The Lower Saxony research network design of environments for ageing: towards interdisciplinary research on information and communication technologies in ageing societies

Worldwide, ageing societies are bringing challenges for independent living and healthcare. Health-enabling technologies for pervasive healthcare and sensor-enhanced health information systems offer new opportunities for care. In order to identify, implement and assess such new information and communication technologies (ICT) the 'Lower Saxony Research Network Design of Environments for Ageing' (GAL) has been launched in 2008 as interdisciplinary research project. In this publication, we inform about the goals and structure of GAL, including first outcomes, as well as to discuss the potentials and possible barriers of such highly interdisciplinary research projects in the field of health-enabling technologies for pervasive healthcare. Although GAL's high interdisciplinarity at the beginning slowed down the speed of research progress, we can now work on problems, which can hardly be solved by one or few disciplines alone. Interdisciplinary research projects on ICT in ageing societies are needed and recommended.     

Quality Improvement in Healthcare Delivery Utilizing the Patient-Centered Medical Home Model

Despite the fact that the United States dedicates so much of its resources to healthcare, the current healthcare delivery system still faces significant quality challenges. The lack of effective communication and coordination of care services across the continuum of care poses disadvantages for those requiring long-term management of their chronic conditions. This is why the new transformation in healthcare known as the patient-centered medical home (PCMH) can help restore confidence in our population that the healthcare services they receive is of the utmost quality and will effectively enhance their quality of life. Healthcare using the PCMH model is delivered with the patient at the center of the transformation and by reinvigorating primary care. The PCMH model strives to deliver effective quality care while attempting to reduce costs. In order to relieve some of our healthcare system distresses, organizations can modify their delivery of care to be patient centered. Enhanced coordination of services, better provider access, self-management, and a team-based approach to care represent some of the key principles of the PCMH model. Patients that can most benefit are those that require long-term management of their conditions such as chronic disease and behavioral health patient populations. The PCMH is a feasible option for delivery reform as pilot studies have documented successful outcomes. Controversy about the lack of a medical neighborhood has created concern about the overall sustainability of the medical home. The medical home can stand independently and continuously provide enhanced care services as a movement toward higher quality care while organizations and government policy assess what types of incentives to put into place for the full collaboration and coordination of care in the healthcare system.     

Managing the performance of general practitioners and specialists referral networks: A system for evaluating the heart failure pathway

High quality chronic disease management requires coordinated care across different healthcare settings, involving multidisciplinary teams of professionals, and performance evaluation systems able to measure this care. Inter-organizational performance should be measured considering the professional relationships between general practitioners (GPs) and specialists, who are usually linked through informal referral networks.The aim of this paper is to identify and evaluate the performance of naturally occurring networks of GPs and hospital-based specialists providing care for congestive heart failure (CHF) patients in Tuscany, Italy. The analysis focuses on the identification and classification of networks, following CHF patients (n = 15,841) through primary care and inpatient care using administrative data, and on the assessment of process and outcome indicators for CHF patients in these referral networks.We demonstrate the existence of informal links between GPs and hospitals based on patterns of patient flow. These networks which are not geographically based vary in the intensity of relationships and quality of care. Such referral networks may represent the most effective accountability level for chronic disease management, since they encompass the multiple care settings experienced by patients. Overall, an integrated approach to evaluation and performance management that considers the naturally occurring links between professionals working in different settings may enable more efficient, integrated care and quality improvements.     

Interdisciplinary education and teamwork: a long and winding road

PURPOSE: This article examines literature on interdisciplinary education and teamwork in health care, to discover the major issues and best practices. METHODS: A literature review of mainly North American articles using search terms such as interdisciplinary, interprofessional, multidisciplinary with medical education. MAIN FINDINGS: Two issues are emerging in health care as clinicians face the complexities of current patient care: the need for specialized health professionals, and the need for these professionals to collaborate. Interdisciplinary health care teams with members from many professions answer the call by working together, collaborating and communicating closely to optimize patient care. Education on how to function within a team is essential if the endeavour is to succeed. Two main categories of issues emerged: those related to the medical education system and those related to the content of the education. CONCLUSIONS: Much of the literature pertained to programme evaluations of academic activities, and did not compare interdisciplinary education with traditional methods. Many questions about when to educate, who to educate and how to educate remain unanswered and open to future research.     

Barriers to effective discharge planning: a qualitative study investigating the perspectives of frontline healthcare professionals

ABSTRACT: BACKGROUND: Studies have shown that effective discharge planning is one of the key factors related to the quality of inpatient care and unnecessary hospital readmission. The perception and understanding of hospital discharge by health professionals is important in developing effective discharge planning. The aims of this present study were to explore the perceived quality of current hospital discharge from the perspective of health service providers and to identify barriers to effective discharge planning in Hong Kong. METHODS: Focus groups interviews were conducted with different healthcare professionals who were currently responsible for coordinating the discharge planning process in the public hospitals. The discussion covered three main areas: current practice on hospital discharge, barriers to effective hospital discharge, and suggested structures and process for an effective discharge planning system. RESULTS: Participants highlighted that there was no standardized hospital-wide discharge planning and policy-driven approach in public health sector in Hong Kong. Potential barriers included lack of standardized policy-driven discharge planning program, and lack of communication and coordination among different health service providers and patients in both acute and sub-acute care provisions which were identified as mainly systemic issues. Improving the quality of hospital discharge was suggested, including a multidisciplinary approach with clearly identified roles among healthcare professionals. Enhancement of health professionals' communication skills and knowledge of patient psychosocial needs were also suggested. CONCLUSIONS: A systematic approach to develop the structure and key processes of the discharge planning system is critical in ensuring the quality of care and maximizing organization effectiveness. In this study, important views on barriers experienced in hospital discharge were provided. Suggestions for building a comprehensive, system-wide, and policy-driven discharge planning process with clearly identified staff roles were raised. Communication and coordination across various healthcare parties and provisions were also suggested to be a key focus.     

Interdisciplinary didactic instruction at academic health centers in the United States: attitudes and barriers

Interdisciplinary care is a method of providing patient care through a team approach that incorporates the efforts of various health care providers. Studies show that this approach can improve patient care and decrease overall costs to the healthcare system. Despite the evidence for the benefits of interdisciplinary care, there are no well-defined models for training students during their didactic years to become members of an interdisciplinary team. This study utilized an investigator-developed questionnaire to determine the attitudes of administrators of professional schools in the USA toward interdisciplinary education, identified the perceived barriers to interdisciplinary education, examined the extent to which interdisciplinary education is occurring at academic health center campuses, and identified the courses that might best be taught in an interdisciplinary format. Administrators from medicine, nursing, and pharmacy hold positive attitudes toward interdisciplinary instruction. Respondents from nursing and pharmacy hold more favorable attitudes than their counterparts from medicine. Positive attitudes are seen more frequently among females than males, and among respondents from public single and multi-campuses than from private campuses. This study demonstrated that administrators espouse very positive attitudes toward interdisciplinary education, although they perceive the barriers to interdisciplinary education and the courses most suited for anointer disciplinary approach differently. More discussions among administrators of various disciplines may allow barriers to be overcome and allow development of interdisciplinary didactic courses that could test the hypothesis that these courses are more cost effective and more likely to foster interdisciplinary teamwork in the clinical setting. This revised version was published online in June 2006 with corrections to the Cover Date.     

Community group practices in Canada: are they ready to reform their practice?

INTRODUCTION: Governments and healthcare organizations in Canada are reforming the clinical practice structures and policies to deliver primary care to the population. A key component of primary healthcare reform is the establishment of an interdisciplinary, community-based team approach to patient care. This study was undertaken to provide in-depth insight regarding primary healthcare providers' beliefs and attitudes in regard to their current group practice, what changes they believe are occurring and those necessary to reform group practice settings, their willingness to embrace changes, and the challenges they face to realize the proposed reform. METHODS: This study employed a mixed-method research design (qualitative and quantitative data collection techniques) through day-long focus groups of primary healthcare professionals (eg, family physicians, specialists, dieticians, psychologists) from across Canada. RESULTS: There is considerable variation in the composition of primary care group practices across Canada. Respondents report that group practices are little more than an economic convenience to facilitate sharing of resources. Even when a practice is composed of several disciplines, there is little to no organized or systematic interaction among healthcare professionals aimed at improving patient care, lack of clarity as to identified leaders/managers of the team, and inconsistencies in the model of care provided to patients. However, there is a perception of value and benefit in working in a cohesive group practice to improve patient care. DISCUSSION: Findings revealed that although healthcare providers report themselves ready to make the necessary changes and willing to move to interdisciplinary team-based practices, there are substantive challenges that impede a movement to truly effective interdisciplinary team practice and functioning. These challenges include the type and allocation of funding, interprofessional healthcare provider education, changing the healthcare provision model, and barriers among healthcare professionals regarding shared and equitable team accountability for patient health outcomes.     

What patients want: A content analysis of key qualities that influence patient satisfaction

We sought to identify key qualities of healthcare that influence patient appraisal of satisfaction with primary care. An Internet survey of patients was used to collect anonymous ratings of physicians on several dimensions of healthcare experiences, as well as comments about aspects of care that were excellent and those that could be improved. Qualitative data analysis was used to discern content clusters and relate them to high and low ratings of patient satisfaction. Content analysis revealed that patients perceive and value at least seven domains of healthcare in defining outstanding quality (access, communication, personality and demeanor of provider, quality of medical care processes, care continuity, quality of the healthcare facilities, and office staff. All seven were cited as reasons for rating physicians as excellent, while four domains (communication, care coordination, interpersonal skills, and barriers to access) drove negative ratings. We conclude that patient satisfaction ratings are highly influenced by a core of communication and follow-up care. Physicians who do not possess these traits will not likely attain high ratings, while having these core traits does not necessarily ensure high patient satisfaction.     

Developing end-of-life interdisciplinary programs in universitywide settings

Interdisciplinary programs in end of life are widely discussed as valuable, particularly approaches to end-of-life care. Despite this emphasis, interdisciplinary programs have not been easy to implement. In universities, the implementation of interdisciplinary programs encounters administrative obstacles, including credit for the time spent in these group efforts and "ownership" of interdisciplinary courses (IDCs). This article details the process of development and the activities of an end-of-life interdisciplinary program at one urban university with a major medical center. The issues faced in the first year are examined. These included trust, group identity, and communication. The lessons from the first-year activities are presented and efforts of the second year described.     

Dutch Institute for Healthcare Improvement guideline, "Treatment of breast cancer"

The first Dutch evidence-based guideline for the treatment of breast cancer has been developed to realise the optimal care of breast cancer patients in the Netherlands. This was possible due to the close cooperation of the Dutch Institute for Healthcare Improvement [Dutch acronym: CBO] and the Dutch Consultative Committee on Breast Cancer [Dutch acronym: NABON]. A broad, multidisciplinary working group was appointed to develop the guideline. This group consisted of surgeons, radiotherapists, internists, pathologists, a radiologist, a nuclear medicine specialist, a plastic surgeon and a clinical geneticist, all of whom had been given a mandate to represent their respective professional societies. In addition to these medical specialists, there were physiotherapists, oncology nurses, psychologists, staff from comprehensive cancer centres and the Dutch Institute for Healthcare Improvement and representatives from the Dutch Breast Cancer Association. This CBO guideline is divided into seven chapters: local treatment of operable breast cancer, systemic adjuvant treatment, locoregionally advanced disease, follow-up, locoregional recurrence, metastasised disease, and the psychosocial aspects of breast cancer. Although the guideline is not intended as a set of instructions that must be rigidly adhered to, deviations from the guideline must be motivated, principally on the basis of published scientific information. To obtain insight into the actual use of the guidelines 'Screening and diagnostics' and 'Treatment of breast cancer' the work group advocates a nationwide prospective registration of all breast cancer patients, including follow-up. Steps to this end have been undertaken. In this way, the CBO guideline will contribute to a further optimisation of breast cancer care in the Netherlands.     

Surveying acute care providers in the U.S. to explore the impact of HIT on the role of nurses and interdisciplinary communication in acute care settings

In 2005, the Healthcare Information and Management Systems Society's Nursing Informatics Task Force surveyed acute care providers across the United States to explore the impact of health information technology on the role of nurses and interdisciplinary communication in acute care settings. More than 1,700 healthcare professionals responded to the online survey and provided numerous insights into the impact that clinical information systems have in their daily communication and workflow patterns. This paper provides an overview of survey results from four large healthcare delivery systems with a focus on how the results will be employed to support an evidence-based approach to improving acute care IT systems across the following healthcare delivery systems: Partners and Lifespan Health Systems in the Northeast, Baptist Health South Florida in the Southeast, and Providence HealthSystem in the Northwest.A case study approach is employed to describe survey findings at the healthcare system level and then provide a set of recommendations to leverage findings to capitalize on the strengths of existing IT applications and tools, and work towards overcoming barriers to interdisciplinary communication or acute care workflows.     

Multidisciplinary management of breast cancer

Breast cancer, with an increasing incidence, is the most frequently diagnosed cancer in women worldwide. The treatments proposed, generally a combination of surgery, radiotherapy, chemotherapy, endocrine therapy and/or targeted therapy, are constantly improving, allowing a reduction in the mortality rate, but they are still causing many side effects, not only early but also late, which leads us to consider the post-cancer period as a chronic condition. Side effects, reviewed in this commentary, may affect physical functions, psychological status, social situation, body composition, well-being and quality of life of the patient. In view of the extent of these areas in which side effects of breast cancer and of its treatments can be found, the supportive care offered at the end of treatment need to be multidisciplinary. Different supportive care interventions may be proposed to the patients such as psychological and behavioral interventions, complementary therapies, diet interventions, physical activity/rehabilitation or also physiotherapy interventions for example, all having shown some beneficial effects in the literature. The benefits of these supportive care interventions are thereby already established and they are described in this article, but others studies will be needed to clearly define indications and most optimal modalities of application to reduce side effects and improve quality of life of patients.     

Examining variables related to successful collaboration on the hospice team

Although social work participation on interdisciplinary teams is long-standing, little research has been done to examine its effectiveness. This study used the Index of Interdisciplinary Collaboration to explore relationships between selected variables and teamwork in the hospice setting.The findings indicate that hospice social workers report a high level of interdisciplinary collaboration with colleagues. Whereas education, hospice census, the presence of other social workers, and quality of care were found to be unrelated to overall levels of collaboration, individual items measuring collaboration proved to be linked with hospice census, the presence of other social workers on the team, and quality of care. Further research is required to investigate other possible related variables and their impact on successful interdisciplinary collaboration and service delivery.     

The Breathmobile Program: structure, implementation, and evolution of a large-scale, urban, pediatric asthma disease management program.

Despite more than a decade of education and research-oriented intervention programs, inner city children with asthma continue to engage in episodic "rescue" patterns of healthcare and experience a disproportionate level of morbidity. The aim of this study was to establish and evaluate a sustainable community-wide pediatric asthma disease management program designed to shift inner city children in Los Angeles from acute episodic care to regular preventive care in accordance with national standards. In 1995 the Southern California Chapter of the Asthma and Allergy Foundation of America (AAFA), the Los Angeles County Department of Health Services (LAC DHS), and the Los Angeles Unified School District (LAUSD) established an agreement to initiate and sustain the Breathmobile Program. This program includes automated case identification, mobile school-based clinics, and highly structured clinical encounters supported by an advanced information technology solution. Interdisciplinary teams of asthma care specialists provide regular and ongoing care to children at school and county clinic sites over a wide geographic area of urban Los Angeles. Each team operates in a specially equipped mobile clinic (Breathmobile), efficiently moving a structured healthcare process to school and county clinic sites with large numbers of children. Demographic, clinical, and participation data is tracked carefully in an electronic medical record system. Program operations, clinical oversight, and patient tracking are centralized at a care coordination center. Clinical operations and methods have been replicated in fixed specialty clinic sites at the Los Angeles County + University of Southern California Medical Center. Clinical and process measures are regularly evaluated to assure quality, plan iterative improvement, and support evidence-based care. Four Breathmobiles deliver ongoing care at more than 90 school sites. The program has engaged over five thousand patients and their families in a continuity care model that has demonstrated efficacy over usual episodic care. More than 90% of patients in all asthma severity categories achieved clinical control of asthma with significant reductions in inpatient (IP) and emergency department (ED) use. On February 14, 2002, the program became the first program in the United States to receive the award of disease-specific care certification by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). Proper design and resource allocation can sustain a school-based community-wide pediatric asthma disease management program and shift a population of inner city children from acute episodic care to routine preventive care in accordance with national standards. An evidence-based approach to evaluating and maintaining quality, coupled with stratified care delivery, can assure the efficient use of safety net healthcare resources.     

Interdisciplinary team working in the Irish primary healthcare system: Analysis of ‘invisible’ bottom up innovations using Normalisation Process Theory

Interdisciplinary team working in primary care is a key policy goal across healthcare jurisdictions. The National Primary Care Strategy (2001) in Ireland is a top down policy for primary healthcare reform, which prioritised the development and implementation of interdisciplinary Primary Care Teams. The number of Primary Care Teams and features of their clinical meetings have been the key metric in Ireland for appraising progress with the implementation of the strategy. However, these have been challenging to organise in practice. The aim of this paper is to analyse empirical evidence of other forms of interdisciplinary working in Irish primary care, using Normalisation Process Theory.Drawing on data from an on-line survey (71 GPs and 498 other healthcare professionals), and an interview study (37 participants; 8 GPs, 7 practice managers/admin support and 22 health care professionals) in three of the four Health Service Executive (HSE) regions in Ireland, we analyse the nature of these other forms of interdisciplinary working and describe innovations for service delivery that have been developed ‘from the ground up’ as a result. We examine levers and barriers to the implementation of these bottom up innovations. The levers are that these innovations make sense to professionals, are based on local needs and focus on preventive patient-centred care. They are driven forward by small groups of professionals from different backgrounds with complementary skills. The evaluations show positive impacts of the innovative services for patients, however, many have ceased to operate due to negative effects of the recent economic recession on the Irish healthcare system.These flexible and localised innovations were shaped in part by the reforms set out in the 2001 Primary Care Strategy but also represent unintended effects of that policy because they are the result of bottom up interdisciplinary working that occurs alongside, or instead of, Primary Care Team clinical meetings. Furthermore, as they not captured by existing metrics, the interdisciplinary work and resultant services have been ‘invisible’ to senior management and policy makers. If appropriately acknowledged and supported, they can shape primary care in the future.     

Breast Center--a virtual unit for the multidisciplinary care of breast patients

Breast cancer, the most prevalent female malignancy represents a major health problem. Breast cancer mortality may be halved by high quality mammography screening and care. The most efficient screening and the best treatment of patients are available at the breast centers that are equipped with special facilities, expertise and significant experience via the treatment of a high number of patients. Breast center is a virtual unit based on the collaboration of various professionals; a tight institutional frame is not a must. In these comprehensive centers, 150 breast cancer patients per year at a minimum are treated, and the most efficient special treatment methods are available. The core members of the staff are the breast pathologists, the mammographists, the breast surgeons, the oncologists/oncoradiologists, the breast nurses, the technicians and the data managers. An easy access to the service of the non-core members, the plastic surgeons, the psychologists, the psychiatrists and the clinical geneticists is necessary. An optimal collaboration of the various experts may be achieved by a training of the members, regular multidisciplinary meetings and guidelines developed and accepted by all. The requirements of a breast center have been published by the European Society of Mastology (EUSOMA), and a directory of the accredited European breast centers is maintained. The Breast Unit of the University of Szeged has been found eligible by EUSOMA to be included in the directory of the European breast units. Two mammographists do screening-mammography and clinical examination, 2 pathologists perform cytopathological, histopathological and immunohistochemical examinations. Three surgeons operate on more than 250 breast cancer patients per year, and apply wire or isotope (ROLL) localisation in case of non-palpable lesion. A plastic surgeon is available if necessary. In a half of all cases, sentinel mapping is performed with isotope- and blue dye-labelling. Two radiotherapists apply conformal radiotherapy in 250 cases per year, and 2 oncologists perform modern chemotherapies in 200 cases as a yearly average; 50 new advanced/metastatic cases per year require oncological treatments. Breast nurses, a psycho-oncologist and a mental hygienist nurse assist the team. There is access to lymphedema treatment and physiotherapy. The final goal of the program is to provide all women with high quality mammography screening and care, if necessary.     

Treatment of metastatic breast cancer in women aged 65 years and older

Breast cancer is a disease of aging and the incidence of breast cancer increases dramatically with increasing age. In spite of major advances in prevention, screening and treatment approximately 40,000 Americans still die of metastatic breast cancer every year--the majority being women aged 65 years and older. Metastatic breast cancer remains incurable regardless of age and the goals of treatment are to reduce symptoms when present and to provide the patient with the best quality of life for as long as possible. Cornerstones of treatment to control metastases include endocrine therapy, chemotherapy and radiation therapy. Supportive care that includes psychosocial support and treatment of pain is also a key component of management. This review focuses on the issues related to the care of older women with metastatic breast cancer.     

Breast Cancer Epidemiology,Prevention and Costs of Care

Breast cancer is the most frequently diagnosed cancer in women and the second leading cause of cancer mortality. It is estimated to account for approximately 20% of all cancer expenditures, making the burden of disease relatively high. One of the most important risk factors for developing breast cancer is age; with demographic trends towards an increasing elderly population in the US, this burden is likely to increase. Recent trends in healthcare delivery have increased the emphasis on evaluating costs of providing care as well as the outcomes of that care.This paper reviews breast cancer epidemiology, primary and secondary prevention and costs of breast cancer care by stage of disease at diagnosis and type of service, and discusses implications for the development of disease management programmes. Implementation of disease management programmes, through the creation of a data infrastructure system, establishment of measurable breast health and cancer care outcomes, and programme evaluation may be an important mechanism for managed-care organisations to provide quality and cost-effective breast cancer management.