Biomedical subjects
Publications and source records attributed to P Chiverton.
This article presents an example of how one hospital identified costs for capitation in psychiatric case management. An 18-month postacute case management pilot project collected data on a nurse-specific and patient-specific basis. Costs were identified using activity-based costing methodology.
Within the rapidly changing health care system, there is an increased need for professionals who can provide cost-effective primary health care for mentally ill patients. This article discusses the role of the Psychiatric Advanced Practice Nurse (APN) with Prescriptive Authority as a cost-effective, high-quality component of comprehensive mental health care delivery. Historical aspects of the development of the Nurse Practitioner (NP) role are discussed, as well as issues specific to the role in psychiatric nursing. The implementation of this role at Rochester is described, followed by recommendations for studying the impact of the psychiatric NP on care delivery, including process and outcome variables.
To establish a school-based health center, it is more important than ever to plan for financial support for building a practice. It is difficult to get to and stay at the target enrollment for this population since it is ever-changing group of students. Plan for increased numbers of initial assessments since every year at least one-fourth of the enrollees in the program change. Work closely with primary care providers and make it clear in verbal and written communication that there is no intent to disrupt the relationship with the student. Assess risk of the population and attempt to predict utilization of services (number and type of encounters) and determine costs of care. It is also important to find ways to track hospitalizations, emergency room visits and other unscheduled access to care. Since adolescents frequently seek confidential care, parents and providers may be uninformed regarding the actual cost of management of covered lives in a managed care environment.
Neurological illness often influences the patient's behavior either as a direct result of trauma or due to pathophysiological changes to the brain. Neurological patients also experience psychological responses to their illness resulting in a heightened potential for a dual impact on behavior. The neuropsychiatric nurse provides care to patients with severe or unusually persistent behavioral manifestations of illness. Neurologic, psychiatric, cognitive and functional assessments are completed by the neuropsychiatric nurse to obtain an accurate picture of the behavioral problem. Nursing interventions are then developed to improve functional ability and promote independence. If a neuropsychiatric nurse is not available many of these assessment skills can be employed by neuroscience nurses and implemented on neurological and neurosurgical units.
This article addresses a neglected area within nursing knowledge development: appropriate conceptual frameworks for guiding care of institutionalized, cognitively-impaired elders. Following a review of possible conceptual frameworks, psychological well-being, as defined by Lawton (1983), is proposed as an appropriate framework for guiding knowledge development and care of this elderly population. Two aspects of psychological well-being, positive and negative affect, may be appropriate indicators of the concept in cognitively-impaired elders. Instruments for measurement of psychological well being are also discussed. The implications of using psychological well-being as a conceptual basis for both research and nursing care are presented.
Secondary analyses of a randomized trial comparing two models of case management of community residing chronically ill elderly showed that the greatest cost savings of the more intensive neighborhood-based team model, as opposed to the centralized individual model, were in the group with dementia. Estimated costs of health care in the team group were 41% lower than costs for the control group. No differences in survivorship, functional and care need status, or in caregiver satisfaction were found, suggesting no negative effect of reduction in use. Team case managers had much smaller caseloads, made many more home visits, (with much more counseling for family support), and made more referrals for medical evaluation, respite, and day care than did case managers for the control group.
This study investigates whether a brief educational program, provided to spouses of patients with Alzheimer's disease, improved the caregivers' coping skills; it also questions whether the gender of the spouse had an effect on coping ability. The sample consisted of 40 spouses who were caring for the Alzheimer patient at home, 20 who participated in the educational program, and 20 controls. The instrument used for the study was the Health Specific Family Coping Index (HSFCI). This instrument provided a quantitative assessment of overall family coping with both potential and actual health problems in the psychosocial and physical domains of health. It is rated in nine domains: physical independence, therapeutic competence, knowledge of the condition, application of principles of personal hygiene, attitude toward health care, emotional competence, family living patterns, physical environment, and use of community resources. A home visit was made by a registered nurse prior to the educational intervention and at the end of the four-week intervention period. The HSFCI was completed at each visit. There were no pretreatment differences between the intervention and control groups in coping ability. Findings indicate that the educational program was beneficial in assisting spouses to feel greater competence in the face of the disease process and to function with greater independence. In the treatment group, the greatest significant increase was in the knowledge domain, followed by therapeutic competence and emotional competence. There was no overall relationship between gender of the spouse and coping ability.
We examined children from Monroe County, New York, to establish the prevalence of Gilles de la Tourette's syndrome (TS) in the county's schools. Patients were recruited for free evaluations from physicians, other health professionals, school personnel, and through extensive coverage in the local news media. Forty-one TS patients were detected among the 142,636 pupils enrolled in the county's public and private schools at the time of the study (estimated prevalence, 28.7 per 100,000). Twenty patients had obsessive-compulsive symptoms, but only three had an impairing, diagnosable disorder. Fifty-six percent had a positive family history for TS or tics. Eighteen needed pharmacotherapy, although, for most, TS was a mild disorder requiring no drug treatment.
Five kindreds with multiple individuals manifesting Tourette syndrome (TS) or related abnormal movements were evaluated for linkage between TS and HLA-A, B, C and DR antigens. Families were selected to have a constellation of affected individuals which gave the appearance of transmission of a major susceptibility gene. All kindreds had at least two clearly affected first or second degree relatives. Although developmental neurobehavioral disorders are candidates for showing a relationship to specific tissue antigens, we found no evidence for a close linkage between a gene locus determining susceptibility to TS and the HLA loci.
Psychiatric emergency services have evolved into more comprehensive programs during the past two decades. With this evolution other disciplines have gained access to the services and integrated their expertise and philosophy into the daily care of patients. Nursing has been an integral part of this process and contributed its perspective in nursing care. This paper outlines the development of psychiatric emergency services with a special emphasis on the contribution of nursing specialists who have developed their role within the psychiatric emergency service. What has been unique about the nursing contribution is the attention to individualizing patient care and modifying treatment approaches to meet the patients' needs and interests in psychiatric treatment. Additionally, nursing has complemented the physician's role by developing expertise in assessment that is both psychologically and biologically oriented. Nursing's future contribution to psychiatric emergency services should address mechanisms for tracking patients who enter the psychiatric emergency service system with an emphasis on linkage with other programs or resolution of the crisis episode.
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Outcomes of a work site disease management program managed by an advanced practice nurse were evaluated. Fifty-four participants were surveyed. A significant number of participants with dyslipidemia and diabetes reported that the program positively changed individual health behaviors. Those with dyslipidemia and hypertension reported improved understanding of their condition after being involved with the program, and participants with asthma indicated more control of their condition. Program satisfaction was high. Continued development and implementation of work site programs are indicated to improve health outcomes of employees.
In the context of market-driven health care reform, interest in cost and quality outcomes has increased. Quality, as defined by Donabedian, includes assessment of structure, process, and outcomes. However, the definition of quality in health care must be expanded to include the expectations and opinions of patients, their representatives, and society. The purpose of this article is to examine the outcome variable of costs in a specific nursing practice setting. Cost is frequently defined as the judicious use of resources consumed by structures and processes of care. This article presents activity-based costing methodology and results of a cost study of primary care and mental health services provided by advanced practice nurses (APNs) in a school-based health center. The application of the methods and outcomes of this pilot study has significant implications for the delivery of health care by APNs in a variety of settings, including community nursing centers, freestanding birthing centers, and rural and urban neighborhood centers. Because much of the health care delivered by APNs in these community-based settings includes health promotion, screening, counseling, and anticipatory guidance, it is important to explore methods such as activity-based costing to identify actual costs of care (versus charges) in emerging community-based practices where primary care is delivered by APNs.