Incorporating a community-oriented approach in primary care

The health care system in the United States depends on primary care services. Yet the limitations imposed by traditional approaches in primary care have resulted in an unrealized potential for primary care. Currently, we rely on the motivation and initiative of persons to acquire the health care services they need, and health care providers have attempted to meet these needs. Community-oriented primary care provides an opportunity for primary care physicians to expand their range of services and their ability to reach out to people. Incorporating community-oriented primary care into primary health care has the potential to make a major contribution in reshaping health care in the United States.     

Care-seeking patterns of inner-city families using an emergency room. A three-decade comparison

OBJECTIVES: Since World War II, the urban hospital emergency room has been a major source of medical care for inner-city poor families, many of whom receive Medicaid. Given the expensive and episodic nature of emergency room care, there has been renewed interest in enrolling Medicaid recipients into managed care plans to increase access to care and to reduce medical costs. Thus, the primary care physician, in many managed care plans, is expected to give prior approval for emergency room care in nonurgent situations. The goals of managed care may create tension between its requirements and historical patterns of inner-city families seeking care in an emergency room. In 1964, Alpert developed a typology that categorized inner-city families' patterns of seeking medical care in a pediatric emergency department (PED) by describing the relation between regular source of medical care and reliance on this source before the PED visit. In 1976, using the same typology, Alpert and Scherzer updated care-seeking patterns in Boston after the introduction of neighborhood health centers (NHCs) and Medicaid. In 1993, the typology is a method that can be used to assess the impact of managed care on PED utilization by inner-city families. This article compares the 1993 pattern of seeking PED care with that measured in 1964 and 1976. METHODS: In 1964, 1976, and 1993 families were interviewed as they sought care in a PED. Families were asked if they had a regular source of care, defined as the place where families take their child most often for either well or sick visits. A judgment was made as to whether or not the PED visit was coordinated with their regular source of care. Coordinated care was defined as having a regular source of care and attempting to contact the source before the PED visit. Uncoordinated care occurred when the family had a regular source and did not attempt contact, or had no regular source. RESULTS: In 1964, 63% of families reported a regular source of care compared with 89% in 1976 and 95% in 1993. The hospital was reported as the regular source of care by 57% of the respondents in 1964, by 31% in 1976, and 43% in 1993. Community-based sources (physicians and NHCs) were identified as a regular source of care by 43% in 1964, 69% in 1976, and 57% in 1993. In 1964, 55% of the families engaged in an uncoordinated pattern of seeking care compared with 64% in 1976 and 72% in 1993. CONCLUSIONS: Efforts to provide access to care through Medicaid, NHCs, and hospital-based primary care resulted in a greater percentage of families reporting a regular source of care; however, a majority of families continue to exhibit an uncoordinated pattern of seeking care. More families in 1993 did not contact their regular source before seeking care in the PED when compared with 1964 and 1976. For managed care plans to increase access and reduce costs, a shift in PED utilization patterns remains necessary. The primary care system must have the capacity to accommodate these changes and considerable patient education must occur if urgent care is to be provided outside the PED.     

Intermediate care, possibilities, requirements and solutions

The inadequate supply of intensive care facilities has focused interest on intermediate care as a means of bridging the gulf between the level of support available in the intensive care unit and the general ward. However, few hospitals have developed intermediate care, in the form of high-dependency care units, and little information exists concerning the use or potential of such areas. Therefore, this review proposes to cover the definition of intermediate care and to discuss some of the possible reasons why intermediate care is now believed necessary. The capabilities of intermediate care for selected groups of patients and the treatment modalities offered are described. The present provision of high-dependency care in the United Kingdom is discussed and the methods for estimating the required size of a high-dependency unit are outlined. The impact of a high-dependency unit on the workload of the intensive care unit and the potential cost saving of managing such patients in an intermediate care area are illustrated.     

Appropriateness in health care delivery: definitions, measurement and policy implications

A major focus of the current health care debate is the notion that a substantial proportion of the health care delivered in Canada is inappropriate. There are two types of appropriateness: appropriateness of a service and appropriateness of the setting in which care is provided (i.e., inpatient v. outpatient or home care). Measuring both types objectively requires the comparison of observed patterns of care with explicit criteria for appropriate care. The few studies of appropriateness conducted in Canada have shown that inappropriate services are provided and inappropriate settings are used. Reducing inappropriate health care delivery could involve active strategies for the implementation of guidelines and better cooperation and coordination within the health care system. However, lower rates of health care delivery or even inappropriate health care will not necessarily translate into higher quality care or lower costs overall.     

Potentials and limitations of the natural antioxidants RRR-alpha-tocopherol, L-ascorbic acid and beta-carotene in cutaneous photoprotection

In Germany the majority of people in need of nursing care are attended to at home. This is also promoted by the German nursing care insurance. Considering the increasing number of people in need of care more (people who care for them) are required. The article describes the readiness to care of a representative sample of 4806 people who are actually not involved in nursing care activities. The results show that the readiness to give nursing care is highly dependant on the care recipient. Independant from age, sex or social class, there is an strong readiness concerning care of the partner. Regarding other relatives (children, parents) or non-related persons like friends or neighbours, women show greater readiness than men to take over nursing care activities. Age and social class provoke differences, but not in such a homogenious way. All in all the readiness to provide nursing care is surprisingly high; it is to be hoped that it leads to realisation, in case of need.     

Reperfusion injury delays healing of intestinal anastomosis in a rat

This SAEM position paper clarifies the role of emergency medicine in health care delivery. It builds upon the working definition of emergency medicine developed by the American College of Emergency Physicians in 1994 by describing the health care role of emergency physicians (EPs). EPs are first-contact providers who care for all patients regardless of age, gender, time of presentation, or ability to pay. They remain the only continuously accessible specialty for patients seeking help and solace in the health care system. They are an essential link in the health care continuum between primary care physicians, specialists, the out-of-hospital system, the patient, inpatient services, and communication services. The EP's role is in organizing and monitoring the emergency care delivery system. Part of this role is to better align the health care provider training and ability with the specific medical needs of a patient. The emergency health care system remains the essential medical safety net for all individuals needing care in this country.     

Psychology can be indispensable to health care reform and the patient-centered medical home.

The Patient Protection and Affordable Care Act (PPACA) was passed into legislation in March 2010, making health care reform a reality. Perhaps the most well-developed model of primary care that aligns with the PPACA's agenda is the patient-centered medical home (PCMH). Integrated care, as defined by collaborative care between mental health and primary care providers and systems, will undoubtedly play a critical role in the success of the PCMH. The role of psychology and integrated care in the PCMH as well as training implications for psychologists are discussed. This article is intended to challenge our discipline to embrace psychology as a health care profession that must prepare for and solidify its added value in the health care delivery models of the future. Requisite skill sets for primary care psychologists and existing training opportunities are presented. Finally, possible mechanisms for training psychologists in integrated care and the professional roles primary care psychologists can expect to fill are proposed. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

The 1996 Helene Hudson Memorial Lecture. Work redesign and re-engineering: a challenge for professional nursing practice

Work redesign and re-engineering have become the buzzwords of the 1990s as all sectors of the health care arena struggle to meet the demands of patient care while coping with increasing fiscal constraint. Redesign and re-engineering are terms that describe a wide range of strategies in health care and radically different models of care delivery. These new approaches to care are shifting the way we view care delivery and how it is structured. This paper describes the principles of redesign and re-engineering, common applications in health care organizations, outcomes and evaluation. Multiskilling and use of genetic health care workers are addressed. The potential impact on the practice of oncology nurses is explored as well as strategies to meet the challenges of today's health care environment.     

Does hospital-at-home make economic sense? Early discharge versus standard care for orthopaedic patients

Hospital-at-home has been promoted as a potentially effective means of replacing costly inpatient care with cheaper domiciliary care. We studied three hospital-at-home schemes in West London providing intensive home care for early discharge orthopaedic patients, comparing their costs with those of standard inpatient care. Although costs per day of hospital-at-home care were lower than those of inpatient care, the schemes appeared to increase the total duration of orthopaedic episodes, so that the costs of standard care, per episode, were lower than those of hospital-at-home. While hospital-at-home may offer considerable future potential, substitution of home care for inpatient care will not necessarily save resources.     

Comparison of long-term care in an acute care institution and in a long-term care institution

BACKGROUND: Acute care hospitals in Quebec are required to reserve 10% of their beds for patients receiving long-term care while awaiting transfer to a long-term care facility. It is widely believed that this is inefficient because it is more costly to provide long-term care in an acute care hospital than in one dedicated to long-term care. The purpose of this study was to compare the quality and cost of long-term care in an acute care hospital and in a long-term care facility. METHODS: A concurrent cross-sectional study was conducted of 101 patients at the acute care hospital and 102 patients at the long-term care hospital. The 2 groups were closely matched in terms of age, sex, nursing care requirements and major diagnoses. Several indicators were used to assess the quality of care: the number of medical specialist consultations, drugs, biochemical tests and radiographic examinations; the number of adverse events (reportable incidents, nosocomial infections and pressure ulcers); and anthropometric and biochemical indicators of nutritional status. Costs were determined for nursing personnel, drugs and biochemical tests. A longitudinal study was conducted of 45 patients who had been receiving long-term care at the acute care hospital for at least 5 months and were then transferred to the long-term care facility where they remained for at least 6 months. For each patient, the number of adverse events, the number of medical specialist consultations and the changes in activities of daily living status were assessed at the 2 institutions. RESULTS: In the concurrent study, no differences in the number of adverse events were observed; however, patients at the acute care hospital received more drugs (5.9 v. 4.7 for each patient, p < 0.01) and underwent more tests (299 v. 79 laboratory units/year for each patient, p < 0.001) and radiographic examinations (64 v. 46 per 1000 patient-weeks, p < 0.05). At both institutions, 36% of the patients showed anthropometric and biochemical evidence of protein-calorie undernutrition; 28% at the acute care hospital and 27% at the long-term care hospital had low serum iron and low transferrin saturation, compatible with iron deficiency. The longitudinal study showed that there were more consultations (61 v. 37 per 1000 patient-weeks, p < 0.02) and fewer pressure ulcers (18 v. 34 per 1000 patient-weeks, p < 0.05) at the acute care hospital than at the long-term care facility; other measures did not differ. The cost per patient-year was $7580 higher at the acute care hospital, attributable to the higher cost of drugs ($42), the greater use of laboratory tests ($189) and, primarily, the higher cost of nursing ($7349). For patients requiring 3.00 nursing hours/day, the acute care hospital provided more hours than the long-term care facility (3.59 v. 3.03 hours), with a higher percentage of hours from professional nurses rather than auxiliary nurses or nursing aides (62% v. 28%). The nurse staffing pattern at the acute care hospital was characteristic of university-affiliated acute care hospitals. INTERPRETATION: The long-term care provided in the acute care hospital involved a more interventionist medical approach and greater use of professional nurses (at a significantly higher cost) but without any overall difference in the quality of care.     

Primary care within the VA: the firm model

Many of the VA medical centers are reorganizing total care across a continuum that includes outpatient, inpatient, long-term, and home based care, into interdisciplinary firms. The goals of reorganization are to improve patient access to care and continuity of care, to improve housestaff education by assigning a specific panel of patients for the residents to follow longitudinally in a variety of situations supervised by the same mentors, and to enhance research in primary care issues. Preliminary results show increased patient satisfaction and improvements in both quality of care and increased efficiency in its delivery. Many large health care organizations might be expected to reorganize care delivery around a similar interdisciplinary team concept.     

Continuity of care and delivery of ambulatory services to children in community health clinics

This study assesses how continuity of care influences receipt of preventive care and overall levels of ambulatory care among children and adolescents in community health clinics (CHCs). It is a secondary data analysis of the 1988 Child Health Supplement to the National Health Interview Survey. Of 17,110 children in the sample population, the 1465 who identified CHCs as their routine source of care formed the study population. Continuity of site was defined as identification of a CHC as a source of both routine and sick care, and continuity with a clinician was defined as identification of a specific clinician for sick visits. In bivariate analyses both continuity with the CHC and with a specific clinician were associated with increased levels of preventive care and overall ambulatory care. In logistic regression models, continuity of care was associated with nearly a two-fold increase in the odds of receiving age-appropriate preventive care. Alternatively, insurance status was a better predictor of receipt of overall levels of ambulatory care. We conclude that expanding financial access alone is unlikely to sufficiently improve low-income children's access to Community Health Clinics. Additional emphasis on localizing the delivery of both routine and sick care services in a single site or with a specific clinician may be needed to achieve higher levels of both preventive care and overall ambulatory care.     

Update on Alzheimer''s disease

The nation's health care system is undergoing a period of rapid change that will profoundly affect women's health care services and, ultimately, women's health. Although managed care is quickly becoming the predominant mode of health care delivery in the United States, a new, more consumer-focused, and accountable model known as organized systems of care (OSC) is emerging. OSC development has been driven by large private and public employers seeking to purchase the highest quality health care for the best price. The changes in health care delivery encouraged by these innovative employers will provide women with optimal care and attention, which will in turn help them attract and retain a competitive and productive workforce.     

Continuity of care: a challenge for ambulatory oncology nursing

Continuity of care has many facets and challenges both as a philosophy and in practice. In an abstract sense, it represents an ideal to which health care professionals strive. It is becoming a professional and consumer expectation that each health care professional contribute to continuity of care. Although a variety of organizational models for providing continuity of care have been established in which nursing plays a prominent role, recent research suggests that some frontline nursing personnel may not fully understand their responsibility to continuity of care. There is a need for nursing curricula in both basic and continuing education programs to address continuity of care concepts, models, and methodologies to strengthen awareness of patient care needs across the disease continuum and across care settings. Performance expectations that include professional accountability for continuity of care also encourage greater attention to this issue.     

Reaction of different cell populations in mouse thymus to a single gamma-irradiation

Acute care facilities are no longer viewed as the center of the health care network. Efforts to reduce hospital length of stay will continue to spur the growth of care delivered in homes. With the downsizing of many hospitals, the need for nurses in acute care settings will decline. Many acute care nurses are finding themselves seeking employment opportunities in home health care settings. The purpose of this study was to examine nurses' experiences when they change from hospital-based practice to home health care nursing. The qualitative mode of inquiry was used to conduct taped-recorded interviews of 25 baccalaureate-prepared nurses in a large metropolitan area. Stressors experienced by the nurses were identified as well as adaptations required to minimize role stress. Continuing education programs can provide information and skills needed to improve nurses' competencies to function in a health care system projected to be more community-based, which includes home health care.     

The nursing home comprehensive eye examination

BACKGROUND: There is significant need for optometric care in long-term care facilities which can be expected to increase in the next decade. METHODS: The previous ophthalmic and medical literature was reviewed and the practical aspects of providing eye care in a nursing home were analyzed. RESULTS: Comprehensive nursing home care requires the integration of portable ophthalmic equipment, a modification of standard testing procedures, clear and concise documentation, and close communication with other health care providers on the nursing home clinical staff. CONCLUSION: Optometrists must consider the incorporation of nursing home care into their clinical practice, while recognizing the unique aspects of providing eye care within a long-term care facility.     

Long-term care insurance and alternatives: a comparison of employer and individual policy markets

This article presents findings from a recently completed Health Insurance Association of America-sponsored survey that sought to measure the extent to which long-term care insurers paid for newer, long-term care alternatives. The focus of the survey was on payment for three services: adult day care, board and care homes, and assisted living facilities. The survey also collected information on companies offering reimbursement for these services under an alternate care benefit (i.e., a plan of nonconventional care and services that can serve as an alternative to more costly inpatient nursing home care). Survey data showed that long-term care insurance sold in employer markets reimburses a richer set of alternative long-term care benefits than policies sold in individual markets. In addition, the majority of employer market companies reimburse for alternatives under their base policy, recognizing the importance of payment for noninstitutional, long-term care alternatives.     

Measurement of efficiency and quality of work in hospitals and ambulatory facilities

Facing high-cost health care and slow rate of economic growth, great attention must be paid to efficiency and quality of care in hospitals and ambulatory care facilities. This is a problem particularly in developing countries where extreme sums of money are spent on developing hospital capacities, whereas primary health care facilities are insufficient causing significant social differences among health care beneficiaries. At the same time, there exists a certain discontent because principles of equality, efficacy, efficiency and quality of health care including satisfaction of patients obtaining health care, are not pointed out in providing health care. Up to recent times it has been very hard to evaluate both qualitative and quantitative efficiency and quality of work in health care institutions, but today it is possible because the World Health Organization created indicators for this kind of evaluation.