Association of Family-Centered Care with Improved Anticipatory Guidance Delivery and Reduced Unmet Needs in Child Health Care

Little is known about the association of family-centered care (FCC) with the quality of pediatric primary care. The objectives were to assess (1) associations between family-centered care (FCC), receipt of anticipatory guidance, and unmet need for health care; and (2) whether these associations vary for children with special health care needs (CSHCN). The study, a secondary data analysis of the 2004 Medical Expenditure Panel Survey, used a nationally representative sample of family members of children 0–17 years. We measured receipt of FCC in the last 12 months with a composite score average >3.5 on a 4 point Likert scale from 4 Consumer Assessment of Healthcare Providers and Systems questions. Outcome measures were six anticipatory guidance and six unmet health care service needs items. FCC was reported by 69.6% of family members. One-fifth (22.1%) were CSHCN. Thirty percent of parents reported ≥4 of 6 anticipatory guidance topics discussed and 32.5% reported ≥1 unmet need. FCC was positively associated with anticipatory guidance for all children (OR = 1.45; 95% CI 1.19, 1.76), but no relation was found for CSHCN in stratified analyses (OR = 1.01; 95% CI .75, 1.37). FCC was associated with reduced unmet needs (OR = .38; 95% CI .31, .46), with consistent findings for both non-CSHCN and CSHCN subgroups. Family-centered care is associated with greater receipt of anticipatory guidance and reduced unmet needs. The association between FCC and anticipatory guidance did not persist for CSHCN, suggesting the need for enhanced understanding of appropriate anticipatory guidance for this population.     

Associations of Family-Centered Care with Health Care Outcomes for Children with Special Health Care Needs

The objective of this study is to examine the association of family-centered care (FCC) with specific health care service outcomes for children with special health care needs (CSHCN). The study is a secondary analysis of the 2005–2006 National Survey of Children with Special Health Care Needs. Receipt of FCC was determined by five questions regarding how well health care providers addressed family concerns in the prior 12 months. We measured family burden by reports of delayed health care, unmet need, financial costs, and time devoted to care; health status, by stability of health care needs; and emergency department and outpatient service use. All statistical analyses used propensity score-based matching models to address selection bias. FCC was reported by 65.6% of respondents (N = 38,915). FCC was associated with less delayed health care (AOR: 0.56; 95% CI: 0.48, 0.66), fewer unmet service needs (AOR: 0.53; 95% CI: 0.47, 0.60), reduced odds of ≥1 h/week coordinating care (AOR: 0.83; 95% CI: 0.74, 0.93) and reductions in out of pocket costs (AOR: 0.88; 95% CI: 0.80, 0.96). FCC was associated with more stable health care needs (AOR: 1.11; 95% CI: 1.01, 1.21), reduced odds of emergency room visits (AOR: 0.90; 95% CI: 0.82, 0.99) and increased odds of doctor visits (AOR: 1.25; 95% CI: 1.14, 1.37). Our study demonstrates associations of positive health and family outcomes with FCC. Realizing the health care delivery benefits of FCC may require additional encounters to build key elements of trust and partnership.     

Family-Centered Care in the Critical Care Setting: Myth or Reality?

Family-centered care (FCC) has been upheld as the standard for providing quality health care for children However, some professionals question its applicability in the critical care setting Despite the barriers to FCC ACCHs eight essential elements of FCC can provide the bases for devising strategies for successfully implementing FCC in the critical care setting.     

Evaluation of Viewpoints of Health Care Professionals on the Role of Ethics Committees and Hospitals in the Resolution of Clinical Ethical Dilemmas Based on Practice Environment

We sought to evaluate whether health care professionals’ viewpoints differed on the role of ethics committees and hospitals in the resolution of clinical ethical dilemmas based on practice location. We conducted a survey study from December 21, 2013 to March 15, 2014 of health care professionals at six hospitals (one tertiary care academic medical center, three large community hospitals and two small community hospitals). The survey consisted of eight clinical ethics cases followed by statements on whether there was a role for the ethics committee or hospital in their resolution, what that role might be and case specific queries. Respondents used a 5-point Likert scale to express their degree of agreement with the premises posed. We used the ANOVA test to evaluate whether respondent views significantly varied based on practice location. 240 health care professionals (108—tertiary care center, 92—large community hospitals, 40—small community hospitals) completed the survey (response rate: 63.6 %). Only three individual queries of 32 showed any significant response variations across practice locations. Overall, viewpoints did not vary across practice locations within question categories on whether the ethics committee or hospital had a role in case resolution, what that role might be and case specific queries. In this multicenter survey study, the viewpoints of health care professionals on the role of ethics committees or hospitals in the resolution of clinical ethics cases varied little based on practice location.     

Central America: The State of Psychosocial Care in Pediatrics

Four free-standing children's hospitals, two large pediatric units in general hospitals, and clinics and other health care facilities that serve children in four countries in Central America were visited in the summer of 1985 This paper summarizes the degree of family involvement and the play opportunities for patients present in these institutions and assesses the likelihood of future developments in psychosocial care in the pediatric facilities of Central America.     

Family-centered Care for Sick Newborns: A Thumbnail View

Family-centered care (FCC) for sick newborns is emerging as a paradigmatic shift in the practice of facility-based newborn care. It seeks to transforming a provider-centered model into a client-centered one and thus build a new therapeutic alliance. FCC is the cornerstone of continuum of care, imparting caregiving competencies to parents/caregivers both within institutions as well as after the discharge. This has potential gains for the newborn, family members, and facility-level staff. The initial model piloted in tertiary-care settings is now undergoing translation at five sites across the country; the outcomes are keenly awaited.     

Coordinating In-Patient and Out-Patient Services

It has been observed that there are problems in the conceptual base of social workers' practice with groups in health settings. This article suggests that to develop a sound conceptual base and to improve the integration of work with groups into the operating structures for delivering social work services in health care, it is necessary to distinguish social work groups from other groups. Criteria for social work practice with groups are identified. Criteria are based on fundamental principles of social work practice in health care and principles of social work practice differentiated to take account of group processes.     

When is it social work? Another look at practice with groups in health care

It has been observed that there are problems in the conceptual base of social workers' practice with groups in health settings. This article suggests that to develop a sound conceptual base and to improve the integration of work with groups into the operating structures for delivering social work services in health care, it is necessary to distinguish social work groups from other groups. Criteria for social work practice with groups are identified. Criteria are based on fundamental principles of social work practice in health care and principles of social work practice differentiated to take account of group processes.     

The 1990s and Beyond: Determining the Need for Community Health and Primary Care Nurses for Rural Populations*

ABSTRACT: Increased numbers of primary care and advanced practice nurses with unique generalist skills will be required to meet the accelerating physiologic and sociocultural health care needs of rural populations. Several factors have been identified that will influence the demands and position of community-based nurses in rural practice settings during the next decade. A back-to-basics type of health care offered out of a growing elderly population; technological breakthroughs that make it possible for more chronically ill patients to live at home; serious substance abuse and other adolescent problems; AIDS; and high infant morbidity and mortality statistics are only some of the concerns that will demand nursing intervention. These changes speak to the need for improved nursing coordination, stronger collegial relationships, and better communication between physicians and nurses. Health care is moving in new directions to offer more efficient and technologically sophisticated care. These changes enhance the need for clinically expert educators who teach and jointly practice in programs with a rural focus. Telecommunications, and heightened computer literacy, will play a major role both in nursing education and clinical practice. The goals of kindergarten through 12th grade health promotion and disease prevention strategies in school health will be the norm and will require better prepared, and positions for, school nurses. More midwives and public health nurses will be needed to care for the growing population of sexually active adolescents who are in need of family planning and prenatal care. Underinsured and indigent populations will continue to fall within the purview of midlevel practitioners, as will providing anesthesia services in small rural hospitals. The transition of some rural hospitals into expanded primary care units (e.g., EACHs and RPCHs), and new models of case management will greatly influence nursing demands. This paper will further identify critical areas of advanced practice nursing within community settings, including new relationships with other health care providers, and will introduce strategies upon which rural health policy recommendations for the 1990s can be addressed.     

The 1990s and Beyond: Determining the Need for Community Health and Primary Care Nurses for Rural Populations*

Increased numbers of primary care and advanced practice nurses with unique generalist skills will be required to meet the accelerating physiologic and sociocultural health care needs of rural populations. Several factors have been identified that will influence the demands and position of community-based nurses in rural practice settings during the next decade. A back-to-basics type of health care offered out of a growing elderly population; technological breakthroughs that make it possible for more chronically ill patients to live at home; serious substance abuse and other adolescent problems; AIDS; and high infant morbidity and mortality statistics are only some of the concerns that will demand nursing intervention. These changes speak to the need for improved nursing coordination, stronger collegial relationships, and better communication between physicians and nurses. Health care is moving in new directions to offer more efficient and technologically sophisticated care. These changes enhance the need for clinically expert educators who teach and jointly practice in programs with a rural focus. Telecommunications, and heightened computer literacy, will play a major role both in nursing education and clinical practice. The goals of kindergarten through 12th grade health promotion and disease prevention strategies in school health will be the norm and will require better prepared, and positions for, school nurses. More midwives and public health nurses will be needed to care for the growing population of sexually active adolescents who are in need of family planning and prenatal care. Underinsured and indigent populations will continue to fall within the purview of midlevel practitioners, as will providing anesthesia services in small rural hospitals. The transition of some rural hospitals into expanded primary care units (e.g., EACHs and RPCHs), and new models of case management will greatly influence nursing demands. This paper will further identify critical areas of advanced practice nursing within community settings, including new relationships with other health care providers, and will introduce strategies upon which rural health policy recommendations for the 1990s can be addressed.     

Neonatal Care Management

Neonatology has become a prime target for specialty care management or population management services. As the cost of caring for the neonatal intensive care unit (NICU) population steadily rises, with no accompanying increase in quality information, health plans and large self-insured groups have increasingly taken notice. Some plans have attempted to manage this challenging population on their own; others have sought outside solutions. One such program is that developed by Paidos Health Management Services, founded in 1996.This article identifies the key issues surrounding neonatology and medically complex newborns and suggests factors that need to be addressed by a comprehensive neonatal care management program. It explains elements of the Paidos program and how this model becomes operational. Using key program elements including a specific patient grouper system, clinical management guidelines, physician advisory boards, outcome measurements and family satisfaction, the success of the program is described.Wide variation in clinical practice is demonstrated by the duration of methyl-xanthine therapy with a 2-fold difference seen in various regions. The cornerstone of improvement in practice is the use of sound clinical management guidelines.As documentation that improvement can be made, a revised feeding guideline improved the time to first feeds by as much as 50% at certain gestational ages. Guideline compliance overall averaged greater than 90%. This success was achieved by developing these evidence-based guidelines in cooperation with practicing physicians.With a fully implemented program, cost savings can reach 10% but vary depending on hospital contracts. Absolute reduction in length of stay and leveling of care are components of cost reductions. For those health plans lacking different contracted levels, there exist opportunities in future contracting with the level-of-care approach. Timely discharge of an infant depends on competent, high quality home care services being available. The high degree of family satisfaction with the program indicates that measures to contain utilization as part of the care management process are not burdensome.There are significant barriers and challenges to overcome when establishing a neonatal care management program. These include the relatively closed practice style of neonatology, financial concerns of physicians and hospitals and the issues of ‘control’ over what is best for the patient. However, given the current climate of managed care, a comprehensive, integrated approach can offer a successful solution.     

Hospitalization due of infectious diarrhea in Rio de Janeiro State

Diarrhea is an important cause of hospitalization among infants. There are many complex factors that influence hospital use: socioeconomic and cultural characteristics, access, medical needs, and supply. The objective was to measure hospitalization rates from diarrhea among infants in Rio de Janeiro in 1996 and the association with demographic, geographical, and clinical data comparing differentials between public/university and private/philanthropic hospital care under the Unified National Health System (SUS). The authors used data from the Hospital Information System. Private/philanthropic hospitals admitted approximately four times more children than public/university hospitals. Analysis shows that variation in age, length of hospital stay, and use of pediatric intensive care may reflect differences in physicians' practice styles. This may in turn influence the respective health care unit's capacity to prevent death associated with diarrhea. The authors conclude that it is necessary to continue the analysis of hospital utilization under the SUS due to implications for the cost and quality of pediatric care.     

Canadian Nationwide Survey on Pediatric Malnutrition Management in Tertiary Hospitals

Background: Disease-associated malnutrition (DAM) is common in hospitalized children. This survey aimed to assess current in-hospital practices for clinical care of pediatric DAM in Canada. Methods: An electronic survey was sent to all 15 tertiary pediatric hospitals in Canada and addressed all pillars of malnutrition care: screening, assessment, treatment, monitoring and follow-up. Results: Responses of 120 health care professionals were used from all 15 hospitals; 57.5% were medical doctors (MDs), 26.7% registered dietitians (RDs) and 15.8% nurses (RNs). An overarching protocol for prevention, detection and intervention of pediatric malnutrition was present or “a work in progress”, according to 9.6% of respondents. Routine nutritional screening on admission was sometimes or always performed, according to 58.8%, although the modality differed among hospitals and profession. For children with poor nutritional status, lack of nutritional follow-up after discharge was reported by 48.5%. Conclusions: The presence of a standardized protocol for the clinical assessment and management of DAM is uncommon in pediatric tertiary care hospitals in Canada. Routine nutritional screening upon admission has not been widely adopted. Moreover, ongoing nutritional care of malnourished children after discharge seems cumbersome. These findings call for the adoption and implementation of a uniform clinical care pathway for malnutrition among pediatric hospitals.     

Acute Care for Elders Units

Older patients often experience a loss of independent physical functioning during the course of an acute illness that requires hospitalization. Although functional outcomes are not usually the focus of care in the hospital, they may be critical determinants of the quality of life, physical independence, cost of care, and prognosis among older patients.Based on a conceptual model of the dysfunctional syndrome (functional decline associated with hospitalization) we developed, implemented and evaluated a multi-component intervention termed Acute Care for Elders (ACE), in hospital medical units of two urban hospitals. ACE is a model of care that combines the principles of geriatric assessment and quality improvement. The ACE intervention includes a prepared environment (environmental modification), patient-centered care (interdisciplinary assessment), interdisciplinary team rounds and planning for home, and medical care review. Results of randomized clinical trials support the effectiveness of ACE to improve outcomes of hospitalization for older patients. Improved functional status, lower risk of nursing home placement and higher levels of patient and professional satisfaction with care are achievable with ACE.The challenges of establishing an ACE unit in community hospitals can be met through a systematic process of implementation and evaluation.ACE is a multi-component intervention that is potentially transportable to other hospital units, with benefits for patients, health professionals and hospital administrators.     

军队医院护理骨干心理护理培训需求

目的了解军队医院护理骨干心理护理实践现状及培训需求,为构建系统性心理护理培训方案提供参考。方法采用临床护士心理护理知信行及需求调查问卷、自编心理护理培训需求问卷等对2018年4批次接受任职教育培训的103名军队医院护理骨干调查。结果军队医院护理骨干心理护理知识、行为、态度、需求维度分别得分56.18±12.61分、28.52±2.38分、57.94±12.93分、18.62±1.72分;97.1%的护理骨干希望接受心理学相关培训,83%希望将“护士职业心理健康促进”作为培训内容,89%希望培训中应用案例分析;军队医院护理骨干的心理护理态度、需求、知识得分分别在工作年限、初始学历、工作科室与培训经历上的差异有统计学意义(P<0.05)。结论军队医院护理骨干心理护理知识掌握不足,一定程度阻碍临床心理护理工作的开展,亟需开展心理护理培训;并且应根据军队医院护理骨干对心理护理培训内容及培训方式的需求,侧重于临床实践应用,构建系统性、模块化、参与式培训,以切实提高军队医院护理骨干心理护理水平。     

Access to Health Care for Undocumented Migrant Children and Pregnant Women: The Paradox Between Values and Attitudes of Health Care Professionals

Access to health care for undocumented migrant children and pregnant women confronts human rights and professional values with political and institutional regulations that limit services. In order to understand how health care professionals deal with these diverging mandates, we assessed their attitudes toward providing care to this population. Clinicians, administrators, and support staff (n = 1,048) in hospitals and primary care centers of a large multiethnic city responded to an online survey about attitudes toward access to health care services. Analysis examined the role of personal and institutional correlates of these attitudes. Foreign-born respondents and those in primary care centers were more likely to assess the present access to care as a serious problem, and to endorse broad or full access to services, primarily based on human rights reasons. Clinicians were more likely than support staff to endorse full or broad access to health care services. Respondents who approved of restricted or no access also endorsed health as a basic human right (61.1%) and child development as a priority (68.6%). A wide gap separates attitudes toward entitlement to health care and the endorsement of principles stemming from human rights and the best interest of the child. Case-based discussions with professionals facing value dilemmas and training on children’s rights are needed to promote equitable practices and advocacy against regulations limiting services.     

Parent and health care professional perspectives on family-centered care for children with special health care needs: are we on the same page?

A family-centered approach to health care for children with special health care needs (CSHCN) is widely acknowledged as the ideal model of service delivery, but less is known about the actual practice of family-centered care (FCC), especially from the viewpoints of parents and health care professionals. This cross-sectional research compared parent and health care professional perspectives on the degree to which FCC is being provided at a large, urban hospital in the United States. The Measure of Process of Care (MPOC) was administered to a representative sample of 92 parents of CSHCN; a convenience sample of 43 health care professionals completed the service provider version of the MPOC. A mixed-model analysis of variance was conducted to test for group differences on matched domain scores of the MPOC. No significant differences emerged between the two stakeholder groups, but significant differences were detected among the four domain scores. The data suggest that health professionals are generally meeting families' needs for specific communication and are respectful of parents' expertise. However, parents and professionals alike indicated the need for continued professional growth in the area of providing holistic, comprehensive services to advance FCC.     

Quality Clinical Care in Nursing Facilities

Despite improvements in selected nursing facility (NF) quality measures such as reduction in antipsychotic use; local, state, and national initiatives; and regulatory incentives, the quality of clinical care delivered in this setting remains inconsistent. Herein, recommendations for overcoming barriers to achieving consistent, high-quality clinical outcomes in long-term (LTC) and post-acute care are provided to address inadequate workforce, suboptimal culture and interprofessional teamwork, insufficiently evidence-based processes of care, and poor adoption and fidelity of technology and integrated clinical decision support. With high staff attrition rates in NFs, mechanisms to measure and close knowledge gaps as well as opportunities for practice simulations should be available to educate and ensure adoption of clinical quality standards on clinician hiring and on an ongoing basis. Multipronged, integrated approaches are needed to further the quest for sustainment of high clinical quality in NF care. In addition to setting a tone for attainment of clinical quality, leadership should champion adoption of practice standards, quality initiatives, and evidence-based guidelines. Maintaining an optimal ratio of hours per resident per day of nurses and nurse aides can improve quality outcomes and staff satisfaction. Clinicians must consistently and effectively apply care processes that include recognition, problem definition, diagnosis, goal identification, intervention, and monitoring resident progress. In order to do so they must have rapid, easy access to necessary tools, including evidence-based standards, algorithms, and care plans, during the care delivery process. Embedding such tools into workflow of electronic health records has the potential to improve quality outcomes. On a national and international level, quality standards should be developed by interprofessional LTC experts committed to applying the highest levels of clinical evidence to improve the care of older persons. The standards should be realistic and practical, and basic principles of implementation science must be used to achieve the desired outcomes.     

Assessment of Quality of Care for Managed Care and Fee-For-Service Patients Based on Analysis of Avoidable Hospitalizations

As managed care has grown to dominate the US health care delivery system, questions have been raised about the impact on the quality of care provided to its enrollees. Two important aspects of health care quality are access to care and the appropriateness of care. This analysis evaluated the occurrence of preventable hospitalizations among managed care (MCO) versus fee for service (FFS) populations to compare access to and appropriateness of preventive, primary, and surgical health care services. Rates of preventable hospitalizations associated with ambulatory sensitive conditions (ASCs) were calculated based on all discharges from Massachusetts hospitals in 1995, and categorized by population characteristics including: age, sex, ethnicity, and insurance status. Multivariate logistic regression models were employed to explain the likelihood of having a preventable hospitalization. Rates of preventable hospitalizations for two of the conditions evaluated (perforated appendix and diabetes complications) were lower for MCO enrollees. For two additional indicators (immunization preventable pneumonia and low birth weight), MCO rates were no different from FFS rates. Results for pediatric asthma were inconclusive. For four out of five quality indicators evaluated, individuals in Massachusetts MCOs are doing better or no worse than their counterparts in FFS plans. Until population-based data on managed care enrollees becomes available, and until such data can be linked to utilization and health outcomes information, investigations into the quality of services provided by MCOs compared to FFS plans cannot be definitive.     

Health Care in Canada: Lessons for the United States

This paper considers various aspects of the Canadian health care system and the implications for the improved delivery of rural health care in the United States. The major aspects examined are access to care, rural hospitals, and rural physicians. A search of the pertinent literature revealed a large amount of information concerning rural physicians in Canada, but less that dealt directly with rural hospitals and access to health care in rural areas. Universal access is the cornerstone of the Canadian health care system, which is operated by each province under certain mandates of the federal government, with both providing funding for the system. The diffusion of medical technology has been slower in Canada than in the United States, which is perceived by some as a major success of the system. Little distinction is made between rural and urban hospitals in Canada, with all hospitals funded by annual global budgets from the province, rather than by direct payment for each service provided. Funding for capital items must be requested separately. This method of reimbursement allows better planning in meeting the needs of each community. Physicians in Canada are mostly private practitioners who are reimbursed by fee for service. As in the United States, there has been difficulty in attracting physicians to rural areas. However, all but one province have incentive programs to encourage physicians to practice in underserved rural areas, with some having disincentives for those locating in overserved areas. Overall, the Canadian health care system has chosen to control costs by focusing on the provider rather than the consumer and appears to be more successful in providing access to health care in rural areas of the country.