Optimizing primary care services

One of the most recent and pervasive trends in healthcare is the restructuring of primary care. In many markets, the solo family practice physicians increasingly family practice physician is a thing of the past. Primary care physicians increasingly are aligning themselves with larger players such as multispecialty groups, hospitals, health plans, or practice management companies. This article draws on the authors' research into 20 healthcare systems in various stages of development as well as their own consulting experience to answer several questions: Why is the establishment or purchase of primary care physician practices an exploding national trend? What are the pros and cons of this approach? Is it better to purchase existing practices or establish new ones from the ground up? What are the pros and cons of virtual integration (affiliation without purchase) versus other forms of integration?     

The professional role of physician's assistants in adult ambulatory care practices.

This article describes the methodology and findings of a national survey of Physician's Assistants (PAs) in adult, ambulatory care practices. Data on patient care roles and other professional activities were collected for a three-day period via a comprehensive self-reporting, log-diary instrument. Completing the instrument were 356 (50.4%) PAs. Survey results address the following questions: What is the typical work week for PAs? How do PAs allocate their time in a professional day? What direct patient care services do PAs provide? How productive are PAs with respect to number of patients seen and dollar income generated? In general, the data are consistent with the PA role model of a primary health care professional who provides basic health care services with an emphasis on patient counseling and disease prevention.     

Older persons’ experiences and perspectives of receiving social care: a systematic review of the qualitative literature

The topic of social care for older people has gained increasing attention from the part of academics, professionals, policy makers and media. However, we know little about this topic from the perspectives of older persons, which hinders future developments in terms of theory, empirical research, professional practice and social policy. This article presents and discusses a systematic review of relevant qualitative research‐based evidence on the older persons’ experiences and perspectives of receiving social care published between 1990 and September 2014. This review aimed to obtain answers to the following questions: How is the reception of social care experienced by the older persons? What are the negative and positive aspects of these experiences? What are the factors which influence the experiences? The synthesis of the findings of reviewed papers identified six analytical themes: asking for care as a major challenge; ambivalences; (dis)engagement in decisions concerning care; multiple losses as outcomes of receiving social care; multiple strategies to deal with losses originated by the ageing process; and properties of ‘good care’. These themes are discussed from the point of view of their implications for theory, care practice and social policy, and future research.     

Information systems for the outcomes movement

Outcomes research, measurement, and management have become hot topics well beyond the realm of the academic medical research community that first popularized the concept. While the ultimate outcomes information system will be some time in coming, it is nevertheless possible to foresee the day when patients, providers, and payers can finally answer the questions, What are our health care options? What are results of those practices? and how can we do better.     

Why health improves: defining the issues concerning 'comprehensive primary health care' and 'selective primary health care'

What is the impact of technology on improving the life situations of people, especially the poor? How is this impact analyzed in terms of health improvements? These questions are paramount in the minds of health planners as they pursue national policies of primary health care, a policy popularized by the World Health Organization (WHO) and the United Nations Children's Fund (UNICEF) and accepted by over 150 governments at Alma Ata in 1978. The purpose of this paper is to explore these questions in depth. It begins by giving the background to the debate, then examines the origins of two concepts which have dominated the field, those of 'primary health care' and 'selective primary health care.' On this basis it suggests areas of differences in the two concepts and discusses the policy and practical implications of confusing the two approaches. The paper suggests that the differences are firstly who controls the outcome of technological interventions and the perceived time frame in which plans can be carried out.     

Defining and assessing the competence of health care professionals in France

INTRODUCTION: During the past decade, the public, health care professionals, and governments have shown much interest in ensuring that professionals, specifically physicians, are skilled in their work and competent in managing health care organizations. The need to assess competence in the health care sector was explored, with the aim of proposing a policy for monitoring and assessing competence during active professional life. METHODS: A literature search and semistructured interviews were conducted. The 16 health care professions listed in the French health care code were included. The main questions were: What is your organization's definition of competence? What are the principal elements that define competence in health care activities? How can a system for assessing competence be implemented? Which methods for such a system are most appropriate, based on foreign experiences? Who are the players in the field of competence? And how can organizations participate in monitoring competence? RESULTS: 265 people representing 148 French organizations were interviewed. Competence in health care should be defined as follows: "professional competence is based on the initial diploma, the implementation of effective continuing education, a minimal professional activity and a regular peer review process." There was an agreement on the basic elements of competence, on the responsibilities of public institutions and professional organizations, and on the need to work together. DISCUSSION: We have shown that in France health care professionals would like to have a better system that allows them to exchange more information on the main health care issues; this is a serious requirement for most professionals.     

Evolution and new perspectives of health care financing in developing countries

Over the last twenty five years, the perspective of health care financing has dramatically changed in developing countries. In this context, it is worth reviewing the literature and the experiences in order to understand the major shifts on this topic. During the sixties, health care policies focused on fighting major epidemics. Programs were dedicated to reduce the threat to population health. Financing related to the mobilization of resources for these programs and most of them were not managed within national administrations. The success of these policies was not sustainable. After Alma Ata, primary health care became a priority but it took some years before the management of the health care district was introduced as a major topic. In the eighties, with the district policy and the Bamako Initiative, the economic approach became a major part of all health care policies. At that time, most of health care financing was related to cost recovery strategies. All the attention was then drawn on how it worked: Fee policies, distribution of revenues, efficient use of resources and so on. In the second half of the nineties, cost recovery was relegated to the back scene, health care financing policy then becoming a major front scene matter. Two major reasons may explain this change in perspective: HIV which causes a major burden on the whole health system, and fighting poverty in relation with debts reduction. In most developing countries, with high HIV prevalence, access to care is no longer possible within the framework of the ongoing heath care financing scheme. Health plays a major role in poverty reduction strategies but health care officials must take into account every aspect of public financing. New facts also have to be taken into account: Decentralization/autonomy policies, the growing role of third party payment and the rising number of qualified health care professionals. All these facts, along with a broader emphasis given to the market, introduce a need for a better management of resources through financing mechanisms. Some major reports from WHO and the World Bank are the landmarks of the evolution on how to approach health care financing: The 1993 World Bank report on investing in health, the 2000 WHO report on health in the world and the WHO report on macroeconomics and health. In this early millenium, there is a general agreement on some major aspects of health care financing such as: Lack of resources for financing health care; cost recovery as a part of any sustainable health care system; health as a public good needing some extended subsidies; protecting people from the burden of disease as a part of financing schemes; equity in relation with the public private mix at the center of many debates; financing as a key mechanism for the regulation of the whole health care system and not only as a resource mobilization; HIV in bringing up new problems clearly shows how all these matters are related. Health care financing is at the heart of ongoing questions on health care reforms. Although developing countries have low insurance coverage and weak modern medical care, they share the same questions as developed countries: How to promote technical and allocative efficiency? What place for incentives? What role for the public sector? How can market and contracting bring results? What progress through stewardship and better governance?     

Loosening the Gordian Knot of governance in integrated health care delivery systems

A new organizational species is emerging--the integrated health care delivery system. Aligned with both the anticipated provisions of federal and state health care reform initiatives and emerging purchaser demands, integrated delivery systems could dominate many health care markets by the end of this decade. Integration is both the defining feature and key imperative of such systems. Because of the unique position of boards, governance is potentially the ultimate integrator. Yet little attention had been focused on integrated delivery system governance. Accordingly, this article will address the governance of integrated delivery systems through three questions: (1) What are the distinguishing characteristics of integrated health care delivery systems? (2) What are the distinctive issues and challenges associated with governing integrated delivery systems? and (3) What different forms of governance can be employed by these systems and what factors influence the effectiveness of these forms?     

Challenges facing nurses' associations and unions: a global perspective

Nurses are at the heart of every country's health care system. What sort of problems do they face at work? What are the coping strategies that they and their organizations pursue? Drawing on the findings of a unique global survey of nurses' associations and unions, the authors provide clear answers to these and related questions at a time when population ageing, epidemics, privatization and understaffing are putting heightened pressures on health care systems around the world. Interestingly, the priority concerns of nurses' organizations the world over have much in common despite the widely differing national contexts in which they operate.     

Ethics in health care marketing: the Twin Cities perspective

Do hospital-based marketers have a common perspective on what practices are ethical for the promotion of health services to consumers? Do they find adequate guidance in making ethical decisions on marketing practices from the mission statements of their institutions? The author sought answers to these questions through a survey of marketers and other health care professionals in the highly competitive Twin Cities health care environment.     

Does general practitioner involvement in commissioning maternity care make a difference?

OBJECTIVES: To evaluate the impact of general practitioners' commissioning of maternity services on women's experiences of care and on resource use, and to consider the implications for primary care commissioning. METHOD: Comparison of women's experiences and resource use between 11 commissioning and 10 non-commissioning general practices. Face-to-face interviews with 212 staff in general practices, National Health Service trusts and health authorities between 1996 and 1998 to establish how maternity care was organised. Women's experience of information, choice, control and resource use obtained by questionnaire mailed 4 weeks post-partum. Data were analysed using multi-level modelling to adjust for case-mix differences. RESULTS: After two reminders, 1957 women (62%) responded to the questionnaire (inter-practice range 52-81%). There were no significant differences in women's experience of care or their resource use between commissioning and non-commissioning practices. Commissioning practices were more likely to be associated with more vertically integrated models of service organisation, but responses to only three of 21 questions about experience of information, choice and control over care, or about resource use, differed between the four models of service organisation identified. CONCLUSIONS: The expectation that giving primary care organisations responsibility for commissioning care will result in improved patients' experiences of care or better use of resources should be treated with caution. The presence of strong national policy may be equally important. Models of service organisation are not proxies for quality of care. The most powerful force shaping patients' experiences of care may be health care professionals' ability to translate national policy into local services.     

Teaching (and learning) family medicine internationally: a cultural survival guide

Around the world, family medicine is emerging as an importantmodel for the delivery of primary health care services. Clinician-educatorsfrom countries with successful family medicine programmes willbe looked to for leadership in the international developmentof the specialty. Family medicine educators who are asked toteach internationally will face numerous challenges as theywork to adapt their knowledge and expertise to fit local needs.These challenges can become either insurmountable obstaclesor enriching experiences. The purpose of this article is tohelp guide educators as they explore, enter into, and returnfrom teaching family medicine abroad. It offers practical suggestionsin response to three questions important in the course of workabroad: What are one's expectations for working abroad? Whatwill one's attitude be toward daily work overseas? What willone have learned upon returning home? The suggestions can beused to enhance personal and professional development, promotecommon pathways in the development of family medicine as a specialty,and encourage bilateral exchange of knowledge and experiencesamong family physicians worldwide.     

Malpractice coverage for health professionals with physical, mental, or substance-abuse impairments. How do insurance companies make their decisions?

How do insurance companies decide whether or not to provide malpractice insurance to health professionals? What information do they gather on applicants and renewing policyholders? Who has the responsibility to determine if health professionals are suffering from physical, mental, or substance-abuse impairments that make them unfit to care for patients? The authors conducted a survey to find the answers to these questions.     

Cultural Variation in Lesbian Bereavement Experiences in Ohio

When a lesbian woman dies, her survivors may not be recognized by health care providers who have limited knowledge of lesbian culture. The objective of this research was to learn about the experiences of lesbian survivors in the context of lesbian culture in Ohio. The three research questions were as follows: (1) Who are the bereaved lesbian survivors when a lesbian woman dies? (2) What are the experiences of these survivors? and (3) What aspects of lesbian culture are evident in the bereavement experiences of these survivors? An emergent ethnographic design was used to learn more about the cultural experiences of bereaved lesbian survivors in the state of Ohio. The design included participant observation, field notes, key informants, artifacts, audiotaped in-person and telephone interviews, demographic data, and kinship network diagrams. Seventeen self-identified survivors were located by networking and advertising in Ohio, and interviewed first in person and then for follow-up by telephone. Cultural data were analyzed using field note coding and data summary charts for themes which emerged from the literature and the experiences of survivors. This article discusses cultural variations on lesbian bereavement experiences in Ohio, using the imagery of four villages: The Big Village, the Womyn's Land, the Rainbow Village, and the Carnival Village.     

Women's Lives After an HIV-Positive Diagnosis: Disclosure and Violence

Objectives: This research addresses four questions: (1) What role do health care providers play in women's disclosure to others of their HIV-positive status? (2) What are women's concerns and experiences with disclosure? (3) What violence do women living with HIV experience? (4) How is the violence related to their diagnosis and disclosures? Methods: Participants were 310 HIV-positive women enrolled in an HIV primary care clinic in an urban teaching hospital. Women were interviewed once using both quantitative and qualitative methods. Results: Women had known they were HIV-positive for an average of 5.8 years; 22% had an HIV-positive partner; 58% had disclosed their status to more than 10 people; and 68% had experienced physical abuse and 32% sexual abuse as an adult. Fifty-seven percent of the sample reported that a health care provider had told them to disclose to their sex partners. Women who were afraid of disclosure-related violence (29%) were significantly more likely than those who were not to report that a health care provider helped them with disclosure (21% vs. 10%). Although 4% reported physical abuse following a disclosure event, 45% reported experiencing emotional, physical, or sexual abuse at some time after their diagnosis. Risk factors for experiencing abuse after diagnosis were a prior history of abuse, drug use, less income, younger age, length of time since diagnosis, and having a partner whose HIV status was negative or unknown. Conclusions: Identifying women at risk for abuse after an HIV-positive diagnosis is important for those who provide HIV testing and care. Routine screening for interpersonal violence should be incorporated into HIV posttest counseling and continuing primary care services.

     

Issues in notification: Reflections of a public health worker

The objectives of notification are to inform individuals of research results so that they can make informed choices regarding health care and risk reduction behaviors, and to inform workers and employers of results and recommendations in order to take actions to improve workplace health and safety. Many questions confront researchers or public health workers engaged in notification efforts. Who should be notified? What information should be included in notification materials? When should notification occur? How and where should notification take place? What is the socioeconomic context in which notification is occurring? This article presents a public health worker's perspective on these issues. © 1993 Wiley-Liss, Inc.     

Legal aspects of prevention in Norway

Prevention in Norway and in Europe more generally, is a multidisciplinary collaboration between many professions, organized largely in municipalities, villages, and counties. This paper addresses three questions: What relevant legislation on prevention currently exists? What are the perspectives of ongoing activities and their intentions? What are the strategic issues? Since 1984, Norway's primary health care system has been based on the Local Authority Health Care Act. In 1995, the Communicable Disease Control Act replaced the chapter on communicable diseases in the old Public Health Act of 1860. The new act emphasizes communicable disease control as more of a right rather than a duty for both the individual and the population. In Europe, future public health policy, practice, and research will need to focus not only causes of disease and injuries, but also on factors promoting health.     

Editorial – What is health promotion ethics?

What does it mean to think about the ethics of health promotion? When most of us think ‘ethics’ we think of the Human Research Ethics Committee applications required for research projects. But I'm thinking of something quite different here: the ethics of health promotion practice. Health promotion ethics is an attempt to answer questions such as: Can we provide a moral justification for what we are doing in health promotion? or What is the right thing to do in health promotion, and how can we tell? As other authors have argued, sometimes these questions are ignored in health promotion in favour of scientific and technical questions about effectiveness. But there is increasing recognition that health promotion is a moral project, that health promotion can be practised in ways that are more or less ethical, and thus that considering ethics in health promotion is just as important as – and related to – considering the evidence about whether or not health promotion works.     

Future spending for medical care

Why does the U.S. spend more for health care than other countries? What do we get for our additional money? Who pays the bills and bears the costs for health care? The article answers these questions and also provides observations about future trends in U.S. health care and challenges facing this country in the new century.