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.     

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.     

Barriers to effective palliative care of terminal patients. An international perspective

Barriers to palliative care around the world include: underutilization of and lack of access to opiates; the separation of palliative (hospice) care from the usual health care system in much of the world; cultural barriers to discussing death and dying; and, especially for the developing countries, financial barriers to good palliative care. Palliative care education for health care providers, pain initiatives as well as flexibility and adaptation of palliative care principles to local resources may help overcome these barriers.     

Population-based primary health care for women. An overview for midwives

This home study program has as its focus population-based care for women. Although clearly significant, concentrating effort solely on the individual does not ensure that the population as a whole is healthier. Experts are encouraging health care providers to consider the population as their "patient" and to begin documenting the incidence and prevalence of its disease. This article addresses the following issues: the definition of population-based health care; the relationship between primary care, women's health care, and population-based health care; the importance of a population-based approach or perspective for midwives; the use of population-based care in the provision of prenatal care; the definition of the populations to whom midwives have historically provided care and the documentation of how those populations are changing; and the research and policy issues for midwives related to population-based health care.     

A rural perspective on health care for the whole person.

The authors summarize the health care problems facing rural and frontier America by addressing five key issues within the framework of health care for the whole person: how to (a) provide health care access, (b) ensure health care quality, (c) provide a range of health care or meet the scope of practice demands, (d) address regional, rural-specific characteristics that may exist, and (e) address health professionals' quality of life. When working in rural and frontier areas it is crucial for providers to collaborate across all types of health care to provide better care and better utilize a region's tautly stretched resources. Rural health care resources are provided. The authors attempt to demonstrate characteristics of rural culture and rural and frontier populations' health care disparities, highlighting the need for collaborative care. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

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.     

Access to hypertensive care. Effects of income, insurance, and source of care

BACKGROUND: This study examines the relationship between income, health insurance, and usual source of care characteristics and screening and management of hypertension. METHODS: This is a secondary analysis of data from the 1987 National Medical Expenditure Survey. Adult survey respondents constitute a sample representative of the total adult noninstitutionalized US population. Screening, follow-up care, and pharmacologic treatment for hypertension were examined among low income individuals, the uninsured, those without a usual source of care place, and those without a particular usual source of care physician. RESULTS: The uninsured, individuals without a usual source of care place, and those without a particular usual source of care physician received less screening, follow-up care, and pharmacologic treatment for hypertension. Income did not affect receipt of hypertensive care. CONCLUSIONS: Lack of health insurance and lack of a usual source of care are barriers to hypertensive care. Policies that increase access to health insurance or to usual source of care physicians may enable more individuals to attain control of hypertension.     

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.     

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.     

Managed care: rationing without justice, but not unjustly

Three ethical criticisms of managed care are often voiced: (1) by "skimming the cream" of the patient population, managed care organizations fail to discharge their obligations to improve access, or at least, to not worsen it; (2) managed care organizations engage in rationing, thereby depriving patients of care to which they are entitled; and (3) by pressuring physicians to ration care, managed care organizations interfere with physicians' fulfillment of their fiduciary obligations to provide the best care for each patient. This article argues that each of these criticisms is misconceived. The first rests on the false assumption that the health care system includes a workable division of responsibility regarding access that assigns obligations concerning access to managed care organizations. The second and third criticisms wrongly assume that we in the United States have taken the first step toward assuring equitable access to care for all, articulating a standard for what counts as an "adequate level of care" to which all are entitled. These three misguided criticisms obscure the most fundamental ethical flaw of managed care: the fact that it operates in an institutional setting within which no connection can be made between the activity of rationing and the basic requirements of justice.     

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.     

The role of psychologists in the care of Iraq and Afghanistan veterans in primary care settings.

Although military personnel serving in Iraq and Afghanistan are at high risk of developing mental health problems, many report significant barriers to care and few seek help. Integrated primary care is a comprehensive model of health care that aims to improve access to care and provides a framework to assess and meet the complex psychiatric needs of newly returning veterans by embedding mental health specialists within primary care. We describe the role of psychologists in a Department of Veterans Affairs (VA) integrated primary care clinic that serves veterans of Iraq and Afghanistan. Psychologists based in primary care can assist veterans with reintegration to civilian life by providing rapid mental health assessment, normalizing re-adjustment concerns, planning for veterans’ safety, implementing brief interventions within primary care, facilitating transition to additional mental health care, and informing veterans of other available psychosocial services. A case example demonstrating the psychologist’s role highlights the benefits of an integrated care model. Implications of employing this model include reduction of symptoms and impairment by reducing stigma and barriers to seeking mental health care, increased motivation to engage in treatment, and implementation of early interventions. This model may also be beneficial in the civilian health care sector with groups that are at high risk for mental health problems, yet experience barriers to care, particularly stigma. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The effect of cost sharing on the use of chiropractic services

OBJECTIVES: Chiropractic care is increasing in the United States, and there are few data about the effect of cost sharing on the use of chiropractic services. This study calculates the effect of cost sharing on chiropractic use. METHODS: The authors analyzed data from the RAND Health Insurance Experiment, a randomized controlled trial of the effect of cost sharing on the use of health services. Families in six US sites were randomized to receive fee-for-service care that was free or required one of several levels of cost sharing, or to receive care from a health maintenance organization (HMO). Enrollees were followed for 3 or 5 years. All fee-for-service plans covered chiropractic services. Persons assigned to the HMO experimental group received free fee-for-service chiropractic care; persons in the HMO control group had 95% cost sharing for chiropractic services. The authors calculated the mean annual chiropractic expense per person in each of the fee-for-service plans, and also predicted their chiropractic expenditures using a two-equation model. Chiropractic use among persons receiving HMO and fee-for-service care were compared. RESULTS: Chiropractic care is very sensitive to price, with any level of coinsurance of 25% or greater decreasing chiropractic expenditures by approximately half. Access to free chiropractic care among HMO enrollees increased chiropractic use ninefold, whereas access to free medical care decreased fee-for-service chiropractic care by 80%. CONCLUSIONS: Chiropractic care is more sensitive to price than general medical care, outpatient medical care, or dental care, or and nearly as sensitive as outpatient mental health care. A substantial cross-price effect with medical care may exist.     

Overview and implications of Medicaid managed care for people with developmental disabilities

The inclusion of people with developmental disabilities in managed care as part of general efforts by states to enroll and Medicaid recipients in such plans was reviewed. Managed care was defined and the processes by which managed care organizations deliver services were explained. Escalating costs and utilization were discussed as the primary reason for the shift to managed care. The use of Medicaid Section 1115 waivers by states to include Medicaid recipients was explored. The relation between acute health care and long-term care, and the utilization patterns in each, were briefly described. Finally, elements of managed care that are particularly important to people with developmental disabilities, such as care coordination, maintenance of quality, and individual and family support, were discussed.     

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.     

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.