An alternative model in geriatric care.

An analysis is presented of one long-term care facility's attempt to develop a comprehensive geriatric program including care of the patient in a hospital, a skilled nursing home, a day hospital, or a clinic for care of the ambulatory aged. The goal was to raise issues for debate and discussion, especially in terms of the evolving role of medical directors in long-term care. The need for group professionalism in cooperation with the Board of citizens in community geriatric practice is emphasized.     

Agents of bioterrorism. Preparing for bioterrorism at the community health care level.

Bioterrorism preparedness is clearly a goal for the health care community, working in concert with city, county, state, and federal public health and emergency authorities and in collaboration with law enforcement at the local and federal levels. Opening the channels of communication between all groups involved, obtaining the necessary resources, and maintaining an understanding of the potential agents and the diseases they cause will foster a smooth transition to a rational program directed at patient, personnel, and community safety.     

The ventilator-assisted individual. Cost analysis of institutionalization vs rehabilitation and in-home management.

The purpose of this article is to present a cost analysis of in-home vs institutionalization for severely physically disabled ventilator-assisted individuals (VAIs). Following rehabilitation and adaptation to noninvasive methods of ventilatory support, 30 VAIs were maintained in the community for 12.9 +/- 1.1 years with personal care attendants organized by a home care vendor reimbursed by New York City Medicaid. The program permitted self-directed severely disabled clients, including these 30 exclusively nontracheostomized VAIs, to live in the community and direct their attendant care and personal affairs. Prior to discharge home, the 30 patients resided in the respiratory unit of a long-term care facility for a mean of 8.9 +/- 10.1 years. The unit is currently reimbursed at a mean rate of $718.80 per patient per day. The current mean total cost of maintaining these VAIs in the community is $235.13 +/- 56.73 per patient per day. The conversion to and/or maintenance on 24-h nontracheostomy ventilatory support permitted discharge to the community by allowing the VAI to be attended by trained but uncredentialed home care attendants, thus avoiding prohibitively expensive in-home nursing for tracheostomy care. This created a savings to the public of 77 percent or $176,137 per year per client. We conclude that conversion to and/or use of noninvasive methods of ventilatory aid can be a reasonable and cost-saving goal. More respiratory rehabilitation centers are needed to free up hospital beds and facilitate discharge of VAIs to the community. There is also evidence that trained attendants should be permitted to suction tracheostomized VAIs in the home.     

Extended care in nursing homes: a program for a county teaching medical center

A continuity care program for patients in nursing homes using internal medicine residents in training has been developed in a county teaching hospital. Resident physicians on a paid basis assume primary care responsibility for 1000 patients in 29 private community nursing homes. A faculty internist coordinates the activities of the residents and monitors patient care through an extended care office in the county hospital. The program has produced a significant upgrading of the continuity and quality of care of patients in these nursing homes as well as providing medical residents with geriatric and nursing home experience. The increased sensitivity and concern for the needs of nursing home patients developed by the medical residents seems to continue after they complete their training.     

Continuing education in rheumatoid arthritis for the primary care physician.

An educational program in rheumatoid arthritis was developed for primary care practitioners. This program is community based and utilizes physicians, identified by their peers as being influential, for the dissemination of information. A marked change in knowledge has been noted in those completing the program, but further followup is needed to determine if a change in the care of patients with rheumatoid arthritis will also result.     

Tuberculosis screening for hospital employees. A five-year experience in a large community hospital.

A 5-year experience in developing an annual tuberculosis screening program for employees of a 570-bed community hospital in a state with a low endemic rate of tuberculosis is described. Using a computerized payroll system to notify employees and the incentive of free lunch tickets, the program reached more than 95 per cent of the eligible employees. No active cases and only 7 skin test conversions (0.11 per cent) were found during the 5-year period; only 3 of the 7 converters worked in patient care. Three other converters (1.03 per cent) were found among the 291 employee contracts of 20 patients who were initially undiagnosed. The costs for comprehensive screening were high in relation to the low conversion rates found, and more selective screening may be justified in similar hospitals where the risk of acquiring tuberculosis is low. Nonetheless, because the problem of poor compliance was managed successfully, the program has provided an effective measure of protection for both patients and personnel.     

Cost of care in the emergency department: impact of an emergency medicine residency program.

STUDY OBJECTIVE: To evaluate the impact of an emergency medicine residency training program on the cost of care in the emergency department. DESIGN: A retrospective chart review was conducted of all ED encounters for a three-month period, six months before and six months after the introduction of an emergency medicine residency program into an urban community hospital. Physician staffing of this ED before the residency period was by nonemergency medicine residency-trained emergency physicians. SETTING: A 27,000-visit-per-year urban community hospital ED. TYPE OF PATIENTS: A consecutive sample of all patients discharged home from the emergency center with one of six diagnoses. The diagnoses studied were viral upper respiratory infection, pharyngitis, acute asthma, seizure, lumbosacral strain, and cervical strain. MAIN OUTCOME MEASURES: Frequency of laboratory test and radiograph ordering pertinent to the evaluation of each diagnostic category were used as a marker of cost of care. RESULTS: The presence of the residency training program did not increase the cost of care as measured by test use and, for three of the six diagnoses, actually lowered the cost of care. This effect was most prominent in the evaluation of lumbosacral and cervical strain when the residency physicians ordered radiographs at a rate five and 2.3 times lower, respectively, than the previous group and in the approach to pharyngitis when they ordered throat cultures 2.8 times less frequently. CONCLUSION: As measured by selected test use for six common discharge diagnoses, the introduction of an emergency medicine residency program did not increase the cost of care in this urban community hospital ED.     

Screening for diabetic retinopathy in communities.

Twelve retinopathy screening clinics serving 489 diabetic patients were conducted in three Michigan communities as part of the outreach effort of the Michigan Diabetes Research and Training Center. Screening activities were initiated by local diabetes educators who conducted a program designed to promote detection of diabetic eye disease and increase patient and health care provider awareness of accepted ophthalmic evaluation guidelines. This experience suggests that retinopathy screening clinics can be successfully conducted if health care professionals in the community consider diabetic retinopathy to be a serious problem, one individual is willing to oversee the organizational aspects of the clinic, and an ophthalmologist with laser treatment capability is present or nearby. These clinics are effective in detecting diabetic eye disease and facilitating subsequent patient visits to an ophthalmologist for evaluation in accordance with national recommendations.     

Deploying the chronic care model to implement and sustain diabetes self-management training programs

PURPOSE: The purpose of this project was to evaluate the utility of using the 6 elements of the chronic care model (CCM; health system, community, decision support, self-management support, clinical information systems, and delivery system design) to implement and financially sustain an effective diabetes self-management training (DSMT) program. METHODS: The University of Pittsburgh Medical Center (UPMC) uses all elements of the CCM. Partnerships were formed between UPMC and western Pennsylvanian community hospitals and practices; the American Diabetes Association DSMT recognition program provided decision support. A clinical data repository and reorganization of primary care practices aided in supporting DSMT. The following process and patient outcomes were measured: number of recognized programs, reimbursement, patient hemoglobin A1C levels, and the proportion of patients who received DSMT in primary care practices versus hospital-based programs. RESULTS: Using elements of the CCM, the researchers were able to gain administrative support; expand the number of recognized programs from 3 to 21; cover costs through increased reimbursement; reduce hemoglobin A1C levels (P < .0001), and increase the proportion of patients receiving DSMT through delivery in primary care (26.4% suburban; 19.8% urban) versus hospital-based practices (8.3%; P < .0001). CONCLUSIONS: The CCM serves as an effective model for implementing and sustaining DSMT programs.     

Respi-Care. An innovative home care program for the patient with chronic obstructive pulmonary disease

The purpose of the present study was to evaluate the effectiveness of a hospital-based home care program for a group of patients with severe COPD. Respi-Care was a multidisciplinary home care program administered by Norwalk Hospital in cooperation with the public health nursing departments of the city of Norwalk and the town of Wilton, Conn. The overall goal of Respi-Care was to provide more comprehensive home care services to patients previously requiring frequent hospitalizations by combining the advantages of hospital resources and community agencies through a unique cooperative effort. Preprogram and on-program data were collected on the following variables for the 48 months of Respi-Care operation: hospitalizations; hospital days; emergency room visits; home care services; and the costs of these services. Costs of operating the Respi-Care program were included in on-program data. Seventeen subjects completed 320.5 months on Respi-Care. Each subject was matched to an equal length of time prior to entering the program, for a total of 641 months analyzed. There were 88 preprogram hospitalizations for the group; hospitalizations while participating in Respi-Care dropped to 53 (p = 0.022; paired t statistics). On-program hospital days showed a significant decrease, from 1,181 preprogram days to 667 on-program days (p = 0.024). Emergency room visits decreased from 105 before the program to 64 during the program (p = 0.017). Costs of care also decreased. Costs for hospitalizations, emergency room visits, and home care fell from $908,031 to $802,999, resulting in a $105,032 savings or $328 per patient per month.(ABSTRACT TRUNCATED AT 250 WORDS)     

Incorporating HIV education and counseling into routine prenatal care: a program model

This article reports how a prenatal clinic in a major urban teaching hospital has developed and integrated an HIV education and counseling program into routine prenatal care. The patient population served are predominantly minority women living in an inner-city community that has been disproportionately affected by the AIDS epidemic. Implementation of the patient program has required training and support for all professional staff. Staff training served as a foundation for this comprehensive patient program, which has reached all prenatal patients regardless of risk behavior. The program has succeeded in involving a large population of women in an educational program, has identified HIV-1 seropositive pregnant women through voluntary testing, and has provided them with the necessary medical and social work services. Principles of program development are identified for use in other settings.     

One Stop Post Op cardiac surgery recovery--a proven success.

The One Stop Post Op model for open heart surgery recovery is an innovative approach to post op care utilized in only a few facilities in the country. This model calls for an integration of acute ICU and step-down phases of care, thus changing the paradigm for nursing care of the open heart surgery patient. Typically, hospitals incur inefficiencies transferring the patient through multiple levels of care, thus resulting in a "disconnect" as new caregivers relearn the patient's care requirements and special needs. The construction of a "one stop" unit allows the patient to remain stationary while the service level changes to accommodate changing care needs. The cardiac "one stop" model is similar to the LDRP concept for obstetrical care. The One Stop Post Op patient rooms are designed to accommodate every level of patient acuity. All rooms meet the regulations for critical care room design, however this is where the aesthetic similarity ends. The patient environment looks more like hotel rooms rather than the traditional ICU setting. Cabinets designed to cover medical gases, in the room's private bathrooms and comfortable furnishings help to create a patient focused environment conducive to recovery. This model has been utilized by several facilities and has demonstrated clear clinical and economic advantages for patients, families, and health care providers. Implementing an open heart surgery (OHS) program presents the opportunity for several community based hospitals to challenge the way they have been providing patient care and establish an innovative approach to post surgery patient care. The One Stop Post Op cardiovascular recovery unit is designed to receive the OHS patient directly from the operating room and to be the "care unit" for the patient's entire stay. Patient flow, quality monitoring and caregiver acceptance in this unit requires new paradigms from the traditional two or three step post OHS care delivery process. The One Stop Post Op model focuses the delivery of care on the patient. With proven success in clinical outcomes, patient, physician and caregiver satisfaction, it is anticipated that this innovative approach will drive hospitals to integrate clinical process with physical planning in the future.     

Acceptability and Feasibility of a Community Approach to Asthma Management: The Neighborhood Asthma Coalition (NAC)

Understanding of asthma and comanagement between patient and physician improves outcome. Feasibility of programs to achieve these goals in underserved settings is not documented. We used the Precede-Proceed model to document (a) community acceptance of a program to engage peer support of asthma management and care; (b) program revision to emphasize greater attention to availability of care and promotional events as channels for education; (c) engagement of intended audiences in planning and implementation; (d) participation of parents in program activities; and (e) peer-based education/support to reach parents, including socially isolated parents whose children experience heightened morbidity.     

Acceptability and Feasibility of a Community Approach to Asthma Management: The Neighborhood Asthma Coalition (NAC)

Understanding of asthma and comanagement between patient and physician improves outcome. Feasibility of programs to achieve these goals in underserved settings is not documented. We used the Precede-Proceed model to document (a) community acceptance of a program to engage peer support of asthma management and care; (b) program revision to emphasize greater attention to availability of care and promotional events as channels for education; (c) engagement of intended audiences in planning and implementation; (d) participation of parents in program activities; and (e) peer-based education/support to reach parents, including socially isolated parents whose children experience heightened morbidity.     

Highly interactive multi-session programs impact physician behavior on hypertension management: outcomes of a new CME model

There has been much discussion and study about the role of continuing medical education (CME) in improving patient care. The authors describe the processes used to develop and implement a series of live, half-day, highly interactive CME events that addressed knowledge, competency, and performance gaps in hypertension diagnosis and management in the primary care community and successfully changed physician behavior toward improved patient outcomes. Participation in an intensive, highly interactive, case-based didactic program was significantly associated with an increase in clinician knowledge and competency in diagnosing and managing patients with hypertension. Participation was also associated with a high likelihood for practice change and making guideline-driven and evidence-based decisions to positively impact patient care. A greater portion of participants were able to identify the appropriate blood pressure goal and select the most appropriate pharmacotherapy regimen for specific patients. Quality of education index indicated that participants were 52% more likely to practice guideline-driven and evidence-based medicine than those who did not participate in the CME activity.     

Outpatient treatment of venous thromboembolism using low molecular weight heparins. An overview.

The development of low-molecular-weight heparins (LMWHs) was a significant advance in the treatment of venous thromboembolism (VTE). Their better bioavailability and more predictable anticoagulant activity than unfractionated heparin (UFH) allow subcutaneous administration without close laboratory monitoring, and thus make outpatient treatment of deep vein thrombosis (DVT) feasible. The safety and efficacy of outpatient treatment in selected patients were established in randomized clinical trials comparing subcutaneous LMWH administered primarily at home with inpatient intravenous UFH. Furthermore, during the last few years a large number of studies have supported these findings in various clinical settings of every-day practice. It is also important that home treatment has lead to substantial cost reductions along with improvement in patients' satisfaction and quality of life. Thus, outpatient treatment of DVT provides an opportunity, rarely seen in medicine, to improve patient care while reducing the overall VTE health-care cost, and it is likely that will be the preferred regime for the majority of patients in the future. However, the implementation of a home treatment program is not simple, as the risks of insufficient or excessive anticoagulation would be considerable. A structured protocol is necessary to ensure that patient care is optimal, and the keys to a successful outpatient treatment program are patient selection, patient education, patient access to health care team, appropriate follow-up and health care team communication.     

Heart failure disease management: impact on hospital care,length of stay,and reimbursement

Congestive heart failure (CHF) is a major medical problem with significant hospital costs. The authors developed an inpatient disease management program for CHF in a community hospital setting to determine if it is possible to: 1) increase implementation of Agency for Health Care Policy and Research criteria for CHF; 2) improve the quality of patient care, while lowering length of stay and treatment cost for CHF; and 3) maintain nursing staff satisfaction. The program encompassed a clinical pathway incorporating Agency for Health Care Policy and Research criteria for CHF, CHF education, and patient educational materials. When compared to "unmanaged" patients (n=197) not participating in the algorithm due to physician choice, "managed" patients (n=396) had significantly increased documentation of left ventricular dysfunction and of angiotensin-converting enzyme inhibitor use. In contrast to unmanaged patients, managed patients had a significantly lower length of stay (3.9+/-2.2 vs. 6.1+/-2.8 days; p<0.0001) with a significant reduction in cost per patient ($4404+/-$1989 vs. $6828+/-$3347; p<0.0001). These changes were sustained in follow-up over 1 year and were associated with an improvement in nursing staff education and nursing care. Thus, a disease management program for CHF can be successfully implemented in a general community hospital setting, achieving improved compliance with Agency for Health Care Policy and Research treatment criteria and enhancing patient care, while reducing length of stay and cost.