Delivering at the right price--the costs of primary maternity care at the Diepkloof Community Health Centre, Soweto

This paper reports on a study of the costs of primary maternity care services at the Diepkloof Community Health Centre (DK) in Soweto. DK, the Soweto community health centre system as a whole and numerous other non-hospital settings provide a wide range of maternal health services to substantial numbers of women, and relieve hospitals of a major potential clinical burden. However, no research has been done in South Africa on the relative costs of the provision of these services in different settings and by different types of health worker. The cost structure of these services at DK is presented and the costs of antenatal care, deliveries in midwife-run labour wards, postnatal care (at the health centre and at home) and family planning services detailed. Some comparisons are made with existing data for another community health centre and with Baragwanath Hospital. These results are relevant to policy and planning of maternal health services. They are also shown to be of relevance to management and several areas of potential improvement of these services are noted.     

Community-based care in cystic fibrosis: role of the cystic fibrosis nurse specialist and implications for patients and families

Improved survival for cystic fibrosis has rapidly increased over the past four decades, with patients now living well into adult life. With changes in the structure of the National Health Service and the formation of provider units and general practitioner (GP) fund-holding practices, it is important to strengthen links between the hospital and community teams to ensure that the CF patient receives adequate care. Increasingly, treatment is being carried out at home, and this emphasis on home-based therapy demands that parents/carers and patients must acquire the skills and knowledge of complex therapies in order to optimize health. It is the role of the CF nurse specialist (NS) to educate those who will deliver the care, co-ordinate the provision of services at home, liaise with the CF team and community health-care professionals and to support the patient and their carers.     

A population-based survey of obstetric practices among rural women in the Bizana district, Transkei

OBJECTIVE: To determine for the Bizana district, Transkei, the proportion of deliveries that occur at home, home delivery practices, the proportion of women with high-risk pregnancies delivered at home, attendance for antenatal care at the health services and at traditional healers, and the reasons why mothers choose to deliver at home or in the health services. DESIGN: Questionnaire survey. SETTING: Rural community, South Africa. PARTICIPANTS: Two hundred women from randomly selected clusters, obtained from a multistage random sampling process. MAIN OUTCOME MEASURES: Place of delivery, home delivery practices and antenatal care for the most recent delivery (within the previous 5 years). RESULTS: Two-thirds had delivered at home and one-third within the health services. Of those who delivered at home, 62 (47%) were alone at the time of delivery while the remainder were assisted by a close relative or neighbour; 38% had one or more risk factors for obstetric complications. Ninety-seven per cent attended at least once for antenatal care. Home delivery practices and reasons for place of delivery are described. CONCLUSIONS: Antenatal care should include education about the home management of a normal childbirth. Waiting areas for mothers should be established at hospital level for high-risk pregnant mothers.     

Health situation of refugee children in Münster

The unique opportunities of databased community health promotion in cooperation with local community health authorities are pointed out. Especially within the local refugee population many organisational and psychological obstacles to otherwise widely distributed health services are obvious. Population-focused community health practice involves home health care with interdisciplinary collaboration, and promotes clients's responsibility and self-care. Health promotion depends on communal health reporting focused on specific needs of subpopulations. Health and population data concerning the refugees in Muenster show a considerably higher proportion of children than among the general population of the town, thus indicating special needs for the paediatric care of this group. Communal data concerning health-relevant indicators such as vaccination rates or routine paediatric checkup coverage illustrate the necessity for improving low levels of health care for the communal refugee population. The concept of transcultural community health nursing with vice versa information about health traditions and practices improves health services and care for the refugee population and the health-related communal culture in general.     

How access to long-term care affects home health transfers

This study examines the determinants of home health use after hospitalization for acute illness for eleven diagnosis-related groups (DRGs) in 1985, drawing on data from four primary sources: Medicare hospital bills, Medicare home health bills, the Medicare and Medicaid Automated Certification System files, and the American Hospital Association Survey. Separate Tobit models are estimated for each DRG. The analysis shows that transfers to home health care are heavily influenced by the hospital's long-term care arrangement and by conditions in local nursing home and home health care markets. Especially important is whether a hospital has its own long-term care unit, swing beds, or both, and whether nursing home beds are available in the local area. Patients discharged from hospitals are more likely to use home health care in areas with a low supply of nursing home beds and low Medicaid reimbursement levels for skilled nursing facilities. The results of this study have implications for proposals to extend Medicare's Prospective Payment System for hospital services to include postacute care. Proponents of a "bundled payment" that encompasses both acute and postacute services argue that the current system leads to inefficiencies and inequities. This analysis points to systematic relationships between home health and nursing home services, which should be factored into the development of a bundled payment policy.     

Recent growth of Medicare home health

Medicare spending for home health services has grown at an unprecedented rate since regulations were revised in 1989. To address the implications of this striking growth, it is necessary to examine the causes. This paper finds that the most important source of growth has been in the number of home health visits received per beneficiary, not in the number of beneficiaries that have been added in response to redefined eligibility criteria. Policymakers should clarify the objectives of the Medicare home health benefit, in light of increased attention to long-term care financing and expanded services for older Americans.     

Characterizations of elderly recipient of home-care and their caregivers. A questionnaire survey of elderly members of a health insurance union

The characteristics of elderly being cared for at home and their caregivers were analyzed based on a questionnaire about health and care for the elderly. We also assessed the problems of home care in view of activities of daily living (ADL) of the home-care recipient. Subjects were members of a health insurance union or their families and ages were more than 65 years old. Results were as follows; 1. The total number of released questionnaires was 5,472, of which responses totally 2,567 (46.9%) were received. Frequencies of the elderly at home without care, at home with care, and in hospitals or nursing home were 86.3%, 9.6% and 4.1%, respectively. 2. We categorized the home care recipient according to their ADL and analyzed their status. The frequency of using health care equipment for home care was significantly higher in the low ADL groups than in the high ADL groups. Caregivers in low ADL groups felt much more care burden than those in high ADL groups. 3. There was a tendency for differences in the use of community welfare services such as visiting nurses or short-stay between the home care recipient with dementia (group D) and the bedfast home care recipient (group C). Approximately 30% of caregivers in group D wanted to transfer the care of the elderly to hospitals or nursing home. 4. In Tokyo and nearby prefectures, there was a highly frequency that main caregivers were recipients' children. In the rural prefecture it was more frequent that the main caregiver was recipients' wife or husband only.     

Use of maternity services by pregnant women in a small Nigerian community

Pregnancy is a time when women's health is placed at risk by a host of factors; however, professionals providing antenatal care can reduce that risk by monitoring women's health regularly and offering preventive services. Hygienic delivery services by a qualified attendant also help to reduce risks associated with childbearing. We explored these considerations in a rural Nigerian town by following 60 Yoruba women through pregnancy to childbirth. Although a functioning government maternity center in the community offered a full range of antenatal and delivery services, most of the women did not register for antenatal care until their sixth month of pregnancy or later, and 65% delivered at home. This behavior is explained in terms of (a) fees for delivery services, (b) level of income, (c) cultural beliefs, and (d) education. We conclude that provision of relatively accessible services does not guarantee their use and that other social and cultural considerations must be taken into account.     

In vitro metabolism of cyanohydroxybutene: formation of a glutathione-S-transferase catalyzed product

This paper examines the financing of elderly health care in Japan for medical institutions, nursing homes, and at home. The analysis demonstrates that the conventional figures for elderly health expenditures in Japan systematically underestimate the real costs by excluding the costs of uninsured services, nursing homes, and home health care. The paper estimates these costs and shows that they add about 10% to the conventional figure for elderly health care costs in Japan. This inquiry also shows how government policy for health care financing shaped distinctive Japanese patterns of elderly care provision. The financing system provided a hidden subsidy--through national health insurance coverage of long-term hospitalization--that encouraged high institutionalization rates of elderly in medical facilities. Public financing for long-term elderly hospitalization, however, has not been matched by government attention to quality of care, resulting in serious quality problems and reflecting a social trade-off between cost and quality. Also, until recently the financing system rarely reimbursed home health care, thereby creating strong disincentives to the development of formal home health care services. This analysis has important implications for reforms now being considered by the Japanese government in the financing and provision of health care for the elderly, especially the limitations of relying on reimbursement price policy. The reforms could have unintended negative consequences for equity, efficiency, and quality of care.     

Physical therapy management for the patient with HIV. Lower extremity challenges

Disability assessment and rehabilitation intervention have implications for specific stages of HIV disease, with the intention of maximizing overall function and decreasing the burden of care. The AIDS epidemic has challenged communities to develop and to mobilize care networks for persons infected with HIV. A major part of that mobilization has been a push toward community and home-based services. Reliable and valid functional assessment data are necessary to evaluate HIV-related disability changes over time for patients in the hospital and at home. Epidemiologic data also hold implications for rehabilitation healthcare workers in terms of expertise in HIV-specific areas and on the staffing level. Access to rehabilitation services will need to be considered by public policymakers and financial concerns will need to be explored. Because individuals with HIV and AIDS are living longer and with greater levels of health, the chronicity of the disease warrants community support and long-term care. Various functional and quality-of-life measures can assist in the development of resources and medical interventions. As survival increases, rehabilitation professionals can anticipate more referrals for the assessment and management of physical disability in persons with HIV infection. A critical task for health service research is to ensure that HIV healthcare settings deliver optimum services at reasonable costs. Optimal care requires maximizing autonomous functioning and reducing periods of disability and dependence.     

Domiciliary terminal care: demands on statutory services

The work of a specialist advisory home care service for the terminally ill during 1980 is reported, with reference to the demands it made on community services. Whilst there was no change in demand for home helps, there was a 44 per cent increase in visiting by community nurses for male patients and a 117 per cent increase for female patients. Commodes, ripple mattresses and backrests were all essential and an increased need of over 100 per cent in each was recorded. Patients were attended on average for three months (men) and six months (women) and 41 per cent were able to remain at home until their death.     

Randomised trial of impact of model of integrated care and case management for older people living in the community

OBJECTIVE: To evaluate the impact of a programme of integrated social and medical care among frail elderly people living in the community. DESIGN: Randomised study with 1 year follow up. SETTING: Town in northern Italy (Rovereto). SUBJECTS: 200 older people already receiving conventional community care services. INTERVENTION: Random allocation to an intervention group receiving integrated social and medical care and case management or to a control group receiving conventional care. MAIN OUTCOME MEASURES: Admission to an institution, use and costs of health services, variations in functional status. RESULTS: Survival analysis showed that admission to hospital or nursing home in the intervention group occurred later and was less common than in controls (hazard ratio 0.69; 95% confidence interval 0.53 to 0.91). Health services were used to the same extent, but control subjects received more frequent home visits by general practitioners. In the intervention group the estimated financial savings were in the order of 1125 ($1800) per year of follow up. The intervention group had improved physical function (activities of daily living score improved by 5.1% v 13.0% loss in controls; P<0.001). Decline of cognitive status (measured by the short portable mental status questionnaire) was also reduced (3.8% v 9.4%; P<0.05). CONCLUSION: Integrated social and medical care with case management programmes may provide a cost effective approach to reduce admission to institutions and functional decline in older people living in the community.     

Metabolical changes induced by adaptation to circumpolar conditions in Spitsbergen

The Home Hospitalization Programme was initiated in Jerusalem in 1991 to provide intensive medical care at home in order to prevent or shorten hospitalizations. The programme was based upon regular home visits by physicians, and nursing assessment to determine the need for regular nursing care. Primary-care physicians and nurses were renumerated by a global monthly fee, and were on 24-h call in addition to their periodic visits. Patients were recruited by senior geriatric physicians from acute hospital wards, as well as from the community, at the family doctor's request. Ancillary services available to the home hospitalization team included laboratory and electrocardiographic testing, specialty consultations, physical occupational or speech therapy, social work and home help up to 3 h daily. Monthly visits by a senior physician provided oversight and further consultation. Home hospitalization grew out of the continuing care division of the Clalit Sick Fund, a health maintenance organization providing umbrella medical insurance and ambulatory care. The programme grew synergistically with the other facilities of continuing care to encompass a network of comprehensive services to acute, subacute and chronic patients both at home and in institutional settings. In 4 years this network succeeded in establishing the focus of subacute intensive care in the community, achieving high levels of patient and family satisfaction, as well as striking economic advantages. In its first 2 years of operation home hospitalization saved S4 million due to reduced hospital utilization, and preliminary data for the subsequent 2 years indicated that this trend continued. Home hospitalization became the hub of a far-reaching system of supportive, intensive and humane care in the community.     

Using community outreach to promote integrated health care: A pilot project.

Although research has demonstrated the efficacy of psychological services for ameliorating physical conditions, consumers are often uninformed of the advantages of integrated health care. To begin to address this knowledge gap, the authors developed, offered, and assessed a 2-hr community outreach program, which included lectures highlighting the benefits of providing psychological services within general health care, a demonstration of stress-reduction techniques, and first-person accounts of the benefits of psychological health care. The preliminary results of the evaluation were positive. It is recommended that similar programs be disseminated in diverse communities. Suggestions for planning and conducting these types of programs are offered. Furthermore, strategies for improving the goals and content of workshops are offered, with a focus on the distinction between promotion of attitudinal change versus practical activism. Finally, implications for community outreach that is intended to inform the public of the value of psychological health care services are discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Emergency department-based home care

STUDY OBJECTIVE: To assess the feasibility of coordinating home care services from an inner-city emergency department. INTERVENTION: In a preintervention survey, the home care needs of 650 consecutive patients being discharged from the ED were evaluated. A nurse-coordinator who arranged and managed rapidly deployed home care services then was assigned to the ED for eight months. Patients were referred, and home care services were provided regardless of insurance status. SETTING: Teaching hospital serving a large indigent population. PARTICIPANTS: Adult patients about to be discharged home from the ED. MAIN RESULTS: Forty-five of 650 (7%) surveyed patients were not receiving home care services for which they were eligible. In the subsequent eight-month period, 670 patients were referred for home care on discharge from the ED (2% of all discharges). Seventy-six percent of these patients were women, and the average age was 73.5 years. Four hundred fifty patients (67%) received visits from home care providers managed by the ED coordinator. For 99 of these patients (22%), the availability of rapidly deployed home care services obviated the need for emergency admission to the hospital. Net billings to third-party payers exceeded the costs of the program. CONCLUSION: A significant proportion of elderly patients being discharged from the ED need home health services. Access to rapidly deployed home care services can obviate the need for hospital admission for a select group of debilitated patients. The provision of home care services from the ED is economically feasible.     

Said another way. Is the ADN graduate prepared to practice in community settings?

The downsizing and closing of acute care facilities and the movement to community-based healthcare services are decreasing the need for RNs in acute care facilities. In the past, the associate-degree nurse (ADN) has filled the majority of positions in acute care. With the trend to provide health services in community setting, will the ADN be prepared for positions in community facilities? ADN educators must reevaluate how they are educating students for practice. The author reviews the 1995 recommendations from the Pew Health Professions Commission and relevant current directives from the National League for Nursing.     

Developing AIDS care in Zimbabwe: a case for residential community centres?

New support services are needed as the AIDS epidemic escalates. Home care has been the cornerstone of new developments in Zimbabwe and the southern African region, essentially resource-strapped countries. However, while home care has many benefits, levels of coverage are often low and many patients at some phase of their disease need more than their home can provide, even with access to support services. Hospital admission is often not a viable option and the need may arise for some form of respite or hospice community centre to provide residential care. This option is debated and potential benefits and pitfalls are explored.     

Development of use and cost measures in a nursing intervention for family caregivers and frail elderly patients

The purpose of this pilot study was to refine and evaluate methods of measuring costs of an innovative home-health nursing intervention designed to support frail, older persons and their family caregivers. We evaluated a multifaceted strategy to collect a detailed utilization profile from 22 caregiver/care receiver dyads for hospital, ambulatory, home health, nursing home, and community services. The strategy was feasible for most participants, maximized accuracy of cost data, and minimized research burden on study participants. Lower overall costs were found in the intervention group, but the difference was not significant. Approaches to the measurement of costs in this study can serve as models for evaluating other innovations in nursing, home care, and long-term care.     

Integrating mental health services within primary care. A Canadian program

The increasingly prominent role of the family physician in delivering mental health care can be enhanced if productive and collaborative relationships can be established with local mental health services. This paper describes a Canadian program that has achieved this by bringing mental health counselors and psychiatrists into the offices of 87 family physicians in 35 practices in a community in Southern Ontario. The paper describes the program, the activities of counselors and psychiatrists within the practices, and the administrative structures set up to coordinate these activities. Data is presented from the evaluation of the first year of the program's operation (13 practices and 45 family physicians) during which time 3085 referrals were received. The program made mental health care more available and accessible, increased continuity of care, provided additional support for the family physician, offered new opportunities for continuing education, and led to a reduced and more efficient use of other mental health services. The components of the program can be adapted to most communities.