From Triple to Quadruple Aim: Care of the Patient Requires Care of the Provider

The Triple Aim—enhancing patient experience, improving population health, and reducing costs—is widely accepted as a compass to optimize health system performance. Yet physicians and other members of the health care workforce report widespread burnout and dissatisfaction. Burnout is associated with lower patient satisfaction, reduced health outcomes, and it may increase costs. Burnout thus imperils the Triple Aim. This article recommends that the Triple Aim be expanded to a Quadruple Aim, adding the goal of improving the work life of health care providers, including clinicians and staff.     

The Practice of Nurse-Midwifery in the Era of Managed Care: Reports from the Field

Objective: The purpose of this paper is to describe the reports of certified nurse-midwives (CNMs) about how changes in the financing and organization of health care in the late 1990s influenced their ability to serve vulnerable populations and provide a woman-centered, prevention-oriented midwifery model of care. Methods: A 13-page survey was mailed to all CNMs ever certified by the American College of Nurse-Midwives (N = 6365) in July 1998. The survey included closed- and open-ended questions. A total of 2405 CNMs responded; of these, 2089 were in clinical practice during the study period (1997–98) and 82% of the 2089 (N = 1704) wrote responses to the open-ended questions and were included in the qualitative database. We present responses to the closed-ended questions about seven domains of practice and elaborate on three major themes identified through content analysis of the qualitative data. Results: The majority (57%) reported that the changes in the larger health care environment had influenced their practices during 1997–98. The effects most frequently reported were 1) increased client loads (31%); 2) altered style of practice (30%); 3) inability to serve the same populations; (20%); 4) decreased client loads (20%); and 5) increased administrative duties (17%). Three major themes were identified and elaborated upon in the qualitative data: 1) challenges to the style of midwifery practice related to the managed care environment; 2) the loss of socially and economically at-risk women from CNMs' client base; and 3) barriers to high quality and comprehensive services for women. Conclusions: During the late 1990s as managed care was expanding and health systems were merging, a significant number of CNMs in the field described threats to their ability to sustain economically viable practices and a style of care consistent with the woman-centered, prevention-oriented midwifery model.     

Further Application of the Care Transitions Intervention: Results of a Randomized Controlled Trial Conducted in a Fee-For-Service Setting

The study objective was to test whether a self-care model for transitional care that has been demonstrated to improve outcomes in Medicare Advantage populations—The Care Transitions Intervention—could also improve outcomes in a Medicare fee-for-service population. Intervention patients were less likely to be readmitted to a hospital in general and for the same condition that prompted their index hospitalization at 30, 90, and 180 days versus control patients. Coaching chronically ill older patients and their caregivers to ensure that their needs are met during care transitions may reduce the rate of subsequent rehospitalization in a Medicare fee-for-service population.     

Rehabilitation Providers' Prediction of the Likely Success of the SNF-to-Home Transition Differs by Discipline

Objectives

Our article's primary objective is to examine whether rehabilitation providers can predict which patients discharged from skilled nursing facility (SNF) rehabilitation will be successful in their transition to home, controlling for sociodemographic factors and physical, mental, and social health characteristics.

The quality and adequacy of care received at home in the last 3 months of life by people who died following a stroke: a retrospective survey of surviving family and friends using the Views of Informal Carers Evaluation of Services questionnaire

Stroke is the third leading cause of death in the UK. Despite this, little is known about the care needs of people who die from or following a stroke. In early 2003, a total of 183 questionnaires were returned from a survey of 493 people who had registered a stroke-related death in four Primary Care Trusts, giving a response rate of 37%. This paper reports on 53 deceased from the survey who had lived at home during their last 3 months and who had been ill for more than 1 month. The data were analysed to explore the role of informal carers and the provision of community-based care in the last 3 months of life. Family and friends helped 82% of deceased with household tasks, 68% with personal care, 66% with taking medication and 54% with night-time care. By contrast, health and social services helped 30% with household tasks, 54% with personal care, 20% with taking medication and 6% with night-time care. Two-fifths (43%) of informants had to give up work or make major life changes to care for the deceased, and 26% of informants found looking after them 'rewarding'. Half (51%) reported that help and support from health services were excellent or good compared to 38% for social services. Results from the Regional Study of Care for the Dying indicated that people who died from a stroke in 1990 and their informal carers would have benefited from increased levels of community-based care and enhanced communication with care professionals. Our data suggest that informal carers continue to provide the majority of care for those who die from stroke, despite government initiatives to improve care for stroke patients and frail elderly people. Further research is required to explore best practice and service provision in caring for this group.     

The Role of the Social Worker in the Adult Critical Care Unit: A Systematic Review of the Literature

Social workers provide care to patients and families in the adult critical care unit. We conducted a systematic review of the literature to more clearly identify the role of the social worker practicing in the intensive care unit. We conducted a comprehensive search of the literature using the Pubmed, Embase, ISI, Scopus, and Social Work Abstracts databases using the terms “intensive care,” “critical care,” and “social work.” Articles were selected for review if they met the following criteria: formal studies or opinion papers whose primary focus was the role or scope of practice of the social worker in the adult critical care unit. Articles were selected and reviewed independently by two social work investigators. Our search retrieved 550 potentially relevant articles. Twelve full-text articles were deemed eligible for abstracting. Three of the articles were studies that examined different aspects of social work practice including implementation of a family assistance program, social work response to anxiety levels of families in critical care and common activities of critical care social workers. Nine articles were primarily opinion pieces. All of the opinion articles described psychosocial support and counseling as a primary role of critical care social work. Other frequently identified roles were crisis intervention, psychosocial assessment, facilitating communication, end-of-life care, and practical assistance. There is little empiric data describing the role of the critical care social worker. Consistent themes from the articles identified include the role of social workers as counseling professionals, facilitators of communication, and resource agents. Further research to identify formal assessment tools and outcome studies of specific counseling techniques will provide important information for best practice guidelines in this area.     

Impact of Home Care Management on the Involvement of Informal Caregivers by Formal Caregivers

This study explores the link between management characteristics of home care agencies and the involvement of informal caregivers in caregiving. Based on a study of policy documents of two agencies and semi-structured interviews with five team managers and 31 formal caregivers, we conclude that, although the importance of involving informal caregivers is emphasized in official documentation, actual contact with informal caregivers is often lacking. Comparison of the work processes of the two agencies shows that contact with informal caregivers and their potential involvement are enhanced by smaller teams, less task division, and clarity about the responsibilities of formal caregivers.     

儿童重症监护病房家属焦虑情绪状况与心理护理干预

目的分析儿童重症监护病房患儿家属的焦虑情绪状况及探讨有效的心理护理干预措施。方法选取该院儿童重症监护病房近期内收治的60例患儿家属作为研究对象,并将入选患儿家属随机平均分为A、B两组,给予A组患儿家属实施常规护理、给予B组患儿家属实施心理干预护理,并采用焦虑自评量表在患儿进入重症监护病房后1、3d时分别对两组患儿家属进行问卷调查。同时调查患儿家属产生焦虑情绪的主要因素。结果引起患儿家属产生焦虑情绪的主要因素包括：担心患儿得不到有效的治疗、担心治疗后出现后遗症、担心患儿得不到较好的照顾等。两组患儿家属的焦虑得分均明显高于国内常模,在实施护理后,两组得分均有明显下降,且B组分数下降优于A组（P〈0.05）。结论重症监护病房的患儿家属会因各种因素导致其产生焦虑情绪,因此临床在对患儿实施治疗时应注意患儿家属的心理变化,并及时的给予患儿家属实施必要的心理干预护理,这样可有效的缓解患儿家属的不良情绪,争取其积极的配合患儿治疗,从而帮助患儿早日康复。     

An exploratory study of spiritual care at the end of life

PURPOSE Although spiritual care is a core element of palliative care, it remains unclear how this care is perceived and delivered at the end of life. We explored how clinicians and other health care workers understand and view spiritual care provided to dying patients and their family members.     

美国整合卫生保健主要做法及启示

随着人口老龄的快速发展、慢性病负担逐步加重,居民对综合、协调、连续、安全、可及的卫生保健服务需求日益增加。整合卫生保健有助于提高卫生保健服务的可及性、公平性、效率和患者满意度。文章梳理美国在整合卫生保健领域的做法,总结特点和成效,提出中国开展整合卫生保健的建议。     

The impact of the Community Care Act: views from the independent sector

The 1990 NHS and Community Care Act introduced changes that had significant implications for independent service providers. The legislation was intended to decrease unnecessary institutionalization, increase the demand for non-statutory community care services, and improve collaboration between the private and public service sectors. Preliminary evidence on the impact of the Act suggests that the principal changes related to private service provision have not been translated into practice, but the data are confined to studies from the local authorities' perspective or that of carers. In this paper, the views of independent service providers in an urban area of Scotland were examined through interviews with 24 administrators of nursing homes or residential care facilities. The study investigated their perceptions of the impact of the law on institutionalization, diversification into community care, and partnerships between the public and private spheres. The findings show that facilities have experienced a range of problems since the law came into effect, including higher vacancy rates, more disabled residents, delays in admissions, cash flow problems and reductions in private pay patients. Those owned by public limited companies were more able to buffer themselves from the adverse effects. A large proportion of the facilities had diversified into community based long-term care, but these were perceived as a minor sideline. Finally, the legislation did not result in links forged between independent service providers and the social service departments of local authorities who are charged with assessing, coordinating and purchasing long-term care.     

An Australian study on the benefits of pastoral care to aged care residents in Christian affiliated homes

This study aimed to understand the experience of pastoral care (PC), that is, the provision of support, comfort and spiritual counselling, from the perspective of Australian aged care residents. A survey research design captured feedback on participants’ PC experience. Outcomes were reported by 575 residents (aged 53–102) across 41 sites. The majority perceived that they received a high quality of care (92%) and benefited from their meeting with the pastoral practitioner (80%), ‘often’ or ‘all of the time’. A few significant differences were found based on participants’ gender, spirituality (i.e. connection and meaning), religiosity (i.e. faith beliefs and religious practices) and well‐being. Females and participants who identified as both religious and spiritual were more likely to feel that their faiths/beliefs were valued. Those with greater psychological well‐being, as defined by the World Health Organisation (1998), were more likely to report receiving a high quality of care and greater benefits from receiving PC than those with poorer well‐being. Three overarching themes and eight subthemes were identified from the open‐ended responses: 1) personal qualities of the pastoral practitioner; caring, supportive, understanding and empathetic; 2) pastoral practitioner met specific needs; spiritual and religious, friendship and company and assistance, advice and help; and 3) positive impact on the participant; feeling listened to, peaceful and valued, accepted and respected. The qualitative findings resonate with Maslow's Hierarchy of Needs, to feel safe, belong and have self‐esteem. There was a synergy between what participants desire in the care they receive, as expressed in the open‐ended questions, and what the pastoral practitioners provide, as indicated in the quantitative findings. A study strength was its mixed‐method, multi‐site and cross‐organisational context, enabling PC to be explored across a diverse sample. Future research should consider a pre‐ and post‐test survey to more comprehensively capture the impact and benefits of PC.     

Strengthening primary care: The Veneto Region’s model of the Integrated Medical Group

PurposeThis paper aims to illustrate the development of the Veneto Region’s (Italy) new primary care model and to report on the preliminary results.BackgroundAchieving integrated management and continuity of care are the two main aims of the Veneto Region’s health planning legislation for 2012-2016. Under this framework, and to meet new emerging population needs, it has become necessary to adopt a new primary care model that embraces multi-professional teams. In response the Veneto Region has developed the Integrated Medical Group (IMG), launched in 2016. The Integrated Medical Group is an innovative model at both the regional and national level and represents a key element of the health care system. It targets several goals: it provides more effective care than in the past; guarantees services within the region while optimizing the use of resources, through integrated patient care and its accompanying care pathways; it builds dialogue between hospitals and community based primary care services; develops relationships of trust between doctors and patients, pursuing shared team goals and enhances the different skills and roles of their constituent members.Regional legislation sets challenging objectives, stating that by the end 2017, 60% of all GPs in the region should conduct their activities as part of an IMG, with a further target of 80% by the end 2018.     

上海市社区家庭保健合同现状分析

家庭保健合同是目前社区卫生服务研究的重要方向，为探讨其可能性和可行性，该研究于1998年10月对上海市社区家庭保健合同服务现状进行了调查。结果表明目前社区服务站提供的服务与居民对服务的需求间存在一定的差距。建议加强宣传力度，增加服务内容，提高服务质量，建立具有中国特色的服务模式。     

Navigating the field of temporally framed care in the Danish home care sector

The organisational and temporal framing of elderly care in Europe has changed in the wake of new public management reforms and standardised care services, the strict measurement of time and work schedules have become central aspects of care work. The article investigates the crafting of care in this framing: how care workers approach the services specified in their rotas and navigate between needs, demands and opportunities in the daily performance of duties. Applying feminist theory on time and anthropological theory on social navigation, it examines the practice of home care work in two Danish municipalities. Data are derived predominantly from participant observation. The article identifies two overarching temporal dilemmas in different home care situations: one where process time prevails over clock time and another where the care workers balance the two. Focusing on how care workers respond to these dilemmas in practice, the article identifies various navigation tactics, including leaving time outside, individualised routinisation, working on different paths simultaneously and postponing tasks. By assessing care workers' performance in the temporal framing of work and focusing on care workers' mediation between different time logics, this study provides an in‐depth perspective on the broader feminist literature on the dilemmas of care.     

Use of midlevel practitioners to achieve labor cost savings in the primary care practice of an MCO

OBJECTIVE: To estimate the savings in labor costs per primary care visit that might be realized from increased use of physician assistants (PAs) and nurse practitioners (NPs) in the primary care practices of a managed care organization (MCO). STUDY SETTING/DATA SOURCES: Twenty-six capitated primary care practices of a group model MCO. Data on approximately two million visits provided by 206 practitioners were extracted from computerized visit records for 1997-2000. Computerized payroll ledgers were the source of annual labor costs per practice from 1997-2000. STUDY DESIGN: Likelihood of a visit attended by a PA/NP versus MD was modeled using logistic regression, with practice fixed effects, by department (adult medicine, pediatrics) and year. Parameter estimates and practice fixed effects from these regressions were used to predict the proportion of PA/NP visits per practice per year given a standard case mix. Least squares regressions, with practice fixed effects, were used to estimate the association of this standardized predicted proportion of PA/NP visits with average annual practitioner and total labor costs per visit, controlling for other practice characteristics. RESULTS: On average, PAs/NPs attended one in three adult medicine visits and one in five pediatric medicine visits. Likelihood of a PA/NP visit was significantly higher than average among patients presenting with minor acute illness (e.g., acute pharyngitis). In adult medicine, likelihood of a PA/NP visit was lower than average among older patients. Practitioner labor costs per visit and total labor costs per visit were lower (p<.01 and p=.08, respectively) among practices with greater use of PAs/NPs, standardized for case mix. CONCLUSIONS: Primary care practices that used more PAs/NPs in care delivery realized lower practitioner labor costs per visit than practices that used less. Future research should investigate the cost savings and cost-effectiveness potential of delivery designs that change staffing mix and division of labor among clinical disciplines.