General Practitioners: Allies or Enemies of Primary Health Care

In this paper the thesis is advanced that the general practitioners can either be a powerful ally or a major roadblock in the development of primary health care in the spirit of the Alma-Ata Declaration. The role they will play depends on their interpretation of, and attitudes towards, the concept. In the first part of the paper, four common interpretations of primary health care (primary health care as a set of activities; as a level of care; as a strategy; and as a philosophy) are described. The second part identifies common misconceptions — traps into which the general practitioners may fall when taking their stand on primary health care. In the third part, a blueprint for transforming the current systems of primary medical care systems into primary health care systems is outlined. The final section suggests some concrete actions to be taken by the general practitioners in implementing this blueprint.     

Trends in Use of Health Care Services in Swedish Primary Care District. A Ten Year Perspective

In a study that covered ten years a questionnaire about use of health care facilities was mailed each autumn to 1/60 representative samples of the population in Sollentuna, a Swedish primary care district with three health centres.

Primary care was the health care form with the greatest contact area with the population studied. However, the strengthening of district physician resources at one of the three health centres did not, in the long term, lead to more people coming into contact with this form of medical care.

It was more common for those who visited a private doctor or school/company doctor also to consult a district physician than vice versa. Similarly, hospital patients visited the health centre to a greater degree than patients of health centres visited hospitals.

The only long-term change in the flow of patients that could be registered was a reduction in the number of patients who visited hospital emergency departments.

It is concluded that the implementation of an annual survey may be considerably more helpful than more sparse investigations in distinguishing between temporary fluctuations and real changes.     

Child Care Health Consultation: An Ecological Model

ISSUES AND PURPOSE. To present an ecological model of child care health consultation that defines the role of the health consultant as a resource and advocate within child care programs, as well as a supportive link among families, child care providers, and the healthcare system.
CONCLUSIONS. Nurses have provided health consultation to child care programs for more than 30 years and represent the majority of health consultants nationally. Pediatric nurses and advanced practice nurses are well prepared to shape and lead the development of this emerging role.
PRACTICE IMPLICATIONS. With expertise in caring for children, understanding families, and care across systems, pediatric nurses and advanced practice nurses should engage in current state and national efforts to develop child care health consultatits.     

Acute cardiogenic pulmonary oedema: reflecting on the management of an intensive care unit patient

Aim: The aim of this paper is to reflect upon the management interventions of non‐invasive ventilation (NIV) and diuretic therapy that were implemented for a patient admitted to an intensive care unit (ICU) with acute cardiogenic pulmonary oedema. Background: Acute pulmonary oedema is a serious and life‐threatening complication of acute heart failure, particularly if this results from an ischaemic event. Statistics highlight that of those patients treated for acute cardiogenic pulmonary oedema, approximately only one third were alive after 1 year. Many of these patients will require intensive care management in order to restore homeostasis. It is therefore imperative that nurses understand the condition and the relevant management of it in order to maximize the already poor prognosis. Results: Using Driscoll's (2000) reflective model to guide critical thinking, this paper reflects on the management of one patient who was admitted to ICU with acute cardiogenic pulmonary oedema as a result of heart failure. Although there are many aspects of patient management that can be explored, specific care interventions that this patient received in relation to NIV and diuretic therapy will be considered. The evidence base for their use, together with the relevant nursing management issues, and patient implications will be critically analysed and outlined. Conclusions: This paper identifies that standard therapy for acute cardiogenic pulmonary oedema is largely supportive and aimed at promoting gaseous exchange. It also highlights that nurses have a key role in ensuring that these essential treatments are as efficacious as possible. Relevance to clinical practice: By using a reflective analysis approach, this paper highlights how reflecting on practice improves knowledge and understanding of the use of NIV and diuretic therapy interventions and should facilitate nurses working in ICU to become more competent in ensuring that the treatment provided for acute cardiogenic pulmonary oedema is as successful as possible.     

Association between continuity of care in Swedish primary care and emergency services utilisation: a population-based cross-sectional study

Objective: The primary objective of this study was to determine the association between longitudinal continuity of care (CoC) in Swedish primary care (PC) and emergency services (ES) utilisation.

Study design: A cross-sectional analysis of longitudinal population data. Setting. PC centres, out-of-hours PC facilities and emergency departments (EDs) in Blekinge County in southern Sweden. Subjects: People of all ages who lived in Blekinge County and who had made two or more visits per year to a general practitioner (GP) during office hours from 1 January 2012 to 31 December 2014.

Main outcome measure: ES utilisation.

Results: Eight-thousand one-hundred and eighty-five people were included in the study. CoC was quantified using three different indices—Usual Provider of Care index (UPC), Continuity of Care index (CoCI), and Sequential Continuity index (SECON). The CoC that the PC centres could offer their enrolled patients varied significantly between the different centres, ranging from 0.23–0.57 for UPC, 0.12–0.43 for CoCI, and 0.25–0.52 for SECON. Association between the three CoC indices and ES utilisation was computed as an incidence rate ratio which ranged between 0.50 and 0.59.

Conclusion: Longitudinal CoC was shown to have a negative association with ES utilisation. The association was significant and of a magnitude that implies clinical relevance. Computed incidence rate ratios suggest that patients with the lowest CoC had twice as many ES visits compared to patients with the highest CoC.     

Quality in Clinical Practice

This paper reports the proceedings of the discussion panel assigned to look at clinical aspects of quality in emergency medicine. One of the seven stated objectives of the Academic Emergency Medicine consensus conference on quality in emergency medicine was to educate emergency physicians regarding quality measures and quality improvement as essential aspects of the practice of emergency medicine. Another topic of interest was a discussion of the value of information technology in facilitating quality care in the clinical practice of emergency medicine. It is important to note that this is not intended to be a comprehensive review of this extensive topic, but instead is designed to report the discussion that occurred at this session of the consensus conference.     

Parental Perceptions of Health Care for Children with Chronic Illness-A Population-based Study in a Swedish Primary Care District

The division of responsibilities between specialized and primary health care for children with chronic illness is unclear. The utilization and perceptions of primary and specialized care were examined by means of a questionnaire mailed to the parents of all chronically ill children and a randomly selected control group. No difference in sociodemographic variables of responders (70%) and nonresponders was found. The study comprised 98 index and 168 control children. The index children utilized both primary and specialized care more than controls. The overall satisfaction with health care was high, but primary care did not come up to the expectations of many chronically ill children's parents. Satisfaction with specialized care but not with primary care had improved during the previous 15 years. Recognition in primary care of childhood chronic illnesses and their psychosocial consequences is important. In co-operation, the two health care levels together could enable a comprehensive, well-coordinated, and continuous care for these children.     

Trends in the perceived complexity of primary health care: a secondary analysis

Rationale If the complexity of the patient's medical problems increases or the complexity of the interactions between the doctor and the patient, the staff or the health care system increase, then complexity of patient care will increase. This study examined trends in patient complexity, and identified doctor, practice and improvement strategy characteristics associated with perceived complexity. Methods This secondary analysis used data from three Community Tracking Surveys with 22 134 primary care doctors completing surveys about themselves, their practice setting, practice improvement strategies and complexity of care in three consecutive 2‐year time periods (1996–1997, 1998–1999, 2000–2001). Data were analysed using hierarchical logistic regression. Results The proportion of primary care doctors who perceived that complexity of care had increased over the past 2 years rose from 31.5% to 35.9%. Perceived complexity of patient care was consistently related to being in solo practice and the belief that they could not frequently obtain high‐quality services and referrals for patients. As availability of services increased, complexity decreased whereas as use of practice improvement strategies increased, complexity also increased. Conclusions Understanding that we cannot determine whether respondents understood care as ‘complicated’ or ‘complex’, potential consequences of this increase in complexity include an increase in medical errors and referral rates along with decreased quality of patient care and career satisfaction.     

Asthma nurse practice improves outcomes and reduces costs in primary health care

OBJECTIVE: The aim of this study was to elucidate the care of patients with asthma in primary health care from medical, patient self-management, health, quality of life, and health economic perspectives. METHODS: Asthma nurse practice (ANP), an alternative asthma self-management strategy, was compared with traditional asthma care in primary health care in southern Sweden regarding medical history, lifestyle, self-management, symptoms caused by asthma, effects on sick leave, state of health, quality of life and health care costs. The first part of the investigation comprised a retrospective study of a randomly selected sample of patient records of asthmatics (n=152). The second part, lasting 3 months, was prospective and included consecutive patients visits (n=347). RESULTS: The ANP approach showed better results in most of the evaluated outcomes such as asthma quality documentation and self-management and the number of asthma symptoms was significantly lower. From a health economic perspective the results were encouraging with respect to ANP. CONCLUSION: This alternative asthma strategy, ANP, improved asthma care in primary health care and resulted in economic advantages in the health care sector. However the result may only be generalized to other practices working with asthma nurses in the same way.     

Primary health care practitioners' tools for mental health care

The purpose of this study was to describe and analyse the content of mental health care from the practitioner's point of view. The specific aim of this paper was to outline the types of mental health care tools and the ways in which they are used by primary health care practitioners. The data were derived from interviews with doctors and nurses (n = 29) working in primary health care in six different health care centres of the Pirkanmaa region in Finland. The data were analysed by using qualitative content analysis. The tools of mental health care used in primary health care were categorized as communicative, ideological, technical and collaborative tools. The interactive tools are either informative, supportive or contextual. The ideological tools consist of patient initiative, acceptance and permissiveness, honesty and genuineness, sense of security and client orientation. The technical tools are actions related to the monitoring of the patient's physical health and medical treatment. The collaborative tools are consultation and family orientation. The primary health care practitioner him/herself is an important tool in mental health care. On the one hand, the practitioner can be categorized as a meta-tool who has control over the other tools. On the other hand, the practitioner him/herself is a tool in the sense that s/he uses his/her personality in the professional context. The professional skills and attitudes of the practitioner have a significant influence on the type of caring the client receives. Compared with previous studies, the present informants from primary health care seemed to use notably versatile tools in mental health work. This observation is important for the implementation and development of mental health practices and education.     

A longitudinal comparison of consumer-directed and agency-directed personal assistance service programmes among persons with physical disabilities

Purpose. To compare outcomes for persons who were enrolled in an agency-directed personal assistance services (PAS) programme and then changed to a consumer-directed PAS programme.

Method. A convenience sample was used for this longitudinal study. In-home interviews were conducted by a trained data collector from April 2000 to December 2001.

Results. Participants reported more satisfaction and safety with personal assistance, and fewer unmet needs after receiving consumer-directed services than after receiving agency-directed services. Other variables related to outcomes included race and ethnicity, employment, functional status, unmet needs, and the level of confidence in obtaining help if assistance is unavailable. Participants (74%) also reported high rates of unmet needs in the past month.

Conclusions. Consumer-directed PAS enhances outcomes for many persons with disabilities. Self-reported outcomes are affected by many factors that could be addressed in PAS program development.     

Important Attributes of Quality Health Care: Consumer Perspectives

Purpose: Despite extensive research on defining and measuring health care quality, little attention has been given to consumers' perspectives of high-quality health care. The purposes of this study were to (a) identify the importance to consumers of attributes of health care quality and nursing care quality, and (b) examine the relationship of consumer perspectives to health status and selected demographic variables.
Design: Exploratory. Consumers (N = 239) were recruited from waiting rooms of clinics and in neighborhoods of a large metropolitan area in the Midwestern United States that included both urban and suburban populations.
Methods: Participants completed the Quality Health Care Questionnaire (QHCQ) and the SF-36 Health Survey. On the QHCQ, they rated the importance of 27 attributes of health care and nursing care quality. The SF-36 is a 36-item instrument for measuring health status in eight general areas.
Findings: The most important indicators of high-quality nursing care to consumers were: being cared for by nurses who are up-to-date and well informed; being able to communicate with the nurse; spending enough time with the nurse and not feeling rushed during the visit; having a nurse teach about the illness, medications, treatments, and staying healthy; and being able to call a nurse with questions. The lowest-rated item was having an opportunity to be cared for by nurse practitioners. Ratings differed by race, age, years of education, income, and health status.
Conclusions: The importance that consumers place on teaching by the nurse was emphasized, particularly among people with less education, low income levels, and chronic illnesses.     

Buurtzorg Nederland: una propuesta de atención domiciliaria dirigida por enfermeras

Buurtzorg Nederland is a Dutch healthcare organization in which nursing teams provide home care in all the skills that affect their profession. This article raises some questions regarding more internal aspects of the organization based on 3 dimensions. The first, the organizational dimension, in which the teams are structured based on 8 roles, without hierarchies and supported by the coaching system. The second, the nursing dimension, in which it is highlighted that nurses deal with all the competences that affect their profession, from basic care to more complex care, with the aim of defragmenting care. And the third, the economic dimension, in which it stands out that the sustainability of the organization is in being a system without managers, of small teams that work in small geographic areas, with a computer system that supports all organizational matters, healthcare and financial.The main characteristics of Buurtzorg Nederland are the self-management of the teams and the defragmented care that both the nurse and the patient satisfy. However, this defragmentation has been achieved in terms of patient care, with the same team attending to all basic and complex care needs at home, but at other levels of care it has not been achieved, and the patient must visit other providers, therefore, health care at other levels continues to be fragmented.     

Mapping the clinical care pathways for advanced stage non-small cell lung cancer patients in Victoria: A retrospective cohort study of supportive and palliative care

The lung cancer Optimal Care Pathway recommends supportive care and palliative care integration throughout its various steps, with early referral to appropriate services improving the quality of life in advanced stage non-small cell lung cancer patients. Using Victorian Lung Cancer Registry data and linked administrative datasets, this retrospective cohort study mapped clinical care pathways of 525 Stage III–IV non-small cell lung cancer patients in Victoria to 11 recommendations in the Optimal Care Pathway, identifying unwarranted variations in clinical care. Supportive care and palliative care delivery were further examined to understand the involvement and timing of specialist care teams. Our findings showed that palliative care utilization is highest at the time of treatment, despite recommendations that it should be provided early after diagnosis to improve patient outcomes and satisfaction. Early supportive care screening was observed in half the cohort and almost three-quarters of the patients had been presented at a multidisciplinary meeting. Multidisciplinary meeting presentations and supportive care provide an opportunity to improve communication about palliative care needs and integration into routine clinical practice, such as at the time of treatment planning.     

Up a river! Interprofessional education and the Canadian healthcare professional of the future

The benefits of an interprofessional approach to patient care are becoming well known and the adoption of these ideas for collaboration by future healthcare professionals will be influenced by positive exposures during pre-licensure education. Although much work has been done, the establishment of interprofessional education in health care programs is still in the developmental phase in many centers. But the need for such education is obvious and urgent. Once these new professionals enter into practice, they will be expected to function as members of interprofessional teams. Therefore, they should be equipped with the skills they will need to function effectively on a team. The future of the healthcare system relies on the education of tomorrow's professionals. When we finally train healthcare professionals to perform as part of a team, “paddling in harmony”, we will be able to steer toward our goal of an efficient, sustainable and safe health care system. If we do not learn to work together, we will continue to go in circles.     

Giving a fig about roles: policy, context and work in community mental health care

Across the UK, mental health professionals are strongly objecting to threats to their roles. Against this background we use ethnographic data from a study of roles and responsibilities in community care, undertaken across two contrasting sites in Wales, to demonstrate how work is sensitive to local organizational features and to show how gaps can grow between the public claims professions make about their contributions and the actual roles which their members fulfil in the workplace. We reveal how, in one of our two research sites, immediate contextual features shaped the work of nurses and social workers towards the fulfilment of expanded packages of activity. We then show how subsequent policy (including 'new ways of working'), combined with new pressures arising from the economic downturn, carry the potential to accelerate the wider creation of workplaces of this type. We examine some implications of these processes for nurses and others, and for the system of mental health care as a whole, and conclude with a call for closer attention to be paid to the potential, wider, impact of current developments.     

Palliative care case management in primary care settings: A nationwide survey

Background

In case management an individual or small team is responsible for navigating the patient through complex care. Characteristics of case management within and throughout different target groups and settings vary widely. Case management is relatively new in palliative care. Insight into the content of care and organisational characteristics of case management in palliative care is needed.

Objectives

To investigate how many case management initiatives for palliative care there are in the Netherlands for patients living at home; to describe the characteristics of these initiatives with regard to content and organisation of care.

Setting

Primary care.

Design and participants

A nationwide survey of all 50 coordinators of networks in palliative care in the Netherlands was conducted. Additional respondents were found through snowball sampling. We looked at 33 possible initiatives using interviews (n = 33) and questionnaires (n = 30).

Results

We identified 20 initiatives for case management. All stated that case management is supplemental to other care. In all initiatives the case managers are registered nurses and most possess higher vocational education and/or further training. All initiatives seek to identify the multidimensional care needs of the patients and the relatives and friends who care for them. Almost all provide information and support and refer patients who need care. Differences are found between the organisations offering the case management, their target groups, the names of the initiatives and whether direct patient care is provided by the case manager.

Conclusions

In the Netherlands, case management in palliative care is new. Several models of delivery were identified. Research is needed to gain insight into the best way to deliver case management. By describing characteristics of case management in palliative care, an important first step is made in identifying effective elements of case management.