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PubMed2000

Managed care and the implementation of the State Children's Health Insurance Program.

More than two years after its enactment, the Health Care Financing Administration, Baltimore, issued proposed regulations implementing the State Children's Health Insurance Program (SCHIP), enacted under the Balanced Budget Act of 1997. This program was enacted to provide health insurance coverage to the estimated 10 million uninsured children living in the United States. This article provides an overview of SCHIP and how it has been implemented in the various states.

Age Factors↗

PubMed2001

Implementation of the enhanced primary care items requires ongoing education and evaluation.

OBJECTIVE: The study aimed to evaluate the uptake and usage of the Federal Government's Enhanced Primary Care (EPC) items by general practitioners in outer urban general practice. METHOD: Faxed questionnaire with telephone follow up of a random sample of 347 GPs in South West Sydney, in March and April 2000. RESULTS: There was a response rate of 70.6%. Seventy-three percent of respondents reported they had heard of the EPC package and 27% of all the respondents had used one or more of the items. Twenty-three percent had claimed for health assessments (median number 3), 4.5% for care plans (median number 3) and 4% for case conferences (median number 1). Just under half of the GPs who had claimed for health assessments had conducted them in the patient's home. Most GPs either had no system for the use of the items or planned to use them opportunistically. Forty-nine percent of GPs had an age-sex register and those who did were more likely to have claimed for an EPC item and to have specific plans for their use. CONCLUSION: While most GPs had heard of the EPC items, only a minority had used them and few planned to use them systematically within their practice. There is a need to address barriers to the uptake of the EPC items and to provide greater support to GPs and health professionals involved with their implementation, especially for care plans and case conferences. Evaluation of the EPC items needs to be an integral part of the implementation process.

Adult↗

PubMedDate not supplied

States' implementation of the Section 510 abstinence education program, FY 1999.

CONTEXT: As part of its reworking of the nation's welfare system in 1996, Congress enacted a major new abstinence education initiative (Section 510 of Title V of the Social Security Act), projected to spend $87.5 million in federal, state and local funds per year for five years. The new program is designed to emphasize abstinence from sexual activity outside of marriage, at any age, rather than premarital abstinence for adolescents, which was typical of earlier efforts. The actual message and impact of the program, however, will depend on how it is implemented. METHODS: Program coordinators in all 50 states, the District of Columbia and Puerto Rico were surveyed concerning implementation of the Section 510 abstinence education program in FY 1999. The questionnaire asked about expenditures and activities performed, about policies established for a variety of specific situations and about how the term "sexual activity" is defined and what specific components of the federal definition of "abstinence education" are emphasized. RESULTS: Forty-five jurisdictions spent a total of $69 million through the Section 510 program in FY 1999. Of this total, $33 million was spent through public entities, $28 million was spent through private entities and $7million (in 22 jurisdictions) was spent through faith-based entities. Almost all jurisdictions reported funding school-related activities, with 38 reporting in-school instruction and presentations. Twenty-eight jurisdictions prohibited organizations from providing information about contraception (aside from failure rates), even at a client's request, while only six jurisdictions prohibited information about sexually transmitted diseases. Few reported having a policy or rendering guidance about providing services addressing sexual abuse, sexual orientation or existing pregnancy and parenthood. Only six respondents said they defined "sexual activity" for purposes of the program, and 16 reported focusing on specific portions of the federal definition of "abstinence education." CONCLUSIONS: More than one in 10 Section 510 dollars were spent through faith-based entities. Programs commonly conducted in-school activities, particularly instruction and presentations, not only through public entities, but also through private and faith-based entities. Most jurisdictions prohibited the provision of information about contraception, about providers of contraceptive services or about both topics, even in response to a direct question and when using other sources of funding. Most also left definitions of "abstinence" and "sexual activity" as local decisions, thus not clearly articulating what the program is designed to encourage clients to abstain from.

Adolescent↗

PubMed2001

Implementing chronic disease management in the public healthcare sector in Singapore: the role of hospitals.

The public health care delivery system in Singapore faces the challenges of a rapidly ageing population, an increasing chronic disease burden, increasing healthcare cost, rising expectations and demand for better health services, and shortage of resources. It is also fragmented, resulting in duplication and lack of coordination between institutions. A disease management approach has been adopted by the National Healthcare Group (NHG) as a critical strategy to provide holistic, cost-effective, seamless and well-coordinated care across the continuum. The framework in the development of the disease management plan included identifying the diseases and defining the target population, organizing a multi-disciplinary team lead by a clinician champion, defining the core components, treatment protocols and evaluation methods, defining the goals, and measuring and managing the outcomes. As disease management and case management for chronic diseases are new approaches adopted in the healthcare delivery system, there is a lack of understanding by healthcare professionals. The leadership and participation of hospital physicians was sought in the planning, design and outcomes monitoring to ensure their 'buy-in' and the successful implementation and effectiveness of the program. The episodic diagnosis related group (DRG)-based framework of funding and subvention for healthcare, and the shortage of step-care care facilities, have been recognized by the Ministry of Health as an impediments to the implementation, and these are currently being addressed.

Case Management↗

PubMed2002

[Analysis of preliminary conditions for the implementation of health training programs within the framework of humanitarian aid].

NGOs must be able to ensure the appropriate design and quality of their training programmes for health workers implemented in developing countries. It is a question of empowering those countries to become more autonomous, and the purpose of this study is to identify factors that can improve the sustainable management of the population's health through the long-term training of competent health workers. A literature review validated by experts distinguished three main characteristics necessary for the success of such programmes; relevance, feasibility and functionality from an educational perspective. Moreover, in addition to the three aforementioned criteria, a fourth transversal attribute was noted: sustainability. The objective of the programme designer is to assess the presence of these conditions in order to decide whether or not the training programme should be implemented.

Delivery of Health Care↗

PubMed2000

Thinking ahead--the importance of exit strategies to successful implementation of clinical effectiveness initiatives.

The Clinical Resource and Audit Group (CRAG) remains the focus for the development of clinical effectiveness with particular emphasis on strategic alignment and implementation. CRAG believes that early consideration and planning of exit strategies is essential to deliver successful dissemination and implementation of clinical effectiveness initiatives. Open sharing of results in encouraged, with due consideration of the challenges of presenting information fairly and clearly to avoid misinterpretation, particularly for the lay public. Valuable lessons from effectiveness initiatives should be shared widely and introduced quickly into normal clinical practice, releasing effectiveness resources for new challenges. CRAG will produce guidance to support the development of exit strategies later in the year; comments and contributions are welcome.

Clinical Competence↗

PubMed2004

Implementing telemedicine technology: lessons from India.

Information and communications technologies have universally helped to bridge the digital divide. As an application of ICT, telemedicine is an efficient pathway for enabling health care delivery. Developing countries, too, have started reaping the benefits of this evolutionary technology, but realisation of such dreams has not been swift. The implementation of a pilot scheme in telemedicine in India has been confounded with challenges right from the very start. One of the prime lessons to be learnt from the implementation of a pilot project in a developing country is to keep the objectives of the project in small modules and to keep the deliverables within sight. An account of some of the challenges faced while developing telemedicine technology in India serves as a useful example for upcoming telemedicine programmes in Third World countries.

Benchmarking↗

PubMed2005

Universal newborn hearing screening in Singapore: the need, implementation and challenges.

With about 1 in 1000 born with severe to profound hearing loss and about 5 in 1000 with lesser degrees of loss, congenital deafness is the commonest major birth defect. It is the recommended standard that hearing loss in newborns be detected by 3 months of age and intervention implemented by 6 months of age. Delayed detection and intervention may affect speech, language and psychosocial development, resulting in poor academic achievements. Universal newborn hearing screening (UNHS) is the only effective way of detecting all babies with hearing loss, within the recommended time frame. A survey in Singapore revealed that traditional childhood hearing screening programmes resulted in late detection (mean age, 20.8 months; range, 0 to 86 months) and late intervention (mean age, 42.4 months; range, 1 to 120 months). Increasingly, UNHS is becoming standard medical care in developed countries. In Singapore, UNHS has been implemented in all hospitals with obstetric services. Although a screening rate of more than 99% has been achieved in public hospitals, private hospitals have a screening rate of only about 77%. Parents' awareness and acceptance of early detection is still lacking, and this needs to be addressed by appropriate public education. Support from obstetricians and paediatricians will significantly contribute towards this objective. Effective programme management is essential; this includes the use of data management systems, the maintenance of a team of experienced screeners, and efficient coordination between screening and diagnostic services. Early detection of childhood deafness, together with early and effective intervention, maximises the chances of successful integration into mainstream education and society.

Audiometry, Evoked Response↗

PubMed2004

Activism in an age of restraint: the resiliency of administrative structure in implementing the State Children's Health Insurance Program.

This article examines state efforts to build administrative structures and outreach networks in the State Children's Health Insurance Program (CHIP) through a comparative review of 18 states that have been the subject of ongoing research by the Nelson A. Rockefeller Institute of Government. The article explores the role that institutional structures play at the state level in shaping the implementation and administration of federal policy choices. States have generally opted to rely largely on existing Medicaid bureaucracies in order to implement the new CHIP programs. As a result, CHIP programs have been tightly integrated into existing Medicaid structures. Rarely put forward as exemplars of responsiveness and, these bureaucracies have nonetheless played a crucial role in building and managing CHIP programs across the United States. As this analysis will show, this has even been the case in those few states that have opted to officially house CHIP administration outside of the Medicaid bureaucracy. Furthermore, existing Medicaid systems have often been active as partners and participants in efforts to publicize and promote the CHIP program through outreach and education efforts. As part of these initiatives, efforts have been made to portray CHIP as a form of health insurance rather than a welfare benefit. A slight paradox results where key actors in the health and human services bureaucracy play an active role in program management while making efforts to dissassociate the program from the traditional welfare system. These efforts have been largely successful. And in doing so, not only have children been brought into the CHIP program but more families have been connected to the Medicaid program. In short, a review of state experiences reveals the resiliency and flexibility of existing state administrative systems in responding to and addressing substantive policy change.

Child↗

PubMed2005

Pressure ulcer prevention and care: implementing the revised guidance to surveyors for long-term care facilities.

The revised guidelines for long-term care surveyors by the Centers for Medicare and Medicaid Services link the existing pressure ulcer prevention and treatment evidence base with federal guidelines. The guidance document is detailed and attempts to ensure that residents receive optimal care to help prevent and manage these wounds. Implementation of the guidance document recommendations requires a complete review, and possibly revision, of existing policies and procedures. Understanding the background, rationale, and methods to implement these recommendations will help administrators and clinicians develop protocols of care that are effective, cost efficient, and comply with the new guidelines.

Health Plan Implementation↗

PubMed2004

Tuberculosis situation among tribal population of Car Nicobar, India, 15 years after intensive tuberculosis control project and implementation of a national tuberculosis programme.

OBJECTIVE: To assess the tuberculosis (TB) situation in the tribal community of Car Nicobar island 15 years after the national TB programme was implemented in this area after an intensive phase of TB control in 1986. METHODS: The entire population of Car Nicobar was enumerated through a house-to-house survey. Children aged <14 years were tuberculin tested and read for reaction sizes. Individuals aged >15 years were asked about the presence of chest symptoms (cough, chest pain, and unexplained fever for two weeks or longer and haemoptysis), and sputum samples were collected from patients with chest symptoms. Sputum samples were examined for presence of acid-fast bacilli. FINDINGS: Among the 4,543 children enumerated, 4,351 (95.8%) were tuberculin tested and read. Of the 981 children without bacille Calmette-Guerin scars, 161 (16.4%) were infected with TB. A total of 77 cases who were smear-positive for TB were detected from among 10,570 people aged >15 years; the observed smear-positive case prevalence was 728.5 per 100,000. The standardized prevalence of TB infection, annual risk of TB infection, and prevalence of cases smear-positive for TB were 17.0%, 2.5%, and 735.3 per 100,000, respectively. CONCLUSION: The prevalence of TB infection and smear-positive cases of TB increased significantly between 1986 and 2002. Such escalation took place despite the implementation of the national TB programme on this island, which was preceded by a set of special anti-TB measures that resulted in sputum conversion in a substantially large proportion of the smear-positive cases prevalent in the community. The most likely reason for the increase seems to be the absence of a district TB programme with enough efficiency to sustain the gains made from the one-time initial phase of special anti-TB measures. High risk of transmission of TB infection currently observed on this island calls for a drastic and sustained improvement in TB control measures.

Adolescent↗

PubMed1999

Changes in continuity of enrollment among high-risk children following implementation of TennCare.

BACKGROUND: TennCare, Tennessee's Medicaid managed care program, was introduced in 1994 with the goals of controlling spending and of improving access to health care. OBJECTIVE: To assess changes in the continuity of enrollment following the implementation of TennCare for 2 groups: infants in the first year of life (defined as persons aged 0-12 months in this study) and children hospitalized with a chronic health condition (defined as persons aged 0-18 years in this study). DESIGN: Retrospective cohort analysis. SETTING AND POPULATION: Infants born during 1992 or 1995 to women enrolled in Medicaid or TennCare and 0- to 18-year-old children enrolled in Medicaid or TennCare who were discharged from a hospital during 1992 or 1995 with a chronic health condition. MAIN OUTCOME MEASURES: For infants, failure to enroll an infant in the first 30 days of life or subsequent gaps in enrollment for 7 days or longer during the first year of life. For children hospitalized with a chronic health condition, any gap in enrollment lasting 7 days or longer by 1 year after discharge from a hospital. RESULTS: There was a reduction in the proportion of infants without continuous enrollment in the first year of life following TennCare (19.4% after vs 25.1% before TennCare; odds ratio, 0.69; 95% confidence interval, 0.67-0.72). Improvements in continuity of enrollment for infants occurred despite an increase in the proportion of infants who were not enrolled in TennCare in the first 30 days of life, even though their mother was enrolled at delivery (14.0% after vs 8.0% before TennCare; odds ratio, 1.86; 95% confidence interval, 1.78-1.96). There was a decrease in the proportion of children hospitalized with a chronic health condition who had subsequent gaps in enrollment by 1 year following discharge from a hospital (14.3% after vs 23.3% before TennCare; odds ratio, 0.52; 95% confidence interval, 0.46-0.59). CONCLUSION: For infants in the first year of life and for children hospitalized with a chronic health condition, implementation of TennCare improved continuity of coverage.

Adolescent↗

PubMed2002

Implementation of a program to teach pediatric residents and faculty about domestic violence.

OBJECTIVES: To obtain information about pediatric resident and staff knowledge, attitudes, and screening practices related to domestic violence (DV), to implement a domestic violence education program, and to evaluate whether the program resulted in changes in these 3 domains. DESIGN: Interventional with before and after survey evaluation. SETTING: A hospital-based, pediatric residency continuity clinic that serves families in Pittsburgh, Pa. PARTICIPANTS: Pediatric residents (n = 51), medicine-pediatric residents (n = 6), continuity clinic faculty (n = 22), and certified-registered nurse practitioners (n = 5). RESULTS: Prior to implementation of the DV education program, respondents correctly answered questions about the prevalence of DV (74 participants [90%]), the racial distribution of DV victims (66 participants [80%]), and the significant overlap between child abuse and DV (75 participants [91%]). Seventy-nine participants (96%) believed that screening for the presence of DV was part of their role as pediatric health care providers. At baseline, 17 (21%) of the 82 participants reported that they were routinely screening for signs of DV during well-child care visits compared with 39 (46%) after attending the education program (P =.005). Among participants who attended both educational session 25% (9/36) were routinely screening for the presence of DV prior to the intervention, compared with 46% (16/35) after the intervention (P =.008). At baseline, 33 (40%) of the 82 participants had identified at least 1 case of DV in the prior 6 months compared with 45 (53%) after training. Prior to training, 18 participants (22%) were aware of resources for DV victims compared with 45 (53%) after training (P<.001). CONCLUSIONS: To our knowledge, this is one of the first pediatric studies to demonstrate that using a short, multifaceted educational module, it is possible to change DV screening practices and to increase identification of DV victims among pediatric residents, continuity clinic faculty, and certified-registered nurse practitioners at a pediatric teaching hospital.

Adult↗

PubMed2004

Childhood immunization rates before and after the implementation of Medicaid managed care.

OBJECTIVE: To evaluate trends in childhood immunization coverage after implementation of Medicaid managed care in Tennessee (TennCare) in 1994. DESIGN: Before-and-after study using the Tennessee Department of Health annual cross-sectional survey of children aged 24 months. PATIENTS: A mean of 1663 children per year who were randomly sampled during 1986-1999. MAIN OUTCOME MEASURE: Completion rate for recommended immunizations by the age of 24 months or younger. RESULTS: A total of 23 044 children were included. The proportion of children continuously enrolled in Medicaid from age 1 to 24 months increased slightly with TennCare. Among children enrolled, immunization rates increased considerably before TennCare (1986-1993) and continued to increase after TennCare (1994-1999), albeit less dramatically. Immunization coverage was significantly lower for children enrolled compared with children not enrolled in fee-for-service Medicaid. Among children enrolled in fee-for-service Medicaid, black children were more likely to be inadequately immunized than white children (40% vs 26%; relative risk [RR], 1.56; 95% confidence interval [CI], 1.40-1.73). These gaps were nearly eliminated after TennCare. An increased proportion of children enrolled in TennCare received immunizations in the private sector. Among children enrolled in fee-for-service Medicaid, those receiving immunizations entirely in the private sector were more likely to have incomplete immunization status than children immunized entirely in the public sector (27% vs 21%; RR, 1.28; 95% CI, 1.20-1.37). Under TennCare and after implementation of the Vaccines for Children program in Tennessee, the difference was not significant. CONCLUSIONS: Overall, TennCare had no discernible negative effect on immunization rates in Tennessee and perhaps contributed to decreasing the immunization gap between children enrolled and children not enrolled in Medicaid and between black and white children.

Black or African American↗

PubMed2003

Evaluation of control measures implemented in the severe acute respiratory syndrome outbreak in Beijing, 2003.

CONTEXT: Beijing, China, experienced the world's largest outbreak of severe acute respiratory syndrome (SARS) beginning in March 2003, with the outbreak resolving rapidly, within 6 weeks of its peak in late April. Little is known about the control measures implemented during this outbreak. OBJECTIVE: To describe and evaluate the measures undertaken to control the SARS outbreak. DESIGN, SETTING, AND PARTICIPANTS: Data were reviewed from standardized surveillance forms from SARS cases (2521 probable cases) and their close contacts observed in Beijing between March 5, 2003, and May 29, 2003. Procedures implemented by health authorities were investigated through review of official documents and discussions with public health officials. MAIN OUTCOME MEASURES: Timeline of major control measures; number of cases and quarantined close contacts and attack rates, with changes in infection control measures, management, and triage of suspected cases; and time lag between illness onset and hospitalization with information dissemination. RESULTS: Health care worker training in use of personal protective equipment and management of patients with SARS and establishing fever clinics and designated SARS wards in hospitals predated the steepest decline in cases. During the outbreak, 30 178 persons were quarantined. Among 2195 quarantined close contacts in 5 districts, the attack rate was 6.3% (95% confidence interval [CI], 5.3%-7.3%), with a range of 15.4% (95% CI, 11.5%-19.2%) among spouses to 0.36% (95% CI, 0%-0.77%) among work and school contacts. The attack rate among quarantined household members increased with age from 5.0% (95% CI, 0%-10.5%) in children younger than 10 years to 27.6% (95% CI, 18.2%-37.0%) in adults aged 60 to 69 years. Among almost 14 million people screened for fever at the airport, train stations, and roadside checkpoints, only 12 were found to have probable SARS. The national and municipal governments held 13 press conferences about SARS. The time lag between illness onset and hospitalization decreased from a median of 5 to 6 days on or before April 20, 2003, the day the outbreak was announced to the public, to 2 days after April 20 (P<.001). CONCLUSIONS: The rapid resolution of the SARS outbreak was multifactorial, involving improvements in management and triage in hospitals and communities of patients with suspected SARS and the dissemination of information to health care workers and the public.

China↗

PubMed1997

Implementing participatory ergonomics teams among health care workers.

Three participatory ergonomics teams have been established among healthcare workers in a metropolitan medical center. Three teams, consisting of orderlies, intensive care unit nurses, and laboratory workers, were selected to provide a diversity of work activities and educational backgrounds. The effectiveness of these teams was assessed by observations of team interactions, by team members' perceptions of their effectiveness, and by the teams' success in identifying problems and implementing solutions. After 1 year, one of the three groups has been highly effective by these measures. To varying degrees, the groups encountered competing time demands and obstacles in implementing solutions within current administrative structures. For some groups of health care workers, participatory ergonomics teams seem to be an effective strategy to improve health and safety. This approach may not be feasible in all areas of health care, especially in high-demand clinical areas where patient needs may take precedence over the safety of health care workers.

Ergonomics↗

PubMed1997

Nurses' job satisfaction, absenteeism, and turnover after implementing a special care unit practice model.

The purpose of the study was to compare job satisfaction, absenteeism, and turnover between nurses working in a nurse-managed special care unit (SCU) and those working in traditional intensive care units (ICU). A case management practice model with a shared governance management model and minimal technology was implemented in the SCU while contrasting features of a primary nursing practice model with a bureaucratic management model and high technology already in place in the traditional ICU. Individual nurses' perceptions of and their preferences for the SCU practice model also were examined related to job satisfaction. Using analysis of covariance, greater satisfaction with a lower absenteeism rate was found in nurses working in the SCU. Nurses' perceptions and preferences for the SCU practice model were closely related to their job satisfaction and growth satisfaction. The findings suggest that individual perception and preference should be taken into account before implementing autonomy, authority, and responsibility at the organizational level to lead to the desired nurse outcomes in a given working environment.

Absenteeism↗

PubMedDate not supplied

Implementation of quantitative perfusion imaging techniques for functional brain mapping using pulsed arterial spin labeling.

We describe here experimental considerations in the implementation of quantitative perfusion imaging techniques for functional MRI using pulsed arterial spin labeling. Three tagging techniques: EPISTAR, PICORE, and FAIR are found to give very similar perfusion results despite large differences in static tissue contrast. Two major sources of systematic error in the perfusion measurement are identified: the transit delay from the tagging region to the imaging slice; and the inclusion of intravascular tagged signal. A modified technique called QUIPSS II is described that decreases sensitivity to these effects by explicitly controlling the time width of the tag bolus and imaging after the bolus is entirely deposited into the slice. With appropriate saturation pulses the pulse sequence can be arranged so as to allow for simultaneous collection of perfusion and BOLD data that can be cleanly separated. Such perfusion and BOLD signals reveal differences in spatial location and dynamics that may be useful both for functional brain mapping and for study of the BOLD contrast mechanism. The implementation of multislice perfusion imaging introduces additional complications, primarily in the elimination of signal from static tissue. In pulsed ASL, this appears to be related to the slice profile of the inversion tag pulse in the presence of relaxation, rather than magnetization transfer effects as in continuous arterial spin labeling, and can be alleviated with careful adjustment of inversion pulse parameters.

Arteries↗