Building healthier communities in a managed care environment: opportunities for advanced practice nurses

Two paradigm shifts are occurring in health care: managed care and community partnerships. The distinct principles and trends of each paradigm are certain to determine the future practice of advanced practice nurses (APNs). The impact of managed care and community partnerships will affect the resource management, clinical decision making, and time management of APNs. Concomitantly, APNs will have opportunities to influence practice guidelines, individual and community decision making, cultural competence, and the cost-effectiveness of care in communities. Capitalizing on these opportunities will enhance the value of APNs to their managed care plan employer and their community.     

Optimizing drug therapy based on genetic differences: implications for the clinical setting

Differences in drug responses due to gene alterations are rapidly being identified. Gene alterations may inhibit the function of an enzyme so that an active drug accumulates, causing adverse reactions with normal doses. Alternatively, gene alterations may accelerate enzymatic function so that an active drug is rapidly eliminated, causing subtherapeutic responses to normal doses. Mutations and polymorphisms have been identified that affect a person's response to many currently prescribed medications including cardiovascular, anti-infective, chemotherapeutic, psychiatric, and analgesic drugs. The potential exists for drug therapy to be optimized by selecting medication and doses based on a person's genotype rather than by trial and error. In the near future, advanced practice nurses in the acute care setting may be expected to order, provide patient education about, and explain results of genetic tests before initiating a specific drug therapy. Advanced practice nurses must be knowledgeable about what genetic tests are analyzing and their benefits, limitations, and risks.     

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)     

Evaluating health plans and marketing the gastroenterology practice under managed care

More patients will have managed care in the future. Therefore, every practice should have a strategy for working with managed care organizations (MCOs). Learn how to evaluate an MCO and how to obtain detailed information about MCOs in your area. Know how to market your practice and build relationships between your group and MCOs. Develop a practice profile that outlines all the benefits that your group can bring to an MCO. Plan how you will respond when an MCO says, "No."     

The medication information line for the elderly: an 8-year cumulative analysis

OBJECTIVE: To present an 8-year (1985-1992) cumulative analysis of the 12,743 calls received by the Medication Information Line for the Elderly (MILE), a consumer-oriented drug information service. DESIGN: Data on all calls received by MILE were documented using a standard format. Certain calls were selected by the pharmacist for follow-up based on the nature and predicted severity of the inquiry. SETTING: MILE is located within the Faculty of Pharmacy of the University of Manitoba and staffed by experienced, practicing pharmacists. Calls were received from the elderly and their care providers. Calls were initially taken on a local Winnipeg line, although in 1987 a toll-free number was made available to rural Manitoba residents. RESULTS: The majority of the calls received by MILE were from women aged 65 years or older who accessed MILE on their own initiative. Ninety-one percent of the calls were rated as not serious. Only 6% of calls were from outside Winnipeg. Although 94% of the older consumers reported having a regular pharmacist, they commonly never thought of using their pharmacist for inquiries. The drugs cited most often by consumers, nurses, physicians, and dentists were the nonsteroidal antiinflammatory agents, cardiac drugs, diuretics, antihypertensives, benzodiazepines, and antidepressants. The type of inquiries most frequently involved adverse drug reactions, drug interactions, and therapeutic use. The drugs cited and inquiries made by pharmacist callers were more diverse than those of consumers and other healthcare professionals. CONCLUSIONS: Many older drug consumers have medication information needs that are not being met. Since a large proportion of the callers appeared to be self-motivated women, MILE may not be accessing all older consumers in need of information. This analysis also suggests that many older consumers are not aware that the pharmacist is available and capable of providing drug information.     

Medical risk report: improving patient management and record keeping through a problem-oriented approach

The problem-oriented record satisfies the needs of the contemporary practitioner by addressing the transition from diagnosis to treatment. The technique organizes collected data, identifies all patient problems (medical and dental), defines solutions and/or management of those problems, and documents treatment rendered. Predictably, the problem-oriented record will avoid problems associated with malpractice litigation, conform to regulations of third-party payers, and facilitate practice analyses and quality assessment, i.e., through computer-assisted tracking of patient care based on problems and not just treatment rendered. As many practices today focus on a "patient-centered" approach to practice, the problem-oriented record clearly supports such a philosophy in its completeness of managing patient care information. The dentist, in consultation with other health care providers, can and should feel confident treating patients from the growing population of patients with medical risk. By integrating the problem-oriented approach into patient management and record keeping, dentists can more easily develop a plan for the complexities that accompany patients. Whether these complexities are of a medical, dental, or combined nature, the problem-oriented record helps the practitioner organize information, plan for treatment, and document patient care in a complete and concise manner.     

Changes in functional health, changes in medication beliefs, and medication adherence.

Objective: Medication adherence often lies below recommendations although it is crucial for effective therapies, particularly in older adults with multiple illnesses. Medication beliefs are important factors for individual adherence, but little is known about their origin. We examine whether changes in functional health predict changes in medication beliefs, and whether such changes in beliefs predict subsequent medication adherence. Design: At three points in time over a 6-month period, 309 older adults (65–85 years) with multiple illnesses were assessed. Latent true change modeling was used to explore changes in functional health and medication beliefs. Adherence was regressed on changes in beliefs. Main Outcome Measures: Medication beliefs were measured by the Beliefs About Medicines Questionnaire; medication adherence by the Reported Adherence to Medication Scale. Results: Functional health and medication beliefs changed over time. Increasing physical limitations predicted increases in specific necessity and specific concern beliefs, but not in general beliefs. Changes in specific necessity beliefs predicted intentional adherence lapses, changes in general overuse beliefs predicted unintentional adherence lapses. Conclusions: Medication beliefs partly depend on health-related changes, and changes in beliefs affect individual adherence, suggesting to target such beliefs in interventions and to support older adults in interpreting health changes. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Predictions of protein secondary structures using factor analysis on Fourier transform infrared spectra: effect of Fourier self-deconvolution of the amide I and amide II bands

AAPB and its membership are faced with a number of giant challenges, including but not limited to: (1) the cost savings efforts of third-party payors and managed care organizations; (2) the lack of public awareness of biofeedback and its usefulness; and (3) the lack of sufficient research data on both the effectiveness and efficacy of biofeedback. In spite of these challenges, there are windows of opportunity that have been or which could be created to move biofeedback further into the realm of conventional treatment. We must focus our efforts on working together to: (1) create strategic plans for creating the future of applied psychophysiology and biofeedback; (2) educate all decision makers, including the general public; (3) establish better relationships with other professionals with common interest; (4) conduct more efficacy and effectiveness research; and (5) create a demand for our services so that the public will be more willing to pay for our services "out of their own pocket." In order for this to happen, we must stop fighting with each other and direct our energies to productive activities that can change fantasies into realities.     

The dynamics of individual preference in the probability and value of reinforcement in the development of experimental neurosis

The creation of a partnership, the hallmark of true collaborative practice, is an ongoing, dynamic process. It demands commitment, energy, and creativity. It is learned and therefore must be role modeled. One must remember that it takes time to develop collaborative relationships. One must begin slowly, walk not run, and have realistic expectations. It is a joy to work in an environment that has developed and is in the process of continually developing true collaborative practice. Hope for the future of health care lies in our ability to deliver coordinated and collaborative care. Nursing, medicine, and administration together can and must provide the solutions to our health care delivery problems before those solutions are legislated. We must set policies and priorities to appropriately allocate scarce resources. We must address personnel needs, credentialing, and compensation to ensure adequate numbers of qualified staff to meet the growing needs of our patients. We must evaluate technology and our physical environments to determine the types of services that we will offer. We must continue to broaden our collaborative efforts to extend from the patient care arena into the realms of education, research, and administration. It is up to each of us and each of our colleagues to work every day toward a more collaborative practice environment. By empowering each other, we can put into place a collaboration which "works jointly with others in intellectual endeavors" rather than one which merely "cooperates with an enemy force."     

Crystal ball gazing: back to the future

This article presents some of the challenges, competencies, and opportunities that advanced practice nurses will face in the near future as the emerging health care system unfolds. Nurses must be knowledgeable about, prepared for, and participate in the creation of a preferred future in health care policy and practice. Advancing educational programs and orienting research and activism in the direction of personal and community health will allow advanced practice nurses to continue to have a significant influence on the transformation of health care and delivery systems.     

Strategic Planning for Building Research—A Process Oriented Methodology

This paper explains and discusses the development of a strategic plan for the management of research in building in a planning horizon of 8–10 years. The plan has three major elements: (1) a knowledge base with ranked long range research needs in each discipline; (2) a second base which defines the main objectives of the building sector and the major interdisciplinary problems that must be solved in order to attain them; and (3) the procedures to be followed in order to initiate and carry out an annual research program in view of the strategic plan and the current information maintained in the two bases. This paper dwells first on the special features of research as a knowledge building and problem solving tool, and then describes the process of the actual development of the strategic plan for building research in Israel, including the construction of the knowledge bases and the generation of the annual research programs. Special attention is given to the objectivity and accountability of the process.     

Document imaging and the patient chart: envisioning the future for your practice

This plan for computerizing the dental patient record is designed to be implemented in a stepwise fashion. It assumes a fully developed and well accepted practice management system is already present in the business office to ensure organizational readiness and a culture embracing technology and its accompanying changes. Electronic claims submission is implemented next to not only realize the competitive advantages of EDI in the dental office; but also, to introduce the process of multi-user communication. Electronic charting in the dental operatory is first implemented as a stand alone system. This allows users to understand the new workflow requirements and oral exam redesign when a computer is introduced in the treatment room. The dental team must understand that the ultimate goal of this plan is to network the entire system and enhance communication both within and external to the dental office. No specific time requirements were given for this plan because of the variability from office to office. People need time to develop awareness, prepare for, and become skilled in using new technology. Financial constraints may also limit the speed at which the plan can be implemented. Finally, individuals in the practice must work together as a team to assess the practice's level of acceptance and ability at each step in the process. Modification will be necessary along the way as technology is constantly changing. This is a significant paradigm shift, considering that many pieces of equipment purchased for the dental office can last the dentist's entire career. This plan allows for alteration, encourages team involvement and requires a long-term strategic vision for information technology's role in the dental office.     

Transition from paediatric to adult-orientated care for adolescents with cystic fibrosis

Adolescence is a time of major physical and psychological change. Young teenagers need to become comfortable with their developing sexuality, to begin moving towards independence with a greater reliance on peer group acceptance, to face the future and to make important decisions about their education, career and goals. Difficulties inherent in all of these steps to adult life are magnified by chronic ill health. It is harder for adolescent patients to break family ties, harder to feel accepted by their peer group, harder to plan realistically for the future. It must be the overriding aim of the professional health carers to encourage these patients to confront the problems of adolescence and to help them maintain their physical and emotional stability throughout this challenging period. Parents also must be supported, and encouraged gradually to devolve to their child responsibilities for decision making and for taking prescribed medication. A planned and sensitive transition from a paediatric to an adult health-care system will aid a successful evolution to an independent adult life. The paediatric hospital environment is not best equipped to deal with the problems of adolescence. Just as parents must allow their child to move on, so the paediatric caring team must loosen its ties with the patient and allow transfer to the adult team. There are several ways of effecting this transfer of care. None of them is proven to be better than any other, but the transfer should always be planned, smooth, efficient and expected by the patient. Ideally, all patients should have the opportunity to transfer to a properly equipped and properly staffed adult cystic fibrosis centre where they can continue to receive the highest standards of care from an experienced multidisciplinary team.     

Evidence-based emergency medicine

Evidence Based (Emergency) Medicine (EB(E)M is a term referring to the application into daily clinical practice of only those methods, procedures, medications etc. which are based on scientific evidence. Where diagnostic and therapeutic principles have not been validated on a prospective, controlled randomised basis, this should be tried out at a later time, if at all possible. This concept may allow to bridge the gap between research and clinical practice, and represents the major goal of EB(E)M. Protagonists of EBEM are at times confronted with criticism that EBEM does not constitute the only but one out of several possible approaches to quality controlled medical care. The fact that more than 50% of all emergency procedures are not evidence based give rise to the question as to whether the performance of randomised controlled studies is ethically justifiable, if control groups are included whose treatment leaves out generally recommended and recognised (though not evidence based) therapeutic and/or diagnostic principles. The following examples may enumerate some of the procedures, methods or medications, respectively, without proven scientific evidence: Medication for resuscitation of cardiac arrest victims. Medication for acute asthmatic attacks Initial treatment of uncontrolled haemorrhagic shock. Endotracheal intubation in VF/VT. The principle need for initial ventilation and the volumes of ventilation in cardiac arrest patients. Effectiveness of ACD- and VEST-CPR. A few typical examples are presented to illustrate the requirements of current study designs which have to be met before results of an evaluation are accepted by the EBEM scientists to obtain approval for application of a procedure, method or medication in clinical practice (large patient numbers, power calculations, ethical issues) as well as their benefits and drawbacks.     

Ethical care at the end of life

In treating dying patients, who by virtue of their physical and emotional situation are frail and vulnerable, physicians must meet a high standard of professional, ethical care. Such a standard is based upon a philosophy of care that recognizes the patients' inherent worth as human beings and their uniqueness as individuals. The ethical and virtuous physician will practice in accordance with the principles of biomedical ethics that form the foundations of thought and treatment approaches in this area and will seek to do the best for the patient and the family. "Doing the best" includes respecting autonomy through gentle truth-telling, helping the patient and family to set treatment goals, and providing for symptom control, continuing attentive care and accompaniment throughout the course of the illness. Total care includes physical, emotional and spiritual aspects, is sensitive to cultural values and is best provided by an interdisciplinary team. Practices of symptom control in routine care and in crisis situations, as well as the cessation and non-initiation of treatment, will have as their goals the relief and comfort of the patient. The ethical physician will not act with the intention of bringing about the death of the patient, whether by ordering medication in excess of that required for symptom control, administering a lethal injection or any other means.     

Management of Nausea, Vomiting, and Diarrhea During Critical Illness

Symptoms are subjective patient experiences that may negatively impact the patient's hospitalization, treatment plan, and quality of life. Critically ill patients frequently experience nausea, vomiting, and diarrhea related to underlying disease, procedures, and medical interventions (eg, medication, enteral feeding, surgery). Optimally, the nurse performs a subjective assessment that explores the patient's perception and impact of these symptoms to develop a comprehensive plan of care. Unfortunately, little evidence is available to guide assessment of nausea, vomiting, and diarrhea in critically ill nonverbal patients. Understanding the disease processes, medical treatments, and pathophysioglogy of these symptoms will assist the critical care nurse in the anticipation of symptoms and development of a proactive plan to alleviate the symptom-associated discomfort.

     

Implementing disease management in community pharmacy practice

Disease management (DM) is a comprehensive approach to preventing and treating disease that: (1) targets patients with specific diseases; (2) provides integrated services across organizational and professional boundaries; (3) utilizes services based on the best scientific evidence available; and (4) focuses on outcomes. DM differs from pharmaceutical care in that pharmaceutical care targets not only patients with specific diseases but also those with risk factors for drug-related problems, a history of nonadherence, and frequent changes in medication regimens. Steps to starting a DM program include: (1) identifying a target population based on the population's strategic importance to the goals and aims of the organization; (2) assessing the organization's available resources, both internal and external; (3) defining key indicators with which to assess the program for the purposes of internal quality control and of obtaining compensation from third-party payers; (4) implementing the program using the best scientific methods available; and (5) assessing the impact of the program. The development of a smoking cessation program at a nationwide retail pharmacy chain is used as an example of a DM program initiated in community pharmacy practice. Pharmacists are well positioned to take a major role in DM, because they are accessible to the community and because DM frequently involves drug therapy. DM is also widely used in managed care. It is important that community pharmacists be closely involved in the DM approach as it evolves.     

Pharmacokinetic/pharmacodynamic consequences of space flight

As astronauts prepare for long-term space missions, the question arises of whether drug medication in a zero gravity environment will have the same effects as under normal gravity. There are two potential kinds of changes that must be evaluated: alterations of pharmacokinetics and pharmacodynamics. Pharmacokinetic changes will affect the drug concentrations produced by a certain dosage regimen. They can be caused by changes in: (1) intrinsic clearance (e.g., enzyme activity and renal function), (2) drug binding (e.g., protein binding and tissue binding), (3) blood flow (e.g., liver blood flow and renal blood flow), and (4) bioavailability (e.g., rate and extent of absorption). Pharmacodynamic changes will affect the response that is produced by a given drug concentration. They can be caused by changes in drug-receptor interaction or changes in disease characteristics. Studies of pharmacokinetic and pharmacodynamic changes in microgravity are limited, and predictions of any alterations are mainly extrapolated from known relationships between certain physiologic parameters and their effects on pharmacokinetics in normal gravity. Almost no data is available on changes in pharmacodynamics. Also, no information is available on the relationship between pharmacokinetics and pharmacodynamics. More studies are needed to elucidate the changes in pharmacokinetics and pharmacodynamics in microgravity to ensure the optimum use of drug therapy during space flight.     

Would you want your child to be a psychologist?

Describes past and present developments in the occupation of psychology and discusses 4 major areas psychology must address to survive as a discipline and preserve something to pass on to future generations. Technological advances will increase the use of computerized testing and assessment services, to identify mental disorders, select treatments, and predict outcomes of interventions. However, psychology must be marketed as primary care, not simply as a mental-health specialty. Although the diversity in psychology will open new markets for researchers and practitioners, psychological researchers and practitioners must be known as psychologists rather than as a proliferation of subspecialists. Psychology must also expand its interactions with other professional disciplines and advocate itself as a discipline for service to human needs. Psychologists should also prepare themselves for learning to prescribe psychotropic medication. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Development of the long-term medication behaviour self-efficacy scale: qualitative study for item development

There are no published instruments of patient self-efficacy related to medication behaviour, yet understanding and promoting medication compliance are central to nursing practice. The purpose of this quanlitative study was to explore patient perceptions, experiences and practices associated with long-term medication behaviour in order to establish an instrument measuring self-efficacy in medication behaviour. In-depth interviews were conducted with 14 patients with lifelong dependency on medicine. Using a phenomenological method of analysis the following themes emerged, all of which could be integrated within Bandura's conceptualization of dimensions of self-efficacy. The dimension of personal attributes comprised the themes of emotional distress, confidence in the physician, perceived health status, and normalcy. Environmental factors included the themes of routine, distraction, social support and cost of medication. The third dimension of self-efficacy, task-related and behavioural factors was composed of themes of side-effects, drug delivery system, medication aids, medication schedule, and knowledge. Based on these themes, items for the Long-Term Medication Behaviour Self-Efficacy Scale, were developed and integrated into a version that is currently being submitted to further psychometric work.