Loss of lifetime due to radiation exposure-averaging problems

The transformation of health care in the United States necessitates developing creative strategies to provide quality and cost-effective care for the critically ill obstetric patient population. A discussion of the care of these patients is presented in a multidisciplinary framework, using a case study to illustrate the management process. The significance of contributions and collaboration of advanced practice nurses in perinatology and critical care in the care management of the critically ill obstetric patient is described. Such strategies as location of the patient and educational preparation for nurses caring for these complex patients are offered for consideration. Implications are described and recommendations are made for administrative and clinical practice.     

Ultrastructure of HIV-1 genomic RNA

The traditional acute care health care environment does not meet the needs of chronically ill patients and their families. The classic paternalistic approach encourages dependence on the health care team. This report reviews several innovative types of patient care delivery models, including patient-focused care, family-centered care, cooperative care, and Program Planetree. The core concepts of these various models are described and compared. Related research is presented. A synthesis of these existing models to meet the needs of chronically ill medical patients holistically is proposed. The implementation of the holistic model with chronically ill patients and their families is depicted.     

Managed care as a vehicle for delivering more effective chronic care for older persons

Chronic illness is now the dominant feature of health care, and its impact will grow with the aging of the population. Managed care could provide an environment conducive to better care for chronically ill patients. A precondition for these activities is a shift in Medicare payment approaches to managed care organizations to recognize differences in risk. To improve care for the chronically ill, changes need to occur in two major areas: (1) The approach to chronic care needs to become more aggressive, with higher expectations about the benefits from care (even if measured by slowing the rate of decline), and (2) an information infrastructure is needed to help focus clinicians' attention on changes in patients' status. Some of these changes may eventually evolve spontaneously in managed care's search for more efficient ways of meeting its service obligations, but external forces, such as certification and federal mandates, could catalyze the transition.     

Health maintenance organizations and children with special health needs. A suitable match?

OBJECTIVE: To address how well health maintenance organizations (HMOs) meet the needs of almost 700,000 children with disabilities due to chronic conditions enrolled in these plans. DESIGN: A cross-sectional survey. MEASUREMENTS/MAIN RESULTS: Health maintenance organizations offered better protection than conventional plans against out-of-pocket expenses and were much more likely than fee-for-service plans to cover ancillary therapies, home care, outpatient mental health care, and medical case management. In addition, few HMOs maintained exclusions for preexisting conditions. Other aspects of HMO policies, however, were found to operate against the interest of families with chronically ill children. In particular, HMOs commonly made specialty services available only when significant improvement was expected within a short period. Also, HMOs typically placed limits on the amount and duration of mental health, ancillary services, and certain other services frequently needed by chronically ill children. Probably the most serious problems for chronically ill children enrolled in HMOs were the lack of choice among and access to appropriate specialty providers. PARTICIPANTS: Individual HMO plans. SELECTION PROCEDURE: A sample of 95 geographically representative HMOs were selected; 59 (62%) responded. INTERVENTIONS: None. CONCLUSIONS: Health maintenance organizations offer several advantages over traditional fee-for-service plans for families whose children have special health needs. However, the results also indicate that HMOs do not always operate effectively as service provision systems for these children. To a large extent, the availability and quality of services available to a child with special needs is likely to depend on the parents' ability to maneuver within the system.     

Improving patient outcomes through CQI: vascular access planning

AIM: The aim of the study was to describe and analyse the hospital delivery system for patients recovering from myocardial infarction, applying the offering and value concepts from service management theory. BACKGROUND: In Nordic hospital care patients traditionally played a minor role. But changes have taken place. By means of information giving and systematic education from the staff many chronically ill patients are now taking a significant part in their treatment and care. METHOD: The method was a case study including 12 individual interviews. CONCLUSIONS: The principal conclusion is that the short and intense periods of hospital inpatient stay make it advantageous to consider the patient a member of the health care team taking an active part in the caring process.     

The promise and performance of HMOs in improving outcomes in older adults

In summary, the promise of HMOs in caring for older adults far exceeds their performance to date. Until recently they had neither the motivation nor the knowledge to revamp their delivery systems to better needs of older, chronically ill patients. Market pressures and skyrocketing costs have provided the motivation. Physicians and researchers trained in epidemiology and health services research from programs such as that at UCLA are providing the knowledge. Based on the literature and experience described above, HMOs with the characteristics supportive of population-based care can put into place an approach to geriatric care likely to improve outcomes if they heed their patients and professionals rather than their accountants. These organizations will give highest priority to preserving function and will be guided by explicit clinical guidelines. Care will be rendered by organized primary care teams supported by systematic self-management approaches, standardized interventions for key risk factors, clinically useful computer systems, and available geriatric expertise. It will require a small revolution as old approaches, roles, and relationships will not go quietly. We are in the early phases of this revolution, and it's not too late to join us on the barricades.     

Transgene expression kinetics after transfection with cationic phosphonolipids in hematopoietic non adherent cells

Persons with chronic mental illnesses have a higher prevalence of medical illnesses and higher mortality rates than the general population. Those living in the community are usually linked with mental health services but are expected to manage their own medical care. The ability to manage their health care and the ability of "surrogate families" to assist them were measured among residents and staff of supervised community residences. In its surrogate role, the agency promoted routine health examinations and follow-up care. Its staff was a central resource for the residents, who sought out staff members for assistance with their health problems. However, residents and staff alike lack knowledge about health problems, medications, and approaches to modifying unhealthy lifestyle practices. Although residents identified lack of knowledge about sexually transmitted diseases as a major concern, staff indicated discomfort with this topic. These findings suggest the importance of supporting chronically mentally ill persons and residential staff in managing residents' health care functions.     

When "the family" is not one voice: conflict in caregiving families

Caregiving families rarely have one voice. This article presents a theoretical framework for normative family conflict in chronic care, identifies types of family conflict, and describes educational and case management models to prevent, identify, buffer, or potentially help resolve family care conflicts that pose barriers to care. Successful application of these models can result in greater family member accessibility for support to each other and enhanced family capacity to distribute equitably and effectively care responsibilities for chronically ill relatives especially those with Alzheimer's disease and other dementia.     

Care and care alike

If family and friends were paid for their care of the chronically ill, the U.S. health care tab would take a $194 billion hit--exceeding home health spending. What do they get for giving so much? Harm to their own health.     

User fees: fair cost containment or a tax on the sick?

The federal government's reduction in transfer payments for health and education, in combination with a severe recession, has put provincial and territorial health ministries, health professionals and hospital administrators under immense financial pressure. In response, user fees are being discussed as one way to maintain medicare. Yet, charging levies for health services presents numerous ethical problems. User fees would end the universality of and accessibility to health care for many Canadians. Hence, they would constitute an unfair tax on the sick and the poor. The hardest hit would be the elderly, children, women, aboriginal people, the disabled and the chronically ill.     

Chronic geriatric patient in the hospital

The cost explosion in the health system, especially in the hospital field, and the prolongation of life, i.e. the increase of the proportion of old people in the total population, oblige us to ask the question as to the part of geriatric patients in the present and future hospital treatment. By means of statistically relevant material, i.e. 25,342 female and 20,189 male in-patients in the Municipal Hospitals Nuremberg during the year 1974, compared with investigations of the year 1964, the growing significance of the geriatric patients for the total health system is demonstrated. Particular interest is paid to the old chronically ill persons, as is shown in an estimate of the internal in-patients. 50% of the internal in-patients are chronically ill persons. The present structure of hospitals is by no means complying with this situation. As an improvement, a ward system with different aims instead of the one complex acute hospital is presented. Apart from the existing acute stations there should be provided geriatric rehabilitation wards, social stations and day-hospitals. Humanitarian and financial advantages to be expected of these new wards are outlined. Particular emphasis is given to the active rehabilitation in the sense of a comprising social-medical help.     

Congenital encephalocele of the medial skull base

Intensive case management for severely psychiatrically ill patients is a relatively new phenomenon in the private sector. The authors describe a comprehensive case management program designed at Blue Cross Blue Shield of Massachusetts to meet the needs of the most severely ill psychiatric patients in a private managed care environment. The case management program emphasizes involvement of patients in creating comprehensive treatment plans; development of a relationship between case managers, patients and their families, and providers; and clinical coordination between the public and private sectors to create individualized treatment plans. The program's case managers are able to flex the benefit limitations of a managed care or indemnity plan to integrate public and private services and can enlist providers outside a managed care network. The paper describes service utilization by the first 33 patients who participated in the program for one year.     

Emotionally focused marital intervention for couples with chronically ill children.

Couples with chronically ill children are at risk for experiencing marital distress. The present study was a randomized control trial that assessed the efficacy of emotionally focused therapy (EFT) in decreasing marital distress in this population of couples. Thirty-two couples with chronically ill children seen at a tertiary care pediatric hospital were randomly assigned to EFT or to a waitlist control group. EFT couples demonstrated significant decreases in marital distress at posttreatment and at a 5-month follow-up in comparison to controls. Clinical improvements in marital functioning following EFT were also demonstrated. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Perceptions of acute care physical therapy practice: issues for physical therapist preparation

BACKGROUND AND PURPOSE: Acute care physical therapists have experienced the effects of dramatic changes in health care reimbursement systems and population demographics. Acute care hospitals now serve a patient population of much older, chronically ill patients who are hospitalized for shorter periods of time in a practice environment in which physical therapy staffing resources are often inadequate. The purposes of this study were to document common experiences in the practice of acute care physical therapy and to identify differences in the perceptions of physical therapists with varying levels of experience and in various sizes of acute care facilities. SUBJECTS AND METHODS: A survey questionnaire was mailed to 500 randomly selected physical therapists employed in acute care facilities. The therapists answered questions regarding the frequency of various physical therapy evaluation and treatment practices, problems encountered in delivering physical therapy services, coordination of the discharge planning process, and perceptions of staffing trends in the acute care setting. The responses of 188 physical therapists who completed the survey were compared by their experience levels and the size of the institutions in which they practiced. RESULTS: Subjects reported that patient factors, such as medical complications and cooperation; organizational factors, such as staffing shortages and large caseloads; and health care system constraints, such as difficulty changing orders and limited time in which to work with the patient interfered with patients reaching physical therapy goals. CONCLUSION AND DISCUSSION: Inadequate skills for successful acute care practice and maladaptive therapist beliefs about acute care career possibilities may adversely affect physical therapist career longevity in the acute care setting.     

Tennessee's failed managed care program for mental health and substance abuse services

In July 1996, Tennessee initiated a managed mental health and substance abuse program called TennCare Partners. This publicly funded "carve-out" experiment started chaotically and soon deteriorated into a crisis. Many patients did not receive care or lost continuity of care, and the traditional "safety net" mental health system nearly disintegrated. This qualitative case study sought to ascertain the impact of the TennCare Partners program. It points out that the program's difficulties stemmed directly from a flawed design that spread funds previously earmarked for severely mentally ill patients across the entire Medicaid population. States contemplating similar reforms should strive to protect vulnerable patients by risk-adjusting capitation payments and by focusing resources on care for severely mentally ill persons. States should also minimize program complexity and ensure the accountability of managed care networks for their patients' behavioral health care needs.     

The mental health system and older adults in the 1990s.

Trends in mental health services for older adults during the past decade were used to predict salient issues for the current decade. These include overreliance on inpatient treatment, increased use of general hospitals as treatment sites, inadequate integration with the nursing-home industry, and insufficient mental health referrals from general medical providers. In the decade ahead, the mental health needs of older adults are unlikely to be an identified focus; rather, the issues will overlap with other priorities (e.g., biomedical research on brain functioning, alternative treatment programs for the chronically mentally ill, and containing health care costs). Advocates for the elderly will be successful to the extent that they cast aging services within the context of these other concerns. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

When a child with a chronic condition needs hospitalization

The hospitalization of a chronically ill child requires meticulous orchestration. Treatment recommendations must be transmitted to the family in a coherent and supportive fashion. Patient comfort and nutrition must be maintained, and psychological support provided. Discharge planning is often extensive. To promote continuity of care, appointment of a case manager is recommended.     

Chronically ill children coping with repeated hospitalizations: their perceptions and suggested interventions

This qualitative research study used grounded theory methodology to learn from chronically ill children who are repeatedly hospitalized how they cope and how they feel others can assist them to cope with their recurrent hospital experiences. Six hospitalized children, ages 10 to 13 years, with various chronic conditions participated in an audiotaped interview, completed a drawing and kept a journal. The subjects identified their perceived stressors of hospitalization; revealed their use of both cognitive and behavioral coping strategies; described how hospital personnel, family, and friends enhanced their coping; and illustrated the impact of the hospital environment on their coping process. From comparison of the data, it is theorized that chronically ill children who are repeatedly hospitalized become adept at identifying and implementing a repertoire of coping strategies, accessing family and friends as resources in the coping process, developing patterns of coping with their parents, and utilizing the hospital environment to promote coping. Their coping is enhanced by familiarity and knowledge and by the respect and patience of gentle, supportive, and competent health care professionals.     

Collaborative practice in pharmacy: Substance or semantics?

Medication use has become increasingly complex with expanding numbers of medications and growing populations of chronically ill patients. Changes in state and federal law and regulation have attempted to keep pace with the need for health care practitioners to oversee safe and effective medication use in various patient populations, including recent changes in Medicare. Pharmacists have experienced significant advancement in their education as well as in the roles they play in acute and chronic health care delivery. Over 44 states now recognize pharmacists' collaborative practice authority that allows for the initiation, monitoring, and modification of medication therapy for patients, typically under protocol. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Deinstitutionalization and women: Assessing the consequences of public policy.

Reviews and analyzes the literature concerning deinstitutionalization and women and highlights specific ways in which a major public policy initiative has affected the lives of both chronically mentally ill women and women who have been charged with the responsibility of caring for the chronically mentally ill. Special effects of deinstitutionalization on mentally ill women are evident in such areas as sexual exploitation and violence, homelessness, diversion into the criminal justice system, and stigmatization. A group of studies points to special circumstances pertaining to sexual behavior and reproductive control in a deinstitutionalized female population. It is suggested that the expectations of women's behavior based on societal role definitions have affected service planning for this population and that the use of such criteria for program planning runs the risk of injuring patients of both sexes. The need for more conceptual work and research on deinstitutionalization is stressed; however, because deinstitutionalization is an exceedingly complex phenomenon, the importance of remaining sensitive to the wide variety of circumstances that contribute to its outcomes is emphasized. (72 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)