The FOOTPRINTS model of pediatric palliative care

Little is known about the optimal context in which to provide care for the more than 53,000 children who die each year in the United States. Poor training in pediatric palliative care contributes to care that is often fragmented and may neglect the physical, psychosocial, and spiritual needs of the child and family. Pediatric hospice care is frequently not available or not chosen by the family or health care providers. In response to a critical need to move beyond the disease oriented, hospital-based model with a lack of continuity between hospital and community-based medical services, we developed FOOTPRINTS, an innovative program of advanced care planning and care coordination. A continuity physician directs the treatment plan regardless of site of care. Staff members coordinate follow up and communication among hospital and community-based care providers. Spiritual support continues through bereavement. Education in the hospital and community supports provision of excellent palliative care by current providers. Satisfaction with this model of care has been high. More than 90% of health care providers and families perceived that the child and family needs as well as the health care provider needs were met by the advanced care planning process and written care plan. All continuity providers would refer another patient. The FOOTPRINTS program promotes quality of care and family and health care provider satisfaction with care. It has been developed to serve as a "best practice" model for care at life's end.     

HIT plants SEEDS in healthcare education

By incorporating a clinical information system in the education curriculum as a teaching platform, the University of Kansas School of Nursing teaches nurses and other health professional students how to assess, plan, document and manage care in an electronic medium that develops healthcare informatics competencies. The outcomes of this integrated technology curriculum brings hope for transforming health professional education for 21st century practice and graduating a workforce with the leadership and competencies for improving quality and safety in patient care. It results in IT savvy healthcare providers who will cross the quality chasm.     

Outcomes: are they a good thing?

One of the current buzzwords for health care these days is outcomes. Everyone, including payers, is attempting to evaluate the quality of care provided by the outcomes achieved. Outcomes can help the caregiver and the client determine if the appropriate care is being provided; identify if changes need to be made in the care plan; develop a mechanism to discuss effects of care that are understood by all health providers; demonstrate to the client the health care they have received, in a fashion that makes sense to them; and document nursing interventions that are most effective. Outcomes can be the basis for quality improvement and can assist in discharge planning. They also help in evaluating the organization's overall performance. As Martha Stewart would say, "It's a good thing."     

The Buyers Health Care Action Group: creating a competitive care system model

The Buyers Health Care Action Group, BHCAG, representing 26 large self-funded employers, has developed a new approach to the health care marketplace. On January 1, 1997 these companies implemented their plan to promote consumer driven competition at the care system rather than the plan level around clinical quality, service quality and cost. This new approach features increased provider autonomy and accountability, while empowering consumers with information to choose care systems based on their own values. Results to date include availability of 90-95% of community primary care physicians (with almost twice the delivery sites as previous offerings), extensive consumer information about providers and the care systems in which they participate, and a 1997 cost reduction of 9% against expected claims.     

Emergency management: expanding the disaster plan

A comprehensive emergency management plan (CEMP) is key to minimizing the disruption of patient care and services during and after a natural or man-made disaster. The home health nurse can play a key role in enhancing, expanding, and evaluating the effectiveness of the organization's disaster plan. The components of a CEMP and lessons learned from actual implementation of disaster plans in home care are addressed. The disasters and emergencies of the past few years, such as threats of terrorism, hurricanes, floods, wildfires, tornadoes, and earthquakes, have validated the need to extend the emergency preparedness plan to a more comprehensive approach to emergency management. Communities, healthcare providers, and individuals/families all have been urged to take a more comprehensive look at their readiness for these types of events. Home healthcare organizations, including home health agencies, hospice providers, infusion providers, and medical equipment companies, can take a fresh and comprehensive look at their emergency management plan.     

Experiences with care co-ordination among people with cerebral palsy,multiple sclerosis,or spinal cord injury

Purpose: To describe the experiences with care co-ordination of people with cerebral palsy, multiple sclerosis, or spinal cord injury; to determine barriers to effective care co-ordination; and to compare experiences across disability and health plan types. Method: Qualitative, semi-structured telephone interviews with 30 people with cerebral palsy, multiple sclerosis, or spinal cord injury. Interviews focused on the care co-ordination experience of individuals in managed care and traditional indemnity health insurance plans in the USA and were analysed using NVivo. Results: Half of the respondents reported that they had a health professional who co-ordinated their care. Participants identified barriers that prevented effective care co-ordination, including a lack of disability specific knowledge, providers' limited time and effort related to care, and insufficient communication among providers. There were few differences between managed care and fee-for-service respondents with regard to these barriers. Conclusions: Study findings reveal few differences in the care co-ordination experiences amongst people with cerebral palsy, multiple sclerosis, or spinal cord injury in both plan types. All providers need to become more literate about the health care needs of people with physical disabilities, and health plans need to reward communication among providers and the time and effort invested in care co-ordination.     

Integrating cultural diversity in patient education

Diversity among clients in the American health care system is increasing as the population of the United States changes in composition. Health providers, educators, and supervisors are in unique positions to enhance patient education among members of diverse cultures by incorporating cultural research and health beliefs into patient and staff education. Using a culturally defined framework, health providers can more holistically assess the client and subsequently plan culturally appropriate care.     

Defining neurosurgical and neurological nursing practice: establishing our clinical parameters, part I

We have examined the education and practice roles of various professional and allied health personnel necessary for providing optimal care to a specialized group of patients, in this case, the neurosurgical/neurological patient group. One needs to investigate these factors in order to plan for effective economic utilization of such personnel in the health care system. The primary goal of all health care providers is quality patient care services, yet secondary concerns cannot be overlooked if we are to accomplish this ultimate goal. Prohibitive health care costs for those we serve and escalating educational costs to become competent to render such services mandate that we choose the most advantageous use of available resource personnel. Placing professionals in appropriate positions which allow them to apply their education and clinical strengths in the care of patients will not only promote excellence in patient care but also excellence in each professional practice role.     

A hitchhiker's guide to competitive managed care

Competition among managed care plans features the dynamic interaction among three primary forces: delivery system integration, managed care health plan risk sharing, and purchaser activism. To evaluate the cost containment potential for a particular market, decision makers need to understand the character of provider integration, the role of managed care insurance plans, and the extent of purchaser activism in contracting with health care providers. This paper provides benchmarks that analysts can use to assess markets, and applies them to the four largest markets in Wisconsin. It concludes that competition among managed care plans can lead to cost-effective care only if purchasers respond to differences in cost, for given quality, by switching from high-priced plans to lower-priced ones.     

Options for small employers

Although offering health benefits is very expensive, many employers (small, medium, and large) make health care purchasing decisions based on very little information. This is largely because employers have not taken the time to learn how to be knowledgeable health care purchasers. Higher health care costs result when employers: purchase programs and services that employees and their dependents do not need and seldom use; pay (unknowingly) for services not offered in their benefit plan; accept and pay for ineffective cost containment programs that increase (not decrease) health care costs (remember that cost containment is a business in itself); make standard recommended changes (e.g., increased copays or deductibles) to their benefit plans, hoping to reduce costs (the result has been higher costs for too many employees); fail to assess whether health plans and insurance companies have effective internal quality and cost management programs; use financial incentives to encourage employees and dependents to enroll in managed care plans without examining whether the health plan or insurer used quality criteria, high standards, and capable processes in developing provider networks. (Capable processes consistently deliver quality products or services.) Most health plans and insurance companies have chosen providers based on their willingness to discount their charges, which places all parties (health plans or insurance companies, employers, and patients) at risk. Most of the problems listed above could be avoided if small employers based their health care purchasing decisions on information obtained from a careful analysis of needs and expectations.(ABSTRACT TRUNCATED AT 250 WORDS)     

Optimize patient health by treating literacy and language barriers

More than 90 million Americans have limited literacy skills. Almost two million US residents cannot speak English, and millions more speak it poorly. The stigma of illiteracy or the inability to speak a country's predominant language keep patients from disclosing their limitations. Recognizing these facts is an important first step in improving health education for this vulnerable population. By adapting teaching techniques to patients' special needs, nurses can ensure that patients understand their health problems and plan of care. Statistics dramatically demonstrate the high cost of neglecting these needs. Patients who do not understand their plan of care do not comply with instructions and, therefore, suffer unnecessary complications. Health care providers who can communicate with their patients through multilingual, low literacy patient education materials and with the use of qualified interpreters markedly improve the quality of care for their patients and the resulting outcomes. AORN J 75 (Feb 2002) 280-293.     

Integrating chiropractic in managed care

Alternatives to traditional health care are emerging as an important element in the mix of services offered by managed care plans. Integrating these nontraditional services, such as chiropractic, presents special challenges for plan managers. ChiroNet, an Oregon-based chiropractic specialty PPO network, has formed partnerships with a variety of managed care plans bringing managed chiropractic services to the PPO, EPO, and HMO environments. Practical experience with benefit design, access protocols, utilization management, quality assurance, provider credentialing, and administrative integration has been developed over the period of the network's cooperation with its managed care partners. Successful integration of these nontraditional provider groups depends on alignment of goals and incentives among all players in the system, including providers, their network, the patients, and the managed care plan.     

Evidence Based Practice: Decreasing Psychiatric Revisits to the Emergency Department

Inpatient psychiatric settings anticipate changes in reimbursement that will link payment rates to objective quality measures. Readmission rates are expected to be one of the quality measures. Inpatient areas are undertaking initiatives to decrease readmission rates in preparation for this change. The emphasis on avoiding readmission could cause an increase in emergency room revisit rates by psychiatric patients. In preparation for this potential impact, the mental health emergency service within the Emergency Department of a not-for-profit community based hospital implemented a proactive process improvement plan. The plan's goal was to insure that all patients’ care was provided according to a defined standardize best practice process. Steps of the plan focused on (1) improving treatment providers’ communications across the continuum of care, (2) enhancing communication between the mental health emergency department nurses and the on-call psychiatrists, (3) developing on-line decisional support to enhance communication, and (4) providing providers with feedback on the impact of changes. Implementation of the improvement process decreased the mean psychiatric emergency revisit rate from 5.7% to 4.3% and decreased the variability in monthly rates from a range of 1.83%–9.53% to a range of 3.53%–5.56%.     

To help or hinder: Which is more important in explaining a physician's willingness to recommend a health plan?

PURPOSE: To examine how specific health plan practices contribute to physicians' willingness to recommend a health plan to a patient, and whether the relative importance of plan practices is viewed differently when patients are seriously ill. METHODS: The Physician's Evaluation of Health Plans Project has surveyed 1,757 generalist physicians in 16 health plans in 5 areas nationwide. Each physician reported on one plan. Three multi-item scales assessed physicians' perceptions of health plan activities that facilitated or impeded high-quality care in the plans and the clinical capabilities of plan physicians. Regression analyses were used to explore relations between facilitators, barriers, and clinical capabilities, and two global physician judgments (the physician's willingness to recommend a plan and their judgment that a plan provided lower quality for sicker patients). RESULTS: A physician's willingness to recommend a health plan is more highly related to what plans do to facilitate care than to the barriers created by plans in managing care. However, barriers to care were substantially more important when evaluating health plan quality for sicker patients. CONCLUSIONS: From the physician's perspective, the relative importance of plan strategies to manage care is different for typical patients and patients who are more seriously ill. Efforts to collect information on health plan quality should separately evaluate care for sicker patients, in addition to evaluating the overall performance of the health plan.     

Health action plans for people with learning disabilities

This article describes the design of a health action plan included in a care package for a person with learning disabilities. It provides working knowledge and guidance to students, nurses and service providers who are currently undertaking similar interventions. The rationale for developing the health action plan is explained and the intervention is detailed in relation to the person's circumstances.     

The orthopaedic critical path.

Health care providers, purchasers, and insurers are struggling to manage the cost of health care while maintaining the quality of care. Alliant Health System has incorporated Total Quality Management (TQM) and the Critical Path Process throughout the corporation as a managed care strategy to deliver cost-effective quality care. Using the Critical Path Process has demonstrated a reduction in Length of Stay (LOS) and cost while maintaining quality. The success of this process depends upon an interdisciplinary and collaborative approach among health care providers in identifying practice patterns to assure appropriate and timely delivery of patient care.     

Stigma and Ageism: Compounding Influences in Making an Accurate Mental Health Assessment

Stigma and ageism are two phenomena that greatly affect the accurate assessment of metally ill elderly and, ultimately, their health care. Healthcare providers, doctors, nurses and others, including mental-healthcare providers, would benefit from awareness of stigma and ageism and their impact on psychiatric care for the elderly, many of whom also have physical problems. Understanding these influences may assist providers to make more accurate diagnoses and a more appropriate plan of care. This paper defines stigma and ageism and their potential and actual influences on assessment and interventions for the mentally ill elderly. Strategies for overcoming the impact of stigma and ageism are presented to assist healthcare providers to advocate for geropsychiatric clients.