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PubMed2005

[Implementing integrated health care--current state and progress].

The legal framework for Integrated Health Care since 2004 offers many opportunities for health professionals and insurers in the competition for "high quality care". Germany's largest statutory health insurance fund, BARMER, has already developed around 100 Integrated Health Care Projects for a wide range of conditions. One important issue is the relationship to disease management programs. Our program "integrated cardiological care" combines both DMP and integrated health care and thus already shows good results with respect to patient acceptance as well as savings trough the changing patterns in interventional cardiology.

Cardiology↗

PubMed2003

Predicting vocational functioning and outcome in schizophrenia outpatients attending a vocational rehabilitation program.

BACKGROUND: Vocational rehabilitation is a central issue in the rehabilitation of patients with chronic schizophrenia. However, even with the help of comprehensive integration programs, achieving this objective remains a very ambitious and difficult undertaking. Therefore, a profound and up-to-date knowledge of vocational functioning and outcome predictors in patients who have the goal to return into competitive employment is imperative. The objective of the present study was to test the predictors summarized in the recent review of Cook and Razzano, as well as to test those predictors specified in the nine hypotheses put forward by Anthony and Jansen in schizophrenia patients enrolled in a vocational rehabilitation program. METHODS: The predictive value of ten hypotheses centering on vocational functioning and outcome were consecutively tested in a sample of 53 schizophrenia patients. Those predictors identified as significant were then taken into a 'winner take all' regression in order to determine which of them were the best. RESULTS: The overall work performance observed in a workshop proved to be the best predictor of vocational functioning. Contrary to the pivotal claim in Anthony and Jansen's review, in our sample, negative symptoms indeed influenced vocational functioning, outcome and functional skills. Cognitive impairments, social competence and fatalistic control beliefs also had predictive value for vocational functioning and outcome. CONCLUSIONS: These results reflect the accumulated findings of the past decade as summarized by Cook and Razzano. Moreover, they serve to substantiate the necessity of promoting the concept of cognitive remediation and associated programs designed to transform fatalistic beliefs into feelings of hopefulness, thereby enhancing the readiness of schizophrenia patients to enroll in rehabilitation programs.

Adult↗

PubMed2000

A model for educating humanistic physicians in the 21st century: the new medicine, patient, and society course at Tel Aviv University.

BACKGROUND: The impact of the social and behavioral sciences on medical education has often been limited due to a variety of organizational, curricular and professional barriers. The new "Medicine, Patient, and Society (MPS)" program in Tel Aviv attempts to rectify this educational shortcoming by exploring new ways to help students acquire the knowledge, attitudes and skills needed for becoming humanistic physicians and for helping patients (and themselves) adopt healthy behaviors. To work toward this goal, this program integrates the biomedical and psychosocial aspects of health care, providing developmentally appropriate learning experiences according to levels of training, together with a variety of educational methods, including learner-centered approaches. OBJECTIVES: To implement and evaluate the MPS pilot program. METHODS: The MPS program uses a "seamless" model of behavioral science education. This integrated curriculum interweaves several elements: behavioral science topics (presented through multiple approaches), clinical experiences, practical medical skills, and an independent project. During the program's first year there is a strong focus on "health" rather than "disease," with activities designed to encourage healthy behaviors, including smoking cessation, stress management, birth control, AIDS education, life cycle and preventive health services. Assessment of the pilot for first-year students included standardized questionnaires, student focus groups, participant observation of educational activities, and committee feedback. RESULTS: Students' quantitative evaluations indicated high levels of satisfaction with the MPS program, but their qualitative evaluations revealed some concerns. Participant observations and focus groups added unexpected insights. Student concerns included performance fears, difficulties with "learner-centered" education, and incompatibilities between more traditional first-year courses and the MPS program. Long-term follow-up will be needed to determine the impact of this emphasis on health during the first year. We assume it serves as a helpful foundation for students before they focus on disease and its sequelae in their later years.

Journal Article↗

PubMed1996

Vertical integration strategies: revenue effects in hospital and Medicare markets.

The purpose of this study was to evaluate the revenue effects of seven vertically integrated strategies on California hospitals. The strategies investigated were managed care contracts, physician affiliations, ambulatory care, ambulatory surgery, home health services, inpatient rehabilitation, and skilled nursing care. The study population included 242 not-for-profit hospitals in continuous operation from 1983 to 1990. Many hospitals developed vertically integrated programs in the 1980s as inpatient utilization fell in response to the Medicare Prospective Payment program. Net revenue rose on average by $2,080 from 1983 to 1990, but fell by $2,421 from the Medicare program. On the whole, the more physicians affiliated with a hospital, the higher the net revenue. However, in the Medicare population, the number of managed care contracts was significant. The pre-hospital strategies generated significant revenue, while the post-hospital strategies did not. In the Medicare program, inpatient rehabilitation significantly reduced revenue.

California↗

PubMed2006

Risk factors and prevention of end stage renal disease in uruguay.

Uruguay is a developing country with a privileged established program for renal replacement therapy (RRT) for all patients with end stage renal disease (ESRD) since 1981. In December 2004, the RRT prevalence reached 916 patients per million population. The ESRD incidence has not changed significantly in the last eight years, differing with what is observed in other countries. In contrast, the ESRD incidence secondary to diabetic nephropathy has shown a permanent increase. The prevention of chronic kidney disease (CKD) began in 1989 with the Program of Prevention and Treatment of Glomerulonephritis (PPTG), being extended in 2002 to all CKD and canalized through the National Program of Renal Healthcare (NPRH) since 2004. The registry of glomerulonephritis has been demonstrated in recent years: patients are referral to nephrologists earlier, there is an increase of the frequency of patients with "clinical remission," and thus there is a decrease of the frequency of ESRD in the first three months after referral. The NPRH has been developed in a progressive way with the involvement of government authorities and the active participation of the nephrologists. A global prevention program, integrating the prevention of CKD, cardiovascular diseases, hypertension, and diabetes was developed. The first steps of the program have had important achievements: a rational reorientation of nephrologic care in the first level of attention, patient access to renoprotective medications without cost; a registration system of patients, the creation of a formal multidisciplinary team, and the instauration of a continuous medical education program.

Disease Progression↗

PubMed2006

Modeling an integrative physical examination program for the Departments of Defense and Veterans Affairs.

Current policies governing the Departments of Defense and Veterans Affairs physical examination programs are out of step with current evidence-based medical practice. Replacing periodic and other routine physical examination types with annual preventive health assessments would afford our service members additional health benefit at reduced cost. Additionally, the Departments of Defense and Veterans Affairs repeat the physical examination process at separation and have been unable to reconcile their respective disability evaluation systems to reduce duplication and waste. A clear, coherent, and coordinated strategy to improve the relevance and utility of our physical examination programs is long overdue. This article discusses existing physical examination programs and proposes a model for a new integrative physical examination program based on need, science, and common sense.

Delivery of Health Care, Integrated↗

PubMed2006

Total quality management in clinical virology laboratories.

The diagnostic laboratories in India are progressively promoting higher standards and are moving towards accreditation and international acceptance. Hence, the concept of "Quality" will need to be understood and implemented. Total quality management (TQM) in a laboratory is an integrated program involving all laboratory staff and management. TQM is a framework to operate and it is aiming for integration, consistency, increase in efficiency and a continuous drive for improvement. A well structured clinical virology service will include serology setup, cell culture facility and capacity for molecular diagnosis. The quality of results from the laboratory is significantly influenced by many pre-analytical and post-analytical factors which needed attention. The end goal of the TQM should be to provide the best care possible for the patient.

Accreditation↗

PubMed2002

The effect of an integrated stress management program on the psychologic and physiologic stress reactions of peptic ulcer in Korea.

The purpose of this study was to identify the effects of an integrated stress management program on symptoms of stress and ulcer healing in a sample of Koreans at a major medical center in Seoul, Korea. The study employed an experimental design with two treatment groups. One treatment group (n=23) participated in an integrated stress management program that consisted of seven 1h sessions over a 4-week period. A second treatment group (n=24) was only given a tape on progressive muscle relaxation. Data were collected over a 4-month period on 47 subjects. Participants were randomly assigned to the two treatment groups. Symptoms of stress were measured by the symptoms of stress scale (Kogan, Self-regulation on Stress Reaction by Biofeedback, Korean Psychiatric Academic Society, Korea) translated into Korean. Stage of ulcer healing was evaluated by a physician using an endoscope. Physiologic stress reactions were measured by biofeedback equipment. The integrated stress management program treatment group reported significantly lower stress symptom scores than the progressive muscle relaxation-only group (t=3.66, P<0.001). The integrated stress management group also demonstrated a greater improvement in ulcer healing than the progressive muscle relaxation group (t=1.95, P<0.05). The integrated stress management program was more effective in decreasing self-reported stress symptoms and resulted in a more significant ulcer healing than the progressive muscle relaxation treatment.

Adolescent↗

PubMed1979

Social work and primary health care: an integrative approach.

An interinstitutional, interagency Consortium has been formed in Houston to develop an innovative service model and provide interdisciplinary primary care/mental health training. The Houston Consortium Program integrates mental health professionals and trainees into the primary care framework of a neighborhood center serving a low-income, predominatly Mexican-American population. The introduction of mental health, psychosocial, and cross-cultural perspectives to complement the long-standing physiological concerns of health professionals fosters an holistic approach to patient care. The social workers' full participation as members of primary care teams builds upon their traditional training to provide them the experience and skills required to function effectively in the expanded coordinative capacity of health/mental health manager as defined by the President's Commission on Mental Health. It is anticipated that Consortium Program can serve as a heuristic model in the development of a nationwide pattern of comprehensive care.

Community Health Centers↗

PubMedDate not supplied

International Health Fellowship: a proposed curriculum for emergency physicians.

There are a growing number of emergency physicians (EPs) working in health care abroad. There are, however, no formal training programs for EPs in international health. An International Health Fellowship has been developed to provide training for EPs in public health and international medicine. The fundamental competencies of a fellow completing the International Health Fellowship include assessment of medical need, program development, integration of programs into the existing health care framework, and evaluation of projects. This article outlines the philosophy of a training program in international health, provides an overview of the goals and objectives for such a program, and describes the development of an existing fellowship. The International Health Fellowship will develop leaders in the field of global health by combining clinical expertise, practical field experience, formal public health training, and research and education in international health. Physicians completing a fellowship will be prepared to work within foreign health systems to develop, integrate, and evaluate health care programs on an international scale.

Curriculum↗

PubMed2004

A review of clinical characteristics and residential treatments for adolescent delinquents with mental health disorders: a promising residential program.

As treatment systems throughout the country have deinstitutionalized, under-use of community-based residential treatment systems has escalated. Reliance on juvenile justice systems for the care of the mentally ill adolescent has increased. There is considerable overlap between the mentally ill adolescent population within the community-based mental health systems and the offender population within the juvenile justice systems. With the inconsistent epidemiological prevalence and longitudinal treatment data, mental health treatment providers have also begun addressing this problem. This is currently being done by designing and implementing community-based residential mental health programs for delinquent adolescents of the juvenile justice system as well as nondelinquent adolescents within the mental health treatment systems. Providers have relied on both systems' literature in establishing theoretical treatment programs. The authors review critical treatment components currently used by both the treatment and juvenile justice systems. A promising integrative program is described.

Adolescent↗

PubMed1991

Clinical and experimental approaches to varieties of memory.

Memory is described as a complex aspect of cognitive functioning. Memory is dependent upon input from the sensory modalities; it relies upon the passage of time; and it requires intervening processes for initial acquisition and subsequent access. Based upon questions posed concerning the relationship between clinical and experimental advances in memory and memory disorders, an example is given to illustrate the influence of research upon techniques for diagnosis and rehabilitation. Suggestions are provided about how to approach answering other related questions in neuropsychology. An integrated program is suggested with the aim of bringing together findings from neuroanatomy, neurochemistry, and neurobehavior. Emphasis is placed upon integrating results of research based upon human and nonhuman models of disordered memory and other cognitive functions. Neuroanatomical systems important for performing delayed-reaction tasks are reviewed, as are results of delayed response and delayed alternation testing in several human populations with neurological dysfunction suggestive of frontal lobe damage.

Adult↗

PubMedDate not supplied

A model for dual disorder treatment in acute psychiatry in a VA population.

One model for addressing the dual disorders of substance abuse and a concomitant mental disorder in an acute-psychiatry inpatient ward of a VA Medical Center utilized psychoeducation and ward policies to empower patients to make decisions affecting their recoveries. Existing staff shared responsibilities for implementing activities and creating ward milieu that supported psychiatric patients toward a life free of alcohol and drugs as they gained in acceptance of responsibility for the management of their mental disorders. Integrated programming assisted patients in constructing a meaningful path of recovery out of multiple treatment approaches and philosophies. Treatment principles, ward policies, and goals for an integrated acute-psychiatry model evolved over 4 years. Designed from a consumer-oriented "strengths perspective," patients responded to the new programming with satisfaction and gratitude. Recent adaptation of these policies, principles, and goals to a newly instituted continuous-care treatment program indicates the appropriateness of their application for outpatient dual disorder treatment and programming as well.

Anti-Anxiety Agents↗

PubMed2003

Integrating treatment with rehabilitation for persons with major mental illnesses.

Psychiatric treatment and rehabilitation are integrated, seamless approaches aimed at restoring persons with major mental disorders to their best possible level of functioning and quality of life. Driven by a thorough assessment, treatment and rehabilitation are keyed to the stage and type of each individual's disorder. Examples of coordinated treatment and rehabilitation are pharmacotherapy, supported employment, social skills training, family psychoeducation, assertive community treatment, and integrated programs for persons with dual diagnoses. The authors conclude by proposing seven principles to guide mental health practitioners in their integration of pharmacologic and psychosocial interventions.

Adult↗

PubMed1996

Drug use prevention efforts at colleges and universities in the United States.

This study examined the extent to which program comprehensiveness, programmatic outcomes, program integration, and environmental factors are being addressed by 336 urban and rural United States college and university drug use prevention programs. College-based prevention programs employed a range of programmatic goals, prevention communication channels, and prevention strategies within a centralized department for drug use prevention. Most program coordinators reported no perceived change in alcohol, tobacco and other drug use, alcohol/drug-related problems, faculty/staff drug use, and alcohol and drug-related crime resulting from prevention efforts on campus. The level of prevention activity differed across institutional type.

Adolescent↗

PubMedDate not supplied

The development and evaluation of lighten up, an Australian community-based weight management program.

UNLABELLED: Programs of widely ranging size were conducted successfully in seven localities and thus the program was considered an operational success. The reductions in weight, blood pressure, and waist and hip measurements observed at the 3-month follow-up compared well with reports of other community-based programs. Almost all participants evaluated the program highly and reported positive changes in behaviors related to food and exercise. Qualitative data indicate that the coordinators developed a sense of ownership of the program--which will be vital to its sustainability. Rapport between coordinators and participants was more easily established in smaller programs than in larger ones and was an important underlying determinant of retention rates. SIGNIFICANCE: The Lighten Up program integrates environmental and individual strategies to facilitate changes towards a positive, lifestyle approach to long-term weight management. The program aims to establish sustainable social support networks with effective links to health services. This study has demonstrated that, with appropriate training and resources, existing public sector, primary health care personnel with no previous experience in health promotion can implement the program successfully in several communities concurrently. In the Australian context, this program can play an important role as one strategy in a range of interventions required to address the issue of obesity. The stepped-care model described by Brownell proposes that program options of varying intensity, and thus cost, be available to meet the variety of needs of overweight people who wish to lose weight. The Lighten Up program was close to the midpoint of that range in that it combined population strategies with one-on-one contact with health care personnel. LIMITATIONS: Participants in the study were self-selected people who had acted quickly to enroll in the program, and it is therefore likely that the sample was overrepresented with early adopters who may have been more successful than others would have been. We cannot tell from this developmental study whether or not the program will appeal to population groups known to be at high risk for obesity. This is an important question that needs to be addressed in future research. No control group was included in the design and thus we cannot be sure the benefits experienced by the participants resulted from the program. However, process evaluation data indicate that nothing that might explain the findings, other than the program, occurred in the communities during the time of the study. Further important issues to be evaluated include: the long-term maintenance of weight loss; whether or not the program will reach targeted populations, particularly groups of low socioeconomic status; and the extent to which the public health staff will maintain enthusiasm for the training and the programs.

Adult↗

PubMed2000

Ready to answer ORYX data questions? Here's what Joint Commission will ask.

The Joint Commission on Accreditation of Healthcare Organizations' ORYX program integrates performance measurement into the accreditation process. Your hospital already should have chosen six measures to report for the ORYX program, and those measures may affect the ED. Surveyors will want to see comparison charts, so your ED can be measured against other facilities, and control charts with internal data. Automatic type I recommendations result if institutions fail to report data they said they would report for two quarters in a row. Your control charts may have findings that are statistically, but not clinically, significant.

Accreditation↗

PubMed2002

Diabetes disease management in a community-based setting.

PURPOSE: The medical cost of diabetes in the United States in 1997 was at least $98 billion. This study illustrates the behavioral change and medical-care utilization impact that occurs in a community-based setting of a diabetes disease-management program that is applied to program participants in a health insurance plan's health maintenance organization and preferred provider organization. DESIGN: A historical control comparison of diabetes-management participants. METHODOLOGY: One hundred twenty-seven identified diabetes patients are followed from baseline through 1 year. Differences in behavior are compared at program intake and at a 6-month reassessment. Differences in medical-service utilization are compared in the baseline year and the year subsequent to program enrollment. Poisson multivariate-regression models are estimated for counts of inpatient, emergency department, physician evaluation and management, and facility visits, while also controlling for potential confounders. PRINCIPAL FINDINGS: Behaviors improved between program intake and the 6-month reassessment. From patient reports, the number of participants having a hemoglobin A1c test increased by 44.9 percent (p < .001), and there was a 53.2-percent decrease in symptoms of hyperglycemia (p = .002). From medical claims after program enrollment, a drop occurred during the program year in every dimension of medical-service utilization. Regression results show that in-patient admissions decreased by 391 (p < .001) per 1,000 for each group, while controlling for age, length of membership, and the number of comorbid claims for congestive heart failure. In the analysis of costs that were pre- and post-enrollment, which included disease-management program costs, a 4.34:1 return on investment was calculated. CONCLUSION: The diabetes program provides patients with comprehensive information and counseling relative to practicing self-management of diabetes through a number of integrated program components. This study strongly suggests that the implementation of such a program is associated with positive behavioral change and, thus, with substantial reduction in medical-service utilization. In addition, the intervention resulted in a net decrease in direct medical costs.

Aged↗