Reorganizing ambulatory care: an administrator's view

Citing a continuing increase in the utilization of hospital outpatient services, the authors discuss the reorganization of the ambulatory care delivery system at a 300-bed community hospital serving the Cambridge, Massachusetts area. Due to the attrition of community-based physicians, the Mount Auburn Hospital had an overburdened emergency services and an underutilized outpatient department. To improve this situation, full-time physicians and a non-physician administrator were hired for the outpatient area. In the four years following the reorganization, patient volume has increased and utilization has shifted from emergency to primary care which has required the hospital to adjust staffing in several ancillary departments. The hospital has now reached the point where growth must be carefully planned and controlled in order to preserve cost-effective, high quality care. The authors conclude that planning for hospital-based ambulatory care units should include: (1) defining the needs of the target communities; (2) marketing programs; and (3) anticipating legislation which will influence the demand for outpatient services.     

Emergency room encounters of pediatric patients with asthma: cost comparisons with other treatment settings

More than 67,000 claims from a national database were analyzed to determine the relative costs of treating pediatric patients with asthma in physicians' offices, hospital outpatient departments, or emergency rooms. Billed charges and paid claims for these cases in emergency rooms average more than 5 times higher than in physician offices. Emergency treatment generally results from a failure of proper management and education in the primary care setting. Educational programs for pediatric patients with asthma and their families could save resources as well as reduce the trauma often associated with visits to the emergency room.     

Fewer hospitalizations result when primary care is highly integrated into a continuing care retirement community

Meeting the medical and social needs of elderly people is likely to be costly, disruptive, and at odds with personal preferences if efforts to do so are not well coordinated. We compared two different models of primary care in four different continuing care retirement communities. In the first model, used in one community, the physicians and two part-time nurse practitioners delivered clinical care only at that site, covered all settings within it, and provided all after-hours coverage. In the second model, used in three communities, on-site primary care physician hours were limited; the same physicians also had independent practices outside the retirement community; and after-hours calls were covered by all members of the practices, including physicians who did not practice on site. We found that residents in the first model had two to three times fewer hospitalizations and emergency department visits. Only 5 percent of those who died did so in a hospital, compared to 15 percent at the other sites and 27 percent nationally. These findings provide insight into what is possible when medical care is highly integrated into a residential retirement setting.     

Understanding frequent emergency room use by Medicaid-insured children with asthma: a combined quantitative and qualitative study

BACKGROUND: Medicaid-insured asthmatic children frequently use emergency rooms (ERs). The reasons are unclear and have predominantly been studied in inner-city populations. METHODS: We used billing data and focus groups to clarify reasons for frequent ER use by Medicaid-insured children with asthma living in rural areas and 23 towns in Kansas. RESULTS: High ER utilization was concentrated in a small percentage of provider practices and children with asthma. Parents expressed strong preference for primary care treatment, and identified real or perceived difficulties in using primary care as the principal reasons for ER use. Difficulties included trouble contacting primary care physicians or obtaining urgent appointments, limited continuity of care, practice systems poorly adapted to patient needs, a perception that physicians preferred patients to use emergency services, and difficulties in obtaining medications. Parents were not aware of preventive measures or case management but reported high interest in these. Parents did not recall provider discussion of asthma risk factors/preventive strategies during primary care visits, although all children with high ER utilization had multiple risk factors, including exposure to high levels of household smoking. CONCLUSIONS: Reducing ER utilization by Medicaid-insured asthmatic children depends on overcoming barriers to effective treatment in primary care and in greater attention to preventive services.     

Primary care and public emergency department overcrowding.

OBJECTIVES. Our objective was to evaluate whether referral to primary care settings would be clinically appropriate for and acceptable to patients waiting for emergency department care for nonemergency conditions. METHODS. We studied 700 patients waiting for emergency department care at a public hospital. Access to alternative sources of medical care, clinical appropriateness of emergency department use, and patients' willingness to use nonemergency services were measured and compared between patients with and without a regular source of care. RESULTS. Nearly half (45%) of the patients cited access barriers to primary care as their reason for using the emergency department. Only 13% of the patients waiting for care had conditions that were clinically appropriate for emergency department services. Patients with a regular source of care used the emergency department more appropriately than did patients without a regular source of care. Thirty-eight percent of the patients expressed a willingness to trade their emergency department visit for an appointment with a physician within 3 days. CONCLUSIONS. Public emergency departments could refer large numbers of patients to appointments at primary care facilities. This alternative would be viable only if the availability and coordination of primary care services were enhanced for low-income populations.     

Rural healthcare needs and solutions

Many rural communities are finding it necessary to create innovative ways to make healthcare more accessible to their residents. Successful rural healthcare delivery systems require the resources of an institution willing to serve the rural healthcare market, a community wanting to improve its healthcare, and dedicated practitioners. Physicians must be willing to see Medicaid and charity care patients. If physicians in the community are too busy or unwilling to accept indigent patients, the community may need more physicians. When the community recruits additional physicians, leaders must clarify that all physicians have a responsibility to serve indigent patients. As a result, a community-wide healthcare planning process is essential. Because residents might not always be aware that they should receive certain routine healthcare services or how to access those services, the community must establish strategies to reduce this knowledge gap. Urban healthcare centers can help by bringing health screening services to the rural community and by providing health education programs. Providers can close another part of the knowledge gap by helping patients fill out the insurance forms required to receive payment and by helping them find and apply for indigent patient coverage. To help solve the physician shortage problem in rural areas, communities can work with urban healthcare providers to purchase or start new practices in rural areas and then supplement the practices with additional primary care physicians or other healthcare practitioners.     

Case study of the integration of a local health department and a community health center.

As rural communities struggle to sustain health services locally, innovative alternatives to traditional programs are being developed. A significant adaptation is the rural health network or alliance that links local health departments and community health centers. The authors describe how a rural local health department and community health center, the core organizations in publicly sponsored primary care, came to share a building and administrative and service activities. Both the details of this alliance and its development are examined. The case history reveals that circumstance and State involvement were the catalysts for service integration, more so than the need for or the benefits of the arrangement. The closure of a county-owned hospital created a situation in which State officials were able to broker a cooperative agreement between the two agencies. This case study suggests two hypotheses: that need for integrated services alone may not be sufficient to catalyze the development of primary care alliances and that strong policy support may override any local and internal resistance to integration.     

Emergency Department Coverage by Primary Care Physicians in a Rural Practice-Based Research Network: Incentives, Confidence, and Training

ABSTRACT:  Context: In rural areas of the United States, emergency departments (EDs) are often staffed by primary care physicians, as contrasted to urban and suburban hospitals where ED coverage is usually provided by physicians who are residency-trained in emergency medicine. Purpose: This study examines the reasons and incentives for rural Oregon primary care physicians to cover the ED and their reported measures of confidence and priorities for additional training. Methods: We conducted a cross-sectional survey of primary care physicians in rural Oregon who are members of the Oregon Rural Practice-Based Research Network (ORPRN). The survey was sent to 70 primary care physicians in 27 rural Oregon practices. Findings: Fifty-two of 70 (74%) ORPRN physicians representing 24 practices returned the questionnaire. Nineteen of the 52 responding physicians reported covering the ED. The majority (75%) of physicians covering the ED did so as a requirement for practice employment and/or hospital privileges. Physicians covering the ED reported low confidence in pediatric emergencies and expressed the need for additional training in pediatric emergencies as their top priority. Conclusions: Almost two fifths of surveyed primary care physicians in a rural practice-based research network provide ED coverage. Based on these physicians' low levels of confidence and desire for additional training in pediatric emergencies, effective education models are needed for physicians covering the ED at their rural hospitals.     

Considerations in establishing visiting consultant clinics in rural hospital communities

Establishing specialty clinics staffed by visiting medical consultants is one way that rural hospitals can increase local access to specialty care. This example of private sector-driven regionalization of health care services typically involves an agreement among urban specialists, rural hospitals, and local primary care physicians. The urban-based physicians provide limited on-site specialty services in the rural community for patients who are referred by local physicians or self-refer to the specialty clinics. The trend toward formalization of regional relationships across large geographic areas prompts both opportunity and need for careful consideration of visiting specialty clinic arrangements in rural hospital communities. This article delineates advantages and disadvantages associated with the development of Visiting Consulting Clinics (VCC) along with some ?ground rules? to consider when establishing this type of service.     

Marketing via extended hours

Group practices that extend their hours of service have a competitive edge over hospital emergency rooms and commercial minor emergency clinics that traditionally are the only facilities to offer after-hours patient care. By answering the need in communities for extended-hours service, many groups are not only experiencing significant patient retention, but a generation of new patients as well.     

The Rural Physician Associate Program: successful outcomes in primary care and rural practice

The Rural Physician Associate Program (RPAP) has trained 1063 medical students in rural communities for the past 34 years and produced 658 primary care physicians and 521 physicians who currently practice in rural communities. While the students' experience in this nine-month clerkship is primarily clinic-based, they see patients in the emergency room, assist in surgery, deliver babies, attend physician meetings and participate in community health education. They experience real continuity of care by following a patient from the clinic or emergency room to the operating room and throughout their recovery. They diagnose a pregnancy, deliver the baby and then do the well-child examination in the clinic. The students recognize the value of this experience, as expressed in their final essays. They value the mentoring of the physicians, the relationship with the patients and the experiences in health care in which they play integral part. While the trend toward primary care in medical education is decreasing, the outcome of the RPAP program is holding steady at approximately 80%. Selection is certainly a factor, because many of the students who apply for RPAP have already expressed an interest in primary care. Additionally, the mentoring relationship with their preceptor, professionally and personally, and the ability to observe the lives of other practising physicians provides a reality check that may guide decisions. The enthusiasm for teaching, and the significant engagement with and impact on the community of the physicians may be another factor in deciding on primary care. Practising alongside physicians who find intellectual challenge and rewarding relationships in primary care is essential in continuing to produce primary care physicians of future.     

三明市医共体总额预付对医疗服务下沉的影响分析

目的: 分析三明市医共体总额预付改革对医疗服务下沉的影响。方法: 收集2016-2019年三明市医共体运行和医保收支数据,通过描述性分析和间断时间序列模型对医共体、医院及基层医疗机构的医疗服务数量及效率变化、医保基金运行情况进行分析。结果: 总额预付改革后,医共体内医院门急诊服务量占比由63.3 %下降至58.1 %,基层医疗机构占比呈上升趋势;2016-2019年医院住院服务量占比和每百人门急诊住院人次数显著减少。医保基金总体结余率由2016年的8.2 %降至2019年的2.6 %。结论: 三明市总额预付改革实施后医保基金总体运行平稳,医共体医疗服务效率有所提升,医疗服务逐步下沉,医院住院人次数下降,基层住院患者占比有所上升。建议各地开展医共体总额预付制改革时应合理制定医共体预算总额,完善医共体内部分配制度与协作机制。     

The missing link: improving quality with a chronic disease management intervention for the primary care office

Bold steps are necessary to improve quality of care for patients with chronic diseases and increase satisfaction of both primary care physicians and patients. Office-based chronic disease management (CDM) workers can achieve these objectives by offering self-management support, maintaining disease registries, and monitoring compliance from the point of care. CDM workers can provide the missing link by connecting patients, primary care physicans, and CDM services sponsored by health plans or in the community. CDM workers should be supported financially by Medicare, Medicaid, and commercial health plans through reimbursements to physicians for units of service, analogous to California's Comprehensive Perinatal Services Program. Care provided by CDM workers should be standardized, and training requirements should be sufficiently flexible to ensure wide dissemination. CDM workers can potentially improve quality while reducing costs for preventable hospitalizations and emergency department visits, but evaluation at multiple levels is recommended.     

Uncompensated care and emergency department utilization: a local study having national implications

This article provides a comprehensive picture of the manner in which uncompensated care patients utilize the emergency departments (EDs) of two Central Florida hospitals. Specifically, this study assesses the impact of treating uncompensated and primary care patients in ED settings on scarce hospital and community resources. Recommendations are being offered to manage a troubling situation that is occurring with alarming frequency in today's health care system throughout the United States. Special emphasis is placed on recommendations addressing alternative triage and financing models that are considered to be both socially responsible and economically viable. The results of this study suggest strongly that health care organizations must find an alternative to the current trend in ED utilization, in order to meet the primary care needs of patients and not compromise the care provided to those with emergent conditions. The recommendations emanating from this study outline a mechanism that can improve the timeliness of emergency care to those in need, while at the same time, making available primary care resources to those seeking services through an emergency department.     

Rural Physician Satisfaction: Its Sources and Relationship to Retention

This study uses survey data to identify areas of satisfaction and dissatisfaction for primary care physicians working in rural areas across the country. It also identifies the specific areas of satisfaction associated with longer retention within a given rural practice, as well as the characteristics of individuals, practices, jobs, and communities associated with the areas of satisfaction that predict retention. Study subjects comprised a sample of 1,600 primary care physicians who moved to nonmetropolitan counties nationwide during the years 1987 through 1990, with oversampling of those who moved to federally designated health professional shortage areas (HPSAs). Physicians serving in the National Health Service Corps (NHSC) were excluded. Sixty-nine percent of the eligible subjects returned completed mail questionnaires in 1991. Analyses for this study were limited to the 620 primary care physicians who worked more than 20 hours per week in towns of fewer than 35,000 population; who were neither in the military nor the NHSC; and who were not in urgent care, emergency room, or full-time teaching positions. Analyses revealed that the areas of rural physicians' greatest satisfaction were their relationships with patients, clinical autonomy, the care they provided to medically needy patients, and life in small communities. Physicians were least satisfied with their access to urban amenities and the amount of time they spent away from their practices. Retention was independently associated only with physicians' satisfaction with their communities and their opportunities to achieve professional goals. Retention was also marginally related to physicians' satisfaction with their earnings. Among the areas of satisfaction not related to retention were satisfaction with autonomy, access to medical information and consultants, and the quality of doctor-patient relationships. In a subsequent series of analyses of the factors that predict the three areas of satisfaction that were associated with retention (satisfaction with the community, professional goal attainment, and earnings), a variety of physician, work, and community factors were identified. These findings reveal that specific features of rural physicians, their work, and their communities predict each of the various aspects of satisfaction and that only certain aspects of satisfaction predict rural physicians' retention. There are no magic bullets to make rural physicians satisfied in all ways. Nevertheless, there are identified approaches to elevate the specific aspects of rural physicians' satisfaction important to their retention. Programs to improve the satisfaction of rural physicians should focus on those areas of satisfaction that predict longer retention and other important outcomes.     

The referral process and urban health care in sub-Saharan Africa: the case of Lusaka, Zambia.

Much of the current reform of urban health systems in sub-Saharan Africa focuses upon the referral system between different levels of care. It is often assumed that patients are by-passing primary facilities which leads to congestion at hospital outpatient departments. Zambia is well advanced in its health sector reform and this case study from the capital, Lusaka, explores the patterns of health seeking behaviour of the urban population, the reasons behind health care choices, the functioning of the referral system and the users' evaluations of the care received. Data were collected across three levels of the system: the community, local health centres and the main hospital (both in- and out-patients). Results showed those who by-passed health centres were doing so because they believed the hospital outpatient department to be cheaper and/or better supplied with drugs (not because they believed they would receive better technical care). Few users were given information about their diagnosis or reason for referral. The most striking result was the degree of unmet need for health services and the large number of individuals who were self-medicating due to lack of money rather than the minor nature of their illness. The current upgrading of urban health centres into 'reference centres' may provide a capacity for unmet need rather than decongesting the hospital outpatient department as originally intended.     

Referrals of patients by family physicians to consultants: a survey of the Israeli Family Practice Research Network

OBJECTIVE: We aimed to analyse factors influencing referral of patients by primary care physicians to specialist consultants at the beginning of the era of direct access to specialists in Israel. METHODS: We carried out a study of referrals by family physicians to specialists over a continuous period of 3 months. Twenty-four certified family physicians filled in a questionnaire detailing referrals during the study period. All patients were referred for consultation to a specialist at regional speciality clinics or hospital out-patient departments. RESULTS: Ten physicians met the study conditions. In 1140 of 10896 (10.5%) visits, patients were referred to specialist consultants. The percentage of referral ranged from 7.4 to 15.9%. The difference between the physicians with the lowest and highest rates of referral was statistically significant (P < 0.0001). The variance in referral rates was not explained by significant differences in physician or practice variables. The types of specialists to whom the most referrals were made were orthopaedic surgeons, ophthalmologists, dermatologists, ear, nose and throat, general surgeons and plastic surgeons. There was a significant correlation between the type of specialist and the age of the patient. Older patients were referred more frequently to urologists, cardiologists and ophthalmologists, while younger patients were referred more frequently to ear, nose and throat specialists and gynaecologists (P < 0.01). CONCLUSIONS: The results of this study can be used as an aid for decision makers in the health services for determining policy. Direct access to some specialties might be appropriate, but not to all. Adoption of a policy based on these findings could lead to reduced health care costs by reducing the burden on hospital emergency rooms. It might also increase patient satisfaction in that the patients will have greater freedom of choice. On the other hand, more appropriate training of family physicians and more extensive self- and peer-quality assurance will increase the primary physician's knowledge and ability to diagnose and treat a broad range of problems and improve the level of care.      

Preliminary Assessment of Appropriateness of Emergency Care Service Use: Actions Taken and Consultations Obtained Before Emergency Care Presentation

Inappropriate use of emergency care services can increase hospital readmissions and related costs. This pilot, cross-sectional survey project determined whether home health care patients who receive emergency care services during a Medicare-approved home care episode sought consultation from health care professionals before they made the emergency care visit. The two research questions were: (a) What actions were taken by the patient before making an emergency care visit?; (b) If prior consultation was obtained, what were the suggestions? Preliminary data were obtained from a Michigan-based, Medicare-certified, not-for-profit home health agency affiliated with a university health system. A two-page questionnaire recorded up to three emergency care visits. Volunteer participants were Medicare patients who had no cognitive deficits and were able to communicate with home health care providers (HHCPs) by themselves. Thirty-five emergency care visits were reported; 31 (88.6%) Medicare patients participated and 4 (11.4%) of them had two emergency care visits. Before the patients made an emergency care visit, they most often called their primary care physicians (PCPs; N = 20, 57.1%), followed by the HHCPs (N = 10, 28.6%). All 20 patients who contacted their PCPs and 7 patients who contacted their HHCPs were advised to seek emergency care services. In 20 emergency care visits the patient was admitted for an acute hospital stay; the other 15 patients went home. Most patients contacted their PCPs or HHCPs before they went to an emergency department or urgent care facility. These results implied that PCPs and HHCPs seemed to perceive that the need for emergency care should be determined at an emergency room or urgent care facility. This study was unable to differentiate the need for emergency care services or the appropriateness of the advice given by PCPs or HHCPs when the home care patients were under the care of a medical team.     

Preliminary assessment of appropriateness of emergency care service use: actions taken and consultations obtained before emergency care presentation

Inappropriate use of emergency care services can increase hospital readmissions and related costs. This pilot, cross-sectional survey project determined whether home health care patients who receive emergency care services during a Medicare-approved home care episode sought consultation from health care professionals before they made the emergency care visit. The two research questions were: (a) What actions were taken by the patient before making an emergency care visit?; (b) If prior consultation was obtained, what were the suggestions? Preliminary data were obtained from a Michigan-based, Medicare-certified, not-for-profit home health agency affiliated with a university health system. A two-page questionnaire recorded up to three emergency care visits. Volunteer participants were Medicare patients who had no cognitive deficits and were able to communicate with home health care providers (HHCPs) by themselves. Thirty-five emergency care visits were reported; 31 (88.6%) Medicare patients participated and 4 (11.4%) of them had two emergency care visits. Before the patients made an emergency care visit, they most often called their primary care physicians (PCPs; N = 20, 57.1%), followed by the HHCPs (N = 10, 28.6%). All 20 patients who contacted their PCPs and 7 patients who contacted their HHCPs were advised to seek emergency care services. In 20 emergency care visits the patient was admitted for an acute hospital stay; the other 15 patients went home. Most patients contacted their PCPs or HHCPs before they went to an emergency department or urgent care facility. These results implied that PCPs and HHCPs seemed to perceive that the need for emergency care should be determined at an emergency room or urgent care facility. This study was unable to differentiate the need for emergency care services or the appropriateness of the advice given by PCPs or HHCPs when the home care patients were under the care of a medical team.