Home is not where the heart is: looming problems of the home care industry

This analysis shows a definite trend of fiscal and social retrenchment policy by the government concerning in-home care service delivery (Tables 1 and 2). Ruggie (1990:164) notes that such shifts and changes in Medicare reimbursement patterns may be efforts of the government to realign itself to become the pivotal force in the provision or delivery of in-home care. Cost-containment pressures, although most needed in the health care industry, are the primary driving force behind retrenchment and the subsequent realignment of government. Such forces tend to impede the development of a comprehensive system for the provision of long-term care services. As noted, the movements and shifts in reimbursement patterns documented by this analysis can lead one to conclude that the same old features will continue to prevail instead of new and innovative delivery structures or public-private partnerships. In other words, the in-home care industry will become more like the nursing home industry--highly regulated and perpetually plagued by questions concerning quality of care. Although government is attempting to diminish its task as the prime provider of health services (i.e., through fiscal retrenchment) and the public's role as the dominant delivery system (i.e., social retrenchment), nevertheless the government has been unable to retrench politically in spite of its present direction of cost containment and fiscal restraint. Consequently, Ruggie (1990:147) notes that "the social welfare functions may continue to be performed" in spite of cost restraint policies. As a result, another "no care zone" is created and policy-makers will continue to develop "crisis policy" such as intense demands to hold unit costs low. The home care system has expanded many of the long-term care options and has emerged as a salient segment of our health and social service system (Applebaum and Phillips, 1990). Yet, policy-makers have not developed a comprehensive long-term care system, particularly one that defines a common policy for home care benefits and engenders the right kind of public-private partnership for the delivery of quality home care.     

Regulation, retrenchment--the DRG experience: problems from changing reimbursement practice

A study of 227,771 discharge abstracts from one U.S. state's short-term, acute care hospitals compares changes in the inpatient market available to the oldest old Medicare patients (85 and older) with those less than 70 and those 70-84 between 1981, the last year when all hospitals were under cost-based reimbursement, and 1984, the first year in which all hospitals were under a prospective payment system based on diagnosis related groups (DRGs). All three populations experienced retrenchment in services as hospitals pursued practice changes to enhance revenue potential. An older, sicker client was admitted as hospitals implemented changes in admission patterns to avoid denial of reimbursement for an admission deemed inappropriate by the Peer Review Organization (PRO). Evidence demonstrates compression in service markets and retrenchment in services for less profitable DRGs and/or cohorts. Inpatient services were reduced the most for the oldest old population although this cohort was the sickest. Changes were observed in utilization of special care units, such as in coronary and intensive care units. Large increases in readmissions in all three cohorts suggests that DRG incentives to reduce length of hospital stay may have promoted premature discharge. Or, perhaps these readmissions resulted from 'unbundling', a practice of splitting patient problems into multiple admissions, as hospitals sought ways to enhance revenue instead of practicing cost-containment. Policy, perceived to be economically stringent, can affect hospital practice and produce undesired results with long-reaching untoward effects on certain segments of the population.     

A strategy for adaptive staffing of hospitals under varying environmental conditions

With many hospitals facing periods of retrenchment or considerable uncertainty in workload and reimbursement policy, an adaptive management response seems to be required. A model is presented for the development and implementation of a system of flexible resource management that is useful for health service managers.     

Variation in inpatient racial composition among acute-care hospitals in New York State

This study examined the racial composition of inpatients among 282 short-stay, non-Federal hospitals in New York State. The primary data sources were two inpatient censuses conducted by Blue Cross in late 1975. These were augmented with data from the American Hospital Association's 1975 Annual Survey and the 1970 U.S. Census. Substantial disparity in racial mix was evident. Within New York City, for example, 24 out of 94 hospitals had fewer than 10% nonwhite patients, while 21 hospitals had 50% or more and 7 had 80% or more nonwhites. The proportion of patients covered by Medicaid was found by multiple regression analysis to be a major correlate of the proportion of patients who were nonwhite. Other factors positively associated with the proportion nonwhite included the proportion of patients admitted from the emergency room or outpatient department; presence of a residency program; and availability of family planning services. Analysis of two quality of care indicators revealed that, taking total patient load into account, hospitals with more nonwhite patients tended to have fewer nurses and total assets. In spite of nonwhite gains in access and utilization, the hospital system can still be characterized as 'separate and unequal'. It is suggested that a renewed effort to integrate health care facilities can have a positive impact on both majority and minority populations in this period of fiscal retrenchment.     

The child care profession: A vision for the future

The authors, recognizing the historical development of the child care profession, examine current societal trends and offer some constructive directions for consideration by the profession to counterbalance a prevailing mood of retrenchment and despair. A model of cyclical change is presented, specific adaptations that consider the essential elements of the child care profession are suggested, and the adoption of a social ecology perspective is proposed.     

Health care in a declining economy: the case of Zambia

The severe and worsening economic crisis in Zambia has set into motion various adjustment measures (subsidy withdrawal or reduction, adjustment of exchange rates, import control, a foreign exchange auction system and retrenchment of government expenditure) which is making it increasingly difficult for the government to maintain the network of health and other social services developed in the 20 years since Independence. The situation became critical particularly after the decline of copper prices which provided Zambia with 90% of its foreign exchange earnings. The resulting fall in the GNP along with rapid inflation, population growth and urbanization has had a number of consequences for health care delivery. These effects are described with particular attention to health manpower/facilities, disease morbidity, malnutrition, expenditure patterns and health policy. Finally, some proposed strategies being considered by the government are presented.     

Research as an impetus for change in a state psychiatric hospital

This article presents recommendations resulting from a study of barriers to discharge from a state psychiatric hospital. The results of this study became the impetus and basis for this particular hospital's definition of its mission within a community support system and for the development of a hospital plan responding to the study recommendations. The programmatic and policy changes initiated by the hospital have demonstrated that a traditional state psychiatric hospital can become more responsive to the needs and desires of consumers and families by utilizing the entire mental health delivery system and other community resources. It is evident that the hospital need not be bound by the physical limits and facility-based resources that have historically restricted its responsiveness.     

History of school meals in Great Britain

This paper describes the early origins of the school meals service, their rapid growth in the second world war, their post war development and their recent retrenchment. The factors contributing to their early success and the problems to be overcome are discussed.     

Financing medical care for the underserved in an era of Federal retrenchment: the health service district

Federal funding programs have, since the 1960s, been available in a variety of forms to deal with problems of access to medical care for the medically underserved. Certain programs, such as the National Health Service Corps, have recently pulled back from their points of maximal impact in terms of numbers of obligated physicians in the field. This change leaves a need for greater contributions by State and local entities in the face of Federal retrenchment. The health service district (HSD) is one such mechanism for filling the gap. It has been available under this name in Arizona law since 1977, but the first such district in the State in only now under development in a small copper mining community. Similar to school districts in concept, the HSDs allow residents in their catchment areas to tax themselves for the purpose of delivering primary health care. Two successful HSDs--or similar entities--in other States are described. One program is in Stickney, IL, and other in Condon, OR. The political success and financial viability of the Condon program are documented.     

Development of a hospital information system simulator for education

When teaching students the hospital information system, it is impossible to use an actual hospital information system because of security reasons. To overcome this problem, a simulator of the hospital information system for student education has been developed. The purpose of this system is to help students understanding a hospital information system from actual experience. The characteristics of this system are as follows: 1) Students can easily learn a hospital information system on the Web pages in the computer training room. 2) The present system is not as complete as a hospital information system, however, helpful explanations regarding the data processing have been inserted. 3) The fictional patient data have been prepared for the pages relating to the electronic medical chart. Consequently, students can understand what kind of data has been saved in this system. Through a questionnaire, students evaluated this system in terms of understandability. The result from four years between 1999 and 2002 showed that 70% of them evaluated it as good system. We therefore consider this system to be effective over a short period of time, and useful for medical education.     

大型三甲医院合并扩建中人力资源薪酬体系规划与探索

目的初步探讨大型三级甲等医院合并扩建过程中人力资源薪酬体系的规划与建立。方法天津市人民医院合并建院以来,根据医院实际情况对医院各类岗位进行了分类管理,同时建立医院岗位价值评估模型,并运用评价体系进行了权重分析,依据价值评估模型对医院合并后各类岗位进行价值评估。结果以岗位设置为基础,初步建立并探讨适合大型三级甲等医院合并扩建后的薪酬结构体系。调动了广大职工工作积极性,充分发挥年轻骨干人才作用,提高了医院职工整体工作效率,节约了医院人力资源成本。结论探索建立大型三级甲等医院合并扩建过程中人力资源薪酬体系是医院合并扩建过程中的重要环节,也是提高职工工作效率节约医院人力资源的重要途径。     

A decision support system for hospital bed assignment

This article presents the use of a computer-based decision support system for hospital bed assignment. The specific computer application discussed involves the development of an expert system, which mimics the decision-making process typically used by experts in a field. Expert systems are useful as consultants for problems that are best approached from the perspective of an expert. The prototype expert system presented in this article can be used to efficiently assign hospital beds to specific patients at the time of hospital admission or during the hospital stay. This assignment is based on a matching process by the expert system of patient needs and hospital bed characteristics. Data needed for this assignment are routinely collected at admission and updated during the patient's stay in the hospital. Use of this computer-based decision support system in conjunction with existing hospital information systems will result in more effective management of physical and human resources. As may be expected, any improvement in efficiency of use of resources will have an associated reduction in cost. Implications of using expert systems for future practice are also discussed.     

浅谈医院物流管理现状与展望

随着我国医疗体制改革的不断深化,医院管理者尝试着从不同视角优化医院的内部结构,构建医院发展模式,降低医院运营成本.而医院的物流管理是形成医院竞争优势的主要因素,医院需要努力改善物流管理,通过构建完善的物流服务体系,降低医院运营成本最终达到提高医院竞争力的目的.本文通过对比国内、国外医院物流现状,对目前状态下国内医院物流管理中存在的问题进行分析,并且针对问题提出了发展方向,阐述以满足医院需求为核心,降低成本、提高效益为理念的医院物流管理的发展理念.     

试论公立医院管理体制创新

公立医院发展面临严重困惑,公立医院的发展方向需要辨明,公立医院的管理体制需要创新。公立医院的存在形式既由自身的性质决定,又受外在环境——健康保障模式的作用。公立医院具有社会公益性质和经济性质,实现保障目的的公立医院管理体制就是要在实现公益性质的目标下同时实现经济发展和效率性质。这样,管理体制要采用公益性质的制度约束公立医院的医疗行为,采用市场机制保证效率,并建立医疗效率管理机制以引导医疗行为按照医乃仁术要求行医,达到公益与效率兼顾的效果。     

Federalism and health policy

This paper presents a cyclical theory of U.S. federalism and social policy: Many social policy initiatives are tested and refined at the state level, especially during conservative periods, and later morph into national policies. The paper describes such federalism cycles and offers an interpretation of why and how they occur, focusing on Medicaid. State activism has preserved and expanded Medicaid through policy innovation and resistance to retrenchment, especially in conservative periods, by taking advantage of the flexibility the program provides. I conclude that Medicaid's incremental/partnership approach is appropriate and feasible to build on for a future expansion of health care coverage.     

Penalizing patients and rewarding providers: user charges and health care utilization in Vietnam

The introduction of a comprehensive system of user charges in 1995 provided public health facilities in Vietnam, especially hospitals, with a growing source of revenue. By 1998 revenues from user charges accounted for 30% of public hospital revenues. Increasingly, provider incomes have relied on fee revenues and provision-based bonuses, the effect of which is that a poorly regulated fee-for-service system has replaced a salary system based upon a centrally determined global budget. This paper examines the potential influence of providers' on the use of publicly provided health services. Using facility-based data over the period 1996-98, the relative contribution of treatment intensity is compared and contrasted under the two sources of hospital revenues from patients, namely a user charge system and a third party payment system based on fee-for-services. The primary focus of the comparison is on the treatment intensity for all hospital contacts, hospital admissions and the length of hospital stays, decisions normally taken by the providers and over which patients have little or no influence. The results indicate that growth in patient revenues was associated with large increases in intensity. The growth in intensity was more pronounced in the case of inpatient contacts. Moreover, both the admission rate and the length of hospital stay were far higher for better off individuals than for the poor, and greater for the insured than the uninsured. The increase in the intensity of hospital care for both health insurance enrollees and the uninsured can be seen as, among other things, an attempt on the part of providers to increase revenue from health insurance premiums and user charges in the face of a shrinking share of public resources allocated to hospitals, and low wages and salaries.     

现代医院管理制度下三级综合医院章程制定的实践与思考

医院章程是现代医院管理制度的重要基石,是一个医院的基本纲领和行为准则.然而国内仅有少数医院制定了医院章程.本研究通过对医院章程制定实践的回顾,总结出目前医院章程制定中存在的理论限制与操作瓶颈,进一步结合国内医院章程制定现状进行深入剖析,提出解决方案,为医疗机构定制现代医院管理制度下的医院章程提供经验.     

Regional and welfare perspectives on the public-private hospital dichotomy in New Zealand

Concern with the social welfare implications of dual (public and private) hospital systems has grown over the last decade as national commitments to welfare state ideals have wavered in the continuing atmosphere of fiscal conservatism that has permeated through western democracies. New Zealand provides an excellent example of a health care system in which private hospitals have survived (and recently flourished) alongside those provided by the state. Following a brief survey of the evolution of the New Zealand hospital system, variations in the 'mix' of public and private hospitals are described at the (regional) Hospital Board District level. It is noted that competition for patients and funding between the public and private sectors occurs almost exclusively in the larger, urban hospital districts, and is invariably to the detriment of public hospitals. Districts with a substantial private hospital presence are found to have fewer resources in the public sector (relative to their population) than those which have few or no private hospitals. The welfare implications of this situation are explored. It is proposed that the maintenance of a dual hospital system in New Zealand has provided, in some parts of the country at least, a 'choice' for those able to afford private hospital charges or insurance coverage, but at the expense of those dependent solely upon a (shrinking) public sector.     

Paraprofessionals in mental health delivery services(1)

Summary During the past 20 years, mental health workers have become an integral part of the mental health delivery system. Their competence and cost-effectiveness are well-documented. They are making valuable contributions to the nature, quality and delivery of mental health services. They provide an economic means by which agencies can meet the burgeoning mental health needs of the community. The time is past, if it ever existed, for attempts at professional retrenchment or a return to traditional services and service deliverers. The field has grown beyond such limited solutions; new approaches must be found. The effectiveness and cost-efficiency of the mental health delivery system in the 1980s depend largely upon innovations in management. Mental health administrators need increased flexibility, creativity and vision to meet the challenges. They must explore a variety of alternatives, including multiple-staffed service delivery teams, cross-agency career linkages, multi-agency training resources, diverse funding sources. They need to increase support and cooperation among their staffs, and to develop expanded liaisons between agencies which share common concerns. The exploration of these and other alternative approaches holds great potential for the increased effectiveness of program and personnel development. Ironically, these approaches actually are extensions of the work mental health workers do so well—outreach, brokering, visitations, collateral counseling. An earlier version of this paper was presented to the Association of Mental Health Administrators, “Innovations in Management in the '80s,” 1980 Annual Meeting, October 9–11, 1980, Capitol Hilton Hotel, Washington, D.C.     

Making accountability less painful: program evaluation in allied health education

Information from a program review can stimulate program change and document program effectiveness in times when retrenchment is of concern to administrators and faculties in higher education. The School of Allied Health Professions at the University of Connecticut conducted a comprehensive program evaluation of its undergraduate programs in physical therapy, medical technology, and clinical dietetics. In this paper the evaluation process is described as well as a model that appears to meet the unique needs of postsecondary programs in allied health fields.