Showing papers on "Integrated care published in 1996"

Integrated Care Pathways: effective tools for continuous evaluation of clinical practice

Abstract: The critical examination of clinical practice should be an integral part of patient care It includes the development and implementation of guidelines, together with continuous evaluation of clinical process and outcomes to improve the quality of care provided Clinical audit has not been successful in achieving this The use of Integrated Care Pathways facilitates the introduction of guidelines and the continuous evaluation of clinical practice Improvements are achieved by frequently revising the pathways to reflect current, local best practice Integrated Care Pathways define the expected course of events in the care of a patient with a particular condition, within a set time-scale A pathway is divided into time intervals during which specific goals and expected progress are defined, together with appropriate investigations and treatment A pathway reflects the activities of a multidisciplinary team and can incorporate established guidelines and evidence-based medicine It is usually unique to the institution in which it was developed The pathway forms part of the clinical record of every patient All variations from the pathway are documented, and the reasons for the variations analysed Solutions are developed to address the causes of potentially avoidable variation, and the pathway is revised to incorporate these improvements Integrated Care Pathways provide a powerful audit tool, as all aspects of the process and outcome of clinical practice can be constantly monitored Variations from set standards are minimized, and improvements are rapidly incorporated into routine practice and subsequently re-evaluated

Integrated care pathways.

Abstract: Integrated care pathways specify and evaluate clinical practice and can improve patient care.' They use multidisciplinary guidelines to develop and implement clinical plans which represents current, local best practice for specific conditions. They may also incorporate national guidelines,' evidence based medicine,3\" and benchmarking.5 Pathways are divided into time intervals during which specific goals and expected progress are indicated, together with guidance on the optimal timing of appropriate investigations and treatment (fig 1).' Pathways are usually unique to the institution in which they are developed. This is partly because they reflect details of care which vary between institutions, but also because the development of the pathway allows evaluation of current practice and results in clarification and coordination of the overall plan of care. However, exchange of information between health professionals using similar pathways can be extremely valuable to improve and extend the use of pathways. They have been used in paediatric surgery, cardiology, neonatology, and for medical conditions such as asthma, diabetes, and leukaemia.' 6

Integrated care for asthma: matching care to the patient

Abstract: The purpose of the present study was to investigate whether criteria associated with assignment of asthma patients between general practice (GP) care alone, integrated care (shared between GP care and hospital clinic) or conventional specialist review could be identified, and whether outcomes for these patients differed over the next 12 months. Seven hundred and sixty four patients with a diagnosis of asthma and previously assigned to either integrated care or clinic care were reviewed after 1 year and reassigned. These patients were then followed for another 12 months and clinical data were collected over this time. After 12 months in clinic care or integrated care, assignment to integrated care was predicted by previous participation in integrated care (OR 2.94), patient preference for integrated care (OR 3.7), no admission (OR 1.56), fewer steroid courses during the previous year (OR 0.88) and nonattendance at review (OR 0.43) in the previous 12 months. Patient discharge to GP care was predicted by higher level of forced expiratory volume in one second (FEV1) (OR 1.49), lower number of GP consultations for troublesome asthma (OR 0.78), and nonattendance for review in the preceding year (OR 2.15). In the following 12 months, the three groups of patients differed significantly in hospital admissions (Discharged = 0.008; Integrated = 0.12; Clinic = 0.31), bronchodilators prescribed (Discharged = 8.5; Integrated = 10.2; Clinic = 13.9), GP consultations (Discharged = 1.3; Integrated = 3.0; Clinic = 4.1) and oral steroid courses (Discharged = 0.62; Integrated = 1.7; Clinic = 2.4). Patients assigned to integrated care, clinic care or discharged to general practice care form three distinct patient populations differing retrospectively and prospectively in morbidity and admission risk. In particular, patients assigned to integrated care fall midway in risk and morbidity between those discharged or those retained in clinic care. These results suggest that integrated care provides general practitioners with a system of management for asthma patients, for whom they do not wish frequent specialist review but who they do not believe can safely be discharged to general practice care only.

Permeating organizational boundaries: the challenge of integration in healthcare.

Abstract: "Integrated Health Systems: Promise and Performance," by Douglas Conrad and Stephen Shortell provides an excellent overview of the extant knowledge about the possibilities for integrated systems in healthcare. The authors effectively clarify the premises and assumptions that underlie the design of integrated health systems, provide a comprehensive summary of the existing literature on the subject, and outline the barriers and success factors associated with system integration. They also challenge system builders to extend their traditional foci and to move beyond managing production systems to service a broader range of needs along the value chain of healthcare delivery. Conrad and Shortell recommend that healthcare leaders achieve what, in effect, has been the unfulfilled promise of HMOs-ensuring the health and well-being of defined populations. One important assumption delineated by Conrad and Shortell that deserves a closer look is the premise that full-fledged, "end-stage" vertical integration is essential for future system success: One of this article's premises. . . is that control of the health services value chain will devolve naturally to those market players who have the comparative advantage in managing the point-of-service delivery of health services, and who are able to hold down direct production costs as well as the indirect "transaction costs" of producing health. Comparative advantage will rest with those organizations that truly integrate and coordinate the flow of patients through successive states in the continuum of health services (page 5). -- This assumption is understandable because there has been such widespread acceptance of the idea that integrated systems represent the ideal model of delivery for the next century (e.g., see Brown 1996). But for integrated systems to achieve their promise, there would first have to be a major restructuring of both markets and systems (which, admittedly, is already under way), a removal of barriers that have historically separated providers at the local level, and a significant investment in the components of system building (e.g., integrated information systems) that are essential for ensuring the coordination of care across the full spectrum of healthcare providers and services. And if integrated systems are to achieve the mythical end stage in system evolution-reaching out to communities to serve the needs of defined populations-they will need to evolve competencies heretofore untested and undemonstrated in established delivery system modalities. All of this is a very tall order, indeed. A building chorus of critics is questioning the rationale for vertical integration in healthcare (Goldsmith 1994; Slomski 1995). The arguments are varied, but all essentially ask whether the benefits of increased integration outweigh the costs of coordination, compromise, and control. The evidence in support of vertical integration, whether drawn from the healthcare or other industries, is, at best, equivocal (Walston et al. 1996). Add to this the unpredictable evolution of state and national health policy and consumer preference. The current spate of public policies to constrain some of the cost control features of managed care organizations (e.g., laws specifying minimum stays for obstetrical deliveries), and consumer preferences for choice, signal possible roadblocks in the "natural" evolution toward fully integrated care delivery. Clearly, caution is warranted by administrators and policy makers alike before they pursue or advocate what could well be a very costly approach to organizational restructuring. Alternative Approaches to Market Consolidation It is important to recognize that vertical integration is being advocated in the context of an unprecedented level of consolidation within the healthcare industry (Zelman 1996; Luke et al. 1996). The difficulties inherent in bringing together disparate partners into coordinated systems are well known. …

Organization and financing of home nursing in the European Union.

Abstract: Objective The aim of this study was to provide an overview of the organization and financing of home nursing in the 15 member states in the European Union. Methods Home nursing was defined as the nursing care provided at the patients' home by professional home nursing organizations. Data were gathered by means of three complementary research methods: desk research, postal questionnaire among identified experts and face-to-face interviews with experts. Results and Conclusion The results showed that there are large differences between the countries in the way home nursing care is financed. There seems to be a relation between the way of funding and the organizational structure. In member states where the organizations receive a fixed budget, based on the number of inhabitants or the demography of the catchment area, home nursing is mainly provided by one type of organization and is freely accessible for the patients. In this situation there is little competition among the organizations, and the catchment areas of the regional organizations do not tend to overlap. On the other hand, in countries where organizations are reimbursed according to a fee-for-service principle and a referral of a doctor is required, home nursing is provided by different types of organizations and also by independent nurses. It seems that fee-for-service reimbursement stimulates competition between providers and a market-oriented home care. In addition, a fee-for-service method of funding also has the consequence that mainly technical nursing procedures and some basic care are reimbursed; this leaves little room for nurses to perform preventive and psychosocial activities or to provide more integrated care. (aut. ref.)

Measuring the burden of disease and the cost-effectiveness of health interventions : a case study in Guinea

Abstract: This study draws upon the methodology of the 1993 World Development Report: Investing in Health to provide analyses of the burden of disease and cost-effectiveness of health interventions. The analysis aims to provide a common framework for the activities of the government in Guinea in prioritizing health care services. The burden of disease analysis presents detailed estimates of mortality in Guinea by cause of death in 1992. The cost-effectiveness analysis compares the costs of forty interventions selected from treatment protocols at health centers, health posts and first referral hospitals' health care intervention with their health impact. These two methodologies complement other methods to measure health system performance. The report concludes with one possible minimum package of health services that includes outreach preventative programs and a package of curative treatments at health center and hospital levels.

Chronic Care in Ambulatory Settings: Components of an Integrated Care System

Abstract: This article describes chronic care management in ambulatory settings and strategies for integrating care across treatment settings to increase efficiency and improve the quality of chronic care. Chronic care management should be client focused, recognizing the client as the primary care manager and promoting educated participation in shared decision making; care must be integrated across health and social service provider settings through case management and advanced information technology; methods must be used for identifying those who are at risk of disability progression and high-cost care; treatment protocols are needed to plan and monitor care and improve outcomes; access to interdisciplinary care teams is required to meet complex care needs; ongoing prevention services are needed to reduce or delay disability and decline; and financial incentives must be aligned to support integration of acute and long-term care.

Guidelines for integrated management of demented patients in nursing homes for the elderly

Abstract: Currently, 30% and above of residents of geriatric care centers are suffering from dementia, most of them in an advanced stage of disease. In 1987, the "Landschaftsverband Rheinland" introduced the so-called "Zuschlagsverfahren" (i.e., additional nursing fees) to promote an integrative care concept for demented people in these institutions. This procedure includes expert rating of the residents, "screening" of the quality of care and teaching of the institutional staff in the field of gerontopsychiatry. The introduced guidelines for integrated care of demented residents of geriatric care centers emerged from practical work in and for such institutions. The guidelines emphasize the inmate-oriented care and housing concept, focusing on the individual biography and on qualified personnel management. An organizational structure is needed that supports the revised care and housing concept.

European prototype for integrated care

Abstract: Describes the EPIC (European prototype for integrated care) project which was set up in 1992 with the aim of “improving the quality of care provided to vulnerable people living in the community through the development of a prototype information system for integrated care capable of supporting the sharing of information between health and social care professionals”. The main application was for care of the elderly with pilot sites in Northern Ireland, Finland and Spain. The prototype supports multidisciplinary assessment, care planning and delivery of care. The project ended in 1994 and further development of the prototype as a generic community information system is being undertaken in the ITHACA project, within the European Commission Fourth Framework Health Telematics Programme.

Adapt or perish? -- the challenge to clinics [letter]

Abstract: E. S. Searle has made a strong case for the need of family planning clinics to adapt or perish. Change and development are possible when built on a firm foundation of mutual respect and cooperation between health professionals. In April 1993 we formed a clinical directorate of sexual health providing education and prevention treatment and care by integrating the services of genitourinary medicine family planning and HIV prevention. In the central clinic under one roof we are now able to offer screening and treatment for sexually transmitted disease (STD) and a full contraceptive service. Referral to other specialist clinics may be made within the same building using the same set of notes. These specialist clinics include colposcopy psychosexual counseling genital dermatology menopause erectile dysfunction HIV outpatient and daycare. Extension of this integrated care to locality clinics is being achieved through the development of clinical management protocols. The sexual health education team has ready access to specialist skills in contraception STD and HIV management and prevention and is better able to meet the expressed needs of a wide spectrum of local people including school children ensuring an holistic approach to sexual health education. The integrated service has been very well received by patients and by those staff who have wished to broaden their clinical expertise and who recognize the benefits for the sexual health of the local population. The development of this specialist sexual health service has happened as a result of vision cooperation and mutual respect within the component parts of the team. Each needs to be led by a recognized specialist in that field. Anxieties about one discipline dominating another have been replaced by a recognition of the synergistic effect of our integrated approach to patient care and sexual health promotion. (full text)

An integrated care system for musculoskeletal disorders in a managed care setting.

Abstract: Practice guidelines, education, consensus building, and extensive communication were the tools used in developing a musculoskeletal care system. Primary care physicians directed patient care using practice guidelines for common musculoskeletal conditions. Patient education and empowerment were emphasized. Specialist consultations were made available by telephone/voicemail to advise primary care physicians regarding treatment plans and the need for specialty referrals. Significant reductions in medical service utilization for this patient population were achieved while high levels of patient satisfaction were maintained. Such integrated systems are likely to work well within other MCOs.

Overcoming barriers to integrated health delivery.

Abstract: As changes in healthcare delivery have swept the country, relationships among insurers, physicians, and hospitals have been altered dramatically. It is my belief that our healthcare systems are being affected by fundamental changes that will not be reversed and will eventually result in less costly, more consumerresponsive care delivery. To what extent provider-based healthcare systems will be altered, however, will be largely influenced by the local environment where healthcare is delivered. Those of us who manage healthcare institutions and services and who believe in the inevitability of these changes see little choice but to develop our organizations so they are part of larger, effective integrated delivery systems. A number of authors, however, are skeptical about the effectiveness of provider-based efforts to develop integrated systems. Jeff Goldsmith has remarked that he finds it "stunning how little hard evidence of economic advantage or market share gain has accrued from system development in healthcare" (Goldsmith 1994). A recent Health Care Management Review article stated that "There is little empirical evidence to support the promised benefits of any type of vertical integration." It was also noted that recent experience with a small number of vertically integrated healthcare systems is suggesting greater inefficiencies and organizational problems than benefits (Walston, Kimberly, and Burns 1996). Those who must reform their organizations to match and better the performance of non-integrated systems recognize that overcoming cultural and organizational barriers will require the support of governance, an external push from the environment, and good luck in the process. Greater Rochester Health System The impact that different regions and communities have in shaping the development of integrated delivery systems became very apparent to me as I recently moved from Chicago to Rochester, New York, to assume the position of president and CEO of the Greater Rochester Health System (GRHS), a new integrated healthcare delivery system. GRHS was established in December 1994 as a result of the union of two Rochester hospital systems, Rochester Health Care, Inc. and TGH Health System, Inc. The CEOs of these two systems, each on the eve of retirement, committed to bring their organizations together to create a new system that would provide seamless, integrated care for the greater Rochester area. Together they comprised Rochester General Hospital, Newark Wayne Community Hospital, The Genesee Hospital, and their affiliated organizations. With 1,415 acute and long-term care beds and more than 8,500 employees, GRHS is now the largest healthcare system in New York outside of New York City. It includes acute, longterm care; mental health services; independent living and housing services for seniors; and, in addition to evolving physician organizations, a private-label HMO. As a new organization, GRHS is going through predictable growing pains and transitions that might be experienced by any new and developing delivery system. The community of which it is a part and the state that establishes its regulation, however, also play a profound role in shaping how this system and others in the community may evolve. The New York Environment New York will be an interesting state to watch-and even more interesting to experience-as providers here make the rapid jump from regulated to competitive managed care markets. While New York ranks seventh in the country in HMO market penetration, with 28.3 percent of the population enrolled (Weil 1996), it has effectively discouraged the unified ownership and management of integrated delivery systems. In 1983, New York established the New York Perspective Hospital Reimbursement Methodology (NYPHRM) to contain cost, support financially stressed hospitals, and finance care for the uninsured (Fraser 1995). NYPHRM provided some of the nation's toughest controls over healthcare providers and insurers, and included community rating, facility rate regulation, and tight restrictions on the growth and expansion of facilities. …