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PubMedDate not supplied

[Evolution and revolution in health].

For the past several years, Mexico has experienced vast transitions which have had an effect on the state of health and the form in which its inhabitants are adequately cared for. The transitions--demographic, epidemiological, cultural/educational, economic, social, and political--show us how changes in the area of health come about. These can be grouped into two categories: (1) a new look at health care and (2) the accelerated progress in biomedical investigation. With regard to health care, the changes are directed towards a preventative emphasis rather than a curative one. This leads us to structural and functional redefinitions of health services. The government, since the past century, has put several experiments into practice (for the purpose of protecting vulnerable groups) by establishing institutions that have served as a foundation for the National Health System. These efforts intend to offer to everyone equal opportunities for the enjoyment of health. The second category shows the accelerated pace of biomedical research and its resulting beneficial achievements. It is now possible to offer better attention with more specific diagnosis and more efficient therapeutic measures.

Culture↗
PubMed2004

Simultaneous care: a model approach to the perceived conflict between investigational therapy and palliative care.

Clinical trials of investigational therapy in patients with advanced cancer may not pay sufficient attention to quality of life (QOL) and supportive care issues, resulting in an adverse impact on the quality of care (QOC). We hypothesized that the simultaneous delivery of investigational therapy and a structured program of supportive care would result in measurable improvements in predefined outcomes without adverse events for patients, caregivers, or the physician/patient interaction. This report describes the findings of a trial designed to test the feasibility and initial results of such an approach. Forty-four patients accrued to Phase I or Phase II investigational therapy trials were simultaneously enrolled into a defined home care program focused on supportive care needs of the patient and family, as well as assessment of the toxicities of investigational therapy. These 44 patients constitute the Simultaneous Care (SC) cohort. Twenty patients receiving investigational therapy and the standard supportive care measures available through the Cancer Center served as a control group, designated the Usual Care (UC) cohort. We measured QOL using baseline and monthly assessments of the Functional Assessment of Cancer Therapy (FACT-G) instrument. This instrument measures four domains of well-being: physical, emotional, functional, and social/family. We prospectively defined QOC as: the percentage of hospice referrals; hospice length of stay; and number of cycles of chemotherapy administered. A summary score for the four FACT domains at each time point for each patient was calculated (FACT 4). The FACT 4 scores of the SC group improved compared to the UC group but did not reach a significant difference. Individual scores reflected a wide range of psychometric variability. A statistically significant difference in referral to hospice was seen in the SC group (35/44) compared to the UC group (8/15) (P=0.034). The median length of stay in hospice was the same for both cohorts but the mean stay was greater in the SC cohort (54 days) compared to the UC cohort (37 days). The mean number of chemotherapy cycles was not different between SC and UC (P=0.25). The self-reported acceptance by patients, caregivers, physicians and Cancer Center support staff was qualitatively excellent. Patients with advanced cancer at the time of enrollment onto investigational therapy should have made an explicit transition to palliative care goals but often have not. In the current health care environment, patients with advanced cancer without curative potential may be forced by their health provider or health insurer to choose between disease-directed therapy (including investigational therapy) or structured best supportive care programs. In this emerging era of targeted therapies, SC provides an approach designed to optimize palliative care goals while supporting the clinical research mission of offering patients with advanced cancer new and potentially better therapeutic interventions. SC is a system of care that enhances patient choice by allowing patients and families to have concurrent access to two beneficial options. SC may enhance coordination of care and facilitate patients' explicit transition from curative intent to palliative intent. In order to validate this approach, a randomized comparative trial evaluating SC has been initiated.

Adult↗
PubMed1996

A model of home care for high-risk childbearing families. Women with diabetes in pregnancy.

With a national trend toward decreased hospitalizations for high-risk childbearing women, home care and follow-up services have gained increased importance. The Quality-Cost Model of Nurse Specialist Transitional Follow Up Care is presented as a method to provide home care for high-risk pregnant women, specifically those whose pregnancies are complicated by diabetes mellitus. The model offers opportunities for intensive education, assessment, intervention, and support throughout the pregnancy and postpartum period. In addition, this model can potentially decrease the burden of care on the woman and her family by providing a comprehensive program of home care, follow up, support, and education.

Adult↗
PubMedDate not supplied

Strategies for a smooth hospital closure.

When a hospital closes it becomes the nurse executive's and human resource director's responsibility to ensure the quality of patient care through the transition as well as manage the staff during a stressful time. How do you keep enough staff to care for the patients during the closing period? This author, who has previous experience managing a hospital closure, describes strategies to keep staff and promote patient continuity during the closure process. She emphasizes the need to focus on both patients and staff.

Continuity of Patient Care↗
PubMed2005

Young, black, and male in foster care: relationship of negative social contextual experiences to factors relevant to mental health service delivery.

Among a small, cross-sectional sample of young Black males transitioning from foster care (n=74), this study explored the relationship of their negative social contextual experiences to two factors relevant to the delivery of mental health services to them: cultural mistrust of mental health professionals and attitudes toward seeking professional help. Three domains of young Black male's negative social contextual experiences were measured: proximal negative experiences, distal negative experiences, and negative imagery experiences. Results of multivariate analysis of covariance (MANCOVA) controlling for custody status, counselling status and history, and psychiatric history showed that young Black males reporting a high frequency of negative social contextual experiences reported significantly greater cultural mistrust of mental health professionals and significantly less positive attitudes toward seeking professional help for mental health problems than young Black males reporting a low frequency of negative social contextual experiences. Implications and future research directions are discussed.

Adolescent↗
PubMed2006

Nursing home care: whodunit?

AIMS AND OBJECTIVES: (1) To analyse and compare (changes and differences in) activity profiles of various types of nursing home care. (2) To assess the impact of integrated care on these activity profiles. BACKGROUND: Because of an ongoing introduction of integrated nursing home care, caregivers increasingly have to co-ordinate their activities, engage into interprofessional relationships and take over each other's tasks. Consequently, activity profiles [i.e. combinations of (contributions to) care activities and the roles that perform them] are expected to change. DESIGN/METHODS: At three measurement points in the period 1999-2003, caregivers (in 18 different roles) recorded and listed direct and indirect care activities. A total of 41,335 lists were analysed to derive activity profiles of traditional, transitional and integrated nursing home care in the Netherlands. RESULTS: Traditional, transitional and integrated care shared some comparable activity profiles. Integrated care differed from the other types with respect to the contribution of the geriatric nurse, recreational activities supervisor, nutrition assistant, household assistant and nursing assistant to activities such as extra care, handling food and club activities. Contrary to the other roles, the licensed practical nurse contributed to (almost) all activities in all types of care. CONCLUSIONS: Nursing home care has several recurring activity profiles. These profiles are the same in all types of nursing home care. The introduction of integrated care implies that particular profiles have to be added to these profiles. As a generalist, the licensed practical nurse seems to play a key role in all activity profiles. RELEVANCE TO CLINICAL PRACTICE: Because of demographic and financial pressures, integrated care for older people becomes increasingly important. By addressing the impact of integrated care on activity profiles, this paper provides information on how new types of care can be delivered in the most effective manner.

Continuity of Patient Care↗
PubMed2004

[The practice guideline 'Pregnancy and puerperium' (first revision) from the Dutch College of General Practitioners; a response from the perspective of gynaecology].

The major benefit of the revised version of the Dutch College of General Practitioners' practice guideline about pregnancy and puerperium is the formal starting point of professional equality of midwives and general practitioners as care providers in antenatal and postpartum care. This thorough evidence-based practice guideline is behind the most recent developments in this field. Scientific evidence on vertical HIV transmission favours screening all pregnant women and not just the selective procedure proposed in this guideline. The restrictive attitude towards routine ultrasound screening during pregnancy hardly seems in line with scientific evidence and the public demand. On the other hand the guideline is very progressive as far as the care of women with thyroid disorders is concerned even though evidence on this subject is meagre. Most importantly the transition of antenatal care from the current almost conveyor belt-like procedure to an efficient but individually-adapted care process was not addressed.

Family Practice↗
PubMed2005

The Managed Military Health System for Force Generation-project.

In summary, the Managed Military Health System for Force Generation will: Allow better understanding of health issues and illness patterns in the Armed Forces. Ensure optimum health and medical fitness of service personnel throughout their military careers by: Promoting health. Protecting health. Providing timely, properly co-ordinated, healthcare from military and civilian providers. In conjunction with DMICP, provide a seamless system of patient care and administration involving all healthcare providers. Enable all military personnel to make good health decisions. Ensure a smooth transition to NHS care on completion of Service. Improve the morale of those in the Defence Medical Services through working in a high quality organisation.

Delivery of Health Care↗
PubMed2000

HIV/AIDS managed care program.

Approximately one-half of all patients with HIV infection who are under care have Medicaid as the third party payor. Unlike Medicare, Medicaid is a state-specific program that has huge variations in reimbursement strategies. Multiple studies have shown that care for persons with AIDS is about $20,000/year, but reimbursement through various state Medicaid programs varies about $100/m/m to $2800/m/m despite the fact that expectations for care are identical. Hopkins has a major commitment to persons with HIV infection with a program that now includes 30 faculty members and a support staff of 170. With the introduction of mandatory managed care for Medicaid recipients in July, 1997, we were confronted with the issue of substantial downsizing with abandonment of over half of our patients, or learning the transition to managed care. This has been a steep learning curve involving negotiations with the state Medicaid office, reorganization of our clinic, careful scrutiny of our database regarding resource utilization and cost, education of providers, and longitudinal collection of new information and integration of the rapid changes in the field. In the process of this transition, we learned that there are precious few resources to provide guidance and that there is a perceived need for assistance by HIV providers throughout the country. Consequently, we have now established the "HIV Managed Care Network" with substantial funding from diverse sources to support education, data collection, and public policy review. It is premature to evaluate performance since most of these activities have just begun, but we expect that this Network will serve as a demonstration model for methods to deal with chronic diseases under managed care.

Acquired Immunodeficiency Syndrome↗
PubMed2005

A description of handover processes in an Australian public hospital.

Handover of patient care has been an ongoing problem within the health care sector. The process remains highly variable and there is a threat to patient safety. Despite the general belief that handover transitions in patient care have become routine, not enough attention or research has been directed at improving this period of care. For this reason there is a need to provide an analysis of the communication processes during handover. A study was conducted of the handover process among doctors during shift changes within a hospital setting. The results suggested a need for process change. Results revealed a handover process which was unstructured, informal and error prone, with the majority of doctors noting that there was no standard or formal procedure for handover. The research found that the majority of hospital doctors recognised the potential benefits of formalising and computerising this process.

Continuity of Patient Care↗
PubMed1996

Community health clinics under managed competition: navigating uncharted waters.

In this article, we consider how major changes in the health care system, both real and proposed, may affect the future of community health clinics (CHCs) in the United States and their ability to continue to provide comprehensive care to underserved populations. We discuss the constraints and opportunities that CHCs face in a health care system that is rapidly moving away from fee-for-service medical care toward a model of managed competition. We describe the role that the National Association of Community Health Centers has played in advocating for CHCs in Congress and the role state primary care associations are playing in spear-heading the development of statewide CHC-sponsored health maintenance organizations. We also analyze CHC reactions to the changes in federal policies that were proposed in the major health care reform bills of the 103d Congress, as well as the prospects for CHCs under Medicaid managed care as it sweeps rapidly across the nation. As a case study, we examine California's policies that mandate that Medicaid recipients enroll in either a private managed care plan or a newly created public plan, which compete against each other within each county. CHCs are vulnerable during the transition to managed care and managed competition, and they have neither the resources nor the ability to integrate or compete successfully with private health maintenance organizations without safeguards, new sources of funding, technical assistance, improved infrastructure, and vigorous monitoring and oversight from federal and state governments, as well as the continued education, training, and policy advocacy provided by the National Association of Community Health Centers and state primary care associations.

California↗
PubMed1997

Hospital program weds case, disease management.

To lower its readmission rates and inpatient length of stay for three high-volume chronic conditions, Memorial Hospital in Colorado Springs, CO, developed a program that combines clinical pathways with a cross-continuum disease management program. Community physicians refer patients to the program. Hospital-based care managers guide patients in the acute setting before handing them off to outpatient case managers, who coordinate the patient's transition to home care. Clinicians at Memorial sold administrators on the "care-case management" approach by arguing that increased inpatient efficiency would offset potential revenue shortfalls due to fewer admissions.

Case Management↗
PubMedDate not supplied

Patients' and their spouses' needs after total joint arthroplasty: a pilot study.

PURPOSE: To describe the experiences and needs of patients and their spouses during hospitalization and recovery from either total hip or total knee arthroplasty. DESIGN: Descriptive. SAMPLE: A purposive sample of 5 patients and their spouses in one health sciences center. METHODS: Qualitative study using a videotaped focus group interview. FINDINGS: Content analysis revealed two perspectives of one theme: patients and their spouses need "help making transitions." Situational and role transitions that were problematic for patients reflected distress over not being able to resume activities they enjoyed within an expected time frame. Incongruence between expectations and reality was the source of distress. As a consequence of role reversal, spouses experienced feelings of insecurity and being overwhelmed. Health and illness transitions that patients experienced were also related to incongruence between expectations of the recovery period and the reality that recovery is a slow process. Pain experienced during postdischarge recovery and rehabilitation, and problems encountered when applying information and skills learned in the hospital to the home setting were sources of concern. CONCLUSION: The needs and experiences of patients and spouses after total joint arthroplasty reflect transitional change--changes in roles, relationships, abilities, and behaviors. Health care professionals can facilitate transitions by providing education that reflects "best case-worst case scenarios" so that expectations of the recovery process are realistic. By being the link between hospital and home, health care professionals can lend support to patients as they continue the recovery process. As a program evaluation strategy, focus groups provide useful information to health care professionals who are interested in the needs and expectations of health care consumers. IMPLICATIONS FOR NURSING RESEARCH: Further exploration of the needs of patients and their spouses following joint replacement surgery is warranted. Use of focus group methodology might provide additional insight into the needs of this population and suggest ways in which health care professionals can modify existing programs to help these patients and their spouses make the transitions.

Adaptation, Psychological↗
PubMed2005

Emotion understanding and theory of mind among maltreated children in foster care: evidence of deficits.

Children in foster care are at heightened risk for poor psychosocial outcomes. This study examined differences in two areas that may be associated with many of these outcomes, emotion understanding and theory of mind, using a sample of 3- to 5-year-old maltreated foster children (n = 60) and a comparison group of same-aged, low-income, nonmaltreated children living with their biological families (n = 31). Being in foster care was significantly associated with worse emotion understanding and theory of mind capabilities, even when accounting for age, intelligence, and executive function. There were no significant associations between length of time in foster care, number of transitions, and emotion understanding and theory of mind. Results help to expand knowledge about the cognitive and affective deficits of children in foster care and suggest that interventions targeted at these deficits include an emphasis on emotion understanding and theory of mind.

Child↗
PubMedDate not supplied

Clinical indicators of treatment futility and imminent terminal decline as discussed by multidisciplinary teams in long-term care.

Focus group methodology was used to describe how members of multidisciplinary teams in long-term care facilities recognize when residents are approaching end-stage disease, document evidence that associated treatment futility has occurred, and convey this information to the residents, each other, and family members. In addition to the typical clinical indicators of treatment futility found in the literature (e.g., recurrent infections, weight loss, falls, functional decline), team members described a set of physical and affective changes that were apparent to them as their residents approached trajectories of imminent terminal decline. While more difficult to quantify and measure, these other indicators have a significant impact on the ways that team members assess and interpret a person's survival potential. Using these indicators of both treatment failure and imminent decline requires knowledge of a resident's history, clinical condition, course of care, and individual idiosyncrasies. Together, the indicators offer important cues that are needed for the identification of persons who might benefit from earlier transitions to palliative care.

Attitude of Health Personnel↗
PubMedDate not supplied

[Local health systems: a transition of the organized social response].

This paper discusses the transition of the organized social response in health with emphasis on local health systems. After reviewing a few basic definitions (health system, local health system, health care system, institutional system of health services), the author discusses the health transition (transition of the concept health-disease, technological transition, epidemiological transition, demographic transition, health care system transition) and the importance attributed to local health systems in Mexico.

Delivery of Health Care↗