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PubMed2002

Adherence to postacute rehabilitation guidelines is associated with functional recovery in stroke.

BACKGROUND AND PURPOSE: The purpose of this study was to determine if compliance with poststroke rehabilitation guidelines was associated with better functional outcomes. METHODS: An inception cohort of 288 stroke patients in 11 Department of Veteran Affairs Medical Centers hospitalized between January 1998 and March 1999 were followed prospectively for 6 months. Data were abstracted from medical records and telephone interviews. The primary study outcome was the Functional Independence Motor Score (FIM). Secondary outcomes included Instrumental Activities of Daily Living (IADL), SF-36 physical functioning, and the Stroke Impact Scale (SIS). Acute and postacute rehabilitation guideline compliance scores (range 0 to 100) were derived from an algorithm. All outcomes were adjusted for case-mix. RESULTS: Average compliance scores in acute and postacute care settings were 68.2% (SD 14) and 69.5% (SD 14.4), respectively. After case-mix adjustment, level of compliance with postacute rehabilitation guidelines was significantly associated with FIM motor, IADL, and the SIS physical domain scores. SF-36 physical function was not associated with guideline compliance. Level of compliance with rehabilitation guidelines in acute settings was unrelated to any of the outcome measures. CONCLUSION: Greater levels of adherence to postacute stroke rehabilitation guidelines were associated with improved patient outcomes. Compliance with guidelines may be viewed as a quality-of-care indicator with which to evaluate new organizational and funding changes involving postacute stroke rehabilitation.

Activities of Daily Living↗
PubMed1991

Designing mental health facilities: an interactive process.

Program and funding changes in mental health service delivery in the past 15 years have resulted in ever-changing demands on the use of physical space in mental health facilities. An interactive planning process facilitated by a multidisciplinary design team can anticipate and address many difficulties with space utilization in construction or renovation. An architectural feasibility, study, including a careful definition of user requirements, is a useful document for facilitating intraagency communication, securing external funding, and moving capital projects to completion.

Adult↗
PubMed2005

Time on wait lists for coronary bypass surgery in British Columbia, Canada, 1991-2000.

BACKGROUND: In British Columbia, Canada, all necessary medical services are funded publicly. Concerned with growing wait lists in the mid-1990s, the provincial government started providing extra funding for coronary artery bypass grafting (CABG) operations annually. Although aimed at improving access, it is not known whether supplementary funding changed the time that patients spent on wait lists for CABG. We sought to determine whether the period of registration on wait lists had an effect on time to isolated CABG and whether the period effect was similar across priority groups. METHODS: Using records from a population-based registry, we studied the wait-list time before and after supplementary funding became available. We compared the number of weeks from registration to surgery for equal proportions of patients in synthetic cohorts defined by five registration periods in the 1990s. RESULTS: Overall, 9,231 patients spent a total of 137,126 person-weeks on the wait lists. The time to surgery increased by the middle of the decade, and decreased toward the end of the decade. Relative to the 1991-92 registration period, the conditional weekly probabilities of undergoing surgery were 30% lower among patients registered on the wait lists in 1995-96, hazard ratio (HR) = 0.70 (0.65-0.76), and 23% lower in 1997-98 patients, HR = 0.77 (0.71-0.83), while there were no differences with 1999-2000 patients, HR = 0.94 (0.88-1.02), after adjusting for priority group at registration, comorbidity, age and sex. We found that the effect of registration period was different across priority groups. CONCLUSION: Our results provide evidence that time to CABG shortened after supplementary funding was provided on an annual basis to tertiary care hospitals within a single publicly funded health system. One plausible explanation is that these hospitals had capacity to increase the number of operations. At the same time, the effect was not uniform across priority groups indicating that changes in clinical practice should be considered when adding extra funding to reduce wait lists.

Aged↗
PubMed2004

Can Community Health Center funding enhance health services for Native American tribes and organizations?

This paper reports on the applicability of the Public Health Service Act (42 USC, 254b) Section 330 Community Health Center program to Arizona Native American tribes and organizations. Data review and analysis consisted of a review of two federal government documents concerning the funding of Community Health Center applications and a review of questionnaire responses received from the Arizona Native American health care community. Findings indicate a general lack of knowledge among the Arizona Native American health care community about the program as well as a need for capacity building among Arizona Native American tribes and organizations. As currently designed, the program has built-in barriers that prevent Native American tribes and organizations from applying for funding. Changes must be made to the existing program and local-level seminars must be offered to make this program and funding more readily available to Arizona Native American tribes and organizations.

Administrative Personnel↗
PubMed1981

Federal funding formulas and the 1980 census.

Distribution of federal funds has achieved equal status with Congressional reapportionment as a motivation and justification for the Census of Population and Housing. This article describes the effects that U.S. population redistribution during the 1970s, as measured by the 1980 Census, will have on the spatial distribution of federal grants-in-aid provided to state and local governments through programs with formula-based funding systems. The conclusion is that funding changes will not match population changes. The overall redistribution of federal grants-in-aid to state and local governments occurring in response to incorporation of 1980 Census population counts into federal funding formulas will be far less than the level of population redistribution since 1970. Use of intercensal data, formula specifications, limited geographic specificity in many formula allocations, and nonformula determinants of formula-based grants all weaken the relationship between Census-measured population change and the receipt of federal funds at the local level. Despite all the intervening factors, it is probably that in many programs there will be some redistribution of funds when the 1980 Census counts are incorporated into the allocation formulas. But the importance of measurement errors and threshold and reclassification effects may equal that of true population change in determining the funds received by local communities.

Financing, Government↗
PubMed1999

Physicians' perceptions of the effect on clinical services of an alternative funding plan at an academic health sciences centre.

BACKGROUND: In July 1994 an alternative funding plan for clinical services (global funding instead of fee-for-service payment) was established at the Southeastern Ontario Health Sciences Centre, Kingston, Ont. This study describes the perceptions of the referring physicians and consultants of the effects of the alternative funding plan 2.5 years after it was initiated. METHODS: A questionnaire was mailed to all physicians in the Kingston area in November 1996. Information was collected on demographics, referring physicians' perceptions of the funding plan's impact on their practices, consultants' perceptions of its impact on their activities, perceptions of referring and consultant physicians of its impact on services provided by consultants, and attitudes toward alternative funding in the context of the Ontario health care system. RESULTS: Of the 772 physicians 531 (68.8%) returned a completed questionnaire (323 referring physicians and 208 consultants). A sizeable proportion of the referring physicians (126 [39.0%]) indicated that they were referring fewer patients to consultants at the study centre. They did not think that their practice volume had increased, but they did report spending more time on complex cases and on patient care after referral or hospital stay, and more time coordinating community care after hospital stay. Of the consultants 81 (38.9%) believed that their time spent on patient care had increased. No consistent impact on time spent on research or teaching activities was perceived. A total of 54 (26.0%) of the consultants were concerned about the impact of the alternative funding plan on quality of care. A significant proportion of the respondents (399 [75.1%]) believed that outpatient waiting times had increased, and 116 (35.9%) of the referring physicians believed that consultants were not as available by telephone. Most (220 [68.1%]) of the referring physicians believed that the funding change had had a negative effect on health care services in the region, and 87 (41.8%) of the consultants agreed. Nevertheless, the respondents believed that other factors such as funding cuts, hospital bed closures and staff layoffs were much more responsible than the alternative funding plan for their negative perceptions. INTERPRETATION: The alternative funding plan appears to have had an impact on the practices of individual physicians. However, it was not the focus for significant opposition or support from either consultants participating in the funding plan or referring physicians.

Academic Medical Centers↗
PubMedDate not supplied

Fiscal strain and access to opiate substitution therapy at Department of Veterans Affairs Medical Centers.

This study examines the relationship between institutional fiscal strain and the availability of opiate substitution therapy (eg, methadone maintenance), an effective but relatively expensive treatment for heroin addiction. An observational design was used to examine the association of changes in funding and changes in provision for treating opiate addiction at 29 VA Medical Centers (VAMCs). We hypothesized that VAMCs experiencing greater fiscal strain would show reduced availability of opiate substitution treatment. Administrative records from each of 29 VAMCs that provided opiate substitution therapy in both Fiscal Year (FY) 1995 and FY 1999 were used to measure changes in the availability of this service, ie, the percent change in total patients treated, annual visits per patient, and total services delivered. Institutional fiscal strain was measured by the percent decline in per capita funding at four levels at each VAMC: the entire medical center, all mental health programs, all substance abuse programs (inpatient and outpatient), and outpatient substance abuse programs alone. The total number of patients receiving opiate substitution increased from 5,549 in FY 1995 to 6,884 in FY 1999 (24%), annual visits per patient decreased by 16%, and the total number of units of services increased by 4%. There were no significant relationships between changes in the delivery of opiate substitution services and changes in per capita funding at any of the four institutional levels. No new programs were started during these years. Although no new programs were started, the availability of opiate substitution therapy at VA facilities with existing programs was maintained over a five-year period regardless of local funding changes, although at somewhat reduced intensity.

Financial Management↗
PubMed1991

The comprehensive treatment team in rehabilitation.

Rehabilitation has prospered in the last several years, but that prosperity is threatened by competition, manpower shortages, continuing preoccupation with costs, and government deliberations about funding changes. The comprehensive treatment team has been the foundation of rehabilitation, but its appropriateness has to be looked at in light of current conditions in health care. Evidence of its effectiveness has been meager. This article is an examination of the origins of the team, its current functioning, and its research on effectiveness. Several alternatives to the current delivery system are suggested, although economic forces may overtake attempts to establish effectiveness by research.

Clinical Protocols↗
PubMed1985

The impact of training in behavioral pediatrics: a study of 24 residency programs.

Three groups of residency programs were compared: 11 externally funded to provide mandatory behavioral training, seven not externally funded but providing mandatory training, and six controls not requiring training. At the beginning and end of 1980-1981, 569 residents (70%) completed questionnaires assessing attitudes regarding behavioral disorders, physical disorders, and "mixed" disorders (with physical and behavioral aspects). Behavioral knowledge was tested by 60 multiple-choice questions. Virtually all significant effects of program type occurred in the PL-2 year. For three attitudinal measures, "competence in management," "ability to advise parents," and "future relevance," only Funded residents demonstrated higher change scores for both behavioral and mixed disorders, relative to physical disorders; Funded and Not Funded residents were superior to Controls regarding behavioral disorders. For "knowledge of resources" and "facility interest," Not Funded change was superior to Control. Given higher Funded ratings initially, Not Funded ratings approximated Funded ratings by the end of the year. Regarding knowledge, Funded and Not Funded residents showed greater improvement than Controls. These data suggest that: changes in attitudes and knowledge are related to mandatory training; Funded programs generate the most consistent changes in both behavioral and "mixed" disorders; and the impact of training is most evident in the PL-2 year.

Attitude of Health Personnel↗
PubMed1995

Teambuilding: a positive force in times of change.

The health care system continues to undergo revolutionary changes in the 90's. Never before in this area have we seen so many changes occur so quickly in such a short period of time. Funding changes and decreases to hospitals are only one of the critical factors ultimately effecting patient care and the direction of health in the future. Staffing changes because of bumping due to seniority and redesign efforts have had an even greater impact on the day to day operation of a hospital unit. This article attempts to address some of these concerns with one practical process that is universally accepted and can be readily implemented. This process which is springing up in the literature and is fast becoming the popular term of this decade is that of "TEAMBUILDING". In the next few pages an interdisciplinary team will describe their successful efforts at teambuilding in one clinical program.

Communication↗
PubMed1997

Review of US medical school finances, 1995-1996.

For the 1995-1996 fiscal year, all 125 accredited US medical schools responded to the annual medical school questionnaire of the Liaison Committee on Medical Education, part I-A. Using data from the financial portion of the questionnaire, we identify patterns of financing medical education during the past 3 years and the practice plan arrangements adopted by medical schools, including their organizational and legal structures. This financial review details differences in how public and private medical schools are being funded and funding changes during the past 3 years. The reported data show that revenues supporting medical school programs and activities totaled more than $31 billion in 1995-1996, an increase of 5.4% in inflation-adjusted dollars during the previous year. Compared with the previous year, revenues, in current and constant dollars, increased in almost every category in 1995-1996.

Financial Management↗
PubMed1998

Restructuring public mental health and substance abuse service systems.

The authors originally circulated the concepts in this proposal during May 1995. The purpose was to support an open, public dialogue regarding the restructuring of the mental health and substance abuse services in Illinois in anticipation of Medicaid funding changes. Restructuring mental health and substance abuse service systems should follow certain key principles. These principles are applicable to other states, particularly those large in territory and population. The authors propose the temporary use of multiple managed care companies serving as administrative services only (ASO) organizations, each of whom would have responsibility for a given geographic portion of a state. The role of the ASOs would be to organize providers into networks on a regional basis and transfer managed care expertise in financing and clinical management to the relevant state departments and provider groups. Changes in the service delivery system would be phased in over time with reorganization of key components of the system during each phase. Where the provision of mental health, substance abuse, and social services is split among multiple state agencies, these agencies would be merged to achieve unified funding and administrative efficiency. Patients and advocacy organizations would play a key role in overseeing and shaping system restructuring at all levels, including a governmental board reporting to the governor, overseeing ASO organizations' operations and assuring quality and access at the provider level. The authors propose funding of public behavioral health services through use of a tiered, integrated funding model.

Case Management↗
PubMed1985

Probable future funding priorities in maternal and child health: a modified Delphi National Survey.

Recent enactment of program consolidation block grants proposed by the Reagan administration has left many observers of public health services wondering about the impact of such a change on categorical programs in maternal and child health (MCH). This study first presents predictions about the future of 23 specific MCH services, derived from a modified Delphi Survey of MCH experts, and then examines the implications of these predictions for future public health.

Adult↗