'What she says she needs doesn't make a lot of sense': seeing and knowing in a field study of home-care case management

Abstract  Foucault's preoccupation with the visual, specifically his positing of a sort of 'positive unconscious of vision', offers an entry point for examining data generated through a field study of home-care case management practice. In Foucault's work, our attention is directed not so much to what is seen but to what can be seen and to the effects of practices of knowledge and power in constituting these particular realities. Knowledge emerges as a matter of what it is possible for knowers, for nurses, to see and to say, as well as the conditions that constitute these specific possibilities for seeing and saying in a given context. Given the significance of practices of seeing in case management – seeing clients, seeing situations – examining how possibilities for understanding are constituted through ways of seeing helps us to 'see' the limits of currently possible practice. In the case examined in this paper, these limits constitute a gap between what a client may actually need and what it is possible, in the context of current practice, to provide. To change practice it seems important, if only as a first step, to recognize the constraints of thought in what we see.     

Integrated dementia care in The Netherlands: a multiple case study of case management programmes

The number of dementia patients is growing, and they require a variety of services, making integrated care essential for the ability to continue living in the community. Many healthcare systems in developed countries are exploring new approaches for delivering health and social care. The purpose of this study was to describe and analyse a new approach in extensive case management programmes concerned with long‐term dementia care in The Netherlands. The focus is on the characteristics, and success and failure factors of these programmes. A multiple case study was conducted in eight regional dementia care provider networks in The Netherlands. Based on a literature study, a questionnaire was developed for the responsible managers and case managers of the eight case management programmes. During 16 semistructured face‐to‐face interviews with both respondent groups, a deeper insight into the dementia care programmes was provided. Project documentation for all the cases was studied. The eight programmes were developed independently to improve the quality and continuity of long‐term dementia care. The programmes show overlap in terms of their vision, tasks of case managers, case management process and the participating partners in the local dementia care networks. Differences concern the targeted dementia patient groups as well as the background of the case managers and their position in the local dementia care provider network. Factors for success concern the expert knowledge of case managers, investment in a strong provider network and coherent conditions for effective inter‐organizational cooperation to deliver integrated care. When explored, caregiver and patient satisfaction was high. Further research into the effects on client outcomes, service use and costs is recommended in order to further analyse the impact of this approach in long‐term care. To facilitate implementation, with a focus on joint responsibilities of the involved care providers, policy recommendations are to develop incentives for collaborative financial contracts between insurers and providers.     

Perceived barriers to implementing case management for medical-aid beneficiaries in South Korea

Medical aid (MA) in South Korea, a national public assistance scheme, provides minimum medical security for low-income families. The Korean government has adopted a case management (CM) programme to control MA beneficiaries' inappropriate medical use and enhance beneficiaries' quality of life. This study aimed to explore case managers' experiences of implementing CM for MA beneficiaries' potential barriers. This study employed a qualitative phenomenological tradition using focus-group interviews. Three focus groups with 19 MA case managers were conducted (July to August 2018) using semistructured interview questions. Data were analysed through qualitative content analysis using the NVivo software programme, followed by consensus meetings between researchers. Participants perceived the structural barriers to CM implementation as a contradictory MA system, lack of communication among government departments and CM guidelines not reflecting reality. Five themes were derived as the personal barriers: burnout, the conflict between private values and CM goals, role confusion, beneficiaries' blame, and lack of acknowledgement from coworkers. To improve case managers' experiences concerning MA beneficiaries, policy solutions and a collaborative environment with beneficiaries, public nurses and social service providers are needed to ensure the workforce's sustainability. Also, it is required to develop practical guidelines that reflect the reality of implementing CM.     

The implications for social services departments of the information task in the social care market

The new information task faced by social services departments (SSDs) implementing the 1990 community care policy is huge. This paper notes the breadth and complexity of the early guidance on the subject and then examines the nature of the task and the issues it raised in a shire county. Three aspects are delineated: mapping needs, mapping the market and monitoring expenditure. We found that the county experienced a culture shift in order to accommodate the new requirements, but had difficulty in timing the introduction of its information and information technology (IT) software systems. Change associated with one aspect of implementation had important knock-on effects in others. We highlight the danger of procedures becoming system-driven and of staff being overwhelmed by the call for information. We note that by the end of 1994 (the end of the research period) the county was facing what we have termed ‘second wave’ challenges. We conclude that implementing community care requires an indefinite investment in people and systems and that the process challenges are in danger of diverting attention away from user and carer experiences and from outcomes.     

信息技术在医院病案管理中的运用

本文针对我国当前病案管理模式现状，着重介绍了电子计算机、电子记录载体、网络技术、条形码自动识别技术、缩微技术、光盘影像技术等信息技术在病案管理中的运用，为促进病案管理的进一步发展，适应我国加入WTO的新形势要求，尽快与国际接轨，提供可借鉴的经验。     

HMIS and decision-making in Zambia: re-thinking information solutions for district health management in decentralized health systems

At the onset of health system decentralization as a primary health care strategy, which constituted a key feature of health sector reforms across the developing world, efficient and effective health management information systems (HMIS) were widely acknowledged and adopted as a critical element of district health management strengthening programmes. The focal concern was about the performance and long-term sustainability of decentralized district health systems. The underlying logic was that effective and efficient HMIS would provide district health managers with the information required to make effective strategic decisions that are the vehicle for district performance and sustainability in these decentralized health systems. However, this argument is rooted in normative management and decision theory without significant unequivocal empirical corroboration. Indeed, extensive empirical evidence continues to indicate that managers' decision-making behaviour and the existence of other forms of information outside the HMIS, within the organizational environment, suggest a far more tenuous relationship between the presence of organizational management information systems (such as HMIS) and effective strategic decision-making. This qualitative comparative case-study conducted in two districts of Zambia focused on investigating the presence and behaviour of five formally identified, different information forms, including that from HMIS, in the strategic decision-making process. The aim was to determine the validity of current arguments for HMIS, and establish implications for current HMIS policies. Evidence from the eight strategic decision-making processes traced in the study confirmed the existence of different forms of information in the organizational environment, including that provided by the conventional HMIS. These information forms attach themselves to various organizational management processes and key aspects of organizational routine. The study results point to the need for a radical re-think of district health management information solutions in ways that account for the existence of other information forms outside the formal HMIS in the district health system.     

Survey of paediatric case management practices in Australia for children and young people with acquired brain injury (ABI)

AIM: To investigate the characteristics of paediatric acquired brain injury (ABI) case managers and their organizations in Australia, and to determine the ways in which case managers deliver their service, maintain professional development and evaluate outcomes. METHODS: Postal survey of 57 known paediatric ABI case managers working at 24 separate organizations in Australia. RESULTS: Out of 40 questionnaires returned (70%), the majority of respondents had been providing case management for over 5 years (55%). Co-ordination of services was ranked the most important component of case management, with services most frequently delivered by telephone. Evaluation of case management outcomes was reported by only 52% of the case managers. Whilst the majority of case managers had received some form of training (83%), this varied widely from informal in-house training, to workshops run by insurance companies and government agencies. DISCUSSION: This survey provides information about current case management practices for children with ABI in Australia. Detailing what case managers do is a first step towards developing controlled research designs which are required to demonstrate whether case management is effective in terms of clinical outcomes and cost-benefit.     

Task shifting in the provision of home and social care in Ontario,Canada: implications for quality of care

Growing healthcare costs have caused home‐care providers to look for more efficient use of healthcare resources. Task shifting is suggested as a strategy to reduce the costs of delivering home‐care services. Task shifting refers to the delegation or transfer of tasks from regulated healthcare professionals to home‐care workers (HCWs). The purpose of this paper is to explore the impacts of task shifting on the quality of care provided to older adults from the perspectives of home healthcare workers. This qualitative study was completed in collaboration with a large home and community care organisation in Ontario, Canada, in 2010–2011. Using a purposive sampling strategy, semi‐structured telephone interviews were conducted with 46 home healthcare workers including HCWs, home‐care worker supervisors, nurses and therapists. Study participants reported that the most common skills transferred or delegated to HCWs were transfers, simple wound care, exercises, catheterisation, colostomies, compression stockings, G‐tube feeding and continence care. A thematic analysis of the data revealed mixed opinions on the impacts of task shifting on the quality of care. HCWs and their supervisors, more often than nurses and therapists, felt that task shifting improved the quality of care through the provision of more consistent care; the development of trust‐based relationships with clients; and because task shifting reduced the number of care providers entering the client's home. Nurses followed by therapists, as well as some supervisors and HCWs, expressed concerns that task shifting might compromise the quality of care because HCWs lacked the knowledge, training and education necessary for more complex tasks, and that scheduling problems might leave clients with inconsistent care once tasks are delegated or transferred. Policy implications for regulating bodies, employers, unions and educators are discussed.     

Success of case management for medical aid initiative in Korea

The purpose of this cross‐sectional study was to determine the effects of case management of Korea Medical Aid on recipients' satisfaction, ability to handle health problems, health behaviour, quality of life (QoL), hospital visiting days and medical expenditure. Data from structured interviews and claim data from medical institutions to the Korea National Health Insurance Corporation were used. Survey data were collected by questionnaire during September 2008. There were 647 responses out of 1069 (response rate 60.5%), but 260 were excluded from the analyses in this paper because they had received case management for <18 months. This left 269 individuals who had received case management services for 18 months continuously and 118 who had received no case management services in the same time period. Among the former group, 86.9% were satisfied or strongly satisfied with the initiative. Results indicate that the satisfaction for the case management was very high. Although there was no difference in terms of health behaviour and QoL between the two groups, the overall ability to handle health problems was higher in the case management group (P < 0.001). As for healthcare use, the programme produced a significant reduction in hospital visiting days (P = 0.034), and while the mean increase in cost from 2007 to 2008 was 29.1% lower for individuals in the programme, the difference between the groups was not significant (P = 0.851). Case management in Korea is in its early stages, and efforts should be made to extend this approach.     

The impact of managed competition on diversity, innovation and creativity in the delivery of home-care services

Reforming publicly funded healthcare systems by introducing elements of competition, often by allowing for-profit providers to compete with not-for-profit providers, is a strategy that has become commonplace in Western democracies. It is widely thought that the competitive forces of the marketplace will lead to greater efficiency, diversity and even innovation in the delivery of services. Between 1997 and 2000, a model of 'managed competition' was introduced as a major reform to the delivery of home-care services in Ontario, Canada. It was expected that by allowing greater competition within the home-care sector, this model would constrain costs and encourage provider agencies to become more innovative and creative in meeting service delivery needs. The purpose of this case study is to explore the impact of the managed competition reform on the for-profit and the not-for-profit organisations that provided rehabilitation home-care services, and, more specifically, to assess the extent to which the goal of greater diversity, innovation and creativity was achieved following implementation of the reform. A purposive sample of 49 key informants were selected for in-depth interviews, and a survey of the 36 organisations that provided rehabilitation home-care services and the 43 community care access centres that purchased services from these provider agencies was conducted. Data were collected between November 2002 and May 2003. Findings demonstrate that a combination of coercive, mimetic and normative isomorphic pressures have constrained diversity, innovation and creativity within the home-care sector. The implication is that the features that have traditionally distinguished for-profit and not-for-profit provider agencies from each other are rapidly disappearing, and a new hybrid organisational structure is evolving.     

影像数据传输及储存系统与放射学信息系统在医院信息化管理中的应用

目的：介绍影像数据传输及储存系统（PACS）和放射学信息系统（RIS）技术在医院信息化管理中的应用.方法：应用PACS及RIS对医院信息进行管理与共享.结果：医院PACS及RIS的实施提高了医疗质量及管理水平;PACS全面解决了医学影像的获取、显示、处理、贮存以及管理等问题;RIS解决了医院普遍出现的病历档案大容量存储的难题.结论：PACS及RIS是医院信息系统重要组成部分,PACS及RIS的应用可有效提高医院信息化管理水平.     

Interdependence in decision-making by medical consultants: implications for improving the efficiency of inpatient physician services

Objectives: Hospital administrators are seeking to improve efficiency in medical consultation services, yet whether consultants make decisions to provide more or less care is unknown. We examined how medical consultants account for prior consultants’ care when determining whether to provide intensive consulting care or sign off in the treatment of complex surgical inpatients. We applied three distinct theoretical frameworks in the interpretation of our results.

Methods: We performed a retrospective cohort study of consultants’ care intensity, measured alternately using a dummy variable for providing two or more days consulting (versus one) and a continuous measure of total days consulting, with 100% Medicare claims data from 2007–2010. Our analytic samples included consults for beneficiaries undergoing coronary artery bypass grafting (n = 61,785) or colectomy (n = 33,460) in general acute care hospitals. We compared the care intensity of consultants who observed different patterns of consulting care before their initial consults using ordinary least squares regression models at the patient-physician dyad level, controlling for patient comorbidity and many other patient- and physician-level factors as well as hospital region and year fixed effects.

Results: Consultants were less likely to provide intensive consulting care with each additional prior consultant on the case (1.2–1.7 percent) or if a prior consultant rendered intensive consulting care (20.6–21.5 percent) but more likely when prior consults were more concentrated across consultants (2.9–3.1 percent). Effects on consultants’ total days consulting were similar.

Conclusion: On average, consultants appeared to calibrate their care intensity for individual patients to maximize their value to all patients. Interventions for improving consulting care efficiency should seek to facilitate (not constrain) consultants’ decision-making processes.     

Understanding and improving communication and decision-making in palliative care for Turkish and Moroccan immigrants: a multiperspective study

Objective. The aim of this study is to explore how communication and decision-making in palliative care among Turkish and Moroccan patients is influenced by different styles of care management between Turkish and Moroccan families and Dutch professional care providers. Problems as well as solutions for these problems are highlighted. Design. A qualitative design was used, totally interviewing 83 people (6 patients, 30 relatives and 47 care providers) covering 33 cases of incurable cancer patients receiving palliative care. Data were analysed thematically and contextually. Results. The analysis reveals that problems in decision-making are partly related to differences in ethnic-cultural views on 'good care' at the end of life: Dutch palliative care providers prefer to focus on quality of life rather than on prolonging life, while Turkish and Moroccan families tend to insist on cure. Another barrier is caused by conflicting views on the role of the 'care management group': Dutch care providers see the patient as their primary discussion partner, while in Turkish and Moroccan families, relatives play a major part in the communication and decision-making. Moreover, the family's insistence on cure often leads to the inclusion of additional care providers in communication, thus complicating joint decision-making. Conclusion. Care providers need to understand that for Turkish and Moroccan patients, decision-making is seldom a matter of one-to-one communication. Next to acknowledging these patients' different cultural backgrounds, they must also recognise that the families of these patients often function as care management groups, with an 'equal' say in communication and decision-making. In addition, professionals should optimise communication within their own professional care management group.     

Linking the power of information technology and case management interventions: an assessment of recent medical-management trends

Imagine a case manager screening a large employer group of 20,000 participants and within less than a couple of minutes: Your first reaction may be one of disbelief. You might think, "Yes, maybe in 2020." However, the reality is that this type of information exchange in the context of case management (CM) is happening today, and it is revolutionizing the medical-management system as we once knew it. This article highlights some of the key changes that have recently occurred in the medical-management field and that are creating a paradigm shift in how CM services will be rendered in the future.     

大型医院病案信息化的管理与实践

病案作为医学临床信息的重要载体，只有将其进行海量存储、快速查阅、远程传输，使之活跃起来，才能真正地满足医疗、教学、科研和管理的需要。将传统的纸质病案进行扫描后保存为光盘，并存入光盘镜像服务器中，实现了网上实时访问、检索、查询、浏览和传输功能，并可以利用病案管理软件进行相应的统计和分析。为医疗信息资源进一步开发和利用，探索了一条大型医院病案信息化管理的有效途径。     

杭州医药站药品分公司管理信息系统的开发与应用

介绍了一个医药商业批发企业的信息管理系统的设计方法、系统功能以及软硬件环境，重点介绍了系统软件特点。     

Invasive meningococcal disease in England and Wales: implications for the introduction of new vaccines

A number of meningococcal vaccines have either been recently licensed or are in late-phase clinical trials. To inform national vaccination policy, it is important to define the burden of disease and the potential impact of any new vaccine. This study describes the epidemiology of invasive meningococcal disease across all age groups in England and Wales for recent epidemiological years between 2006 and 2010. The Health Protection Agency (HPA) conducts enhanced national meningococcal surveillance through a combination of clinical and laboratory reporting. Between 2006/07 and 2010/11, the average annual incidence of invasive meningococcal disease across all age groups was 2.0/100,000. Capsular group B (MenB) accounted for 87% (4777/5471) cases, with an overall incidence of 1.8/100,000. The highest MenB incidence observed among infants (36.2/100,000) where cases increased from birth to 5 months of age then gradually declined. An annual average of 245 MenB cases occurred in infants (135 in those aged ≤ 6 months) representing 26% (and 14%) of all MenB cases, respectively. After infancy, MenB rates declined until the age of 12 years, rising to a second smaller peak at 18 years. MenB case fatality ratio (CFR) was 5.2% (247/4777 cases) overall and was highest among ≥ 65 year-olds (28/161; 17.4%). The largest number of deaths (n=125), however, occurred among <5 year-olds. Clonal complexes cc269 and cc41/44 each accounted for around a third of cases across the age groups. Other capsular groups rarely caused invasive disease, although capsular group Y (MenY) cases more than doubled from 35 in 2006/07 to 86 in 2010/11. Thus, universal meningococcal vaccination with an effective broad-spectrum formulation has potential to prevent most disease, particularly if the vaccine is immunogenic early in infancy, but, there is currently little justification for routine quadrivalent ACWY conjugate vaccination in the UK, although the increase in MenY disease warrants continued surveillance.     

Rethinking medical professionalism: the role of information technology and practice innovations

CONTEXT: Physician leaders and the public have become increasingly concerned about the erosion of medical professionalism. Changes in the organization, economics, and technology of medical care have made it difficult to maintain competence, meet patients' expectations, escape serious conflicts of interest, and distribute finite resources fairly. Information technology (IT), electronic health records (EHRs), improved models of disease management, and new ways of relating to and sharing responsibility for patients' care can contribute to both professionalism and quality of care. METHODS: The potential of IT, EHRs, and other practice facilitators for professionalism is assessed through diverse but relevant literatures, examination of relevant websites, and experience in working with medical leaders on renewing professionalism. FINDINGS: IT and EHRs are the basis of needed efforts to reinforce medical competence, improve relationships with patients, implement disease management programs, and, by increasing transparency and accountability, help reduce some conflicts of interest. Barriers include the misalignment of goals with payment incentives and time pressures in meeting patients' expectations and practice demands. Implementing IT and EHRs in small, dispersed medical practices is particularly challenging because of short-term financial costs, disruptions in practice caused by learning and adaptation, and the lack of confidence in needed support services. Large organized systems like the VA, Kaiser Permanente, and general practice in the United Kingdom have successfully overcome such challenges. CONCLUSIONS: IT and the other tools examined in this article are important adjuncts to professional capacities and aspirations. They have potential to help reverse the decline of primary care and make physicians' practices more effective and rewarding. The cooperation, collaboration, and shared responsibility of government, insurers, medical organizations, and physicians, as well as financial and technical support, are needed to implement these tools in the United States' dispersed and fragmented medical care system.