Primary medical care for elderly patients part II: Results of a survey of office based clinicians

Evidence of the degree of fit between the special needs of the elderly and the service mix and payment level of ambulatory services offered under the Medicare program is presented in this second part of a two-part study of geriatric office care. Results from interviews with a focus group of 60 practicing clinicians, incorporating diversity of geography and practice setting, are described and compared with the view of geriatricians. Between 30 and 57% of the clinicians are aware of negative effects of Medicare's benefit structure on specific aspects of their practice.Marianne C. Fahs, Ph.D., M.P.H., is Assistant Professor of Health Economics, Department of Community Medicine, Mount Sinai School of Medicine.Charlotte Muller, Ph.D., is Professor of Economics and Sociology, City University of New York Graduate School, and Professor of Health Economics, Department of Community Medicine, Mount Sinai School of Medicine.Malvin Schechter, M.S., is Assistant Professor of Geriatrics Ritter Department of Geriatrics and Adult Medicine, Mount Sinai School of Medicine.Supported by a conference grant from the National Center for Health Services Research, Herbert C. Traxler, Ph.D., project director.A briefer version of this paper was presented at the annual meeting of the Association for the Social Sciences in Health, Las Vegas, Nevada, 1986.The research assistance of Helen Hooke is gratefully acknowledged.     

Community-oriented health services education: A strategy for international cooperation

This paper describes the approach of the Department of Community Medicine of the Mount Sinai School of Medicine in the education of local and foreign physicians and their participation in the development of community oriented health care systems. It also presents the first steps taken by this medical school to create an international program whose aims are to develop long-term partnership agreements with foreign universities by bringing together and integrating medical education with the development of community-oriented health care services.Samuel J. Bosch, M.D., is Charles G. Bluhdorn Professor of International Community Medicine, Department of Community Medicine, The Mount Sinai School of Medicine of the City University of New York. One Gustave L. Levy Place, New York, N.Y. 10029.Alan Silver, M.D. is Assistant Professor and Director of the Education Unit, Department of Community Medicine, The Mount Sinai School of Medicine of the City University of New York. One Gustave L. Levy Place, New York, N.Y. 10029     

A medical school's involvement in the development of a community-based health center

This paper presents a planning model developed by the Department of Community Medicine of the Mount Sinai School of Medicine to facilitate the interactions between the medical school and the community. The planning process involved application of the model, exemplified through the growth and development of a neighborhood health center governed by a community agency. The main characteristics of the medical school, of the community, and of the community agency are presented briefly and the seven-year history of the development of the neighborhood health center is summarized. In recapitulating that history three distinct phases are identified in the planning process: how the planning was planned, how the plan was prepared, and how the services program was implemented. The role of the Department of Community Medicine in each phase is analyzed.Dr. Merino is Assistant Professor, Department of Community Medicine, Mount Sinai School of Medicine, New York, NY 10029. Dr. Rose is Instructor, Departments of Medicine and Community Medicine, Mount Sinai School of Medicine, New York, NY 10029. Dr. Bosch is Professor and Deputy Chairman, Department of Community Medicine, Mount Sinai School of Medicine, New York, NY 10029.     

Clinical validation of a nutritional risk index

This research assessed the clinical validity of a nutritional risk index (NRI). Subjects were 377 male veterans, aged 55+, attending general medicine and geriatric outpatient clinics. Data were collected by personal interviews, anthropometric measurements, laboratory assay of nutritional parameters, three-day food records, and medical record reviews. Although the results showed that the NRI correlated significantly with only two nutritional measures (body mass index, total energy intake), critical values or threshold levels of NRI were identified that significantly discriminated low risk from high risk patients on four nutritional parameters (body mass index, total energy intake, laboratory risk, and medications risk). It was concluded that the NRI is a valid measure of health status and contains a nutritional dimension.John M. Prendergast, MD, MPH is Medical Director, Program on Aging, Mercy Hospital, Pittsburgh, PA 15219; Rodney M. Coe, PhD is Professor, Department of Community Medicine, St. Louis University School of Medicine and Education Coordinator, Geriatric Research, Education and Clinical Center (GRECC), VA Medical Center, St. Louis, MO 63104; M. Noel Chavez, PhD, RD is Assistant Professor, Department of Community Health Sciences, School of Public Health, University of Illinois, Chicago, IL 60612; James C. Romeis, PhD is Associate Professor, Center for Health Services, Education and Research, St. Louis University and Coordinator, Health Services Research and Development, VA Medical Center, St. Louis, MO 63104; Douglas K. Miller, MD is Assistant Professor, Department of Internal Medicine, St. Louis University School of Medicine, St. Louis, MO 63104; Fredric D. Wolinsky, PhD is Professor, Department of Sociology, Texas A&M University, College Station, TX 77843.This project was supported in part by grant #84-017 from the Veterans Administration and by K07-AG-00302 and K04-AG00328 from the National Institute on Aging.     

HMO development in an academic medical center: The rise and fall of a prepaid health program in New York City

Through a documented case study the authors identify the critical factors that impede the introduction of prepaid medical care as part of education and practice within a prestigious and well established academic medical center. The inherent conflicts between individual fee-for-service practice and population-based prepaid practice and the resistance to innovations in medical care organization as they surfaced in that center, are presented. The need for a clear understanding of the complexities of HMO development and of an appreciation for the importance of a planning process in which all interested parties are involved, is emphasized. A clear commitment by policy makers, administrators and providers is highlighted as fundamental for the implementation of a system where practitioners are motivated to assume responsibility for the comprehensive care of a defined population that prepays for their services. The rewards as well as the difficulties for institutionalizing commitment to this form of health care delivery and impacting on medical education are discussed.Samuel J. Bosch, MD, is Professor Emeritus of Community Medicine and International Health, Mount Sinai School of Medicine; Kurt W. Deuschle, MD, is Chairman Emeritus and Professor of Community Medicine, Mount Sinai School of Medicine.     

The role and functions assumed by a department of community medicine in planning a group practice.

This paper describes the technical assistance role and the functions assumed by the Department of Community Medicine of the Mount Sinai School of Medicine in a planning process that led to the development of a group practice in the Department of Medicine of the Mount Sinai Hospital. Three distinct phases are identified in the process: how the planning was planned, how the plan was prepared, and how the implementation was planned. The role of Community Medicine in each phase is analyzed.     

Development of faculty consultants in a problem-based third year community medicine clerkship

This paper describes the development of consultancy groups in behavioral science, epidemiology and biostatistics, and information science in a required community medicine rotation with a twenty year history. The addition of consultants to individual student tutors and field preceptors has led to a structure which promotes student-project flexibility, development of critical assessment skills and independent learning while maximizing faculty expertise and effectiveness.Alan Silver is Assistant Chairman and Education Director of the Department of Community Medicine, Mount Sinai School of Medicine of The City University of New York. Clyde Schechter and Virginia Walther are the Co-directors of the third year community medicine clerkship. Kurt Deuschle is Professor and past chairman of the Department of Community Medicine.The authors wish to thank current and former clerkship directors and consultants for their invaluable skills in the ongoing evolution of the clerkship. These include Samuel J. Bosch, Bess Dana, James Godbold, George Jackson, Harriet Meiss, David Rose, Edward Speedling and Jean Sullivant.     

A proposed network to improve access to high-quality health care for medicaid-eligible families

There is today both a need and an opportunity to develop and test a variety of models—organizational and financial—for improving the delivery of health care services. This article describes the structure and functioning of one such model and highlights the organizational problems expected to arise during its implemèntation. The proposed health plan is intended to facilitate the access of Medicaideligible, inner-city families to already available health services. The central hypothesis is that in low-income urban areas the elementary schools offer an organizational focus for the development of a health plan. As a prepaid, community-based model, this plan is designed to address the issues of accessibility, equity, accountability, continuity of care, and consumer participation, primarily through the development of a coordinating agency, the health plan office (HPO), which assures the linking of consumers and providers of health care. Adapted from the Kaiser-Permanente model, the HPO also assumes responsibility for marketing, enrollment, coordination of services, consumer advocacy, and quality surveillance.Dr. Bosch is Professor and Deputy Chairman of the Department of Community Medicine, Mount Sinai School of Medicine, New York City 10029. Dr. Merino is Assistant Professor, Mrs. Daniels is Coordinator of Community Program Planning, and Ms. Fischer is a Technical Associate in the Department. Dr. Rosenthal is Director of Dental Services, East Harlem Council for Human Services Neighborhood Health Center. The work reported in this article was conducted under a grant from the Robert Wood Johnson Foundation.     

Curing and caring—A proposed method for self-assessment in primary care organizations

Key research in the area of quality assessment is reviewed and a method for periodic assessment in primary care organizations is proposed. The suggested approach is designed for administrative, rather than research, purposes. Therefore, it focuses on indicators that are both practical and realistic for use in periodic monitoring.The proposed method is two-staged and includes both technical performance (curing) and satisfaction (caring). At the first level of evaluation, general areas of performance are examined; these are key performance indicators in prevention, diagnosis, and management of illness, and questionnaires dealing with the accessibility and acceptability of care, coupled with objective measures of satisfaction. Those areas of performance that are not up to management standards are then examined in greater detail at the second level of evaluation. Using this approach, organizations can build a longitudinal picture of performance and chart their progress annually.Ms. Howell, formerly an instructor in the Department of Community Medicine and International Health, Georgetown University School of Medicine, is now attending the John F. Kennedy School of Government, Harvard University. Dr. Osterweis is Assistant Professor, Department of Community Medicine and International Health, Georgetown University School of Medicine, Washington, D.C. 20007. Dr. Huntley is Professor and Chairman of that department. Reprint requests should be addressed to Dr. Osterweis. This work was supported in part by grant R18-HS-01040 from the National Center for Health Services Research.     

The international role of a U.S. medical school in developing health services

This paper discusses the educational approach taken by the Department of Community Medicine of the Mount Sinai School of Medicine in providing technical assistance in foreign countries. Using a specific project in the Dominican Republic as an example, the paper describes the role and different functions assumed by the department in planning and developing a health care system in the eastern region of that country.     

Screening for cervical and breast cancer among Caribbean immigrants

A screening program for cervical and breast cancer, focused on immigrant Caribbean women, was carried out at neighborhood sites (churches, schools, etc.) in a low-income area of Brooklyn, New York.The yield of abnormal Pap tests was 13.3/1000 women screened; the yield of breast cancer was 2.2/1000 women examined. Approximately half of the Haitian immigrants (N=361) had no prior Pap test, compared to one-quarter of the English-speaking Caribbean immigrants (N=228) and one-tenth of the U.S.-born Black women (N=264). Only 47% of Haitian women had a regular source of health care compared to 74% of the English speaking Caribbean women and 83% of the U.S.-born Black women. Haitian women were much less likely to practice breast self-examination or to use contraception than were U.S.-born Black women.This program reveals significant needs for preventive health services among low-income Caribbean immigrant women, and demonstrates that selective neighborhood-site programs can be effective in reaching those in need.Rachel G. Fruchter, MPH, PhD, is Assistant Professor, Department of Obstetrics and Gynecology. Carolyn Wright, MS, is Community Health Educator/Coordinator, Department of Preventive Medicine and Community Health. Barbara Habenstreit, MA, is Assistant to the Chairman, Department of Preventive Medicine and Community Health. Jean Claude Remy, MD, is Assistant Professor, Department of Obstetrics and Gynecology. John G. Boyce, MD, is Professor, Department of Obstetrics and Gynecology. Pascal James Imperato, MD, MPH & TM is Professor and Chairman, Department of Preventive Medicine and Community Health, State University of New York, Downstate Medical Center.This research was supported by grants from the New York Community Trust and the Morgan Guaranty Trust Company of New York Charitable Trust     

Self-instructional teaching of biostatistics for medical students

A growing body of literature deals with the use of self-instructional methods for teaching biostatistics to medical students. The University of Tennessee Department of Community Medicine tested the hypothesis that, in controlled, randomized situations, learning of statistical material by self-instruction is equivalent to learning identical material by the lecture method. An analysis of student performance, in terms of the grades obtained on two separate examinations, showed that students learning by self-instruction did as well or better than their colleagues taking lectures. On the basis of these results, self-instructional biostatistics for medical students at the University of Tennessee has been selected as the major teaching method of that subject.Dr. Robinson is Professor and Chief of Biostatistics in the Department of Community Medicine, University of Tennessee College of Medicine, 800 Madison Avenue, Memphis, Tennessee 38163. Mr. Burke is Instructor in the Department of Community Medicine, University of Tennessee, and Director of Statistical Services in the Memphis and Shelby County Health Department. Dr. Stahl was Assistant Professor of Community Health and Medical Practice, Section of Health Care Studies, University of Missouri, Columbia, Missouri, during this study. He is currently Assistant Professor of Sociology, Purdue University, School of Humanities, Social Science and Education, Lafayette, Indiana. Requests for reprints should be addressed to Dr. Robinson. John W. Runyan, Jr., M.D., and Stephen T. Miller, M.D., of the Department of Community Medicine, University of Tennessee, made valuable suggestions during the preparation of this paper.     

Project connect: An interagency partnership to confront new challenges facing at-risk women and children in New York City

Project CONNECT is a New York State—New York City collaborative venture to facilitate access to, coordinate and expand the delivery of health and human services, during the perinatal period to women and children in the three areas of New York City with the highest rates of morbidity and mortality. Based on the concept of comprehensive case management, CONNECT coordinates diverse providers around existing resources. Services implemented by community-based case managers for families in need include: medical care, substance/alcohol abuse treatment, foster care preventive services, parent education, developmental assessment, screening and child care.The initial points of entry to CONNECT are specific hospitals within the three targeted neighborhoods. Additional points of entry, including other hospitals and prenatal care sites, are being added on an incremental basis. Enrollment in CONNECT is also enrollment in Medicaid and participants are eligible for Medicaid services.It is expected that the CONNECT program will result in improved birth and health outcomes for women and their children, reduction in chemical dependency and improved family preservation.The state and city agencies that created CONNECT hope that by working together, through a very specific interagency agreement monitored by the offices of the Governor and the Mayor, they will be able to reach those families who have many needs, but traditionally have been difficult to engage and keep involved in the service delivery system. The ultimate benefit will go to the family as a whole, particularly the children, both the newborns and their siblings. By providing servicesin the community with providersfrom the community, Project CONNECT will achieve its goal of strengthening and empowering families to stay together.Linda A. Randolph, MD, MPH, is Clinical Professor in the Department of Community Medicine, Mt. Sinai School of Medicine on assignment to Carnegie Corporation of New York, 437 Madison Avenue, New York, NY 10022; She is the former Director of the Office of Public Health, New York State Department of Health. Barry R. Sherman, PhD, is Director of Research and Program Evaluation in the New York State Department of Health, Bureau of Child and Adolescent Health and Assistant Professor of Health Policy and Management in the State University of New York at Albany, School of Public Health, 208 Corning Tower, Empire State Plaza, Albany, NY 12237.     

Teaching community-oriented primary care (COPC): A practical approach

To improve education in community-oriented primary care (COPC) and to promote its practice in the community, the University of California's School of Public Health in Berkeley and School of Medicine in San Francisco are collaborating in an innovative program in cooperation with several federally-funded community clinics in the San Francisco Bay Area. The School of Public Health designed a COPC track for graduate public health students from various departments of the school who wished to work in community health care. The track includes a seminar given in the spring of the students' first year in which COPC theory is taught and teams of students working with a faculty advisor and a clinic preceptor design COPC projects for the primary care sites. These projects are then implemented in the summer and fall by students who elect to use this experience to satisfy their fieldwork requirement. This paper is a report of the first year's experience with this collaborative effort.Emilie H.S. Osborn, M.D., M.P.H. is Assistant Professor, Family and Community Medicine, University of California at San Francisco. Norman Hearst, M.D., M.P.H. is Assistant Clinical Professor, Clinical Epidemiology and Family and Community Medicine, University of California at San Francisco. Joyce C. Lashof, M.D., is Dean, School of Public Health, University of California at Berkeley. W. McFate Smith, M.D., M.P.H. is Director, Preventive Medicine Residency, School of Public Health, University of California at Berkeley.This project has been supported in part with Federal funds from the Bureau of Health Care Delivery and Assistance, Health Resources and Services Administration, U.S. Public Health Service, under contract #240-84-0124. The content of this publication does not necessarily reflect the views or policies of the Department of Health and Human Services.     

Health education in Nigerian secondary schools

A survey of 600 secondary school teachers and 120 secondary school administrators was conducted in Oyo State, Nigeria, to identify their attitudes and practices regarding school health education. Nearly all teachers and administrators felt that health education is important and should be an integral part of the curriculum. None-theless, there were few resources and little curriculum time devoted to health education. Since many of the health problems of developing countries can be addressed by enhancing the health knowledge of the populace, health education in the schools of such countries deserves more emphasis.Amos K. Fabiyi, MPH, PhD is Lecturer and Consultant (Health Education), Department of Community Health and Nutrition, Faculty of Medicine, Obafemi Awolowo University, Ile-Ife, Nigeria.Daniel S. Blumenthal, MD, MPH is Professor and Chairman, Department of Community Health and Preventive Medicine, Morehouse School of Medicine, 720 Westview Dr., Atlanta GA 30310.     

An interpretation of implicit judgments in chart review

The effects of methods that are commonly employed to summarize implicit judgments about quality-of-care assessments, based on medical records, are examined. A sample of 250 medical records, from three outpatient clinics in a municipal hospital, was studied. Two, or three, reviewers judged the quality of both the process of care and the outcome of care, as reflected in each medical record; the reviewers were medical school faculty members. Thirty-seven combinations of the data were used to summarize the judgments made on each medical record. These combinations resulted in significant differences in interpretation within each clinic, but there were only insignificant differences in interpretation across the three clinics. Hence, the use of a single method to summarize data may distort the conclusions. These results demonstrate that data often should be summarized by several methods and that measures of association should be used to supplement tests of significance so as to develop a comprehensive understanding of a set of data.Dr. Horn is Assistant Professor, Department of Health Care Organization, School of Hygiene and Public Health, The Johns Hopkins University, 615 North Wolfe Street, Baltimore, Maryland 21205. Dr. Pozen is presently Assistant Professor, Department of Medicine, Boston University School of Medicine at Boston City Hospital, Thorndike Memorial Laboratories. This study was begun while he was at the Department of Medicine at Baltimore City Hospitals and the Department of Health Care Organization at The Johns Hopkins University. This work was supported by DHEW grant 5-R01-HS-01590 from the National Center for Health Services Research and Development.     

Attitudes of professionals in providing maternity care in a primary health care system in Saudi Arabia

This study was done on a sample of the primary care centers in the Al-Baha region, Saudi Arabia to assess the opinions of the medical and paramedical staff regarding the capability and acceptability of providing antenatal and intrapartum care in the primary health care setting. The study showed that 96% of all the respondents supported the provision of antenatal care services in primary health care with 60% of them giving the reason that it is more convenient for pregnant women.90% of the respondents wanted the antenatal care to be delivered through special clinics and the majority of them wanted to give a greater role to the midwives in antenatal care. Questioned about the intranatal care provision in the centers, 98% of all the respondents agreed to the utilization of primary health care in such service. A similar percentage of them claimed to have the ability to do deliveries in the centers with existing facilities.To avoid duplication of care and to best use of available resources, low risk pregnancies should be seen antenatally and delivered in the primary health care centres provided the quality of such care is kept under control.Abdulaziz N. Al-Nasser is Assistant Professor of Primary Health Care; Mohammed A. Al-Sekait is Assistant Professor of Community Medicine; Elijah A. Bamgboye is Assistant Professor of Medical Statistics; all in the Department of Family and Community Medicine, College of Medicine, King Saud University, Riyadh 11472, Saudi Arabia.Wahid A. Khan is coordinator in the Primary Health Care Program, Al-Baha, Saudi Arabia.     

The 1974 reorganization of the British National Health Service: An analysis

The British National Health Service was reorganized on April 1, 1974, for the first time since its formation in 1948. The Reorganization attacked one serious problem: the anomalous separation of the general practitioners (and other nonhospital, non-local authority ambulatory services), hospitals, local government authority public health services, and teaching hospitals into different administrative units with different boundaries. These services are now integrated into one structure. However, other important problems will not be affected substantially.Dr. Jonas is Associate Professor of Community Medicine in the Health Sciences Center, State University of New York, Stony Brook, New York 11794. Dr. Banta is Associate Professor of Community Medicine at the Mount Sinai School of Medicine of the City University of New York and Robert Wood Johnson Health Policy Fellow in the Institute of Medicine, National Academy of Sciences, Washington, D.C. An earlier version of this paper was presented by Dr. Jonas at the American Public Health Association annual meeting, San Francisco, California, November 8, 1973. Dr. Banta is grateful to the Milbank Memorial Fund, whose support made possible visits to Britain in 1970, 1971, and 1974. The authors would like to thank Drs. Brian Abel-Smith, Peter Draper, Geoffrey Gibson, Wilfred Harding, David Stark Murray, and Julian Tudor-Hart for the helpful comments they made on the earlier paper by Dr. Jonas and also Dr. John Brotherston for his contributions to this work.     

Compliance with medication regimens among chronically ill,inner city patients

Patient adherence to medication regimens is explored as a function of (1) patient beliefs, perceptions, and knowledge of the illness, (2) extent of social support for health actions, (3) complexity of and specific knowledge about the regimen, and (4) satisfaction with clinical encounters and the health care facility. One hundred and ninety patients receiving care on an outpatient basis at a municipal teaching hospital were interviewed. The patients' medical records provided an additional data source. Path analysis generally supported the stated hypotheses. The only variables that had a significant effect opposite to that hypothesized were perceived severity about and susceptibility to the illness. The factors with the greatest predictive power in regard to patient compliance were (1) patients' ability to state the names of or accurately describe their medicines, (2) patients' ability to state the functions of their drugs, and (3) the complexity of the medication regimen as measured by the number of drugs prescribed for the patient.Dr. Greene is a Research Associate in the Department of Medicine, Indiana University School of Medicine and Regenstrief Institute for Health Care, 1001 West Tenth Street, Indianapolis, Indiana 46202; Dr. Weinberger is Assistant Professor of Medicine, Indiana University School of Medicine and Regenstrief Institute for Health Care; Dr. Jerin is Assistant Professor of Sociology at Saint Ambrose College; and Dr. Mamlin is Professor of Medicine, Indiana University School of Medicine and Regenstrief Institute for Health Care.     

Importance of community size in practice location decisions of final year residents

Final year residents in training in Louisiana were surveyed regarding plans for medical practice and their perceptions of the importance of various factors in choosing practice locations. Most specialty groups selected smaller communities at similar rates. Growing up in small towns is associated with wanting to practice in small towns while concerns about opportunities for the family and income of the region are associated with wanting to practice in a larger city.This study was supported by the Louisiana Council for Statewide Planning for Physician Manpower through Contract No. 23058, Louisiana Department of Health and Human Resources.Ms. Samaha is a data analyst for the Louisiana Council for Statewide Planning for Physician Manpower; Robert R. Franklin, M.D. is Executive Secretary of the Council and Assistant Professor, Department of Biostatistics and Epidemiolgy, Tulane University School of Public Health and Tropical Medicine; Janet C. Rice is Assistant Pofessor, Department of Biostatistics and Epidemiology at the Tulane University School of Public Health and Tropical Medicine, New Orleans, Louisiana 70112.