Showing papers on "Integrated care published in 1999"

Primary Care Physicians' Approach to Depressive Disorders Effects of Physician Specialty and Practice Structure

Abstract: Background Because primary care physicians (PCPs) are the initial health care contact for most patients with depression, they are in a unique position to provide early detection and integrated care for persons with depression and coexisting medical illness. Despite this opportunity, care for depression is often suboptimal. Objective To better understand how to design interventions to improve care, we examine PCPs' approach to recognition and management and the effects of physician specialty and degree of capitation on barriers to care for 3 common depressive disorders. Methods A 53-item questionnaire was mailed to 3375 randomly selected subjects, divided equally among family physicians, general internists, and obstetrician-gynecologists. The questionnaire assessed reported diagnosis and treatment practices for each subject's most recent patient recognized to have major or minor depression or dysthymia and barriers to the recognition and treatment of depression. Eligible physicians were PCPs who worked at least half-time seeing outpatients for longitudinal care. Results Of 2316 physicians with known eligibility, 1350 (58.3%) returned the questionnaire. Respondents were family physicians (n = 621), general internists (n = 474), and obstetrician-gynecologists (n = 255). The PCPs report recognition and evaluation practices related to their most recent case as follows: recognition by routine questioning or screening for depression (9%), diagnosis based on formal criteria (33.7%), direct questioning about suicide (58%), and assessment for substance abuse (68.1%) or medical causes of depression (84.1%). Reported treatment practices were watchful waiting only (6.1%), PCP counseling for more than 5 minutes (39.7%), antidepressant medication prescription (72.5%), and mental health referral (38.4%). Diagnostic evaluation and treatment approaches varied significantly by specialty but not by the type of depression or degree of capitation. Physician barriers differed by specialty more than by degree of capitation. In contrast, organizational barriers, such as time for an adequate history and the affordability of mental health professionals, differed by degree of capitation more than by physician specialty. Patient barriers were common but did not vary by physician specialty or degree of capitation. Conclusions A substantial proportion of PCPs report diagnostic and treatment approaches that are consistent with high-quality care. Differences in approach were associated more with specialty than with type of depressive disorder or degree of capitation. Quality improvement efforts need to (1) be tailored for different physician specialties, (2) emphasize the importance of differentiating major depression from other depressive disorders and tailoring the treatment approach accordingly, and (3) address organizational barriers to best practice and knowledge gaps about depression treatment.

Development and evaluation of complex interventions in health services research: case study of the Southampton heart integrated care project (SHIP)

Abstract: Interventions are often defined pragmatically and lack any clear theoretical basis, which limits generalisability. Implementation is rarely described, which limits understanding of why an intervention is or is not locally successful. Integration of qualitative methods within pilot trials can help interpret the quantitative result by clarifying process and testing theory. This approach defines three levels of understanding: the evidence and theory which inform the intervention, the tasks and processes involved in applying the theoretical principles, and people with whom, and context within which, the intervention is operationalised. A case study shows how this novel method of programme development and evaluation can be applied.

Best practice guidelines.

Abstract: Best practice guidelines and multidisciplinary pathways of care are becoming an established and essential feature of clinical practice. They can be seen in a wide variety of clinical settings ranging right across the primary, secondary and tertiary health and social care spectrums. The 1997 White Paper places strong emphasis on quality and consistency of care delivery and gives assurances of performance measurements, integrated care (Wilson, 1996) and clinical governance. It suggests making healthcare delivery against national standards a local responsibility and quality of care the driving force for decision making at every level of the service to ensure excellence for patients no matter where the care is provided. A number of controversial issues surround the use of guidelines. Some argue that they are a fetter on clinical discretion, clinical freedom and can lead to the practice of 'cookbook medicine'. Others maintain that they are an essential aid to providing safe and appropriate medical and nursing care.

On-site primary care and mental health services in outpatient drug abuse treatment units

Abstract: Providing health services to drug abuse treatment clients improves their outcomes. Using data from a 1995 national survey of 597 outpatient drug abuse treatment units, this article examines the relationship between these units' organizational features and the degree to which they provided onsite primary care and mental health services. In two-stage models, Joint Commission on Accreditation of Healthcare Organizations-certified and methadone programs delivered more on-site primary care services. Units affiliated with mental health centers provided more on-site mental health services but less direct medical care. Units with more dual-diagnosis clients provided more on-site mental health but fewer on-site HIV/AIDS treatment services. Organizational features appear to influence the degree to which health services are incorporated into drug abuse treatment. Fully integrated care might be an unattainable ideal for many such organizations, but quality improvement across the treatment system might increase the reliability of clients' access to health services.

Clinical governance : making it happen

Abstract: Introduction Organisational framework for clinical governance Patient expectations of clinical governance Clinical effectiveness and EBM Clinical audit and clinical governance Clinical risk management Claims management Learning from complaints The role of the medical director Legal aspects of clinical governance Information, data, quality and clinical governance Integrated care and clinical governance Guide to sources Continuous professional development.

Understanding the feasibility of integrated care: a rival viewpoint on the influence of actions and the institutional context.

Abstract: There is in Europe growing awareness that the delivery of integrated care is required to meet the demands of an increasing number of patients with multiple problems. It is also clear that the provision of integrated care is difficult to achieve. As yet, the debate about the circumstances enabling or hindering provision is not settled. The objective of this article is to generate more knowledge on this issue. It is often assumed that the feasibility of integrated care provision is caused by characteristics of the legislation, the financing system and other aspects of the institutional context. Here it is argued that these characteristics are relevant but not decisive. Based on empirical evidence from the Dutch case a rival viewpoint is presented, suggesting that it is the commitment of the actors involved, their support, and the way developments are being managed, that make the difference. Following presentation of the evidence, the implications of the findings for integrated care policy are discussed. Copyright © 1999 John Wiley & Sons, Ltd.

Are psychiatrists cost-effective? An analysis of integrated versus split treatment

Abstract: OBJECTIVE: Managed care organizations prefer putatively less expensive split treatment, i.e., a psychopharmacologist plus a non-M.D. psychotherapist. In this study the cost of integrated care by a psychiatrist was compared with split care. METHOD: Using 1998 fee schedules of seven large managed care organizations (with 54.3% market share and 67.8 million lives) plus Medicare (37 million people), the author modeled clinical scenarios of psychotherapy alone, medication alone, and combined treatment provided by a psychiatrist or split with a psychologist or social worker. RESULTS: Brief psychotherapy by a social worker was the least expensive treatment. When treatment required both psychotherapy and medication, combined treatment by a psychiatrist cost about the same or less than split treatment with a social worker psychotherapist; it was usually less expensive than split treatment with a psychologist psychotherapist. CONCLUSIONS: The integrated biopsychosocial model practiced by psychiatry is both theoreti...

Integrated care management: applying control theory to networks.

Abstract: Delivery of integrated care by interorganisational networks attracts much attention in Europe. Such care is required to meet the demands of multi‐problem patients. Many efforts are made to establish networks. Often, established networks do not deliver integrated care. Managers must understand the background of this problem, in order to deal with it. The issue addressed here concerns behaviour control in networks of autonomous care‐providing organisations. So far, publications have focused on behaviour control in single organisations. Based on empirical data we argue that, due to an essential distinction between networks and single organisations, behaviour control in the former should be approached differently. In addition, we discuss the implications of our findings for the management of integrated care delivery.

Designing interdisciplinary documentation for the continuum of care.

Abstract: An increased emphasis on integrated care delivery and the need to access information across the care continuum led to an assessment and modification of the current documentation system at Summa Health System in Akron, Ohio. The goal was to achieve more complete and concise interdisciplinary charting. This article describes the process the two-hospital system developed to achieve integrated documentation reflecting the patient's progress toward team-defined outcomes. Steps in the evaluation and modification of the old system, lessons learned, and results/implications for quality improvement are shared.

Making sense of integrated care in New Zealand.

Abstract: Integrated care is becoming a significant feature of New Zealand's current health system.Initiatives to date focus on service coordination or devolution of purchasing, which may be viewed as complementary approaches aimed at meeting a common goal of improving services.They are, however, likely to yield different benefits and pose different risks. This article outlines the background to current integrated care developments in New Zealand and offers a conceptual framework for distinguishing the approaches adopted. It also discusses a number of practical issues that will need to be addressed as such initiatives evolve, and considers some of the factors that need to be taken into account when considering where health care purchasing decisions are best made.

Care pathways and the information for health strategy

Abstract: The paper first defines integrated care pathways (ICPs) and demonstrates the important role for ICPs revealed by the NHS ‘Information for Health’ (IfH) strategy and related documents. Following a review of the main features of ICPs, the paper continues by considering their status in the UK and how their profile is raised by the IfH document. This discussion explores the relationship of ICPs to electronic patient records, seamless care, and the quality initiatives raised by the organizational changes broadcast in the White Paper, ‘The New NHS’. The paper then summarizes the main reasons for the limited uptake of ICPs and suggests that the clinical and cultural barriers could be more readily overcome if the production of electronic, computerized ICPs were more facile. It concludes by advancing a simple model for electronic ICP production and offers a hierarchical approach to incremental design and development.

Assessment of Mental Health Problems

Abstract: This paper examines the process of assessing mental health needs for people with learning disabilities, considering questions of targeting, mental illness and challenging behaviour, diagnostic assessment and quality of life. It recommends comprehensive assessment within an integrated care approach.

Dimensions of class in the integration of health and social care

Abstract: The paper draws upon a research based consultancy to recommend an appropriate form of integration of health and social care for the elderly population of an outer London Health Authority, which included a general practice Total Purchasing project It makes a critical analysis of current practice, and argues that prevailing managerial models of intetprofessional care reflect traditional class assumptions about the organisation of work processes in this field The report developed an argrument for integration which built upon informal and formal joint working among frontline staff provinding home based care This perspective privileges and legitimates users' perspectives, informal networks, joint working and home care and identifies them as key elements for effective integration The final policy recommendation of the report that Home care should become the link service between health care and social services reflected this perspective

The success of an integrated care programme for patients with ischaemic heart disease: the practice nurses’ perspective of SHIP

Abstract: • Follow-up care of patients with angina and myocardial infarction after hospital discharge is known to be suboptimal across the UK. • The employment of cardiac liaison nurses ensured timely notification of hospital discharge and good communication of each patient's current and planned care. • The direct ongoing support of the liaison nurse was valued by more practice nurses than educational support meetings and the initial counselling skills course. • The most important factor which enabled practice nurses to expand their role to provide post-hospital follow-up care was the support of the doctors in the practice. • After the conclusion of the Southampton Heart Integrated Care Project (SHIP) and the withdrawal of cardiac liaison nurses, the lack of hospital discharge notification was the most important reason for practice nurses discontinuing follow-up care.

Towards primary care groups Joining up care in London—establishing the North Southwark Primary Care Group

Abstract: This is the second of four articles showing how primary care groups have been set up in various areas in Britain The shadow board of the North Southwark Primary Care Group brings together representatives from primary healthcare professionals, local social services, and the public from some of the most deprived inner city communities in the United Kingdom.1 The inner London borough of Southwark extends from the River Thames in the north to affluent Dulwich in the south (box). Regeneration of rundown public housing estates has brought with it dramatic changes in the socioeconomic profile in the wards of Bermondsey and Rotherhithe, and the regeneration of Peckham will result in the movement of more than 1000 council tenants over a five year period. The borough is the second most deprived in Britain and is more deprived than its neighbours, Lambeth and Greenwich. The borough is recognised by the government as both a health and education action zone. In addition to the five key areas in the government's Health of the Nation targets, the Southwark Health Charter identified sickle cell disease and diabetes as key health issues for Southwark's population.1 #### Summary points North Southwark Primary Care Group was established against a backdrop of substantial local deprivation A supportive health authority facilitated the process Collaborative working arrangements underpin the ethos of the governing board Clinical governance is seen as an important opportunity, to be implemented by encouragement rather than coercion Integrated care crossing boundaries is the goal Since 1990 the south London umbrella group of general practitioners and the local health authority have encouraged and supported the development of locality groups representing the views of local general practitioners across south London. By 1997 four such groups existed in Southwark. In North Southwark, general practitioners were reluctant to embrace fundholding (of 25 local practices, …

A unified model to support an information intensive health care environment.

Abstract: The two parts of this paper respectively analyses the mismatch between current systems and practice in health care, and present an outline design for enhanced Integrated Care Pathways (ICP) knowledge and information management based upon mature ICT technologies.

The Ultimate Challenge for Integrated Care

Abstract: For most clinicians and health care managers, integrated care means trying to deliver patient-oriented care in a way that transcends organisational boundaries. The care pathways approach to hospital care is a good example ofan attempt to integrate systems across departmental boundaries in hospitals. A wider vision of integrated care is also possible. Intica, an organisation which exists to promote discussion and development of integrated care, offers a broader definition:

New frontiers in integrated care.

Abstract: A combination of extended life expectancy and the graying of America is resulting in a rapidly growing industry known as assisted living. Based on a Scandinavian model for senior housing, assisted living first emerged in America during the mid 1980s. The concept is still so new that states that license these facilities do not agree on a precise definition. It is generally considered a residential alternative between independent retirement living and total institutionalized skilled care.

Penn Health for Women: the evolution of a women’s health program in an academic setting☆

Abstract: Penn Health for Women is an interdisciplinary model for women’s health care created and implemented in an academic setting to provide comprehensive, integrated care to women of all ages and to establish a leadership position in women’s health within the surrounding communities.

The New NHS: What Can We Learn From Managed Care in New Zealand and the US?

Abstract: • The integration of health care is the defining theme of policy developments in the UK, US and New Zealand. The common element between the three countries has been the development of multipractice and multi-professional groups in primary care settings. • International learning has become commonplace and has accelerated the introduction of innovations in the UK. • The ability to learn from international experience, however, requires careful consideration since the particular historical, social and cultural context of each health care system differs. Whilst there is great value in international comparisons, implementing overseas innovations should only be considered where a conscious effort is made to identify their relevance to domestic issues allied to a process of evaluation. • As the U K moves towards an integrated health and social care system organised around primary care-based organisations, policy makers will have a lot to learn from the experience of integrated care organisations in the US and New Zealand. Common features between all of these approaches include capitated primary care networks, the devolution of financial and clinical responsibilities, and the development of public/private partnerships. • Learning can also be transferred in the organisational process/management techniques area. For example, in determining measures of quality of outcome and patient experiences. • New Zealand and the US can also learn from the UK. For example, the development of Health Action Zones and long-term service agreements relates closely to the New Zealand experimentation with integrated care pilots. • In conclusion, different countries need to develop flexible health care systems with the ability to adapt to changes in medical technology and economic and social conditions. Learning from international experience, through the sharing of information on areas such as best clinical and management practice, is important in this process.

A Potential Role for Integrated Care Pathways in Resource Management

Abstract: A major issue facing the National Health Service (NHS) at present is the continual upward spiral in waiting lists and demands for secondary patient care. A dilemma for any initiative has been the problem of how best this should be tackled and, whilst the issue obviously has significant political implications, the negative quality aspects in protracted waiting times must also be considered. Irrespective of the political meanderings on an individual patient basis, long waiting times for surgery are obviously wholly unacceptable and unsatisfactory, and have to be addressed. An understandable approach to the problem has been injection of fresh capital into the system in order to fund waiting list initiatives, extra hospital beds and the like, in order to cope with the demand. There are, however, major reservations about this approach; very often, irrespective of funding, the staff and facilities are simply not available to take on the extra workload. Alternative approaches are therefore needed which move away from viewing resource allocation as the only solution to the problem.

Making Integrated Health Care Work

Abstract: Making Integrated Health Care Work, by Dean C. Coddington, Keith D. Moore, and Elizabeth A. Fischer (Center for Research in Ambulatory Health Care Administration, 1996). Integrated health care systems (IHC's) have grown in importance since this book was written in 1996. This growth has been marked by a large increase in provider-owned HMO's. As John Koster of VHA, Inc. remarked in his forward to this book, IHC's have grown out of the need to improve clinical effectiveness within a setting of cost constraints. In 1999 this need for improvement is even greater due to: (1) three years of flat or declining premium rates; (2) the consolidation of publicly-owned health care plans; (3) government push of Medicare and Medicaid enrollees into managed care; and (4) the budget squeeze on providers induced by the Balanced Budget Act of 1997. Despite its title, Making Integrated Health Care Work is not a "how to" book. The aim of the book is to describe the characteristics of mature IHC's that permit them to add value to the health care marketplace. The ultimate goal of a successful health care system is like that of any other successful business: deliver what the customer wants by providing high quality care at an affordable cost with outstanding service. The book has the same structure as the authors' last text entitled Integrated Health Care, which was published in 1994. Both books are based on the authors' research (in the year prior to publication) of ten different health systems with varying maturity levels of integrated care. Unfortunately, the reader does not learn much about these health systems from this book. Nor does the reader get a sense as to whether the success or lack of same is a result of the health system's maturity as an IHC. Case studies for each of the organizations were published in a separate volume available through the Center for Research in Ambulatory Health Care Administration. What the reader does obtain are useful checklists of the characteristics necessary to become a mature IHC and the various strategies taken by the IHC's to achieve value added. An integrated health care system is defined as: "[A system combining] physicians, hospital, and other medical services with a health plan (or the ability of the system to enter into risk contracts) to provide the complete spectrum of medical care for its customers. In a fully-integrated system, the three key elements---physicians, hospital(s) and health plan membership---are in balance in terms of matching medical resources with the needs of purchasers and patients." The characteristics of a mature integrated system are: (1) physicians play a key leadership role; (2) the organizational structure promotes coordination; (3) primary care physicians are economically integrated; (4) practice sites provide geographic coverage; (5) the system is appropriately sized; (6) physicians are organized; (7) health plans and partners are owned by the system; (8) financial incentives are aligned; (9) clinical and management information systems tie together the elements of the system; and (10) the system has access to and the ability to shift financial resources. The heart of the book focuses on how IHC's develop and implement critical strategies to gain competitive advantage and improve value added. Value is added by: (1) improving quality of care; (2) improving service; (3) improving accessibility; (4) reducing unit costs; (5) increasing operating efficiency; (6) strengthening customer ties; and (7) enhancing product offerings. In the authors' view the two most important decisions are developing a primary care network and starting/growing a health plan. The key ingredients for starting an IHC are obtaining physician buy-in and developing physician leadership in all aspects of clinical and administrative functions. Also required are a commitment to a common vision, respect for primary care, and sufficient funding. …

Community health services must be considered in proposals for integrated records

Abstract: EDITOR—Rigby et al argue that without the sharing of clinical information it is difficult to achieve integrated care that focuses on the patient1; this undermines the effective functioning of extended primary care teams (however constituted) on which the NHS will increasingly depend. Our recent experience during a review of the primary care records of adolescents in Edinburgh suggests that attention should be paid to health professionals' skills and behaviour and to organisational factors. We found that antenatal and birth data were generally missing from the …