Assessing structure, process and outcome in palliative day care: a pilot study for a multicentre trial

Palliative day care is an expanding service which remains under-researched. Study designs need to be developed to evaluate the costs and outcomes of the service in ways which are meaningful to patients, clinicians and policy-makers. At the same time, these must be open to the same criteria for rigour and reliability as techniques used elsewhere in health and social service evaluation. To this end, a developmental stage of exploratory research was undertaken at the start of a major multicentre trial of palliative day care to meet two clear aims: to understand more about the structure and processes of palliative day care, and to identify ways in which service outcomes could be evaluated and measured. In-depth observations at five palliative day care centres were undertaken across one health region. This provided a better understanding of the models, outcomes and processes of palliative day care in five different environments. Centres represented the spectrum of medical and social care models and findings were analysed using an organisational systems approach. The findings showed that, despite the lack of a national strategic approach to developing the service, the centres all provided a core set of services which were broadly similar. However, differences in philosophy, ownership, and organisation affected how the services were provided and may have an impact on the costs of the service. The study has provided a more in-depth understanding of palliative day care services in order to design an effective research strategy for evaluating a service which crosses the boundaries of health and social care.     

A manual for community mental health activities for a public health center in Japan]

A system for treatment of persons with chronic mental disease such as schizophrenics in the present structure of the Japanese public Health Center is proposed. Presently, while cases are handled by responsible staff members, incorporation into the health center system with full utilization of its personnel and resources is seldom accomplished. There is a necessity for a systems approach in order to organize essential programs that would provide care for the mentally diseased. Health centers would have three main roles in this system: as a coordinator of mental health resources in the community, as a specialized agency for case management, and responsibility for public relations in its service area. For proper administration of its system, health centers should follow a team concept. The team would consist of a director of health centers, physicians, part-time psychiatrists, public health nurses, psychiatric social workers and clerical staff. At case conferences discussion of whether a prospective case should be registered, assessment of the needs, and development of management plans for all of the registered cases would be conducted. The files and documents of each case would be deleted or re-registered 5 years after initial registration. Cases would have a case-manager to coordinate public health care, including home visits, family care, psycho-educational consultation and crisis intervention. Health centers would be responsible for bringing together available social resources such as sheltered workshops and transient residential programs. The goal of health centers' mental health activities would be to facilitate the normalization of the mentally diseased within the community.     

Understanding complex care for older adults within Canadian home care: a systematic literature review

In the context of an aging population, both the need for home care services and its complexity of care have increased in many high-income countries. Yet, the definition of what constitutes complex care is largely elusive. This systematic review examined the conceptual definition of complex care within the home care environment using several social and health science databases for research published from 2000 to 2017. Of the 25 articles and reports identified, only 16 addressed complex care specifically and included older adults, aging, and/or home care. The results showed that complex care for older adults is primarily defined from a biomedical approach focusing on chronic disease and management and less commonly from the perspective of the social determinants of health. Future studies should consider the importance of the continuum of care needs from both the biomedical and the social determinants to adequately plan and provide care for older adults.     

Integrated dementia care in The Netherlands: a multiple case study of case management programmes

The number of dementia patients is growing, and they require a variety of services, making integrated care essential for the ability to continue living in the community. Many healthcare systems in developed countries are exploring new approaches for delivering health and social care. The purpose of this study was to describe and analyse a new approach in extensive case management programmes concerned with long‐term dementia care in The Netherlands. The focus is on the characteristics, and success and failure factors of these programmes. A multiple case study was conducted in eight regional dementia care provider networks in The Netherlands. Based on a literature study, a questionnaire was developed for the responsible managers and case managers of the eight case management programmes. During 16 semistructured face‐to‐face interviews with both respondent groups, a deeper insight into the dementia care programmes was provided. Project documentation for all the cases was studied. The eight programmes were developed independently to improve the quality and continuity of long‐term dementia care. The programmes show overlap in terms of their vision, tasks of case managers, case management process and the participating partners in the local dementia care networks. Differences concern the targeted dementia patient groups as well as the background of the case managers and their position in the local dementia care provider network. Factors for success concern the expert knowledge of case managers, investment in a strong provider network and coherent conditions for effective inter‐organizational cooperation to deliver integrated care. When explored, caregiver and patient satisfaction was high. Further research into the effects on client outcomes, service use and costs is recommended in order to further analyse the impact of this approach in long‐term care. To facilitate implementation, with a focus on joint responsibilities of the involved care providers, policy recommendations are to develop incentives for collaborative financial contracts between insurers and providers.     

Involving communities in health service planning in primary care

Recent health service policy in the United Kingdom has emphasized the need to involve local people in health service planning. This paper will describe how local communities were involved in the development of Primary Care Resource Centres. These centres are designed to provide a base for the delivery of a range of health, social welfare and information services within a community setting. Four centres in the process of being developed in one region were selected for in-depth study. The main method of data collection consisted of semi-structured interviews with key “stakeholders”, namely purchasers and providers of primary health care, social care providers, hospital outreach staff and local community and voluntary group workers (Weiss 1983). This paper examines how the health service organizations developing the centres involved local communities in planning them and the obstacles and difficulties encountered. The paper suggests lessons that can be learned for future community involvement in the planning of local health services.     

Professional autonomy and managed care in Dutch health centres: stakeholders' perceptions of a strategic option

The on-going reforms of the Dutch health care systems call for the introduction of managed care elements. Health centres in the Netherlands already bear some resemblance to health maintenance organizations in the USA. However, managed care challenges provider autonomy, and the strategic development of managed care plans may be hampered by providers' perceptions. We draw a distinction between managed care within an insurance arrangement and managed care as a package of methods. Both options are evaluated as suitable for Dutch health centres, though with differences in terms of strategic logic and cultural fit. Lastly, some general conditions are formulated that should be considered before care management processes can be implemented. These include: specify clear objectives for introduction of managed care; strengthen corporate culture; develop internal motivation for change; develop a practice criterion with health centre professionals; reduce workloads in order to provide development time; and, promote better cooperation between general practitioners and specialists.     

Interorganisational cooperation and its effects on community rehabilitation for people with severe mental disorders in Beijing,China: A case study

A national comprehensive management pilot project for mental health has been implemented in China to provide integrated care for people with severe mental disorders through strengthened cooperation among government organisations and between government and other relevant social organisations. The promotion of community rehabilitation has been included as a key part of this pilot program. The present study took the AD district of Beijing as a case study to examine interorganisational cooperation and its effects on community rehabilitation in a real-world setting. Interviews were conducted with 14 frontline workers, including 7 mental health workers from community health centres and 3 staff and 4 social workers working in rehabilitation centres. Five officials from relevant health and social welfare departments and a social work organisation were also interviewed. Experiences in Beijing revealed that interorganisational cooperation helped to build a multiagency workforce furnished with basic mental health knowledge at the community level, which rendered it possible for frontline workers to provide fundamental follow-up services, pilot the case management model of service provision and increase the provision of psychosocial rehabilitation services within the poorly resourced context of Chinese mental healthcare. Moreover, the engagement of social organisations provided bottom-up pressure to innovate through the active bringing forward of new ideas concerning cooperation and service delivery. However, differences in professional authority and commitment were observed. Health department officials and health professionals seemed to exercise a dominant role as compared to social welfare department officials and social workers. Future policy making should motivate social welfare department officials to improve social care for people with severe mental disorders. Social workers require training to improve their knowledge of mental health matters, and social organisations need greater latitude to strengthen their influence over the development of community rehabilitation services for people with severe mental disorders.     

Understanding complex trajectories in health and social care provision

Abstract Ensuring collaboration between health and social care providers is a well-established policy concern in most developed countries. Thus far, however, this has proved to be a frustratingly elusive goal. Despite the growing body of empirical work devoted to this issue, social scientific theorising on the management of complex caring trajectories remains under-developed. This paper is an attempt to begin to address this gap in the literature. Drawing on Strauss et al.'s (1985) writings on illness trajectories and Elias's (1978) game model, we offer a framework - centred on the notion of a caring trajectory game - that can assist understanding of the linkages between individual trajectories of care and broader health and social care systems. It is only when we have developed a more theoretically sophisticated understanding of this relationship that we can begin to explain why trajectories of care take the course that they do. The framework arises from our analysis of eight ethnographic case studies of adults undergoing rehabilitation from a first acute stroke. In this paper we illustrate its utility by reference to one specific case: Edward.     

Creating clinical and economic "wins" through integrated case management: lessons for physicians and health system administrators

OBJECTIVE: This article describes an innovative integrated approach to case management using a standardized complexity assessment grid and communication tool, which is designed to identify barriers to improvement in 4 domains: biological, psychological, social, and health system; to create and implement holistic care plans based on "anchored barriers; and to document ongoing targeted outcomes. PRACTICE SETTINGS: Adult and pediatric case and disease managers working for hospitals or clinics, health care delivery systems, general medical health plans, care management vendors, government agencies, and employers can effectively employ integrated case management procedures. INTEGRATED CASE MANAGEMENT: Integrated case management augments traditional care coordination by allowing trained medical or mental health managers to assist with cross-disciplinary barriers without handoffs; to connect multidomain barriers to mutually agreed-upon care plan goals and activities; and to measure clinical, functional, fiscal, quality of life, and satisfaction outcomes as a part of the management process, especially in high-cost, complex patients. IMPLICATIONS FOR CASE MANAGEMENT PRACTICE: Integrated case management provides a step-by-step interdisciplinary approach for helping complex patients that has the potential to maximize clinical and functional value, while reducing total health-related costs.     

Assessing the efficiency of rural health centres in Burkina Faso: an application of Data Envelopment Analysis

Background  Effective health care provision benefits from the support of measurement techniques. Contrary to the situation in industrialised countries efficiency analyses in the health care sector in Africa are a very recent phenomenon. Hardly any of the existing studies was conducted at the level of primary care. Aim  The purpose of this study was twofold: (1) to evaluate the relative efficiency of health centres in rural Burkina Faso and (2) to investigate reasons for inefficient performance. Methods  Data Envelopment Analysis (DEA) was applied. To account for the situation in that country, the output-oriented approach was used in connection with different returns to scale assumptions. To identify the spatial effect of the catchment area on efficiency the Tobit model was applied. Results  According to constant returns to scale, 14 health centres were relatively efficient. The DEA projections suggest that the inefficient units were too big to be efficient. Tobit regression showed that the relatively efficient health centres are located close to villages in their catchment area. Conclusions  For ethical reasons it is not appropriate to try to improve the efficiency of health centres by closing some of them. Their efficiency can be improved and lives can be saved if access to health centres is enhanced. Funding: This study was supported by a research grant of the German Research Foundation (Deutsche Forschungsgemeinschaft).     

Participation and Citizenship of Elderly Persons

Abstract

In the article the participation of the aged users and their relatives in a local health care and social service system will be discussed. How is their citizenship defined at the grass roots level? The research data were gathered during a case management project of the action research type in a Finnish rural municipality. The data of this study consist of 13 theme interviews: five elderly persons as care receivers and eight caregivers. The research approach is a dialogue between data based analysis and conceptual reasoning.

Citizenship rights and obligations and participation should be defined flexibly and individually in the context of the local health care and social services. In the research data the elderly persons and their caregivers described participation in multiple ways. The modes of participation vary from passive and active disengagement from the process to contacting, negotiating, cooperating, and demanding     

Designing residential aged care for people at risk of,or experiencing,homelessness: An exploratory Australian study

The number of older people experiencing or at risk of homelessness, both long‐term and first‐time homelessness, is increasing. The proportion of women facing homelessness within that cohort is also increasing. When combined with complex health needs, appropriate long‐term care options remain limited. This qualitative study conducted in Sydney, Australia, aimed to explore the care needs of older people with comorbid health issues who are facing homelessness and, from this assessment, derive a preferred model of residential aged care. Interviews and focus groups were conducted with 29 participants from providers in the aged care and homelessness sectors. Data were analysed using a grounded theory approach. Causal and contextual factors, and consequences surrounding the experience of homelessness, informed the wide range of care needs of this group (model of care), and the organisational resources required to deliver them (management issues and staff). A trauma‐informed approach to care consistently applied by all staff to all processes throughout the care home was recommended. Such an approach would further strengthen existing models of care and take into account both health needs (such as mental health, substance dependence and acquired brain injury) and significant losses through the life course of this vulnerable population.     

Barriers and enablers to health service access amongst people with diabetes: An exploration of the perceptions of health care staff in regional Australia

Healthcare staff are in a unique position of understanding client experiences, physiological impacts of client behaviour, the local healthcare system and the physical environment in which the services operate. Their perspectives may provide insights into the feasibility and effectiveness of existing models of diabetes care and suggestions for improvements to models of care (MoC). The objective of this qualitative study was to explore the experiences of healthcare staff delivering care for people with diabetes at the request of an existing healthcare service. Semi-structured interviews were conducted with 21 healthcare staff from three community health centres in one region of Victoria, Australia, in 2018. Interviews were audio-recorded and transcribed verbatim. Data were subject to qualitative content analysis and, subsequently, emerging themes were classified at individual, relationship, community and societal levels of the social–ecological model (SEM). Perceived barriers of access to health services using the current MoC included a lack of public transport, low socioeconomic status, job insecurity (resulting in an inability to take time away from work) and inflexible appointment times, all of which negatively impact diabetes management. Perceived enablers included having a co-located, multidisciplinary team, a holistic approach to diabetes management and motivation resulting from improvement in diabetes-related health outcomes. The findings indicate that there is potential to improve the service in this region by adopting a more integrated, team-focused and accessible MoC.     

Reconceptualizing case management in theory and practice: a frontline perspective.

'Case management' in the health and social service sector is controversial, highly political and saturated with conflicting agendas among stakeholders. Research was conducted recently to explore the role of case managers in three evolving, Australian-based, long-term care, case management models. The findings have relevance to countries worldwide that contend with delivering quality care that is cost effective. The research captures the perspectives of 51 open-ended interviews with front-line case managers who have first-hand knowledge of the models' effect on their clients and on their own roles. Contrary to the rhetoric that case management is client-centred, case management is concluded to be 'system centred' based on a unilateral approach taken by each of the three models. Case managers had a limited ability to attain necessary services for clients. Success was dependent on the range of case managers' skills and experience, relationship with the client, degree of job satisfaction, level of influence in the health and social system and ability to collaborate with relevant professionals. The relationship between the three primary influences (system, model, client) affecting case managers' pursuit of achieving appropriate client services was also reviewed. A reconceptualized multidimensional approach, or 'neo-process-centred' case management, is proposed. The revised approach can be applied to existing and new models and has direct implications for policy makers, management and practitioners aspiring to improve client care within existing constraints.     

A Social Work Practice Reflection on Issues Arising for LGBTI Older People Interfacing With Health and Residential Care: Rights,Decision Making and End-of-Life Care

This article is a social work practice reflection on issues arising for lesbian, gay, bisexual, transgender, and intersex (LGBTI) older people interfacing with health and residential care in Australia; focusing on clients, families, and carers in relation to rights, decision making, and end-of-life care. The article explores relevant case examples from social work practice in a health and residential care setting that highlight some specific complexities of working with this client group. This article brings greater attention to issues arising for older LBGTI when interfacing with health and residential care and has the potential to improve practice for social workers and other health professionals and improve outcomes for LGBTI older people.     

From rhetoric to reality: including patient voices in supportive cancer care planning

OBJECTIVE: To explore the extent and manner of patient participation in the planning of regional supportive care networks throughout the province of Ontario. We consider the disconnect between the rhetoric and reality of patient involvement in network planning and co-ordination. CONTEXT: In 1997, the Province of Ontario, Canada, established a new, regionalized cancer care system. By transferring responsibility to the regional level and to networks, the architects of the new provincial system hoped to broaden participation in decision making and to enhance the responsiveness of decisions to communities. RESEARCH APPROACH: Through a qualitative, multiple case study approach we evaluated the processes of involving patients in network development. In-depth, semi-structured interviews and document analysis were complemented by observations of provincial meetings, regional council and network meetings. RESULTS: The network development processes in the three case study regions reveal a significant gap between intentions to involve patients in health planning and their actual involvement. This gap can be explained by: (i) a lack of clear direction regarding networks and patient participation in these networks; (ii) the dominance of regional cancer centres in network planning activities; and, (iii) the emergence of competing provincial priorities. DISCUSSION: These three trends expose the complexity of the notion of public participation and how it is embedded in social and political contexts. The failed attempt at involving patients in health planning efforts is the result of benign neglect of public participation intents and the social and political contexts in which public and patient participation is meant to occur.     

Accountable Communities for Health: Moving From Providing Accountable Care to Creating Health

Lessons from community-oriented primary care in the United States can offer insights into how we could improve population health by integrating the public health, social service, and health care sectors to form accountable communities for health (ACHs). Unlike traditional accountable care organizations (ACOs) that address population health from a health care perspective, ACHs address health from a community perspective and consider the total investment in health across all sectors. The approach embeds the ACO in a community context where multiple stakeholders come together to share responsibility for tackling multiple determinants of health. ACOs using the ACH model provide a roadmap for embedding health care in communities in a way that uniquely addresses local social determinants of health.     

Case management in health care

Case management in health care currently is increasing as a result of intentions to lower or control health care costs and to facilitate client access to services. The author examines case management, identifies the issues that it raises for social workers, and discusses case management trends. Several strategic actions that social workers can take in response to this expanding form of health care delivery also are proposed.     

Dementia, disability and contact with formal services: a comparison of dementia sufferers and non-sufferers in rural and urban settings

This paper is based on data from studies conducted in the City of Liverpool and in a rural area of North Wales, relating to people aged 75 years and over living in the community. It compares those identified in these studies as suffering from cognitive brain disorders with other older people identified as being cognitively unimpaired and looks at levels of competence with activities of daily living and the subsequent levels of contact with a range of health and social services personnel and other community workers. It shows that although levels of contact with formal services are generally higher for people with dementia than for non-sufferers, most of these differences are below the level of statistical significance. It was found that levels of contact for people receiving most services are low, especially for specialist mental health services and social work. The implications for community care are discussed, it is suggested that expansion of domiciliary care services for people with dementia and for their carers would demand more resources than are currently being made available but that it would be better value for money on a case by case basis.