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PubMedDate not supplied

Case management of the elderly in a health maintenance organization: the implications for program administration under managed care.

Kaiser Permanente initiated a two-year demonstration ambulatory case management program in its Ohio region to evaluate five outcomes: perceived health status, functional status, and satisfaction with care, service use, and service costs. Expected results were not consistently obtained for the five outcome measures. Treatment group members did not, however, experience the functional status impairments or decline in health status perceptions reported by the control group during the study period. The unexpected finding that costs were not affected may be attributed to the type of case management intervention used in the demonstration program. This study is broadly applicable to managed care settings facing the challenge of developing programs to minimize the risk for bearing the costs of the Medicare beneficiaries' overall health when all services are not covered. Managed care administrators should be favorably disposed to implementing a case management model with the potential for affecting functional status, the most significant predictor of expensive continuing care for this cohort of Medicare beneficiaries, while working to develop more effective protocols and resource control strategies.

Aged↗

PubMed2003

Health data management and strategic management in Brittany: some practical problems.

Recent changes in the organisation of the French health system include 1996's ordinances, and more recently (4th Law march 2002). The general tendency of all these reforms is the management of the health system at the regional level in France. In This paper we try to find how health data management systems could be concerned by this changes. In the first part we will explain why the health data management systems are implicated in theses changes. After that we specify the kind of information needed for strategic management of health at the regional level in Brittany. Then we discuss what information is available from all health data management systems at the regional level as far as decision making in health is concerned.

Database Management Systems↗

PubMed1990

An investigation of managed health care case managers.

Managed care case management is a relatively new concept within health and rehabilitation. As such, it lacks both definition and profiles of those providing services. This paper constructs a definition of managed care case management and presents the detailed results of a survey that identified the characteristics of case managers in the Midwest. The survey was mailed to 250 subjects. The respondents of the survey (N = 56) were relatively young (the largest number of respondents were 30 to 39 years of age), relatively new to their jobs (means = 2.2 years), and were typically employed full-time. They primarily served mental health (n = 43) and physically impaired (n = 30) clients. The highest number of their service referrals were made to vocational rehabilitation specialists, social workers, occupational therapists, nurses, and physical therapists.

Administrative Personnel↗

PubMed1988

A management development program for middle level nurse managers.

In an economic-oriented, competitive health care environment, middle level nurse managers must now perform their roles with a higher level of managerial and leadership skills than previously required. A systematic, consistent approach to the development of nurse managers will assist them in meeting role responsibilities. The authors describe a management development program for middle level nurse managers. An orientation curriculum plan is presented and a framework for advanced management enhancements is illustrated.

Administrative Personnel↗

PubMed1994

Managed health-care: managing demand through the control of supply.

Managed Care has been developed in the United States as a strategy over the failure of the insurance system in controlling costs and utilisation. It works through a model which incorporates financing and delivery of services, with the control of health-care providers, facilities and services, as well as programmes like quality assurance and utilisation review, to achieve its goal of providing adequate care at an affordable price. In economic terms, that is to manage demand through the control of supply. In Singapore, the National Trade Union Congress (NTUC) has launched the pilot large-scale managed care plan in 1994. It is not recommended in this article that the entire managed care model be transplanted into Singapore, but some of the principles could be used to improve our healthcare system. Applicability of the managed care concept must be viewed with the peculiar health system in Singapore such as the already existing low-cost and easily accessible primary care service. More time would also be required to prepare the health-care professionals as well as the public for this new health-care venture.

Cost Control↗

PubMed1994

Critical care medicine in managed competition and a managed care environment.

The high cost of medical care in the United States and diminishing access to health care for many Americans has spurred healthcare reform efforts in this country. Several bills have been introduced into Congress. Many of these healthcare bills and other proposals embrace the concept of managed care and managed competition as their central feature. The steady growth of managed care organizations and the possible adoption of managed competition stands to significantly alter the way critical care medicine is practiced and delivered in the United States. The number of ICUs and ICU beds may be reduced, affecting both patient case mix and the overall mission of the ICU and critical care practice. Furthermore, fewer critical care practitioners may be available as a result of diminished educational funding and reduced training programs. In view of these and other impending changes in the American healthcare system, it is vital to investigate the impact of managed care on ICU practice and patient outcome and to study the incremental and value-added contributions of critical care medicine.

Cost Control↗

PubMed1997

The role of managed care "products" in managed care "plans".

This paper presents information about the form and structure of managed care products offered by group/staff health maintenance organizations (HMOs), network/independent practice association (IPA) HMOs, and preferred provider organizations (PPOs). The information comes from a 1994 national survey of managed care plans and their arrangements with physicians. The findings confirm that multiple product offerings are now common in managed care plans. The two reasons plans most often cite for including these expanded offerings are to respond to customer interest and to ease the transition to more traditional managed care. Though plans commonly use a consistent provider network for different products, they also vary some arrangements with physicians across their products and pay them in different ways. We discuss the implications of our findings-the most comprehensive study of these issues to date-to aid in understanding the evolution of markets and of managed care, and as a basis for the design of future research and the databases it will require.

Data Collection↗

PubMed2002

The evolving role and care management approaches of safety-net Medicaid managed care plans.

This article provides new empirical data about the viability and the care management activities of Medicaid managed-care plans sponsored by provider organizations that serve Medicaid and other low-income populations. Using survey and case study methods, we studied these "safety-net" health plans in 1998 and 2000. Although the number of safety-net plans declined over this period, the surviving plans were larger and enjoying greater financial success than the plans we surveyed in 1998. We also found that, based on a partnership with providers, safety-net plans are moving toward more sophisticated efforts to manage the care of their enrollees. Our study suggests that, with supportive state policies, safety-net plans are capable of remaining viable. Contracting with safety-net plans may not be an efficient mechanism for enabling Medicaid recipients to "enter the mainstream of American health care," but it may provide states with an effective way to manage and coordinate the care of Medicaid recipients, while helping to maintain the health care safety-net for the uninsured.

Accreditation↗

PubMed2001

Integrating end-of-life care with disease management programs: a new role for case managers.

Case managers are crucial to any well-designed disease management program. However, in the progressive course of serious illness, patients, their families, and MCOs need the skills of case manager more than ever to help them through end-of-life care choices. The author describes what case managers will need in their "toolbox" to provide insight to these health plan members.

Case Management↗

PubMed2000

Surgery versus thrombolysis for acute limb ischaemia: initial management.

BACKGROUND: Peripheral arterial thrombolysis has become established as a useful adjunct in the management of peripheral arterial ischaemia. Much has been learnt about indications, risks and benefits using this technique, although data from randomised controlled studies is not extensive. The optimal initial management of the acutely ischaemic leg needs to be determined. OBJECTIVES: To determine if surgery or thrombolysis is the preferred option in the initial treatment of acute limb ischaemia. SEARCH STRATEGY: The search strategy was that adopted by the Cochrane Review Group on Peripheral Vascular Diseases. Additionally, reference lists of papers resulting from this search were reviewed. SELECTION CRITERIA: All randomised studies comparing thrombolysis and surgery in the management of acute limb ischaemia. DATA COLLECTION AND ANALYSIS: Trial quality was assessed and data were extracted independently by all three reviewers. MAIN RESULTS: Patients with acute lesions of less than seven days duration had a significantly increased survival at one year for patients having thrombolysis, compared to those undergoing initial surgery [84% v 58%, p=0.01; Odds ratio (95% CI) 0.28 (0.13,0.63)] largely associated with a reduced level of in-hospital cardio-pulmonary complications (Ouriel 1994). Lesions less than 14 days duration fared better with initial lysis with a reduced amputation and reduced death rate at six months [15.3% v 37.5%; p=0.001; Odds ratio (95%CI) 0.29 (0.12,0.72)] (STILE 1994), compared to initial surgery. Analysis of the same trial at one year however revealed that native vessel thromboses had a more favourable outcome with initial surgery, largely due to continuing ischaemia in the lytic group [64% v 35%; p<0.0001; Odds ratio (95%CI) 3.26(1.96,5.52)] (Weaver 1996). Bypass graft thromboses less than 14 days old treated with initial thrombolysis were shown to have a reduced amputation rate (15% v 47%; p=0.05). However, overall, one year results revealed that thrombolysis of thrombosed grafts was associated with a higher level of continued ischaemia [73% v 50%; P=0.010; Odds ratio (95%CI) 2.72(1.27,5.80)] (Comerota 1996). REVIEWER'S CONCLUSIONS: A universal initial treatment with either surgery or thrombolysis cannot be advocated on the available evidence. There is no overall difference in limb salvage or death at one year between initial surgery and initial thrombolysis. Thrombolysis may however be associated with a higher risk of ongoing limb ischaemia, and a higher overall risk of haemorrhagic complications including stroke. The higher risk of complications needs to be balanced against the risks of surgery in the individual patient.

Humans↗

PubMed2004

Community participation in natural resources management: reality or rhetoric? Lessons learnt from the Kasanka Game Management Area (GMA) communities, Serenje District, Zambia.

In the developing world, the term 'participation' has in recent years become a household word in the same way that 'democracy' or 'gender' have. Development agencies are demanding increased participation in their programmes. The use of the word or its application has become a centre of debate. Due to the difficulties involved in measuring 'participation' or indeed determining levels at which participation should take place, who participates and when, many 'doubting Thomases' have questioned its effectiveness. It has, however been acknowledged in many areas that popular participation changes policies and enhances management and governance. In complex issues of natural resources management, participatory techniques have helped communities develop collective responsibilities towards management of their resources and projects. This paper discusses the complexities of community participation in natural resources management, ranging from interrelations among stakeholders to resource ownership based on the experiences in the Kasanka Game Management Area (KGMA).

Animals↗

PubMed2007

Descriptive analysis of the process and quality of oral anticoagulation management in real-life practice in patients with chronic non-valvular atrial fibrillation: the international study of anticoagulation management (ISAM).

BACKGROUND/OBJECTIVES: Expert oral anticoagulation management is the key to good outcomes and is performed variably in different health care systems throughout the world. We set out to assess the quality of anticoagulation management in five countries in patients receiving vitamin K antagonists (VKAs) for stroke prophylaxis in chronic non-valvular atrial fibrillation (NVAF), and to compare the anticoagulation management practices in these countries. METHODS AND RESULTS: This was a retrospective, multi-centre cohort study in the United States, Canada, France, Italy, and Spain. About 1,511 patients were randomly recruited from representative practices (routine medical care (RMC) in the US, Canada, and France; anticoagulation clinics in Italy and Spain) and data pertaining to their oral anticoagulation care were abstracted from their medical records. The predominant anticoagulant in use was warfarin in the US, Canada, and Italy; acenocoumarol in Spain; and fluindione in France. Documentation of care was poor in the US, Canada, and France, countries where RMC was studied. Percent INRs or time-in-therapeutic range was greater in the two anticoagulation clinic samples compared with the RMC samples. CONCLUSION: Oral anticoagulation care varies considerably from country to country. Findings suggest that anticoagulation clinic care (ACC) may provide better outcomes as assessed by international normalized ratio (INR) time-in-range. Physicians tend to under treat more than over treat. Finally, documentation of care is often inadequate. Condensed Abstract Oral anticoagulation management (routine medical care or anticoagulation clinic care) was retrospectively assessed in 5 countries using a uniform, structured assessment tool. Major management differences were detected, especially between anticoagulation clinic care and routine care. Documentation was often a problem in the latter setting. Less time in therapeutic INR range was noted in routine medical care. Findings suggest that anticoagulation clinic care may provide better outcomes as assessed by international normalized ratio (INR) time-in-range. Physicians tend to under treat more than over treat. Finally, documentation of care is often inadequate.

Acenocoumarol↗

PubMed2005

Impact of invasive management versus noninvasive management on functional status and quality of life following non-Q-wave myocardial infarction: a randomized clinical trial.

BACKGROUND: Multiple studies have examined whether clinical outcomes are improved by invasive management following non-Q-wave myocardial infarction (NQWMI). However, it remains unclear whether functional status and quality of life are affected by an invasive strategy. METHODS: Following NQWMI, we randomized 88 patients to invasive management vs noninvasive management. The primary end point was functional status assessed at 12 months using maximal endurance exercise treadmill testing measured in metabolic equivalents. Secondary end points included changes in scores between baseline and 12 months on the Duke Activity Status Index, the Seattle Angina Questionnaire, and the Medical Outcomes Study 36-Item Short-Form Survey. RESULTS: Of the 42 patients in the invasive arm, 83% underwent initial angiography. Of the 46 patients in the noninvasive arm, 91% underwent initial stress testing. Inhospital and 12-month revascularization rates were similar in the 2 arms (24% vs 22%, P > or = .99; 31% vs 30%, P > or = .99). Maximal endurance exercise treadmill testing was also similar at 12 months (7.8 vs 6.7 metabolic equivalents, P = .24). Patients in the invasive arm showed improved functional status by mean difference in their Duke Activity Status Index scores (4.3 vs -3.5, P = .04). Improvements in angina-specific quality of life for patients in the invasive arm were demonstrated by the Seattle Angina Questionnaire measures of anginal stability (21.6 vs -5.3, P = .02), anginal frequency (22.9 vs 2.3, P = .02), treatment satisfaction (11.2 vs -10.3, P = .02), and disease perception (24.7% vs 10.9%, P = .07). CONCLUSIONS: Compared with patients undergoing noninvasive management of NQWMI, patients undergoing invasive management have some measures indicative of improved functional status.

Coronary Angiography↗

PubMed2004

Acceptable, manageable, and tolerable days: patient daily goals for medication management of persistent pain.

Although the construct of "a symptom-free day" has been widely applied in asthma and gastric reflux disease, there is no analogous concept in the field of pain management. This study represents the initial development of a "day of acceptable or manageable pain control," a construct which reflects patients' daily strategic use of pain medication in order to allow the accomplishment of desired activities while minimizing side effects. Focus group methodology was used to extract patient-generated themes of "an acceptable day of pain control." Fifty-three outpatients with persistent moderate to severe average pain intensity due to osteoarthritis (n=18), metastatic cancer (n=15), and low back pain (n=20) participated. Participants preferred the term "manageable" or "tolerable" to "acceptable." Thematic analysis revealed components of a manageable/tolerable day of pain control as including: 1) taking the edge off the pain, 2) performing valued activities; 3) relief from dysphoria and irritability; 4) reduced medication side effects; 5) feeling well enough to socialize. Additional cancer-specific themes included relief from fatigue and ability to have a positive day when one's future days were perceived as being limited. The set of themes is presented and their relevance for developing a measure of "a manageable day of pain control" discussed. Study findings identify a novel construct that can inform development of an outcome for evaluating the effectiveness of different pharmacotherapies for pain management.

Adult↗

PubMed2005

Integrating HIV management for children into the Integrated Management of Childhood Illness guidelines.

The WHO/UNICEF strategy of Integrated Management of Childhood Illness (IMCI) has been adopted as a strategy for improving paediatric care in resource-poor settings. The original IMCI guidelines recommend referral of children with severe or recurrent illnesses such as those common in HIV/AIDS, however the specific identification and management was not included. In many countries, especially in sub-Saharan Africa, HIV/AIDS contributes significantly to child morbidity and mortality. There was a need to include the specific assessment and management of symptomatic HIV infection in IMCI guidelines. A draft HIV component of the IMCI guidelines was developed, which included management of symptomatic HIV cases with referral for counselling and testing, and was evaluated in South Africa. A revised version was then validated in Ethiopia and Uganda where HIV, malnutrition and malaria prevalence is different from South Africa. IMCI materials have been adapted to include an HIV component. Currently, very few children under 15 years of age receive antiretroviral therapy (ART). Chronic HIV care of children, including ART for children, has been developed within the Integrated Management of Adolescent and Adult Illness (IMAI) initiative of the WHO. Through this initiative, the WHO is assisting countries to facilitate care and treatment of children undergoing ART.

Adolescent↗

PubMed2001

A controlled clinical trial of home care management versus hospital care management for preterm labour.

Prenatal hospitalisation has not been shown to reduce perinatal morbidity and mortality, yet it is still the treatment of choice for women who experience preterm labour. Home care management may be an alternative means of delivering safe, efficacious and care for these women. The objectives of this controlled clinical trial were to examine differences in neonate's gestational age and birthweight, and antenatal stress, social support satisfaction, and family functioning among pregnant women receiving home care and those receiving hospital care management. Pregnant women experiencing preterm labour (N=250) were randomly assigned to home care management (the experimental group [EG]) or hospital care management (the control group [CG]). A Perinatal Information Form was used to collect data on sociodemographic and pregnancy variables. The High-Risk Pregnancy Stress Scale, Brown's Social Behaviors Inventory, and the Family Assessment Measure III Dyadic Relationships Scale were administered to the women at randomisation (T1) and at 1-week (T2) and 2-weeks (T3) after randomisation. Gestational age and birthweight were similar in the two groups of neonates. Women in the EG reported that antenatal stress was significantly lower at T3 than at T1 and T2, while for those in the CG, antenatal stress was significantly lower at T3 than at T1, and significantly lower at T2 than at T1. Women in the EG were more satisfied with support from the male partner at T3 than women in the CG. There was no significant difference between the two groups in family functioning at T1, T2 and T3. These findings indicate that home care management is a safe and efficacious mode of health care delivery for women experiencing preterm labour.

Adult↗

PubMed2002

Measuring the quality of children's postoperative pain management: initial validation of the child/parent Total Quality Pain Management (TQPM) instruments.

Quality improvement measurement instruments for pediatric postoperative pain management are virtually nonexistent. Without standardized instruments to measure pediatric pain management outcomes, practitioners are hampered in their efforts to improve the quality of pain management for children. In this study, instruments for children (8--12 years) and parents were developed and tested to measure the quality of children's postoperative pain management. The child (Child TQPM) and parent (Parent TQPM) Total Quality Pain Management instruments were tested with 50 parent/child dyads across two large treatment centers. The pain rating scale modified for these instruments demonstrated good criterion validity with the well established Varni/Thompson Pediatric Pain Questionnaire Visual Analogue Scale. Parent--child agreement was described for responses across instruments. Construct validity was examined through selected inter-item relationships. Psychometric analyses support the initial measurement properties of the pediatric TQPM instruments.

Adult↗

PubMed2003

[Asthma education and self-management: inevitable requirements to enhance disease control and achieve the goals for long-term asthma management].

The patient should be the primary manager of chronic disease guided and coached by a doctor and healthcare workers. The challenge now is to recognise that establishing patient-provider partnerships is an essential step in helping patients to learn and manage chronic illnesses like asthma. This article focuses on what is known about asthma patient education and on reducing the barriers to effectively applying what is known. Whereas traditional patient education offers information and technical skills, self-management education teaches problem-solving skills. A central concept in self-management is self-efficacy, the confidence to carry out a behavior necessary to reach a desired goal (outcome-efficacy). Effective teaching on chronic diseases must be based more closely on the findings of behavioural research. Therefore, self-management education has to become an integral part of high-quality care in asthma.

Asthma↗