scispace - formally typeset
Search or ask a question

Showing papers on "Integrated care published in 2000"


Journal ArticleDOI
TL;DR: This analysis strongly suggests that fully integrated models of care, such as the social health maintenance organisation and program of all-inclusive care for the elderly, are not only feasible, but offer significant potential to improve the delivery of health and social care for frail elderly patients.
Abstract: Purpose: Integrated care for the frail elderly and other populations with complex, chronic, disabling conditions has taken centre stage among policymakers, planners and providers in the United States and other countries. There is a growing belief that integrated care strategies offer the potential to improve service co-ordination, quality outcomes, and efficiency. Therefore, it is critical to have a conceptual understanding of the meaning of integrated care and its various organisational models, as well as practical examples of how such models work. This article examines so-called “fully integrated” models of care in detail, concentrating on two major, well-established American programs, the social health maintenance organisation and the program of all-inclusive care for the elderly. Theory: A major challenge to understanding the performance and outcomes of fully integrated care and other organisational models is the lack of a meaningful, analytical paradigm. This article builds upon the work of Walter Leutz, to develop a framework by which new and existing programs can be analysed. This framework is then applied to the two American models that are the focus of this article. Methods: Existing data about integrated care in general, and the two model programs in particular, were collected and analysed from reports published by governmental and non-governmental organisations, and journal articles retrieved from Medline, HealthStar and other sources. Results and conclusions: This analysis strongly suggests that fully integrated models of care, such as the social health maintenance organisation and program of all-inclusive care for the elderly, are not only feasible, but offer significant potential to improve the delivery of health and social care for frail elderly patients. In addition, the authors identify the factors that are the most critical to the success of fully integrated care, and offer lessons for their development and implementation. Finally, issues are raised concerning the transferability of this complex model to other countries, as well as the vital importance of evidence-based evaluation research in furthering the evolution of integrated care.

211 citations


Journal ArticleDOI
TL;DR: In this article, the authors evaluated a model of integrated diabetic footcare for identification and clinical management of the high risk diabetic foot, centred on the primary care-based diabetic annual review.
Abstract: SUMMARY Aims To evaluate a model of integrated diabetic footcare, for identification and clinical management of the high risk diabetic foot, centred on the primary care-based diabetic annual review. Methods A pragmatic randomized controlled study was undertaken with matched cluster randomization of practices from 10 towns drawn from mid and east Devon responsible for the care of 1939 people with diabetes (age ≥ 18 years). Outcome measures were patients' attitudes regarding the value and importance of footcare, patients' footcare knowledge, healthcare professionals' footcare knowledge and pattern of service utilization. Results Attitudes towards footcare improved in both intervention and control groups (mean percentage change 3.91, 0.68) with a significant difference in change of 3.18 (95% confidence interval (CI) 1.29–5.07) between the groups. Patients knowledge about diabetic foot problems improved significantly in both groups (mean percentage change 1.09, 1.32) but with no significant difference in change: −0.09 (95% CI −1.81–1.63) between groups. Health professionals' knowledge scores improved in the intervention group (mean percentage change 13.2; P < 0.001). No improvement was seen in the control group (mean percentage change −0.2; P = 0.1) with a significant difference in change of 13.46 (95% CI 8.30–18.62) between groups. Appropriate referrals from intervention practices to the specialized foot clinic rose significantly (P = 0.05) compared with control practices (P = 0.14). Conclusions Provision of integrated care arrangements for the diabetic foot has a positive impact on primary care staffs' knowledge and patients' attitudes resulting in an increased number of appropriate referrals to acute specialist services.

89 citations



Journal ArticleDOI
TL;DR: This review will review rigorous intervention studies which address the following question: Does case management affect the acceptability of patients, and the quality, efficiency and effectiveness of care, ie are patients assigned to case management healthier, more satisfied, better or more quickly cared for, or cared for at lower cost than those not assigned toCase management.
Abstract: This is the protocol for a review and there is no abstract. The objectives are as follows: We will review rigorous intervention studies which address the following question: Does case management affect the acceptability of patients, and the quality, efficiency and effectiveness of care, ie are patients assigned to case management healthier, more satisfied, better or more quickly cared for, or cared for at lower cost than those not assigned to case management? The specific objectives of this review are: 1. To search the literature for studies which evaluate case management interventions. Studies to be included in the review will be aimed solely or separately at evaluating case management interventions. Studies excluded on methodological grounds may be used to describe the level of development of research in this field. Studies will be included only if they use a sufficiently rigorous design to evaluate the effects of the intervention on outcomes of care. Studies which address psychiatric care will be excluded, as a review has already been completed on this topic (Marshall 2000). 2. To describe the overall effects of case management on patient care. Outcomes will include length of stay, resource use, patient satisfaction, survival, unplanned readmission, complications, iatrogenic disease and other quality of care measures and measures of professional practice. 3. To summarise narratively, qualitatively by simple study count and, if possible through meta-analysis, the effect of interventions on outcome. 4. To investigate the effects on patient care of different models of case management: some named models are brokerage, integrated case management, patient empowerment, integrated care pathways, managed clinical networks, liaison services and locality care. Differences in case managers (graduate nurses, clinical nurses, other professions, non professionals) working alone or in teams, motivation behind the development of programmes (quality of care, cost containment), times of initiation (at admission, during stay, at discharge, in community), settings (academic hospital, acute hospital, long stay hospital, primary care, community services) and approaches to evaluating the need for interdisciplinary intervention (problem based versus scheduled follow up) are variants of models which may result in different outcomes, whose impact will be explored.

66 citations


Journal ArticleDOI
TL;DR: This article presents some of the data from a study exploring the experiences and views of a range of professional staff using care pathways in their everyday practice, focusing on doctors, nurses, and therapists.
Abstract: This article presents some of the data from a study exploring the experiences and views of a range of professional staff using care pathways in their everyday practice. It focuses on the views of doctors, nurses, and therapists. Within the context of delivering integrated care, several themes are explored in relation to the successful implementation of evidence-based care pathways.

59 citations


Journal ArticleDOI
TL;DR: A wide range of problems for the management of comorbid disorders were identified and many may be addressed by closer liaison between existing services, while solution of some problems will require resource allocation.
Abstract: Objectives: To determine opinions and experiences of health professionals concerning the management of people with comorbid substance misuse and mental health disorders. Method: We conducted a survey of staff from mental health services and alcohol and drug services across Queensland. Survey items on problems and potential solutions had been generated by focus groups. Results: We analysed responses from 112 staff of alcohol and drug services and 380 mental health staff, representing a return of 79% and 42% respectively of the distributed surveys. One or more issues presented a substantial clinical management problem for 98% of respondents. Needs for increased facilities or services for dual disorder clients figured prominently. These included accommodation or respite care, work and rehabilitation programs, and support groups and resource materials for families. Needs for adolescent dual diagnosis services and after-hours alcohol and drug consultations were also reported. Each of these issues raised substantial problems for over 70% of staff. Another set of problems involved coordination of client care across mental health and alcohol and drug services, including disputes over duty of care. Difficulties with intersectoral liaison were more pronounced for alcohol and drug staff than for mental health. A majority of survey respondents identified 13 solutions as practical. These included routine screening for dual diagnosis at intake, and a range of proposals for closer intersectoral communication such as exchanging client information, developing shared treatment plans, conducting joint case conferences and offering consultation facilities. Conclusions: A wide range of problems for the management of comorbid disorders were identified. While solution of some problems will require resource allocation, many may be addressed by closer liaison between existing services.

58 citations


Journal Article
TL;DR: The background and effects of the reform of Swedish care of the elderly are explained and the costs and benefits are explained.
Abstract: Integrated care for the elderly. : The background and effects of the reform of Swedish care of the elderly.

52 citations


Journal ArticleDOI
TL;DR: In conclusion, integrated care pathway methodology may facilitate quality and cost improvements in stroke care, but evidence is weak and uncertainty exists.
Abstract: Background an organized, goal-defined and time-specified plan of management as envisaged by the integrated care pathway approach can achieve quality outcomes at lower cost. Integrated care pathways may have applications to stroke management because diagnosis is well defined, complex interdisciplinary inputs are required and there is good evidence on best practice. Method we reviewed medical, nursing, rehabilitation and health services databases to identify studies on integrated care pathways in stroke management. Criteria for inclusion were: use of a care pathway or similar methods in acute or rehabilitation settings, randomized studies or non-randomized comparisons with concurrent or historical controls and some form of outcome assessment. Results we identified six non-randomized studies of acute stroke. One used concurrent controls; the rest used historical controls. Only one study investigated stroke rehabilitation and this used a quasi-randomized controlled design. Five studies in the acute setting demonstrated reduced hospital stay. A reduction in costs of care was reported in all five studies that examined costs. Two studies reported improved uptake of medical interventions. No difference in length of hospital stay, costs or functional status was seen in the rehabilitation study. Conclusions integrated care pathway methodology may facilitate quality and cost improvements in stroke care, but evidence is weak and uncertainty exists. Further evidence is needed before implementation in practice.

50 citations


Journal ArticleDOI
TL;DR: It is concluded that integrated care innovations are implemented in both primary care as well as in secondary care-orientated countries, and whether these innovations positively influence the quality of care, costs of care or patients' use of health care facilities remains rather unclear.
Abstract: This literature review focuses on substitution-related innovations in the nursing care of chronic patients in six western industrialized countries. Differences between primary and secondary care-orientated countries in the kind of innovations implemented are discussed. Health care systems are increasingly being confronted with chronic patients who need complex interventions tailored to their individual needs. However, it seems that today's health care professionals, organizations and budgets are not sufficiently prepared to provide this kind of care. As a result, health care policy in many countries targets innovations which reduce health care costs and, at the same time, improve the quality of care. Frequently, these innovations are related directly to the 'substitution of care' phenomenon, in which care is provided by the most appropriate professional at the lowest cast level, and encompass advanced nursing practice, hospital-at-home care and integrated care. The main conclusion of this paper is that integrated care innovations are implemented in both primary care as well as in secondary care-orientated countries. However, innovations in hospital-at-home care and advanced nursing practice are primarly implemented in primary care-orientated countries. Whether these innovations positively influence the quality of care, costs of care or patients' use of health care facilities remains rather unclear. (aut.ref.)

47 citations


Journal ArticleDOI
TL;DR: It is concluded that health purchasers may need to consider contributing to Direct Payments in acknowledgement of the health care which such schemes are currently providing.
Abstract: This paper reports on a study of disabled people with receiving Direct Payments who were able to purchase assistance in ways that cross conventional boundaries between ‘health’ and ‘social’ services. Indeed, most of the Direct Payment recipients used the term ‘personal care’ to describe a range of help that extended right across this conventional divide. Nevertheless, most of the users reported purchasing help with aspects of health care through their Direct Payments, including physiotherapy, management of incontinence, chiropody, changing dressings and sustaining tissue viability. They chose to purchase this help from their personal assistants (PAs) because statutory services were not available, had been withdrawn, or because they were able to retain greater independence and control over their lives compared with receiving conventional services. Many Direct Payment users wanted more opportunities to purchase a range of health-related services, although this also raised questions about training, supervision and the professionalisation of flexible personal assistance. The paper concludes that health purchasers may need to consider contributing to Direct Payments in acknowledgement of the health care which such schemes are currently providing.

45 citations


Journal ArticleDOI
TL;DR: A complex system is one, where the parts or actors cannot fulfil the over-all aims without co-operation and IT-systems are used to facilitate the integration.
Abstract: A complex system is one, where the parts or actors cannot fulfil the over-all aims without co-operation. Relations between people working in them at all levels create the systems and structures in all complex organisations. Interdependency between units and parts as well as the complementary role of each of them are important features (Scott 1961) w5, 29x. The need of frequent communication between different system units can be reduced by agreements on specific administrative activities and standardisation— guidelines. IT-systems are used to facilitate the integration (Channell 1998).

Journal ArticleDOI
26 Feb 2000-BMJ
TL;DR: Integrated care is a key plank in the government's NHS modernisation programme and commands wide international support as the optimal approach to planning and delivering health care.
Abstract: Education and debate p 563, 566 Disease management, often known as integrated care or care pathways, has wide appeal for health care reformers keen to contain costs and improve outcomes. 1 2 Integrated care is a key plank in the government's NHS modernisation programme.3 It is also particularly relevant to chronic illness. Disease management commands wide international support as the optimal approach to planning and delivering health care.4 It is welcomed as a structured systems response to a set of problems that are evident to some degree in all health services. These include uncoordinated arrangements for delivering care, a bias towards acute treatment, a neglect of preventive care, and inappropriate treatment. The theory behind disease management is that resources can be used more effectively if the patient becomes the pivot around which health care is organised.5 In place of functional divisions, such as those between primary care and hospitals or between different clinical specialties, the divisions …

Journal ArticleDOI
TL;DR: It is not possible to introduce practice and professional development plans (organisational development and organisational learning projects) in a publicly funded health care system without first addressing existing educational and management structures.
Abstract: Improving the quality and effectiveness of clinical practice is becoming a key task within all health services. Primary medical care, as organised in the UK is composed of clinicians who work in independent partnerships (general practices) that collaborate with other health care professionals. Although many practices have successfully introduced innovations, there are no organisational development structures in place that support the evolution of primary medical care towards integrated care processes. Providing incentives for attendance at passive educational events and promoting 'teamwork' without first identifying organisational priorities are interventions that have proved to be ineffective at changing clinical processes. A practice and professional development plan feasibility study was evaluated in Wales and provided the experiential basis for a summary of the lessons learnt on how best to guide organisational development systems for primary medical care.

Book
01 Jan 2000
TL;DR: The next generation of integrated care pathways will need to consider how to introduce clinical pathways, as well as the barriers to entry and barriers to adoption, among other things.
Abstract: PART ONE: What are integrated pathways? PART TWO: Why introduce integrated care pathways? PART THREE: How to introduce clinical pathways?

Journal ArticleDOI
TL;DR: Les résultats of cette étude montrent that si les populations choisissent les soins offerts par le centre de santé, c'est parce qu'elles les jugent de bonne qualité.
Abstract: This study analyses the choice determinants of the population for health centres through a survey of the behaviour of families in a representative sample of 1,000 households in the health districts of Kinshasa, Congo in 1997. For the most recent episode of illness, the respondents turned to seven types of care: the health centre (37%), private dispensaries (26.5%), self-medication through a pharmacy (23.9%), traditional practitioner (21%), traditional self-medication (16.9%), private outpatients' clinic (16.7%) and a reference hospital (10.4%). Past logistics have shown that patients resort to a health centre rather than another type of care structure (P = 0.05) when looking for quality care, reasonable prices and the availability of varied services. On the other hand, concern about the geographical proximity in relation to the family's residence calls for using the private dispensary. When looking for a doctor or the existence of a 'convention', families are more inclined to choose a private officially recognized outpatients' clinic. Those who had been looking for a solution to a special type of illness opted primarily for a traditional practitioner. In conclusion, the results of this study show that if people choose the care offered by health centres, it is because they judge it to be of good quality. The integrated care offered by the same technician, with a required training, is a major asset in the acceptability of the first line of primary health care in Kinshasa. This study suggests that it would no doubt be beneficial to integrate non-official private care structures into the primary health care system, as far as it is possible for them to achieve a level of quality comparable to that of the health centres. In order that the traditional practitioner might play an important complementary role in the realization of primary health care, even in urban areas, the possibility of promoting sites of communication should be studied. Moreover, considering the weak buying power of the city's inhabitants and the previous existence of tontines out of solidarity, the 'conventions' providing relief of health care costs, under the leadership of the local communities, should be integrated into the organization of the urban health system.

Journal ArticleDOI
TL;DR: This study found serious deficits in the assessment and meeting of need, arising from weaknesses at the health and social care interface, in the wake of the 1990 National Health Service and Community Care Act.
Abstract: The delivery of health and social care has undergone massive change in the UK in the 1990s. A key factor in the drive for reform was the failure of joint working arrange ments between health and social services and the need to provide integrated care for people who have overlapping health and social care needs. This article draws on a research study investigating the community care provided to people with Parkinson's disease in the wake of the 1990 National Health Service and Community Care Act. As a chronic progressive disease predominantly affecting older people, the management of Parkinson's provides an exemplar of some of the key features of supporting people with cohtinuing care needs. This study found serious deficits in the assessment and meeting of need, arising from weaknesses at the health and social care interface. The article concludes by considering an approach which resources and supports the service user/carer in managing their own care pathway.


Journal ArticleDOI
TL;DR: The integrated care pathway approach shows promise as a means of facilitating the development of audit within clinical genetics services and was found to have a very poor evidence base for management of patients with the conditions studied.
Abstract: OBJECTIVE To establish national clinical guidelines and integrated care pathways for five conditions (tuberous sclerosis (TS), Huntington9s disease (HD), myotonic dystrophy (MD), neurofibromatosis type 1 (NF1), and Marfan syndrome (MS)) and audit their use in Scotland. DESIGN Systematic review of published reports followed by consensus conferences to prepare clinical guidelines and integrated care pathways. Structured review of medical records before and after introduction of integrated care pathways to document changes in practice. Survey of staff views on procedures adopted. SETTING All four clinical genetics centres in Scotland. RESULTS Project resulted in reduced variation in practice across centres, improved data recording in medical records, and improved communication with other professional groups. A very poor evidence base for management of patients with the conditions studied was found. CONCLUSIONS A collaborative structure for undertaking clinical research would improve the evidence base for current practice. National discussion of the boundaries of responsibility of care for the long term management of patients with these disorders is required. The integrated care pathway approach shows promise as a means of facilitating the development of audit within clinical genetics services.

Book
05 Jun 2000
TL;DR: This paper presents an overview of the history of Quality Assurance, and discusses approaches to quality assurance, clinical guidelines and evidence-Based Practice, and Integrated Care Pathways Accreditation with a difference.
Abstract: Introduction: An Overview of the History of Quality Assurance Approaches to Quality Assurance Total Quality Management Clinical Audit Clinical Effectiveness, Clinical Guidelines and Evidence-Based Practice Clinical Governance Integrated Care Pathways Accreditation with a Difference Glossary of Terms

Journal ArticleDOI
TL;DR: A follow up to this landmark survey, showing a marked increase in both the use of alternative care and the number of individuals seeking such care, revealed that 42.1% of Americans consulted at least 1 of 16 alternative therapies during 1997, an increase from 33.8% in 1990.
Abstract: I. INTRODUCTION Alternative medicine has been rapidly expanding as consumers drive the demand for more cost-effective, accessible and individualized healthcare.1 A commonly cited survey in the New England Journal of Medicine (NEJM) found that more Americans were consulting alternative care providers than allopathic/conventional physicians.2 In 1998, David Eisenberg published a follow up to this landmark survey, showing a marked increase in both the use of alternative care and the number of individuals seeking such care.3 The study revealed that 42.1% of Americans consulted at least 1 of 16 alternative therapies during 1997, an increase from 33.8% in 1990.4 Total visits to alternative practitioners soared from 427 million in 1990 to 629 million in 1997.5 This explosion of alternative care in the United States has begun to force prominent medical schools across the country to offer courses in alternative medical techniques.6 Over seventy-five major medical schools have begun to teach courses in alternative modalities.7 Moreover, the alternative care industry has established several journals to cover its expanding field.8 In an attempt to monitor the expanding field of medicine, Congress directed the National Institutes for Health to establish the Office of Alternative Medicine (OAM) in 1993.9 The OAM provides research grants to evaluate the safety and efficacy of alternative modalities.10 Since its inception, the OAM has funded over ninety research grants totaling over $13 million.11 Under the 1999 Omnibus appropriations bill, enacted on October 21, 1998, Congress established the National Center for Complementary and Alternative Medicine (NCCAM) in place of the OAM.12 Congress appropriated $50 million to establish NCCAM with the purpose of identifying and evaluating alternative modalities.13 For Fiscal Year 2000, Congress increased appropriations to $68.4 million to reflect growing interest in alternative care.14 "NCCAM has already begun a number of activities that will serve to facilitate the integration of validated CAM theories into conventional medical practice."15 Despite the dramatic surge in the promotion and use of alternative care, several obstacles still block alternative medicine's transition into the mainstream. Most notably, the American Medical Association (AMA) has impeded alternative providers access to its physicians' patients.16 An editorial in the NEJM lambasted alternative care, claiming that these therapies are insufficiently tested, "rely ... on anecdotes and theories", are possibly dangerous, and are "a reversion to irrational approaches to medical practice."17 In addition, the insurance industry has been slow to react to the rise in demand for alternative treatment and has only recently begun to experiment with coverage.19 The percentage of users paying entirely out-of-pocket for alternative therapies has improved only slightly between 1990 (64.0%) and 1997 (58.3%).19 These statistics demonstrate the difficulty still faced by consumers in obtaining coverage for alternative care. Consumer demand has created a market for alternative care; however, discrimination against these providers abounds.20 This Note focuses on the expanding field of alternative medicine and its struggle to find a place in the healthcare quagmire. Part II describes the five fields of practice that fall under the rubric of alternative medicine and their licensure status throughout the United States. Part III provides an overview of state medical practice statutes as they pertain to alternative care and their varying acceptance of non-conventional modalities. Part IV illustrates legislative and judicial reluctance to bring alternative medicine into the mainstream. Part V discusses both federal and state legislation to provide choice of care to consumers. Part VI enumerates reasons to provide consumers with freedom of choice as well as mechanisms for its regulation. Part VII concludes by arguing that federal and state government should enact legislation to bring conventional and alternative medicine together to accommodate the integrated care that consumers increasingly demand. …

01 Jan 2000
TL;DR: In this paper, the authors compared outcomes of care for patients receiving institutional rehabilitation for hip fracture in fee-for-service and group/staff HMO delivery systems and found no differences were found between patients with acute hip fracture on admission to inpatient rehabilitation.
Abstract: CONTEXT. Previous studies examining differences in the quality of care between capitated and fee-for-service payment systems have focused on the care delivered in a single setting. No study to date has compared outcomes over an entire episode of care delivered across multiple settings. OBJECTIVE. To compare outcomes of care for patients receiving institutional rehabilitation for hip fracture in fee-for-service and group/staff HMO delivery systems. DESIGN. One-year prospective inception cohort. SETTING. Six hospital-based, integrated care systems paid on a traditional fee-forservice model and five group/staff HMOs (paid fixed capitation rate by Medicare). The 11 delivery systems were selected because of their commitment to geriatric rehabilitation. PATIENTS. 196 fee-for-service and 140 group/staff HMO patients with acute hip fracture were identified on admission to inpatient rehabilitation. MEASURES. Four primary outcomes—recovery of activities of daily living, improvement in ambulation, return to community living, and mortality—were measured at 3, 6, 9, and 12 months. Service utilization was assessed in the acute-care hospital setting, rehabilitation setting, and at each 3-month follow-up interval. Risk adjustment was performed by using multiple and logistic regression. RESULTS. Overall, no differences were found between patients in group/staff HMOs and fee-for-service patients. Group/staff HMO patients experienced improved functional recovery at 6 months (P <0.01) and improved ambulation at 12 months (P =0.05) compared with fee-for-service patients, although these were isolated findings. With regard to utilization, group/staff HMO delivery systems used physician services less intensively and substituted less-skilled allied health personnel. CONCLUSION. Compared with fee-for-service delivery systems, with a similar commitment to excellence in geriatric rehabilitation, group/staff HMOs can achieve equivalent outcomes in older patients recovering from hip fracture with less-intense service utilization.

Journal ArticleDOI
TL;DR: Whether a shift towards integrated health care actually represents a Pareto‐optimal change is analyzed and an analysis of the consequences shows that care demanders, providers and informal care givers, to some extent and under certain conditions, can be expected to benefit from the introduction of integrated health Care.
Abstract: In many countries, health care reforms are being made with the purpose of stimulating actors to make economically sound decisions. Recent attempts in The Netherlands encompass the development and introduction of integrated health care arrangements. Since these arrangements are directly tailored to care demand, it is generally expected that integrated health care will enhance efficiency. This paper analyses whether a shift towards integrated health care actually represents a Pareto‐optimal change. An analysis of the consequences shows that care demanders, providers and informal care givers, to some extent and under certain conditions, can be expected to benefit from the introduction of integrated health care. Under long‐term considerations, the introduction of integrated care may be categorised as a potential Pareto‐improvement.

01 Sep 2000
TL;DR: Compared with fee-for-service delivery systems, with a similar commitment to excellence in geriatric rehabilitation, group/staff HMOs can achieve equivalent outcomes in older patients recovering from hip fracture with less-intense service utilization.
Abstract: CONTEXT Previous studies examining differences in the quality of care between capitated and fee-for-service payment systems have focused on the care delivered in a single setting. No study to date has compared outcomes over an entire episode of care delivered across multiple settings. OBJECTIVE To compare outcomes of care for patients receiving institutional rehabilitation for hip fracture in fee-for-service and group/staff HMO delivery systems. DESIGN One-year prospective inception cohort. SETTING Six hospital-based, integrated care systems paid on a traditional fee-for-service model and five group/staff HMOs (paid fixed capitation rate by Medicare). The 11 delivery systems were selected because of their commitment to geriatric rehabilitation. PATIENTS 196 fee-for-service and 140 group/staff HMO patients with acute hip fracture were identified on admission to inpatient rehabilitation. MEASURES Four primary outcomes--recovery of activities of daily living, improvement in ambulation, return to community living, and mortality--were measured at 3, 6, 9, and 12 months. Service utilization was assessed in the acute-care hospital setting, rehabilitation setting, and at each 3-month follow-up interval. Risk adjustment was performed by using multiple and logistic regression. RESULTS Overall, no differences were found between patients in group/staff HMOs and fee-for-service patients. Group/staff HMO patients experienced improved functional recovery at 6 months (P < 0.01) and improved ambulation at 12 months (P = 0.05) compared with fee-for-service patients, although these were isolated findings. With regard to utilization, group/staff HMO delivery systems used physician services less intensively and substituted less-skilled allied health personnel. CONCLUSION Compared with fee-for-service delivery systems, with a similar commitment to excellence in geriatric rehabilitation, group/staff HMOs can achieve equivalent outcomes in older patients recovering from hip fracture with less-intense service utilization.

Journal ArticleDOI
TL;DR: The role of the community pharmacist involved in primary care has been undergoing change, and emphasis was given to providing patient‐centered care and documenting cognitive services and methods for measuring performance are still lacking.
Abstract: The role of the community pharmacist involved in primary care has been undergoing change. In the late 1970s and early 1980s, developments in computerized medication surveillance within the Netherlands enabled pharmacists to react to prescriptions and detect inappropriate pharmacotherapy in community pharmacy sites. This activity became more clinically or patient-oriented in the late 1980s. In the early 1990s, pharmaceutical care was introduced in community pharmacy practice, and emphasis was given to providing patient-centered care and documenting cognitive services. The key features of pharmaceutical care provided in the primary care setting are described based on a review of the literature and on experiences in the Netherlands. Patient outcomes have yet to be shown to be improved by community pharmacy practice; methods for measuring performance are still lacking. Methods to evaluate the extent of integration of community pharmacy services into the clinical team are also lacking but are needed in order to define the future role of community pharmacists in the primary care setting. Integrated care needs to be developed in the Netherlands in order to present the next phase in the process of the "pharmaceutical evolution."

Journal ArticleDOI
TL;DR: The aim of the audit described in this article was to improve care for children with fever and neutropenia by introducing an integrated care pathway and the pathway has been changed to reflect care and can now be used to introduce new evidence or research in this field.
Abstract: The families of children undergoing treatment for cancer encounter many professionals with varying levels of training, experience and competency. This can lead to variance in the care and advice they receive. The aim of the audit described in this article was to improve care for children with fever and neutropenia by introducing an integrated care pathway. Guidelines for neutropenia were examined and a retrospective analysis of notes undertaken to study what was happening before a pathway was introduced. From this, standards were set and a pathway developed which was introduced to all members of the oncology unit and implemented as part of the children’s care. This article will also focus on the audit and evaluation of the pathway. Following this, the pathway has been changed to reflect care and can now be used to introduce new evidence or research in this field.

Journal ArticleDOI
TL;DR: The consumerist methodology for the PCDP was designed to maximise staff involvement in capturing user views, in order to develop services at a district general hospital, and is being used to develop multi-agency integrated care pathways.
Abstract: A number of approaches have been developed in recent years to try effectively to engage service users in the process of planning and delivering health‐care services. The consumerist methodology for the strategy described in this paper was designed to maximise staff involvement in capturing user views, in order to develop services at a district general hospital. This strategy – the Patient Care Development Programme (PCDP) – provides a framework for both staff and patient involvement in shaping and influencing the development of health‐care services. Uses the findings from applying the strategy to modify care packages, roles, skills, layouts, protocols and procedures, in response to both the “shortfalls” and the service strengths that the patient’s view uncovers. Discusses the results of an evaluation of the programme which has been replicated in another part of the UK. The PCDP now forms part of a clinical governance framework and is being used to develop multi‐agency integrated care pathways.

Journal ArticleDOI
TL;DR: In this article, the authors evaluated GP-hospital integration and highlighted areas where further research, development, and evaluation are required, and found that GP-Hospitals made substantial progress towards their goals and highlighted important aspects of successful collaboration.
Abstract: The aim of the study reported here was to evaluate current initiatives in GP-hospital integration and highlight areaswhere further research, development and evaluation are required. Seven pre-existing GP-hospital programs wereselected and given supplementary funding to allow for more effective evaluation. These local evaluations were thenincorporated into a national program on GP-hospital collaboration.We found that the seven projects made substantial progress towards their goals, and in the process highlighted importantaspects of successful collaboration. The collective evaluation of DHIP identified expected benefits of collaboration forpatients (improved access to services, reduced anxiety, and fewer post discharge complications), for GPs (increasedinvolvement in acute care and in hospital decision making), and for service organisations (stronger workingrelationships, increased capacity, and greater efficiency). Barriers to service integration were also identified, includingthe different cultures of Divisions and hospitals, their lack of internal coherence and the Commonwealth-state divide.The evaluation showed that much has been achieved in building the relationships and the capacity needed for GP-hospitalcollaboration, and that effective models exist. The current challenge is to extend successful models acrosshealth areas and make effective collaboration part of the normal system of care. Substantial progress towardsintegrated care relies on a shift from a focus on systems within general practice or hospital environments to a patientcentred approach. This will require general practice, hospitals, community services and consumer organisations toform long term partnerships and move beyond their currently disjointed view of acute and community care. Thedevelopment of practical indicators for integrated care will support the process and facilitate shared learning acrossCommonwealth and state divides.

Journal ArticleDOI
TL;DR: The principal messages in this paper are about the relationships that nurses build with patients and their families over long periods of care, the paradoxical sense of 'outsideness' that can occur when the home becomes medicalized and the importance of the home as a healing environment.
Abstract: The paper describes aspects of a journey through the health-care system following a domestic accident. The journey commenced in the accident and emergency department and, over a 3 month period, traversed the operating theatre, intensive care and an orthopaedic ward before moving into a Hospital in the Home programme and community health and district nursing services. The paper explores the experiences of the accident victim, a 56-year-old man, and his wife who is an experienced nurse and university lecturer. The paper supports the 'seamless delivery' concept of integrated care while, at the same time, sounding notes of caution. The principal messages in this paper are about the relationships that nurses build with patients and their families over long periods of care, the paradoxical sense of 'outsideness' that can occur when the home becomes medicalized and the importance of the home as a healing environment.

Journal ArticleDOI
TL;DR: A new strategy for development of primary care in the Czech Republic encourages integration of care and defines primary care as co-ordinated and complex care provided at the level of the first contact of an individual with the health care system.
Abstract: The objective of this paper is to describe the recent history, current situation and perspectives for further development of the integrated system of primary care in the Czech Republic. The role of primary care in the whole health care system is discussed and new initiatives aimed at strengthening and integrating primary care are outlined. Changes brought about by the recent reform processes are generally seen as favourable, however, a lack of integration of health services under the current system is causing various kinds of problems. A new strategy for development of primary care in the Czech Republic encourages integration of care and defines primary care as co-ordinated and complex care provided at the level of the first contact of an individual with the health care system.

Journal Article
S Johnson, M Dracass, J Vartan, S Summers, J Edington 
TL;DR: An integrated care pathway is a tool that can help to deliver clinical governance objectives if implemented well and key factors of successful implementation are: effective project management; communication and training; and top-down and bottom-up support for the process.
Abstract: An integrated care pathway is a tool that can help to deliver clinical governance objectives if implemented well. Key factors of successful implementation are: effective project management; communication and training; and top-down and bottom-up support for the process.