.4 percent share of the GNP was a dramatic increase from the 8.9 percent share in 1979.Health care expenditures amounted to $1,067 per person in 1980 (Table 1). Of that amount, $450, or 42.2 percent, came from public funds.Expenditures for health care included $64.9 billion in premiums to private health insurance, $70.9 billion in Federal payments, and $33.3 billion in State and local government funds (Table 2).Hospital care accounted for 40.3 percent of total health care spending in 1980 (Table 3). These expenditures increased 16.2 percent between 1979 and 1980, to a level of $99.6 billion.Spending for the services of physicians increased 14.5 percent to $46.6 billion, 18.9 percent of all health care spending.All third parties combined—private health insurers, governments, philanthropists, and industry—financed 67.6 percent of the $217.9 billion spent for personal health care in 1980 (Table 4), ranging from 90.9 percent of hospital care services to 62.7 percent of physicians' services and 38.5 percent of the remainder (Table 5).Direct payments by consumers reached $70.6 billion in 1980 (Table 6). This accounted for 32.4 percent of all personal health care expenses.Outlays for health care benefits by the Medicare and Medicaid programs totaled $60.6 billion, including $35.8 billion for hospital care. The two programs combined to pay for 27.8 percent of all personal health care in the nation (Table 7). PMID:10309470

National Health Expenditures, 19811

PubMed Central

Gibson, Robert M.; Waldo, Daniel R.

1982-01-01

The United States spent an estimated $287 billion for health care in 1981 (Figure 1), an amount equal to 9.8 percent of the Gross National Product (GNP). Highlights of the figures that underly this estimate include the following: Health care expenditures continued to grow at a rapid rate in 1981, at a time when the economy as a whole exhibited sluggish growth. The 9.8 percent share of the GNP was a dramatic increase from the 8.9 percent share seen just two years earlier.Health care expenditures amounted to $1,225 per person in 1981 (Table 1). Of that amount, $524, or 42.7 percent, came from public funds.Hospital care accounted for 41.2 percent of total health care spending in 1981 (Table 2). These expenditures increased 17.5 percent from 1980, to a level of $118 billion.Spending for the services of physicians increased 16.9 percent to $55 billion—19.1 percent of all health care spending.Public sources provided 42.7 percent of the money spent on health in 1981, including Federal payments of $84 billion and $39 billion in State and local government funds (Table 3).All third parties combined—private health insurers, governments, private charities, and Industry—financed 67.9 percent of the $255 billion in personal health care in 1981 (Table 4), covering 89.2 percent of hospital care services, 62.1 percent of physicians' services, and 41.3 percent of the remainder (Table 5).Direct patient payments for health care reached $82 billion in 1981, accounting for 32.1 percent of all personal health care expenses (Table 6). Consumers and their employers paid another $73 billion in premiums to private health insurers, $67 billion of which was returned in the form of benefits.Outlays for health care benefits by the Medicare and Medicaid programs totaled $73 billion, including $42 billion for hospital care. The two programs combined paid for 28.6 percent of all personal health care in the nation (Table 7). PMID:10309718

An enrichment program for South Carolina high school students interested in future biomedical science professions.

PubMed

McLean, A H; Gibbs, T; Sugimoto, T; Altekruse, J M

1983-06-01

The Biomedical Sciences Program of the University of South Carolina intends to increase the number of qualified, economically disadvantaged minority students graduating from educational programs that lead to careers in the health field. The objective is to provide students with an overview of the health care delivery system in the United States and to acquaint students with a wide range of health care occupations and opportunities in the health care field. Experience-based learning, through site visits to different health care centers, is used in this program.In 1981, 100 ninth-grade students from rural school districts in South Carolina were recruited to participate in the program from 1981 through 1985. To assist in evaluation of the summer program, each student completed a self-administered questionnaire composed of questions related to background information and a pre-test covering factual material derived from information provided by visits to health care delivery agencies. At the completion of the summer program, the same test (excluding the collection of background material) was administered as a post-test.Of the 113 students who took the pre-test, 89 students also took the post-test. The decrease in students was accounted for by early withdrawal from the summer program or conflicts in scheduled events. Of the post-test group, 75 (84.3 percent) were nonwhite and 14 (15.7 percent) were white. The sex distribution was 60 women (67.4 percent) and 29 men (32.6 percent).Follow-up on academic advancement and career development progress is planned for each student over the next five years.

The role of disease management in pay-for-performance programs for improving the care of chronically ill patients.

PubMed

Beich, Jeff; Scanlon, Dennis P; Ulbrecht, Jan; Ford, Eric W; Ibrahim, Ibrahim A

2006-02-01

To date, pay-for-performance programs targeting the care of persons with chronic conditions have primarily been directed at physicians and provide an alternative to health plan-sponsored chronic disease management (DM) programs. Both approaches require similar infrastructure, and each has its own advantages and disadvantages for program implementation. Pay-for-performance programs use incentives based on patient outcomes; however, an alternative system might incorporate measures of structure and process. Using a conceptual framework, the authors explore the variation in 50 diabetes DM programs using data from the 2002 National Business Coalition on Health's eValue8 Request for Information (RFI). The authors raise issues relevant to the assignment of accountability for patient outcomes to either health plans or physicians. They analyze the association between RFI scores measuring structures and processes, and HEDIS diabetes intermediate outcome measures. Finally, the strengths and weaknesses of using the RFI scores as an alternative metric for pay-for-performance programs are discussed.

Workplace Financial Wellness Programs Help Employees Manage Health Care Changes.

PubMed

Meyer, Cynthia; Smith, Michael C

Employers and employees are navigating major changes in health insurance benefits, including the move to high-deductible health plans in conjunction with health savings accounts (HSAs). The HSA offers unique benefits that could prove instrumental in helping workers both navigate current health care expenses and build a nest egg for much larger health care costs in retirement. Yet employees often don't understand the HSA and how to best use it. How can employers help employees make wise benefits choices that work for their personal financial circumstances?

42 CFR 438.6 - Contract requirements.

Code of Federal Regulations, 2012 CFR

2012-10-01

...) MEDICAL ASSISTANCE PROGRAMS MANAGED CARE General Provisions § 438.6 Contract requirements. (a) Regional...) Terminology. As used in this paragraph, the following terms have the indicated meanings: (i) Actuarially sound... adjustments to account for factors such as medical trend inflation, incomplete data, MCO, PIHP, or PAHP...

42 CFR 438.6 - Contract requirements.

Code of Federal Regulations, 2011 CFR

2011-10-01

...) MEDICAL ASSISTANCE PROGRAMS MANAGED CARE General Provisions § 438.6 Contract requirements. (a) Regional...) Terminology. As used in this paragraph, the following terms have the indicated meanings: (i) Actuarially sound... adjustments to account for factors such as medical trend inflation, incomplete data, MCO, PIHP, or PAHP...

42 CFR 438.6 - Contract requirements.

Code of Federal Regulations, 2010 CFR

2010-10-01

...) MEDICAL ASSISTANCE PROGRAMS MANAGED CARE General Provisions § 438.6 Contract requirements. (a) Regional...) Terminology. As used in this paragraph, the following terms have the indicated meanings: (i) Actuarially sound... adjustments to account for factors such as medical trend inflation, incomplete data, MCO, PIHP, or PAHP...

Better big data.

PubMed

Al Kazzi, Elie S; Hutfless, Susan

2015-01-01

By 2018, Medicare payments will be tied to quality of care. The Centers for Medicare and Medicaid Services currently use quality-based metric for some reimbursements through their different programs. Existing and future quality metrics will rely on risk adjustment to avoid unfairly punishing those who see the sickest, highest-risk patients. Despite the limitations of the data used for risk adjustment, there are potential solutions to improve the accuracy of these codes by calibrating data by merging databases and compiling information collected for multiple reporting programs to improve accuracy. In addition, healthcare staff should be informed about the importance of risk adjustment for quality of care assessment and reimbursement. As the number of encounters tied to value-based reimbursements increases in inpatient and outpatient care, coupled with accurate data collection and utilization, the methods used for risk adjustment could be expanded to better account for differences in the care delivered in diverse settings.

Dynamic modeling of cost-effectiveness of rotavirus vaccination, Kazakhstan.

PubMed

Freiesleben de Blasio, Birgitte; Flem, Elmira; Latipov, Renat; Kuatbaeva, Ajnagul; Kristiansen, Ivar Sønbø

2014-01-01

The government of Kazakhstan, a middle-income country in Central Asia, is considering the introduction of rotavirus vaccination into its national immunization program. We performed a cost-effectiveness analysis of rotavirus vaccination spanning 20 years by using a synthesis of dynamic transmission models accounting for herd protection. We found that a vaccination program with 90% coverage would prevent ≈880 rotavirus deaths and save an average of 54,784 life-years for children <5 years of age. Indirect protection accounted for 40% and 60% reduction in severe and mild rotavirus gastroenteritis, respectively. Cost per life year gained was US $18,044 from a societal perspective and US $23,892 from a health care perspective. Comparing the 2 key parameters of cost-effectiveness, mortality rates and vaccine cost at

Clinical Nurse Specialists Guide Staff Nurses to Promote Practice Accountability Through Peer Review.

PubMed

Semper, Julie; Halvorson, Betty; Hersh, Mary; Torres, Clare; Lillington, Linda

2016-01-01

The aim of the study was to describe the clinical nurse specialist role in developing and implementing a staff nurse education program to promote practice accountability using peer review principles. Peer review is essential for professional nursing practice demanding a significant culture change. Clinical nurse specialists in a Magnet-designated community hospital were charged with developing a staff nurse peer review education program. Peer review is a recognized mechanism of professional self-regulation to ensure delivery of quality care. The American Nurses Association strongly urges incorporating peer review in professional nursing practice models. Clinical nurse specialists play a critical role in educating staff nurses about practice accountability. Clinical nurse specialists developed an education program guided by the American Nurses Association's principles of peer review. A baseline needs assessment identified potential barriers and learning needs. Content incorporated tools and strategies to build communication skills, collaboration, practice change, and peer accountability. The education program resulted in increased staff nurse knowledge about peer review and application of peer review principles in practice. Clinical nurse specialists played a critical role in helping staff nurses understand peer review and its application to practice. The clinical nurse specialist role will continue to be important in sustaining the application of peer review principles in practice.

Technical efficiency of women's health prevention programs in Bucaramanga, Colombia: a four-stage analysis.

PubMed

Ruiz-Rodriguez, Myriam; Rodriguez-Villamizar, Laura A; Heredia-Pi, Ileana

2016-10-13

Primary Health Care (PHC) is an efficient strategy to improve health outcomes in populations. Nevertheless, studies of technical efficiency in health care have focused on hospitals, with very little on primary health care centers. The objective of the present study was to use the Data Envelopment Analysis to estimate the technical efficiency of three women's health promotion and disease prevention programs offered by primary care centers in Bucaramanga, Colombia. Efficiency was measured using a four-stage data envelopment analysis with a series of Tobit regressions to account for the effect of quality outcomes and context variables. Input/output information was collected from the institutions' records, chart reviews and personal interviews. Information about contextual variables was obtained from databases from the primary health program in the municipality. A jackknife analysis was used to assess the robustness of the results. The analysis was based on data from 21 public primary health care centers. The average efficiency scores, after adjusting for quality and context, were 92.4 %, 97.5 % and 86.2 % for the antenatal care (ANC), early detection of cervical cancer (EDCC) and family planning (FP) programs, respectively. On each program, 12 of the 21 (57.1 %) health centers were found to be technically efficient; having had the best-practice frontiers. Adjusting for context variables changed the scores and reference rankings of the three programs offered by the health centers. The performance of the women's health prevention programs offered by the centers was found to be heterogeneous. Adjusting for context and health care quality variables had a significant effect on the technical efficiency scores and ranking. The results can serve as a guide to strengthen management and organizational and planning processes related to local primary care services operating within a market-based model such as the one in Colombia.

76 FR 33305 - Medicare Program; Accelerated Development Sessions for Accountable Care Organizations-June 20, 21...

Federal Register 2010, 2011, 2012, 2013, 2014

2011-06-08

... as accelerated development sessions (ADSs) instead of accelerated development learning sessions... Sessions'' is corrected to read ``Accelerated Development Learning Sessions''. (2) In the SUMMARY, the... first of four accelerated development learning sessions (ADLSs) that will provide executives with the...

Understanding dual enrollees' use of Medicare home health services: the effects of differences in Medicaid home care programs.

PubMed

Kenney, G; Rajan, S

2000-01-01

Both the Medicare and Medicaid programs have experienced considerable growth in spending on home care in recent years. As policymakers adopt measures (such as those legislated in the Balanced Budget Act of 1997) to curb the rate of spending growth on home care services, it is important to understand interactions between the Medicare and Medicaid home care programs in serving the dually enrolled population. This study examines the potential effects of the Medicaid home care program on Medicare home health utilization using multivariate models. The study relied on data from the Health Care Financing Administration's Medicare Current Beneficiary Survey (MCBS), a longitudinal survey of Medicare enrollees. The primary MCBS file used was from Round 1 of the survey, which was fielded between September and December 1991. The unit of analysis was individuals. The authors used descriptive and multivariate methods to explore the relationship between Medicare coverage and state home care program characteristics. Included were variables that have been found to be significant determinants of Medicare home health utilization in other studies as well as variables to indicate the availability and generosity of Medicaid home care services in each state represented in the survey. The findings were consistent with those of previous studies, in that dual enrollees were disproportionate users of Medicare home health services, accounting for only 16% of enrollees but receiving 40% of all visits. In addition, lower levels of Medicare home health use were observed in states with relatively higher Medicaid spending on home health and personal care services, but this relationship appeared to be heavily dominated by the inclusion of enrollees living in New York State. When individuals from New York were excluded from the analysis, we found a negative but statistically significant relationship between Medicaid outlays on home health and personal care services and Medicare home health utilization. Because the Medicare and Medicaid programs are interconnected through the sizable dual enrollee population, changes in one program are likely to have ramifications for the other. This study presents another step in exploring how the two programs interact and emphasizes the fact that costs can be shifted between the two programs as policy changes are made to control the rate of home care spending growth.

Reflections on forty years of rendering medical care to women.

PubMed Central

Stuermer, V. M.

1995-01-01

This paper provides a brief account of events leading to the establishment of the constitutional right to privacy in the case known as Griswold vs. State of Connecticut. It also discusses changes in the training of residents in the Department of Obstetrics and Gynecology at Yale University School of Medicine and the evolving role of women in the residency program. It concludes with reflections and speculations about new directions in medical care for women. PMID:8903042

Toxic Substances: The Extent of Lead Hazards in Child Care Facilities and Schools Is Unknown. Report to the Chairman, Subcommittee on Health and the Environment, Committee on Energy and Commerce, House of Representatives.

ERIC Educational Resources Information Center

General Accounting Office, Washington, DC. Resources, Community, and Economic Development Div.

This report by the United States General Accounting Office discusses federal, state, and local programs and activities to inspect for and address lead hazards in the nation's child care facilities and schools, and existing information on the extent and treatment of lead hazards in these facilities and schools. Federal agencies conduct numerous…

National health expenditures, 1984

PubMed Central

Levit, Katharine R.; Lazenby, Helen; Waldo, Daniel R.; Davidoff, Lawrence M.

1985-01-01

Growth in health care expenditures slowed to 9.1 percent in 1984, the smallest increase in expenditures in 19 years. Economic forces and emerging structural changes within the health sector played a role in slowing growth. Of the $1,580 per person spent for health care in 1984, 41 percent was financed by public programs; 31 percent by private health insurance; and the remainder by other private sources. Together, Medicare and Medicaid accounted for 27 percent of all health spending. PMID:10311395

Planning a study abroad clinical experience.

PubMed

Wright, Dolores J

2010-05-01

Not only is globalization expanding areas of human activity, it is also influencing the variety of educational offerings in universities. Therefore, globalization must be considered by nurse educators as they reevaluate ways of preparing nursing students to meet the health care needs of populations they currently serve and will care for in the future. Study abroad programs have been encouraged to be part of the college experience in the United States for more than 30 years; however, these programs have been relatively lacking in nursing education. Most of the study abroad programs described in the nursing literature are research-based or first-person accounts of an experience and provide little information about planning a study abroad program. This article describes a study abroad learning experience for senior nursing students and discusses the issues such as student selection, student safety, and available clinical experiences that need to be considered before undertaking such an endeavor.

The gap between coverage and care-what can Canadian paediatricians do about access to health services for refugee claimant children?

PubMed

Rink, N; Muttalib, F; Morantz, G; Chase, L; Cleveland, J; Rousseau, C; Li, P

2017-11-01

In June 2012, the government of Canada severely restricted the scope of the Interim Federal Health Program that had hitherto provided coverage for the health care needs of refugee claimants. The Quebec government decided to supplement coverage via the provincial health program. Despite this, we hypothesized that refugee claimant children in Montreal would continue to experience significant difficulties in accessing basic health care. (1) Report the narrative experiences of refugee claimant families who were denied health care services in Montreal following June 2012, (2) describe the predominant barriers to accessing health care services and understanding their impact using thematic analysis and (3) derive concrete recommendations for child health care providers to improve access to care for refugee claimant children. Eleven parents recruited from two sites in Montreal participated in semi-structured interviews designed to elicit a narrative account of their experiences seeking health care. Interviews were recorded, transcribed, coded using NVivo software and subjected to thematic analysis. Thematic analysis of the data revealed five themes concerning barriers to health care access: lack of continuous health coverage, health care administrators/providers' lack of understanding of Interim Federal Health Program coverage, refusal of services or fees charged, refugee claimants' lack of understanding about health care rights and services and language barriers, and four themes concerning the impact of denial of care episodes: potential for adverse health outcomes, psychological distress, financial burden and social stigma. We propose eight action points for advocacy by Canadian paediatricians to improve access to health care for refugee claimant children in their communities and institutions.

Outpatient care programs of mental health organizations, United States, 1988.

PubMed

Redick, R W; Witkin, M J; Atay, J E; Manderscheid, R W

1991-09-01

In 1988, 2,989 (60 percent) of the 4,961 mental health organizations in the United States (including the territories) offered outpatient care programs. A total of 5.8 million patient care episodes were generated by these organized outpatient programs. These episodes included 3.1 million outpatient additions, produced 54 million outpatient visits, and represented 67 percent of all patient care episodes in mental health organizations in 1988. Although the number of mental health organizations with outpatient care programs increased by less than one percent between 1986 and 1988, the number of outpatient additions showed an 11 percent gain during this period. Multiservice mental health organizations were the primary locus of outpatient care in 1988, accounting for 41 percent of the 2,989 mental health organizations providing this care. Ranking next in this respect, were free-standing psychiatric outpatient clinics, and the separate psychiatric outpatient services in non-Federal general hospitals, with 25 and 16 percent, respectively, of the total outpatient care programs. In general, these three organization types had similar rankings with respect to the volume of the outpatient caseload. By definition, all of the freestanding psychiatric outpatient clinics provided outpatient care, and almost all of the VA mental health programs and multiservice mental health organizations also offered this care (99 and 92 percent, respectively). In contrast, psychiatric outpatient care was available in only 37 percent of non-Federal general hospitals with separate psychiatric services, 36 percent of private psychiatric hospitals, 29 percent of State mental hospitals, and 22 percent of RTCs for emotionally disturbed children. Outpatient care was available in mental health organizations in all States in 1988, with every State having at least two or more organization types providing this service. In general, the most populous States had the largest number and the greatest variety of mental health organizations with outpatient care programs. Of the 2.87 million clients receiving outpatient care in mental health organizations at the end of 1988, 23 percent were under 18 years of age, 68 percent were 18 to 64, and 9 percent were 65 and older. Male outpatient clients slightly outnumbered female clients. The majority (77 percent) of the outpatient clients were white, with blacks representing 21 percent; native Americans and Asians/Pacific Islanders, the remaining two percent. Eleven percent of the total client population were reported to be of Hispanic origin.(ABSTRACT TRUNCATED AT 400 WORDS)

Episode-Based Payment and Direct Employer Purchasing of Healthcare Services: Recent Bundled Payment Innovations and the Geisinger Health System Experience.

PubMed

Slotkin, Jonathan R; Ross, Olivia A; Newman, Eric D; Comrey, Janet L; Watson, Victoria; Lee, Rachel V; Brosious, Megan M; Gerrity, Gloria; Davis, Scott M; Paul, Jacquelyn; Miller, E Lynn; Feinberg, David T; Toms, Steven A

2017-04-01

One significant driver of the disjointed healthcare often observed in the United States is the traditional fee-for-service payment model which financially incentivizes the volume of care delivered over the quality and coordination of care. This problem is compounded by the wide, often unwarranted variation in healthcare charges that purchasers of health services encounter for substantially similar episodes of care. The last 10 years have seen many stakeholder organizations begin to experiment with novel financial payment models that strive to obviate many of the challenges inherent in customary quantity-based cost paradigms. The Patient Protection and Affordable Care Act has allowed many care delivery systems to partner with Medicare in episode-based payment programs such as the Bundled Payments for Care Improvement (BPCI) initiative, and in patient-based models such as the Medicare Shared Savings Program. Several employer purchasers of healthcare services are experimenting with innovative payment models to include episode-based bundled rate destination centers of excellence programs and the direct purchasing of accountable care organization services. The Geisinger Health System has over 10 years of experience with episode-based payment bundling coupled with the care delivery reengineering which is integral to its ProvenCare® program. Recent experiences at Geisinger have included participation in BPCI and also partnership with employer-purchasers of healthcare through the Pacific Business Group on Health (representing Walmart, Lowe's, and JetBlue Airways). As the shift towards value-focused care delivery and patient experience progresses forward, bundled payment arrangements and direct purchasing of healthcare will be critical financial drivers in effecting change. Copyright © 2017 by the Congress of Neurological Surgeons.

Risk Adjustment May Lessen Penalties On Hospitals Treating Complex Cardiac Patients Under Medicare's Bundled Payments.

PubMed

Markovitz, Adam A; Ellimoottil, Chandy; Sukul, Devraj; Mullangi, Samyukta; Chen, Lena M; Nallamothu, Brahmajee K; Ryan, Andrew M

2017-12-01

To reduce variation in spending, Medicare has considered implementing a cardiac bundled payment program for acute myocardial infarction and coronary artery bypass graft. Because the proposed program does not account for patient risk factors when calculating hospital penalties or rewards ("reconciliation payments"), it might unfairly penalize certain hospitals. We estimated the impact of adjusting for patients' medical complexity and social risk on reconciliation payments for Medicare beneficiaries hospitalized for the two conditions in the period 2011-13. Average spending per episode was $29,394. Accounting for medical complexity substantially narrowed the gap in reconciliation payments between hospitals with high medical severity (from a penalty of $1,809 to one of $820, or a net reduction of $989), safety-net hospitals (from a penalty of $217 to one of $87, a reduction of $130), and minority-serving hospitals (from a penalty of $70 to a reward of $56, an improvement of $126) and their counterparts. Accounting for social risk alone narrowed these gaps but had minimal incremental effects after medical complexity was accounted for. Risk adjustment may preserve incentives to care for patients with complex conditions under Medicare bundled payment programs.

42 CFR § 512.307 - Subsequent calculations.

Code of Federal Regulations, 2010 CFR

2017-10-01

... (CONTINUED) HEALTH CARE INFRASTRUCTURE AND MODEL PROGRAMS EPISODE PAYMENT MODEL Pricing and Payment § 512.307... the initial NPRA, using claims data and non-claims-based payment data available at that time, to account for final claims run-out, final changes in non-claims-based payment data, and any additional...

Prenatal nutrition services: a cost analysis.

PubMed

Splett, P L; Caldwell, H M; Holey, E S; Alton, I R

1987-02-01

The scarcity of information about program costs in relation to quality care prompted a cost analysis of prenatal nutrition services in two urban settings. This study examined prenatal nutrition services in terms of total costs, per client costs, per visit costs, and cost per successful outcome. Standard cost-accounting principles were used. Outcome measures, based on written quality assurance criteria, were audited using standard procedures. In the studied programs, nutrition services were delivered for a per client cost of $72 in a health department setting and $121 in a hospital-based prenatal care program. Further analysis illustrates that total and per client costs can be misleading and that costs related to successful outcomes are much higher. The three levels of cost analysis reported provide baseline data for quantifying the costs of providing prenatal nutrition services to healthy pregnant women. Cost information from these cost analysis procedures can be used to guide adjustments in service delivery to assure successful outcomes of nutrition care. Accurate cost and outcome data are necessary prerequisites to cost-effectiveness and cost-benefit studies.

Health Care Financing Administration--Medicare and Medicaid programs; protection of patients' funds. Final regulation.

PubMed

1980-07-24

This rule sets forth expanded standards for protection of personal funds of patients in skilled nursing facilities (SNFs) and intermediate care facilities (ICFs) that participate in the Medicare or Medicaid programs. The changes are required for SNFs by Section 21(a) of Pub. L. 95-142, the Medicare-Medcaid Anti-Fraud and Abuse Amendments of 1977, and for ICFs by Section 8(c) of Pub. L. 95-292, the End-Stage Renal Disease Amendments of 1978. The intent is to safeguard patient funds from misuse by facilities, and to assure that personal funds held by the the facilities are fully accounted for and made available to patients when they need or want them.

Care 3 phase 2 report, maintenance manual

NASA Technical Reports Server (NTRS)

Bryant, L. A.; Stiffler, J. J.

1982-01-01

CARE 3 (Computer-Aided Reliability Estimation, version three) is a computer program designed to help estimate the reliability of complex, redundant systems. Although the program can model a wide variety of redundant structures, it was developed specifically for fault-tolerant avionics systems--systems distinguished by the need for extremely reliable performance since a system failure could well result in the loss of human life. It substantially generalizes the class of redundant configurations that could be accommodated, and includes a coverage model to determine the various coverage probabilities as a function of the applicable fault recovery mechanisms (detection delay, diagnostic scheduling interval, isolation and recovery delay, etc.). CARE 3 further generalizes the class of system structures that can be modeled and greatly expands the coverage model to take into account such effects as intermittent and transient faults, latent faults, error propagation, etc.

Designing payment for Collaborative Care for Depression in primary care.

PubMed

Bao, Yuhua; Casalino, Lawrence P; Ettner, Susan L; Bruce, Martha L; Solberg, Leif I; Unützer, Jürgen

2011-10-01

To design a bundled case rate for Collaborative Care for Depression (CCD) that aligns incentives with evidence-based depression care in primary care. A clinical information system used by all care managers in a randomized controlled trial of CCD for older primary care patients. We conducted an empirical investigation of factors accounting for variation in CCD resource use over time and across patients. CCD resource use at the patient-episode and patient-month levels was measured by number of care manager contacts and direct patient contact time and analyzed with count data (Poisson or negative binomial) models. Episode-level resource use varies substantially with patient's time in the program. Monthly use declines sharply in the first 6 months regardless of treatment response or remission status, but it remains stable afterwards. An adjusted episode or monthly case rate design better matches payment with variation in resource use compared with a fixed design. Our findings lend support to an episode payment adjusted by number of months receiving CCD and a monthly payment adjusted by the ordinal month. Nonpayment tools including program certification and performance evaluation and reward systems are needed to fully align incentives. © Health Research and Educational Trust.

Integration Strategies of Pharmacists in Primary Care-Based Accountable Care Organizations: A Report from the Accountable Care Organization Research Network, Services, and Education.

PubMed

Joseph, Tina; Hale, Genevieve M; Eltaki, Sara M; Prados, Yesenia; Jones, Renee; Seamon, Matthew J; Moreau, Cynthia; Gernant, Stephanie A

2017-05-01

The accountable care organization (ACO) is an innovative health care delivery model centered on value-based care. ACOs consisting of primary care providers are increasingly becoming commonplace in practice; however, medication management remains suboptimal. As experts in medication management, pharmacists perform direct patient care and assist in the transition from one provider to another, which places them in an ideal position to manage multiple aspects of patient care. Pharmacist-provided care has been shown to reduce drug expenditures, hospital readmissions, length of stay, and emergency department visits. Although pharmacists have become key team members of interdisciplinary teams within traditional care settings, their role has often been overlooked in the primary care-based ACO. In 2015, Nova Southeastern University College of Pharmacy founded the Accountable Care Organization Research Network, Services, and Education (ACORN SEED), a team of pharmacy practice faculty dedicated to using innovative approaches to patient care, while providing unique learning experiences for pharmacy students by partnering with ACOs in the South Florida region. Five opportunities are presented for pharmacists to improve medication use specifically in primary care-based ACOs: medication therapy management, annual wellness visits, chronic disease state management, chronic care management, and transitions of care. Several challenges and barriers that prevent the full integration of pharmacists into primary care-based ACOs include lack of awareness of pharmacist roles in primary care; complex laws and regulations surrounding clinical protocols, such as collaborative practice agreements; provider status that allows compensation for pharmacist services; and limited access to medical records. By understanding and maximizing the role of pharmacists, several opportunities exist to better manage the medication-use process in value-based care settings. As more organizations realize benefits and overcome barriers to the integration of pharmacists into patient care, programs involve pharmacists will become an increasingly common approach to improve outcomes and reduce the total cost of care and will improve the financial viability of primary care-based ACOs. No outside funding supported this research. The authors report no conflicts of interest related to this manuscript. Study concept and design were contributed by Joseph, Hale, and Eltaki, with assistance from the other authors. Prados and Jones took the lead in data collection and data interpretation and analysis, with assistance from the other authors. The manuscript was written primarily by Joseph and Hale, along with the other authors, and revised primarily by Seamon and Gernant, along with the other authors.

Economic analysis of an internet-based depression prevention intervention.

PubMed

Ruby, Alexander; Marko-Holguin, Monika; Fogel, Joshua; Van Voorhees, Benjamin W

2013-09-01

The transition through adolescence places adolescents at increased risk of depression, yet care-seeking in this population is low, and treatment is often ineffective. In response, we developed an Internet-based depression prevention intervention (CATCH-IT) targeting at-risk adolescents. We explore CATCH-IT program costs, especially safety costs, in the context of an Accountable Care Organization as well as the perceived value of the Internet program. Total and per-patient costs of development were calculated using an assumed cohort of a 5,000-patient Accountable Care Organization. Total and per-patient costs of implementation were calculated from grant data and the Medicare Resource-Based Relative Value Scale (RBRVS) and were compared to the willingness-to-pay for CATCH-IT and to the cost of current treatment options. The cost effectiveness of the safety protocol was assessed using the number of safety calls placed and the percentage of patients receiving at least one safety call. The willingness-to-pay for CATCH-IT, a measure of its perceived value, was assessed using post-study questionnaires and was compared to the development cost for a break-even point. We found the total cost of developing the intervention to be USD 138,683.03. Of the total, 54% was devoted to content development with per patient cost of USD 27.74. The total cost of implementation was found to be USD 49,592.25, with per patient cost of USD 597.50. Safety costs accounted for 35% of the total cost of implementation. For comparison, the cost of a 15-session group cognitive behavioral therapy (CBT) intervention aimed at at-risk adolescents was USD 1,632 per patient. Safety calls were successfully placed to 96.4% of the study participants. The cost per call was USD 40.51 with a cost per participant of USD 197.99. The willingness-to-pay for the Internet portion of CATCH-IT had a median of USD 40. The break-even point to offset the cost of development was 3,468 individuals. Developing Internet-based interventions like CATCH-IT appears economically viable in the context of an Accountable Care Organization. Furthermore, while the cost of implementing an effective safety protocol is proportionally high for this intervention, CATCH-IT is still significantly cheaper to implement than current treatment options. Limitations of this research included diminished participation in follow-up surveys assessing willingness-to-pay. IMPLICATIONS FOR HEALTH CARE PROVISION AND USE AND HEALTH POLICIES: This research emphasizes that preventive interventions have the potential to be cheaper to implement than treatment protocols, even before taking into account lost productivity due to illness. Research such as this business application analysis of the CATCH-IT program highlights the importance of supporting preventive medical interventions as the healthcare system already does for treatment interventions. This research is the first to analyze the economic costs of an Internet-based intervention. Further research into the costs and outcomes of such interventions is certainly warranted before they are widely adopted. Furthermore, more research regarding the safety of Internet-based programs will likely need to be conducted before they are broadly accepted.

Attitudes of anesthesiology residents toward critical care medicine training.

PubMed

Durbin, C G; McLafferty, C L

1993-09-01

The number of anesthesiology residents pursuing critical care medicine (CCM) fellowship training has been decreasing in recent years. A significant number of training positions remain unfilled each year. Possible causes of this decline were evaluated by surveying residents regarding their attitudes toward practice and training in CCM. All 38 anesthesiology programs having accredited CCM fellowships were surveyed. Four of these and one program without CCM fellowships were used to develop the survey instrument. Four programs without CCM fellowships and 34 programs with CCM fellowships make up the survey group. Returned were 640 surveys from 37 (97%) programs accounting for over 30% of the possible residents. Resident interest in pursuing CCM training decreased as year of residency increased (P < 0.0001). Residents in programs with little patient care responsibility during intensive care unit (ICU) rotations expressed less interest in CCM training (P < 0.012). The administrative role of the anesthesiology department in the ICU also influenced resident interest (P < 0.014). Written responses to open-ended questions suggested resident concerns with the following: stress of chronic care, financial consequences of additional year of training, ICU call frequency and load, ICU role ambiguity, and shared decision-making in the ICU. A recurring question was, "Are there jobs (outside of academics) for anesthesiologist intensivists?" Most residents knew a CCM anesthesiologist they admired and knew that there were unfilled fellowship positions available. Defining the job market, improving curriculum and teaching, supporting deferment of student loans, and introducing residents and medical students to the ICU earlier may increase the interest in CCM practice among anesthesiology residents.

The effect of managed care on the incomes of primary care and specialty physicians.

PubMed

Simon, C J; Dranove, D; White, W D

1998-08-01

To determine the effects of managed care growth on the incomes of primary care and specialist physicians. Data on physician income and managed care penetration from the American Medical Association, Socioeconomic Monitoring System (SMS) Surveys for 1985 and 1993. We use secondary data from the Area Resource File and U.S. Census publications to construct geographical socioeconomic control variables, and we examine data from the National Residency Matching Program. Two-stage least squares regressions are estimated to determine the effect of local managed care penetration on specialty-specific physician incomes, while controlling for factors associated with local variation in supply and demand and accounting for the potential endogeneity of managed care penetration. The SMS survey is an annual telephone survey conducted by the American Medical Association of approximately one percent of nonfederal, post-residency U.S. physicians. Response rates average 60-70 percent, and analysis is weighted to account for nonresponse bias. The incomes of primary care physicians rose most rapidly in states with higher managed care growth, while the income growth of hospital-based specialists was negatively associated with managed care growth. Incomes of medical subspecialists were not significantly affected by managed care growth over this period. These findings are consistent with trends in postgraduate training choices of new physicians. Evidence is consistent with a relative increase in the demand for primary care physicians and a decline in the demand for some specialists under managed care. Market adjustments have important implications for health policy and physician workforce planning.

Accounting for charity care on a systemwide basis.

PubMed

Peck, T

1988-06-01

The Daughters of Charity National Health System (DCNHS), St. Louis, has developed a systemwide model which formally sets a policy statement, goals, and procedures that enable the 42 DCNHS health-care ministries to effectively serve the poor in their communities on a daily basis, while addressing the long-term challenges of providing charity care for the sick poor. One of the first steps was forming a task force known as the Working Group on Care of the Poor. Its goal was to set the stage for the expansion and accountability of charity care at every level within the new national system. The group outlined these objectives: To identify and recommend several advocacy models. To recommend test models of healthcare delivery for the poor. To recommend strategies for involving the private sector. To develop a method of documenting charity care. To recommend linkage models to jointly provide charity care with related organizations. To gain a firm knowledge of charity care actually provided by the Daughters of Charity After hours of discussions and research, the task force developed a cohesive, workable set of goals and policies that today is helping individual health-care ministries nationwide meet local needs for care of the sick poor. By identifying specific programs and determining how to report charity care in terms of money and services, individual health-care institutions gain insights into their annual operational planning and reporting for the present and the future. This approach ensures that charity care remains in the forefront at every level of planning.

The Impact Of Medicare ACOs On Improving Integration And Coordination Of Physical And Behavioral Health Care.

PubMed

Fullerton, Catherine A; Henke, Rachel M; Crable, Erika L; Hohlbauch, Andriana; Cummings, Nicholas

2016-07-01

The accountable care organization (ACO) model holds the promise of reducing costs and improving the quality of care by realigning payment incentives to focus on health outcomes instead of service volume. One key to managing the total cost of care is improving care coordination for and treatment of people with behavioral health disorders. We examined qualitative data from ninety organizations participating in Medicare ACO demonstration programs from 2012 through 2015 to determine whether and how they focused on behavioral health care. These ACOs had mixed degrees of engagement in improving behavioral health care for their populations. The biggest challenges included a lack of behavioral health care providers, data availability, and sustainable financing models. Nonetheless, we found substantial interest in integrating behavioral health care into primary care across a majority of the ACOs. Project HOPE—The People-to-People Health Foundation, Inc.

The accountability of nonprofit hospitals: lessons from Maryland's community benefit reporting requirements.

PubMed

Gray, Bradford H; Schlesinger, Mark

2009-01-01

Under Internal Revenue Service requirements, nonprofit hospitals will begin filing new community benefit reports in 2010. Maryland has had similar requirements since 2004. This paper, based on interviews at 20 hospitals, describes how Maryland's requirements affected hospitals and their activities. Increases in reported community benefit expenditures since the program began are due to both changes in activities and better data capture. Charity care accounts for one-third of community benefit dollars. A key distinction concerns whether hospitals take an accounting or managerial approach to community benefit. The Maryland experience suggests the issues that will arise when the national requirements are implemented.

The business of pediatric hospital medicine.

PubMed

Percelay, Jack M; Zipes, David G

2014-07-01

Pediatric hospital medicine (PHM) programs are mission driven, not margin driven. Very rarely do professional fee revenues exceed physician billing collections. In general, inpatient hospital care codes reimburse less than procedures, payer mix is poor, and pediatric inpatient care is inherently time-consuming. Using traditional accounting principles, almost all PHM programs will have a negative bottom line in the narrow sense of program costs and revenues generated. However, well-run PHM programs contribute positively to the bottom line of the system as a whole through the value-added services hospitalists provide and hospitalists' ability to improve overall system efficiency and productivity. This article provides an overview of the business of hospital medicine with emphasis on the basics of designing and maintaining a program that attends carefully to physician staffing (the major cost component of a program) and physician charges (the major revenue component of the program). Outside of these traditional calculations, resource stewardship is discussed as a way to reduce hospital costs in a capitated or diagnosis-related group reimbursement model and further improve profit-or at least limit losses. Shortening length of stay creates bed capacity for a program already running at capacity. The article concludes with a discussion of how hospitalists add value to the system by making other providers and other parts of the hospital more efficient and productive. Copyright 2014, SLACK Incorporated.

Accountable care organization readiness and academic medical centers.

PubMed

Berkowitz, Scott A; Pahira, Jennifer J

2014-09-01

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

The Cultural Meaning of Cardiac Illness and Self-Care Among Lebanese Patients With Coronary Artery Disease.

PubMed

Dumit, Nuhad Yazbik; Magilvy, Joan Kathy; Afifi, Rima

2016-07-01

Cardiac disease is the leading cause of death in Lebanon, accounting for 22% to 26% of total deaths in the country. A thorough understanding of perceptions of cardiac illness and related self-care management is critical to the development of secondary prevention programs that are specific to the Lebanese culture. To explore the cultural perceptions of cardiac illness and the associated meaning of self-care among Lebanese patients. Using a qualitative descriptive method, semistructured interviews were conducted with a purposive sample of 15 Lebanese cardiac patients recruited from a medical center in Beirut, Lebanon. The qualitative descriptive analysis yielded one overarching and two other themes describing perceptions of cardiac illness and self-care within the Lebanese cultural context. The overarching cultural theme was, "Lebanese cardiac patients were unfamiliar with the term concept and meaning of self-care." Lebanese cardiac patients thanked God and accepted their fate (Theme I). The participants considered their cardiac incident a life or death warning (Theme II). Health care providers need to consider patients' cultural perception of illness while planning and evaluating cardiac self-care programs. © The Author(s) 2015.

Medical Care Provided Under California's Workers' Compensation Program: Effects of the Reforms and Additional Opportunities to Improve the Quality and Efficiency of Care.

PubMed

Wynn, Barbara O; Timbie, Justin W; Sorbero, Melony E

2011-01-01

Since 2004, significant changes have been made to the California workers' compensation (WC) system. The Commission on Health and Safety and Workers' Compensation (CHSWC) asked the RAND Corporation to examine the impact that these changes have on the medical care provided to injured workers. This study synthesizes findings from interviews and available information regarding the implementation of the changes affecting WC medical care and identifies areas in which additional changes might increase the quality and efficiency of care delivered under the WC system. To improve incentives for efficiently providing medically appropriate care, California should revise its fee schedule allowances for services provided by hospitals to inpatients, freestanding ambulatory surgery centers, and physicians, create nonmonetary incentives for providing medically appropriate care in the medical provider network (MPN) context through more-selective contracting with providers and reducing medical review requirements for high-performing physicians; reduce incentives for inappropriate prescribing practices by curtailing in-office physician dispensing; and implement pharmacy benefit network regulations. To increase accountability for performance, California should revise the MPN certification process to place accountability for meeting MPN standards on the entity contracting with the physician network; strengthen Division of Workers' Compensation (DWC) authorities to provide intermediate sanctions for failure to comply with MPN requirements; and modify the Labor Code to remove payers and MPNs from the definition of individually identifiable data so that performance on key measures can be publicly available. To facilitate monitoring and oversight, California should provide DWC with more flexibility to add needed data elements to medical data reporting and provide penalties for a claim administrator failing to comply with the data-reporting requirements; require that medical cost-containment expenses be reported by category of cost; compile information on the types of medical services that are subject to UR denials and expedited hearings; and expand ongoing monitoring of system performance. Finally, to increase administrative efficiency, California should use an external medical review organization to review medical-necessity determinations, and it should explore best practices of other WC programs and health programs in carrying out medical cost-containment activities.

A taxonomy of hospitals participating in Medicare accountable care organizations.

PubMed

Bazzoli, Gloria J; Harless, David W; Chukmaitov, Askar S

2017-03-03

Medicare was an early innovator of accountable care organizations (ACOs), establishing the Medicare Shared Savings Program (MSSP) and Pioneer programs in 2012-2013. Existing research has documented that ACOs bring together an array of health providers with hospitals serving as important participants. Hospitals vary markedly in their service structure and organizational capabilities, and thus, one would expect hospital ACO participants to vary in these regards. Our research identifies hospital subgroups that share certain capabilities and competencies. Such research, in conjunction with existing ACO research, provides deeper understanding of the structure and operation of these organizations. Given that Medicare was an initiator of the ACO concept, our findings provide a baseline to track the evolution of ACO hospitals over time. Hierarchical clustering methods are used in separate analyses of MSSP and Pioneer ACO hospitals. Hospitals participating in ACOs with 2012-2013 start dates are identified through multiple sources. Study data come from the Centers for Medicare and Medicaid Services, American Hospital Association, and Health Information and Management Systems Society. Five-cluster solutions were developed separately for the MSSP and Pioneer hospital samples. Both the MSSP and Pioneer taxonomies had several clusters with high levels of health information technology capabilities. Also distinct clusters with strong physician linkages were present. We examined Pioneer ACO hospitals that subsequently left the program and found that they commonly had low levels of ambulatory care services or health information technology. Distinct subgroups of hospitals exist in both the MSSP and Pioneer programs, suggesting that individual hospitals serve different roles within an ACO. Health information technology and physician linkages appear to be particularly important features in ACO hospitals. ACOs need to consider not only geographic and service mix when selecting hospital participants but also their vertical integration features and management competencies.

Understanding Patient Satisfaction Ratings for Radiology Services

PubMed Central

Lang, Elvira V.; Yuh, William T.C.; Kelly, Ronda; Macadam, Luke; Potts, Richard; Mayr, Nina A.

2015-01-01

Under the Hospital Value-Based Purchasing Program of the Centers for Medicare & Medicaid Services patient satisfaction accounts for 30% of the measures of and payments for quality of care. Understanding what drives satisfaction data, how it is obtained, converted into scores, and formulated into rankings, is increasingly critical for imaging departments. PMID:24261356

Food Allergies: Being Aware and Planning for Care

ERIC Educational Resources Information Center

Graville, Iris

2010-01-01

In recent years, parents and early childhood educators have become increasingly aware of food allergies in childhood. And since food allergies account for about 150 deaths a year, there is good reason to be concerned. The early childhood program can provide valuable learning for those without food allergies through explanations about why certain…

Why We Should Care if Teachers Get A's: Teacher Test Scores and Student Achievement in Mexico

ERIC Educational Resources Information Center

Santibanez, Lucrecia

2006-01-01

Understanding the relationship between teacher test scores and student achievement is important in an accountability environment that favors using quantitative measures of teaching quality, as is the case with Mexico's national "Carrera Magisterial" (CM) teacher incentive program. The results of this paper suggest that teacher test…

76 FR 29249 - Medicare Program; Pioneer Accountable Care Organization Model: Request for Applications

Federal Register 2010, 2011, 2012, 2013, 2014

2011-05-20

... on the Innovation Center Web site http://innovations.cms.gov/areas-of-focus/seamless-and-coordinated... Medicare and Medicaid Innovation, Centers for Medicare and Medicaid Services, Mail Stop S3-13-05, 7500... and Medicaid Innovation (Innovation Center). The Pioneer ACO Model is an Innovation Center initiative...

Contributions of Qualitative Research to Understanding Savings for Children and Youth

ERIC Educational Resources Information Center

Sherraden, Margaret; Peters, Clark; Wagner, Kristen; Guo, Baorong; Clancy, Margaret

2013-01-01

This paper explores contributions of qualitative research to saving theory for children, youth, and parents in children's development account (CDAs) programs. It brings together findings from three studies: (1) elementary school age children saving for college, (2) youth transitioning from foster care saving for education and other purposes, and…

75 FR 78246 - Medicare Program; Re-Chartering of the Advisory Panel on Ambulatory Payment Classification (APC...

Federal Register 2010, 2011, 2012, 2013, 2014

2010-12-15

... Administrator among the fields of hospital payment systems; hospital medical care delivery systems; provider billing and accounting systems; APC groups; Current Procedural Terminology codes; HCPCS codes; the use of, and payment for, drugs, medical devices, and other services in the outpatient setting; and other forms...

Leveraging lean principles in creating a comprehensive quality program: The UCLA health readmission reduction initiative.

PubMed

Afsar-Manesh, Nasim; Lonowski, Sarah; Namavar, Aram A

2017-12-01

UCLA Health embarked to transform care by integrating lean methodology in a key clinical project, Readmission Reduction Initiative (RRI). The first step focused on assembling a leadership team to articulate system-wide priorities for quality improvement. The lean principle of creating a culture of change and accountability was established by: 1) engaging stakeholders, 2) managing the process with performance accountability, and, 3) delivering patient-centered care. The RRI utilized three major lean principles: 1) A3, 2) root cause analyses, 3) value stream mapping. Baseline readmission rate at UCLA from 9/2010-12/2011 illustrated a mean of 12.1%. After the start of the RRI program, for the period of 1/2012-6/2013, the readmission rate decreased to 11.3% (p<0.05). To impact readmissions, solutions must evolve from smaller service- and location-based interventions into strategies with broader approach. As elucidated, a systematic clinical approach grounded in lean methodologies is a viable solution to this complex problem. Copyright © 2017 Elsevier Inc. All rights reserved.

Factors Accounting for a Missed Diagnosis of Cystic Fibrosis After Newborn Screening

PubMed Central

Rock, Michael J.; Levy, Hara; Zaleski, Christina; Farrell, Philip M.

2015-01-01

Summary Newborn screening is a public health policy program involving the centralized testing laboratory, infant and their family, primary care provider, and subspecialist for confirmatory testing and follow-up of abnormal results. Cystic fibrosis (CF) newborn screening has now been enacted in all 50 states and the District of Columbia and throughout many countries in the world. Although CF neonatal screening will identify the vast majority of infants with CF, there are many factors in the newborn screening system that can lead to a missed diagnosis of CF. To inform clinicians, this article summarizes the CF newborn screening system and highlights 14 factors that can account for a missed diagnosis of CF. Care providers should maintain a high suspicion for CF if there are compatible symptoms, regardless of the results of the newborn screening test. These factors in newborn screening programs leading to a missed diagnosis of CF present opportunities for quality improvement in specimen collection, laboratory analysis of immunoreactive tryspinogen (IRT) and CF mutation testing, communication, and sweat testing. PMID:22081556

The Business Case for Palliative Care: Translating Research Into Program Development in the U.S.

PubMed

Cassel, J Brian; Kerr, Kathleen M; Kalman, Noah S; Smith, Thomas J

2015-12-01

Specialist palliative care (PC) often embraces a "less is more" philosophy that runs counter to the revenue-centric nature of most health care financing in the U.S. A special business case is needed in which the financial benefits for organizations such as hospitals and payers are aligned with the demonstrable clinical benefits for patients. Based on published studies and our work with PC programs over the past 15 years, we identified 10 principles that together form a business model for specialist PC. These principles are relatively well established for inpatient PC but are only now emerging for community-based PC. Three developments that are key for the latter are the increasing penalties from payers for overutilization of hospital stays, the variety of alternative payment models such as accountable care organizations, which foster a population health management perspective, and payer-provider partnerships that allow for greater access to and funding of community-based PC. Copyright © 2015 The Authors. Published by Elsevier Inc. All rights reserved.

ASSOCIATION BETWEEN PAYMENT REFORM AND PROVIDER CONSOLIDATION

PubMed Central

Neprash, Hannah T.; Chernew, Michael E.; McWilliams, J. Michael

2017-01-01

Provider consolidation has been associated with higher health care prices and spending. Prevailing wisdom assumes that payment reform will accelerate consolidation, especially between physicians and hospitals and among physician groups, as providers position themselves to bear financial risk for the full continuum of patient care. Drawing from a number of data sources from 2008 onward, we examined the relationship between Medicare’s Accountable Care Organization (ACO) programs and provider consolidation. According to multiple measures, consolidation was underway in 2008–2010, before the Affordable Care Act (ACA) established the ACO programs. While the number of hospital mergers and specialty-oriented physician group size increased after the ACA, we found minimal evidence associating consolidation with ACO penetration at a market level or with ACO participation by physicians within markets. We conclude that payment reform has been associated with little acceleration in consolidation apart from trends already underway, but with some evidence of potential defensive consolidation in response to new payment models. PMID:28167725

Implementing oral care practices and policy into long-term care: the Brushing up on Mouth Care project.

PubMed

McNally, Mary; Martin-Misener, Ruth; McNeil, Karen; Brillant, Martha; Moorhouse, Paige; Crowell, Sandra; Matthews, Debora; Clovis, Joanne

2015-03-01

Optimal mouth care is integral to the health and quality of life of dependent older adults.Yet, a persistent lack of adequate oral care in long-term care (LTC) facilities exacerbates the burden of disease experienced by residents. The reasons for this are complex and create enormous challenges for care providers, clinicians, and administrators dedicated to comprehensive high quality care. The aim of this study was to develop, implement, and evaluate a comprehensive program for daily mouth care for LTC. A case study design using a participatory and qualitative approach examined how individual, organizational (workplace practices and culture), and system factors (standards and policy) influenced the development and implementation of a comprehensive program to improve the delivery of daily oral care in LTC. The research was undertaken in 3 LTC residences administered under the same health authority and included personal care providers, nurse managers, and directors of care. A comprehensive program for care providers including, education, resources, and organizational guidelines, to improve the delivery of daily mouth care to LTC residents was created, rolled out, and refined over a 12-month period. Data was collected through diary studies, targeted interviews, field notes, oral care activities records, site team meetings, and direct feedback from members of the care team. The oral care intervention resulted in a heightened awareness, support and greater efficiency amongst care team. The presence of a "champion" was a key feature for sustaining processes. Management had a clear role to play to ensure support and accountability for the intervention. Optimizing oral care in long-term care can be achieved through an integrated approach that includes education, provision of resources, an oral care champion, support from managers and administrators, and appropriate organizational policy. Copyright © 2015 AMDA – The Society for Post-Acute and Long-Term Care Medicine. Published by Elsevier Inc. All rights reserved.

MEDICARE PAYMENTS AND SYSTEM-LEVEL HEALTH-CARE USE

PubMed Central

ROBBINS, JACOB A.

2015-01-01

The rapid growth of Medicare managed care over the past decade has the potential to increase the efficiency of health-care delivery. Improvements in care management for some may improve efficiency system-wide, with implications for optimal payment policy in public insurance programs. These system-level effects may depend on local health-care market structure and vary based on patient characteristics. We use exogenous variation in the Medicare payment schedule to isolate the effects of market-level managed care enrollment on the quantity and quality of care delivered. We find that in areas with greater enrollment of Medicare beneficiaries in managed care, the non–managed care beneficiaries have fewer days in the hospital but more outpatient visits, consistent with a substitution of less expensive outpatient care for more expensive inpatient care, particularly at high levels of managed care. We find no evidence that care is of lower quality. Optimal payment policies for Medicare managed care enrollees that account for system-level spillovers may thus be higher than those that do not. PMID:27042687

Use of a cost accounting system to evaluate costs of a VA special program.

PubMed

Menke, T J; Wray, N P

1999-04-01

The Department of Veterans Affairs (VA) established six mobile clinics to provide care for rural veterans. Each was operated by a parent VA Medical Center (VAMC). To describe the use of a cost-accounting system which does not provide costs at the service or patient level to determine the costs of the mobile clinics. Costs per visit were compared among the mobile clinics with the parent VAMCs and with simulated fixed-location clinics. Cost data came from VA's Centralized Accounting for Local Management (CALM) data. Utilization data came from VA's outpatient file. Information was obtained from the VAMCs' fiscal services to reallocate costs among the CALM subaccounts to generate cost data that was comparable among the mobile clinics. Costs per visit for the mobile clinics were twice as high as those of the parent VAMCs. Costs per visit would be lower at fixed-location clinics unless the volume were substantially less than that provided by the mobile clinics. Differences between cost allocations for accounting purposes and research are likely to necessitate adjusting cost accounting data for research purposes. Fortunately, information from the accountants or primary data can lead to a cost database which is appropriate for research evaluations. In the mobile clinics study, the analysis of cost accounting data led to the conclusion that mobile clinics were not a cost-effective way in which to provide care to rural veterans.

Health behaviors, service utilization, and access to care among older mothers of color who have children with developmental disabilities.

PubMed

Magaña, Sandy; Smith, Matthew J

2008-08-01

This study examined health behaviors, utilization, and access to care among older Latina and Black American mothers who co-reside with a child with developmental disabilities. Using data from the National Health Interview Survey National Center for Health Statistics (2005a), we compared Latina and Black American caregivers to similar women who did not have caregiving responsibilities. Findings showed that Latina caregivers were more likely to smoke and have insurance; Black American caregivers were less likely to be able to afford medication and mental health care; and both groups were less likely to have seen a doctor in the past year than their noncaregiving counterparts. Findings suggest that service providers should consider developing programs that focus on health for caregivers of color. Furthermore, results suggest that providers should take into account differing trends across ethnicities when designing programs.

Toward population management in an integrated care model.

PubMed

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

2013-04-01

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

Toward population management in an integrated care model.

PubMed

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

2013-01-01

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

Redefining "Medical Care."

PubMed

Roth, Lauren R

President Donald J. Trump has said he will repeal the Affordable Care Act (ACA) and replace it with health savings accounts (HSAs). Conservatives have long preferred individual accounts to meet social welfare needs instead of more traditional entitlement programs. The types of "medical care" that can be reimbursed through an HSA are listed in section 213(d) of the Internal Revenue Code (Code) and include expenses "for the diagnosis, cure, mitigation, treatment, or prevention of disease, or for the purpose of affecting any structure or function of the body." In spite of the broad language, regulations and court interpretations have narrowed this definition substantially. It does not include the many social factors that determine health outcomes. Though the United States spends over seventeen percent of gross domestic product (GDP) on "healthcare", the country's focus on the traditional medicalized model of health results in overall population health that is far beneath the results of other countries that spend significantly less. Precision medicine is one exceptional way in which American healthcare has focused more on individuals instead of providing broad, one-size-fits-all medical care. The precision medicine movement calls for using the genetic code of individuals to both predict future illness and to target treatments for current illnesses. Yet the definition of "medical care" under the Code remains the same for all. My proposal for precision healthcare accounts involves two steps-- the first of which requires permitting physicians to write prescriptions for a broader range of goods and services. The social determinants of health are as important to health outcomes as are surgical procedures and drugs--or perhaps more so according to many population health studies. The second step requires agencies and courts to interpret what constitutes "medical care" under the Code differently depending on the taxpayer's income level. Childhood sports programs and payments for fruits and vegetables may be covered for those in the lower income brackets who could not otherwise afford these items and would not choose to spend scarce resources on them if they could. This all assumes that the government takes funds previously used to subsidize the purchase of health insurance under the ACA (or allocates new funds) and puts the funds in individual accounts so the poor or near poor have money to pay for these expenses. Section I of this Article will explore the current definition of medical care, which excludes the social determinants of health from "healthcare" spending. I then address how precision medicine has changed the types of services and treatments that it makes sense to reimburse for each individual. If efficacy can vary from person to person based on genetic code, then it also can vary depending on environment. There is an opportunity to not only vary the types of "medical care" that can be reimbursed or deducted within the traditional range of services and drugs, but also outside of that range. Section II addresses the historical shift towards health financing through individual accounts, and specifically through HSAs. If this is the only avenue for health reform in the next few years, I advocate using it to engage in the type of experiments that are typically only possible under the cover of tax expenditures. My proposal for precision healthcare accounts moves the government to experiment with individual social spending that can lead to improved overall health outcomes. Finally, in Section III, I address two dichotomies that affect any healthcare proposal: (1) entitlement programs v. grants-in-aid, and (2) pooled insurance v. consumer-driven health plans (CDHPs). In the end, I argue that an entitlement method of funding precision HSAs along with pooled insurance subsidized by the government is the most realistic resolution to these dichotomies. Only a broad-based entitlement to funding for all healthcare expenses (medical and social) allows for significant improvements in overall population health.

The Disproportionate Cost of Smoking for African Americans in California

PubMed Central

Sung, Hai-Yen; Tucker, Lue-Yen; Stark, Brad

2010-01-01

Objectives. We estimated the economic impact of smoking on African Americans in California in 2002, including smoking-attributable health care expenditures and productivity losses from smoking-caused mortality. Methods. We estimated econometric models of smoking-attributable ambulatory care, prescription drugs, inpatient care, and home health care using national and state survey data. We assessed smoking-attributable mortality using epidemiological models. Results. Adult smoking prevalence for African Americans was 19.3% compared with 15.4% for all Californians. The health care cost of smoking was $626 million for the African American community. A total of 3013 African American Californians died of smoking-attributable illness in 2002, representing a loss of over 49 000 years of life and $784 million in productivity. The total cost of smoking for this community amounted to $1.4 billion, or $1.8 billion expressed in 2008 dollars. Conclusions. Although African Americans account for 6% of the California adult population, they account for over 8% of smoking-attributable expenditures and fully 13% of smoking-attributable mortality costs. Our findings confirm the need to tailor tobacco control programs to African Americans to mitigate the disproportionate burden of smoking for this community. PMID:19965569

Creating the Business Case for Achieving Health Equity.

PubMed

Chin, Marshall H

2016-07-01

Health care organizations have increasingly acknowledged the presence of health care disparities across race/ethnicity and socioeconomic status, but significantly fewer have made health equity for diverse patients a true priority. Lack of financial incentives is a major barrier to achieving health equity. To create a business case for equity, governmental and private payors can: 1) Require health care organizations to report clinical performance data stratified by race, ethnicity, and socioeconomic status. 2) Incentivize preventive care and primary care. Implement more aggressive shared savings plans, update physician relative value unit fee schedules, and encourage partnerships across clinical and non-clinical sectors. 3) Incentivize the reduction of health disparities with equity accountability measures in payment programs. 4) Align equity accountability measures across public and private payors. 5) Assist safety-net organizations. Provide adequate Medicaid reimbursement, risk-adjust clinical performance scores for sociodemographic characteristics of patients, provide support for quality improvement efforts, and calibrate cuts to Disproportionate Share Hospital (DSH) payments to the pace of health insurance expansion. 6) Conduct demonstration projects to test payment and delivery system reform interventions to reduce disparities. Commitment to social justice is essential to achieve health equity, but insufficient without a strong business case that makes interventions financially feasible.

Functional performance and exercise of older adults in long-term care settings.

PubMed

Resnick, B

2000-03-01

Performing functional activities and exercising are important for older adults living in long-term care settings. Participation in these activities not only improves and maintains function in older adults but also can improve physical and emotional health and quality of life. The purpose of this study was to explore the variables that influence functional performance and exercise activity in a group of nursing home residents. Participants included 59 residents in a long-term care facility. The mean age of participants was 88 +/- 6.9, and the majority were women (76%), White (97%), and unmarried (76%). Residents participated in a single face-to-face interview. Chart reviews for demographic and health information also were performed. Based on stepwise multiple regression analyses, upper and lower extremity contractures and cognitive status were the only variables that significantly influenced functional performance and accounted for 49% of the variance in function. Self-efficacy and outcome expectations were the only variables to significantly influence exercise behavior and accounted for 57% of the variance in this behavior. These findings can be used to help develop and implement effective restorative nursing care programs in long-term care settings.

Quality of Post-Acute Care in Skilled Nursing Facilities That Disproportionately Serve Black and Hispanic Patients.

PubMed

Rivera-Hernandez, Maricruz; Rahman, Momotazur; Mukamel, Dana B; Mor, Vincent; Trivedi, Amal N

2018-04-25

Understanding and addressing racial and ethnic disparities in the quality of post-acute care in skilled nursing facilities is an important health policy issue, particularly as the Medicare program initiates value-based payments for these institutions. Our final cohort included 649,187 Medicare beneficiaries in either the fee-for-service or Medicare Advantage programs, who were 65 and older and were admitted to a skilled nursing facility following an acute hospital stay, from 8,375 skilled nursing facilities. We examined the quality of care in skilled nursing facilities that disproportionately serve minority patients compared to non-Hispanic whites. Three measures, all calculated at the level of the facility, were used to assess quality of care in skilled nursing facilities: 1) 30-day rehospitalization rate; 2) successful discharge from the facility to the community; and 3) Medicare five-star quality ratings. We found that African-American post-acute patients are highly concentrated in a small number of institutions, with 28% of facilities accounting for 80% of all post-acute admissions for African-American patients. Similarly, just 20% of facilities accounted for 80% of all admissions for Hispanics. Skilled nursing facilities with higher fractions of African-American patients had worse performance for three publicly-reported quality measures: rehospitalization, successful discharge to the community, and the star rating indicator. Efforts to address disparities should focus attention on institutions that disproportionately serve minority patients and monitor unintended consequences of value-based payments to skilled nursing facilities.

Current State of Value-Based Purchasing Programs.

PubMed

Chee, Tingyin T; Ryan, Andrew M; Wasfy, Jason H; Borden, William B

2016-05-31

The US healthcare system is rapidly moving toward rewarding value. Recent legislation, such as the Affordable Care Act and the Medicare Access and CHIP Reauthorization Act, solidified the role of value-based payment in Medicare. Many private insurers are following Medicare's lead. Much of the policy attention has been on programs such as accountable care organizations and bundled payments; yet, value-based purchasing (VBP) or pay-for-performance, defined as providers being paid fee-for-service with payment adjustments up or down based on value metrics, remains a core element of value payment in Medicare Access and CHIP Reauthorization Act and will likely remain so for the foreseeable future. This review article summarizes the current state of VBP programs and provides analysis of the strengths, weaknesses, and opportunities for the future. Multiple inpatient and outpatient VBP programs have been implemented and evaluated; the impact of those programs has been marginal. Opportunities to enhance the performance of VBP programs include improving the quality measurement science, strengthening both the size and design of incentives, reducing health disparities, establishing broad outcome measurement, choosing appropriate comparison targets, and determining the optimal role of VBP relative to alternative payment models. VBP programs will play a significant role in healthcare delivery for years to come, and they serve as an opportunity for providers to build the infrastructure needed for value-oriented care. © 2016 American Heart Association, Inc.

Current State of Value-Based Purchasing Programs

PubMed Central

Chee, Tingyin T.; Ryan, Andrew M.; Wasfy, Jason H.; Borden, William B.

2016-01-01

The United States healthcare system is rapidly moving toward rewarding value. Recent legislation, such as the Affordable Care Act and the Medicare Access and CHIP Reauthorization Act (MACRA), solidified the role of value-based payment in Medicare. Many private insurers are following Medicare’s lead. Much of the policy attention has been on programs such as accountable care organizations and bundled payments; yet, value-based purchasing (VBP) or pay-for-performance, defined as providers being paid fee-for-service with payment adjustments up or down based on value metrics, remains a core element of value payment in MACRA and will likely remain so for the foreseeable future. This review article summarizes the current state of VBP programs and provides analysis of the strengths, weaknesses, and opportunities for the future. Multiple inpatient and outpatient VBP programs have been implemented and evaluated, with the impact of those programs being marginal. Opportunities to enhance the performance of VBP programs include improving the quality measurement science, strengthening both the size and design of incentives, reducing health disparities, establishing broad outcome measurement, choosing appropriate comparison targets, and determining the optimal role of VBP relative to alternative payment models. VBP programs will play a significant role in healthcare delivery for years to come, and they serve as an opportunity for providers to build the infrastructure needed for value-oriented care. PMID:27245648

Deeply discounted medications: Implications of generic prescription drug wars.

PubMed

Czechowski, Jessica L; Tjia, Jennifer; Triller, Darren M

2010-01-01

To describe the history of generic prescription pricing programs at major pharmacy chains and their potential implications on prescribing, quality of care, and patient safety. Publicly available generic prescription discount program drug lists as of May 1, 2009. Fierce competition among major pharmacy chains such as Walgreens, CVS, and Walmart has led to a generic prescription pricing war with unclear public health implications. Introduced in 2006, currently 7 of the 10 largest pharmacy chains advertise a version of a deeply discounted medication (DDM) program, accounting for more than 25,000 locations nationally. By early 2008, almost 70 million Americans had used these programs. Although DDM programs lower drug costs for many patients, DDM formularies include potentially ineffective or harmful medications, have the potential to influence physician prescribing behavior, and may impair pharmacists' ability to review complete drug-dispensing records. DDMs are widespread but have the potential for unintended consequences on patients, providers, and the health care system. A systematic review of DDMs needs to evaluate the clinical, economic, and system-level implications of such programs.

Emergency Department Involvement in Accountable Care Organizations in Massachusetts: A Survey Study.

PubMed

Ali, Nissa J; McWilliams, J Michael; Epstein, Stephen K; Smulowitz, Peter B

2017-11-01

We assess Massachusetts emergency department (ED) involvement and internal ED constructs within accountable care organization contracts. An online survey was distributed to 70 Massachusetts ED directors. Questions attempted to assess involvement of EDs in accountable care organizations and the structures in place in EDs-from departmental resources to physician incentives-to help achieve accountable care organization goals of decreasing spending and improving quality. Of responding ED directors, 79% reported alignment between the ED and an accountable care organization. Almost all ED groups (88%) reported bearing no financial risk as a result of the accountable care organization contracts in which their organizations participated. Major obstacles to meeting accountable care organization objectives included care coordination challenges (62%) and lack of familiarity with accountable care organization goals (58%). The most common cost-reduction strategies included ED case management (85%) and information technology (61%). Limitations of this study include that information was self-reported by ED directors, a focus limited to Massachusetts, and a survey response rate of 47%. The ED directors perceived that the majority of physicians were not familiar with accountable care organization goals, many challenges remain in coordinating care for patients in the ED, and most EDs have no financial incentives tied to accountable care organizations. EDs in Massachusetts have begun to implement strategies aimed at reducing admissions, utilization, and overall cost, but these strategies are not widespread apart from case management, even in a state with heavy accountable care organization penetration. Our results suggest that Massachusetts EDs still lack clear directives and direct involvement in meeting accountable care organization goals. Copyright © 2017 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.

Effects of a Community-Based Fall Management Program on Medicare Cost Savings.

PubMed

Ghimire, Ekta; Colligan, Erin M; Howell, Benjamin; Perlroth, Daniella; Marrufo, Grecia; Rusev, Emil; Packard, Michael

2015-12-01

Fall-related injuries and health risks associated with reduced mobility or physical inactivity account for significant costs to the U.S. healthcare system. The widely disseminated lay-led A Matter of Balance (MOB) program aims to help older adults reduce their risk of falling and associated activity limitations. This study examined effects of MOB participation on health service utilization and costs for Medicare beneficiaries, as a part of a larger effort to understand the value of community-based prevention and wellness programs for Medicare. A controlled retrospective cohort study was conducted in 2012-2013, using 2007-2011 MOB program data and 2006-2013 Medicare data. It investigated program effects on falls and fall-related fractures, and health service utilization and costs (standardized to 2012 dollars), of 6,136 Medicare beneficiaries enrolled in MOB from 2007 through 2011. A difference-in-differences analysis was employed to compare outcomes of MOB participants with matched controls. MOB participation was associated with total medical cost savings of $938 per person (95% CI=$379, $1,498) at 1 year. Savings per person amounted to $517 (95% CI=$265, $769) for unplanned hospitalizations; $81 for home health care (95% CI=$20, $141); and $234 (95% CI=$55, $413) for skilled nursing facility care. Changes in the incidence of falls or fall-related fractures were not detected, suggesting that cost savings accrue through other mechanisms. This study suggests that MOB and similar prevention programs have the potential to reduce Medicare costs. Further research accounting for program delivery costs would help inform the development of Medicare-covered preventive benefits. Copyright © 2015 American Journal of Preventive Medicine. All rights reserved.

The business management preceptorship within the nurse practitioner program.

PubMed

Wing, D M

1998-01-01

Changes in health care reimbursement practices have affected the way in which primary health care is provided. To be successful, nurse practitioners must have a proficient understanding of basic business functions, including accounting, finance, economics, marketing, and reimbursement practices. Yet, many graduates of nurse practitioner programs are not adequately prepared to make fundamental business decisions. Therefore, it is essential that nurse practitioner faculty provide learning experiences on primary practice business. Because the preceptor experience is an integral aspect of nurse practitioner education, a business preceptorship provides students with pragmatic knowledge of the clinical practice within a business framework. The University of Indianapolis School of Nursing offers a nurse practitioner business preceptorship. The implementation, challenges, and positive outcomes of the course are discussed in this article.

[Electronic data processing-assisted bookkeeping and accounting system at the Düsseldorf Institute of Forensic Medicine].

PubMed

Bonte, W; Bonte, I

1989-01-01

In 1985 we reported about the usefulness of a simple home computer (here: Commodore C 64) for scientific work. This paper will demonstrate, that such an instrument also can be an appropriate tool for the entire accountancy of a medicolegal institute. Presented were self-designed programs which deal with the following matters: complication of monthly performance reports, calculation of services for clinical care, typing of analytical results and brief interpretations, typing of liquidations, clearing of proceeds from written expertises and autopsies against administration and staff.

Medical Transport of Children with Complex Chronic Conditions

PubMed Central

Lerner, Carlos F.; Kelly, Robert B.; Hamilton, Leslie J.; Klitzner, Thomas S.

2012-01-01

One of the most notable trends in child health has been the increase in the number of children with special health care needs, including those with complex chronic conditions. Care of these children accounts for a growing fraction of health care resources. We examine recent developments in health care, especially with regard to medical transport and prehospital care, that have emerged to adapt to this remarkable demographic trend. One such development is the focus on care coordination, including the dissemination of the patient-centered medical home concept. In the prehospital setting, the need for greater coordination has catalyzed the development of the emergency information form. Training programs for prehospital providers now incorporate specific modules for children with complex conditions. Another notable trend is the shift to a family-centered model of care. We explore efforts toward regionalization of care, including the development of specialized pediatric transport teams, and conclude with recommendations for a research agenda. PMID:22315689

The home hemodialysis hub: physical infrastructure and integrated governance structure.

PubMed

Marshall, Mark R; Young, Bessie A; Fox, Sally J; Cleland, Calli J; Walker, Robert J; Masakane, Ikuto; Herold, Aaron M

2015-04-01

An effective home hemodialysis program critically depends on adequate hub facilities and support functions and on transparent and accountable organizational processes. The likelihood of optimal service delivery and patient care will be enhanced by fit-for-purpose facilities and implementation of a well-considered governance structure. In this article, we describe the required accommodation and infrastructure for a home hemodialysis program and a generic organizational structure that will support both patient-facing clinical activities and business processes. © 2015 International Society for Hemodialysis.

A Novel Internet Based Geriatric Education Program for Emergency Medical Services Providers

PubMed Central

Shah, Manish N.; Swanson, Peter A.; Nobay, Flavia; Peterson, Lars-Kristofer N.; Caprio, Thomas V.; Karuza, Jurgis

2012-01-01

Despite caring for large numbers of older adults, prehospital emergency medical services (EMS) providers receive minimal geriatrics-specific training while obtaining their certification. Studies have shown that they desire further training to improve their comfort level and knowledge in caring for older adults. However, continuing education programs to address these needs must account for each EMS provider's specific needs, consider each provider's learning styles, and provide an engaging, interactive experience. We developed and implemented a novel, internet-based, video podcast-based geriatric continuing education program for EMS providers and evaluated their perceived value of the program. They found this resource to be highly valuable and were strongly supportive of both the modality and the specific training provided. Technical challenges were reported by some as a barrier, as well as the inability to engage in a discussion to clarify topics. Both were felt to be addressable through programmatic and technological revisions. This study demonstrates the proof of concept of video podcast training to address deficiencies in EMS education regarding the care for older patients. However, further work is needed to demonstrate the educational impact of video podcasts on the knowledge and skills of trainees. PMID:22906239

Cost-effectiveness of a program to prevent depression relapse in primary care.

PubMed

Simon, Gregory E; Von Korff, Michael; Ludman, Evette J; Katon, Wayne J; Rutter, Carolyn; Unützer, Jürgen; Lin, Elizabeth H B; Bush, Terry; Walker, Edward

2002-10-01

Evaluate the incremental cost-effectiveness of a depression relapse prevention program in primary care. Primary care patients initiating antidepressant treatment completed a standardized telephone assessment 6-8 weeks later. Those recovered from the current episode but at high risk for relapse (based on history of recurrent depression or dysthymia) were offered randomization to usual care or a relapse prevention intervention. The intervention included systematic patient education, two psychoeducational visits with a depression prevention specialist, shared decision-making regarding maintenance pharmacotherapy, and telephone and mail monitoring of medication adherence and depressive symptoms. Outcomes in both groups were assessed via blinded telephone assessments at 3, 6, 9, and 12 months and health plan claims and accounting data. Intervention patients experienced 13.9 additional depression-free days during a 12-month period (95% CI, -1.5 to 29.3). Incremental costs of the intervention were $273 (95% CI, $102 to $418) for depression treatment costs only and $160 (95% CI, -$173 to $512) for total outpatient costs. Incremental cost-effectiveness ratio was $24 per depression-free day (95% CI, -$59 to $496) for depression treatment costs only and $14 per depression-free day (95% CI, -$35 to $248) for total outpatient costs. A program to prevent depression relapse in primary care yields modest increases in days free of depression and modest increases in treatment costs. These modest differences reflect high rates of treatment in usual care. Along with other recent studies, these findings suggest that improved care of depression in primary care is a prudent investment of health care resources.

Improving Care Transitions Management: Examining the Role of Accountable Care Organization Participation and Expanded Electronic Health Record Functionality.

PubMed

Huber, Thomas P; Shortell, Stephen M; Rodriguez, Hector P

2017-08-01

Examine the extent to which physician organization participation in an accountable care organization (ACO) and electronic health record (EHR) functionality are associated with greater adoption of care transition management (CTM) processes. A total of 1,398 physician organizations from the third National Study of Physician Organization survey (NSPO3), a nationally representative sample of medical practices in the United States (January 2012-May 2013). We used data from the third National Study of Physician Organization survey (NSPO3) to assess medical practice characteristics, including CTM processes, ACO participation, EHR functionality, practice type, organization size, ownership, public reporting, and pay-for-performance participation. Multivariate linear regression models estimated the extent to which ACO participation and EHR functionality were associated with greater CTM capabilities, controlling for practice size, ownership, public reporting, and pay-for-performance participation. Approximately half (52.4 percent) of medical practices had a formal program for managing care transitions in place. In adjusted analyses, ACO participation (p < .001) and EHR functionality (p < .001) were independently associated with greater use of CTM processes among medical practices. The growth of ACOs and similar provider risk-bearing arrangements across the country may improve the management of care transitions by physician organizations. © Health Research and Educational Trust.

Leadership development programs for health care middle managers: An exploration of the top management team member perspective.

PubMed

Whaley, Alan; Gillis, William E

Hospitals throughout the United States establish leadership and management programs for their middle managers. Despite their pervasiveness and an increased emphasis on physician leadership, there is limited research regarding the development programs designed for clinical and nonclinical health care middle managers. Using two theoretical lenses, signaling and institutional theory, this exploratory study investigates mid-sized hospital development programs from the perspective of top management team (TMT) members. Our objective is to find out what types of programs hospitals have, how they are developed, and how they are evaluated. We conducted semistructured interviews with 13 TMT members in six purposefully selected hospitals and matched these interviews with program curricula. Careful coding of the data allowed us not only to show our data in a meaningful visual representation but also to show the progression of the data from raw form to aggregate themes in the qualitative research process. We identified four types of development programs used in the selected hospitals: (a) ongoing series, (b) curriculum-based, (c) management orientation, and (d) mentoring. Challenges existed in aligning the need for the program with program content. Communication occurred both through direct messaging regarding policies and procedures and through hidden signals. TMT members referenced other programs for guidance but were not always clear about what it is they wanted the programs to accomplish. Finally, there was limited program outcome measurement. Our small sample indicates that specific, structured, and comprehensive programs perform best. The better programs were always trying to improve but that most needed better accountability of tracking outcomes. In setting up a program, a collaborative approach among TMT members to establish what the needs are and how to measure outcomes worked well. Successful programs also tied in their leadership development with overall employee development.

Impairments in Life Quality among Clients in Geriatric Home Care: Associations with Depressive and Anxiety Symptoms

PubMed Central

Diefenbach, Gretchen J.; Tolin, David F.; Gilliam, Christina M.

2012-01-01

Objective The aim of this study was to determine the independent contributions of depressive and anxiety symptoms to quality of life among older adults who were receiving services through a home care program. Methods The study sample consisted of 66 community-dwelling older adults (ages 65 and older), who were experiencing chronic medical illness and concomitant functional disability necessitating home care. Participants completed self-report measures of depression, anxiety, and health-related quality of life. Additional data on cognitive, health, and functional status were collected to be used as covariates. Results The associations of depressive symptoms with quality of life impairments in home care were substantial and pervasive. Depressive symptoms were significantly associated with quality of life impairments in nearly all domains. After controlling for depressive symptoms, anxiety symptoms accounted for additional and statistically significant variance in impaired life quality in the domains of Mental Health, Role Emotional Functioning, and Bodily Pain. Conclusions These results indicate that depressive and anxiety symptoms demonstrate negative associations with life quality among older adults in home care, and highlight the importance of developing community-based programs to assess and treat depressive and anxiety symptoms among home care clients. PMID:21960438

Integrating Spiritual Care into a Baccalaureate Nursing Program in Mainland China.

PubMed

Yuan, Hua; Porr, Caroline

2014-09-01

Holistic nursing care takes into account individual, family, community and population well-being. At the level of individual well-being, the nurse considers biological, psychological, social, and spiritual factors. However, in Mainland China spiritual factors are not well understood by nursing students. And accordingly, nursing faculty and students are reluctant to broach the topic of spirituality because it is either unknown to students or students believe that the provision of spiritual care is beyond their capabilities. We wonder then, what can we do as nurse educators to integrate spiritual care into a baccalaureate nursing program in Mainland China? The purpose of this article is to propose the integration of Chinese sociocultural traditions (namely religious/spiritual practices) into undergraduate nursing curricula as a means to enter into dialogue about spiritual well-being, to promote spiritual care; and to fulfill the requirements of holistic nursing care. However, prior to discussing recommendations, an overview of the cultural context is in order. Thus, this article is constructed as follows: first, the complexity of Chinese society is briefly described; second, the historical evolution of nursing education in Mainland China is presented; and, third, strategies to integrate Chinese religious/spiritual practices into curricula are proposed. © The Author(s) 2014.

Descriptive analysis of childbirth healthcare costs in an area with high levels of immigration in Spain

PubMed Central

2011-01-01

Background The aim of this study was to estimate the cost of childbirth in a teaching hospital in Barcelona, Spain, including the costs of prenatal care, delivery and postnatal care (3 months). Costs were assessed by taking into account maternal origin and delivery type. Methods We performed a cross-sectional study of all deliveries in a teaching hospital to mothers living in its catchment area between October 2006 and September 2007. A process cost analysis based on a full cost accounting system was performed. The main information sources were the primary care program for sexual and reproductive health, and hospital care and costs records. Partial and total costs were compared according to maternal origin and delivery type. A regression model was fit to explain the total cost of the childbirth process as a function of maternal age and origin, prenatal care, delivery type, maternal and neonatal severity, and multiple delivery. Results The average cost of childbirth was 4,328€, with an average of 18.28 contacts between the mother or the newborn and the healthcare facilities. The delivery itself accounted for more than 75% of the overall cost: maternal admission accounted for 57% and neonatal admission for 20%. Prenatal care represented 18% of the overall cost and 75% of overall acts. The average overall cost was 5,815€ for cesarean sections, 4,064€ for vaginal instrumented deliveries and 3,682€ for vaginal non-instrumented deliveries (p < 0.001). The regression model explained 45.5% of the cost variability. The incremental cost of a delivery through cesarean section was 955€ (an increase of 31.9%) compared with an increase of 193€ (6.4%) for an instrumented vaginal delivery. The incremental cost of admitting the newborn to hospital ranged from 420€ (14.0%) to 1,951€ (65.2%) depending on the newborn's severity. Age, origin and prenatal care were not statistically significant or economically relevant. Conclusions Neither immigration nor prenatal care were associated with a substantial difference in costs. The most important predictors of cost were delivery type and neonatal severity. Given the impact of cesarean sections on the overall cost of childbirth, attempts should be made to take into account its higher cost in the decision of performing a cesarean section. PMID:21492486

Descriptive analysis of childbirth healthcare costs in an area with high levels of immigration in Spain.

PubMed

Comas, Mercè; Català, Laura; Sala, Maria; Payà, Antoni; Sala, Assumpció; Del Amo, Elisabeth; Castells, Xavier; Cots, Francesc

2011-04-15

The aim of this study was to estimate the cost of childbirth in a teaching hospital in Barcelona, Spain, including the costs of prenatal care, delivery and postnatal care (3 months). Costs were assessed by taking into account maternal origin and delivery type. We performed a cross-sectional study of all deliveries in a teaching hospital to mothers living in its catchment area between October 2006 and September 2007. A process cost analysis based on a full cost accounting system was performed. The main information sources were the primary care program for sexual and reproductive health, and hospital care and costs records. Partial and total costs were compared according to maternal origin and delivery type. A regression model was fit to explain the total cost of the childbirth process as a function of maternal age and origin, prenatal care, delivery type, maternal and neonatal severity, and multiple delivery. The average cost of childbirth was 4,328€, with an average of 18.28 contacts between the mother or the newborn and the healthcare facilities. The delivery itself accounted for more than 75% of the overall cost: maternal admission accounted for 57% and neonatal admission for 20%. Prenatal care represented 18% of the overall cost and 75% of overall acts. The average overall cost was 5,815€ for cesarean sections, 4,064€ for vaginal instrumented deliveries and 3,682€ for vaginal non-instrumented deliveries (p < 0.001). The regression model explained 45.5% of the cost variability. The incremental cost of a delivery through cesarean section was 955€ (an increase of 31.9%) compared with an increase of 193€ (6.4%) for an instrumented vaginal delivery. The incremental cost of admitting the newborn to hospital ranged from 420€ (14.0%) to 1,951€ (65.2%) depending on the newborn's severity. Age, origin and prenatal care were not statistically significant or economically relevant. Neither immigration nor prenatal care were associated with a substantial difference in costs. The most important predictors of cost were delivery type and neonatal severity. Given the impact of cesarean sections on the overall cost of childbirth, attempts should be made to take into account its higher cost in the decision of performing a cesarean section.

Development and Evaluation of a Continuing Education Program for Nursing Technicians at a Pediatric Cardiac Intensive Care Unit in a Developing Country.

PubMed

Borim, Bruna Cury; Croti, Ulisses A; Silveira, Patricia C; De Marchi, Carlos H; Moscardini, Airton C; Hickey, Patricia; Jenkins, Kathy

2017-11-01

The nursing profession faces continuous transformations demonstrating the importance of professional continuing education to extend knowledge following technological development without impairing quality of care. Nursing assistants and technicians account for nearly 80% of nursing professionals in Brazil and are responsible for uninterrupted patient care. Extensive knowledge improvement is needed to achieve excellence in nursing care. The objective was to develop and evaluate a continuing education program for nursing technicians at a pediatric cardiac intensive care unit (PCICU) using a virtual learning environment entitled EDUCATE. From July to September 2015, a total of 24 nursing technicians working at the PCICU at a children's hospital located in the northwestern region of São Paulo state (Brazil) fully participated in the continuing education program developed in a virtual learning environment using Wix platform, allowing access to video classes and pre- and post-training theoretical evaluation questionnaires outside the work environment. The evaluation tools recorded participants' knowledge evolution, technological difficulties, educational, and overall rating. Knowledge development was descriptively presented as positive in more than 66.7%. Content and training were considered "excellent" by most participants and 90% showed an interest in the use of technological resources. Technical difficulties were found and quickly resolved by 40% of participants including Internet access, login, and lack of technical expertise. The continuing education program using a virtual learning environment positively contributed to the improvement in theoretical knowledge of nursing technicians in PCICU.

Health workers' views of a program to facilitate physical health care in mental health settings: implications for implementation and training.

PubMed

Baker, Wendy; Harris, Melanie; Battersby, Malcolm

2014-12-01

Physical comorbidities shorten the lifespan of people with severe mental illness therefore mental health clinicians need to support service users in risk factor-related behaviour change. We investigated mental health care workers' views of a physical health self-management support program in order to identify implementation requirements. Qualitative interviews were conducted with workers who had differing levels of experience with a self-management support program. Themes were identified using interpretive descriptive analysis and then matched against domains used in implementation models to draw implications for successful practice change. Three main themes emerged related to: (1) understandings of disease management within job roles; (2) requirements for putting self-management support into practice; and (3) challenges of coordination in disease management. Priority domains from implementation models were inner and outer health service settings. While staff training is required, practice change for care which takes account of both mental and physical health also requires changes in organisational frameworks. © The Royal Australian and New Zealand College of Psychiatrists 2014.

Governance: current trends in board education, competencies, and qualifications.

PubMed

Nash, David B; Murphy, Sean Patrick; Mullaney, Anne D

2011-01-01

Hospitals and health system boards have been under enormous pressure to be more accountable. However, there is now an emerging trend of voluntary, mandatory, and payer-driven board education programs. Currently, 13 states have some type of formal, organized board education and development initiative, 10 of which are classified as "director and/ or board certificate" or "certification" programs; the American Hospital Association (through and with its affiliated Center for Healthcare Governance) has issued a Blue Ribbon Panel Report on core competencies. Finally, both Congress and the Securities and Exchange Commission require publicly traded companies to disclose board and director qualifications. This article reviews these emerging trends and posits that these developments are a necessary prerequisite not only for accountability and better governance but also for quality care.

45 CFR 264.74 - How will we determine the Contingency Fund MOE level for the annual reconciliation?

Code of Federal Regulations, 2010 CFR

2010-10-01

... will exclude the State's share of expenditures from the former IV-A child care programs (AFDC/JOBS..., DEPARTMENT OF HEALTH AND HUMAN SERVICES OTHER ACCOUNTABILITY PROVISIONS What Are the Requirements for the...? (a)(1) The Contingency Fund MOE level includes the State's share of expenditures for AFDC benefit...

45 CFR 264.74 - How will we determine the Contingency Fund MOE level for the annual reconciliation?

Code of Federal Regulations, 2012 CFR

2012-10-01

... will exclude the State's share of expenditures from the former IV-A child care programs (AFDC/JOBS..., DEPARTMENT OF HEALTH AND HUMAN SERVICES OTHER ACCOUNTABILITY PROVISIONS What Are the Requirements for the...? (a)(1) The Contingency Fund MOE level includes the State's share of expenditures for AFDC benefit...

45 CFR 264.74 - How will we determine the Contingency Fund MOE level for the annual reconciliation?

Code of Federal Regulations, 2014 CFR

2014-10-01

... will exclude the State's share of expenditures from the former IV-A child care programs (AFDC/JOBS..., DEPARTMENT OF HEALTH AND HUMAN SERVICES OTHER ACCOUNTABILITY PROVISIONS What Are the Requirements for the...? (a)(1) The Contingency Fund MOE level includes the State's share of expenditures for AFDC benefit...

45 CFR 264.74 - How will we determine the Contingency Fund MOE level for the annual reconciliation?

Code of Federal Regulations, 2011 CFR

2011-10-01

... will exclude the State's share of expenditures from the former IV-A child care programs (AFDC/JOBS..., DEPARTMENT OF HEALTH AND HUMAN SERVICES OTHER ACCOUNTABILITY PROVISIONS What Are the Requirements for the...? (a)(1) The Contingency Fund MOE level includes the State's share of expenditures for AFDC benefit...

45 CFR 264.74 - How will we determine the Contingency Fund MOE level for the annual reconciliation?

Code of Federal Regulations, 2013 CFR

2013-10-01

... will exclude the State's share of expenditures from the former IV-A child care programs (AFDC/JOBS..., DEPARTMENT OF HEALTH AND HUMAN SERVICES OTHER ACCOUNTABILITY PROVISIONS What Are the Requirements for the...? (a)(1) The Contingency Fund MOE level includes the State's share of expenditures for AFDC benefit...

Hanging Out: Community-Based After-School Programs for Children.

ERIC Educational Resources Information Center

Garner, Ruth, Ed.

Noting the major changes in mothers' work lives and the significance that out-of-home care arrangements take on in children's lives, this book is a collection of accounts of what children do after school, both outside and inside after-school centers. The centers described are in differing communities, with differing values and differing ways of…

Counterfeit Compliance with the HIPAA Security Rule: A Study of Information System Success

ERIC Educational Resources Information Center

Johnson, James R.

2013-01-01

The intent of the security standards adopted by the Department of Health and Human Services (DHS) implementing some of the requirements of the Administrative Simplification (AS) subtitle of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) was to improve Federal and private health care programs and to improve the…

Process evaluation to explore internal and external validity of the "Act in Case of Depression" care program in nursing homes.

PubMed

Leontjevas, Ruslan; Gerritsen, Debby L; Koopmans, Raymond T C M; Smalbrugge, Martin; Vernooij-Dassen, Myrra J F J

2012-06-01

A multidisciplinary, evidence-based care program to improve the management of depression in nursing home residents was implemented and tested using a stepped-wedge design in 23 nursing homes (NHs): "Act in case of Depression" (AiD). Before effect analyses, to evaluate AiD process data on sampling quality (recruitment and randomization, reach) and intervention quality (relevance and feasibility, extent to which AiD was performed), which can be used for understanding internal and external validity. In this article, a model is presented that divides process evaluation data into first- and second-order process data. Qualitative and quantitative data based on personal files of residents, interviews of nursing home professionals, and a research database were analyzed according to the following process evaluation components: sampling quality and intervention quality. Nursing home. The pattern of residents' informed consent rates differed for dementia special care units and somatic units during the study. The nursing home staff was satisfied with the AiD program and reported that the program was feasible and relevant. With the exception of the first screening step (nursing staff members using a short observer-based depression scale), AiD components were not performed fully by NH staff as prescribed in the AiD protocol. Although NH staff found the program relevant and feasible and was satisfied with the program content, individual AiD components may have different feasibility. The results on sampling quality implied that statistical analyses of AiD effectiveness should account for the type of unit, whereas the findings on intervention quality implied that, next to the type of unit, analyses should account for the extent to which individual AiD program components were performed. In general, our first-order process data evaluation confirmed internal and external validity of the AiD trial, and this evaluation enabled further statistical fine tuning. The importance of evaluating the first-order process data before executing statistical effect analyses is thus underlined. Copyright © 2012 American Medical Directors Association, Inc. Published by Elsevier Inc. All rights reserved.

Public health departments and accountable care organizations: finding common ground in population health.

PubMed

Ingram, Richard; Scutchfield, F Douglas; Costich, Julia F

2015-05-01

We examined areas of potential collaboration between accountable care organizations and public health agencies, as well as perceived barriers and facilitators. We interviewed 9 key informants on 4 topics: advantages of public health agency involvement in accountable care organizations; services public health agencies could provide; practical, cultural, and legal barriers to accountable care organization-public health agency involvement; and business models that facilitate accountable care organization-public health agency collaboration. Public health agencies could help accountable care organizations partner with community organizations and reach vulnerable patients, provide population-based services and surveillance data, and promote policies that improve member health. Barriers include accountable care organizations' need for short-term financial yield, limited public health agency technical and financial capacity, and the absence of a financial model.

Public Health Departments and Accountable Care Organizations: Finding Common Ground in Population Health

PubMed Central

Ingram, Richard; Scutchfield, F. Douglas

2015-01-01

We examined areas of potential collaboration between accountable care organizations and public health agencies, as well as perceived barriers and facilitators. We interviewed 9 key informants on 4 topics: advantages of public health agency involvement in accountable care organizations; services public health agencies could provide; practical, cultural, and legal barriers to accountable care organization–public health agency involvement; and business models that facilitate accountable care organization–public health agency collaboration. Public health agencies could help accountable care organizations partner with community organizations and reach vulnerable patients, provide population-based services and surveillance data, and promote policies that improve member health. Barriers include accountable care organizations’ need for short-term financial yield, limited public health agency technical and financial capacity, and the absence of a financial model. PMID:25790392

Relevance of stroke code, stroke unit and stroke networks in organization of acute stroke care--the Madrid acute stroke care program.

PubMed

Alonso de Leciñana-Cases, María; Gil-Núñez, Antonio; Díez-Tejedor, Exuperio

2009-01-01

Stroke is a neurological emergency. The early administration of specific treatment improves the prognosis of the patients. Emergency care systems with early warning for the hospital regarding patients who are candidates for this treatment (stroke code) increases the number of patients treated. Currently, reperfusion via thrombolysis for ischemic stroke and attention in stroke units are the bases of treatment. Healthcare professionals and health provision authorities need to work together to organize systems that ensure continuous quality care for the patients during the whole process of their disease. To implement this, there needs to be an appropriate analysis of the requirements and resources with the objective of their adjustment for efficient use. It is necessary to provide adequate information and continuous training for all professionals who are involved in stroke care, including primary care physicians, extrahospital emergency teams and all physicians involved in the care of stroke patients within the hospital. The neurologist has the function of coordinating the protocols of intrahospital care. These organizational plans should also take into account the process beyond the acute phase, to ensure the appropriate application of measures of secondary prevention, rehabilitation, and chronic care of the patients that remain in a dependent state. We describe here the stroke care program in the Community of Madrid (Spain). (c) 2009 S. Karger AG, Basel.

Managed Behavioral Health Care: An Instrument to Characterize Critical Elements of Public Sector Programs

PubMed Central

Ridgely, M Susan; Giard, Julienne; Shern, David; Mulkern, Virginia; Burnam, M Audrey

2002-01-01

Objective To develop an instrument to characterize public sector managed behavioral health care arrangements to capture key differences between managed and “unmanaged” care and among managed care arrangements. Study Design The instrument was developed by a multi-institutional group of collaborators with participation of an expert panel. Included are six domains predicted to have an impact on access, service utilization, costs, and quality. The domains are: characteristics of the managed care plan, enrolled population, benefit design, payment and risk arrangements, composition of provider networks, and accountability. Data are collected at three levels: managed care organization, subcontractor, and network of service providers. Data Collection Methods Data are collected through contract abstraction and key informant interviews. A multilevel coding scheme is used to organize the data into a matrix along key domains, which is then reviewed and verified by the key informants. Principal Findings This instrument can usefully differentiate between and among Medicaid fee-for-service programs and Medicaid managed care plans along key domains of interest. Beyond documenting basic features of the plans and providing contextual information, these data will support the refinement and testing of hypotheses about the impact of public sector managed care on access, quality, costs, and outcomes of care. Conclusions If managed behavioral health care research is to advance beyond simple case study comparisons, a well-conceptualized set of instruments is necessary. PMID:12236386

Effect of the Army Oral Health Maintenance Program (AOHMP) on the Dental Health Status of Army Personnel. AOHMP Evaluation Study. Part 3. Dental Care Requirements of Active Duty Army Personnel, 1978

DTIC Science & Technology

1979-06-01

endodontics , crown and bridge, full and partial dentures, and periodontal therapy , account for about one- third of the time requirements for the...Examiners indicated the numbers of restorations, extractions, teeth needing endodontic therapy , units of crown and bridge, complete den- tures...might be that lieutenants and captains are in a younger age range where the removal of third molars is usually recommended. (3) In the care need areas

China's medical savings accounts: an analysis of the price elasticity of demand for health care.

PubMed

Yu, Hao

2017-07-01

Although medical savings accounts (MSAs) have drawn intensive attention across the world for their potential in cost control, there is limited evidence of their impact on the demand for health care. This paper is intended to fill that gap. First, we built up a dynamic model of a consumer's problem of utility maximization in the presence of a nonlinear price schedule embedded in an MSA. Second, the model was implemented using data from a 2-year MSA pilot program in China. The estimated price elasticity under MSAs was between -0.42 and -0.58, i.e., higher than that reported in the literature. The relatively high price elasticity suggests that MSAs as an insurance feature may help control costs. However, the long-term effect of MSAs on health costs is subject to further analysis.

Socially Accountable Medical Education: An Innovative Approach at Florida International University Herbert Wertheim College of Medicine.

PubMed

Greer, Pedro J; Brown, David R; Brewster, Luther G; Lage, Onelia G; Esposito, Karin F; Whisenant, Ebony B; Anderson, Frederick W; Castellanos, Natalie K; Stefano, Troy A; Rock, John A

2018-01-01

Despite medical advances, health disparities persist, resulting in medicine's renewed emphasis on the social determinants of health and calls for reform in medical education. The Green Family Foundation Neighborhood Health Education Learning Program (NeighborhoodHELP) at Herbert Wertheim College of Medicine provides a platform for the school's community-focused mission. NeighborhoodHELP emphasizes social accountability and interprofessional education while providing evidence-based, patient- and household-centered care. NeighborhoodHELP is a required, longitudinal service-learning outreach program in which each medical student is assigned a household in a medically underserved community. Students, teamed with learners from other professional schools, provide social and clinical services to their household for three years. Here the authors describe the program's engagement approach, logistics, and educational goals and structure. During the first six years of NeighborhoodHELP (September 2010-August 2016), 1,470 interprofessional students conducted 7,452 visits to 848 households with, collectively, 2,252 members. From August 2012, when mobile health centers were added to the program, through August 2016, students saw a total of 1,021 household members through 7,207 mobile health center visits. Throughout this time, households received a variety of free health and social services (e.g., legal aid, tutoring). Compared with peers from other schools, graduating medical students reported more experience with clinical interprofessional education and health disparities. Surveyed residency program directors rated graduates highly for their cultural sensitivity, teamwork, and accountability. Faculty and administrators are focusing on social accountability curriculum integration, systems for assessing and tracking relevant educational and household outcomes, and policy analysis.

Accountable care organizations and prostate cancer care.

PubMed

Hollenbeck, Brent K; Kaufman, Samuel R; Borza, Tudor; Yan, Phyllis; Herrel, Lindsey A; Miller, David C; Luckenbaugh, Amy N; Skolarus, Ted A; Shahinian, Vahakn B

2017-11-01

Accountable care organizations have the potential to increase the value of healthcare by improving population health and enhanced financial stewardship. How practice context modifies effects on a specialty-focused disease, such as prostate cancer care, has implications for their success. We performed a retrospective cohort study of newly diagnosed men with prostate cancer between 2012 and 2013 using national Medicare data. Practice affiliation (small single-specialty, large single-specialty, multispecialty groups) and accountable care organization alignment were measured at the patient level. Generalized linear multivariable models were fitted to derive adjusted rates of treatment and spending for the 12-month period after diagnosis according to accountable care organization alignment and practice affiliation. Of 15,640 patients with newly diagnosed prostate cancer, 1,100 (7.0%) were aligned with accountable care organizations. Patients in these organizations had similar use of curative treatment to those not in accountable care organizations (71.4% vs. 70.0%, respectively; p=0.33), which did not vary with practice affiliation (p=0.39). Adjusted spending was higher among patients in accountable care organizations ($20,916 vs. $19,773, p=0.03); however, this relationship was independent of the practice affiliation (p=0.90). Higher accountable care organization penetration within a practice was associated with increased spending (p<0.05) but not with treatment (p=0.87). Prostate cancer patients aligned with accountable care organizations had similar rates of treatment, but increased spending, in the year following diagnosis. These findings were similar across practice affiliations. Better specialist engagement by accountable care organizations may be necessary for them to alter practice patterns for specialty care.

Early impact of Medicare accountable care organizations on cancer surgery outcomes.

PubMed

Herrel, Lindsey A; Norton, Edward C; Hawken, Scott R; Ye, Zaojun; Hollenbeck, Brent K; Miller, David C

2016-09-01

Accountable care organizations (ACOs) were established to improve care and outcomes for beneficiaries requiring highly coordinated, complex care. The objective of this study was to evaluate the association between hospital ACO participation and the outcomes of major surgical oncology procedures. This was a retrospective cohort study of Medicare beneficiaries older than 65 years who were undergoing a major surgical resection for colorectal, bladder, esophageal, kidney, liver, ovarian, pancreatic, lung, or prostate cancer from 2011 through 2013. A difference-in-differences analysis was implemented to compare the postimplementation period (January 2013 through December 2013) with the baseline period (January 2011 through December 2012) to assess the impact of hospital ACO participation on 30-day mortality, complications, readmissions, and length of stay (LOS). Among 384,519 patients undergoing major cancer surgery at 106 ACO hospitals and 2561 control hospitals, this study found a 30-day mortality rate of 3.4%, a readmission rate of 12.5%, a complication rate of 43.8%, and a prolonged LOS rate of 10.0% in control hospitals and similar rates in ACO hospitals. Secular trends were noted, with reductions in perioperative adverse events in control hospitals between the baseline and postimplementation periods: mortality (percentage-point reduction, 0.1%; P = .19), readmissions (percentage-point reduction, 0.4%; P = .001), complications (percentage-point reduction, 1.0%; P < .001), and prolonged LOS (percentage-point reduction, 1.1%; P < .001). After accounting for these secular trends, this study identified no significant effect of hospital participation in an ACO on the frequency of perioperative outcomes (difference-in-differences estimator P values, .24-.72). Early hospital participation in the Medicare Shared Savings Program ACO program was not associated with greater reductions in adverse perioperative outcomes for patients undergoing major cancer surgery in comparison with control hospitals. Cancer 2016. © 2016 American Cancer Society. Cancer 2016;122:2739-2746. © 2016 American Cancer Society. © 2016 American Cancer Society.

Utilizing Team Debate to Increase Student Abilities for Mentoring and Critical Appraisal of Global Health Care in Doctor of Nursing Practice Programs.

PubMed

Elliott, Naomi; Farnum, Karen; Beauchesne, Michelle

2016-01-01

Although graduates of doctor of nursing practice (DNP) programs are expected to demonstrate competence in advanced clinical scholarship, mentoring, and leadership, little is published about how team debate on a global health care topic supports DNP student learning and skill development. This article reports on an illuminative evaluation of DNP student learning experiences of team debate in the context of a 2-week international school program in Ireland. A focused illuminative evaluation approach involving a cohort of seven DNP students, who had participated in an international school team debate, was used. Data were collected using a Web-based qualitative questionnaire designed to elicit in-depth reflective accounts of DNP students' learning experiences. Content analysis revealed that team debate on a global health care topic enhanced learning in relation to fostering critical thinking and critical appraisal skills; encouraging teamwork; providing opportunities for mentoring, relationship building, and socialization into profession; and, from the DNP student perspective, increasing knowledge and global understanding of health care. This evaluation provides insights for nurse educators into the benefits of introducing team debate as a group activity to enhancing scholarly inquiry and mentoring skills of DNP students. Further research to evaluate team debate in other nurse education programs is needed. Copyright © 2016 Elsevier Inc. All rights reserved.

Future considerations for clinical dermatology in the setting of 21st century American policy reform: The Medicare Access and Children's Health Insurance Program Reauthorization Act and Alternative Payment Models in dermatology.

PubMed

Barbieri, John S; Miller, Jeffrey J; Nguyen, Harrison P; Forman, Howard P; Bolognia, Jean L; VanBeek, Marta J

2017-06-01

With the introduction of the Medicare Access and Children's Health Insurance Program Reauthorization Act, clinicians who are not eligible for an exemption must choose to participate in 1 of 2 new reimbursement models: the Merit-based Incentive Payment System or Alternative Payment Models (APMs). Although most dermatologists are expected to default into the Merit-based Incentive Payment System, some may have an interest in exploring APMs, which have associated financial incentives. However, for dermatologists interested in the APM pathway, there are currently no options other than joining a qualifying Accountable Care Organization, which make up only a small subset of Accountable Care Organizations overall. As a result, additional APMs relevant to dermatologists are needed to allow those interested in the APMs to explore this pathway. Fortunately, the Medicare Access and Children's Health Insurance Program Reauthorization Act establishes a process for new APMs to be approved and the creation of bundled payments for skin diseases may represent an opportunity to increase the number of APMs available to dermatologists. In this article, we will provide a detailed review of APMs under the Medicare Access and Children's Health Insurance Program Reauthorization Act and discuss the development and introduction of APMs as they pertain to dermatology. Copyright © 2017 American Academy of Dermatology, Inc. Published by Elsevier Inc. All rights reserved.

Improving quality in Medicaid: the use of care management processes for chronic illness and preventive care.

PubMed

Rittenhouse, Diane R; Robinson, James C

2006-01-01

Care management processes (CMPs), tools to improve the efficiency and quality of primary care delivery, are particularly important for low-income patients facing substantial barriers to care. To measure the adoption of CMPs by medical groups, Independent Practice Associations, community clinics, and hospital-based clinics in California's Medicaid program and the factors associated with CMP adoption. Telephone survey of every provider organization with at least 6 primary care physicians and at least 1 Medi-Cal HMO contract, Spring 2003. One hundred twenty-three organizations participated, accounting for 64% of provider organizations serving Medicaid managed care in California. We surveyed 30 measures of CMP use for asthma and diabetes, and for child and adolescent preventive services. The mean number of CMPs used by each organization was 4.5 for asthma and 4.9 for diabetes (of a possible 8). The mean number of CMPs for preventive services was 4.0 for children and 3.5 for adolescents (of a possible 7). Organizations with more extensive involvement in Medi-Cal managed care used more CMPs for chronic illness and preventive service. Community clinics and hospital-based clinics used more CMPs for asthma and diabetes than did Independent Practice Associations (IPAs), and profitable organizations used more CMPs for child and adolescent preventive services than did entities facing severe financial constraints. The use of CMPs by Medicaid HMOs and the presence of external (financial and nonfinancial) incentives for clinical performance were strongly associated with use of care management by provider organizations. Physician and provider organizations heavily involved in California's Medicaid program are extensively engaged in preventive and chronic care management programs.

Oregon's Medicaid Reform And Transition To Global Budgets Were Associated With Reductions In Expenditures.

PubMed

McConnell, K John; Renfro, Stephanie; Lindrooth, Richard C; Cohen, Deborah J; Wallace, Neal T; Chernew, Michael E

2017-03-01

In 2012 Oregon initiated an ambitious delivery system reform, moving the majority of its Medicaid enrollees into sixteen coordinated care organizations, a type of Medicaid accountable care organization. Using claims data, we assessed measures of access, appropriateness of care, utilization, and expenditures for five service areas (evaluation and management, imaging, procedures, tests, and inpatient facility care), comparing Oregon to the neighboring state of Washington. Overall, the transformation into coordinated care organizations was associated with a 7 percent relative reduction in expenditures across the sum of these services, attributable primarily to reductions in inpatient utilization. The change to coordinated care organizations also demonstrated reductions in avoidable emergency department visits and improvements in some measures of appropriateness of care, but also exhibited reductions in primary care visits, a potential area of concern. Oregon's coordinated care organizations could provide lessons for controlling health care spending for other state Medicaid programs. Project HOPE—The People-to-People Health Foundation, Inc.

High Risk of Readmission in Octogenarians Undergoing Primary Hip Arthroplasty.

PubMed

Malkani, Arthur L; Dilworth, Brian; Ong, Kevin; Baykal, Doruk; Lau, Edmund; Mackin, Theresa N; Lee, Gwo-Chin

2017-12-01

As life expectancy increases, more elderly patients with end-stage hip arthritis are electing to undergo primary THA. Octogenarians undergoing THA have more comorbidities than younger patients, but this is not reflected in risk adjustment models for bundled care programs. The burden of care associated with THA in octogenarians has not been well characterized, and doing so may help these value-based programs make adjustments so that this vulnerable patient population does not risk losing access under accountable care models. The purpose of this study was to describe care use, comorbidities, and complications among octogenarians undergoing primary THA. Five percent of the Medicare national administrative claims data was queried to identify patients diagnosed with hip osteoarthritis between January 1, 1998, and December 31, 2013. Patients who underwent primary THA were identified and followed longitudinally during the study period using their unique, encrypted Medicare beneficiary identifiers. We compared risk factors and complications between the octogenarian group versus those aged 65 to 69 years. Multivariate Cox regression was used to evaluate the effect of patient/hospital factors on risk of revision, periprosthetic joint infection, dislocation, venous thromboembolism (VTE), and mortality. Patient factors in the model included age, sex, race, region, socioeconomic status, and health status based on Charlson comorbidity score 12 months before replacement surgery. There were 11,960 THAs in the octogenarians in 1998, which increased to 21,620 in 2013, an 81% increase during this study period. Octogenarians were more likely to have a Charlson score of 3 or higher than those patients aged 65 to 69 years (30% versus 17%, odds ratio [OR] 2.07 [1.98-2.20]; p < 0.001), and they were more likely to have coronary artery disease or congestive heart failure (47% versus 29%, OR 2.16 [2.06-2.26]; p < 0.001). The octogenarian group had a greater risk of dislocation (+12%, p = 0.01), VTE (+14%, p < 0.001), and mortality (+150%, p < 0.001) compared with the younger age cohort. A total of 21% of the octogenarians were readmitted after surgery compared with 12% for patients in the younger group (OR=1.64, 95% confidence interval 1.54-1.75; p < 0.001). Because octogenarians are at increased risk of dislocation, VTE, medical complications, and mortality after THA, value-based care models that penalize hospitals for readmissions and complications may inadvertently result in loss of access to care for this group of patients as a result of the financial makeup of these bundled care models. Value-based care models were developed to improve care and decrease healthcare costs but may have unintended consequences in the octogenarian with higher complication and readmission risks. Financial losses may lead to institutions from withdrawing from the Bundled Payments for Care Improvement program. To try to prevent this from happening to this vulnerable patient population, bundled care programs should evolve and be modified to allow for risk stratification in the overall payment formula to account for increased age and comorbid conditions to ensure continued successful participation in the program among all the stakeholders. Level III, therapeutic study.

The Latino Physician Shortage: How the Affordable Care Act Increases the Value of Latino Spanish-Speaking Physicians and What Efforts Can Increase Their Supply.

PubMed

Daar, David A; Alvarez-Estrada, Miguel; Alpert, Abigail E

2018-02-01

The United States Latino population is growing at a rapid pace and is set to reach nearly 30% by 2050. The demand for culturally and linguistically competent health care is increasing in lockstep with this growth; however, the supply of doctors with skills and experience suited for this care is lagging. In particular, there is a major shortage of Latino Spanish-speaking physicians, and the gap between demand and supply is widening. The implementation of the Affordable Care Act (ACA) has increased the capacity of the US healthcare system to care for the growing Latino Spanish-speaking population, through health insurance exchanges, increased funding for safety net institutions, and efforts to improve efficiency and coordination of care, particularly with Accountable Care Organizations and the Hospital Readmissions Reduction Program. With these policies in mind, the authors discuss how the value of Latino Spanish-speaking physicians to the healthcare system has increased under the environment of the ACA. In addition, the authors highlight key efforts to increase the supply of this physician population, including the implementation of the Deferred Action for Childhood Arrivals Act, premedical pipeline programs, and academic medicine and medical school education initiatives to increase Latino representation among physicians.

US Health Care Reform and Transplantation, Part II: impact on the public sector and novel health care delivery systems.

PubMed

Axelrod, D A; Millman, D; Abecassis, M M

2010-10-01

The Patient Protection and Affordable Care Act passed in 2010 will result in dramatic expansion of publically funded health insurance coverage for low-income individuals. It is estimated that of the 32 million newly insured, 16 million will obtain coverage through expansion of the Medicaid Program, and the remaining 16 million will purchase coverage through their employer or newly legislated insurance exchanges. While the Act contains numerous provisions to improve access to private insurance as discussed in Part I of this analysis, public sector coverage will significantly be affected. The cost of health care reform will be borne disproportionately by Medicare, which faces nearly $500 billion in cuts to be identified by a new independent board. Transplant centers should be concerned about the impact of the reform on the financial aspects of transplantation. In addition, this legislation also utilizes the Medicare Program to drive reform of the health care delivery system, by encouraging the development of integrated Accountable Care Organizations, experimentation with new 'models' of healthcare delivery, and expanded support for Comparative Effectiveness Research. Transplant providers, including transplant centers and physicians/surgeons need to lead this movement, drawing on our experience providing comprehensive multidisciplinary care under global budgets with publically reported outcomes.

Guidelines for a Comprehensive Care Program to Ostomized Patients and Families: a Nursing proposal1

PubMed Central

de Figueiredo, Paula Alvarenga; Alvim, Neide Aparecida Titonelli

2016-01-01

Objectives: describe care needs and demands that mark the discursive practices of ostomized clients and family members and discuss guidelines for a comprehensive care program to ostomized clients and their families, organized by macrosociological categories. Method: Creative and Sensitive, involving 17 ostomized subjects and family members at a municipal outpatient clinic. The ethical aspects were complied with. A characterization form was used, as well as Creativity and Sensitivity Dynamics: "speaking map", "body-knowledge" and "calendar". Critical Discourse Analysis was applied. Results: the health needs and care demands of the ostomized patients and their family members, in their multiple dimensions, were constituted in the home and community, outpatient and social context, implying new orientations for nursing care. The unveiling of the data brought elements that constituted guidelines, in a macrosociological approach, to achieve the expanded integrality of nursing care. Conclusion: the ostomized clients are unique in their genre/peculiar from Latin sui generis, calling for strategies that respond to and distinguish their specificities. Elaborating a Public Health Policy that improves and reorganizes the care demands, taking into account these individual biopsychosocial and spiritual aspects, is a possible and irrevocable target in the attempt to achieve better conditions of health and wellbeing. PMID:27192418

Impact of Early Head Start in North Carolina on Dental Care Use Among Children Younger Than 3 Years.

PubMed

Burgette, Jacqueline M; Preisser, John S; Weinberger, Morris; King, Rebecca S; Lee, Jessica Y; Rozier, R Gary

2017-04-01

To examine the effects of North Carolina Early Head Start (EHS), an early education program for low-income children younger than 3 years and their families, on dental care use among children. We performed a quasi-experimental study in which we interviewed 479 EHS and 699 non-EHS parent-child dyads at baseline (2010-2012) and at a 24-month follow-up (2012-2014). We estimated the effects of EHS participation on the probability of having a dental care visit after controlling for baseline dental care need and use and a propensity score covariate; we included random effects to account for EHS program clustering. The odds of having a dental care visit of any type (adjusted odds ratio [OR] = 2.5; 95% confidence interval [CI] = 1.74, 3.48) and having a preventive dental visit (adjusted OR = 2.6; 95% CI = 1.84, 3.63) were higher among EHS children than among non-EHS children. In addition, the adjusted mean number of dental care visits among EHS children was 1.3 times (95% CI = 1.17, 1.55) the mean number among non-EHS children. This study is the first, to our knowledge, to demonstrate that EHS participation increases dental care use among disadvantaged young children.

Primary care training and the evolving healthcare system.

PubMed

Peccoralo, Lauren A; Callahan, Kathryn; Stark, Rachel; DeCherrie, Linda V

2012-01-01

With growing numbers of patient-centered medical homes and accountable care organizations, and the potential implementation of the Patient Protection and Affordable Care Act, the provision of primary care in the United States is expanding and changing. Therefore, there is an urgent need to create more primary-care physicians and to train physicians to practice in this environment. In this article, we review the impact that the changing US healthcare system has on trainees, strategies to recruit and retain medical students and residents into primary-care internal medicine, and the preparation of trainees to work in the changing healthcare system. Recruitment methods for medical students include early preclinical exposure to patients in the primary-care setting, enhanced longitudinal patient experiences in clinical clerkships, and primary-care tracks. Recruitment methods for residents include enhanced ambulatory-care training and primary-care programs. Financial-incentive programs such as loan forgiveness may encourage trainees to enter primary care. Retaining residents in primary-care careers may be encouraged via focused postgraduate fellowships or continuing medical education to prepare primary-care physicians as both teachers and practitioners in the changing environment. Finally, to prepare primary-care trainees to effectively and efficiently practice within the changing system, educators should consider shifting ambulatory training to community-based practices, encouraging resident participation in team-based care, providing interprofessional educational experiences, and involving trainees in quality-improvement initiatives. Medical educators in primary care must think innovatively and collaboratively to effectively recruit and train the future generation of primary-care physicians. © 2012 Mount Sinai School of Medicine.

A generic model for evaluating payor net cost savings from a disease management program.

PubMed

McKay, Niccie L

2006-01-01

Private and public payors increasingly are turning to disease management programs as a means of improving the quality of care provided and controlling expenditures for individuals with specific medical conditions. This article presents a generic model that can be adapted to evaluate payor net cost savings from a variety of types of disease management programs, with net cost savings taking into account both changes in expenditures resulting from the program and the costs of setting up and operating the program. The model specifies the required data, describes the data collection process, and shows how to calculate the net cost savings in a spreadsheet format. An accompanying hypothetical example illustrates how to use the model.

An Analysis of a Biometric Screening and Premium Incentive-Based Employee Wellness Program: Enrollment Patterns, Cost, and Outcome.

PubMed

Maeng, Daniel D; Geng, Zhi; Marshall, Wendy M; Hess, Allison L; Tomcavage, Janet F

2017-11-14

Since 2012, a large health care system has offered an employee wellness program providing premium discounts for those who voluntarily undergo biometric screenings and meet goals. This study evaluates the program impact on care utilization and total cost of care, taking into account employee self-selection into the program. A retrospective claims data analysis of 6453 employees between 2011 and 2015 was conducted, categorizing the sample into 3 mutually exclusive subgroups: Subgroup 1 enrolled and met goals in all years, Subgroup 2 enrolled or met goals in some years but not all, and Subgroup 3 never enrolled. Each subgroup was compared to a cohort of employees in other employer groups (N = 24,061). Using a difference-in-difference method, significant reductions in total medical cost (14.2%; P = 0.014) and emergency department (ED) visits (11.2%; P = 0.058) were observed only among Subgroup 2 in 2015. No significant impact was detected among those in Subgroup 1. Those in Subgroup 1 were less likely to have chronic conditions at baseline. The results indicate that the wellness program enrollment was characterized by self-selection of healthier employees, among whom the program appeared to have no significant impact. Yet, cost savings and reductions in ED visits were observed among the subset of employees who enrolled or met goal in some years but not all, suggesting a potential link between the wellness program and positive behavior changes among certain subsets of the employee population.

Surgical education to improve the quality of patient care: the role of practice-based learning and improvement.

PubMed

Sachdeva, Ajit K

2007-11-01

Health care is going through immense change, and concerns regarding the quality of patient care and patient safety continue to be expressed in many national forums. A variety of stakeholders are demanding greater accountability from the health care profession. Education is key to supporting surgeons' efforts to provide high-quality patient care during these challenging times. Educational programs for surgeons should be founded on principles of continuous professional development (CPD) and practice-based learning and improvement (PBLI). CPD focuses on the specific needs of individual surgeons and involves lifelong learning throughout a surgeon's career. It needs to form the basis of PBLI efforts. PBLI involves a cycle of four steps--identifying areas for improvement, engaging in learning, applying new knowledge and skills to practice, and checking for improvement. Ongoing involvement in PBLI activities to address specific learning needs should positively impact a surgeon's practice and improve outcomes of surgical care.

Linking and integrating computers for maternity care.

PubMed

Lumb, M; Fawdry, R

1990-12-01

Functionally separate computer systems have been developed for many different areas relevant to maternity care, e.g. maternity data collection, pathology and imaging reports, staff rostering, personnel, accounting, audit, primary care etc. Using land lines, modems and network gateways, many such quite distinct computer programs or databases can be made accessible from a single terminal. If computer systems are to attain their full potential for the improvement of the maternity care, there will be a need not only for terminal emulation but also for more complex integration. Major obstacles must be overcome before such integration is widely achieved. Technical and conceptual progress towards overcoming these problems is discussed, with particular reference to the OSI (open systems interconnection) initiative, to the Read clinical classification and to the MUMMIES CBS (Common Basic Specification) Maternity Care Project. The issue of confidentiality is also briefly explored.

Quality of Care Improves for Patients with Diabetes in Medicare Shared Savings Accountable Care Organizations: Organizational Characteristics Associated with Performance.

PubMed

Fraze, Taressa K; Lewis, Valerie A; Tierney, Emily; Colla, Carrie H

2017-12-06

Accountable care organizations (ACOs), a primary care-centric delivery and payment model, aim to promote integrated population health, which may improve care for those with chronic conditions such as diabetes. Research has shown that, overall, the ACO model is effective at reducing costs, but there is substantial variation in how effective different types of ACOs are at impacting costs and improving care delivery. This study examines how ACO organizational characteristics - such as composition, staffing, care management, and experiences with health reform - were associated with quality of care delivered to patients with diabetes. Secondary data were analyzed retrospectively to examine Medicare Shared Savings Program (MSSP) ACOs' performance on diabetes metrics in the first 2 years of ACO contracts. Ordinary least squares was used to analyze 162 MSSP ACOs with publicly available performance data and the National Survey of ACOs. ACOs improved performance significantly for patients with diabetes between contract years 1 and 2. In year 1, also having a private payer contract and an increased number of services within the ACO were positively associated with performance, while having a community health center or a hospital were negatively associated with performance. Better performance in year 1 was negatively associated with improved performance in year 2. This study found that ACOs substantively improved diabetes management within initial contract years. ACOs may need different types of support throughout their contracts to ensure continued improvements in performance.

Children's Specialized Hospital and GetWellNetwork Collaborate to Improve Patient Education and Outcomes Using an Innovative Approach.

PubMed

Kompany, Laura; Luis, Kiersten; Manganaro, Julie; Motacki, Kathleen; Mustacchio, Elaine; Provenzano, Donna

2016-01-01

Patient education in a pediatric setting is unique. There are different patient ages, degrees of learning, and diagnoses to take into account when educating children and their families. A new and innovative trend in practice called Interactive Patient Care (IPC) integrates technology into care processes to advance pediatric nursing education and patient and family satisfaction. Children's Specialized Hospital is the first pediatric rehabilitation hospital to develop and implement this type of program using an IPC platform from the GetWellNetwork. With the implementation of the GetWellNetwork, Children's Specialized Hospital has achieved positive results in patient satisfaction, health care utilization, quality, and safety measures.

Predicting the Reliability of Ceramics Under Transient Loads and Temperatures With CARES/Life

NASA Technical Reports Server (NTRS)

Nemeth, Noel N.; Jadaan, Osama M.; Palfi, Tamas; Baker, Eric H.

2003-01-01

A methodology is shown for predicting the time-dependent reliability of ceramic components against catastrophic rupture when subjected to transient thermomechanical loads (including cyclic loads). The methodology takes into account the changes in material response that can occur with temperature or time (i.e., changing fatigue and Weibull parameters with temperature or time). This capability has been added to the NASA CARES/Life (Ceramic Analysis and Reliability Evaluation of Structures/Life) code. The code has been modified to have the ability to interface with commercially available finite element analysis (FEA) codes executed for transient load histories. Examples are provided to demonstrate the features of the methodology as implemented in the CARES/Life program.

Reciprocal Love: Mentoring Black and Latino Males through an Ethos of Care

ERIC Educational Resources Information Center

Jackson, Iesha; Sealey-Ruiz, Yolanda; Watson, Wanda

2014-01-01

Although mentoring programs can produce positive outcomes for youth, more research is needed that offers an account of how Black and Latino male mentors and mentees experience mentoring. This phenomenological study highlights the voices of a mentor and 14 Black and Latino males who are part of the Umoja Network for Young Men (UMOJA) an all-male,…

Health Facilities: New York State's Oversight of Nursing Homes and Hospitals. Report to the Honorable Bill Green, House of Representatives.

ERIC Educational Resources Information Center

General Accounting Office, New York, NY. Regional Office.

At the request of Congressman William Green, the General Accounting Office (GAO) evaluated the validity of allegations about deficiencies in the New York State Department of Health's nursing home and hospital inspection processes for certification for participation in the Medicare and Medicaid programs. Health Care Financing Administration and…

Planning the Development of Measurement and Evaluation Services for Use in Occupational Programs at Postsecondary Institutions. Final Report.

ERIC Educational Resources Information Center

Sharon, Amiel T.; And Others

The purpose of this study was to obtain information that will make it possible to plan for the development of occupational competency assessment procedures in a rational manner, based on the expressed needs of occupational educators and employers. Eight fields were selected for scrutiny: Accounting, Agribusiness, Data Processing, Day Care,…

Little Evidence Exists To Support The Expectation That Providers Would Consolidate To Enter New Payment Models.

PubMed

Neprash, Hannah T; Chernew, Michael E; McWilliams, J Michael

2017-02-01

Provider consolidation has been associated with higher health care prices and spending. The prevailing wisdom is that payment reform will accelerate consolidation, especially between physicians and hospitals and among physician groups, as providers position themselves to bear financial risk for the full continuum of patient care. Drawing on data from a number of sources from 2008 onward, we examined the relationship between Medicare's accountable care organization (ACO) programs and provider consolidation. We found that consolidation was under way in the period 2008-10, before the Affordable Care Act (ACA) established the ACO programs. While the number of hospital mergers and the size of specialty-oriented physician groups increased after the ACA was passed, we found minimal evidence that consolidation was associated with ACO penetration at the market level or with physicians' participation in ACOs within markets. We conclude that payment reform has been associated with little acceleration in consolidation in addition to trends already under way, but there is evidence of potential defensive consolidation in response to new payment models. Project HOPE—The People-to-People Health Foundation, Inc.

Introducing health gains in location-allocation models: A stochastic model for planning the delivery of long-term care

NASA Astrophysics Data System (ADS)

Cardoso, T.; Oliveira, M. D.; Barbosa-Póvoa, A.; Nickel, S.

2015-05-01

Although the maximization of health is a key objective in health care systems, location-allocation literature has not yet considered this dimension. This study proposes a multi-objective stochastic mathematical programming approach to support the planning of a multi-service network of long-term care (LTC), both in terms of services location and capacity planning. This approach is based on a mixed integer linear programming model with two objectives - the maximization of expected health gains and the minimization of expected costs - with satisficing levels in several dimensions of equity - namely, equity of access, equity of utilization, socioeconomic equity and geographical equity - being imposed as constraints. The augmented ε-constraint method is used to explore the trade-off between these conflicting objectives, with uncertainty in the demand and delivery of care being accounted for. The model is applied to analyze the (re)organization of the LTC network currently operating in the Great Lisbon region in Portugal for the 2014-2016 period. Results show that extending the network of LTC is a cost-effective investment.

Establishing a baseline to measure change in political will and the use of data for decision-making in maternal and newborn health in six African countries.

PubMed

Nove, Andrea; Hulton, Louise; Martin-Hilber, Adriane; Matthews, Zoe

2014-10-01

The Evidence for Action (E4A) program assumes that both resource allocation and quality of care can improve via a strategy that combines evidence and advocacy to stimulate accountability. The present paper explains the methods used to collect baseline monitoring data using two tools developed to inform program design in six focus countries. The first tool is designed to understand the extent to which decision-makers have access to the data they need, when they need it, and in meaningful formats, and then to use the data to prioritize, plan, and allocate resources. The second tool seeks the views of people working in the area of maternal and newborn health (MNH) about political will, including: quality of care, the political and financial priority accorded to MNH, and the extent to which MNH decision-makers are accountable to service users. Findings indicate significant potential to improve access to and use of data for decision-making, particularly at subnational levels. Respondents across all six program countries reported lack of access by ordinary citizens to information on the health and MNH budget, and data on MNH outcomes. In all six countries there was a perceived inequity in the distribution of resources and a perception that politicians do not fully understand the priorities of their constituents. Copyright © 2014. Published by Elsevier Ireland Ltd.

Preventive care quality of Medicare Accountable Care Organizations: Associations of organizational characteristics with performance

PubMed Central

Albright, Benjamin B.; Lewis, Valerie A.; Ross, Joseph S.; Colla, Carrie H.

2015-01-01

Background Accountable Care Organizations (ACOs) are a delivery and payment model aiming to coordinate care, control costs, and improve quality. Medicare ACOs are responsible for eight measures of preventive care quality. Objectives To create composite measures of preventive care quality and examine associations of ACO characteristics with performance. Design Cross-sectional study of Medicare Shared Savings Program and Pioneer participants. We linked quality performance to descriptive data from the National Survey of ACOs. We created composite measures using exploratory factor analysis, and used regression to assess associations with organizational characteristics. Results Of 252 eligible ACOs, 246 reported on preventive care quality, 177 of which completed the survey (response rate=72%). In their first year, ACOs lagged behind PPO performance on the majority of comparable measures. We identified two underlying factors among eight measures and created composites for each: disease prevention, driven by vaccines and cancer screenings, and wellness screening, driven by annual health screenings. Participation in the Advanced Payment Model, having fewer specialists, and having more Medicare ACO beneficiaries per primary care provider were associated with significantly better performance on both composites. Better performance on disease prevention was also associated with inclusion of a hospital, greater electronic health record capabilities, a larger primary care workforce, and fewer minority beneficiaries. Conclusions ACO preventive care quality performance is related to provider composition and benefitted by upfront investment. Vaccine and cancer screening quality performance is more dependent on organizational structure and characteristics than performance on annual wellness screenings, likely due to greater complexity in eligibility determination and service administration. PMID:26759974

Preventive Care Quality of Medicare Accountable Care Organizations: Associations of Organizational Characteristics With Performance.

PubMed

Albright, Benjamin B; Lewis, Valerie A; Ross, Joseph S; Colla, Carrie H

2016-03-01

Accountable Care Organizations (ACOs) are a delivery and payment model aiming to coordinate care, control costs, and improve quality. Medicare ACOs are responsible for 8 measures of preventive care quality. To create composite measures of preventive care quality and examine associations of ACO characteristics with performance. This is a cross-sectional study of Medicare Shared Savings Program and Pioneer participants. We linked quality performance to descriptive data from the National Survey of ACOs. We created composite measures using exploratory factor analysis, and used regression to assess associations with organizational characteristics. Of 252 eligible ACOs, 246 reported on preventive care quality, 177 of which completed the survey (response rate=72%). In their first year, ACOs lagged behind PPO performance on the majority of comparable measures. We identified 2 underlying factors among 8 measures and created composites for each: disease prevention, driven by vaccines and cancer screenings, and wellness screening, driven by annual health screenings. Participation in the Advanced Payment Model, having fewer specialists, and having more Medicare ACO beneficiaries per primary care provider were associated with significantly better performance on both composites. Better performance on disease prevention was also associated with inclusion of a hospital, greater electronic health record capabilities, a larger primary care workforce, and fewer minority beneficiaries. ACO preventive care quality performance is related to provider composition and benefitted by upfront investment. Vaccine and cancer screening quality performance is more dependent on organizational structure and characteristics than performance on annual wellness screenings, likely due to greater complexity in eligibility determination and service administration.

Moving toward implementation: the potential for accountable care organizations and private-public partnerships to advance active neighborhood design.

PubMed

Zusman, Edie E; Carr, Sara Jensen; Robinson, Judy; Kasirye, Olivia; Zell, Bonnie; Miller, William Jahmal; Duarte, Teri; Engel, Adrian B; Hernandez, Monica; Horton, Mark B; Williams, Frank

2014-12-01

The 2010 Affordable Care Act's (ACA) aims of lowering costs and improving quality of care will renew focus on preventive health strategies. This coincides with a trend in medicine to reconsider population health approaches as part of the standard curriculum. This intersection of new policy and educational climates presents a unique opportunity to reconsider traditional healthcare structures. This paper introduces and advances an alignment that few have considered. We propose that accountable care organizations (ACOs), which are expected to proliferate under the ACA, present the best opportunity to establish partnerships between healthcare, public health, and community-based organizations to achieve the legislation's goals. One example is encouraging daily physical activity via built environment interventions and programs, which is recommended by numerous groups. We highlight how nonprofit organizations in Sacramento, California have been able to leverage influence, capital, and policy to encourage design for active living, and how their work is coordinating with public health and healthcare initiatives. In conclusion, we critically examine potential barriers to the success of partnerships between ACOs and community organizations and encourage further exploration and evaluation. Copyright © 2014 Elsevier Inc. All rights reserved.

Who wins and who loses? Public transfer accounts for US generations born 1850 to 2090

PubMed Central

Bommier, Antoine; Miller, Tim; Zuber, Stéphane

2010-01-01

Public transfer programs in industrial nations are thought to benefit the elderly through pension and health care programs at the expense of the young and future generations. However, this intergenerational picture changes if public education is also considered as a transfer program. We calculate the net present value (NPV) of benefits received minus taxes paid for US generations born 1850 to 2090. Surprisingly, all generations 1950 to 2050 are net gainers, while many current elderly are losers. Windfall gains from starting Social Security and Medicare partially offset windfall losses from starting public education, roughly consistent with the Becker-Murphy theory. PMID:20300431

Levels of maternal care in dogs affect adult offspring temperament

NASA Astrophysics Data System (ADS)

Foyer, Pernilla; Wilsson, Erik; Jensen, Per

2016-01-01

Dog puppies are born in a state of large neural immaturity; therefore, the nervous system is sensitive to environmental influences early in life. In primates and rodents, early experiences, such as maternal care, have been shown to have profound and lasting effects on the later behaviour and physiology of offspring. We hypothesised that this would also be the case for dogs with important implications for the breeding of working dogs. In the present study, variation in the mother-offspring interactions of German Shepherd dogs within the Swedish breeding program for military working dogs was studied by video recording 22 mothers with their litters during the first three weeks postpartum. The aim was to classify mothers with respect to their level of maternal care and to investigate the effect of this care on pup behaviour in a standardised temperament test carried out at approximately 18 months of age. The results show that females differed consistently in their level of maternal care, which significantly affected the adult behaviour of the offspring, mainly with respect to behaviours classified as Physical and Social Engagement, as well as Aggression. Taking maternal quality into account in breeding programs may therefore improve the process of selecting working dogs.

Evaluation of a counseling training program for nursing staff.

PubMed

Arranz, Pilar; Ulla, Sara M; Ramos, José L; Del Rincón, Carolina; López-Fando, Teresa

2005-02-01

One of the essential issues in nurses' daily work is interaction with patients, patients' families, and co-workers. However, in the Spanish academic programs for Nursing Schools, social interaction skills do not receive adequate attention and nurses often report communication problems. In order to diminish these difficulties and to train nursing staff to better manage interaction, an intensive counseling training program was designed and implemented in a General University Hospital. The main aim of this study was to evaluate the effects of a counseling training program and assessing the evolution of difficulties that professionals perceived in their work in three different periods: before the training, after the training, and at follow-up, 2 months after the program was delivered. According to the results, we can maintain the hypothesis that the counseling training program reduces perceived interaction difficulties in nursing staff. Consequently, we can expect a further improvement in the interaction performance with patients and their families after the training. These findings suggest that counseling training has to be taken into account to improve quality of care in health care providers, and it may also help to prevent professional burnout by increasing competence level at minimum personal cost.

Costs and consequences of a cash transfer for hospital births in a rural district of Uttar Pradesh, India.

PubMed

Coffey, Diane

2014-08-01

The Janani Suraksha Yojana, India's "safe motherhood program," is a conditional cash transfer to encourage women to give birth in health facilities. Despite the program's apparent success in increasing facility-based births, quantitative evaluations have not found corresponding improvements in health outcomes. This study analyses original qualitative data collected between January, 2012 and November, 2013 in a rural district in Uttar Pradesh to address the question of why the program has not improved health outcomes. It finds that health service providers are focused on capturing economic rents associated with the program, and provide an extremely poor quality care. Further, the program does not ultimately provide beneficiaries a large net monetary transfer at the time of birth. Based on a detailed accounting of the monetary costs of hospital and home deliveries, this study finds that the value of the transfer to beneficiaries is small due to costs associated with hospital births. Finally, this study also documents important emotional and psychological costs to women of delivering in the hospital. These findings suggest the need for a substantial rethinking of the program, paying careful attention to incentivizing health outcomes. Copyright © 2014 Elsevier Ltd. All rights reserved.

The impact of a visual arts program on quality of life, communication, and well-being of people living with dementia: a mixed-methods longitudinal investigation.

PubMed

Windle, Gill; Joling, Karlijn J; Howson-Griffiths, Teri; Woods, Bob; Jones, Catrin Hedd; van de Ven, Peter M; Newman, Andrew; Parkinson, Clive

2018-03-01

ABSTRACTBackground:Research reviews highlight methodological limitations and gaps in the evidence base for the arts in dementia care. In response, we developed a 12-week visual art program and evaluated the impact on people living with dementia through a mixed-methods longitudinal investigation. One hundred and twenty-five people living with mild to severe dementia were recruited across three research settings in England and Wales (residential care homes, a county hospital, and community venues). Quantitative and qualitative data on quality of life (QoL), communication and perceptions of the program were obtained through interviews and self-reports with participants and their carers. Eight domains of well-being were measured using a standardized observation tool, and data compared to an alternative activity with no art. Across all sites, scores for the well-being domains of interest, attention, pleasure, self-esteem, negative affect, and sadness were significantly better in the art program than the alternative condition. Proxy-reported QoL significantly improved between baseline and 3-month follow-up, but no improvements in QoL were reported by the participants with dementia. This was contrasted by their qualitative accounts, which described a stimulating experience important for social connectedness, well-being, and inner-strength. Communication deteriorated between baseline and follow-up in the hospital setting, but improved in the residential care setting. The findings highlight the potential for creative aging within dementia care, the benefits of art activities and the influence of the environment. We encourage dementia care providers and arts and cultural services to work toward embedding art activities within routine care provision.

Acute care hospitals' accountability to provincial funders.

PubMed

Kromm, Seija K; Ross Baker, G; Wodchis, Walter P; Deber, Raisa B

2014-09-01

Ontario's acute care hospitals are subject to a number of tools, including legislation and performance measurement for fiscal accountability and accountability for quality. Examination of accountability documents used in Ontario at the government, regional and acute care hospital levels reveals three trends: (a) the number of performance measures being used in the acute care hospital sector has increased significantly; (b) the focus of the health system has expanded from accountability for funding and service volumes to include accountability for quality and patient safety; and (c) the accountability requirements are misaligned at the different levels. These trends may affect the success of the accountability approach currently being used. Copyright © 2014 Longwoods Publishing.

Delivery System Integration and Health Care Spending and Quality for Medicare Beneficiaries

PubMed Central

McWilliams, J. Michael; Chernew, Michael E.; Zaslavsky, Alan M.; Hamed, Pasha; Landon, Bruce E.

2013-01-01

Background The Medicare accountable care organization (ACO) programs rely on delivery system integration and provider risk sharing to lower spending while improving quality of care. Methods Using 2009 Medicare claims and linked American Medical Association Group Practice data, we assigned 4.29 million beneficiaries to provider groups based on primary care use. We categorized group size according to eligibility thresholds for the Shared Savings (≥5,000 assigned beneficiaries) and Pioneer (≥15,000) ACO programs and distinguished hospital-based from independent groups. We compared spending and quality of care between larger and smaller provider groups and examined how size-related differences varied by 2 factors considered central to ACO performance: group primary care orientation (measured by the primary care share of large groups’ specialty mix) and provider risk sharing (measured by county health maintenance organization penetration and its relationship to financial risk accepted by different group types for managed care patients). Spending and quality of care measures included total medical spending, spending by type of service, 5 process measures of quality, and 30-day readmissions, all adjusted for sociodemographic and clinical characteristics. Results Compared with smaller groups, larger hospital-based groups had higher total per-beneficiary spending in 2009 (mean difference: +$849), higher 30-day readmission rates (+1.3% percentage points), and similar performance on 4 of 5 process measures of quality. In contrast, larger independent physician groups performed better than smaller groups on all process measures and exhibited significantly lower per-beneficiary spending in counties where risk sharing by these groups was more common (−$426). Among all groups sufficiently large to participate in ACO programs, a strong primary care orientation was associated with lower spending, fewer readmissions, and better quality of diabetes care. Conclusions Spending was lower and quality of care better for Medicare beneficiaries served by larger independent physician groups with strong primary care orientations in environments where providers accepted greater risk. PMID:23780467

Value of a regional family practice residency training program site: perceptions of residents, nurses, and physicians.

PubMed

Fletcher, Sarah; Mullett, Jennifer; Beerman, Steve

2014-09-01

To examine the perceptions of residents, nurses, and physicians about the effect of a regional family practice residency site on the delivery of health services in the community, as well as on the community health care providers. Interviews and focus groups were conducted. Nanaimo, BC. A total of 16 residents, 15 nurses, and 20 physicians involved with the family practice residency training program at the Nanaimo site. A series of semistructured interviews and focus groups was conducted. Transcripts of interviews and focus groups were analyzed thematically by the research team. Overall, participants agreed that having a family practice residency training site in the community contributed to community life and to the delivery of health services in the following ways: increased community capacity and social capital; motivated positive relationships and attitudes in the hospital and community settings; improved communication and teamwork, as well as accessibility and understanding of the health care system; increased the standard of care; and facilitated the recruitment and retention of family physicians. This family practice residency training site was beneficial for the community it served. Future planning for distributed medical education sites should take into account the effects of these sites on the health care community and ensure that they continue to be positive influences. Further research in this area could focus on patients' perceptions of how residency programs affect their care, as well as on the effect of residency programs on wait times and workload for physicians and nurses. Copyright© the College of Family Physicians of Canada.

Value of a regional family practice residency training program site

PubMed Central

Fletcher, Sarah; Mullett, Jennifer; Beerman, Steve

2014-01-01

Abstract Objective To examine the perceptions of residents, nurses, and physicians about the effect of a regional family practice residency site on the delivery of health services in the community, as well as on the community health care providers. Design Interviews and focus groups were conducted. Setting Nanaimo, BC. Participants A total of 16 residents, 15 nurses, and 20 physicians involved with the family practice residency training program at the Nanaimo site. Methods A series of semistructured interviews and focus groups was conducted. Transcripts of interviews and focus groups were analyzed thematically by the research team. Main findings Overall, participants agreed that having a family practice residency training site in the community contributed to community life and to the delivery of health services in the following ways: increased community capacity and social capital; motivated positive relationships and attitudes in the hospital and community settings; improved communication and teamwork, as well as accessibility and understanding of the health care system; increased the standard of care; and facilitated the recruitment and retention of family physicians. Conclusion This family practice residency training site was beneficial for the community it served. Future planning for distributed medical education sites should take into account the effects of these sites on the health care community and ensure that they continue to be positive influences. Further research in this area could focus on patients’ perceptions of how residency programs affect their care, as well as on the effect of residency programs on wait times and workload for physicians and nurses. PMID:25217693

Health Games: A Key Component for the Evolution of Wellness Programs.

PubMed

Lenihan, David

2012-06-01

Healthcare cost growth has been a major concern for both governments and employers. Considerable efforts have been made to "bend the trend" or find ways to control costs. At the highest levels, this has been the move from indemnity care models to managed care and then to consumer-directed health models using Healthcare Reimbursement Accounts and Healthcare Spending Accounts in plan designs. Accompanying this move in plan design has been an effort to get the consumer/patient/employee more engaged and responsible for his or her health expenditures, health decision-making, and activities. Consumers have gone through the phases of health being doctor-centric (indemnity care model), to health plan-centric (managed care models), to consumer-centric (consumer-directed health models). There is currently a need to incorporate wellness into the equation. Simply put, wellness is intended to keep people out of the health system by reducing the risk factors that would put them into the system in the first place. This includes things like smoking cessation, exercise, weight management, nutrition, and other factors over which individuals have a significant level of control over, as well as condition management such as medication adherence, and condition monitoring (such as glucose monitoring for diabetics). Wellness will become increasingly more common for major buyers, initially large self-funded employers and then health plans that will offer it as a part of their overall Plan Design and Administration services. Wellness initiatives will also be offered by Federal and State governments and will include programs for the elderly and at-risk populations as well as for the general population. The measure of success of wellness programs to actually "bend the trend" will be engagement. How large a piece of the population can be captured and retained will be the critical metric for success…and metrics require real data and will be used by the entire healthcare value-chain to measure efficacy and efficiency of "wellness spending."

A novel internet-based geriatric education program for emergency medical services providers.

PubMed

Shah, Manish N; Swanson, Peter A; Nobay, Flavia; Peterson, Lars-Kristofer N; Caprio, Thomas V; Karuza, Jurgis

2012-09-01

Despite caring for large numbers of older adults, prehospital emergency medical services (EMS) providers receive minimal geriatrics-specific training while obtaining their certification. Studies have shown that they desire further training to improve their comfort level and knowledge in caring for older adults, but continuing education programs to address these needs must account for each EMS provider's specific needs, consider each provider's learning styles, and provide an engaging, interactive experience. A novel, Internet-based, video podcast-based geriatric continuing education program was developed and implemented for EMS providers, and their perceived value of the program was evaluated. They found this resource to be highly valuable and were strongly supportive of the modality and the specific training provided. Some reported technical challenges and the inability to engage in a discussion to clarify topics as barriers. It was felt that both of these barriers could be addressed through programmatic and technological revisions. This study demonstrates the proof of concept of video podcast training to address deficiencies in EMS education regarding the care of older adults, although further work is needed to demonstrate the educational effect of video podcasts on the knowledge and skills of trainees. © 2012, Copyright the Authors Journal compilation © 2012, The American Geriatrics Society.

AHRQ series paper 3: identifying, selecting, and refining topics for comparative effectiveness systematic reviews: AHRQ and the effective health-care program.

PubMed

Whitlock, Evelyn P; Lopez, Sarah A; Chang, Stephanie; Helfand, Mark; Eder, Michelle; Floyd, Nicole

2010-05-01

This article discusses the identification, selection, and refinement of topics for comparative effectiveness systematic reviews within the Agency for Healthcare Research and Quality's Effective Health Care (EHC) program. The EHC program seeks to align its research topic selection with the overall goals of the program, impartially and consistently apply predefined criteria to potential topics, involve stakeholders to identify high-priority topics, be transparent and accountable, and continually evaluate and improve processes. A topic prioritization group representing stakeholder and scientific perspectives evaluates topic nominations that fit within the EHC program (are "appropriate") to determine how "important" topics are as considered against seven criteria. The group then judges whether a new comparative effectiveness systematic review would be a duplication of existing research syntheses, and if not duplicative, if there is adequate type and volume of research to conduct a new systematic review. Finally, the group considers the "potential value and impact" of a comparative effectiveness systematic review. As the EHC program develops, ongoing challenges include ensuring the program addresses truly unmet needs for synthesized research because national and international efforts in this arena are uncoordinated, as well as engaging a range of stakeholders in program decisions while also achieving efficiency and timeliness.

Analysis & commentary: The accountable care organization: whatever its growing pains, the concept is too vitally important to fail.

PubMed

Crosson, Francis J

2011-07-01

The success of health reform efforts will depend, in part, on creating new and better ways to organize, deliver, and pay for health care. Increasingly central to this idea is the accountable care organization model proposed for Medicare and a slightly different model for commercial health care. But these new health care delivery and payment models face considerable skepticism. Can Medicare succeed with accountable care organizations if physicians can't determine whether patients are in the organization or not? Will commercial hospitals use their clout to create accountable care organizations, leaving physician practices in a weaker position? This article answers those and other criticisms of the developing accountable care organization movement. If the concept fails, the nation may face indiscriminate cuts to health care payments, with resulting reductions in access, service, and quality.

Perspectives of primary health care staff on the implementation of a sexual health quality improvement program: a qualitative study in remote aboriginal communities in Australia.

PubMed

Hengel, Belinda; Bell, Stephen; Garton, Linda; Ward, James; Rumbold, Alice; Taylor-Thomson, Debbie; Silver, Bronwyn; McGregor, Skye; Dyda, Amalie; Knox, Janet; Guy, Rebecca; Maher, Lisa; Kaldor, John Martin

2018-04-02

Young people living in remote Australian Aboriginal communities experience high rates of sexually transmissible infections (STIs). STRIVE (STIs in Remote communities, ImproVed and Enhanced primary care) was a cluster randomised control trial of a sexual health continuous quality improvement (CQI) program. As part of the trial, qualitative research was conducted to explore staff perceptions of the CQI components, their normalisation and integration into routine practice, and the factors which influenced these processes. In-depth semi-structured interviews were conducted with 41 clinical staff at 22 remote community clinics during 2011-2013. Normalisation process theory was used to frame the analysis of interview data and to provide insights into enablers and barriers to the integration and normalisation of the CQI program and its six specific components. Of the CQI components, participants reported that the clinical data reports had the highest degree of integration and normalisation. Action plan setting, the Systems Assessment Tool, and the STRIVE coordinator role, were perceived as adding value to the program, but were less readily integrated or normalised. The remaining two components (dedicated funding for health promotion and service incentive payments) were seen as least relevant. Our analysis also highlighted factors which enabled greater integration of the CQI components. These included familiarity with CQI tools, increased accountability of health centre staff and the translation of the CQI program into guideline-driven care. The analysis also identified barriers, including high staff turnover, limited time involved in the program and competing clinical demands and programs. Across all of the CQI components, the clinical data reports had the highest degree of integration and normalisation. The action plans, systems assessment tool and the STRIVE coordinator role all complemented the data reports and allowed these components to be translated directly into clinical activity. To ensure their uptake, CQI programs must acknowledge local clinical guidelines, be compatible with translation into clinical activity and have managerial support. Sexual health CQI needs to align with other CQI activities, engage staff and promote accountability through the provision of clinic specific data and regular face-to-face meetings. Australian and New Zealand Clinical Trials Registry ACTRN12610000358044 . Registered 6/05/2010. Prospectively Registered.

Medical Expenditures Associated With Diabetes Among Youth With Medicaid Coverage.

PubMed

Shrestha, Sundar S; Zhang, Ping; Thompson, Theodore J; Gregg, Edward W; Albright, Ann; Imperatore, Giuseppina

2017-07-01

Information on diabetes-related excess medical expenditures for youth is important to understand the magnitude of financial burden and to plan the health care resources needed for managing diabetes. However, diabetes-related excess medical expenditures for youth covered by Medicaid program have not been investigated recently. To estimate excess diabetes-related medical expenditures among youth aged below 20 years enrolled in Medicaid programs in the United States. We analyzed data from 2008 to 2012 MarketScan multistate Medicaid database for 6502 youths with diagnosed diabetes and 6502 propensity score matched youths without diabetes, enrolled in fee-for-service payment plans. We stratified analysis by Medicaid eligibility criteria (poverty or disability). We used 2-part regression models to estimate diabetes-related excess medical expenditures, adjusted for age, sex, race/ethnicity, year of claims, depression status, asthma status, and interaction terms. For poverty-based Medicaid enrollees, estimated annual diabetes-related total medical expenditure was $9046 per person [$3681 (no diabetes) vs. $12,727 (diabetes); P<0001], of which 41.7%, 34.0%, and 24.3% were accounted for by prescription drugs, outpatient, and inpatient care, respectively. For disability-based Medicaid enrollees, the estimated annual diabetes-related total medical expenditure was $9944 per person ($14,149 vs. $24,093; P<0001), of which 41.5% was accounted for by prescription drugs, 31.3% by inpatient, and 27.3% by outpatient care. The per capita annual diabetes-related medical expenditures in youth covered by publicly financed Medicaid programs are substantial, which is larger among those with disabilities than without disabilities. Identifying cost-effective ways of managing diabetes in this vulnerable segment of the youth population is needed.

The Relationship Among Heart Failure Disease Management, Quality of Care, and Hospitalizations.

PubMed

Chung, Eugene S; Bartone, Cheryl; Daly, Kathleen; Menon, Santosh; McDonald, Mark

2015-01-01

Heart failure (HF) affects 5.1 million adult patients, accounting for over 1 million hospitalizations, 1.8 million office visits, and nearly 680,000 emergency department visits annually. HF hospitalizations have been incorporated into a national measure of hospital and provider quality, with associated financial penalties based on the 30-day readmission rate after an index hospitalization for HF. However, it is not clear whether the number of HF-related hospitalizations or 30-day readmissions is consistently related to quality of care. The relationships between various measures of HF care quality and hospitalization rates were evaluated by performing a cohort study of an HF disease management program in a clinical practice setting. Following the statistical analyses assessing outcomes and survival, the conclusion was that an HF disease management program in clinical practice associated with improved utilization of evidence-based medical and device therapies tends to improve ejection fraction and survival, and reduce sex and race disparities, but not with an associated reduction in hospitalizations or total hospital days.

PubMed Central

CICIRIELLO, E.

2016-01-01

SUMMARY Non-uniform, late, or inappropriate care of childhood with permanent hearing impairment (PHI) predisposes many children to develop communicative- behaviour problems and impaired psychosocial adjustment that can persist in adolescence and adulthood.In March 2014, the CCM (Centro Controllo Malattie or Disease Control Centre) of the Italian Ministry of Health funded a project entitled " Preventing Communication Disorders: a Regional Program for Early Identification, Intervention and Care of Hearing Impaired Children". The project involved 5 tertiary centres with UNHS programs formally approved by the Region. The main purpose of the project is to define and launch an integrated regionally-based public health model for identification, diagnosis and intervention of childhood PHI. The first phase of the project investigated the state of art and produced recommendations for positive changes in identification, diagnosis, therapy and care of childhood PHI in Italy, taking into account diagnostic and treatment innovations, family empowerment, treatment alliance and an interdisciplinary approach. Recommendations drawn from this initial phase will represent the basis for a regional system for early intervention that is validated, integrated and shared between the five regions. PMID:27054384

Consumer-directed models of personal care: lessons from Medicaid.

PubMed

Doty, P; Kasper, J; Litvak, S

1996-01-01

"Consumer-directed" models of financing and services delivery are compared with models that emphasize professional control and accountability within the context of Medicaid-financed personal care services (PCS). The Medicaid PCS benefit finances aide or attendant services for low-income persons with functional disabilities to assist them with daily living tasks. Consumer-directed modes of service provision permit service recipients themselves to have greater choice and control over all aspects of service provision. Client surveys in three states found that clients were most satisfied with the program elements of Medicaid PCS services that gave them more choice and control. Case studies of how Medicaid PCS programs in particular states are administered indicate that the use of aides who are independent providers, unattached to a home health or home care agency, is a critical aspect of consumer direction. By itself, however, this factor does not guarantee consumer direction because other Medicaid PCS rules and regulations may restrict client choice and control.

Out-of-pocket health spending by poor and near-poor elderly Medicare beneficiaries.

PubMed

Gross, D J; Alecxih, L; Gibson, M J; Corea, J; Caplan, C; Brangan, N

1999-04-01

To estimate out-of-pocket health care spending by lower-income Medicare beneficiaries, and to examine spending variations between those who receive Medicaid assistance and those who do not receive such aid. DATA SOURCES AND COLLECTION: 1993 Medicare Current Beneficiary Survey (MCBS) Cost and Use files, supplemented with data from the Bureau of the Census (Current Population Survey); the Congressional Budget Office; the Health Care Financing Administration, Office of the Actuary (National Health Accounts); and the Social Security Administration. We analyzed out-of-pocket spending through a Medicare Benefits Simulation model, which projects out-of-pocket health care spending from the 1993 MCBS to 1997. Out-of-pocket health care spending is defined to include Medicare deductibles and coinsurance; premiums for private insurance, Medicare Part B, and Medicare HMOs; payments for non-covered goods and services; and balance billing by physicians. It excludes the costs of home care and nursing facility services, as well as indirect tax payments toward health care financing. Almost 60 percent of beneficiaries with incomes below the poverty level did not receive Medicaid assistance in 1997. We estimate that these beneficiaries spent, on average, about half their income out-of-pocket for health care, whether they were enrolled in a Medicare HMO or in the traditional fee-for-service program. The 75 percent of beneficiaries with incomes between 100 and 125 percent of the poverty level who were not enrolled in Medicaid spent an estimated 30 percent of their income out-of-pocket on health care if they were in the traditional program and about 23 percent of their income if they were enrolled in a Medicare HMO. Average out-of-pocket spending among fee-for-service beneficiaries varied depending on whether beneficiaries had Medigap policies, employer-provided supplemental insurance, or no supplemental coverage. Those without supplemental coverage spent more on health care goods and services, but spent less than the other groups on prescription drugs and dental care-services not covered by Medicare. While Medicaid provides substantial protection for some lower-income Medicare beneficiaries, out-of-pocket health care spending continues to be a substantial burden for most of this population. Medicare reform discussions that focus on shifting more costs to beneficiaries should take into account the dramatic costs of health care already faced by this vulnerable population.

The influence of maternal health literacy and child's age on participation in social welfare programs.

PubMed

Pati, Susmita; Siewert, Elizabeth; Wong, Angie T; Bhatt, Suraj K; Calixte, Rose E; Cnaan, Avital

2014-07-01

The objective of this study is to determine the influence of maternal health literacy and child's age on participation in social welfare programs benefiting children. In a longitudinal prospective cohort study of 560 Medicaid-eligible mother-infant dyads recruited in Philadelphia, maternal health literacy was assessed using the test of functional health literacy in adults (short version). Participation in social welfare programs [Temporary Assistance to Needy Families (TANF), Supplemental Nutrition Assistance Program (SNAP), Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), child care subsidy, and public housing] was self-reported at child's birth, and at the 6, 12, 18, 24 month follow-up interviews. Generalized estimating equations quantified the strength of maternal health literacy as an estimator of program participation. The mothers were primarily African-Americans (83%), single (87%), with multiple children (62%). Nearly 24% of the mothers had inadequate or marginal health literacy. Children whose mothers had inadequate health literacy were less likely to receive child care subsidy (adjusted OR = 0.54, 95% CI 0.34-0.85) than children whose mothers had adequate health literacy. Health literacy was not a significant predictor for TANF, SNAP, WIC or housing assistance. The predicted probability for participation in all programs decreased from birth to 24 months. Most notably, predicted WIC participation declined rapidly after age one. During the first 24 months, mothers with inadequate health literacy could benefit from simplified or facilitated child care subsidy application processes. Targeted outreach and enrollment efforts conducted by social welfare programs need to take into account the changing needs of families as children age.

The Next Phase of Title VII Funding for Training Primary Care Physicians for America’s Health Care Needs

PubMed Central

Phillips, Robert L.; Turner, Barbara J.

2012-01-01

Health care reform will add millions of Americans to the ranks of the insured; however, their access to health care is threatened by a deep decline in the production of primary care physicians. Poorer access to primary care risks poorer health outcomes and higher costs. Meeting this increased demand requires a major investment in primary care training. Title VII, Section 747 of the Public Health Service Act previously supported the growth of the health care workforce but has been severely cut over the past 2 decades. New and expanded Title VII initiatives are required to increase the production of primary care physicians; establish high-functioning academic, community-based training practices; increase the supply of well-trained primary care faculty; foster innovation and rigorous evaluation of these programs; and ultimately to improve the responsiveness of teaching hospitals to community needs. To accomplish these goals, Congress should act on the Council on Graduate Medical Education’s recommendation to increase funding for Title VII, Section 747 roughly 14-fold to $560 million annually. This amount represents a small investment in light of the billions that Medicare currently spends to support graduate medical education, and both should be held to account for meeting physician workforce needs. Expansion of Title VII, Section 747 with the goal of improving access to primary care would be an important part of a needed, broader effort to counter the decline of primary care. Failure to launch such a national primary care workforce revitalization program will put the health and economic viability of our nation at risk. PMID:22412009

The next phase of Title VII funding for training primary care physicians for America's health care needs.

PubMed

Phillips, Robert L; Turner, Barbara J

2012-01-01

Health care reform will add millions of Americans to the ranks of the insured; however, their access to health care is threatened by a deep decline in the production of primary care physicians. Poorer access to primary care risks poorer health outcomes and higher costs. Meeting this increased demand requires a major investment in primary care training. Title VII, Section 747 of the Public Health Service Act previously supported the growth of the health care workforce but has been severely cut over the past 2 decades. New and expanded Title VII initiatives are required to increase the production of primary care physicians; establish high-functioning academic, community-based training practices; increase the supply of well-trained primary care faculty; foster innovation and rigorous evaluation of these programs; and ultimately to improve the responsiveness of teaching hospitals to community needs. To accomplish these goals, Congress should act on the Council on Graduate Medical Education's recommendation to increase funding for Title VII, Section 747 roughly 14-fold to $560 million annually. This amount represents a small investment in light of the billions that Medicare currently spends to support graduate medical education, and both should be held to account for meeting physician workforce needs. Expansion of Title VII, Section 747 with the goal of improving access to primary care would be an important part of a needed, broader effort to counter the decline of primary care. Failure to launch such a national primary care workforce revitalization program will put the health and economic viability of our nation at risk.

A model of determining a fair market value for teaching residents: who profits?

PubMed

Cullen, Edward J; Lawless, Stephen T; Hertzog, James H; Penfil, Scott; Bradford, Kathleen K; Nadkarni, Vinay M; Corddry, David H; Costarino, Andrew T

2003-07-01

Centers for Medicare & Medicaid Services (CMS) Health Resources and Services Administration Children's Hospitals Graduate Medical Education (GME) Payment Program now supports freestanding children's teaching hospitals. To analyze the fair market value impact of GME payment on resident teaching efforts in our pediatric intensive care unit (PICU). Cost-accounting model, developed from a 1-year retrospective, descriptive, single-institution, longitudinal study, applied to physician teachers, residents, and CMS. Sixteen-bed PICU in a freestanding, university-affiliated children's teaching hospital. Pediatric critical care physicians, second-year residents. Cost of physician opportunity time; CMS investment return; the teaching physicians' investment return; residents' investment return; service balance between CMS and teaching service investment margins; economic balance points; fair market value. GME payments to our hospital increased 4.8-fold from 577 886 dollars to 2 772 606 dollars during a 1-year period. Critical care physicians' teaching opportunity cost rose from 250 097 dollars to 262 215 dollars to provide 1523 educational hours (6853 relative value units). Residents' net financial value for service provided to the PICU rose from 245 964 dollars to 317 299 dollars. There is an uneven return on investment in resident education for CMS, critical care physicians, and residents. Economic balance points are achievable for the present educational efforts of the CMS, critical care physicians, and residents if the present direct medical education payment increases from 29.38% to 36%. The current CMS Health Resources and Services Administration Children's Hospitals GME Payment Program produces uneven investment returns for CMS, critical care physicians, and residents. We propose a cost-accounting model, based on perceived production capability measured in relative value units and available GME funds, that would allow a clinical service to balance and obtain a fair market value for the resident education efforts of CMS, physician teachers, and residents.

Creating a network of high-quality skilled nursing facilities: preliminary data on the postacute care quality improvement experiences of an accountable care organization.

PubMed

Lage, Daniel E; Rusinak, Donna; Carr, Darcy; Grabowski, David C; Ackerly, D Clay

2015-04-01

Postacute care (PAC) is an important source of cost growth and variation in the Medicare program and is critical to accountable care organization (ACO) and bundled payment efforts to improve quality and value in the Medicare program, but ACOs must often look outside their walls to identify high-value external PAC partners, including skilled nursing facilities (SNFs). As a solution to this problem, the integrated health system, Partners HealthCare System (PHS) and its Pioneer ACO launched the PHS SNF Collaborative Network in October 2013 to identify and partner with high-quality SNFs. This study details the method by which PHS selected SNFs using minimum criteria based on public scores and secondary criteria based on self-reported measures, describes the characteristics of selected and nonselected SNFs, and reports SNF satisfaction with the collaborative. The selected SNFs (n = 47) had significantly higher CMS Five-Star scores than the nonselected SNFs (n = 93) (4.6 vs 3.2, P < .001) and were more likely than nonselected SNFs that met the minimum criteria (n = 35) to have more than 5 days of clinical coverage (17.0% vs 2.9%, P = .02) and to have a physician see admitted individuals within 24 (38.3% vs 17.1%, P = .02) and 48 hours (93.6% vs 80.0%, P = .03). A survey sent to collaborative SNFs found high satisfaction with the process (average satisfaction, 4.6/5, with 1 = very dissatisfied and 5 = very satisfied, n = 19). Although the challenges of improving care in SNFs remain daunting, this approach can serve as a first step toward greater clinical collaboration between acute and postacute settings that will lead to better outcomes for frail older adults. © 2015, Copyright the Authors Journal compilation © 2015, The American Geriatrics Society.

TennCare and academic medical centers: the lessons from Tennessee.

PubMed

Meyer, G S; Blumenthal, D

1996-09-04

To ascertain the potential impact of public-sector-driven health system reform (Medicaid and Medicare programs) on academic medical centers (AMCs). A qualitative, case-study investigation of how 2 of Tennessee's 4 AMCs were affected by the TennCare program, which enrolled all of the state's Medicaid recipients and a sizable portion of its uninsured in managed care organizations (MCOs) in January 1994. We reviewed pertinent documents related to the AMCs, response to TennCare; interviewed AMC executives and staff, state officials, and representatives of MCOs serving TennCare beneficiaries; and conducted site visits at both AMCs. Changes in clinical revenues, clinical volume, patient selection, support for the AMCs, teaching and research missions, and the AMCs' response to these changes. Both AMCs studied experienced large revenue shortfalls, the closure of some specialty services, adverse patient selection, and loss of the patient volume needed to do clinical research, and had to reduce the number of training program positions. Longer-term consequences of TennCare for AMCs may include the integration of community-based services into academic missions, the acceleration of clinical diversification, and the attainment of experience in managed care, anticipating the evolution of the private-sector market. The consequences of public-sector health system reform for AMCs are similar to, and equally as challenging as, the effects of private-sector changes in health care delivery. Important differences include the rapidity with which public-sector reforms can transform the AMC market, the vulnerability of special payments to AMCs, such as graduate medical education funding, and the accountability of managers of public-sector initiatives to the political process. It remains to be seen whether public-sector reforms will afford some competitive advantage to AMCs over the long term.

Quality of Care in Episodes of Common Respiratory Infections in a Disadvantaged Population,

DTIC Science & Technology

1980-10-01

otitis media , acute bronchitis, influenza, and acute upper respiratory tract infection. Data were taken from the New Mexico Medicaid program on a cohort of persons who had been enrolled in the Aid to Families with Dependent Children aid category continuously for the years covered by the study. The cohort changed in no way except natural aging. It comprised primarily women and children, was predominantly white, and accounted for a large portion of New Mexico Medicaid expenditures during this period. Quality-of-care profiles were based on explicit process criteria and took

Protocol for the evaluation of a quality-based pay for performance scheme in Liberia.

PubMed

Bawo, Luke; Leonard, Kenneth L; Mohammed, Rianna

2015-01-13

Improving the quality of care at hospitals is a key next step in rebuilding Liberia's health system. In order to improve the efficiency, effectiveness, and quality of care at the secondary hospital level, the country is developing a system to upgrade health worker skills and competencies, and shifting towards improved provider accountability for results, including a Graduate Medical Residency Program (GMRP) and provider accountability for improvements in quality through performance-based financing (PBF) at the hospital level. This document outlines the protocol for the impact evaluation of the hospital improvement program. The evaluation will provide an estimate of the impact of the project and investigate the mechanism for success in a way that can provide general lessons about the quality of health care in low-income countries. The evaluation aims 1) to provide the best possible estimate of program impact and 2) to quantitatively describe the changes that took place within facilities as a result of the program. In particular, the impact evaluation focuses on the changes in human resources within the hospitals. As such, we use a three-period intensive evaluation of treated and matched comparison hospitals to see how services change in treated hospitals as well as a continuous data collection effort to track the activities of individual health workers within treated hospitals. We are particularly interested in understanding how facilities met quality targets. Did they bring in new health workers with higher qualifications? Did they improve the knowledge or competence of their existing staff? Did they improve the availability of medicines and equipment so that the capacities of existing health workers were improved? Did they address the motivation of health workers so that individuals with the same competence and capacity were able to provide higher quality? And, if they did improve quality, did patients notice?

Care coordination experiences of people with disabilities enrolled in medicaid managed care.

PubMed

Bowers, Anne; Owen, Randall; Heller, Tamar

2017-10-01

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

Cardiac patients' perception of patient-centred care: a qualitative study.

PubMed

Esmaeili, Maryam; Cheraghi, Mohammad A; Salsali, Mahvash

2016-03-01

The aim of this study was to explore cardiac patients' perception of patient-centred care. Despite patient's importance in the process of care, less attention has been paid to experiences and expectations of patients in definitions of patient-centred care. As patients are an important element in process of patient-centred care, organizing care programs according to their perceptions and expectations will lead to enhanced quality of care and greater patient satisfaction. This study is a descriptive qualitative study. Content analysis approach was performed for data analysis. Participants were 18 cardiac patients (10 women and 8 men) hospitalized in coronary care units of teaching hospitals affiliated to Tehran University of Medical Sciences. We collected the study data through conducting personal face-to-face semi-structured interviews. The participants' perceptions of patient-centred care fell into three main themes including managing patients uncertainty, providing care with more flexibility and establishing a therapeutic communication. The second theme consisted of two sub-themes: empathizing with patients and having the right to make independent decisions. Receiving patient-centred care is essential for cardiac patients. Attention to priorities and preferences of cardiac patients and making decisions accordingly is among effective strategies for achieving patient-centred care. Cardiac care unit nurses ought to be aware that in spite of technological developments and advances, it is still important to pay attention to patients' needs and expectations in order to achieve patient satisfaction. In planning care programs, they should consider accountability towards patients' needs, flexibility in process of care and establishing medical interactions as an effective strategy for improving quality of care. © 2014 British Association of Critical Care Nurses.

Protocol for a randomised controlled trial of chronic disease self-management support for older Australians with multiple chronic diseases.

PubMed

Reed, Richard L; Battersby, Malcolm; Osborne, Richard H; Bond, Malcolm J; Howard, Sara L; Roeger, Leigh

2011-11-01

The prevalence of older Australians with multiple chronic diseases is increasing and now accounts for a large proportion of total health care utilisation. Chronic disease self-management support (CDSMS) has become a core service component of many community based health programs because it is considered a useful tool in improving population health outcomes and reducing the financial burden of chronic disease care. However, the evidence base to justify these support programs is limited, particularly for older people with multiple chronic diseases. We describe an ongoing trial examining the effectiveness of a particular CDSMS approach called the Flinders Program. The Flinders Program is a clinician-led generic self-management intervention that provides a set of tools and a structured process that enables health workers and patients to collaboratively assess self-management behaviours, identify problems, set goals, and develop individual care plans covering key self-care, medical, psychosocial and carer issues. A sample of 252 older Australians that have two or more chronic conditions will be randomly assigned to receive either CDSMS or an attention control intervention (health information only) for 6 months. Outcomes will be assessed using self-reported health measures taken at baseline and post-intervention. This project will be the first comprehensive evaluation of CDSMS in this population. Findings are expected to guide consumers, clinicians and policymakers in the use of CDSMS, as well as facilitate prioritisation of public monies towards evidence-based services. Copyright © 2011 Elsevier Inc. All rights reserved.

Evidence for the effect of disease management: is $1 billion a year a good investment?

PubMed

Mattke, Soeren; Seid, Michael; Ma, Sai

2007-12-01

To assess the evidence for the effect of disease management on quality of care, disease control, and cost, with a focus on population-based programs. Literature review. We conducted a literature search for and a structured review of studies on population-based disease management programs, as well as for reviews and meta-analyses of disease management interventions. We identified 3 evaluations of large-scale population-based programs, as well as 10 meta-analyses and 16 systematic reviews, covering 317 unique studies. We found consistent evidence that disease management improves processes of care and disease control but no conclusive support for its effect on health outcomes. Overall, disease management does not seem to affect utilization except for a reduction in hospitalization rates among patients with congestive heart failure and an increase in outpatient care and prescription drug use among patients with depression. When the costs of the intervention were appropriately accounted for and subtracted from any savings, there was no conclusive evidence that disease management leads to a net reduction of direct medical costs. Although disease management seems to improve quality of care, its effect on cost is uncertain. Most of the evidence to date addresses small-scale programs targeting high-risk individuals, while only 3 studies evaluate large population-based interventions, implying that little is known about their effect. Payers and policy makers should remain skeptical about vendor claims and should demand supporting evidence based on transparent and scientifically sound methods.

Breast care screening for underserved African American women: Community-based participatory approach.

PubMed

Davis, Cindy; Darby, Kathleen; Moore, Matthew; Cadet, Tamara; Brown, Gwendolynn

2017-01-01

Traditional health promotion models often do not take into account the importance of shared cultural backgrounds, beliefs, and experiences unique to underserved African American women when designing community-based cancer screening and prevention programs. Thus, the purpose of this study was the development, implementation, and evaluation of a community-based participatory research (CBPR) program designed to increase breast cancer screening awareness in an underserved African American population by providing culturally appropriate social support and information. The study includes 357 African American women who participated in the program and completed the 6-month follow-up questionnaire. The program consisted of a 45-minute play, using community members and storytelling to honor and incorporate five different cultural experiences (skits) with breast care and cancer. Overall, findings indicate that the educational intervention was effective. In addition, these findings are consistent with the literature that suggests that educational interventions that include knowledge to alleviate concerns, dispel myths, and create awareness can increase breast cancer screening participation rates. Furthermore, these findings confirm the importance of CBPR in health promotion activities in reducing health and cancer disparities.

Accountable care around the world: a framework to guide reform strategies.

PubMed

McClellan, Mark; Kent, James; Beales, Stephen J; Cohen, Samuel I A; Macdonnell, Michael; Thoumi, Andrea; Abdulmalik, Mariam; Darzi, Ara

2014-09-01

Accountable care--a way to align health care payments with patient-focused reform goals--is currently being pursued in the United States, but its principles are also being applied in many other countries. In this article we review experiences with such reforms to offer a globally applicable definition of an accountable care system and propose a conceptual framework for characterizing and assessing accountable care reforms. The framework consists of five components: population, outcomes, metrics and learning, payments and incentives, and coordinated delivery. We describe how the framework applies to accountable care reforms that are already being implemented in Spain and Singapore. We also describe how it can be used to map progress through increasingly sophisticated levels of reforms. We recommend that policy makers pursuing accountable care reforms emphasize the following steps: highlight population health and wellness instead of just treating illness; pay for outcomes instead of activities; create a more favorable environment for collaboration and coordinated care; and promote interoperable data systems. Project HOPE—The People-to-People Health Foundation, Inc.

Health care ethics consultation: an update on core competencies and emerging standards from the American Society For Bioethics and Humanities' core competencies update task force.

PubMed

Tarzian, Anita J

2013-01-01

Ethics consultation has become an integral part of the fabric of U.S. health care delivery. This article summarizes the second edition of the Core Competencies for Health Care Ethics Consultation report of the American Society for Bioethics and Humanities. The core knowledge and skills competencies identified in the first edition of Core Competencies have been adopted by various ethics consultation services and education programs, providing evidence of their endorsement as health care ethics consultation (HCEC) standards. This revised report was prompted by thinking in the field that has evolved since the original report. Patients, family members, and health care providers who encounter ethical questions or concerns that ethics consultants could help address deserve access to efficient, effective, and accountable HCEC services. All individuals providing such services should be held to the standards of competence and quality described in the revised report.

Retention in care among HIV-infected patients in resource-limited settings: emerging insights and new directions.

PubMed

Geng, Elvin H; Nash, Denis; Kambugu, Andrew; Zhang, Yao; Braitstein, Paula; Christopoulos, Katerina A; Muyindike, Winnie; Bwana, Mwebesa Bosco; Yiannoutsos, Constantin T; Petersen, Maya L; Martin, Jeffrey N

2010-11-01

In resource-limited settings--where a massive scale-up of HIV services has occurred in the last 5 years--both understanding the extent of and improving retention in care presents special challenges. First, retention in care within the decentralizing network of services is likely higher than existing estimates that account only for retention in clinic, and therefore antiretroviral therapy services may be more effective than currently believed. Second, both magnitude and determinants of patient retention vary substantially and therefore encouraging the conduct of locally relevant epidemiology is needed to inform programmatic decisions. Third, socio-structural factors such as program characteristics, transportation, poverty, work/child care responsibilities, and social relations are the major determinants of retention in care, and therefore interventions to improve retention in care should focus on implementation strategies. Research to assess and improve retention in care for HIV-infected patients can be strengthened by incorporating novel methods such as sampling-based approaches and a causal analytic framework.

[The education and training of manpower in elderly & long-term care].

PubMed

Chen, Huey-Tzy

2008-08-01

With the rapid expansion of the aged population, elderly & long-term care has become a significant issue in Taiwan, as in many developed countries, such as Japan. Service resources in long-term care have benefitted profoundly from investment and development in the past 15 years in Taiwan, but the education and training of manpower in long-term care has only recently begun to be addressed. The purpose of this article is to describe the education and training of nursing manpower in long-term care in Taiwan and in other countries. Three recommendations are also made: (1) To integrate Gerontology Nursing & Practicum into the nursing curriculum to cultivate nursing students with competency in providing direct care and competency in accountability. (2) To prepare RN-BSN students with secondary competency in management/information & communication/activities design. (3) To incorporate faculty from across disciplines in the running of gerontology & long-term care programs in order to develop students' competency in transdisciplinary team work.

School-based health centers: accessibility and accountability.

PubMed

Brindis, Claire D; Klein, Jonathan; Schlitt, John; Santelli, John; Juszczak, Linda; Nystrom, Robert J

2003-06-01

To examine the current experience of school-based health centers (SBHCs) in meeting the needs of children and adolescents, changes over time in services provided and program sponsorship, and program adaptations to the changing medical marketplace. Information for the 1998-1999 Census of School-Based Health Centers was collected through a questionnaire mailed to health centers in December 1998. A total of 806 SBHCs operating in schools or on school property responded, representing a 70% response rate. Descriptive statistics and cross-tab analyses were conducted. The number of SBHCs grew from 120 in 1988 to nearly 1200 in 1998, serving an estimated 1.1 million students. No longer primarily in urban high schools, health centers now operate in diverse areas in 45 states, serving students from kindergarten through high school. Sponsorship has shifted from community-based clinics to hospitals, local health departments, and community health centers, which represent 73% of all sponsors. Most use computer-based patient-tracking systems (88%), and 73% bill Medicaid and other third-party insurers for student-patient encounters. SBHCs have demonstrated leadership by implementing medical standards of care and providing accountable sources of health care. Although the SBHC model is responsive to local community needs, centers provide care for only 2% of children enrolled in U.S. schools. A lack of stable financing streams continues to challenge sustainability. As communities seek to meet the needs of this population, they are learning important lessons about providing acceptable, accessible, and comprehensive services and about implementing quality assurance mechanisms.

Regional cost and experience, not size or hospital inclusion, helps predict ACO success.

PubMed

Schulz, John; DeCamp, Matthew; Berkowitz, Scott A

2017-06-01

The Medicare Shared Savings Program (MSSP) continues to expand and now includes 434 accountable care organizations (ACOs) serving more than 7 million beneficiaries. During 2014, 86 of these ACOs earned over $300 million in shared savings payments by promoting higher-quality patient care at a lower cost.Whether organizational characteristics, regional cost of care, or experience in the MSSP are associated with the ability to achieve shared savings remains uncertain.Using financial results from 2013 and 2014, we examined all 339 MSSP ACOs with a 2012, 2013, or 2014 start-date. We used a cross-sectional analysis to examine all ACOs and used a multivariate logistic model to predict probability of achieving shared savings.Experience, as measured by years in the MSSP program, was associated with success and the ability to earn shared savings varied regionally. This variation was strongly associated with differences in regional Medicare fee-for-service per capita costs: ACOs in high cost regions were more likely to earn savings. In the multivariate model, the number of ACO beneficiaries, inclusion of a hospital or involvement of an academic medical center, was not associated with likelihood of earning shared savings, after accounting for regional baseline cost variation.These results suggest ACOs are learning and improving from their experience. Additionally, the results highlight regional differences in ACO success and the strong association with variation in regional per capita costs, which can inform CMS policy to help promote ACO success nationwide.

Preserving community in health care.

PubMed

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.

Delivery system integration and health care spending and quality for Medicare beneficiaries.

PubMed

McWilliams, J Michael; Chernew, Michael E; Zaslavsky, Alan M; Hamed, Pasha; Landon, Bruce E

2013-08-12

The Medicare accountable care organization (ACO) programs rely on delivery system integration and health care provider risk sharing to lower spending while improving quality of care. To compare spending and quality between larger and smaller provider groups and examine how size-related differences vary by 2 factors considered central to ACO performance: group primary care orientation and financial risk sharing by health care providers. Using 2009 Medicare claims and linked American Medical Association Group Practice data, we assigned 4.29 million beneficiaries to health care provider groups based on primary care use. We categorized group size according to eligibility thresholds for the Shared Savings (≥5000 assigned beneficiaries) and Pioneer (≥15,000) ACO programs and distinguished hospital-based from independent groups. We assessed the primary care orientation of larger groups' specialty mix and used health maintenance organization market penetration and data from the Community Tracking Study to measure the extent of financial risk accepted by different types of provider groups in different areas for managed care patients. We estimated linear regression models comparing spending and quality between larger and smaller health care provider groups, allowing size-related differences to vary by measures of group primary care orientation and risk sharing. Spending and quality measures included total medical spending, spending by type of service, 5 process measures of quality, and 30-day readmissions, all adjusted for sociodemographic and clinical characteristics. Compared with smaller groups, larger hospital-based groups had higher total per-beneficiary spending in 2009 (mean difference, +$849), higher 30-day readmission rates (+1.3 percentage points), and similar performance on 4 of 5 process measures of quality. In contrast, larger independent physician groups performed better than smaller groups on all process measures and exhibited significantly lower per-beneficiary spending in counties where risk sharing by these groups was more common (-$426). Among all groups sufficiently large to participate in ACO programs, a strong primary care orientation was associated with lower spending, fewer readmissions, and better quality of diabetes care. Spending was lower and quality of care better for Medicare beneficiaries served by larger independent physician groups with strong primary care orientations in environments where health care providers accepted greater risk.

Association Between Medicare Accountable Care Organization Implementation and Spending Among Clinically Vulnerable Beneficiaries.

PubMed

Colla, Carrie H; Lewis, Valerie A; Kao, Lee-Sien; O'Malley, A James; Chang, Chiang-Hua; Fisher, Elliott S

2016-08-01

Accountable care contracts hold physician groups financially responsible for the quality and cost of health care delivered to patients. Focusing on clinically vulnerable patients, those with serious conditions who are responsible for the greatest proportion of spending, may result in the largest effects on both patient outcomes and financial rewards for participating physician groups. To estimate the effect of Medicare accountable care organization (ACO) contracts on spending and high-cost institutional use for all Medicare beneficiaries and for clinically vulnerable beneficiaries. For this cohort study, 2 study populations were defined: the overall Medicare population and the clinically vulnerable subgroup of Medicare beneficiaries. The overall Medicare population was based on a random 40% sample drawn from continuously enrolled fee-for-service beneficiaries with at least 1 evaluation and management visit in a calendar year. The clinically vulnerable study population included all Medicare beneficiaries 66 years or older who had at least 3 Hierarchical Condition Categories (HCCs). Beneficiaries entered the cohort during the quarter between January 2009 to December 2011 when they first had at least 3 HCCs and remained in the cohort until death. Cohort entry was restricted to the preperiod to account for potential changes in coding practices after ACO implementation. Difference-in-difference estimations were used to compare changes in health care outcomes for Medicare beneficiaries attributed to physicians in ACOs with those attributed to non-ACO physicians from January 2009 to December 2013. Medicare ACOs beginning contracts in January 2012, April 2012, July 2012, and January 2013 through the Pioneer and Medicare Shared Savings Programs. Total spending per beneficiary-quarter, spending categories, use of hospitals and emergency departments, ambulatory care sensitive admissions, and 30-day readmissions. Total spending decreased by $34 (95% CI, -$52 to -$15) per beneficiary-quarter after ACO contract implementation across the overall Medicare population (n = 15 592 600) and decreased $114 in clinically vulnerable patients (n = 8 673 823) (95% CI, -$178 to -$50). In the overall Medicare cohort, hospitalizations and emergency department visits decreased by 1.3 and 3.0 events per 1000 beneficiaries per quarter, respectively (95% CIs: -2.1 to -0.4 and -4.8 to -1.3), and hospitalizations and emergency department visits decreased in the clinically vulnerable cohort by 2.9 and 4.1 events per 1000 beneficiaries per quarter, respectively (95% CIs: -5.2 to -0.7 and -7.1 to -1.2). Changes in total spending associated with ACOs did not vary by clinical condition of beneficiaries. Medicare ACO programs are associated with modest reductions in spending and use of hospitals and emergency departments. Savings were realized through reductions in use of institutional settings in clinically vulnerable patients.

Improving oversight of the graduate medical education enterprise: one institution's strategies and tools.

PubMed

Afrin, Lawrence B; Arana, George W; Medio, Franklin J; Ybarra, Angela F N; Clarke, Harry S

2006-05-01

Accreditation organizations, financial stakeholders, legal systems, and regulatory agencies have increased the need for accountability in educational processes and curricular outcomes of graduate medical education. This demand for greater programmatic monitoring has placed pressure on institutions with graduate medical education (GME) programs to develop greater oversight of these programs. Meeting these challenges requires development of new GME management strategies and tools for institutional GME administrators to scrutinize programs, while still allowing these programs the autonomy to develop and implement educational methods to meet their unique training needs. At the Medical University of South Carolina (MUSC), senior administrators in the college of medicine felt electronic information management was a critical strategy for success and thus proceeded to carefully select an electronic residency management system (ERMS) to provide functionality for both individual programs and the GME enterprise as a whole. Initial plans in 2002 for a phased deployment had to be changed to a much more rapid deployment due to regulatory issues. Extensive communication and cooperation among MUSC's GME leaders resulted in a successful deployment in 2003. Evaluation completion rates have substantially improved, duty hours are carefully monitored, patient safety has improved through more careful oversight of residents' procedural privileges, regulators have been pleased, and central GME administrative visibility of program performance has dramatically improved. The system is now being expanded to MUSC's medical school and other health professions colleges. The authors discuss lessons learned and opportunities and challenges ahead, which include improving tracking of development of procedural competency, establishing and monitoring program performance standards, and integrating the ERMS with GME reimbursement systems.

The coming changes in tax-exempt health care finance.

PubMed

Carlile, L L; Serchuk, B M

1995-01-01

On December 30, 1994, the Internal Revenue Service (IRS) published proposed regulations (Proposed Regulations) that if enacted would significantly change the climate and rules of federal income tax law controlling the issuance and maintenance of tax-exempt bonds for governmental and 501(c)(3) health care borrowers. This article (1) summarizes the aspects of the Proposed Regulations dealing with private activity tests, management contracts, allocation and accounting rules, change in use of financed facilities, and antiabuse rules, and (2) summarizes the possible interrelationship of the IRS's audit program for tax-exempt bonds and the Proposed Regulations. The article reviews features of the Proposed Regulations that will affect either the costs or administrative burdens of managing the federal tax compliance of future tax-exempt health care borrowings.

Reliability analysis of laminated CMC components through shell subelement techniques

NASA Technical Reports Server (NTRS)

Starlinger, Alois; Duffy, Stephen F.; Gyekenyesi, John P.

1992-01-01

An updated version of the integrated design program Composite Ceramics Analysis and Reliability Evaluation of Structures (C/CARES) was developed for the reliability evaluation of ceramic matrix composites (CMC) laminated shell components. The algorithm is now split into two modules: a finite-element data interface program and a reliability evaluation algorithm. More flexibility is achieved, allowing for easy implementation with various finite-element programs. The interface program creates a neutral data base which is then read by the reliability module. This neutral data base concept allows easy data transfer between different computer systems. The new interface program from the finite-element code Matrix Automated Reduction and Coupling (MARC) also includes the option of using hybrid laminates (a combination of plies of different materials or different layups) and allows for variations in temperature fields throughout the component. In the current version of C/CARES, a subelement technique was implemented, enabling stress gradients within an element to be taken into account. The noninteractive reliability function is now evaluated at each Gaussian integration point instead of using averaging techniques. As a result of the increased number of stress evaluation points, considerable improvements in the accuracy of reliability analyses were realized.

Costs and Consequences of a Cash Transfer for Hospital Births in a Rural District of Uttar Pradesh, India

PubMed Central

Coffey, Diane

2014-01-01

The Janani Suraksha Yojana, India’s “safe motherhood program,” is a conditional cash transfer to encourage women to give birth in health facilities. Despite the program’s apparent success in increasing facility-based births, quantitative evaluations have not found corresponding improvements in health outcomes. This study analyses original qualitative data collected between January, 2012 and November, 2013 in a rural district in Uttar Pradesh to address the question of why the program has not improved health outcomes. It finds that health service providers are focused on capturing economic rents associated with the program, and provide an extremely poor quality care. Further, the program does not ultimately provide beneficiaries a large net monetary transfer at the time of birth. Based on a detailed accounting of the monetary costs of hospital and home deliveries, this study finds that the value of the transfer to beneficiaries is small due to costs associated with hospital births. Finally, this study also documents important emotional and psychological costs to women of delivering in the hospital. These findings suggest the need for a substantial rethinking of the program, paying careful attention to incentivizing health outcomes. PMID:24911512

Rapid spread of complex change: a case study in inpatient palliative care.

PubMed

Della Penna, Richard; Martel, Helene; Neuwirth, Esther B; Rice, Jennifer; Filipski, Marta I; Green, Jennifer; Bellows, Jim

2009-12-29

Based on positive findings from a randomized controlled trial, Kaiser Permanente's national executive leadership group set an expectation that all Kaiser Permanente and partner hospitals would implement a consultative model of interdisciplinary, inpatient-based palliative care (IPC). Within one year, the number of IPC consultations program-wide increased almost tenfold from baseline, and the number of teams nearly doubled. We report here results from a qualitative evaluation of the IPC initiative after a year of implementation; our purpose was to understand factors supporting or impeding the rapid and consistent spread of a complex program. Quality improvement study using a case study design and qualitative analysis of in-depth semi-structured interviews with 36 national, regional, and local leaders. Compelling evidence of impacts on patient satisfaction and quality of care generated 'pull' among adopters, expressed as a remarkably high degree of conviction about the value of the model. Broad leadership agreement gave rise to sponsorship and support that permeated the organization. A robust social network promoted knowledge exchange and built on an existing network with a strong interest in palliative care. Resource constraints, pre-existing programs of a different model, and ambiguous accountability for implementation impeded spread. A complex, hospital-based, interdisciplinary intervention in a large health care organization spread rapidly due to a synergy between organizational 'push' strategies and grassroots-level pull. The combination of push and pull may be especially important when the organizational context or the practice to be spread is complex.

32 CFR 732.25 - Accounting classifications for nonnaval medical and dental care expenses.

Code of Federal Regulations, 2010 CFR

2010-07-01

... and dental care expenses. 732.25 Section 732.25 National Defense Department of Defense (Continued) DEPARTMENT OF THE NAVY PERSONNEL NONNAVAL MEDICAL AND DENTAL CARE Accounting Classifications for Nonnaval Medical and Dental Care Expenses and Standard Document Numbers § 732.25 Accounting classifications for...

32 CFR 732.25 - Accounting classifications for nonnaval medical and dental care expenses.

Code of Federal Regulations, 2012 CFR

2012-07-01

... and dental care expenses. 732.25 Section 732.25 National Defense Department of Defense (Continued) DEPARTMENT OF THE NAVY PERSONNEL NONNAVAL MEDICAL AND DENTAL CARE Accounting Classifications for Nonnaval Medical and Dental Care Expenses and Standard Document Numbers § 732.25 Accounting classifications for...

32 CFR 732.25 - Accounting classifications for nonnaval medical and dental care expenses.

Code of Federal Regulations, 2013 CFR

2013-07-01

... and dental care expenses. 732.25 Section 732.25 National Defense Department of Defense (Continued) DEPARTMENT OF THE NAVY PERSONNEL NONNAVAL MEDICAL AND DENTAL CARE Accounting Classifications for Nonnaval Medical and Dental Care Expenses and Standard Document Numbers § 732.25 Accounting classifications for...

32 CFR 732.25 - Accounting classifications for nonnaval medical and dental care expenses.

Code of Federal Regulations, 2011 CFR

2011-07-01

... and dental care expenses. 732.25 Section 732.25 National Defense Department of Defense (Continued) DEPARTMENT OF THE NAVY PERSONNEL NONNAVAL MEDICAL AND DENTAL CARE Accounting Classifications for Nonnaval Medical and Dental Care Expenses and Standard Document Numbers § 732.25 Accounting classifications for...

32 CFR 732.25 - Accounting classifications for nonnaval medical and dental care expenses.

Code of Federal Regulations, 2014 CFR

2014-07-01

... and dental care expenses. 732.25 Section 732.25 National Defense Department of Defense (Continued) DEPARTMENT OF THE NAVY PERSONNEL NONNAVAL MEDICAL AND DENTAL CARE Accounting Classifications for Nonnaval Medical and Dental Care Expenses and Standard Document Numbers § 732.25 Accounting classifications for...

Perceived barriers to seeking mental health care among United States Marine Corps noncommissioned officers serving as gatekeepers for suicide prevention.

PubMed

VanSickle, Marcus; Werbel, Aaron; Perera, Kanchana; Pak, Kyna; DeYoung, Kathryn; Ghahramanlou-Holloway, Marjan

2016-08-01

Reducing mental health stigma and perceived barriers to care is a necessary strategy for addressing the public health problem of suicide among the United States Armed Forces. The purpose of this study was threefold: (a) to empirically evaluate the principal component structure of the Perceived Barriers to Care (PBTC) measure; (b) to gain an understanding of the perceived barriers to seeking mental health services among Marine Corps noncommissioned officers (NCOs) selected to participate in a primary suicide prevention training program, Never Leave a Marine Behind (NLMB); and (c) to explore the relationship among sex, education, prior exposure to suicide within one's military unit, and perceived barriers to seeking mental health services. The data for the PBTC (N = 1,758) were drawn from a previously performed pretest/posttest program evaluation study of the Marine Corp's NLMB program, which took place over 6 months in 2009 (April-October). The three highest perceptions of barriers to care reported by NCOs for their Marines were related to being embarrassed, having members of one's unit have less confidence in the Marine, and concerns about being treated differently by military unit leadership. Three principal components for PBTC were identified, accounting for approximately 59% of the total variance. Higher education and prior exposure to suicide within one's military unit significantly correlated with greater perceived barriers to care; sex was not significantly correlated with greater perceived barriers to care. Implications of these findings, in relation to future research, are further discussed. (PsycINFO Database Record (c) 2016 APA, all rights reserved).

Disease diagnosis in primary care in Uganda.

PubMed

Mbonye, Martin Kayitale; Burnett, Sarah M; Colebunders, Robert; Naikoba, Sarah; Van Geertruyden, Jean-Pierre; Weaver, Marcia R; Ronald, Allan

2014-10-08

The overall burden of disease (BOD) especially for infectious diseases is higher in Sub-Saharan Africa than other regions of the world. Existing data collected through the Health Management Information System (HMIS) may not be optimal to measure BOD. The Infectious Diseases Capacity Building Evaluation (IDCAP) cooperated with the Ugandan Ministry of Health to improve the quality of HMIS data. We describe diagnoses with associated clinical assessments and laboratory investigations of outpatients attending primary care in Uganda. IDCAP supported HMIS data collection at 36 health center IVs in Uganda for five months (November 2009 to March 2010) prior to implementation of the IDCAP interventions. Descriptive analyses were performed on a cross-sectional dataset of 209,734 outpatient visits during this period. Over 500 illnesses were diagnosed. Infectious diseases accounted for 76.3% of these and over 30% of visits resulted in multiple diagnoses. Malaria (48.3%), cough/cold (19.4%), and intestinal worms (6.6%) were the most frequently diagnosed illnesses. Body weight was recorded for 36.8% of patients and less than 10% had other clinical assessments recorded. Malaria smears (64.2%) and HIV tests (12.2%) accounted for the majority of 84,638 laboratory tests ordered. Fewer than 30% of patients for whom a laboratory investigation was available to confirm the clinical impression had the specific test performed. We observed a broad range of diagnoses, a high percentage of multiple diagnoses including true co-morbidities, and underutilization of laboratory support. This emphasizes the complexity of illnesses to be addressed by primary healthcare workers. An improved HMIS collecting timely, quality data is needed. This would adequately describe the burden of disease and processes of care at primary care level, enable appropriate national guidelines, programs and policies and improve accountability for the quality of care.

Environmental health training: a survey of family practice residency program directors.

PubMed

Musham, C; Bellack, J P; Graber, D R; Holmes, D

1996-01-01

The Institute of Medicine and the American College of Physicians have advocated that physicians broaden their participation in the environmental aspects of medical care. Accordingly, both organizations recommend training of future primary care physicians for greater competency in and appreciation of this area of medicine. This study assessed the present emphasis on environmental health in family practice residency programs by examining the extent program directors expect graduates to have specific competencies in environmental medicine. A written survey was mailed to directors of all 393 family practice residency programs listed in the 1993 Directory of Family Practice Residency Programs. Respondents were asked to indicate the extent to which each of eight environmental health competencies was expected of their graduates. The list of environmental health competencies was based on the literature and on interviews with family practice educators. Perceptions about the "present" and "ideal" environmental health emphasis in their programs were also measured. A total of 262 completed surveys were returned for a response rate of 67%. Respondents reported that they expected their graduates to have general knowledge of and competence in environmental health areas that pertain to patient care. Competencies with social and political implications were least likely to be expected. Two thirds of respondents indicated that "minimal emphasis" is presently placed on environmental health. Seventy percent indicated that the "ideal" amount of emphasis placed on this topic is "moderate." This survey's results suggest that family practice residency program directors expect their graduates to know basic environmental health concepts and be skilled in related aspects of patient care. The development of environmental health training programs must take into account that environmental health may be viewed as a topic of secondary importance and that in most residencies, faculty expertise in this area is limited. For this reason, a self-tutoring strategy, aimed toward the educational needs of both faculty and residents, is recommended.

Predictors of Rural Health Clinics Managers' Willingness to Join Accountable Care Organizations.

PubMed

T H Wan, Thomas; Masri, Maysoun Dimachkie; Ortiz, Judith

2014-01-01

The implementation of the Patient Protection and Affordable Care Act has facilitated the development of an innovative and integrated delivery care system, Accountable Care Organizations (ACOs). It is timely, to identify how health care managers in rural health clinics are responding to the ACO model. This research examines RHC managers' perceived benefits and barriers for implementing ACOs from an organizational ecology perspective. A survey was conducted in Spring of 2012 covering the present RHC network working infrastructures - 1) Organizational social network; 2) organizational care delivery structure; 3) ACO knowledge, perceived benefits, and perceived barriers; 4) quality and disease management programs; and 5) health information technology (HIT) infrastructure. One thousand one hundred sixty clinics were surveyed in the United States. They cover eight southeastern states (Alabama, Florida, Georgia, Kentucky, Mississippi, North Carolina, South Carolina, and Tennessee) and California. A total of ninety-one responses were received. RHC managers' personal perceptions on ACO's benefits and knowledge level explained the most variance in their willingness to join ACOs. Individual perceptions appear to be more influential than organizational and context factors in the predictive analysis. The study is primarily focused in the Southeastern region of the U.S. The generalizability is limited to this region. The predictors of rural health clinics' participation in ACOs are germane to guide the development of organizational strategies for enhancing the general knowledge about the innovativeness of delivering coordinated care and containing health care costs inspired by the Affordable Care Act. Rural health clinics are lagged behind the growth curve of ACO adoption. The diffusion of new knowledge about pros and cons of ACO is essential to reinforce the health care reform in the United States.

Predictors of Rural Health Clinics Managers' Willingness to Join Accountable Care Organizations

PubMed Central

T.H.Wan, Thomas; Masri, Maysoun Dimachkie; Ortiz, Judith

2014-01-01

Purpose The implementation of the Patient Protection and Affordable Care Act has facilitated the development of an innovative and integrated delivery care system, Accountable Care Organizations (ACOs). It is timely, to identify how health care managers in rural health clinics are responding to the ACO model. This research examines RHC managers' perceived benefits and barriers for implementing ACOs from an organizational ecology perspective. Methodology/Approach A survey was conducted in Spring of 2012 covering the present RHC network working infrastructures – 1) Organizational social network; 2) organizational care delivery structure; 3) ACO knowledge, perceived benefits, and perceived barriers; 4) quality and disease management programs; and 5) health information technology (HIT) infrastructure. One thousand one hundred sixty clinics were surveyed in the United States. They cover eight southeastern states (Alabama, Florida, Georgia, Kentucky, Mississippi, North Carolina, South Carolina, and Tennessee) and California. A total of ninety-one responses were received. Findings RHC managers' personal perceptions on ACO's benefits and knowledge level explained the most variance in their willingness to join ACOs. Individual perceptions appear to be more influential than organizational and context factors in the predictive analysis. Research limitations/implications The study is primarily focused in the Southeastern region of the U.S. The generalizability is limited to this region. The predictors of rural health clinics' participation in ACOs are germane to guide the development of organizational strategies for enhancing the general knowledge about the innovativeness of delivering coordinated care and containing health care costs inspired by the Affordable Care Act. Originality/Value of Paper Rural health clinics are lagged behind the growth curve of ACO adoption. The diffusion of new knowledge about pros and cons of ACO is essential to reinforce the health care reform in the United States. PMID:25541569

The Impact of WIC on Birth Outcomes: New Evidence from South Carolina.

PubMed

Sonchak, Lyudmyla

2016-07-01

Objectives To investigate the impact of the Special Supplemental Nutrition Program for Women, Infants and Children (WIC) on a variety of infant health outcomes using recent South Carolina Vital Statistics data (2004-2012). Methods To account for non-random WIC participation, the study relies on a maternal fixed effects estimation, due to the availability of unique maternally linked data. Results The results indicate that WIC participation is associated with an increase in birth weight and length of gestation, decrease in the probability of low birth weight, prematurity, and Neonatal Intensive Care Unit admission. Additionally, addressing gestational bias and accounting for the length of gestation, WIC participation is associated with a decrease in the probability of delivering a low weight infant and a small for gestational age infant among black mothers. Conclusions for Practice Accounting for non-random program participation, the study documents a large improvement in birth outcomes among infants of WIC participating mothers. Even in the context of somewhat restrictive gestation-adjusted specification, the positive impact of WIC remains within the subsample of black mothers.

Health care access and health care workforce for immigrant workers in the agriculture, forestry, and fisheries sector in the southeastern US.

PubMed

Frank, Arthur L; Liebman, Amy K; Ryder, Bobbi; Weir, Maria; Arcury, Thomas A

2013-08-01

The Agriculture, Forestry, and Fishery (AgFF) Sector workforce in the US is comprised primarily of Latino immigrants. Health care access for these workers is limited and increases health disparities. This article addresses health care access for immigrant workers in the AgFF Sector, and the workforce providing care to these workers. Immigrant workers bear a disproportionate burden of poverty and ill health and additionally face significant occupational hazards. AgFF laborers largely are uninsured, ineligible for benefits, and unable to afford health services. The new Affordable Care Act will likely not benefit such individuals. Community and Migrant Health Centers (C/MHCs) are the frontline of health care access for immigrant AgFF workers. C/MHCs offer discounted health services that are tailored to meet the special needs of their underserved clientele. C/MHCs struggle, however, with a shortage of primary care providers and staff prepared to treat occupational illness and injury among AgFF workers. A number of programs across the US aim to increase the number of primary care physicians and care givers trained in occupational health at C/MHCs. While such programs are beneficial, substantial action is needed at the national level to strengthen and expand the C/MHC system and to establish widely Medical Home models and Accountable Care Organizations. System-wide policy changes alone have the potential to reduce and eliminate the rampant health disparities experienced by the immigrant workers who sustain the vital Agricultural, Forestry, and Fishery sector in the US. Copyright © 2013 Wiley Periodicals, Inc.

Clean cord care practices and neonatal mortality: evidence from rural Uttar Pradesh, India.

PubMed

Agrawal, Praween K; Agrawal, Sutapa; Mullany, Luke C; Darmstadt, Gary L; Kumar, Vishwajeet; Kiran, Usha; Ahuja, Ramesh C; Srivastava, Vinod K; Santosham, Mathuram; Black, Robert E; Baqui, Abdullah H

2012-08-01

About a million newborns die each year in India, accounting for about a fourth of total global neonatal deaths. Infections are among the leading causes of neonatal mortality. Care practices immediately following delivery contribute to newborns' risk of infection and mortality. This study examined the association between clean cord care practices and neonatal mortality in rural Uttar Pradesh, India. The study used data from a household survey conducted to evaluate a community-based intervention program in two districts of Uttar Pradesh, India. Analysis included data from 5741 singleton live births delivered at home during 2005. The association between clean cord care (clean instrument used to cut cord, clean thread used to tie cord and antiseptics or nothing applied to the cord) and neonatal mortality was estimated using multivariate logistic regression models. Thirty per cent of the study mothers practiced clean cord care. Neonatal mortality rate was significantly lower among newborns exposed to clean cord care (36.5/1000 live births, 95% CI 28.0 to 46.8) than those who did not practice (53.0/1000 live births, 95% CI 46.1 to 60.6). Clean cord care was associated with 37% lower neonatal mortality (OR=0.63; 95% CI 0.46 to 0.87) after adjusting for mother's age, education, caste/tribe, religion, household wealth, newborn thermal care practice and care-seeking during the first week after birth and study arms. Promoting clean cord care practice among neonates in community-based maternal and newborn care programs has the potential to improve neonatal survival in rural India and similar other settings.

The Fiscal Consequences Attributed to Changes in Morbidity and Mortality Linked to Investments in Health Care: A Government Perspective Analytic Framework.

PubMed

Connolly, Mark P; Kotsopoulos, Nikolaos; Postma, Maarten J; Bhatt, Aomesh

2017-02-01

Governments have an enormous economic and political stake in the health of their populations. Population health is not only fundamental to economic growth but also affects short-term and long-term government expenditure on health care, disability, and other social programs and influences direct and indirect tax receipts. Fiscal transfers between citizen and state are mostly ignored in conventional welfare economics analyses based on the hypothesis that there are no winners or losers through transference of wealth. However, from the government perspective, this position is flawed, as disability costs and lost taxes attributed to poor health and reduced productive output represent real costs that pose budgetary and growth implications. To address the value of health and health care investments for government, we have developed a fiscal health analytic framework that captures how changes in morbidity and mortality influence tax revenue and transfer costs (e.g., disability, allowances, ongoing health costs). The framework can be used to evaluate the marginal impact of discrete investments or a mix of interventions in health care to inform governmental budgetary consequences. In this context, the framework can be considered as a fiscal budget impact and/or cost-benefit analysis model that accounts for how morbidity and mortality linked to specific programs represent both ongoing costs and tax revenue for government. Mathematical models identical to those used in cost-effectiveness analyses can be employed in fiscal analysis to reflect how disease progression influences public accounts (e.g., tax revenue and transfers). Copyright © 2017 International Society for Pharmacoeconomics and Outcomes Research (ISPOR). Published by Elsevier Inc. All rights reserved.

Utilization of the medical librarian in a state Medicaid program to provide information services geared to health policy and health disparities

PubMed Central

Droese, Peter; Peterson, Nancy

2006-01-01

Objective: The role of two solo medical librarians in supporting Medicaid programs by functioning as information specialists at regional and state levels is examined. Setting: A solo librarian for the Massachusetts Medicaid (MassHealth) program and a solo librarian for the New England States Consortium Systems Organization (NESCSO) functioned as information specialists in context to support Medicaid policy development and clinical, administrative, and program staff for state Medicaid programs. Brief Description: The librarian for MassHealth initially focused on acquiring library materials and providing research support on culturally competent health care and outreach, as part of the United States Department of Health and Human Services Culturally and Linguistically Appropriate Services in Health Care Standards. The NESCSO librarian focused on state Medicaid system issues surrounding the implementation of the Health Insurance Portability and Accountability Act. The research focus expanded for both the librarians, shaping their roles to more directly support clinical and administrative policy development. Of note, the availability and dissemination of information to policy leaders facilitated efforts to reduce health disparities. In Massachusetts, this led to a state legislative special commission to eliminate health disparities, which released a report in November 2005. On a regional level, the NESCSO librarian provided opportunities for states in New England to share ideas and Medicaid program information. The Centers for Medicaid and Medicare are working with NESCSO to explore the potential for using the NESCSO model for collaboration for other regions of the United States. Results/Outcomes: With the increased attention on evidence-based health care and reduction of health disparities, medical librarians are called on to support a variety of health care information needs. Nationally, state Medicaid programs are being called on to provide coverage and make complex medical decisions regarding the delivery of benefits. Increasing numbers of beneficiaries and shrinking Medicaid budgets demand effective and proactive decision making to provide quality care and to accomplish the missions of state Medicaid programs. In this environment, the opportunities for information professionals to provide value and knowledge management are increasing. PMID:16636710

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

PubMed Central

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

2012-01-01

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

Monitoring Resource Utilization in a Health Care Coordination Program.

PubMed

Popejoy, Lori L; Jaddoo, Julie; Sherman, Jan; Howk, Christopher; Nguyen, Raymond; Parker, Jerry C

2015-01-01

This initial article describes the development of a health care coordination intervention and documentation system designed using the Agency for Healthcare Research and Quality (AHRQ) Care Coordination Atlas framework for Centers for Medicare & Medicaid-funded innovation project, Leveraging Information Technology to Guide High-Tech, High-Touch Care (LIGHT). The study occurred at an academic medical center that serves 114 counties. Twenty-five registered nurse care managers (NCMs) were hired to work with 137 providers in 10 family community and internal medicine clinics. Patients were allocated into one of the four tiers on the basis of their chronic medical conditions and health care utilization. Using a documentation system on the basis of the AHRQ domains developed for this study, time and touch data were calculated for 8,593 Medicare, Medicaid, or dual-eligible patients. We discovered through the touch and time analysis that the majority of health care coordination activity occurred in the AHRQ domains of communication, assess needs and goals, and facilitate transitions, accounting for 79% of the NCM time and 61% of the touches. As expected, increasing tier levels resulted in increased use of NCM resources. Tier 3 accounted for roughly 16% of the patients and received 159 minutes/member (33% of total minutes), and Tier 4 accounted for 4% of patients and received 316 minutes/member (17% of all minutes). In contrast Tier 2, which did not require routine touches per protocol, had 5,507 patients (64%), and those patients received 5,246 hours of health care coordination, or 57 minutes/member, and took 48% of NCM time. 1. The AHRQ Care Coordination Atlas offered a systematic way to build a documentation system that allowed for the extraction of data that was used to calculate the amount of time and the number of touches that NCMs delivered per member. 2. Using a framework to systematically guide the work of health care coordination helped NCMs to think strategically about the care being delivered, and has implications for improving coordination of care. 3. For the purpose of reimbursement and communication with payers about quality metrics, it is vital that the type of touches and amount of time spent in delivering care coordination be documented in a manner that can be easily retrieved to guide practice decisions.

Social Determinants of Health in Managed Care Payment Formulas.

PubMed

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.

Self-care of patients with diabetes mellitus cared for at an emergency service in Mexico.

PubMed

Baquedano, Irasema Romero; dos Santos, Manoel Antônio; Martins, Tatiane Aparecida; Zanetti, Maria Lúcia

2010-01-01

This study examines the self-care ability of type 2 diabetes mellitus patients and relates it to sociodemographic and clinical variables. The study included 251 patients who were cared for by an emergency service in Mexico, in 2007. Data were obtained through structured interviews held at participants' households, through a form, a questionnaire and the Self-Care Ability Scale. Descriptive and correlation statistics were used for data analysis. The results show that 83 (33.5%) individuals displayed good self-care ability and 168 (66.5%) individuals displayed regular ability. A directly proportional correlation was found between self-care ability and schooling (r=0.124; p<0.05), as well as a negative correlation for religion (rs=-0.435; p<0.05) and duration of disease evolution (r=-0.667; p<0.05). The conclusion is that most of the individuals with type 2 diabetes mellitus displayed regular ability for self-care. Self-care ability is related to multiple variables that should be taken into account by health professionals when suggesting educational programs.

The influence of maternal health literacy and child’s age on participation in social welfare programs

PubMed Central

Pati, Susmita; Siewert, Elizabeth; Wong, Angie T.; Bhatt, Suraj K.; Calixte, Rose E.; Cnaan, Avital

2013-01-01

Objective To determine the influence of maternal health literacy and child’s age on participation in social welfare programs benefiting children. Methods In a longitudinal prospective cohort study of 560 Medicaid-eligible mother-infant dyads recruited in Philadelphia, maternal health literacy was assessed using the Test of Functional Health Literacy in Adults (short version). Participation in social welfare programs (Temporary Assistance to Needy Families [TANF], Supplemental Nutrition Assistance Program [SNAP], Special Supplemental Nutrition Program for Women, Infants, and Children [WIC], child care subsidy, and public housing) was self-reported at child’s birth, and at the 6, 12, 18, 24 month follow-up interviews. Generalized estimating equations quantified the strength of maternal health literacy as an estimator of program participation. Results The mothers were primarily African-Americans (83%), single (87%), with multiple children (62%). Nearly 24% of the mothers had inadequate or marginal health literacy. Children whose mothers had inadequate health literacy were less likely to receive child care subsidy (adjusted OR= 0.54, 95% CI: 0.34–0.85) than children whose mothers had adequate health literacy. Health literacy was not a significant predictor for TANF, SNAP, WIC or housing assistance. The predicted probability for participation in all programs decreased from birth to 24 months. Most notably, predicted WIC participation declined rapidly after age one. Conclusions During the first 24 months, mothers with inadequate health literacy could benefit from simplified or facilitated child care subsidy application processes. Targeted outreach and enrollment efforts conducted by social welfare programs need to take into account the changing needs of families as children age. PMID:23990157

Health savings accounts--a revolutionary method of funding medical care expenses.

PubMed

Knox, George Con

2004-10-01

Health Savings Accounts coupled with a High-Deductible Health Care plan offer many eligible individuals the opportunity to reduce their insurance premiums and create a tax-deductible account to pay medical, dental, and vision care expenses.

Comprehensive survivorship care with cost and revenue analysis.

PubMed

Rosales, Alicia R; Byrne, Dia; Burnham, Christa; Watts, Lori; Clifford, Kathleen; Zuckerman, Dan S; Beck, Thomas

2014-03-01

The 2015 Commission on Cancer standards require that cancer survivors receive an individualized survivorship care plan (SCP). To meet this new standard, St Luke's Mountain States Tumor Institute (MSTI), with support from the National Community Cancer Centers Program, implemented a successful survivorship model. At MSTI, the patient's SCP is prepared in the electronic health record by a registered health information technician. This document is reviewed during an appointment with a nurse practitioner and social worker. The provider's dictation is mailed to the primary care physician with the SCP. From August 2011 to Oct 2012, 118 patients with breast cancer were seen for survivorship appointments. Medical record audit and follow-up telephone call were completed to evaluate patient survivorship needs and satisfaction with the appointment. Patient accounts were reviewed for reimbursement. From medical record review, the most common patient concerns were weight management (35%), fatigue (30%), sexuality (27%), anxiety (23%), caregiver stress (17%), and depression (16%). Telephone calls showed high patient satisfaction and understanding. Patients rated the following statements on a Likert scale from 1 (strongly disagree) to 5 (strongly agree): I understand my treatment summary and care plan (88% strongly agree or agree), and I feel the survivorship visit met my survivorship needs (86% strongly agree or agree). At 1 month, 80% of participants were still working on wellness goals. Patient accounts analysis showed revenue covered costs. Survivorship care at MSTI meets new standards, allows for patient engagement and satisfaction, and improves care coordination. Costs are covered by reimbursement.

The role of employee flexible spending accounts in health care financing.

PubMed

Schweitzer, M; Asch, D A

1996-08-01

Employee flexible spending accounts for health care represent one component of the current health care financing system that merits serious reform. These accounts create a system of undesirable incentives, force employees and employers to take complicated gambles, reduce tax revenues, and fail to meet their purported policy objectives. This paper describes shortcomings in these accounts from both a theoretical and an empirical perspective. Some proposed alternatives; including medical spending accounts and zero balance accounts, resolve many of these concerns but not all of them.

Recovery Audit Contractor medical necessity readiness: one health system's journey.

PubMed

Scott, Judith A; Camden, Mindy

2011-01-01

To develop a sustainable approach to Recovery Audit Contractor medical necessity readiness that mitigates the regulatory and financial risks of the organization. Acute care hospitals. Utilizing the model for improvement and plan-do-study-act methodology, this health system designed and implemented a medical necessity case management program. We focused on 3 areas for improvement: medical necessity review accuracy, review timeliness, and physician adviser participation for secondary reviews. Over several months, we improved accuracy and timeliness of our medical necessity reviews while also generating additional inpatient revenue for the health system. We successfully enhanced regulatory compliance and reduced our financial risks associated with Recovery Audit Contractor medical necessity audits. A successful medical necessity case management program can not only enhance regulatory compliance and reduce the amount of payments recouped by Medicare, but also generate additional inpatient revenue for your organization. With health care reform and accountable care organizations on the horizon, hospitals must find ways to protect and enhance revenue in order to carry out their missions. This is one way for case managers to help in that cause, to advocate for the care of their patients, and to bring value to the organization.

Management by Parent Objectives: A Case Study Establishing the Feasibility of Employer-Sponsored Child Care and Other Family Supports.

ERIC Educational Resources Information Center

Friedman, Dana E.

This paper addresses the feasibility of family support programs as a means by which management may constructively respond to the changes in the workforce in order to fulfill its own objectives. The analysis takes into account both theory and practice, applying learned concepts to the design and execution of an actual feasibility study at a small,…

Long-Term Implications of the Fiscal Year 2009 Future Years Defense Program

DTIC Science & Technology

2009-01-01

accrual basis, with payments into the Medicare -Eligible Retiree Health Care Fund charged against the military personnel accounts.20 The indepen- dent...P A P E R CBO Report Documentation Page Form ApprovedOMB No. 0704-0188 Public reporting burden for the collection of information is estimated to...information, including suggestions for reducing this burden, to Washington Headquarters Services, Directorate for Information Operations and Reports , 1215

Accountability for end-stage organ care: implications of geographic variation in access to kidney transplantation.

PubMed

Axelrod, David A; Lentine, Krista L; Xiao, Huiling; Bubolz, Thomas; Goodman, David; Freeman, Richard; Tuttle-Newhall, Janet E; Schnitzler, Mark A

2014-05-01

The provision of effective surgical care for end-stage renal disease (ESRD) requires efficient evaluation and transplantation. Prior assessments of transplant access have focused primarily on waitlisted patients rather than the overall populations served by "accountable" providers of transplant services. Novel transplant referral regions (TRRs) were defined using United Network for Organ Sharing registry data for 301,092 kidney transplant listings to assign zip codes to "accountable" transplant programs. Subsequently, risk-adjusted observed to expected (O:E) rates of listing and transplant procedures were calculated for each TRR. Finally, the impact of variation in TRR listing and transplant rates on mortality was assessed for ESRD patients <60 years old diagnosed between 2000 and 2008. In total, 113 TRRs were defined, 51% of which included >1 transplant center. The likelihood of being evaluated and listed for transplant varied significantly between TRRs (risk-adjusted O:E, 0.58-1.95). Variation was greater for the overall transplant rate (0.62-2.19), living donor transplantation (0.36-3.08), and donation after cardiac death transplant (0-15.4) than for standard criteria donors (0.64-2.86). Mortality was decreased for ESRD patients living in TRRs in the highest tertile of listings (hazard ratio, 0.89; P < .0001) and transplantation (0.90; P < .0001). Residence in a TRR with care delivery systems that increase access to transplant services is associated with significant, risk-adjusted decreases in ESRD-related mortality. Transplant centers should continue to focus on improving access to care within the communities they serve. Copyright © 2014 Mosby, Inc. All rights reserved.

Continuing Care and Trauma in Women Offenders’ Substance Use, Psychiatric Status, and Self-Efficacy Outcomes

PubMed Central

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

2015-01-01

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

Chronic heart failure management in Australia -- time for general practice centred models of care?

PubMed

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.

Oral Health Care Delivery Within the Accountable Care Organization.

PubMed

Blue, Christine; Riggs, Sheila

2016-06-01

The accountable care organization (ACO) provides an opportunity to strategically design a comprehensive health system in which oral health works within primary care. A dental hygienist/therapist within the ACO represents value-based health care in action. Inspired by health care reform efforts in Minnesota, a vision of an accountable care organization that integrates oral health into primary health care was developed. Dental hygienists and dental therapists can help accelerate the integration of oral health into primary care, particularly in light of the compelling evidence confirming the cost-effectiveness of care delivered by an allied workforce. A dental insurance Chief Operating Officer and a dental hygiene educator used their unique perspectives and experience to describe the potential of an interdisciplinary team-based approach to individual and population health, including oral health, via an accountable care community. The principles of the patient-centered medical home and the vision for accountable care communities present a paradigm shift from a curative system of care to a prevention-based system that encompasses the behavioral, social, nutritional, economic, and environmental factors that impact health and well-being. Oral health measures embedded in the spectrum of general health care have the potential to ensure a truly comprehensive healthcare system. Published by Elsevier Inc.

Integrating telemedicine and telehealth: putting it all together.

PubMed

Weinstein, Ronald S; Lopez, Ana Maria; Krupinski, Elizabeth A; Beinar, Sandra J; Holcomb, Michael; McNeely, Richard A; Latifi, Rifat; Barker, Gail

2008-01-01

Telemedicine and telehealth programs are inherently complex compared with their traditional on-site health care delivery counterparts. Relatively few organizations have developed sustainable, multi-specialty telemedicine programs, although single service programs, such as teleradiology and telepsychiatry programs, are common. A number of factors are barriers to the development of sustainable telemedicine and telehealth programs. First, starting programs is often challenging since relatively few organizations have, in house, a critical mass of individuals with the skill sets required to organize and manage a telemedicine program. Therefore, it is necessary to "boot strap" many of the start-up activities using available personnel. Another challenge is to assemble a management team that has time to champion telemedicine and telehealth while dealing with the broad range of issues that often confront telemedicine programs. Telemedicine programs housed within a single health care delivery system have advantages over programs that serve as umbrella telehealth organizations for multiple health care systems. Planning a telemedicine program can involve developing a shared vision among the participants, including the parent organizations, management, customers and the public. Developing shared visions can be a time-consuming, iterative process. Part of planning includes having the partnering organizations and their management teams reach a consensus on the initial program goals, priorities, strategies, and implementation plans. Staffing requirements of telemedicine and telehealth programs may be met by sharing existent resources, hiring additional personnel, or outsourcing activities. Business models, such as the Application Service Provider (ASP) model used by the Arizona Telemedicine Program, are designed to provide staffing flexibility by offering a combination of in-house and out-sourced services, depending on the needs of the individual participating health care organizations. Telemedicine programs should perform ongoing assessments of activities, ranging from service usage to quality of service assessments, to ongoing analyses of financial performance. The financial assessments should include evaluations of costs and benefits, coding issues, reimbursement, account receivables, bad debt and network utilization. Long-range strategic planning for a telemedicine and telehealth program should be carried out on an on-going basis and should include the program's governing board. This planning process should include goal setting and the periodic updating of the program's vision and mission statements. There can be additional special issues for multi-organization telemedicine and telehealth programs. For example, authority management can require the use of innovative approaches tailored to the realities of the organizational structures of the participating members. Inter-institutional relations may introduce additional issues when competing health care organizations are utilizing shared resources. Branding issues are preferably addressed during the initial planning of a multi-organizational telemedicine and telehealth program. Ideally, public policy regarding telemedicine and telehealth within a service region will complement the objectives of telemedicine and telehealth programs within that service area.

Monitoring quality of care at dialysis facilities: a case for regulatory parsimony--and beyond.

PubMed

Stivelman, John C

2012-10-01

With the issuance of the new Conditions for Coverage in 2008 and the implementation of the Prospective Payment System in 2011, the Centers for Medicare & Medicaid Services has fundamentally altered the regulatory landscape of quality in the ESRD program. Although these changes-largely through use of tools comparing individual facility performance to regional and national quality expectations-have increased facility accountability for the quality of patient care in many quarters, they have also complicated both substance and process of facility adherence to quality rules in that component of the program. This editorial critically assesses the main quality tools now in use for dialysis facilities and reviews the issues arising from their conjoint use. A scheme for improving the effectiveness of each quality tool is proposed, and an assessment of their future value and effectiveness in quality improvement is offered.

[Application of a shared interdisciplinary and multiprofessional cardio-oncology in-hospital pathway].

PubMed

Canale, Maria Laura; Camerini, Andrea; Magnacca, Massimo; Del Meglio, Jacopo; Lilli, Alessio; Donati, Sara; Belli, Lucia; Lencioni, Stefania; Amoroso, Domenico; Casolo, Giancarlo

2017-11-01

The burden of cardiac side effects in oncology patients will dramatically increase in the near future as a result of the widespread use of anticancer agents affecting the cardiovascular system, the general population aging, the heightened attention in the detection of cardiac toxicity and the absolute gain in terms of overall survival. The relationship between cardiologists and oncologists should therefore be closer leading to the definition of cardio-oncology. The increased number of such patients requires the creation of a dedicated patient assistance program in order to guarantee every patient the possibility of an interdisciplinary and multiprofessional approach. A dedicated care pathway needs a reorganization of internal resources to ensure high standards of care. The proposed pathway is actually active at our institution and has been implemented taking into account available facilities and planned work amount. Our patient cardio-oncology program could be adapted with minimal changes to different hospitals.

Medicaid care management: description of high-cost addictions treatment clients.

PubMed

Neighbors, Charles J; Sun, Yi; Yerneni, Rajeev; Tesiny, Ed; Burke, Constance; Bardsley, Leland; McDonald, Rebecca; Morgenstern, Jon

2013-09-01

High utilizers of alcohol and other drug treatment (AODTx) services are a priority for healthcare cost control. We examine characteristics of Medicaid-funded AODTx clients, comparing three groups: individuals <90th percentile of AODTx expenditures (n=41,054); high-cost clients in the top decile of AODTx expenditures (HC; n=5,718); and 1760 enrollees in a chronic care management (CM) program for HC clients implemented in 22 counties in New York State. Medicaid and state AODTx registry databases were combined to draw demographic, clinical, social needs and treatment history data. HC clients accounted for 49% of AODTx costs funded by Medicaid. As expected, HC clients had significant social welfare needs, comorbid medical and psychiatric conditions, and use of inpatient services. The CM program was successful in enrolling some high-needs, high-cost clients but faced barriers to reaching the most costly and disengaged individuals. Copyright © 2013 Elsevier Inc. All rights reserved.

Grounding theories of W(e)Learn: a framework for online interprofessional education.

PubMed

Casimiro, Lynn; MacDonald, Colla J; Thompson, Terrie Lynn; Stodel, Emma J

2009-07-01

Interprofessional care (IPC) is a prerequisite for enhanced communication between healthcare team members, improved quality of care, and better outcomes for patients. A move to an IPC model requires changing the learning experiences of healthcare providers during and after their qualification program. With the rapid growth of online and blended approaches to learning, an educational framework that explains how to construct quality learning events to provide IPC is pressing. Such a framework would offer a quality standard to help educators design, develop, deliver, and evaluate online interprofessional education (IPE) programs. IPE is an extremely delicate process due to issues related to knowledge, status, power, accountability, personality traits, and culture that surround IPC. In this paper, a review of the pertinent literature that would inform the development of such a framework is presented. The review covers IPC, IPE, learning theories, and eLearning in healthcare.

No hospital left behind? Education policy lessons for value-based payment in healthcare.

PubMed

Maurer, Kristin A; Ryan, Andrew M

2016-01-01

Value-based payment systems have been widely implemented in healthcare in an effort to improve the quality of care. However, these programs have not broadly improved quality, and some evidence suggests that they may increase inequities in care. No Child Left Behind is a parallel effort in education to address uneven achievement and inequalities. Yet, by penalizing the lowest performers, No Child Left Behind's approach to accountability has led to a number of unintended consequences. This article draws lessons from education policy, arguing that financial incentives should be designed to support the lowest performers to improve quality. © 2015 Society of Hospital Medicine.

Improving Aboriginal maternal and infant health services in the 'Top End' of Australia; synthesis of the findings of a health services research program aimed at engaging stakeholders, developing research capacity and embedding change.

PubMed

Barclay, Lesley; Kruske, Sue; Bar-Zeev, Sarah; Steenkamp, Malinda; Josif, Cathryn; Narjic, Concepta Wulili; Wardaguga, Molly; Belton, Suzanne; Gao, Yu; Dunbar, Terry; Kildea, Sue

2014-06-02

Health services research is a well-articulated research methodology and can be a powerful vehicle to implement sustainable health service reform. This paper presents a summary of a five-year collaborative program between stakeholders and researchers that led to sustainable improvements in the maternity services for remote-dwelling Aboriginal women and their infants in the Top End (TE) of Australia. A mixed-methods health services research program of work was designed, using a participatory approach. The study area consisted of two large remote Aboriginal communities in the Top End of Australia and the hospital in the regional centre (RC) that provided birth and tertiary care for these communities. The stakeholders included consumers, midwives, doctors, nurses, Aboriginal Health Workers (AHW), managers, policy makers and support staff. Data were sourced from: hospital and health centre records; perinatal data sets and costing data sets; observations of maternal and infant health service delivery and parenting styles; formal and informal interviews with providers and women and focus groups. Studies examined: indicator sets that identify best care, the impact of quality of care and remoteness on health outcomes, discrepancies in the birth counts in a range of different data sets and ethnographic studies of 'out of hospital' or health centre birth and parenting. A new model of maternity care was introduced by the health service aiming to improve care following the findings of our research. Some of these improvements introduced during the five-year research program of research were evaluated. Cost effective improvements were made to the acceptability, quality and outcomes of maternity care. However, our synthesis identified system-wide problems that still account for poor quality of infant services, specifically, unacceptable standards of infant care and parent support, no apparent relationship between volume and acuity of presentations and staff numbers with the required skills for providing care for infants, and an 'outpatient' model of care. Services were also characterised by absent Aboriginal leadership and inadequate coordination between remote and tertiary services that is essential to improve quality of care and reduce 'system-introduced' risk. Evidence-informed redesign of maternity services and delivery of care has improved clinical effectiveness and quality for women. However, more work is needed to address substandard care provided for infants and their parents.

Analysing the role of the PICU nurse to guide education of new graduate nurses.

PubMed

Long, Debbie A; Young, Jeanine; Rickard, Claire M; Mitchell, Marion L

2013-04-01

One strategy to address the current nursing shortage in specialty areas has been to introduce graduate nurse programs. However introducing novice nurses to specialty areas raises concerns around education and competency which, in turn, highlights the need to identify and prioritise the elements of competent paediatric intensive care unit (PICU) nursing care considered essential to safe practice. To determine the key knowledge, skills and attributes of competent level PICU nurses. A practice analysis survey of 15 nurse educators was conducted in all eight Australian and New Zealand PICUs during 2008. Three areas of practice essential to PICU nursing competence were explored: patients most commonly cared for; frequency and criticality of activities performed; and level of independence against critical care nursing competency standards. Data were analysed using descriptive statistics. Cardiac and respiratory problems accounted for over 50% of patients cared for by competent level nurses. Cardiac and respiratory activities were therefore also ranked as the most important activities. Respondents identified that competency domains of teamwork and professional practice are performed with minimal supervision, whereas clinical problem solving requires supervision and assistance. PICU nurses are performing activities and caring for a breadth of complex patients within a year of entering the workforce. Using a practice analysis to define actual practice and expectations can assist in the identification and prioritisation of content for graduate and other educational programs. Copyright © 2013 Elsevier Ltd. All rights reserved.

Community-Based Noncommunicable Disease Care for Syrian Refugees in Lebanon

PubMed Central

Sethi, Stephen; Jonsson, Rebecka; Skaff, Rony; Tyler, Frank

2017-01-01

ABSTRACT In the sixth year of the Syrian conflict, 11 million people have been displaced, including more than 1.1 million seeking refuge in Lebanon. Prior to the crisis, noncommunicable diseases (NCDs) accounted for 80% of all deaths in Syria, and the underlying health behaviors such as tobacco use, obesity, and physical inactivity are still prevalent among Syrian refugees in Lebanon. Humanitarian agencies initially responded to the acute health care needs of refugees by delivering services to informal settlements via mobile medical clinics. As the crisis has become more protracted, humanitarian response plans have shifted their focus to strengthening local health systems in order to better address the needs of both the host and refugee populations. To that end, we identified gaps in care for NCDs and launched a program to deliver chronic disease care for refugees. Based on a participatory needs assessment and community surveys, and building on the success of community health programs in other contexts, we developed a network of 500 refugee outreach volunteers who are supported with training, supervision, and materials to facilitate health promotion and disease control for community members, target NCDs and other priority conditions, and make referrals to a primary health care center for subsidized care. This model demonstrates that volunteer refugee health workers can implement community-based primary health activities in a complex humanitarian emergency. PMID:28928227

Impact of Financial Incentives for Prenatal Care on Birth Outcomes and Spending

PubMed Central

Rosenthal, Meredith B; Li, Zhonghe; Robertson, Audra D; Milstein, Arnold

2009-01-01

Objective To evaluate the impact of offering US$100 each to patients and their obstetricians or midwives for timely and comprehensive prenatal care on low birth weight, neonatal intensive care admissions, and total pediatric health care spending in the first year of life. Data Sources/Study Setting Claims and enrollment profiles of the predominantly low-income and Hispanic participants of a union-sponsored, health insurance plan from 1998 to 2001. Study Design Panel data analysis of outcomes and spending for participants and nonparticipants using instrumental variables to account for selection bias. Data Collection/Abstraction Methods Data provided were analyzed using t-tests and chi-squared tests to compare maternal characteristics and birth outcomes for incentive program participants and nonparticipants, with and without instrumental variables to address selection bias. Adjusted variables were analyzed using logistic regression models. Principle Findings Participation in the incentive program was significantly associated with lower odds of neonatal intensive care unit admission (0.45; 95 percent CI, 0.23–0.88) and spending in the first year of life (estimated elasticity of −0.07; 95 percent CI, −0.12 to −0.01), but not low birth weight (0.53; 95 percent CI, 0.23–1.18). Conclusion The use of patient and physician incentives may be an effective mechanism for improving use of recommended prenatal care and associated outcomes, particularly among low-income women. PMID:19619248

Community-Based Noncommunicable Disease Care for Syrian Refugees in Lebanon.

PubMed

Sethi, Stephen; Jonsson, Rebecka; Skaff, Rony; Tyler, Frank

2017-09-27

In the sixth year of the Syrian conflict, 11 million people have been displaced, including more than 1.1 million seeking refuge in Lebanon. Prior to the crisis, noncommunicable diseases (NCDs) accounted for 80% of all deaths in Syria, and the underlying health behaviors such as tobacco use, obesity, and physical inactivity are still prevalent among Syrian refugees in Lebanon. Humanitarian agencies initially responded to the acute health care needs of refugees by delivering services to informal settlements via mobile medical clinics. As the crisis has become more protracted, humanitarian response plans have shifted their focus to strengthening local health systems in order to better address the needs of both the host and refugee populations. To that end, we identified gaps in care for NCDs and launched a program to deliver chronic disease care for refugees. Based on a participatory needs assessment and community surveys, and building on the success of community health programs in other contexts, we developed a network of 500 refugee outreach volunteers who are supported with training, supervision, and materials to facilitate health promotion and disease control for community members, target NCDs and other priority conditions, and make referrals to a primary health care center for subsidized care. This model demonstrates that volunteer refugee health workers can implement community-based primary health activities in a complex humanitarian emergency. © Sethi et al.

Measuring the direct costs of graduate medical education training in Minnesota.

PubMed

Blewett, L A; Smith, M A; Caldis, T G

2001-05-01

To demonstrate the usefulness of self-reported cost-accounting data from the sponsors of training programs for estimating the direct costs of graduate medical education (GME). The study also assesses the relative contributions of resident, faculty, and administrative costs to primary care, surgery, and the combined programs of radiology, emergency medicine, anesthesiology, and pathology (REAP). The data were the FY97 direct costs of clinical education reported to Minnesota's Department of Health by eight sponsors of 117 accredited medical education programs, representing 394 sites of training (both hospital- and community-based) and 2,084 full-time-equivalent trainees (both residents and fellows). Average costs of clinical training were calculated as residency, faculty, and administrative costs. Preliminary analysis showed average costs by type of training programs, comparing the cost components for surgery, primary care, and REAP. The average direct cost of clinical training in FY97 was $130,843. Faculty costs were 52%, resident costs were 26%, and administrative costs were 20% of the total. Primary care programs' average costs were lower than were those of either surgery or REAP programs, but proportionally they included more administrative costs. As policymakers assess government subsidies for GME, more detailed cost information will be required. Self-reported data are more cost-effective and efficient than are the more detailed and costly time-and-motion studies. This data-collection study also revealed that faculty costs, driven by faculty hours and base salaries, represent a higher proportion of direct costs of GME than studies have shown in the past.

[Governance in a project addressing care of disabled elderly persons within the regional healthcare system of Tuscany, Italy].

PubMed

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

2017-01-01

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

Socially Accountable Medical Education: An Innovative Approach at Florida International University Herbert Wertheim College of Medicine

PubMed Central

Greer, Pedro J.; Brewster, Luther G.; Lage, Onelia G.; Esposito, Karin F.; Whisenant, Ebony B.; Anderson, Frederick W.; Castellanos, Natalie K.; Stefano, Troy A.; Rock, John A.

2018-01-01

Problem Despite medical advances, health disparities persist, resulting in medicine’s renewed emphasis on the social determinants of health and calls for reform in medical education. Approach The Green Family Foundation Neighborhood Health Education Learning Program (NeighborhoodHELP) at Herbert Wertheim College of Medicine provides a platform for the school’s community-focused mission. NeighborhoodHELP emphasizes social accountability and interprofessional education while providing evidence-based, patient- and household-centered care. NeighborhoodHELP is a required, longitudinal service–learning outreach program in which each medical student is assigned a household in a medically underserved community. Students, teamed with learners from other professional schools, provide social and clinical services to their household for three years. Here the authors describe the program’s engagement approach, logistics, and educational goals and structure. Outcomes During the first six years of NeighborhoodHELP (September 2010–August 2016), 1,470 interprofessional students conducted 7,452 visits to 848 households with, collectively, 2,252 members. From August 2012, when mobile health centers were added to the program, through August 2016, students saw a total of 1,021 household members through 7,207 mobile health center visits. Throughout this time, households received a variety of free health and social services (e.g., legal aid, tutoring). Compared with peers from other schools, graduating medical students reported more experience with clinical interprofessional education and health disparities. Surveyed residency program directors rated graduates highly for their cultural sensitivity, teamwork, and accountability. Next Steps Faculty and administrators are focusing on social accountability curriculum integration, systems for assessing and tracking relevant educational and household outcomes, and policy analysis. PMID:28658020

The medical director and quality requirements in the dialysis facility.

PubMed

Schiller, Brigitte

2015-03-06

Four decades after the successful implementation of the ESRD program currently providing life-saving dialysis therapy to >430,000 patients, the definitions of and demands for a high-quality program have evolved and increased at the same time. Through substantial technological advances ESRD care improved, with a predominant focus on the technical aspects of care and the introduction of medications such as erythropoiesis-stimulating agents and active vitamin D for anemia and bone disease management. Despite many advances, the size of the program and the increasingly older and multimorbid patient population have contributed to continuing challenges for providing consistently high-quality care. Medicare's Final Rule of the Conditions for Coverage (April 2008) define the medical director of the dialysis center as the leader of the interdisciplinary team and the person ultimately accountable for quality, safety, and care provided in the center. Knowledge and active leadership with a hands-on approach in the quality assessment and performance improvement process (QAPI) is essential for the achievement of high-quality outcomes in dialysis centers. A collaborative approach between the dialysis provider and medical director is required to optimize outcomes and deliver evidence-based quality care. In 2011 the Centers for Medicare & Medicaid Services introduced a pay-for-performance program-the ESRD quality incentive program (QIP)- with yearly varying quality metrics that result in payment reductions in subsequent years when targets are not achieved during the performance period. Success with the QIP requires a clear understanding of the structure, metrics, and scoring methods. Information on achievement and nonachievement is publicly available, both in facilities (through the facility performance score card) and on public websites (including Medicare's Dialysis Facility Compare). By assuming the leadership role in the quality program of dialysis facilities, the medical director is given an important opportunity to improve patients' lives and effect true change in a patient population dealing with a very challenging chronic disease. This article in the series on the role of the medical director summarizes the medical director's specific role in the quality improvement process in the dialysis facility and the associated requirements and programs, including QAPI and QIP. Copyright © 2015 by the American Society of Nephrology.

Making the Health Insurance Flexibility and Accountability (HIFA) waiver work through collaborative governance.

PubMed

Zabawa, Barbara J

2003-01-01

This paper argues that collaborative governance should be an essential component in any HIFA waiver proposal, due to the fact that the health care system is moving away from a federal and hierarchical program design and implementation towards a more local, collaborative approach. As several current collaborative projects demonstrate, collaboration may overcome barriers to health expansion program success, such as stakeholder buy-in, notice, and state access to private health coverage information. Furthermore, collaboration within the context of the HIFA waiver process may maximize the strengths of current collaborations, such as providing: (a) access to greater and more stable funding sources; (b) access to a facilitator that can collect and distribute data; and (c) an avenue for accountability. Multiple challenges in ensuring collaborative governance are reviewed. Ms. Zabawa argues that these challenges are not insurmountable if states adopt a truly collaborative approach to designing and implementing programs under the HIFA waiver; there may be hope in expanding and improving health coverage, since collaboration is the most appropriate mechanism to address the complexity of health system reform.

Access assured: a pilot program to finance primary care for uninsured patients using a monthly enrollment fee.

PubMed

Saultz, John W; Brown, David; Stenberg, Stephen; Rdesinski, Rebecca E; Tillotson, Carrie J; Eigner, Danielle; Devoe, Jennifer

2010-01-01

Access Assured is an experimental program being used by 2 academic family medicine practices to deliver primary care to an uninsured patient population using a monthly retainer payment system in addition to a sliding fee schedule for office visits. This prospective cohort study was designed to determine whether patients would join such a program, to describe the population of people who did so, and to assess the program's financial viability. We used data abstracted from our electronic medical record system to describe the demographic characteristics and care utilization patterns of those patients enrolling during the first year of the study, between February 1, 2008, and January 31, 2009. We also compared 2 subpopulations of enrollees defined by their eligibility for office fee discounts based on income. A total of 600 Access Assured members made 1943 office visits during the study period, receiving a total of 4538.22 relative value units of service. Based on the membership fee, office visit fee collections, and remaining accounts receivable, this resulted in an expected reimbursement rate of $42.88 per relative value units. Three hundred one of the 600 (50.2%) patients had incomes above 400% of the federal poverty level (FPL) at the time of each of their office visits and were therefore not eligible for any visit fee discount. Another 156 patients (26.0%) were eligible for a 100% discount of all visit fees based on their income below 200% of the FPL. Using a multivariable Poisson regression analysis of these 2 groups, we determined that age was a significant determinant of return visit rate, with a 0.7% increase in return visit rate for each additional year of age (P = .006). Women had a 26% higher return visit rate than men (P = .001). After accounting for age, sex, and clinic site, fee discount level based on income was not a significant independent determinant of return visit rate (P = .118). A retainer-based program to enroll uninsured patients being used in 2 academic family medicine clinics attracted 600 patients during its first year. The program was financially viable and resulted in an expansion of our service to uninsured patients. More than half of the patients had incomes above 400% of the FPL, suggesting that the population of uninsured Oregonians may be economically more diverse than suspected.

Aligning career development with organizational goals: working towards the development of a strong and sustainable workforce.

PubMed

Saxe-Braithwaite, Marcy; Carlton, Sandra; Bass, Brenda

2009-01-01

The rapidly changing world of healthcare is faced with many challenges, not the least of which is a diminishing workforce. Healthcare organizations must develop multiple strategies, not only to attract and retain employees, but also to ensure that workers are prepared for continuous change in the workplace, are working at their full scope of practice and are committed to, and accountable for, the provision of high-quality care. There is evidence that by creating a healthier workplace, improved patient care will follow. Aligning Healthy Workplace Initiatives with an organization's strategic goals, corporate culture and vision reinforces their importance within the organization. In this paper, we describe an innovative pilot to assess a career development program, one of multiple Healthy Workplace Initiatives taking place at Providence Care in Kingston, Ontario in support of our three strategic goals. The results of the pilot were very encouraging; subsequent success in obtaining funding from HealthForceOntario has allowed the implementation of a sustainable program of career development within the organization. More work is required to evaluate its long-term effectiveness.

The use of performance standards by AAALAC International to evaluate ethical review in European institutions.

PubMed

Guillen, Javier

2010-02-01

During the past several decades, society has become increasingly concerned about the welfare of animals used in research. Today, the public asks scientists to justify the use of research animals and to be accountable for their welfare. Research institutions, government bodies and other regulatory authorities have developed mechanisms to ensure that researchers follow the principles of the 3Rs and use and care for research animals in an ethical manner. Additionally, organizations such as the Association for Assessment and Accreditation of Laboratory Animal Care International (AAALAC International) have developed voluntary programs that can help researchers to ensure that they are caring for research animals appropriately. The author discusses how AAALAC International uses performance standards to evaluate the ethical review processes of European institutions.

Using Bayesian Imputation to Assess Racial and Ethnic Disparities in Pediatric Performance Measures.

PubMed

Brown, David P; Knapp, Caprice; Baker, Kimberly; Kaufmann, Meggen

2016-06-01

To analyze health care disparities in pediatric quality of care measures and determine the impact of data imputation. Five HEDIS measures are calculated based on 2012 administrative data for 145,652 children in two public insurance programs in Florida. The Bayesian Improved Surname and Geocoding (BISG) imputation method is used to impute missing race and ethnicity data for 42 percent of the sample (61,954 children). Models are estimated with and without the imputed race and ethnicity data. Dropping individuals with missing race and ethnicity data biases quality of care measures for minorities downward relative to nonminority children for several measures. These results provide further support for the importance of appropriately accounting for missing race and ethnicity data through imputation methods. © Health Research and Educational Trust.

Enrollment of Specialty Mental Health Clinics in a State Medicaid Program to Promote Physical Health Services

PubMed Central

Breslau, Joshua; Yu, Hao; Horvitz-Lennon, Marcela; Leckman-Westin, Emily; Scharf, Deborah M.; Connor, Kathryn; Finnerty, Molly T.

2016-01-01

OBJECTIVE To promote integrated physical health care for individuals with serious mental illness, the New York State Office of Mental Health (NYOMH) established regulations allowing specialty mental health clinics to provide Medicaid-reimbursable health monitoring (HM) and health physicals (HP). This paper examines clinics’ enrollment in this program to understand its potential to reach individuals with serious mental illness. METHODS Information on enrollment and clinic characteristics (N=500) were drawn from NYOMH administrative databases. Clinic enrollment in the HM/HP program was examined from the program’s first five years (2010–2015). Logistic regression models accounting for the clustering of multiple clinics within agencies were used to examine characteristics associated with enrollment. RESULTS Two-hundred ninety one of 500 clinics (58%) enrolled in the HM/HP program, potentially reaching 62.5% of all Medicaid enrollees with serious mental illness seen in specialty mental health clinics in the state. State-operated clinics were required to participate, and had 91.8% enrollment. Over half of hospital-affiliated and freestanding mental health clinics elected to enroll in the program (52.6% and 53.7% respectively). In adjusted models, enrollment was higher among freestanding clinics relative to hospital-affiliated clinics, higher in larger relative to smaller clinics, and higher in county-operated relative to private non-profit clinics. CONCLUSIONS The high level of enrollment in the HM/HP program indicates strong interest among mental health clinics in providing physical health care services. However, supplemental policies may be needed to extend the program to areas of the mental health system where barriers to physical health care services are highest. PMID:27524372

Cost-analysis of an oral health outreach program for preschool children in a low socioeconomic multicultural area in Sweden.

PubMed

Wennhall, Inger; Norlund, Anders; Matsson, Lars; Twetman, Svante

2010-01-01

The aim was to calculate the total and the net costs per child included in a 3-year caries preventive program for preschool children and to make estimates of expected lowest and highest costs in a sensitivity analysis. The direct costs for prevention and dental care were applied retrospectively to a comprehensive oral health outreach project for preschool children conducted in a low-socioeconomic multi-cultural urban area. The outcome was compared with historical controls from the same area with conventional dental care. The cost per minute for the various dental professions was added to the cost of materials, rental facilities and equipment based on accounting data. The cost for fillings was extracted from a specified per diem list. Overhead costs were assumed to correspond to 50% of salaries and all costs were calculated as net present value per participating child in the program and expressed in Euro. The results revealed an estimated total cost of 310 Euro per included child (net present value) in the 3-year program. Half of the costs were attributed to the first year of the program and the costs of manpower constituted 45% of the total costs. When the total cost was reduced with the cost of conventional care and the revenue of avoided fillings, the net cost was estimated to 30 Euro. A sensitivity analysis displayed that a net gain could be possible with a maximal outcome of the program. In conclusion, the estimated net costs were displayed and available to those considering implementation of a similar population-based preventive program in areas where preschool children are at high caries risk.

[Effectiveness of an early discharge program after normal childbirth].

PubMed

Teulón González, M; Martínez Pillado, M; Cuadrado Martín, M M; Rivero Martín, M J; Cerezuela Requena, J F

To implement a program of early hospital discharge after an uncomplicated birth, in order to improve the effectiveness, as well as ensuring clinical safety and patient acceptability. Descriptive study of the effectiveness of an early discharge program after uncomplicated delivery between February 2012 and September 2013. The populations are post-partum women and newborns admitted to the University Hospital of Fuenlabrada, with a duration of less than 24h after uncomplicated delivery that met the defined inclusion criteria. Satisfaction was assessed using a Likert scale. The effectiveness of the program was monitored by safety indicators, productivity, adaptation, and continuity of care. A total of 20% of cases capable of early discharge from Fuenlabrada University Hospital completed the program. Almost all (94%) were normal deliveries. The 188 cases included were from 911 patients with uncomplicated childbirth, accounting for 6.5% of the 2,857 total births. The mean stay of patients included showed a decrease of 50% (2.4 to 1.2 days). All patients received continuity of care after hospital discharge. The review consultation was reprogrammed for 4.8% of cases, with 2% of patients re-admitted within 96h. with no serious problems. Four newborns (2%) required attention in the emergency department (mother or newborn) before 96h. The assessment of patient satisfaction achieved a score of 4.5 out of 5. The program achieved a decrease in the average stay by 50%, favouring the autonomy of midwives. This acceptance level is in line with similar interventions. The deployment of the program may be useful for other changes in care processes. Copyright © 2016 SECA. Publicado por Elsevier España, S.L.U. All rights reserved.

Randomized Trial of Four Financial-Incentive Programs for Smoking Cessation

PubMed Central

Halpern, Scott D.; French, Benjamin; Small, Dylan S.; Saulsgiver, Kathryn; Harhay, Michael O.; Audrain-McGovern, Janet; Loewenstein, George; Brennan, Troyen A.; Asch, David A.; Volpp, Kevin G.

2015-01-01

BACKGROUND Financial incentives promote many health behaviors, but effective ways to deliver health incentives remain uncertain. METHODS We randomly assigned CVS Caremark employees and their relatives and friends to one of four incentive programs or to usual care for smoking cessation. Two of the incentive programs targeted individuals, and two targeted groups of six participants. One of the individual-oriented programs and one of the group-oriented programs entailed rewards of approximately $800 for smoking cessation; the others entailed refundable deposits of $150 plus $650 in reward payments for successful participants. Usual care included informational resources and free smoking-cessation aids. RESULTS Overall, 2538 participants were enrolled. Of those assigned to reward-based programs, 90.0% accepted the assignment, as compared with 13.7% of those assigned to deposit-based programs (P<0.001). In intention-to-treat analyses, rates of sustained abstinence from smoking through 6 months were higher with each of the four incentive programs (range, 9.4 to 16.0%) than with usual care (6.0%) (P<0.05 for all comparisons); the superiority of reward-based programs was sustained through 12 months. Group-oriented and individual-oriented programs were associated with similar 6-month abstinence rates (13.7% and 12.1%, respectively; P = 0.29). Reward-based programs were associated with higher abstinence rates than deposit-based programs (15.7% vs. 10.2%, P<0.001). However, in instrumental-variable analyses that accounted for differential acceptance, the rate of abstinence at 6 months was 13.2 percentage points (95% confidence interval, 3.1 to 22.8) higher in the deposit-based programs than in the reward-based programs among the estimated 13.7% of the participants who would accept participation in either type of program. CONCLUSIONS Reward-based programs were much more commonly accepted than deposit-based programs, leading to higher rates of sustained abstinence from smoking. Group-oriented incentive programs were no more effective than individual-oriented programs. (Funded by the National Institutes of Health and CVS Caremark; ClinicalTrials.gov number, NCT01526265.) PMID:25970009

Medicaid Program; Disproportionate Share Hospital Payments--Treatment of Third Party Payers in Calculating Uncompensated Care Costs. Final rule.

PubMed

2017-04-03

This final rule addresses the hospital-specific limitation on Medicaid disproportionate share hospital (DSH) payments under section 1923(g)(1)(A) of the Social Security Act (Act), and the application of such limitation in the annual DSH audits required under section 1923(j) of the Act, by clarifying that the hospital-specific DSH limit is based only on uncompensated care costs. Specifically, this rule makes explicit in the text of the regulation, an existing interpretation that uncompensated care costs include only those costs for Medicaid eligible individuals that remain after accounting for payments made to hospitals by or on behalf of Medicaid eligible individuals, including Medicare and other third party payments that compensate the hospitals for care furnished to such individuals. As a result, the hospital-specific limit calculation will reflect only the costs for Medicaid eligible individuals for which the hospital has not received payment from any source.

A Phenomenological Study of Nurse Manager Interventions Related to Workplace Bullying.

PubMed

Skarbek, Anita J; Johnson, Sandra; Dawson, Christina M

2015-10-01

The aim of this study was to acquire nurse managers' perspectives as to the scope of workplace bullying, which interventions were deemed as effective and ineffective, and what environmental characteristics cultivated a healthy, caring work environment. Research has linked workplace bullying among RNs to medical errors, unsafe hospital environments, and negative patient outcomes. Limited research had been conducted with nurse managers to discern their perspectives. Six nurse managers from hospital settings participated in in-depth, semistructured interviews. Ray's theory of bureaucratic caring guided the study. These themes emerged: (a) awareness, (b) scope of the problem, (c) quality of performance, and (d) healthy, caring environment. Findings indicated mandated antibullying programs were not as effective as individual manager interventions. Systems must be in place to hold individuals accountable for their behavior. Communication, collective support, and teamwork are essential to create environments that lead to the delivery of safe, optimum patient care.

National findings regarding health IT use and participation in health care delivery reform programs among office-based physicians.

PubMed

Heisey-Grove, Dawn; Patel, Vaishali

2017-01-01

Our objective was to characterize physicians' participation in delivery and payment reform programs over time and describe how participants in these programs were using health information technology (IT) to coordinate care, engage patients, manage patient populations, and improve quality. A nationally representative cohort of physicians was surveyed in 2012 (unweighted N = 2567) and 2013 (unweighted N = 2399). Regression analyses used those survey responses to identify associations between health IT use and participation in and attrition from patient-centered medical homes (PCMHs), accountable care organizations (ACOs), and pay-for-performance programs (P4Ps). In 2013, 45% of physicians participated in PCMHs, ACOs, or P4Ps. While participation in each program increased (P < .05) between 2012 and 2013, program attrition ranged from 31-40%. Health IT use was associated with greater program participation (RR = 1.07-1.16). PCMH, ACO, and P4P participants were more likely than nonparticipants to perform quality improvement and patient engagement activities electronically (RR = 1.09-1.14); only ACO participants were more likely to share information electronically (RR = 1.07-1.09). Participation in delivery and payment reform programs increased between 2012 and 2013. Participating physicians were more likely to use health IT. There was significant attrition from and switching between PCMHs, ACOs, and P4Ps. This work provides the basis for understanding physician participation in and attrition from delivery and payment reform programs, as well as how health IT was used to support those programs. Understanding health IT use by program participants may help to identify factors enabling a smooth transition to alternative payment models. Published by Oxford University Press on behalf of the American Medical Informatics Association 2016. This work is written by US Government employees and is in the public domain in the United States.

What Does Professionalism Mean to the Physician?

PubMed Central

Kanter, Michael H; Nguyen, Miki; Klau, Marc H; Spiegel, Nancy H; Ambrosini, Virginia L

2013-01-01

Professionalism, which is a core competency for physicians, can be described as a spectrum of behaviors and may have a significant impact on the problems in today’s changing health care climate. In this article, we discuss the meaning of professionalism and its role in the Southern California Permanente Medical Group (SCPMG) and consider how it may be applied to integrated care delivery systems such as Kaiser Permanente. To understand professionalism, one must consider Stern’s definition, which consists of four principles: excellence, humanism, accountability, and altruism. SCPMG has taken three of these principles—excellence, accountability, and altruism—and divided the fourth, humanism, into another three principles similar to those identified by the University of California Los Angeles Task Force on Professionalism: humanitarianism, respect for others, and honor and integrity. SCPMG has a rich history and culture of promoting clinical excellence and professionalism, as evidenced by the programs and initiatives described throughout this article. Indeed, the SCPMG experience validates professionalism as a core physician competency comprising a set of behaviors that are continually refined. PMID:24355895

Democratic transitions, health institutions, and financial protection in the emerging economies: insights from Asia.

PubMed

Gómez, Eduardo J

2017-07-01

In recent years, several emerging economies have introduced national health insurance programs ensuring access to health care while offering financial protection from out-of-pocket and catastrophic expenses. Nevertheless, in several nations these expenses continue to increase. While recent research has emphasized the lack of funding, poor policy design and corruption as the main culprits, little is known about the politics of establishing federal regulatory agencies ensuring that state governments adhere to national insurance reimbursement and coverage procedures. This article fills in this lacuna by providing an alternative perspective, one that accounts for differences between nations in the creation of regulatory institutions, with an emphasis instead on governing elite strategies to campaign on access to health care during transitions to democracy, civil societal mobilization, constitutional constraints and the national electoral incentives to overcome ineffective decentralization processes. The cases of Indonesia and China are introduced as examples of how and why their differences in this political process accounted for Indonesia's success and China's failure to ensure financial protection.

Accountable Care Organizations and Transaction Cost Economics.

PubMed

Mick, Stephen S Farnsworth; Shay, Patrick D

2016-12-01

Using a Transaction Cost Economics (TCE) approach, this paper explores which organizational forms Accountable Care Organizations (ACOs) may take. A critical question about form is the amount of vertical integration that an ACO may have, a topic central to TCE. We posit that contextual factors outside and inside an ACO will produce variable transaction costs (the non-production costs of care) such that the decision to integrate vertically will derive from a comparison of these external versus internal costs, assuming reasonably rational management abilities. External costs include those arising from environmental uncertainty and complexity, small numbers bargaining, asset specificity, frequency of exchanges, and information "impactedness." Internal costs include those arising from human resource activities including hiring and staffing, training, evaluating (i.e., disciplining, appraising, or promoting), and otherwise administering programs. At the extreme, these different costs may produce either total vertical integration or little to no vertical integration with most ACOs falling in between. This essay demonstrates how TCE can be applied to the ACO organization form issue, explains TCE, considers ACO activity from the TCE perspective, and reflects on research directions that may inform TCE and facilitate ACO development. © The Author(s) 2016.

Beyond Measurement and Reward: Methods of Motivating Quality Improvement and Accountability.

PubMed

Berenson, Robert A; Rice, Thomas

2015-12-01

The article examines public policies designed to improve quality and accountability that do not rely on financial incentives and public reporting of provider performance. Payment policy should help temper the current "more is better" attitude of physicians and provider organizations. Incentive neutrality would better support health professionals' intrinsic motivation to act in their patients' best interests to improve overall quality than would pay-for-performance plans targeted to specific areas of clinical care. Public policy can support clinicians' intrinsic motivation through approaches that support systematic feedback to clinicians and provide concrete opportunities to collaborate to improve care. Some programs administered by the Centers for Medicare & Medicaid Services, including Partnership for Patients and Conditions of Participation, deserve more attention; they represent available, but largely ignored, approaches to support providers to improve quality and protect beneficiaries against substandard care. Public policies related to quality improvement should focus more on methods of enhancing professional intrinsic motivation, while recognizing the potential role of organizations to actively promote and facilitate that motivation. Actually achieving improvement, however, will require a reexamination of the role played by financial incentives embedded in payments and the unrealistic expectations placed on marginal incentives in pay-for-performance schemes. © Health Research and Educational Trust.

Exploring implementation of the 2010 Institute of Medicine’s Child and Adult Food Care Program recommendations for after-school snacks

PubMed Central

Nanney, Marilyn S; Glatt, Carissa

2012-01-01

Objective The aim of the present study was to explore the implementation of nutrition recommendations made in the 2010 Institute of Medicine (IOM) report, Child and Adult Care Food Program: Aligning Dietary Guidance for All, in school-based after-school snack programmes. Design A descriptive study. Setting One large suburban school district in Minneapolis, Minnesota, USA. Subjects None. Results Major challenges to implementation included limited access to product labelling and specifications inconsistent with the IOM’s Child and Adult Care Food Program (CACFP) recommendations, limited access to healthier foods due to current school district buying consortium agreement, and increased costs of wholegrain and lower-sodium foods and pre-packaged fruits and vegetables. Conclusions Opportunities for government and industry policy development and partnerships to support schools in their efforts to promote healthy after-school food environments remain. Several federal, state and industry leadership opportunities are proposed: provide product labelling that makes identifying snacks which comply with the 2010 IOM CACFP recommended standards easy; encourage compliance with recommendations by providing incentives to programmes; prioritize the implementation of paperwork and technology that simplifies enrolment and accountability systems; and provide support for food safety training and/or certification for non-food service personnel. PMID:22050891

A new approach to the design of information systems for foodservice management in health care facilities.

PubMed

Matthews, M E; Norback, J P

1984-06-01

An organizational framework for integrating foodservice data into an information system for management decision making is presented. The framework involves the application to foodservice of principles developed by the disciplines of managerial economics and accounting, mathematics, computer science, and information systems. The first step is to conceptualize a foodservice system from an input-output perspective, in which inputs are units of resources available to managers and outputs are servings of menu items. Next, methods of full cost accounting, from the management accounting literature, are suggested as a mechanism for developing and assigning costs of using resources within a foodservice operation. Then matrix multiplication is used to illustrate types of information that matrix data structures could make available for management planning and control when combined with a conversational mode of computer programming.

DIABETES, DEPRESSION, AND DEATH: A RANDOMIZED CONTROLLED TRIAL OF A DEPRESSION TREATMENT PROGRAM FOR OLDER ADULTS BASED IN PRIMARY CARE (PROSPECT)

PubMed Central

Bogner, Hillary R; Morales, Knashawn H; Post, Edward P; Bruce, Martha L

2009-01-01

OBJECTIVE Our a priori hypothesis was that depressed patients with diabetes in practices implementing a depression management program would have a decreased risk of mortality compared to depressed patients with diabetes in usual care practices. RESEARCH DESIGN AND METHODS Multi-site practice-randomized controlled trial PROSPECT (Prevention of Suicide in Primary Care Elderly: Collaborative Trial) with patient recruitment from 5/99-8/01 and supplemented with a search of the National Death Index. Twenty primary care practices participated from New York City, Philadelphia, and Pittsburgh. In all, 584 participants who were identified though a two-stage, age-stratified (60-74; 75+) depression screening of randomly sampled patients and were classified as depressed with complete information on diabetes status are included in these analyses. Of all the 584 participants, 123 (21.2%) reported a history of diabetes. A depression care manager worked with primary care physicians to provide algorithm-based care. Vital status was assessed at 5 years. RESULTS After a median follow-up of 52.0 months, 110 depressed patients had died. Depressed patients with diabetes in the Intervention Condition were less likely to have died during the 5-year follow-up interval than were depressed persons with diabetes in Usual Care after accounting for baseline differences among patients (adjusted hazard ratio 0.49, 95% CI [0.24, 0.98]). CONCLUSIONS Older depressed primary care patients with diabetes in practices implementing depression care management were less likely to die over the course of a 5-year interval than were depressed patients with diabetes in usual care practices. PMID:17717284

Diabetes Care in India.

PubMed

Joshi, Shashank R

2015-01-01

Diabetes has become a major health care problem in India with an estimated 66.8 million people suffering from the condition, representing the largest number of any country in the world. The rising burden of diabetes has greatly affected the health care sector and economy in India. The goal of health care experts in India is to transform India into a diabetes care capital in the world. An expert detailed review of the medical literature with an Asian Indian context was performed. Recent epidemiologic studies from India point to a great burden from diabetes. Diabetes control in India is far from ideal with a mean hemoglobin A1c of 9.0%-at least 2.0% higher than suggested by international bodies. Nearly half of people with diabetes remain undetected, accounting for complications at the time of diagnosis. Screening can differentiate an asymptomatic individual at high risk from one at low risk for diabetes. Despite the large number of people with diabetes in India, awareness is low and needs to be addressed. Other challenges include balancing the need for glycemic control with risk reduction due to overly tight control, especially in high-risk groups and taking into account health care professional expertise, attitudes, and perceptions. Pharmacologic care should be individualized with early consideration of combination therapy. Regular exercise, yoga, mindful eating, and stress management form a cornerstone in the management of diabetes. Considering the high cost incurred at various steps of screening, diagnosis, monitoring, and management, it is important to realize the cost-effective measures of diabetes care that are necessary to implement. Result-oriented organized programs involving patient education, as well as updating the medical fraternity on various developments in the management of diabetes, are required to combat the current diabetes epidemic in India. Copyright © 2015. Published by Elsevier Inc.

Humanitarian Outreach in Cardiothoracic Surgery: From Setup to Sustainability.

PubMed

Dearani, Joseph A; Jacobs, Jeffrey P; Bolman, R Morton; Swain, JaBaris D; Vricella, Luca A; Weinstein, Samuel; Farkas, Emily A; Calhoon, John H

2016-09-01

Noncommunicable diseases account for 38 million deaths each year, and approximately 75% of these deaths occur in the developing world. The most common causes include cardiovascular diseases, cancer, respiratory diseases, and diabetes mellitus. Many adults with acquired cardiothoracic disease around the world have limited access to health care. In addition, congenital heart disease is present in approximately 1% of live births and is therefore the most common congenital abnormality. More than one million children in the world are born with congenital heart disease each year, and approximately 90% of these children receive suboptimal care or have no access to care. Furthermore, many children affected by noncongenital cardiac conditions also require prevention, diagnosis, and treatment. Medical and surgical volunteerism can help facilitate improvement in cardiothoracic health care in developing countries. As we move into the future, it is essential for physicians and surgeons to be actively involved in political, economic, and social aspects of society to serve health care interests of the underprivileged around the world. Consequently, in developing countries, a critical need exists to establish an increased number of reputable cardiothoracic programs and to enhance many of the programs that already exist. The optimal strategy is usually based on a long-term educational and technical model of support so that as case volumes increase, quality improves and mortality and morbidity decrease. Humanitarian outreach activities should focus on education and sustainability, and surgical tourism should be limited to those countries that will never have the capability to have free-standing cardiothoracic programs. Copyright © 2016 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.

Accelerating Research Impact in a Learning Health Care System

PubMed Central

Elwy, A. Rani; Sales, Anne E.; Atkins, David

2017-01-01

Background: Since 1998, the Veterans Health Administration (VHA) Quality Enhancement Research Initiative (QUERI) has supported more rapid implementation of research into clinical practice. Objectives: With the passage of the Veterans Access, Choice and Accountability Act of 2014 (Choice Act), QUERI further evolved to support VHA’s transformation into a Learning Health Care System by aligning science with clinical priority goals based on a strategic planning process and alignment of funding priorities with updated VHA priority goals in response to the Choice Act. Design: QUERI updated its strategic goals in response to independent assessments mandated by the Choice Act that recommended VHA reduce variation in care by providing a clear path to implement best practices. Specifically, QUERI updated its application process to ensure its centers (Programs) focus on cross-cutting VHA priorities and specify roadmaps for implementation of research-informed practices across different settings. QUERI also increased funding for scientific evaluations of the Choice Act and other policies in response to Commission on Care recommendations. Results: QUERI’s national network of Programs deploys effective practices using implementation strategies across different settings. QUERI Choice Act evaluations informed the law’s further implementation, setting the stage for additional rigorous national evaluations of other VHA programs and policies including community provider networks. Conclusions: Grounded in implementation science and evidence-based policy, QUERI serves as an example of how to operationalize core components of a Learning Health Care System, notably through rigorous evaluation and scientific testing of implementation strategies to ultimately reduce variation in quality and improve overall population health. PMID:27997456

Improving Healthcare Quality in the United States: A New Approach.

PubMed

Nix, Kathryn A; O'Shea, John S

2015-06-01

Improving the quality of health care has been a focus of health reformers during the last 2 decades, yet meaningful and sustainable quality improvement has remained elusive in many ways. Although a number of individual institutions have made great strides toward more effective and efficient care, progress has not gone far enough on a national scale. Barriers to quality of care lie in fundamental, systemwide factors that impede large-scale change. Notable among these is the third-party financing arrangement that dominates the healthcare system. Long-term goals for healthcare reform should address this barrier to higher quality of care. A new model for healthcare financing that includes patient awareness of the cost of care will encourage better quality and reduced spending by engaging patients in the pursuit of value, aligning incentives for insurers to reduce costs with patients' desire to receive excellent care, and holding providers accountable for the quality and cost of the care they provide. Several new programs implemented under the Patient Protection and Affordable Care Act aim to catalyze improvement in the quality of care, but the law takes the wrong approach, directing incentives at providers only and maintaining a system that excludes patients from the search for high-value care.

[Algorithm for taking into account the average annual background of air pollution in the assessment of health risks].

PubMed

Fokin, M V

2013-01-01

State Budgetary Educational Institution of Higher Professional Education "I.M. Sechenov First Moscow State Medical University" of the Ministry of Health care and Social Development, Moscow, Russian Federation. The assessment of health risks from air pollution with emissions from industrial facilities, without the average annual background of air pollution does not meet sanitary legislation. However Russian Federal Service for Hydrometeorology and Environmental Monitoring issues official certificates for a limited number of areas covered by the observations of the full program on the stationary points. Questions of accounting average background air pollution in the evaluation of health risks from exposure to emissions from industrial facilities are considered.

Scorecards and social accountability for improved maternal and newborn health services: A pilot in the Ashanti and Volta regions of Ghana.

PubMed

Blake, Carolyn; Annorbah-Sarpei, Nii Ankonu; Bailey, Claire; Ismaila, Yakubu; Deganus, Sylvia; Bosomprah, Samuel; Galli, Francesco; Clark, Sarah

2016-12-01

With the limited availability of quality emergency obstetric and newborn care (EmONC) in Ghana, and a lack of dialogue on the issue at district level, the Evidence for Action (E4A) program (2011-2015) initiated a pilot intervention using a social accountability approach in two regions of Ghana. Using scorecards to assess and improve maternal and newborn health services, the intervention study evaluated the effectiveness of engaging multiple, health and non-health sector stakeholders at district level to improve the enabling environment for quality EmONC. The quantitative study component comprised two rounds of assessments in 37 health facilities. The qualitative component is based on an independent prospective policy study. Results show a marked growth in a culture of accountability, with heightened levels of community participation, transparency, and improved clarity of lines of accountability among decision-makers. The breadth and type of quality of care improvements were dependent on the strength of community and government engagement in the process, especially in regard to more complex systemic changes. Engaging a broad network of stakeholders to support MNH services has great potential if implemented in ways that are context-appropriate and that build around full collaboration with government and civil society stakeholders. Copyright © 2016 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.

The potential impact of accountable care organizations with respect to cost and quality with special attention to imaging.

PubMed

Mukherji, Suresh K

2014-04-01

An accountable care organization is a form of a managed care organization in which a group of networked health care providers, which may include hospitals, group practices, networks of practices, hospital-provider partnerships, or joint ventures, are accountable for the health care of a defined group of patients. Initial results of the institutions participating in CMS's Physician Group Demonstration Project did not demonstrate a substantial reduction in imaging that could be directly attributed to the accountable care organization model. However, the initial results suggest that incentive-based methodology appears to be successful for increasing compliance for measuring quality metrics. Copyright © 2014 American College of Radiology. Published by Elsevier Inc. All rights reserved.

Virtual reality or real virtuality: the space of flows and nursing practice.

PubMed

Barnes, Lynne; Rudge, Trudy

2005-12-01

The use of virtual environments for the provision of health-care is on the increase, and with each new development brings debates about their impact on care, nursing and nursing practice. Such environments offer opportunities for extending care and improvements in communication. Others believe these developments threaten aspects of nursing they hold sacrosanct. This paper explores the development of an assemblage of computer networks, databases, information systems, software programs and management systems that together work to manage health-care in Australia, namely casemix. We contend that spatial theories on network society show how this assemblage co-ordinates and operates to manage care. We discuss how this assemblage affects care and suggest that changes in organisation may be a part of the shift in how bodily organisation occurs more generally, but more specifically in health-care. We also suggest how nurses are enrolled in and by such networks, leading to transformation in nurses' practices. Finally, we argue that using spatial forms of analysis allows an interpretation of such assemblages that may account for their strengths and their shortcomings.

An Analysis of Young Driver Crash Types and the Associated Lifetime Care Cost in Victoria, Australia.

PubMed

Buckis, Samantha; Lenné, Mike G; Fitzharris, Michael

2015-01-01

The elevated crash involvement rate of young drivers is well documented. Given the higher crash risk of young drivers and the need for innovative policy and programs, it remains important to fully understand the type of crashes young drivers are involved in, and knowledge of the lifetime care cost of crashes can support effective policy development. The aim of this article is to document the number and type of young driver crashes, as well as the associated lifetime care cost over a 9-year period (2005-2013) in Victoria, Australia. In Victoria, Australia, the Transport Accident Commission (TAC) has legislated responsibility for road safety and the care of persons injured in road crashes, irrespective of fault. TAC claims data for the period 2005-2013 were used to document the number and type of young driver crashes. Lifetime care costs (past and future payment liabilities) were calculated by Taylor Fry actuarial consultancy. License and population data were used to define the crash involvement rate of young drivers. Over the 9-year period, 16,817 claims were lodged to the TAC by drivers 18-25 years of age following a crash. There were 646 fewer drivers aged 18-25 killed and injured in 2013, compared to 2005, representing an unadjusted change of -28.7% (-29.8% males; -28.4% females). The total lifetime care cost of young drivers killed and injured in Victoria for the period 2005-2013 was estimated to be AU$634 million (US$493 million). Differences between males and females, single- and multivehicle crashes, and fatalities and injuries were found to be statistically significant. Run-off-road crashes and crashes from opposing direction were overrepresented in the lifetime care costs for young driver claimants. Twenty-eight injured drivers were classified as high-severity claims. These 28 claimants require additional long-term care, which was estimated to be AU$219 million; of these 28, 24 were male (85.7%). The long-term care costs for these 28 drivers (0.16%) accounts for 34.5% of the total lifetime care cost of all 18- to 25-year-old injured drivers. By using no-fault lifetime care costs that account for medical and like expenses, rehabilitation, and social reintegration costs, a more accurate understanding of the cost of young driver crashes can be determined. Application of these costs to specific crash types highlights new priorities and opportunities for developing programs to reduce young driver crashes.

Health informatics and analytics - building a program to integrate business analytics across clinical and administrative disciplines.

PubMed

Tremblay, Monica Chiarini; Deckard, Gloria J; Klein, Richard

2016-07-01

Health care organizations must develop integrated health information systems to respond to the numerous government mandates driving the movement toward reimbursement models emphasizing value-based and accountable care. Success in this transition requires integrated data analytics, supported by the combination of health informatics, interoperability, business process design, and advanced decision support tools. This case study presents the development of a master's level cross- and multidisciplinary informatics program offered through a business school. The program provides students from diverse backgrounds with the knowledge, leadership, and practical application skills of health informatics, information systems, and data analytics that bridge the interests of clinical and nonclinical professionals. This case presents the actions taken and challenges encountered in navigating intra-university politics, specifying curriculum, recruiting the requisite interdisciplinary faculty, innovating the educational format, managing students with diverse educational and professional backgrounds, and balancing multiple accreditation agencies. © The Author 2016. Published by Oxford University Press on behalf of the American Medical Informatics Association. All rights reserved. For Permissions, please email: journals.permissions@oup.com.

Association Between Medicare Accountable Care Organization Implementation and Spending Among Clinically Vulnerable Beneficiaries

PubMed Central

Colla, Carrie H.; Lewis, Valerie A.; Kao, Lee-Sien; O’Malley, A. James; Chang, Chiang-Hua; Fisher, Elliott S.

2016-01-01

IMPORTANCE Accountable care contracts hold physician groups financially responsible for the quality and cost of health care delivered to patients. Focusing on clinically vulnerable patients, those with serious conditions who are responsible for the greatest proportion of spending, may result in the largest effects on both patient outcomes and financial rewards for participating physician groups. OBJECTIVE To estimate the effect of Medicare accountable care organization (ACO) contracts on spending and high-cost institutional use for all Medicare beneficiaries and for clinically vulnerable beneficiaries. DESIGN, SETTING, AND PARTICIPANTS For this cohort study, 2 study populations were defined: the overall Medicare population and the clinically vulnerable subgroup of Medicare beneficiaries. The overall Medicare population was based on a random 40% sample drawn from continuously enrolled fee-for-service beneficiaries with at least 1 evaluation and management visit in a calendar year. The clinically vulnerable study population included all Medicare beneficiaries 66 years or older who had at least 3 Hierarchical Condition Categories (HCCs). Beneficiaries entered the cohort during the quarter between January 2009 to December 2011 when they first had at least 3 HCCs and remained in the cohort until death. Cohort entry was restricted to the preperiod to account for potential changes in coding practices after ACO implementation. Difference-in-difference estimations were used to compare changes in health care outcomes for Medicare beneficiaries attributed to physicians in ACOs with those attributed to non-ACO physicians from January 2009 to December 2013. EXPOSURES Medicare ACOs beginning contracts in January 2012, April 2012, July 2012, and January 2013 through the Pioneer and Medicare Shared Savings Programs. MAIN OUTCOMES AND MEASURES Total spending per beneficiary-quarter, spending categories, use of hospitals and emergency departments, ambulatory care sensitive admissions, and 30-day readmissions. RESULTS Total spending decreased by $34 (95% CI, −$52 to −$15) per beneficiary-quarter after ACO contract implementation across the overall Medicare population (n = 15 592 600) and decreased $114 in clinically vulnerable patients (n = 8 673 823) (95% CI, −$178 to −$50). In the overall Medicare cohort, hospitalizations and emergency department visits decreased by 1.3 and 3.0 events per 1000 beneficiaries per quarter, respectively (95% CIs: −2.1 to −0.4 and −4.8 to −1.3), and hospitalizations and emergency department visits decreased in the clinically vulnerable cohort by 2.9 and 4.1 events per 1000 beneficiaries per quarter, respectively (95% CIs: −5.2 to −0.7 and −7.1 to −1.2). Changes in total spending associated with ACOs did not vary by clinical condition of beneficiaries. CONCLUSIONS AND RELEVANCE Medicare ACO programs are associated with modest reductions in spending and use of hospitals and emergency departments. Savings were realized through reductions in use of institutional settings in clinically vulnerable patients. PMID:27322485

Quality-based financial incentives in health care: can we improve quality by paying for it?

PubMed

Conrad, Douglas A; Perry, Lisa

2009-01-01

This article asks whether financial incentives can improve the quality of health care. A conceptual framework drawn from microeconomics, agency theory, behavioral economics, and cognitive psychology motivates a set of propositions about incentive effects on clinical quality. These propositions are evaluated through a synthesis of extant peer-reviewed empirical evidence. Comprehensive financial incentives--balancing rewards and penalties; blending structure, process, and outcome measures; emphasizing continuous, absolute performance standards; tailoring the size of incremental rewards to increasing marginal costs of quality improvement; and assuring certainty, frequency, and sustainability of incentive payoffs--offer the prospect of significantly enhancing quality beyond the modest impacts of prevailing pay-for-performance (P4P) programs. Such organizational innovations as the primary care medical home and accountable health care organizations are expected to catalyze more powerful quality incentive models: risk- and quality-adjusted capitation, episode of care payments, and enhanced fee-for-service payments for quality dimensions (e.g., prevention) most amenable to piece-rate delivery.

Case Study: Clinical Governance as an Approach to Improve Maternal and Newborn Health in 22 Hospitals in Indonesia.

PubMed

Amelia, Dwirani; Suhowatsky, Stephanie; Baharuddin, Mohammad; Tholandi, Maya; Hyre, Anne; Sethi, Reena

Clinical governance is a concept used to improve management, accountability and the provision of quality healthcare. An approach to strengthen clinical governance as a means to improve the quality of maternal and newborn care in Indonesia was developed by the Expanding Maternal and Neonatal Survival (EMAS) Program. This case study presents findings and lessons learned from EMAS program experience in 22 hospitals where peer-to-peer mentoring supported staff in strengthening clinical governance from 2012-2015. Efforts resulted in improved hospital preparedness and significantly increased the odds of facility-level coverage for three evidence-based maternal and newborn healthcare interventions.

Cost-Effectiveness and Cost-Utility of Internet-Based Computer Tailoring for Smoking Cessation

PubMed Central

Evers, Silvia MAA; de Vries, Hein; Hoving, Ciska

2013-01-01

Background Although effective smoking cessation interventions exist, information is limited about their cost-effectiveness and cost-utility. Objective To assess the cost-effectiveness and cost-utility of an Internet-based multiple computer-tailored smoking cessation program and tailored counseling by practice nurses working in Dutch general practices compared with an Internet-based multiple computer-tailored program only and care as usual. Methods The economic evaluation was embedded in a randomized controlled trial, for which 91 practice nurses recruited 414 eligible smokers. Smokers were randomized to receive multiple tailoring and counseling (n=163), multiple tailoring only (n=132), or usual care (n=119). Self-reported cost and quality of life were assessed during a 12-month follow-up period. Prolonged abstinence and 24-hour and 7-day point prevalence abstinence were assessed at 12-month follow-up. The trial-based economic evaluation was conducted from a societal perspective. Uncertainty was accounted for by bootstrapping (1000 times) and sensitivity analyses. Results No significant differences were found between the intervention arms with regard to baseline characteristics or effects on abstinence, quality of life, and addiction level. However, participants in the multiple tailoring and counseling group reported significantly more annual health care–related costs than participants in the usual care group. Cost-effectiveness analysis, using prolonged abstinence as the outcome measure, showed that the mere multiple computer-tailored program had the highest probability of being cost-effective. Compared with usual care, in this group €5100 had to be paid for each additional abstinent participant. With regard to cost-utility analyses, using quality of life as the outcome measure, usual care was probably most efficient. Conclusions To our knowledge, this was the first study to determine the cost-effectiveness and cost-utility of an Internet-based smoking cessation program with and without counseling by a practice nurse. Although the Internet-based multiple computer-tailored program seemed to be the most cost-effective treatment, the cost-utility was probably highest for care as usual. However, to ease the interpretation of cost-effectiveness results, future research should aim at identifying an acceptable cutoff point for the willingness to pay per abstinent participant. PMID:23491820

Cost and quality impact of Intermountain's mental health integration program.

PubMed

Reiss-Brennan, Brenda; Briot, Pascal C; Savitz, Lucy A; Cannon, Wayne; Staheli, Russ

2010-01-01

Most patients with mental health (MH) conditions, such as depression, receive care for their conditions from a primary care physician (PCP) in their health/medical home. Providing MH care, however, presents many challenges for the PCP, including (1) the difficulty of getting needed consultation from an MH specialist; (2) the time constraints of a busy PCP practice; (3) the complicated nature of recognizing depression, which may be described with only somatic complaints; (4) the barriers to reimbursement and compensation; and (5) associated medical and social comorbidities. Practice managers, emergency departments, and health plans are stretched to provide care for complex patients with unmet MH needs. At the same time, payment reform linked to accountable care organizations and/or episodic bundle payments, MH parity rules, and increasing MH costs to large employers and payers all highlight the critical need to identify high-quality, efficient, integrated MH care delivery practices. Over the past ten years, Intermountain Healthcare has developed a team-based approach-known as mental health integration (MHI)-for caring for these patients and their families. The team includes the PCPs and their staff, and they, in turn, are integrated with MH professionals, community resources, care management, and the patient and his or her family. The integration model goes far beyond co-location in its team-based approach; it is operationalized at the clinic, thereby improving both physician and staff satisfaction. Patients treated in MHI clinics also show improved satisfaction, lower costs, and better quality outcomes. The MHI program is financially sustainable in routinized clinics without subsidies. MHI is a successful approach to improving care for patients with MH conditions in primary care health homes.

Financial Incentives, Workplace Wellness Program Participation, and Utilization of Health Care Services and Spending.

PubMed

Fronstin, Paul; Roebuck, M Christopher

2015-08-01

This paper analyzes data from a large employer that enhanced financial incentives to encourage participation in its workplace wellness programs. It examines, first, the effect of financial incentives on wellness program participation, and second, it estimates the impact of wellness program participation on utilization of health care services and spending. The Patient Protection and Affordable Care Act of 2010 (PPACA) allows employers to provide financial incentives of as much as 30 percent of the total cost of coverage when tied to participation in a wellness program. Participation in health risk assessments (HRAs) increased by 50 percentage points among members of unions that bargained in the incentive, and increased 22 percentage points among non-union employees. Participation in the biometric screening program increased 55 percentage points when financial incentives were provided. Biometric screenings led to an average increase of 0.31 annual prescription drug fills, with related spending higher by $56 per member per year. Otherwise, no significant effects of participation in HRAs or biometric screenings on utilization of health care services and spending were found. The largest increase in medication utilization as a result of biometric screening was for statins, which are widely used to treat high cholesterol. This therapeutic class accounted for one-sixth of the overall increase in prescription drug utilization. Second were antidepressants, followed by ACE inhibitors (for hypertension), and thyroid hormones (for hypothyroidism). Biometric screening also led to significantly higher utilization of biologic response modifiers and immunosuppressants. These specialty medications are used to treat autoimmune diseases, such as rheumatoid arthritis and multiple sclerosis, and are relatively expensive compared with non-specialty medications. The added spending associated with the combined increase in fills of 0.02 was $27 per member per year--about one-half of the overall increase in prescription drug spending from those who participated in biometric screenings.

Comprehensive Survivorship Care With Cost and Revenue Analysis

PubMed Central

Rosales, Alicia R.; Byrne, Dia; Burnham, Christa; Watts, Lori; Clifford, Kathleen; Zuckerman, Dan S.; Beck, Thomas

2014-01-01

Purpose: The 2015 Commission on Cancer standards require that cancer survivors receive an individualized survivorship care plan (SCP). To meet this new standard, St Luke's Mountain States Tumor Institute (MSTI), with support from the National Community Cancer Centers Program, implemented a successful survivorship model. Patients and Methods: At MSTI, the patient's SCP is prepared in the electronic health record by a registered health information technician. This document is reviewed during an appointment with a nurse practitioner and social worker. The provider's dictation is mailed to the primary care physician with the SCP. From August 2011 to Oct 2012, 118 patients with breast cancer were seen for survivorship appointments. Medical record audit and follow-up telephone call were completed to evaluate patient survivorship needs and satisfaction with the appointment. Patient accounts were reviewed for reimbursement. Results: From medical record review, the most common patient concerns were weight management (35%), fatigue (30%), sexuality (27%), anxiety (23%), caregiver stress (17%), and depression (16%). Telephone calls showed high patient satisfaction and understanding. Patients rated the following statements on a Likert scale from 1 (strongly disagree) to 5 (strongly agree): I understand my treatment summary and care plan (88% strongly agree or agree), and I feel the survivorship visit met my survivorship needs (86% strongly agree or agree). At 1 month, 80% of participants were still working on wellness goals. Patient accounts analysis showed revenue covered costs. Conclusion: Survivorship care at MSTI meets new standards, allows for patient engagement and satisfaction, and improves care coordination. Costs are covered by reimbursement. PMID:24065401

Oversight mechanisms in public managed care programs: from little oversight to negotiations to shared decision-making.

PubMed

Beinecke, R H

1999-01-01

An expanded range of oversight mechanisms is being adopted to hold public human service programs more accountable to funding sources as well as consumers, family members, and providers. Most of these approaches are hierarchical in nature. Some involve negotiated agreements and each is designed to meet certain goals and functions. Each utilizes different forms of decision-making. Stakeholders prefer to be part of a shared decision-making process. Understanding these underlying premises can help to assess the strengths and weaknesses of each method and can suggest how to most effectively utilize combinations of approaches to improve program performance. Whether we will move toward a new paradigm emphasizing participation and collaboration rather than more formal structural approaches is yet undetermined but will greatly affect how programs are monitored and evaluated in the future.

Affordable Care Act risk adjustment: overview, context, and challenges.

PubMed

Kautter, John; Pope, Gregory C; Keenan, Patricia

2014-01-01

Beginning in 2014, individuals and small businesses will be able to purchase private health insurance through competitive marketplaces. The Affordable Care Act (ACA) provides for a program of risk adjustment in the individual and small group markets in 2014 as Marketplaces are implemented and new market reforms take effect. The purpose of risk adjustment is to lessen or eliminate the influence of risk selection on the premiums that plans charge and the incentive for plans to avoid sicker enrollees. This article--the first of three in the Medicare & Medicaid Research Review--describes the key program goal and issues in the Department of Health and Human Services (HHS) developed risk adjustment methodology, and identifies key choices in how the methodology responds to these issues. The goal of the HHS risk adjustment methodology is to compensate health insurance plans for differences in enrollee health mix so that plan premiums reflect differences in scope of coverage and other plan factors, but not differences in health status. The methodology includes a risk adjustment model and a risk transfer formula that together address this program goal as well as three issues specific to ACA risk adjustment: 1) new population; 2) cost and rating factors; and 3) balanced transfers within state/market. The risk adjustment model, described in the second article, estimates differences in health risks taking into account the new population and scope of coverage (actuarial value level). The transfer formula, described in the third article, calculates balanced transfers that are intended to account for health risk differences while preserving permissible premium differences.

The consumer choice model: a humane reconstruction of the U.S. health care system.

PubMed

Coulter, C H

2000-01-01

"Consumer choice," "defined contribution health programs," "voucher systems," and "health marts" are variations on a theme: employees buying their own health care. This new approach to health care purchasing, which is designed to minimize the role of employers, is being proposed by an array of economists and by both Republican and Democratic legislators as the best way to address the nation's health care ills. Although enabling national legislation is unlikely to pass soon, the debate will nevertheless change the face of health care in America. The prospect is reminiscent of the debate over "Clinton Care" in 1993--although legislation was never passed, managed care rapidly came to dominate the U.S. health care system. As this reform takes hold, beneficiaries will make their own health plan selections but will have more responsibility and may bear more cost. Providers will have to adapt to new, customer-driven requirements for performance, accountability, and communications but will also find opportunities in a marketplace that they will have a major role in shaping. Physicians, health plans, and insurers should understand how these proposals will transform their role in health care.

Quality and safety in medical care: what does the future hold?

PubMed

Liang, Bryan A; Mackey, Tim

2011-11-01

The rapid changes in health care policy, embracing quality and safety mandates, have culminated in programs and initiatives under the Patient Protection and Affordable Care Act. To review the context of, and anticipated quality and patient safety mandates for, delivery systems, incentives under health care reform, and models for future accountability for outcomes of care. Assessment of the provisions of Patient Protection and Affordable Care Act, other reform efforts, and reform initiatives focusing on future quality and safety provisions for health care providers. Health care reform and other efforts focus on consumerism in the context of price. Quality and safety efforts will be structured using financial incentives, best-practices research, and new delivery models that focus on reaching benchmarks while reducing costs. In addition, patient experience will be a key component of reimbursement, and a move toward "retail" approaches directed at the individual patient may supplant traditional "wholesale" efforts at attracting employers. Quality and safety have always been of prime importance in medicine. However, in the future, under health care reform and associated initiatives, a shift in the paradigm of medicine will integrate quality and safety measurement with financial incentives and a new emphasis on consumerism.

Effectiveness of an early mobilization protocol in a trauma and burns intensive care unit: a retrospective cohort study.

PubMed

Clark, Diane E; Lowman, John D; Griffin, Russell L; Matthews, Helen M; Reiff, Donald A

2013-02-01

Bed rest and immobility in patients on mechanical ventilation or in an intensive care unit (ICU) have detrimental effects. Studies in medical ICUs show that early mobilization is safe, does not increase costs, and can be associated with decreased ICU and hospital lengths of stay (LOS). The purpose of this study was to assess the effects of an early mobilization protocol on complication rates, ventilator days, and ICU and hospital LOS for patients admitted to a trauma and burn ICU (TBICU). This was a retrospective cohort study of an interdisciplinary quality-improvement program. Pre- and post-early mobility program patient data from the trauma registry for 2,176 patients admitted to the TBICU between May 2008 and April 2010 were compared. No adverse events were reported related to the early mobility program. After adjusting for age and injury severity, there was a decrease in airway, pulmonary, and vascular complications (including pneumonia and deep vein thrombosis) post-early mobility program. Ventilator days and TBICU and hospital lengths of stay were not significantly decreased. Using a historical control group, there was no way to account for other changes in patient care that may have occurred between the 2 periods that could have affected patient outcomes. The dose of physical activity both before and after the early mobility program were not specifically assessed. Early mobilization of patients in a TBICU was safe and effective. Medical, nursing, and physical therapy staff, as well as hospital administrators, have embraced the new culture of early mobilization in the ICU.

Mentoring by design: integrating medical professional competencies into bioengineering and medical physics graduate training.

PubMed

Woods, Kendra V; Peek, Kathryn E; Richards-Kortum, Rebecca

2014-12-01

Many students in bioengineering and medical physics doctoral programs plan careers in translational research. However, while such students generally have strong quantitative abilities, they often lack experience with the culture, communication norms, and practice of bedside medicine. This may limit students' ability to function as members of multidisciplinary translational research teams. To improve students' preparation for careers in cancer translational research, we developed and implemented a mentoring program that is integrated with students' doctoral studies and aims to promote competencies in communication, biomedical ethics, teamwork, altruism, multiculturalism, and accountability. Throughout the program, patient-centered approaches and professional competencies are presented as foundational to optimal clinical care and integral to translational research. Mentoring is conducted by senior biomedical faculty and administrators and includes didactic teaching, online learning, laboratory mini-courses, clinical practicums, and multidisciplinary patient planning conferences (year 1); student development and facilitation of problem-based patient cases (year 2); and individualized mentoring based on research problems and progress toward degree completion (years 3-5). Each phase includes formative and summative evaluations. Nineteen students entered the program from 2009 through 2011. On periodic anonymous surveys, the most recent in September 2013, students indicated that the program substantially improved their knowledge of cancer biology, cancer medicine, and academic medicine; that the mentors were knowledgeable, good teachers, and dedicated to students; and that the program motivated them to become well-rounded scientists and scholars. We believe this program can be modified and disseminated to other graduate research and professional health care programs.

Financial management challenges for general hospital psychiatry 2001.

PubMed

Goldberg, R J

2001-01-01

Psychiatry programs are facing significant business and financial challenges. This paper provides an overview of these management challenges in five areas: departmental, hospital, payment system, general finance, and policy. Psychiatric leaders will require skills in a variety of business management areas to ensure their program success. Many programs will need to develop new compensation models with more of an emphasis on revenue collection and overhead management. Programs which cannot master these areas are likely to go out of business. For academic programs, incentive systems must address not only clinical productivity, but academic and teaching output as well. General hospital programs will need to develop increased sophistication in differential cost accounting in order to be able to advocate for their patients and program in the current management climate. Clinical leaders will need the skills (ranging from actuarial to negotiations) to be at the table with contract development, since those decisions are inseparable from clinical care issues. Strategic planning needs to consider the value of improving integration with primary care, along with the ability to understand the advantages and disadvantages of risk-sharing models. Psychiatry leaders need to define and develop useful reports shared with clinical division leadership to track progress and identify problems and opportunities. Leaders should be responsible for a strategy for developing appropriate information system architecture and infrastructure. Finally, it is hoped that some leaders will emerge who can further our needs to address inequities in mental health fee schedules and parity issues which affect our program viability.

Performance Differences in Year 1 of Pioneer Accountable Care Organizations

PubMed Central

McWilliams, J. Michael; Chernew, Michael E.; Landon, Bruce E.; Schwartz, Aaron L.

2015-01-01

BACKGROUND In 2012, a total of 32 organizations entered the Pioneer accountable care organization (ACO) program, in which providers can share savings with Medicare if spending falls below a financial benchmark. Performance differences associated with characteristics of Pioneer ACOs have not been well described. METHODS In a difference-in-differences analysis of Medicare fee-for-service claims, we compared Medicare spending for beneficiaries attributed to Pioneer ACOs (ACO group) with other beneficiaries (control group) before (2009 through 2011) and after (2012) the start of Pioneer ACO contracts, with adjustment for geographic area and beneficiaries’ sociodemographic and clinical characteristics. We estimated differential changes in spending for several subgroups of ACOs: those with and those without clear financial integration between hospitals and physician groups, those with higher and those with lower baseline spending, and the 13 ACOs that withdrew from the Pioneer program after 2012 and the 19 that did not. RESULTS Adjusted Medicare spending and spending trends were similar in the ACO group and the control group during the precontract period. In 2012, the total adjusted per-beneficiary spending differentially changed in the ACO group as compared with the control group (−$29.2 per quarter, P = 0.007), consistent with a 1.2% savings. Savings were significantly greater for ACOs with baseline spending above the local average, as compared with those with baseline spending below the local average (P = 0.05 for interaction), and for those serving high-spending areas, as compared with those serving low-spending areas (P = 0.04). Savings were similar in ACOs with financial integration between hospitals and physician groups and those without, as well as in ACOs that withdrew from the program and those that did not. CONCLUSIONS Year 1 of the Pioneer ACO program was associated with modest reductions in Medicare spending. Savings were greater for ACOs with higher baseline spending than for those with lower baseline spending and were unrelated to withdrawal from the program. (Funded by the National Institute on Aging and others.) PMID:25875195

Start-Up and Ongoing Practice Expenses of Behavioral Health and Primary Care Integration Interventions in the Advancing Care Together (ACT) Program.

PubMed

Wallace, Neal T; Cohen, Deborah J; Gunn, Rose; Beck, Arne; Melek, Steve; Bechtold, Donald; Green, Larry A

2015-01-01

Provide credible estimates of the start-up and ongoing effort and incremental practice expenses for the Advancing Care Together (ACT) behavioral health and primary care integration interventions. Expenditure data were collected from 10 practice intervention sites using an instrument with a standardized general format that could accommodate the unique elements of each intervention. Average start-up effort expenses were $44,076 and monthly ongoing effort expenses per patient were $40.39. Incremental expenses averaged $20,788 for start-up and $4.58 per patient for monthly ongoing activities. Variations in expenditures across practices reflect the differences in intervention specifics and organizational settings. Differences in effort to incremental expenditures reflect the extensive use of existing resources in implementing the interventions. ACT program incremental expenses suggest that widespread adoption would likely have a relatively modest effect on overall health systems expenditures. Practice effort expenses are not trivial and may pose barriers to adoption. Payers and purchasers interested in attaining widespread adoption of integrated care must consider external support to practices that accounts for both incremental and effort expense levels. Existing knowledge transfer mechanisms should be employed to minimize developmental start-up expenses and payment reform focused toward value-based, Triple Aim-oriented reimbursement and purchasing mechanisms are likely needed. © Copyright 2015 by the American Board of Family Medicine.

Patient safety principles in family medicine residency accreditation standards and curriculum objectives

PubMed Central

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

2016-01-01

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

Using an Electronic Medication Refill System to Improve Provider Productivity in an Accountable Care Setting.

PubMed

Schoenhaus, Robert; Lustig, Adam; Rivas, Silvia; Monrreal, Victor; Westrich, Kimberly D; Dubois, Robert W

2016-03-01

Even within fully integrated health care systems, primary care providers (PCPs) often lack support for medication management. Because challenges with conducting medication reconciliation, improving adherence, and achieving optimal patient outcomes continue to be prevalent nationally, it is critical that PCPs are provided the resources and support they need to provide high-quality, patient-centered care in an accountable care environment. Sharp Rees-Stealy Medical Group uses a fully electronic medication refill system that allows for a centralized team to manage all incoming requests. Over time, 16 disease-specific protocols were created that allowed the pharmacy team to absorb approximately 80% of incoming refill requests for all enrolled PCPs. The refill clinic assessed all clinic information that a PCP would normally review in order to approve a refill. Tasks performed by the clinical pharmacists included medication reconciliation, dosage adjustment, and coordination of distribution from external mail order and retail pharmacies. In 2014, the number of tasks related to refill management reviewed by the refill/medication therapy management service totaled 302,592, resulting in 140,350 refill authorizations and multiple interventions related to medication use. Physicians have estimated that the service provides between 20 and 30 minutes of time savings per day. Assuming an annual PCP salary of around $200,000, 20 to 30 minutes per day would amount to $33 to $50 saved per day per physician. The savings is even higher when time savings from other clinical staff is included. The development of this electronic medication refill service has provided the following important lessons: (a) organizations rely on a leader or champion to push through process reforms--this program started with reluctant physicians first to determine best practices; (b) the lack of clinical pharmacist profiles within electronic health records (EHR) is a serious concern, since the creation of these profiles may not be easy or timely; and (c) PCPs working within an EHR environment will quickly embrace the idea of a service that can save them up to 30 minutes per day. With PCPs continuing to take on additional population health management tasks in accountable care organizations, pharmacists can provide workload offsets by meaningfully contributing to medication-related care.

Medicaid program; appeals from cancellation of approval of Medicaid long-term care facilities--HCFA. Final rule.

PubMed

1988-08-18

This rule corrects an oversight by setting forth time limits for new issues that may be considered by an Administrative Law Judge (ALJ) during a hearing afforded a Medicaid skilled nursing facility (SNF) or intermediate care facility (ICF) because the Secretary proposes to cancel its approval under section 1910(c)(1) of the Social Security Act (the Act). This amendment is necessary because current rules do not take account of the fact that hearings under section 1910(c) of the Act (unlike Medicare hearings) may take place before the cancellation is put into effect. The purpose is to establish time limits appropriate to section 1910(c) situations.

Minimum savings requirements in shared savings provider payment.

PubMed

Pope, Gregory C; Kautter, John

2012-11-01

Payer (insurer) sharing of savings is a way of motivating providers of medical services to reduce cost growth. A Medicare shared savings program is established for accountable care organizations in the 2010 Patient Protection and Affordable Care Act. However, savings created by providers cannot be distinguished from the normal (random) variation in medical claims costs, setting up a classic principal-agent problem. To lessen the likelihood of paying undeserved bonuses, payers may pay bonuses only if observed savings exceed minimum levels. We study the trade-off between two types of errors in setting minimum savings requirements: paying bonuses when providers do not create savings and not paying bonuses when providers create savings. Copyright © 2011 John Wiley & Sons, Ltd.

Utilisation of podiatry services in Australia under the Medicare Enhanced Primary Care program, 2004-2008.

PubMed

Menz, Hylton B

2009-10-30

In 2004, as an extension of the Enhanced Primary Care (EPC) program, the Australian Government introduced a policy of providing Medicare rebates for allied health services provided to patients with chronic or complex health conditions. The objective of this study was to evaluate the utilisation of podiatry services provided under this scheme between 2004 and 2008. Data pertaining to the Medicare item 10962 for the calendar years 2004-2008 were extracted from the Australian Medicare Benefits Schedule (MBS) database and cross-tabulated by sex and age. Descriptive analyses were undertaken to assess sex and age differences in the number of consultations provided and to assess for temporal trends over the five-year assessment period. The total cost to Medicare over this period was also determined. During the 2004-2008 period, a total of 1,338,044 EPC consultations were provided by podiatrists in Australia. Females exhibited higher utilisation than males (63 versus 37%), and those aged over 65 years accounted for 75% of consultations. There was a marked increase in the number of consultations provided from 2004 to 2008, and the total cost of providing EPC podiatry services during this period was $62.9 M. Podiatry services have been extensively utilised under the EPC program by primary care patients, particularly older women, and the number of services provided has increased dramatically between 2004 and 2008. Further research is required to determine whether the EPC program enhances clinical outcomes compared to standard practice.

Can disease management target patients most likely to generate high costs? The impact of comorbidity.

PubMed

Charlson, Mary; Charlson, Robert E; Briggs, William; Hollenberg, James

2007-04-01

Disease management programs are increasingly used to manage costs of patients with chronic disease. We sought to examine the clinical characteristics and measure the health care expenditures of patients most likely to be targeted by disease management programs. Retrospective analysis of prospectively obtained data. A general medicine practice with both faculty and residents at an urban academic medical center. Five thousand eight hundred sixty-one patients enrolled in the practice for at least 1 year. Annual cost of diseases targeted by disease management. Patients' clinical and demographic information were collected from a computer system used to manage patients. Data included diagnostic information, medications, and resource usage over 1 year. We looked at 10 common diseases targeted by disease management programs. Unadjusted annual median costs for chronic diseases ranged between $1,100 and $1,500. Congestive heart failure ($1,500), stroke ($1,500), diabetes ($1,500), and cancer ($1,400) were the most expensive. As comorbidity increased, annual adjusted costs increased exponentially. Those with comorbidity scores of 2 or more accounted for 26% of the population but 50% of the overall costs. Costs for individual chronic conditions vary within a relatively narrow range. However, the costs for patients with multiple coexisting medical conditions increase rapidly. Reducing health care costs will require focusing on patients with multiple comorbid diseases, not just single diseases. The overwhelming impact of comorbidity on costs raises significant concerns about the potential ability of disease management programs to limit the costs of care.

Enhancing the role of private practitioners in tuberculosis prevention and care activities in India.

PubMed

Anand, Tanu; Babu, Ranjith; Jacob, Anil G; Sagili, Karuna; Chadha, Sarabjit S

2017-01-01

India accounts for the highest number of incident tuberculosis (TB) cases globally. Hence, to impact the TB incidence world over, there is an urgent need to address and accelerate TB control activities in the country. Nearly, half of the TB patients first seek TB care in private sector. However, the participation of private practitioners (PPs) has been patchy in TB prevention and care and distrust exists between public and private sector. PPs usually have varied diagnostic and treatment practices that are inadequate and amplify the risk of drug resistance. Hence, their regulation and involvement as key stakeholders are important in TB prevention and care in India if we are to achieve TB control at global level. However, there remain certain barriers and gaps, which are preventing their upscaling. The current paper aims to discuss the status of private sector involvement in TB prevention and care in India. The paper also discusses the strategies and initiatives taken by the government in this regard as evidence shows that the involvement of private sector in co-opting directly observed treatment short-course (DOTS) helps to enhance case finding and treatment outcomes; it improves the accessibility of quality TB care with greater geographic coverage. Besides public-private mix, DOTS has been found more cost-effective and reduces financial burden of patients. The paper also offers to present some more solutions both at policy and program level for upscaling the engagement of PPs in the national TB control program.

Enhancing the role of private practitioners in tuberculosis prevention and care activities in India

PubMed Central

Anand, Tanu; Babu, Ranjith; Jacob, Anil G.; Sagili, Karuna; Chadha, Sarabjit S.

2017-01-01

India accounts for the highest number of incident tuberculosis (TB) cases globally. Hence, to impact the TB incidence world over, there is an urgent need to address and accelerate TB control activities in the country. Nearly, half of the TB patients first seek TB care in private sector. However, the participation of private practitioners (PPs) has been patchy in TB prevention and care and distrust exists between public and private sector. PPs usually have varied diagnostic and treatment practices that are inadequate and amplify the risk of drug resistance. Hence, their regulation and involvement as key stakeholders are important in TB prevention and care in India if we are to achieve TB control at global level. However, there remain certain barriers and gaps, which are preventing their upscaling. The current paper aims to discuss the status of private sector involvement in TB prevention and care in India. The paper also discusses the strategies and initiatives taken by the government in this regard as evidence shows that the involvement of private sector in co-opting directly observed treatment short-course (DOTS) helps to enhance case finding and treatment outcomes; it improves the accessibility of quality TB care with greater geographic coverage. Besides public-private mix, DOTS has been found more cost-effective and reduces financial burden of patients. The paper also offers to present some more solutions both at policy and program level for upscaling the engagement of PPs in the national TB control program. PMID:29099000

The financial impacts of the nursing shortage.

PubMed

Rivers, Patrick A; Tsai, Kai-Li; Munchus, George

2005-01-01

This article examines the multiple factors leading to the nursing shortage and the financial impact of the nursing shortage on hospitals and health care providers, the government, society and educational institutions. Nursing shortages have occurred in this country throughout history, however, the current shortage is especially grappling due to the financial condition of the health care system, Health Insurance Portability and Accountability Act, the Balanced Budget Act, the compounding conditions that have led up to the shortage and the forecasted health care needs. Many solutions have been proposed to improve the nursing shortage. This article provides recommendations to problem solving methods and discusses some current policy alternatives, including recently enacted "nurse-patient ratio" regulation, demonstrated by California state policy and the "Magnet Certification" program developed by American Nursing Credential Center (ANCC). This article further examines the financial impacts on nursing shortage problem.

Informal payments and the financing of health care in developing and transition countries.

PubMed

Lewis, Maureen

2007-01-01

Informal, under-the-table payments to public health care providers are increasingly viewed as a critically important source of health care financing in developing and transition countries. With minimal funding levels and limited accountability, publicly financed and delivered care falls prey to illegal payments, which require payments that can exceed 100 percent of a country's median income. Methods to address the abuse include establishing official fees, combined with improved oversight and accountability for public health care providers, and a role for communities in holding providers accountable.

Labelling Angles: Care, Indifference and Mathematical Symbols

ERIC Educational Resources Information Center

Long, Julie

2011-01-01

In this article, I explore tensions of care in the context of school mathematics by examining two accounts of a classroom moment involving labelling an angle. In particular, I draw attention to how caring for students and caring for mathematical ideas interplay in complex ways by inquiring into the two accounts through ideas of care and…

Nursing accounting competencies related to HIV in a Papua New Guinea context.

PubMed

Brown, Alistair M

2013-01-01

Nursing administration is an important part of the campaign to eliminate HIV across Papua New Guinea (PNG). This paper considers the critical importance of developing nursing leadership in effective accounting competencies in relation to HIV projects in PNG. The results of the study's textual analysis of audit reports of the Auditor General of PNG revealed a failure on the part of PNG's main health agencies involved with its national HIV program to provide competent financial reporting. In light of these results, this study shows how improving accounting and other financial competencies among nursing leaders would benefit the implementation of the PNG HIV national strategy. The findings of this study have implications not only for the internal control of HIV nursing competencies but also for nursing leadership related to HIV issues in a developing-country context. Copyright © 2013 Association of Nurses in AIDS Care. Published by Elsevier Inc. All rights reserved.

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

PubMed

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

1998-03-01

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

Online versus Face-to-Face Accounting Education: A Comparison of CPA Exam Outcomes across Matched Institutions

ERIC Educational Resources Information Center

Morgan, John Daniel

2015-01-01

Programmatic-level comparisons are made between the certified public accountant (CPA) exam outcomes of two types of accounting programs: online or distance accounting programs and face-to-face or classroom accounting programs. After matching programs from each group on student selectivity at admission, the two types of programs are compared on CPA…

Improving Aboriginal maternal and infant health services in the ‘Top End’ of Australia; synthesis of the findings of a health services research program aimed at engaging stakeholders, developing research capacity and embedding change

PubMed Central

2014-01-01

Background Health services research is a well-articulated research methodology and can be a powerful vehicle to implement sustainable health service reform. This paper presents a summary of a five-year collaborative program between stakeholders and researchers that led to sustainable improvements in the maternity services for remote-dwelling Aboriginal women and their infants in the Top End (TE) of Australia. Methods A mixed-methods health services research program of work was designed, using a participatory approach. The study area consisted of two large remote Aboriginal communities in the Top End of Australia and the hospital in the regional centre (RC) that provided birth and tertiary care for these communities. The stakeholders included consumers, midwives, doctors, nurses, Aboriginal Health Workers (AHW), managers, policy makers and support staff. Data were sourced from: hospital and health centre records; perinatal data sets and costing data sets; observations of maternal and infant health service delivery and parenting styles; formal and informal interviews with providers and women and focus groups. Studies examined: indicator sets that identify best care, the impact of quality of care and remoteness on health outcomes, discrepancies in the birth counts in a range of different data sets and ethnographic studies of ‘out of hospital’ or health centre birth and parenting. A new model of maternity care was introduced by the health service aiming to improve care following the findings of our research. Some of these improvements introduced during the five-year research program of research were evaluated. Results Cost effective improvements were made to the acceptability, quality and outcomes of maternity care. However, our synthesis identified system-wide problems that still account for poor quality of infant services, specifically, unacceptable standards of infant care and parent support, no apparent relationship between volume and acuity of presentations and staff numbers with the required skills for providing care for infants, and an ‘outpatient’ model of care. Services were also characterised by absent Aboriginal leadership and inadequate coordination between remote and tertiary services that is essential to improve quality of care and reduce ‘system-introduced’ risk. Conclusion Evidence-informed redesign of maternity services and delivery of care has improved clinical effectiveness and quality for women. However, more work is needed to address substandard care provided for infants and their parents. PMID:24890910

A realist evaluation of value-based care delivery in home care: The influence of actors, autonomy and accountability.

PubMed

Dainty, Katie N; Golden, Brian R; Hannam, Rosemary; Webster, Fiona; Browne, Gina; Mittmann, Nicole; Stern, Anita; Zwarenstein, Merrick

2018-06-01

The increasing demand for home care is occurring in tandem with the need for governments to contain health care costs, maximize appropriate resource utilization and respond to patient preferences for where they receive care. We describe the evaluation of the Integrated Client Care Project (ICCP), a government funded project designed to improve value for outcomes for patients referred to community wound care services in Ontario, Canada. We applied a realist evaluation methodology in order to unpack the influences of contextual and mechanistic choices on the intended outcomes of the ICCP implementation. We collected data through ethnographic methods including 36 months of field observation, 46 key informant interviews and contemporaneous document analysis. The findings presented here highlight how theoretical mechanisms were negatively impacted by strong contextual patterns and weak implementation which led to underwhelming outcomes. Autonomy of the participant organizations, lack of power within the implementation team to drive change, opacity of the goals of the program, and disregard for the impact of complex historical relations within the home care sector compounded to undermine the intended outcome. Copyright © 2018 Elsevier Ltd. All rights reserved.

A randomized clinical trial of tailored interventions for health promotion and recidivism reduction among homeless parolees: outcomes and cost analysis

PubMed Central

Zhang, Sheldon; Salem, Benissa E.; Farabee, David; Hall, Betsy; Marlow, Elizabeth; Faucette, Mark; Bond, Doug; Yadav, Kartik

2015-01-01

Objectives This study conducted a randomized controlled trial with 600 recently released homeless men exiting California jails and prisons. Methods The purpose of this study was to primarily ascertain how different levels of intensity in peer coaching and nurse-partnered intervention programs may impact reentry outcomes; specifically: (a) an intensive peer coach and nurse case managed (PC-NCM) program; (b) an intermediate peer coaching (PC) program with brief nurse counseling; and (c) the usual care (UC) program involving limited peer coaching and brief nurse counseling. Secondary outcomes evaluated the operational cost of each program. Results When compared to baseline, all three groups made progress on key health-related outcomes during the 12-month intervention period; further, 84.5 % of all participants eligible for hepatitis A/B vaccination completed their vaccine series. The results of the detailed operational cost analysis suggest the least costly approach (i.e., UC), which accounted for only 2.11 % of the total project expenditure, was as effective in achieving comparable outcomes for this parolee population as the PC-NCM and PC approaches, which accounted for 53.98 % and 43.91 %, respectively, of the project budget. Conclusions In this study, all three intervention strategies were found to be comparable in achieving a high rate of vaccine completion, which over time will likely produce tremendous savings to the public health system. PMID:27217822

A randomized clinical trial of tailored interventions for health promotion and recidivism reduction among homeless parolees: outcomes and cost analysis.

PubMed

Nyamathi, Adeline M; Zhang, Sheldon; Salem, Benissa E; Farabee, David; Hall, Betsy; Marlow, Elizabeth; Faucette, Mark; Bond, Doug; Yadav, Kartik

2016-03-01

This study conducted a randomized controlled trial with 600 recently released homeless men exiting California jails and prisons. The purpose of this study was to primarily ascertain how different levels of intensity in peer coaching and nurse-partnered intervention programs may impact reentry outcomes; specifically: (a) an intensive peer coach and nurse case managed (PC-NCM) program; (b) an intermediate peer coaching (PC) program with brief nurse counseling; and (c) the usual care (UC) program involving limited peer coaching and brief nurse counseling. Secondary outcomes evaluated the operational cost of each program. When compared to baseline, all three groups made progress on key health-related outcomes during the 12-month intervention period; further, 84.5 % of all participants eligible for hepatitis A/B vaccination completed their vaccine series. The results of the detailed operational cost analysis suggest the least costly approach (i.e., UC), which accounted for only 2.11 % of the total project expenditure, was as effective in achieving comparable outcomes for this parolee population as the PC-NCM and PC approaches, which accounted for 53.98 % and 43.91 %, respectively, of the project budget. In this study, all three intervention strategies were found to be comparable in achieving a high rate of vaccine completion, which over time will likely produce tremendous savings to the public health system.

Evaluation of the 2014 Best Undergraduate Accounting Programs as Compared to the 2004 Top Undergraduate Accounting Programs

ERIC Educational Resources Information Center

Moore, Paula Hearn; Griffin, Richard B.

2017-01-01

This paper describes and compares the profiles of the top accounting programs in the United States as identified by "U.S. News and World Report" in 2004 with the profiles of the top accounting programs in the United States as identified by the "Accounting Degree Review" in 2014. The "Accounting Degree Review"'s list…

Identifying Care Coordination Interventions Provided to Community-Dwelling Older Adults Using Electronic Health Records

PubMed Central

Kim, Tae Youn; Marek, Karen D.; Coenen, Amy

2016-01-01

Although care coordination is a popular intervention, there is no standard method of delivery. Also little is known about who most benefits or characteristics that predict the amount of care coordination needed, especially with chronically ill older adults. The purpose of this study was to identify types and amount of nurse care coordination interventions provided to 231 chronically ill older adults who participated in a 12-month home care medication management program in the Midwestern. For each participant, the nurse care coordinator spent an average of 134 minutes/month providing in-person home care, 48 minutes/month of travel, and 18 minutes/month of indirect care occurring outside the home visit. This accounted for 67.2%, 23.8%, and 9.0% of nursing time respectively for home visits, travel, and indirect care. Four of 11 nursing interventions focused on medication management were provided to all participants. Seven of the 11 main interventions were individualized according to each person’s special needs. Wide variations were observed in time provided with in-person home care and communications with multiple stakeholders. Study findings indicate the importance of individualizing interventions and the variability in the amount of nursing time needed to provide care coordination to chronically ill older adults. PMID:26985762

75 FR 70703 - Humana Insurance Company a Division of Carenetwork, Inc. Front End Operations and Account...

Federal Register 2010, 2011, 2012, 2013, 2014

2010-11-18

... Division of CareNetwork, Inc., Front End Operations and Account Installation-Product Testing Groups, De... a Division of Carenetwork, Inc. Front End Operations and Account Installation-Product Testing Groups..., a Division of CareNetwork, Inc., Front End Operations and Account Installation- Product Testing...

Peer-professional workgroups in palliative care: a strategy for advancing professional discourse and practice.

PubMed

Byock, Ira; Twohig, Jeanne Sheils; Merriman, Melanie; Collins, Karyn

2006-08-01

As part of a comprehensive national effort to improve care at the end of life, the Promoting Excellence in End-of-Life Care program of The Robert Wood Johnson Foundation convened "national peer-professional workgroups" of recognized authorities or leaders to advance palliative aspects of practice in their respective specialties or fields. The conveners' goals were to establish research and practice agendas to integrate palliative care within selected fields and health care settings, and to expand delivery of palliative care to special patient populations that have been underserved by palliative care. We hypothesized that leading professionals within specific fields, chartered to achieve clear goals, and then provided with sufficient administrative and logistical support, could develop recommendations for expanding access to, quality of and financing for palliative care within their disciplines. Staff at the national program office of Promoting Excellence in End-of-Life Care convened eight disease-based, specialty-based or issue-based workgroups (the selected workgroup topics were amyotrophic lateral sclerosis, cost accounting, critical care, end-stage renal disease, human immunodeficiency virus/acquired immune deficiency syndrome [HIV/AIDS] disease, Huntington's disease, pediatric care, and surgical palliative care). The national program office implemented a small group process design in convening the groups, and provided coordination, oversight and administrative support, along with funds to support meetings (telephone and in-person). A workgroup "charter" guided groups in determining the scope of efforts and set specific, time-limited goals. From the outset, the workgroups developed plans for dissemination of workgroup recommendations to defined stakeholder audiences, including health care providers, policy-makers, payers, researchers, funders, educators, professional organizations and patient advocacy groups. Groups averaged 25 members and met for an average of 24 months. Promoting Excellence leadership chose workgroup topic areas that addressed patient populations underserved for palliative care, and corresponding professional specialties with demonstrated interest and readiness to improve education, evidence base, and professional expertise in palliative aspects of care. Each workgroup was highly productive and advanced changes in respective fields through developing and disseminating recommendations to their respective fields regarding practice, education, clinical and health service research and policy. Beyond their chartered responsibilities, workgroups also developed educational programs and curricula and a wide array of resources. The workgroups also authored articles for publication, intended to stimulate professional discourse and influence clinical norms and culture. The national peer-professional workgroup model exceeded original expectations and produced well-considered Recommendations to the Field as well as a body of resources for professionals in expanding access to and quality of palliative care. Results of this experimental venture in professional change suggest that the workgroup model may be a useful, cost-effective, rapid-change strategy for quality improvement in other areas of professional practice and service delivery.

Alternative Reimbursement Models: Bundled Payment and Beyond: AOA Critical Issues.

PubMed

Greenwald, A Seth; Bassano, Amy; Wiggins, Stephen; Froimson, Mark I

2016-06-01

The Bundled Payments for Care Improvement (BPCI) initiative was begun in January 2013 by the U.S. Centers for Medicare & Medicaid Services (CMS) through its Innovation Center authority, which was created by the U.S. Patient Protection and Affordable Care Act (PPACA). The BPCI program seeks to improve health-care delivery and to ultimately reduce costs by allowing providers to enter into prenegotiated payment arrangements that include financial and performance accountability for a clinical episode in which a risk-and-reward calculus must be determined. BPCI is a contemporary 3-year experiment designed to test the applicability of episode-based payment models as a viable strategy to transform the CMS payment methodology while improving health outcomes. A summary of the 4 models being evaluated in the BPCI initiative is presented in addition to the awardee types and the number of awardees in each model. Data from one of the BPCI-designated pilot sites demonstrate that strategies do exist for successful implementation of an alternative payment model by keeping patients first while simultaneously improving coordination, alignment of care, and quality and reducing cost. Providers will need to embrace change and their areas of opportunity to gain a competitive advantage. Health-care providers, including orthopaedic surgeons, health-care professionals at post-acute care institutions, and product suppliers, all have a role in determining the strategies for success. Open dialogue between CMS and awardees should be encouraged to arrive at a solution that provides opportunity for gainsharing, as this program continues to gain traction and to evolve. Copyright © 2016 by The Journal of Bone and Joint Surgery, Incorporated.

Not All Are Lost: Interrupted Laboratory Monitoring, Early Death, and Loss to Follow-Up (LTFU) in a Large South African Treatment Program

PubMed Central

Ahonkhai, Aima A.; Noubary, Farzad; Munro, Alison; Stark, Ruth; Wilke, Marisa; Freedberg, Kenneth A.; Wood, Robin; Losina, Elena

2012-01-01

Background Many HIV treatment programs in resource-limited settings are plagued by high rates of loss to follow-up (LTFU). Most studies have not distinguished between those who briefly interrupt, but return to care, and those more chronically lost to follow-up. Methods We conducted a retrospective cohort study of 11,397 adults initiating antiretroviral therapy (ART) in 71 Southern African Catholic Bishops Conference/Catholic Relief Services HIV treatment clinics between January 2004 and December 2008. We distinguished among patients with early death, within the first 7 months on ART; patients with interruptions in laboratory monitoring (ILM), defined as missing visits in the first 7 months on ART, but returning to care by 12 months; and those LTFU, defined as missing all follow-up visits in the first 12 months on ART. We used multilevel logistic regression models to determine patient and clinic-level characteristics associated with these outcomes. Results In the first year on ART, 60% of patients remained in care, 30% missed laboratory visits, and 10% suffered early death. Of the 3,194 patients who missed laboratory visits, 40% had ILM, resuming care by 12 months. After 12 months on ART, patients with ILM had a 30% increase in detectable viremia compared to those who remained in care. Risk of LTFU decreased with increasing enrollment year, and was lowest for patients who enrolled in 2008 compared to 2004 [OR 0.49, 95%CI 0.39–0.62]. Conclusions In a large community-based cohort in South Africa, nearly 30% of patients miss follow-up visits for CD4 monitoring in the first year after starting ART. Of those, 40% have ILM but return to clinic with worse virologic outcomes than those who remain in care. The risk of chronic LTFU decreased with enrollment year. As ART availability increases, interruptions in care may become more common, and should be accounted for in addressing program LTFU. PMID:22427925

Forecasting client transitions in British Columbia's Long-Term Care Program.

PubMed Central

Lane, D; Uyeno, D; Stark, A; Gutman, G; McCashin, B

1987-01-01

This article presents a model for the annual transitions of clients through various home and facility placements in a long-term care program. The model, an application of Markov chain analysis, is developed, tested, and applied to over 9,000 clients (N = 9,483) in British Columbia's Long Term Care Program (LTC) over the period 1978-1983. Results show that the model gives accurate forecasts of the progress of groups of clients from state to state in the long-term care system from time of admission until eventual death. Statistical methods are used to test the modeling hypothesis that clients' year-over-year transitions occur in constant proportions from state to state within the long-term care system. Tests are carried out by examining actual year-over-year transitions of each year's new admission cohort (1978-1983). Various subsets of the available data are analyzed and, after accounting for clear differences among annual cohorts, the most acceptable model of the actual client transition data occurred when clients were separated into male and female groups, i.e., the transition behavior of each group is describable by a different Markov model. To validate the model, we develop model estimates for the numbers of existing clients in each state of the long-term care system for the period (1981-1983) for which actual data are available. When these estimates are compared with the actual data, total weighted absolute deviations do not exceed 10 percent of actuals. Finally, we use the properties of the Markov chain probability transition matrix and simulation methods to develop three-year forecasts with prediction intervals for the distribution of the existing total clients into each state of the system. The tests, forecasts, and Markov model supplemental information are contained in a mechanized procedure suitable for a microcomputer. The procedure provides a powerful, efficient tool for decision makers planning facilities and services in response to the needs of long-term care clients. PMID:3121537

[The application of National AIDS spending assessment in a county of Dehong prefecture, Yunnan province, China].

PubMed

Shan, Duo; Sun, Jiang-ping; Yakusik, Anna; Chen, Zhong-dan; Yuan, Jian-hua; Li, Tao; Duan, Song; Yang, Xing; Wei, Mei; Michael, Sante; Ye, Run-hua; Xiang, Li-fen; Yang, Yue-cheng; Ren, Da

2012-11-01

To calculate the actual expenditures in a county of Dehong prefecture, Yunnan province, China by using the method of National AIDS Spending Assessment (NASA) in 2010. Data were collected through NASA data collection form based on adapted NASA classification in the county of Dehong prefecture from October to December, 2011, and complemented by semi-structured interview with 16 well trained programmatic and financial representatives in 8 spending units. Data were entered in Resource Tracking Software (RTS) V 2009.3.0, and SPSS 13.0 was used for data processing and analysis. The NASA estimations showed that the county spent a total of ¥16 235 954 on HIV/AIDS in 2010. Public funds constituted 96.3% of the total expenditure (¥15 630 937), followed by Global Fund which accounted for 3.0% (¥484 585) and private sources which accounted for 0.7% (¥120 432). Findings based on NASA categories showed that AIDS spendings were mainly on 4 areas, and expenditure on Care & Treatment was ¥12 401 382 (76.4% of total expenditure), followed by Prevention which accounted for 14.3% (¥2 325 707), Program Management & Administration which accounted for 7.8% (¥1 268 523) and human resources which accounted for 1.5% (¥240 342). The most beneficial population group was People Living with HIV (PLHIV), accounting for 84.7% of total expenditure. (¥13 753 428), followed by 4.8% for high risk population, including female sex workers and their partners (¥297 333), injection drug users and their partners (¥293 143), men having sex with men and their partners (¥185 136) and 1.5% (¥241 429) for the general population. The local funds for HIV/AIDS in this county was insufficient. The local government should increase corresponding funds based on central government funding. Care and treatment was the first spending priority in the county and the investment of prevention services needs to be increased. Prevention and treatment and care should be combined to ensure the effectiveness of comprehensive prevention and treatment of AIDS.

Clinical coordination in accountable care organizations: A qualitative study.

PubMed

Lewis, Valerie A; Schoenherr, Karen; Fraze, Taressa; Cunningham, Aleen

2016-12-06

Accountable care organizations (ACOs) are becoming a common payment and delivery model. Despite widespread interest, little empirical research has examined what efforts or strategies ACOs are using to change care and reduce costs. Knowledge of ACOs' clinical efforts can provide important context for understanding ACO performance, particularly to distinguish arenas where ACOs have and have not attempted care transformation. The aim of the study was to understand ACOs' efforts to change clinical care during the first 18 months of ACO contracts. We conducted semistructured interviews between July and December 2013. Our sample includes ACOs that began performance contracts in 2012, including Medicare Shared Savings Program and Pioneer participants, stratified across key factors. In total, we conducted interviews with executives from 30 ACOs. Iterative qualitative analysis identified common patterns and themes. ACOs in the first year of performance contracts are commonly focusing on four areas: first, transforming primary care through increased access and team-based care; second, reducing avoidable emergency department use; third, strengthening practice-based care management; and fourth, developing new boundary spanner roles and activities. ACOs were doing little around transforming specialty care, acute and postacute care, or standardizing care across practices during the first 18 months of ACO performance contracts. Results suggest that cost reductions associated with ACOs in the first years of contracts may be related to primary care. Although in the long term many hope ACOs will achieve coordination across a wide array of care settings and providers, in the short term providers under ACO contracts are focused largely on primary care-related strategies. Our work provides a template of the common areas of clinical activity in the first years of ACO contracts, which may be informative to providers considering becoming an ACO. Further research will be needed to understand how these strategies are associated with performance.This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial License 4.0 (CCBY-NC), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal.

Advanced Imaging Utilization and Cost Savings Among Medicare Shared Savings Program Accountable Care Organizations: An Initial Exploratory Analysis.

PubMed

Rosenkrantz, Andrew B; Duszak, Richard

2018-03-01

The purpose of this study was to explore associations between CT and MRI utilization and cost savings achieved by Medicare Shared Savings Program (MSSP)-participating accountable care organizations (ACOs). Summary data were obtained for all MSSP-participating ACOs (n = 214 in 2013; n = 333 in 2014). Multivariable regressions were performed to assess associations of CT and MRI utilization with ACOs' total savings and reaching minimum savings rates to share in Medicare savings. In 2014, 54.4% of ACOs achieved savings, meeting minimum rates to share in savings in 27.6%. Independent positive predictors of total savings included beneficiary risk scores (β = +20,265,720, P = .003) and MRI events (β = +19,964, P = .018) but not CT events (β = +2,084, P = .635). Independent positive predictors of meeting minimum savings rates included beneficiary risk scores (odds ratio = 2108, P = .001) and MRI events (odds ratio = 1.008, P = .002), but not CT events (odds ratio = 1.002, P = .289). Measures not independently associated with savings were total beneficiaries; beneficiaries' gender, age, race or ethnicity; and Medicare enrollment type (P > .05). For ACOs with 2013 and 2014 data, neither increases nor decreases in CT and MRI events between years were associated with 2014 total savings or meeting savings thresholds (P ≥ .466). Higher MRI utilization rates were independently associated with small but significant MSSP ACO savings. The value of MRI might relate to the favorable impact of appropriate advanced imaging utilization on downstream outcomes and other resource utilization. Because MSSP ACOs represent a highly select group of sophisticated organizations subject to rigorous quality and care coordination standards, further research will be necessary to determine if these associations are generalizable to other health care settings. Copyright © 2017 American College of Radiology. Published by Elsevier Inc. All rights reserved.

Surgical care for the direct and indirect victims of violence in the eastern Democratic Republic of Congo.

PubMed

Chu, Kathryn; Havet, Philippe; Ford, Nathan; Trelles, Miguel

2010-04-14

The provision of surgical assistance in conflict is often associated with care for victims of violence. However, there is an increasing appreciation that surgical care is needed for non-traumatic morbidities. In this paper we report on surgical interventions carried out by Médecins sans Frontières in Masisi, North Kivu, Democratic Republic of Congo to contribute to the scarce evidence base on surgical needs in conflict. We analysed data on all surgical interventions done at Masisi district hospital between September 2007 and December 2009. Types of interventions are described, and logistic regression used to model associations with violence-related injury. 2869 operations were performed on 2441 patients. Obstetric emergencies accounted for over half (675, 57%) of all surgical pathology and infections for another quarter (160, 14%). Trauma-related injuries accounted for only one quarter (681, 24%) of all interventions; among these, 363 (13%) were violence-related. Male gender (adjusted odds ratio (AOR) = 20.0, p < 0.001), military status (AOR = 4.1, p < 0.001), and age less than 20 years (AOR = 2.1, p < 0.001) were associated with violence-related injury. Immediate peri-operative mortality was 0.2%. In this study, most surgical interventions were unrelated to violent trauma and rather reflected the general surgical needs of a low-income tropical country. Programs in conflict zones in low-income countries need to be prepared to treat both the war-wounded and non-trauma related life-threatening surgical needs of the general population. Given the limited surgical workforce in these areas, training of local staff and task shifting is recommended to support broad availability of essential surgical care. Further studies into the surgical needs of the population are warranted, including population-based surveys, to improve program planning and resource allocation and the effectiveness of the humanitarian response.

Back to Basics: The Effect of Healthy Diet and Exercise on Chronic Disease Management.

PubMed

Allison, Robert L

2017-01-01

The increase in obesity rates in the U.S. and other less developed industrial countries have led to a worldwide epidemic of chronic disease states. Increased obesity rates are implicated in the treatment failures for illnesses such as coronary artery disease, diabetes, heart failure, hypertension and cancer. Effective prevention of obesity through diet and exercise contributes to the successful medical management of multiple chronic disease states. Review the last 10 years of literature (2006-2016) on the effects of diet and exercise as they relate to the prevention of chronic disease. Cochran Database of Systematic Reviews and other original articles using the National Center for Biotechnical Information database. The success in management of chronic disease lies in a physician's ability to educate patients and effective utilization of the resources available to that provider. Patient accountability for their individual chronic disease states is a problem related to patient education, patient participation, access to care, and payment resources. Financial, racial, and socioeconomic barriers must be addressed in the creation of an effective plan. Teaching on the importance of diet and exercise needs to occur early in life and be continually reinforced for successful outcomes. In the last 10 years, there has not been a significant study suggesting a single successful model of diet and exercise that can control chronic diseases. Cardiac, diabetic, and cancer patients have reduced hospital admissions, improved diabetic control, and improved quality of life scores related to coordinated diet and exercise programs, however. Patients may be unwilling or unable to be accountable for health care coordination. The development of exercise and obesity prevention policies and the adjustment in financial rewards to health care organizations will have a major impact in implementing these programs over the next 10 years.

Organizational responses to accountability requirements: Do we get what we expect?

PubMed

Gray, Carolyn Steele; Berta, Whitney; Deber, Raisa; Lum, Janet

In health care, accountability is being championed as a promising approach to meeting the dual imperatives of improving care quality while managing constrained budgets. Few studies focus on public sector organizations' responsiveness to government imperatives for accountability. We applied and adapted a theory of organizational responsiveness to community care agencies operating in Ontario, Canada, asking the question: What is the array of realized organizational responses to government-imposed accountability requirements among community agencies that receive public funds to provide home and community care? A sequential complementary mixed methods approach was used. It gathered data through a survey of 114 home and community care organizations in Ontario and interviews with 20 key informants representing 13 home and community care agencies and four government agencies. It generated findings using a parallel mixed analysis technique. In addition to responses predicted by the theory, we found that organizations engage in active, as well as passive, forms of compliance; we refer to this response as internal modification in which internal policies, practices, and/or procedures are changed to meet accountability requirements. We also found that environmental factors, such as the presence of an association representing organizational interests, can influence bargaining tactics. Our study helps us to better understand the range of likely responses to accountability requirements and is a first step toward encouraging the development of accountability frameworks that favor positive outcomes for organizations and those holding them to account. Tailoring agreements to organizational environments, aligning perceived compliance with behaviors that encourage improved performance, and allowing for flexibility in accountability arrangements are suggested strategies to support beneficial outcomes.

Are professional psychology training programs willing the future to economic illiterates?: a clarion call for pedagogical action.

PubMed

Friedberg, Robert D

2016-10-01

The behavioral health care environment in the United States is changing and many experts expect seismic shifts in access, accountability and reimbursement policies. Students in professional psychology training programs will be called upon to administer, manage, supervise and deliver clinically sound as well as cost effective services. While in general, traditional professional psychology training curricula prepare students well for clinical challenges, most students enter the profession naïve to the economic, financial and business enterprise crucibles in the behavioral health care marketplace. This article examines the problem of such naiveté and offers several recommendations for improving graduate students' economic literacy. Moreover, the article argues that increased business and economic acumen may serve to close the research-practice gap in professional psychology. The article reviews literature pertinent to training psychologists and highlights pedagogical gaps. Several recommendations for curricular development are offered. Specifically, adding courses in health care economics and basic business principles is suggested. Integrating cost-effectiveness analyses across all course content is proposed. The article also emphasizes both didactic and experiential learning opportunities. Course work should be augmented with training opportunities at the practicum, internship, and post-doctoral fellowship level.

Payment system reform: one state's journey.

PubMed

Millwee, Billy; Goldfield, Norbert; Averill, Richard; Hughes, John

2013-01-01

In June 2011, Texas enacted Senate Bill 7, which mandates a Medicaid quality-based outcomes payment program on the basis of a common set of outcomes that apply to all types of provider systems including hospitals, managed care plans, medical homes, managed long-term care plans, and Accountable Care Organizations. The quality-based outcome measures focus on potentially preventable events (services) such as preventable admissions and readmissions that result in unnecessary expense, patient inconvenience, and risk of complications. The payment adjustments relate to a provider system's effectiveness in reducing the rate at which potentially preventable events occur. The program envisioned by Texas Medicaid is one that is administratively simple, establishes the right financial incentives to drive delivery system improvement, and does not intrude on the provider practice or the patient. Rather than imposing a series of processes that must be followed or require rigid adherence to standardized protocols, the payment adjustments are based on risk-adjusted comparisons of the rate of potentially preventable events for an individual provider systems to an empirically derived performance standard such as the state average. This article proposes a payment system design that can meet the ambitious objectives of the Texas legislation.

Neurology in Asia.

PubMed

Tan, Chong-Tin

2015-02-10

Asia is important as it accounts for more than half of the world population. The majority of Asian countries fall into the middle income category. As for cultural traditions, Asia is highly varied, with many languages spoken. The pattern of neurologic diseases in Asia is largely similar to the West, with some disease features being specific to Asia. Whereas Asia constitutes 60% of the world's population, it contains only 20% of the world's neurologists. This disparity is particularly evident in South and South East Asia. As for neurologic care, it is highly variable depending on whether it is an urban or rural setting, the level of economic development, and the system of health care financing. To help remedy the shortage of neurologists, most counties with larger populations have established training programs in neurology. These programs are diverse, with many areas of concern. There are regional organizations serving as a vehicle for networking in neurology and various subspecialties, as well as an official journal (Neurology Asia). The Asian Epilepsy Academy, with its emphasis on workshops in various locations, EEG certification examination, and fellowships, may provide a template of effective regional networking for improving neurology care in the region. © 2015 American Academy of Neurology.

[Methods of data selection from the French medical information system program for trauma patient's analysis: Burns and traumatic brain injuries].

PubMed

Paget, L-M; Dupont, A; Pédrono, G; Lasbeur, L; Thélot, B

2017-10-01

Data from the French medical information system program in medicine, surgery, obstetrics and dentistry can be adapted in some cases and under certain conditions, to account for hospitalizations for injuries. Two areas have been explored: burn and traumatic brain injury victims. An algorithm selecting data from the Medical information system program was established and implemented for several years for the study of burn victims. The methods of selection of stays for traumatic brain injuries, which are the subject of a more recent exploration, are described. Production of results in routine on the hospitalization for burns. Expected production of results on the hospitalization for traumatic brain injuries. In both cases, the knowledge obtained from these utilizations of the Medical information system program contributes to epidemiological surveillance and prevention and are useful for health care organization. Copyright © 2017 Elsevier Masson SAS. All rights reserved.

Why increasing availability of ART is not enough: a rapid, community-based study on how HIV-related stigma impacts engagement to care in rural South Africa.

PubMed

Treves-Kagan, Sarah; Steward, Wayne T; Ntswane, Lebogang; Haller, Robin; Gilvydis, Jennifer M; Gulati, Harnik; Barnhart, Scott; Lippman, Sheri A

2016-01-28

Stigma is a known barrier to HIV testing and care. Because access to antiretroviral therapy reduces overt illness and mortality, some scholars theorized that HIV-related stigma would decrease as treatment availability increased. However, the association between ART accessibility and stigma has not been as straightforward as originally predicted. We conducted a "situational analysis"--a rapid, community-based qualitative assessment to inform a combination HIV prevention program in high prevalence communities. In the context of this community-based research, we conducted semi-structured interviews and focus groups with 684 individuals in four low-resource sub-districts in North West Province, South Africa. In addition to using this data to inform programming, we examined the impact of stigma on the uptake of services. Findings suggested that anticipated stigma remains a barrier to care. Although participants reported less enacted stigma, or hostility toward people living with HIV, they also felt that HIV remains synonymous with promiscuity and infidelity. Participants described community members taking steps to avoid being identified as HIV-positive, including avoiding healthcare facilities entirely, using traditional healers, or paying for private doctors. Such behaviors led to delays in testing and accessing care, and problems adhering to medications, especially for men and youth with no other health condition that could plausibly account for their utilization of medical services. We conclude that providing access to ART alone will not end HIV-related stigma. Instead, individuals will remain hesitant to seek care as long as they fear that doing so will lead to prejudice and discrimination. It is critical to combat this trend by increasing cultural acceptance of being seropositive, integrating HIV care into general primary care and normalizing men and youths' accessing health care.

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

PubMed Central

Sidhu, Ravindar S.; Walker, G. Ross

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

The behaviours of nurses that increase student accountability for learning in clinical practice: An integrative review.

PubMed

Perry, Christina; Henderson, Amanda; Grealish, Laurie

2018-06-01

To identify nurses' behaviours that promote student accountability for learning in clinical practice. Health care services are experiencing significant strain in meeting clinical education requirements of increasing numbers of nursing students enrolled in undergraduate nursing programs. Internationally, the transition to university based education for nurses has seen the emergence of issues for busy clinicians trying to manage increasing workloads with responsibility for student learning. An understanding of what types of supervisor behaviours promote student accountability for learning, may support clinicians to more effectively manage their dual roles of clinical care and student support. An integrative approach was adopted for this review. A search of the Cumulative Index of Nursing and Allied Health Literature, Pubmed, Scopus and Embase was undertaken, limited to articles published between 2000 and March 2017. Whittemore and Knafls' (2005) framework for conducting integrative reviews was used to ensure a methodological and rigorous approach. Nine studies were considered. Behaviours emerged in relation to four themes including: belongingness associated with a genuine partnership; empowerment and increasing student self-efficacy; trust linked to increasing and staged independence; and balancing clinical and educational requirements. Behaviours of nurses significantly influence students' accountability for learning and accordingly, their ability to be adequately prepared for professional nursing practice. Understanding behaviours that impact on students' approach to clinical placement can guide nurses in their approach to facilitating student learning, in particular, behaviours that increase student responsibility and independence over the continuum of clinical education. Copyright © 2018 Elsevier Ltd. All rights reserved.

Physician-Owned Surgical Hospitals Outperform Other Hospitals in Medicare Value-Based Purchasing Program.

PubMed

Ramirez, Adriana G; Tracci, Margaret C; Stukenborg, George J; Turrentine, Florence E; Kozower, Benjamin D; Jones, R Scott

2016-10-01

The Hospital Value-Based Purchasing Program measures value of care provided by participating Medicare hospitals and creates financial incentives for quality improvement and fosters increased transparency. Limited information is available comparing hospital performance across health care business models. The 2015 Hospital Value-Based Purchasing Program results were used to examine hospital performance by business model. General linear modeling assessed differences in mean total performance score, hospital case mix index, and differences after adjustment for differences in hospital case mix index. Of 3,089 hospitals with total performance scores, categories of representative health care business models included 104 physician-owned surgical hospitals, 111 University HealthSystem Consortium, 14 US News & World Report Honor Roll hospitals, 33 Kaiser Permanente, and 124 Pioneer accountable care organization affiliated hospitals. Estimated mean total performance scores for physician-owned surgical hospitals (64.4; 95% CI, 61.83-66.38) and Kaiser Permanente (60.79; 95% CI, 56.56-65.03) were significantly higher compared with all remaining hospitals, and University HealthSystem Consortium members (36.8; 95% CI, 34.51-39.17) performed below the mean (p < 0.0001). Significant differences in mean hospital case mix index included physician-owned surgical hospitals (mean 2.32; p < 0.0001), US News & World Report honorees (mean 2.24; p = 0.0140), and University HealthSystem Consortium members (mean 1.99; p < 0.0001), and Kaiser Permanente hospitals had lower case mix value (mean 1.54; p < 0.0001). Re-estimation of total performance scores did not change the original results after adjustment for differences in hospital case mix index. The Hospital Value-Based Purchasing Program revealed superior hospital performance associated with business model. Closer inspection of high-value hospitals can guide value improvement and policy-making decisions for all Medicare Value-Based Purchasing Program Hospitals. Copyright © 2016 American College of Surgeons. Published by Elsevier Inc. All rights reserved.

Interorganizational networks: fundamental to the Accreditation Canada program.

PubMed

Mitchell, Jonathan I; Nicklin, Wendy; MacDonald, Bernadette

2014-01-01

Within the Canadian healthcare system, the term population-accountable health network defines the use of collective resources to optimize the health of a population through integrated interventions. The leadership of these networks has also been identified as a critical factor, highlighting the need for creative management of resources in determining effective, balanced sets of interventions. In this article, using specific principles embedded in the Accreditation Canada program, the benefits of a network approach are highlighted, including knowledge sharing, improving the consistency of practice through standards, and a broader systems-and-population view of healthcare delivery across the continuum of care. The implications for Canadian health leaders to leverage the benefits of interorganizational networks are discussed.

Three large-scale changes to the Medicare program could curb its costs but also reduce enrollment

PubMed Central

Eibner, Christine; Goldman, Dana P.; Sullivan, Jeffrey; Garber, Alan M.

2013-01-01

Medicare spending accounts for a substantial fraction of Federal spending, and significant program changes may be necessary for long-run fiscal balance. We used a microsimulation approach to estimate how benefit changes to Medicare–including Part A, for hospital care, premiums, premium support credits, and changing the eligibility age–affect long-term Medicare spending and enrollment. All policies considered reduce spending, with reductions ranging from 2.4 to 24 percent between 2012 and 2036. However, the policies also reduce coverage among the elderly. To achieve significant costs savings without causing substantial uninsurance among seniors, benefits changes would likely need to occur in combination with other options. PMID:23650322

Child health: fertile ground for philanthropic investment.

PubMed

Schwartz, Anne L; LeRoy, Lauren

2004-01-01

Children and youth are the focus for many foundations and corporate-giving programs working in the health field. Total foundation giving targeted to children and youth more than doubled during the late 1990s; in 2000, health accounted for 25 percent of philanthropic dollars invested in this population. This funding covers a broad range of child health issues but clusters in four key areas-promoting healthy behavior, improving access to care and expanding insurance coverage, strengthening mental health services, and addressing the broader determinants of health.

Integrated, Accountable Care For Medicaid Expansion Enrollees: A Comparative Evaluation of Hennepin Health.

PubMed

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.

Probabilistic Prediction of Lifetimes of Ceramic Parts

NASA Technical Reports Server (NTRS)

Nemeth, Noel N.; Gyekenyesi, John P.; Jadaan, Osama M.; Palfi, Tamas; Powers, Lynn; Reh, Stefan; Baker, Eric H.

2006-01-01

ANSYS/CARES/PDS is a software system that combines the ANSYS Probabilistic Design System (PDS) software with a modified version of the Ceramics Analysis and Reliability Evaluation of Structures Life (CARES/Life) Version 6.0 software. [A prior version of CARES/Life was reported in Program for Evaluation of Reliability of Ceramic Parts (LEW-16018), NASA Tech Briefs, Vol. 20, No. 3 (March 1996), page 28.] CARES/Life models effects of stochastic strength, slow crack growth, and stress distribution on the overall reliability of a ceramic component. The essence of the enhancement in CARES/Life 6.0 is the capability to predict the probability of failure using results from transient finite-element analysis. ANSYS PDS models the effects of uncertainty in material properties, dimensions, and loading on the stress distribution and deformation. ANSYS/CARES/PDS accounts for the effects of probabilistic strength, probabilistic loads, probabilistic material properties, and probabilistic tolerances on the lifetime and reliability of the component. Even failure probability becomes a stochastic quantity that can be tracked as a response variable. ANSYS/CARES/PDS enables tracking of all stochastic quantities in the design space, thereby enabling more precise probabilistic prediction of lifetimes of ceramic components.

Conflict management styles among Iranian critical care nursing staff: a cross-sectional study.

PubMed

Ahanchian, Mohammad Reza; Emami Zeydi, Amir; Armat, Mohammad Reza

2015-01-01

Conflict among nurses has been recognized as an extremely important issue within health care settings throughout the world. Identifying the conflict management style would be a key strategy for conflict management. The aim of this study was to evaluate the prevalence of conflict management styles and its related factors among Iranian critical care nursing staff. In a descriptive cross-sectional study, a total of 149 critical care nurses who worked in the critical care units of 4 teaching hospitals in Sari (Iran) were evaluated. A 2-part self-reported questionnaire including personal information and Rahim Organizational Conflict Inventory II was used for data collection. Although Iranian critical care nurses used all 5 conflict management styles to manage conflict with their peers, the collaborating style was the most prevalent conflict management style used by them, followed by compromising, accommodating, avoiding, and competing. Male gender was a predictor for both compromising and competing styles, whereas position and shift time were significant predictors for compromising and competing styles, respectively. Based on the results of this study, nurse managers need to take these factors into account in designing programs to help nurses constructively manage unavoidable conflicts in health care setting.

The impact of threshold language assistance programming on the accessibility of mental health services for persons with limited English proficiency in the Medi-Cal setting.

PubMed

McClellan, Sean R; Wu, Frances M; Snowden, Lonnie R

2012-06-01

Title VI of the 1964 Civil Rights Act prohibits federal funds recipients from providing care to limited English proficiency (LEP) persons more limited in scope or lower in quality than care provided to others. In 1999, the California Department of Mental Health implemented a "threshold language access policy" to meet its Title VI obligations. Under this policy, Medi-Cal agencies must provide language assistance programming in a non-English language where a county's Medical population contains either 3000 residents or 5% speakers of that language. We examine the impact of threshold language policy-required language assistance programming on LEP persons' access to mental health services by analyzing the county-level penetration rate of services for Russian, Spanish, and Vietnamese speakers across 34 California counties, over 10 years of quarterly data. Exploiting a time series with nonequivalent control group study design, we studied this phenomena using linear regression with random county effects to account for trends over time. Threshold language policy-required assistance programming led to an immediate and significant increase in the penetration rate of mental health services for Russian (8.2, P < 0.01) and Vietnamese (3.3, P < 0.01) language speaking persons. Threshold language assistance programming was effective in increasing mental health access for Russian and Vietnamese, but not for Spanish-speaking LEP persons.

Expenditures and use of wraparound health insurance for employed people with disabilities.

PubMed

Gettens, John; Hoffman, Denise; Henry, Alexis D

2016-04-01

The Affordable Care Act (ACA) provides health insurance to many working-age adults with disabilities, but we do not expect the new coverage or existing insurance options to fully meet their employment-related health care needs. Wraparound services have the potential to foster employment among people with disabilities. We use Massachusetts, which implemented health care reform in 2006, as a case study to estimate the wraparound health care expenditures and use for workers with disabilities. We identified a group of employed, working-age people with disabilities whose primary health insurance is Medicare or private insurance and who use the Medicaid Buy-In Program for wraparound coverage. We analyzed claims to estimate expenditures and use. Wraparound expenditures averaged $427 per member per month. Community-based services for both mental and non-mental health, which are generally not covered by Medicare or private insurance, accounted for 63% of all expenditures. The number who used community-based services was low, but the expenditures were high. The majority of the remaining expenditures were for services usually covered by primary insurance including: inpatient and outpatient, pharmacy and professional services. Expenditures were higher for people with Medicare compared to private insurance. This case study suggests that, from a total program cost perspective, wraparound demand is greatest for community-based services. From a member utilization perspective, the demand is greatest for coverage that alleviates out-of-pocket costs for services provided by primary insurance. Additional analysis is needed to further assess the design options for wraparound programs and their feasibility. Copyright © 2016 Elsevier Inc. All rights reserved.

Informal caregivers' views on the division of responsibilities between themselves and professionals: A scoping review.

PubMed

Wittenberg, Yvette; Kwekkeboom, Rick; Staaks, Janneke; Verhoeff, Arnoud; de Boer, Alice

2017-12-18

This scoping review focuses on the views of informal caregivers regarding the division of care responsibilities between citizens, governments and professionals and the question of to what extent professionals take these views into account during collaboration with them. In Europe, the normative discourse on informal care has changed. Retreating governments and decreasing residential care increase the need to enhance the collaboration between informal caregivers and professionals. Professionals are assumed to adequately address the needs and wishes of informal caregivers, but little is known about informal caregivers' views on the division of care responsibilities. We performed a scoping review and searched for relevant studies published between 2000 and September 1, 2016 in seven databases. Thirteen papers were included, all published in Western countries. Most included papers described research with a qualitative research design. Based on the opinion of informal caregivers, we conclude that professionals do not seem to explicitly take into account the views of informal caregivers about the division of responsibilities during their collaboration with them. Roles of the informal caregivers and professionals are not always discussed and the division of responsibilities sometimes seems unclear. Acknowledging the role and expertise of informal caregivers seems to facilitate good collaboration, as well as attitudes such as professionals being open and honest, proactive and compassionate. Inflexible structures and services hinder good collaboration. Asking informal caregivers what their opinion is about the division of responsibilities could improve clarity about the care that is given by both informal caregivers and professionals and could improve their collaboration. Educational programs in social work, health and allied health professions should put more emphasis on this specific characteristic of collaboration. © 2017 The Authors. Health and Social Care in the Community Published by John Wiley & Sons Ltd.

Critical features of a curriculum in health care quality and resource management.

PubMed

Norman, D K; Randall, R S; Hornsby, B J

1990-09-01

In response to mounting demands for quality and accountability in health care, a science of health care quality and resource management (QRM) has evolved, but too slowly and without the academic base needed to prepare practitioners to assume new roles and fulfill requirements to regulate their practice. To develop such a base, The University of Houston and The University of Texas Health Science Center sponsored a needs assessment survey to identify areas of knowledge and skills to be included in a master's degree curriculum in QRM. The study used a three-cycle Focus Delphi technique to secure experts' refinement of the survey instrument and consensus among participants, who included practitioner-members of the National Association of Quality Assurance Professionals (NAQAP), of health care administration educational program directors, and hospital administrators. Starting with a listing based on a competency outline obtained from NAQAP, the study identified critical learning needs and elaborated a framework with 12 broad categories and 108 specific knowledge and skill areas.

Coordinated Care Organizations: Neonatal and Infant Outcomes in Oregon.

PubMed

Harvey, S Marie; Oakley, Lisa P; Yoon, Jangho; Luck, Jeff

2017-11-01

In 2012, Oregon's Medicaid program implemented a comprehensive accountable care model delivered through coordinated care organizations (CCOs). Because CCOs are expected to improve utilization of services and health outcomes, neonatal and infant outcomes may be important indicators of their impact. Estimating difference-in-differences models, we compared prepost CCO changes in outcomes (e.g., low birth weight, abnormal conditions, 5-minute Apgar score, congenital anomalies, and infant mortality) between Medicaid and non-Medicaid births among 99,924 infants born in Oregon during 2011 and 2013. We further examined differences in the impact of CCOs by ethnicity and rurality. Following CCO implementation the likelihood of low birth weight and abnormal conditions decreased by 0.95% and 1.08%, a reduction of 13.4% and 10.4% compared with the pre-CCO level for Medicaid enrollees, respectively. These reductions could be predictive of lifelong health benefits for infants and lower costs for acute care and are, therefore, important markers of success for the CCO model.

Kangaroo Mother Care in Colombia: A Subaltern Health Innovation against For-profit Biomedicine.

PubMed

Abadía-Barrero, César Ernesto

2018-01-24

This ethnographic study presents the origins, growth, and collapse of the first Kangaroo Mother Care (KMC) program, a well-established practice for neonatal care created in 1978 in Colombia. The WHO and UNICEF praised this zero-cost revolutionary technique for its promotion of skin-to-skin contact between premature and low-birth-weight newborns and family members. KMC facilitates early hospital discharge, brings many clinical and psychological benefits, and constitutes an excellent alternative to placing babies in incubators. However, these benefits and political potential against biomedical interventions were undermined after being relabeled as a "reverse innovation," a business concept that encourages corporate investments in low-income countries to develop technologies that can both solve global health problems and boost multinational corporations profits. In response, I propose "subaltern health innovations" as a label for KMC that accounts for the power dynamics in global health between health care initiatives that originate in the Global South and neoliberal configurations of for-profit biomedicine. © 2018 by the American Anthropological Association.

Rural and remote care

PubMed Central

Marciniuk, Darcy

2016-01-01

The challenges of providing quality respiratory care to persons living in rural or remote communities can be daunting. These populations are often vulnerable in terms of both health status and access to care, highlighting the need for innovation in service delivery. The rapidly expanding options available using telehealthcare technologies have the capacity to allow patients in rural and remote communities to connect with providers at distant sites and to facilitate the provision of diagnostic, monitoring, and therapeutic services. Successful implementation of telehealthcare programs in rural and remote settings is, however, contingent upon accounting for key technical, organizational, social, and legal considerations at the individual, community, and system levels. This review article discusses five types of telehealthcare delivery that can facilitate respiratory care for residents of rural or remote communities: remote monitoring (including wearable and ambient systems; remote consultations (between providers and between patients and providers), remote pulmonary rehabilitation, telepharmacy, and remote sleep monitoring. Current and future challenges related to telehealthcare are discussed. PMID:26902542

7 CFR 1700.32 - Program Accounting and Regulatory Analysis.

Code of Federal Regulations, 2014 CFR

2014-01-01

... 7 Agriculture 11 2014-01-01 2014-01-01 false Program Accounting and Regulatory Analysis. 1700.32... SERVICE, DEPARTMENT OF AGRICULTURE GENERAL INFORMATION Agency Organization and Functions § 1700.32 Program Accounting and Regulatory Analysis. RUS, through Program Accounting and Regulatory Analysis, monitors and...

7 CFR 1700.32 - Program Accounting and Regulatory Analysis.

Code of Federal Regulations, 2013 CFR

2013-01-01

... 7 Agriculture 11 2013-01-01 2013-01-01 false Program Accounting and Regulatory Analysis. 1700.32... SERVICE, DEPARTMENT OF AGRICULTURE GENERAL INFORMATION Agency Organization and Functions § 1700.32 Program Accounting and Regulatory Analysis. RUS, through Program Accounting and Regulatory Analysis, monitors and...

Patient care delivery and integration: stimulating advancement of ambulatory care pharmacy practice in an era of healthcare reform.

PubMed

Epplen, Kelly T

2014-08-15

This article discusses how to plan and implement an ambulatory care pharmacist service, how to integrate a hospital- or health-system-based service with the mission and operations of the institution, and how to help the institution meet its challenges related to quality improvement, continuity of care, and financial sustainability. The steps in implementing an ambulatory care pharmacist service include (1) conducting a needs assessment, (2) aligning plans for the service with the mission and goals of the parent institution, (3) collaborating with patients and physicians, (4) standardizing the patient care process, (5) proposing the service, (6) attaining the necessary resources, (7) identifying stakeholders, (8) identifying applicable quality standards, (9) defining competency standards, (10) planning for service payment, and (11) monitoring outcomes. Ambulatory care pharmacists have current opportunities to become engaged with patient-centered medical homes, accountable care organizations, preventive and wellness programs, and continuity of care initiatives. Common barriers to the advancement of ambulatory care pharmacist services include lack of complete access to patient information, inadequate information technology, and lack of payment. Ambulatory care pharmacy practitioners must assertively promote appropriate medication use, provide patient-centered care, pursue integration with the patient care team, and seek appropriate recognition and compensation for the services they provide. Copyright © 2014 by the American Society of Health-System Pharmacists, Inc. All rights reserved.

Academic Medical Centers Forming Accountable Care Organizations and Partnering With Community Providers: The Experience of the Johns Hopkins Medicine Alliance for Patients.

PubMed

Berkowitz, Scott A; Ishii, Lisa; Schulz, John; Poffenroth, Matt

2016-03-01

Academic medical centers (AMCs)--which include teaching hospital(s) and additional care delivery entities--that form accountable care organizations (ACOs) must decide whether to partner with other provider entities, such as community practices. Indeed, 67% (33/49) of AMC ACOs through the Medicare Shared Savings Program through 2014 are believed to include an outside community practice. There are opportunities for both the AMC and the community partners in pursuing such relationships, including possible alignment around shared goals and adding ACO beneficiaries. To create the Johns Hopkins Medicine Alliance for Patients (JMAP), in January 2014, Johns Hopkins Medicine chose to partner with two community primary care groups and one cardiology practice to support clinical integration while adding approximately 60 providers and 5,000 Medicare beneficiaries. The principal initial interventions within JMAP included care coordination for high-risk beneficiaries and later, in 2014, generating dashboards of ACO quality measures to facilitate quality improvement and early efforts at incorporating clinical pathways and Choosing Wisely recommendations. Additional interventions began in 2015.The principal initial challenges JMAP faced were data integration, generation of quality measure reports among disparate electronic medical records, receiving and then analyzing claims data, and seeking to achieve provider engagement; all these affected timely deployment of the early interventions. JMAP also created three regional advisory councils as a forum promoting engagement of local leadership. Network strategies among AMCs, including adding community practices in a nonemployment model, will continue to require thoughtful strategic planning and a keen understanding of local context.

Breaching the security of the Kaiser Permanente Internet patient portal: the organizational foundations of information security.

PubMed

Collmann, Jeff; Cooper, Ted

2007-01-01

This case study describes and analyzes a breach of the confidentiality and integrity of personally identified health information (e.g. appointment details, answers to patients' questions, medical advice) for over 800 Kaiser Permanente (KP) members through KP Online, a web-enabled health care portal. The authors obtained and analyzed multiple types of qualitative data about this incident including interviews with KP staff, incident reports, root cause analyses, and media reports. Reasons at multiple levels account for the breach, including the architecture of the information system, the motivations of individual staff members, and differences among the subcultures of individual groups within as well as technical and social relations across the Kaiser IT program. None of these reasons could be classified, strictly speaking, as "security violations." This case study, thus, suggests that, to protect sensitive patient information, health care organizations should build safe organizational contexts for complex health information systems in addition to complying with good information security practice and regulations such as the Health Insurance Portability and Accountability Act (HIPAA) of 1996.

Ultrasound in telemedicine: its impact in high-risk obstetric health care delivery.

PubMed

Long, Megan Chang; Angtuaco, Teresita; Lowery, Curtis

2014-09-01

The aim of this study was to determine the impact of Antenatal and Neonatal Guidelines, Education, and Learning System (ANGELS), a statewide telemedicine project, on health care delivery to patients with high-risk pregnancies in Arkansas. With institutional review board approval, a Health Insurance Portability and Accountability Act-compliant retrospective review, in which the requirement for informed patient consent was waived, was performed. The population studied is the Arkansas maternal Medicaid population. Data for evaluation were collected from maternal Medicaid claims, ANGELS administrative records, and birth records from the Arkansas Vital Statistics record system. Data collected from before the inception of ANGELS (2001-2003) were compared with data collected after the inception of ANGELS (2004-2007).Antenatal and Neonatal Guidelines, Education, and Learning System is a multidisciplinary, multifaceted telemedicine program designed in Arkansas to enhance high-risk obstetric health care delivery across the state. An essential component of the program is real-time interactive targeted level II ultrasound examination of patients. Since the inception of the ANGELS program in 2003, a growing number of telemedicine consultations and real-time ultrasound examinations are being performed every year. The number and percentage of high-risk pregnancies identified each year show a slight decrease since inception of the ANGELS program, and findings suggest that identification of high-risk pregnancies is shifting from the second trimester to the first trimester, but trends vary over time. Antenatal and Neonatal Guidelines, Education, and Learning System has created a telemedicine network across the state that has made possible, among many other things, access to real-time level II ultrasound examinations and consultations. This program has ultimately led to improved prenatal access across the state.

[Differences between German and Turkish-speaking participants in a chronic heart failure management program].

PubMed

Ernstmann, N; Karbach, U

2017-02-01

German and Turkish-speaking patients were recruited for a chronic heart failure management program. So far little is known about the special needs and characteristics of Turkish-speaking patients with chronic heart failure; therefore, the aim of this study was to examine sociodemographic and illness-related differences between German and Turkish-speaking patients with chronic heart failure. German and Turkish-speaking patients suffering from chronic heart failure and insured with the AOK Rheinland/Hamburg or the BARMER GEK health insurance companies and living in Cologne, Germany, were enrolled. Recruitment took place in hospitals, private practices and at information events. Components of the program were coordination of a guideline-oriented medical care, telemonitoring (e.g., blood pressure, electrocardiogram, and weight), a 24-h information hotline, attendance by German and Turkish-speaking nurses and a patient education program. Data were collected by standardized interviews in German or Turkish language. Data were analyzed with descriptive measures and tested for significance differences using Pearson's χ 2 -test and the t‑test. A total of 465 patients (average age 71 years, 55 % male and 33 % Turkish-speaking) were enrolled in the care program during the study period. Significant differences between German and Turkish-speaking patients were found for age, education, employment status, comorbidities, risk perception, knowledge on heart failure and fear of loss of independence. The response rate could be achieved with the help of specific measures for patient enrollment by Turkish-speaking integration nurses. The differences between German and Turkish-speaking patients should in future be taken into account in the care of people with chronic heart failure.

Return-on-Investment (ROI) Analyses of an Inpatient Lay Health Worker Model on 30-Day Readmission Rates in a Rural Community Hospital.

PubMed

Cardarelli, Roberto; Bausch, Gregory; Murdock, Joan; Chyatte, Michelle Renee

2017-07-07

The purpose of the study was to assess the return-on-investment (ROI) of an inpatient lay health worker (LHW) model in a rural Appalachian community hospital impacting 30-day readmission rates. The Bridges to Home (BTH) study completed an evaluation in 2015 of an inpatient LHW model in a rural Kentucky hospital that demonstrated a reduction in 30-day readmission rates by 47.7% compared to a baseline period. Using the hospital's utilization and financial data, a validated ROI calculator specific to care transition programs was used to assess the ROI of the BTH model comparing 3 types of payment models including Diagnosis Related Group (DRG)-only payments, pay-for-performance (P4P) contracts, and accountable care organizations (ACOs). The BTH program had a -$0.67 ROI if the hospital had only a DRG-based payment model. If the hospital had P4P contracts with payers and 0.1% of its annual operating revenue was at risk, the ROI increased to $7.03 for every $1 spent on the BTH program. However, if the hospital was an ACO as was the case for this study's community hospital, the ROI significantly increased to $38.48 for every $1 spent on the BTH program. The BTH model showed a viable ROI to be considered by community hospitals that are part of an ACO or P4P program. A LHW care transition model may be a cost-effective alternative for impacting excess 30-day readmissions and avoiding associated penalties for hospital systems with a value-based payment model. © 2017 National Rural Health Association.

The March to Accountable Care Organizations--How Will Rural Fare?

ERIC Educational Resources Information Center

MacKinney, A. Clinton; Mueller, Keith J.; McBride, Timothy D.

2011-01-01

Purpose: This article describes a strategy for rural providers, communities, and policy makers to support or establish accountable care organizations (ACOs). Methods: ACOs represent a new health care delivery and provider payment system designed to improve clinical quality and control costs. The Patient Protection and Affordable Care Act (ACA)…

Veterans Health Care: Improvements Needed in Operationalizing Strategic Goals and Objectives

DTIC Science & Technology

2016-10-01

Congressional Requesters October 2016 GAO-17-50 United States Government Accountability Office United States Government Accountability Office...Abbreviations Choice Act Veterans Access, Choice, and Accountability Act of 2014 FY fiscal year GPRA...health care, among other things, Congress enacted and the President signed into law the Veterans Access, Choice, and Accountability Act of 2014

A targeted e-learning program for surgical trainees to enhance patient safety in preventing surgical infection.

PubMed

McHugh, Seamus Mark; Corrigan, Mark; Dimitrov, Borislav; Cowman, Seamus; Tierney, Sean; Humphreys, Hilary; Hill, Arnold

2010-01-01

Surgical site infection accounts for 20% of all health care-associated infections (HCAIs); however, a program incorporating the education of surgeons has yet to be established across the specialty. An audit of surgical practice in infection prevention was carried out in Beaumont Hospital from July to November 2009. An educational Web site was developed targeting deficiencies highlighted in the audit. Interactive clinical cases were constructed using PHP coding, an HTML-embedded language, and then linked to a MySQL relational database. PowerPoint tutorials were produced as online Flash audiovisual movies. An online repository of streaming videos demonstrating best practice was made available, and weekly podcasts were made available on the iTunes© store for free download. Usage of the e-learning program was assessed quantitatively over 6 weeks in May and June 2010 using the commercial company Hitslink. During the 5-month audit, deficiencies in practice were highlighted, including the timing of surgical prophylaxis (33% noncompliance) and intravascular catheter care in surgical patients (38% noncompliance regarding necessity). Over the 6-week assessment of the educational material, the SurgInfection.com Web pages were accessed more than 8000 times; 77.9% of the visitors were from Ireland. The most commonly accessed modality was the repository with interactive clinical cases, accounting for 3463 (43%) of the Web site visits. The average user spent 57 minutes per visit, with 30% of them visiting the Web site multiple times. Interactive virtual cases mirroring real-life clinical scenarios are likely to be successful as an e-learning modality. User-friendly interfaces and 24-hour accessibility will increases uptake by surgical trainees.

How "accountable" are accountable care organizations?

PubMed

Addicott, Rachael; Shortell, Stephen M

2014-01-01

The establishment of accountable care organizations (ACOs) in the Affordable Care Act (ACA) was intended to support both cost savings and high-quality care. However, a key challenge will be to ensure that governance and accountability mechanisms are sufficient to support those twin ambitions. This exploratory study considers how recently developed ACOs have established governance structures and accountability mechanisms, particularly focusing on attempts at collaborative accountability and shared governance arrangements. Four case studies of ACOs across the United States were undertaken, with data collected throughout 2012. These involved 34 semistructured interviews with ACO administrative and clinical leaders, observation of nine meetings, and a review of documentary materials from each ACO. We identified very few examples of physicians being held to account as a collective and therefore only limited evidence of collaborative accountability impacting on behavior change. However, ACO leaders do have many mechanisms available to stimulate change across physicians. The challenge is to determine governance structure(s) and accountability mechanisms that facilitate the most effective combination of approaches, measures, incentives, and sanctions to achieve the goals of more accountable care. Accountability structures and processes will need to be tailored to local membership composition, historical evolution, and current stage of development. There are also some common lessons to be drawn. Shared goals and incentives should be reflected through performance criteria. It is important to align measures and thresholds across payers to ensure ACOs are not unnecessarily burdened or compromised by reporting on different and potentially disjointed measures. Finally, emphasis needs to be placed on the importance of credible, transparent data. This exploratory study provides early evidence regarding how ACOs are establishing their governance and accountability arrangements and provides a foundation for future research and theory-building in this area.

The Islamic dialogue with African traditional religion: divination and health care.

PubMed

Kirby, J P

1993-02-01

In rural Africa delivering better health care is more complicated than simply offering good medical services; it must also take into account peoples' religious orientation and beliefs. Here the non-material causes of illness are at least as important as the biological or material and, in many places, one can only determine the exact nature of the problem and its corresponding remedy after the fact, through a process involving divination and sacrifice. In northern Ghana, by adapting to traditional methods of divination, Islam is gradually introducing a future perspective and expanding the possibilities of preventative action. By so doing it is bringing about a religio-epistemological transformation that is, among other things, helping people to understand and make better use of Western bio-medicine and primary health care programs. The author argues for a similar adaptation and dialogue between African traditional beliefs and Western medical institutions.

Health status among elderly Hungarians and Americans.

PubMed

Buss, T F; Beres, C; Hofstetter, C R; Pomidor, A

1994-07-01

Selected health status data for elderly populations from similar industrial cities-Youngstown, Ohio, USA, and Debrecen, Hungary-were compared. Because of their impoverished health care system, unregulated heavily industrialized society, and unhealthful life-styles Hungarians were hypothesized to have poorer health status than Americans, even after taking into account demographic mediating factors. The study provides a health status baseline for elderly Hungarians shortly after communism's fall in 1989-1990 and shows how great a gap exists between Hungarian health status and that in the West. Hungarians were in much poorer health as measured by functional status, symptomatology, medical condition, depression, and subjective health status. Distinctions persisted when controlling for gender, age, and education. Poverty-level (and income) did not explain health status differences. The paper concludes that Hungary should pay more attention to health promotion, prevention, and primary care, as well as to reforming patient management in hospitals, nursing homes, and home care programs.

A Comprehensive Observational Coding Scheme for Analyzing Instrumental, Affective, and Relational Communication in Health Care Contexts

PubMed Central

SIMINOFF, LAURA A.; STEP, MARY M.

2011-01-01

Many observational coding schemes have been offered to measure communication in health care settings. These schemes fall short of capturing multiple functions of communication among providers, patients, and other participants. After a brief review of observational communication coding, the authors present a comprehensive scheme for coding communication that is (a) grounded in communication theory, (b) accounts for instrumental and relational communication, and (c) captures important contextual features with tailored coding templates: the Siminoff Communication Content & Affect Program (SCCAP). To test SCCAP reliability and validity, the authors coded data from two communication studies. The SCCAP provided reliable measurement of communication variables including tailored content areas and observer ratings of speaker immediacy, affiliation, confirmation, and disconfirmation behaviors. PMID:21213170

Best practices: an electronic drug alert program to improve safety in an accountable care environment.

PubMed

Griesbach, Sara; Lustig, Adam; Malsin, Luanne; Carley, Blake; Westrich, Kimberly D; Dubois, Robert W

2015-04-01

The accountable care organization (ACO), one of the most promising and talked about new models of care, focuses on improving communication and care transitions by tying potential shared savings to specific clinical and financial benchmarks. An important factor in meeting these benchmarks is an ACO's ability to manage medications in an environment where medical and pharmacy care has been integrated. The program described in this article highlights the critical components of Marshfield Clinic's Drug Safety Alert Program (DSAP), which focuses on prioritizing and communicating safety issues related to medications with the goal of reducing potential adverse drug events. Once the medication safety concern is identified, it is reviewed to evaluate whether an alert warrants sending prescribers a communication that identifies individual patients or a general communication to all physicians describing the safety concern. Instead of basing its decisions regarding clinician notification about drug alerts on subjective criteria, the Marshfield Clinic's DSAP uses an internally developed scoring system. The scoring system includes criteria developed from previous drug alerts, such as level of evidence, size of population affected, severity of adverse event identified or targeted, litigation risk, available alternatives, and potential for duration of medication use. Each of the 6 criteria is assigned a weight and is scored based upon the content and severity of the alert received.  In its first 12 months, the program targeted 6 medication safety concerns involving the following medications: topiramate, glyburide, simvastatin, citalopram, pioglitazone, and lovastatin. Baseline and follow-up prescribing data were gathered on the targeted medications. Follow-up review of prescribing data demonstrated that the DSAP provided quality up-to-date safety information that led to changes in drug therapy and to decreases in potential adverse drug events. In aggregate, nearly 10,000 total potential adverse drug events were identified with baseline data from the DSAP initiatives, and nearly 8,000 were resolved by changes in prescribing.  Implications and additional thoughts from The Working Group on Optimizing Medication Therapy in Value-Based Healthcare were provided for the following categories: leveraging electronic health records, importance of data collection and reassessment, preventing alert fatigue utilizing various techniques, relevance to ACO quality measurement, and limitations of a retrospective system. While health information technologies have been recognized as a cornerstone for an ACO's success, additional research is needed on comparing these types of technological innovations. Future research should focus on reviewing comparable scoring criteria and alert systems utilized in a variety of ACOs. In addition, an examination of different data mining procedures used within different electronic health record platforms would prove useful to ACOs looking to improve the care of not only the subpopulations with specific metrics associated with them, but their patient population as a whole. The authors also highlight the need for additional research on health information exchanges, including the cost and resource requirements needed to successfully participate in these types of networks.

Home and community care sector accountability.

PubMed

Steele Gray, Carolyn; Berta, Whitney; Deber, Raisa B; Lum, Janet

2014-09-01

This paper focuses on accountability for the home and community care (HCC) sector in Ontario. The many different service delivery approaches, funding methods and types of organizations delivering HCC services make this sector highly heterogeneous. Findings from a document analysis and environmental scan suggest that organizations delivering HCC services face multiple accountability requirements from a wide array of stakeholders. Government stakeholders tend to rely on regulatory and expenditure instruments to hold organizations to account for service delivery. Semi-structured key informant interview respondents reported that the expenditure-based accountability tools being used carried a number of unintended consequences, both positive and negative. These include an increased organizational focus on quality, shifting care time away from clients (particularly problematic for small agencies), dissuading innovation, and reliance on performance indicators that do not adequately support the delivery of high-quality care. Copyright © 2014 Longwoods Publishing.

Home and Community Care Sector Accountability

PubMed Central

Gray, Carolyn Steele; Berta, Whitney; Deber, Raisa B.; Lum, Janet

2014-01-01

This paper focuses on accountability for the home and community care (HCC) sector in Ontario. The many different service delivery approaches, funding methods and types of organizations delivering HCC services make this sector highly heterogeneous. Findings from a document analysis and environmental scan suggest that organizations delivering HCC services face multiple accountability requirements from a wide array of stakeholders. Government stakeholders tend to rely on regulatory and expenditure instruments to hold organizations to account for service delivery. Semi-structured key informant interview respondents reported that the expenditure-based accountability tools being used carried a number of unintended consequences, both positive and negative. These include an increased organizational focus on quality, shifting care time away from clients (particularly problematic for small agencies), dissuading innovation, and reliance on performance indicators that do not adequately support the delivery of high-quality care. PMID:25305389

Using accountability to improve reproductive health care.

PubMed

George, Asha

2003-05-01

Accountability is best understood as a referee of the dynamics in two-way relationships, often between unequal partners. The literature on accountability distinguishes between political, fiscal, administrative, legal and constitutional accountability. This paper focuses on accountability mechanisms in health care and how they mediate between service providers and communities and between different kinds of health personnel at the primary health care level. It refers to case studies of participatory processes for improving sexual and reproductive health service delivery. Information, dialogue and negotiation are important elements that enable accountability mechanisms to address problems by supporting change and engagement between participants. In order to succeed, however, efforts towards better accountability that broaden the participation of users must take into account the social contexts and the policy and service delivery systems in which they are applied, address power relations and improve the representation of marginalised groups within communities and service delivery systems.

The Carter Center Mental Health Program: addressing the public health crisis in the field of mental health through policy change and stigma reduction.

PubMed

Palpant, Rebecca G; Steimnitz, Rachael; Bornemann, Thomas H; Hawkins, Katie

2006-04-01

Some of the most pervasive and debilitating illnesses are mental illnesses, according to World Health Organization's The World Health Report 2001--Mental Health: New Understanding, New Hope. Neuropsychiatric conditions account for four of the top five leading causes of years of life lived with disability in people aged 15 to 44 in the Western world. Many barriers prevent people with mental illnesses from seeking care, such as prohibitive costs, lack of insurance, and the stigma and discrimination associated with mental illnesses. The Carter Center Mental Health Program, established in 1991, focuses on mental health policy issues within the United States and internationally. This article examines the public health crisis in the field of mental health and focuses on The Carter Center Mental Health Program's initiatives, which work to increase public knowledge of and decrease the stigma associated with mental illnesses through their four strategic goals: reducing stigma and discrimination against people with mental illnesses; achieving equity of mental health care comparable with other health services; advancing early promotion, prevention, and early intervention services for children and their families; and increasing public awareness about mental illnesses and mental health issues.

Moving Towards the Age-friendly Hospital: A Paradigm Shift for the Hospital-based Care of the Elderly.

PubMed

Huang, Allen R; Larente, Nadine; Morais, Jose A

2011-12-01

Care of the older adult in the acute care hospital is becoming more challenging. Patients 65 years and older account for 35% of hospital discharges and 45% of hospital days. Up to one-third of the hospitalized frail elderly loses independent functioning in one or more activities of daily living as a result of the 'hostile environment' that is present in the acute hospitals. A critical deficit of health care workers with expertise and experience in the care of the elderly also jeopardizes successful care delivery in the acute hospital setting. We propose a paradigm shift in the culture and practice of event-driven acute hospital-based care of the elderly which we call the Age-friendly Hospital concept. Guiding principles include: a favourable physical environment; zero tolerance for ageism throughout the organization; an integrated process to develop comprehensive services using the geriatric approach; assistance with appropriateness decision-making and fostering links between the hospital and the community. Our current proposed strategy is to focus on delirium management as a hospital-wide condition that both requires and highlights the Geriatric Medicine specialist as an expert of content, for program development and of evaluation. The Age-friendly Hospital concept we propose may lead the way to enable hospitals in the fast-moving health care system to deliver high-quality care without jeopardizing risk-benefit, function, and quality of life balances for the frail elderly. Recruitment and retention of skilled health care professionals would benefit from this positive 'branding' of an institution. Convincing hospital management and managing change are significant challenges, especially with competing priorities in a fiscal environment with limited funding. The implementation of a hospital-wide delirium management program is an example of an intervention that embodies many of the principles in the Age-friendly Hospital concept. It is important to change the way hospital care is delivered to older adults in time to meet our needs when we need hospital services ourselves.

Health care administration in the United States and Canada: micromanagement, macro costs.

PubMed

Woolhandler, Steffie; Campbell, Terry; Himmelstein, David U

2004-01-01

A decade ago, U.S. health administration costs greatly exceeded Canada's. Have the computerization of billing and the adoption of a more business-like approach to care cut administrative costs? For the United States and Canada, the authors calculated the 1999 administrative costs of health insurers, employers' health benefit programs, hospitals, practitioners' offices, nursing homes, and home care agencies; they analyzed published data, surveys of physicians, employment data, and detailed cost reports filed by hospitals, nursing homes, and home care agencies; they used census surveys to explore time trends in administrative employment in health care settings. Health administration costs totaled at least dollar 294.3 billion, dollar 1,059 per capita, in the United States vs. dollar 9.4 billion, dollar 307 per capita, in Canada. After exclusions, health administration accounted for 31.0 percent of U.S. health expenditures vs. 16.7 percent of Canadian. Canada's national health insurance program had an overhead of 1.3 percent, but overhead among Canada's private insurers was higher than in the U.S.: 13.2 vs. 11.7 percent. Providers' administrative costs were far lower in Canada. Between 1969 and 1999 administrative workers' share of the U.S. health labor force grew from 18.2 to 27.3 percent; in Canada it grew from 16.0 percent in 1971 to 19.1 percent in 1996. Reducing U.S. administrative costs to Canadian levels would save at least dollar 209 billion annually, enough to fund universal coverage.

[Parent support activities in neonatal intensive care units: a national survey in Israel].

PubMed

Glasser, Saralee; Lerner-Geva, Liat; Levitski, Orna; Reichman, Brian

2009-04-01

Parents of infants in Neonatal Intensive Care Units (NICU) suffer extended periods of stress. The staffs of these departments have a major role in assisting them through this period. To describe services, programs and facilities to support parents of these infants, during and following hospitalization. Social workers of 23 NICU's completed a structured questionnaire, and the responses were summarized. The majority of units have paramedical staff in addition to social workers. Twenty-two units offer structured instruction for parents, and 12 offer lecture series. Topics include: coping with the birth of a premature infant, the infant's development and care, breastfeeding, discharge preparation, etc. In 19 departments grandparents are allowed to visit and nine also allow siblings. Most departments have breast-pump facilities and a lounge for parents; some also have refrigerators, personal lockers, etc.. Twenty units employ the "Kangaroo" method of skin-to-skin contact, and three practice elements of "individualized developmental care". Communication with parents is conducted both formally and informally. All departments have guidelines for contact with community health providers - some regularly, and some as-needed. Despite the multiplicity of programs reported in the survey, many are conducted in only a few departments. It is recommended that national guidelines be developed, which would integrate many existing activities, taking into account the needs of parents and families, medical and paramedical staff, as well as economic constraints. Clear policy guidelines and standards are necessary for this aspect of care, as they are for the medical aspects.

Quality or financing: what drives design of the health care system?

PubMed Central

McLoughlin, V; Leatherman, S

2003-01-01



 The scope and scale of problems in the quality of health service provision have been increasingly recognised in recent years. Policy and planning for financing are usually concerned with how funding is made available and allocated, rather than with what is being achieved, including the quality of health services delivered. A fundamental challenge is how to improve the delivery of health services to achieve improved patient outcomes and to optimize financial outcomes. To accomplish this it is essential that the debates on quality of care and financing are aligned. Approaches to improving the quality of care are drawn from Australia, the US, and the UK. Financing arrangments for care at a national level have a bearing on how payment incentives can be used to promote or impede quality. The level of overall expenditure is obviously important, as are the mechanisms for payment. Long term programs to build knowledge, standardise processes, provide credible performance data and foster accountability are required to ensure that further investments lead to improvement in care. PMID:12679511

Creating community collaboration to improve the care of patients with high blood pressure: lessons from Rochester, New York.

PubMed

Bisognano, John D; Speranza, Paul S; Becker, Lawrence M; Norwood, Wade S; Bradley, Al; Nazar, Michael D; Beckman, Howard B

2012-03-01

Over the past two years, the business community of Monroe County, which includes Rochester, New York, has been engaging in a collaborative to improve outcomes for people with high blood pressure. As the employers examined the costs of care in the community, they recognized two important factors. First, the costs of care for the uninsured, the underinsured, and the Medicare population influence the business community's cost of care. Second, trying to redesign care just for their employees alone was not effective. This project is unique in that the stimulus and funding for community-wide action comes from the business community. They saw beyond the often unsuccessful short-term cost reduction programs and joined with a community-focused organization, the Finger Lakes Health Systems Agency, to construct a multi-year, multi-faceted intervention designed to encourage practice redesign and an invigorated community commitment to partnership and accountability. This report describes the process to date and hopefully will stimulate conversations about mechanisms to encourage similar collaboration within other communities. © 2012 Wiley Periodicals, Inc.

Navigating the legal and ethical foundations of informed consent and confidentiality in integrated primary care.

PubMed

Hudgins, Cathy; Rose, Sandra; Fifield, Peter Y; Arnault, Steve

2013-03-01

This article describes findings from ongoing research and analysis of current literature in addition to discussions with leaders in the field, communications with lawyers and administrators of advocacy and government agencies pertaining to integrated primary care (IPC). Standards of care are established based on a myriad of factors, including professional codes of ethics, case law, state and federal laws, professional standards, existing best practices, current professional guidelines, administrative rules and regulations, and licensing board regulations. Regulations may differ for behavioral health and medical providers, posing challenges in IPC settings. This article provides a review of these regulations, particularly 42CFR Part 2, a federal law governing confidentiality for substance abuse programs, Health Insurance Portability and Accountability Act (HIPAA), and state laws relevant to patient care in IPC settings. On the basis of findings from the study, the authors make recommendations related to patient care practices concerning informed consent and release of information procedures, treatment and warm hand-off protocols, documentation and electronic record keeping, agreements with other providers, and billing. (PsycINFO Database Record (c) 2013 APA, all rights reserved).

Surgical referral coordination from a first-level hospital: a prospective case study from rural Nepal.

PubMed

Fleming, Matthew; King, Caroline; Rajeev, Sindhya; Baruwal, Ashma; Schwarz, Dan; Schwarz, Ryan; Khadka, Nirajan; Pande, Sami; Khanal, Sumesh; Acharya, Bibhav; Benton, Adia; Rogers, Selwyn O; Panizales, Maria; Gyorki, David; McGee, Heather; Shaye, David; Maru, Duncan

2017-09-25

Patients in isolated rural communities typically lack access to surgical care. It is not feasible for most rural first-level hospitals to provide a full suite of surgical specialty services. Comprehensive surgical care thus depends on referral systems. There is minimal literature, however, on the functioning of such systems. We undertook a prospective case study of the referral and care coordination process for cardiac, orthopedic, plastic, gynecologic, and general surgical conditions at a district hospital in rural Nepal from 2012 to 2014. We assessed the referral process using the World Health Organization's Health Systems Framework. We followed the initial 292 patients referred for surgical services in the program. 152 patients (52%) received surgery and four (1%) suffered a complication (three deaths and one patient reported complication). The three most common types of surgery performed were: orthopedics (43%), general (32%), and plastics (10%). The average direct and indirect cost per patient referred, including food, transportation, lodging, medications, diagnostic examinations, treatments, and human resources was US$840, which was over 1.5 times the local district's per capita income. We identified and mapped challenges according to the World Health Organization's Health Systems Framework. Given the requirement of intensive human capital, poor quality control of surgical services, and the overall costs of the program, hospital leadership decided to terminate the referral coordination program and continue to build local surgical capacity. The results of our case study provide some context into the challenges of rural surgical referral systems. The high relative costs to the system and challenges in accountability rendered the program untenable for the implementing organization.

Can Disease Management Target Patients Most Likely to Generate High Costs? The Impact of Comorbidity

PubMed Central

Charlson, Robert E.; Briggs, William; Hollenberg, James

2007-01-01

Context Disease management programs are increasingly used to manage costs of patients with chronic disease. Objective We sought to examine the clinical characteristics and measure the health care expenditures of patients most likely to be targeted by disease management programs. Design Retrospective analysis of prospectively obtained data. Setting A general medicine practice with both faculty and residents at an urban academic medical center. Participants Five thousand eight hundred sixty-one patients enrolled in the practice for at least 1 year. Main Outcomes Annual cost of diseases targeted by disease management. Measurements Patients’ clinical and demographic information were collected from a computer system used to manage patients. Data included diagnostic information, medications, and resource usage over 1 year. We looked at 10 common diseases targeted by disease management programs. Results Unadjusted annual median costs for chronic diseases ranged between $1,100 and $1,500. Congestive heart failure ($1,500), stroke ($1,500), diabetes ($1,500), and cancer ($1,400) were the most expensive. As comorbidity increased, annual adjusted costs increased exponentially. Those with comorbidity scores of 2 or more accounted for 26% of the population but 50% of the overall costs. Conclusions Costs for individual chronic conditions vary within a relatively narrow range. However, the costs for patients with multiple coexisting medical conditions increase rapidly. Reducing health care costs will require focusing on patients with multiple comorbid diseases, not just single diseases. The overwhelming impact of comorbidity on costs raises significant concerns about the potential ability of disease management programs to limit the costs of care. PMID:17372794

The Impact of Child Care Subsidy Use on Child Care Quality

PubMed Central

Ryan, Rebecca M.; Johnson, Anna; Rigby, Elizabeth; Brooks-Gunn, Jeanne

2010-01-01

In 2008, the federal government allotted $7 billion in child care subsidies to low-income families through the state-administered Child Care and Development Fund (CCDF), now the government’s largest child care program (US DHHS, 2008). Although subsidies reduce costs for families and facilitate parental employment, it is unclear how they impact the quality of care families purchase. This study investigates the impact of government subsidization on parents’ selection of child care quality using multivariate regression and propensity score matching approaches to account for differential selection into subsidy receipt and care arrangements. Data were drawn from the Child Care Supplement to the Fragile Families and Child Wellbeing Study (CCS-FFCWS), conducted in 2002 and 2003 in 14 of the 20 FFCWS cities when focal children were 3 years old (N = 456). Our results indicate that families who used subsidies chose higher quality care than comparable mothers who did not use subsidies, but only because subsidy recipients were more likely to use center-based care. Subgroup analyses revealed that families using subsidies purchased higher-quality home-based care but lower-quality center-based care than comparable non-recipients. Findings suggest that child care subsidies may serve as more than a work support for low-income families by enhancing the quality of nonmaternal care children experience but that this effect is largely attributable to recipients’ using formal child care arrangements (versus kith and kin care) more often than non-recipients. PMID:21874092

Heterogeneous impact of the "Seguro Popular" program on the utilization of obstetrical services in Mexico, 2001-2006: a multinomial probit model with a discrete endogenous variable.

PubMed

Sosa-Rubí, Sandra G; Galárraga, Omar; Harris, Jeffrey E

2009-01-01

We evaluated the impact of Seguro Popular (SP), a program introduced in 2001 in Mexico primarily to finance health care for the poor. We focused on the effect of household enrollment in SP on pregnant women's access to obstetrical services, an important outcome measure of both maternal and infant health. We relied upon data from the cross-sectional 2006 National Health and Nutrition Survey (ENSANUT) in Mexico. We analyzed the responses of 3890 women who delivered babies during 2001-2006 and whose households lacked employer-based health care coverage. We formulated a multinomial probit model that distinguished between three mutually exclusive sites for delivering a baby: a health unit specifically accredited by SP; a non-SP-accredited clinic run by the Department of Health (Secretaría de Salud, or SSA); and private obstetrical care. Our model accounted for the endogeneity of the household's binary decision to enroll in the SP program. Women in households that participated in the SP program had a much stronger preference for having a baby in a SP-sponsored unit rather than paying out of pocket for a private delivery. At the same time, participation in SP was associated with a stronger preference for delivering in the private sector rather than at a state-run SSA clinic. On balance, the Seguro Popular program reduced pregnant women's attendance at an SSA clinic much more than it reduced the probability of delivering a baby in the private sector. The quantitative impact of the SP program varied with the woman's education and health, as well as the assets and location (rural vs. urban) of the household. The SP program had a robust, significantly positive impact on access to obstetrical services. Our finding that women enrolled in SP switched from non-SP state-run facilities, rather than from out-of-pocket private services, is important for public policy and requires further exploration.

Toward graduate medical education (GME) accountability: measuring the outcomes of GME institutions.

PubMed

Chen, Candice; Petterson, Stephen; Phillips, Robert L; Mullan, Fitzhugh; Bazemore, Andrew; O'Donnell, Sarah D

2013-09-01

Graduate medical education (GME) plays a key role in the U.S. health care workforce, defining its overall size and specialty distribution and influencing physician practice locations. Medicare provides nearly $10 billion annually to support GME and faces growing policy maker interest in creating accountability measures. The purpose of this study was to develop and test candidate GME outcome measures related to physician workforce. The authors performed a secondary analysis of data from the American Medical Association Physician Masterfile, National Provider Identifier file, Medicare claims, and National Health Service Corps, measuring the number and percentage of graduates from 2006 to 2008 practicing in high-need specialties and underserved areas aggregated by their U.S. GME program. Average overall primary care production rate was 25.2% for the study period, although this is an overestimate because hospitalists could not be excluded. Of 759 sponsoring institutions, 158 produced no primary care graduates, and 184 produced more than 80%. An average of 37.9% of internal medicine residents were retained in primary care, including hospitalists. Mean general surgery retention was 38.4%. Overall, 4.8% of graduates practiced in rural areas; 198 institutions produced no rural physicians, and 283 institutions produced no Federally Qualified Health Center or Rural Health Clinic physicians. GME outcomes are measurable for most institutions and training sites. Specialty and geographic locations vary significantly. These findings can inform educators and policy makers during a period of increased calls to align the GME system with national health needs.

The effect of accountable care organizations on oncology practice.

PubMed

Shulman, Lawrence N

2014-01-01

Cancer care accounts for a significant portion of the rise in health care costs, and therefore, as national efforts escalate to control cost, cancer care will be a focus of concern. Cost increases in cancer care are related to many factors, including increasing cancer incidence in an aging population, the introduction of new high-cost therapeutics, and the high cost of end-of-life care. Accountable care organizations (ACOs) have been one of the major efforts directed at controlling health care costs. How cancer care will fit into the rubric of ACOs is not entirely clear but will certainly evolve over the coming years. The oncology profession has the opportunity to play a role in this evolution or could leave the evolution to others driving the process, such as the Centers for Medicare and Medicaid Services (CMS), private payers, and ACOs. Ideally all parties will work together to provide a construct for high-value, high-quality care for patients with cancer while contributing to cost control in overall health care.

Patient engagement and patient-centred care in the management of advanced chronic kidney disease and chronic kidney failure.

PubMed

Bear, Robert Allan; Stockie, Suzanne

2014-01-01

The purpose of this article is to review the current status of patient-centred care (PCC) and patient engagement (PE) in the management of patients with advanced chronic kidney disease (CKD) and end-stage renal disease (ESRD), to identify some of the barriers that exist to the achievement of PCC and PE, and to describe how these barriers can be overcome. The review is based on the professional experience of one of the authors (RB) as a Nephrologist and health care consultant, on the MBA thesis of one of the authors (SS) and on a review of pertinent internet-based information and published literature. Evidence exists that, currently, the care of patients with advanced CKD and ESRD is not fully patient-centred or fully supportive of PE. A number of barriers exist, including: conflict with other priorities; lack of training and fear of change; the unequal balance of power between patients and providers; physician culture and behaviour; the fee-for-service model of physician compensation; slow implementation of electronic health records; and, fear of accountability. These barriers can be overcome by committed leadership and the development of an information-based implementation plan. Established Renal Agencies in Canada appear interested in facilitating this work by collaborating in the development of a toolkit of recommended educational resources and preferred implementation practices for use by ESRD Programs. A limitation of this review is the absence of a substantial pre-existing literature on this topic. Receiving care that is patient-centred and that promotes PE benefits patients with serious chronic diseases such as advanced CKD and ESRD. Considerable work is required by ESRD Programs to ensure that such care is provided. Canadian Renal Agencies can play an important role by ensuring that ESRD Programs have access to essential educational material and proven implementation approaches and that implementation successes are celebrated. In this area, enabling policies are required, as are clinical research studies focusing on the measurement of outcomes.