Social work management in emerging health care systems

An overview of the health care industry's trend toward multihealth systems is presented and specific adaptive strategies for social work managers in health care are suggested. The challenges to social work leaders during this transition from largely free-standing, privately owned health care institutions to corporately owned, horizontally and vertically integrated delivery systems are discussed in terms of identity, style, and substance. Directors of social work departments in multihealth corporations will need to resolve issues of institutional versus corporate identity as well as those of corporate versus professional identity. A multioptional management style that incorporates networking and political expertise should be cultivated. Substantive demands in the areas of management information systems, productivity, quality assurance, and budgeting also must be addressed. The emergence of multihealth systems poses major challenges and unique opportunities to the social work profession. Awareness of managerial strategies and critical content areas can help social work leaders enhance the role and contribution of social work in these exciting and complex health care delivery systems.     

Measuring key integration outcomes: a case study of a large urban health center

BACKGROUND: Health care reform, through innovative health delivery systems, has been a high priority to address staff shortages, increasingly complex care needs of the aging population, and fragmentation of care. Community health centers have been promoted as one service delivery model with large potential for integration and collaboration. The South Calgary Health Centre (SCHC) opened in June 2004 with the mandate to provide a new model for accessible, accountable, integrated, and community-based health services. PURPOSE: The primary objective was to determine the performance of the SCHC; and further, to establish the value of the evaluation framework used in measuring organizational performance of an integrated service delivery model. METHODOLOGY: Multiple stakeholders were involved in the evaluation in a utilization-focused, participatory way. A comprehensive evaluation framework was developed and implemented to assess the performance of the SCHC at system, provider, and patient levels. Functional, clinical, and community integration were key systems outcomes within this framework. Case-study methodology with mixed methods drawing on multiple data sources (both qualitative and quantitative) was used. FINDINGS: The evaluation findings suggest that the center is functioning well and that staff and client satisfaction are high. Although the model has not achieved all that was originally intended (i.e., fully realized clinical integration), participants felt that the model has been successful and has great potential for integration. The comprehensive evaluation framework developed for this project proved useful in assessing different aspects of integration as well as provider and client perceptions of the center's performance. PRACTICE IMPLICATIONS: Evaluation findings and recommendations have been used to inform operations at the SCHC and for the planning of future health centers. The evaluation framework may help to standardize evaluation approaches across projects and can be used for monitoring progress of the SCHC as well as future evaluations of integrated service delivery models.     

Competencies for health management practice: a practitioner's perspective

The current health care environment will require executive leadership with a new set of management competencies to effectively lead and manage the various components of a restructured health care delivery system. The traditional management skills of planning, organizing, directing, controlling, and staffing resources will remain relevant, but the true measure of professional success will be the development of conceptual skills. This means the ability to look at the health care enterprise as a whole, and recognize how changes in the environment shape your strategic mission, goals, and objectives. The successful health care leader will have a demonstrated ability to apply these conceptual skills to the development of information systems and integrated networks that position their organization to accept capitated risks. This paper examines the United States and Canadian health care systems from the perspective of both the more traditional hospital and the emerging medical care organizations. New importance of the team approach to leadership and management and all that entails is stressed.     

Examining the scope of multibusiness health care firms: implications for strategy and financial performance

OBJECTIVE: Use theory and data to examine the scope of corporate strategies for multibusiness health care firms, also known as organized or integrated health care delivery systems. DATA SOURCES: Data are from the 2000 HIMSS Analytics Annual Survey of integrated health care delivery systems (IHDS), which provides complete information on businesses owned by IHDS. STUDY DESIGN: Scope defined as the breadth and type of businesses in which a firm chooses to compete is measured across seven separate business areas: (1) health plans, (2) ambulatory, (3) acute, (4) subacute, (5) home health, (6) other related nonpatient care businesses, and (7) external collaborations. Theories on strategy and organizational configurations along with measures of scope and a novel dataset were used to classify 796 firms into five mutually exclusive groups. The bases for classification were two competitive dimensions of scope: (1) breadth of businesses and (2) mix of existing core businesses versus new noncore businesses. Data Extraction METHODS: Unit of analysis is the multibusiness health care firm. Sample consists of 796 firms, defined as nonprofit organizations that own two or more direct patient care businesses in two or more separate areas across the health care value chain. Firms were clustered into five mutually exclusive organizational configurations with unique scope characteristics revealing a new taxonomy of corporate strategies. PRINCIPAL FINDINGS: Analysis of the scope variables revealed five strategic types (along with the number of firms and distinguishing features of each strategy) defined as follows: (1) Core Service Provider (340 firms with the smallest scope providing core set of patient care services), (2) Mission Based (52 firms with the next smallest scope offering core set of services to underserved populations), (3) Contractor (266 firms with medium scope and contracting with physician groups), (4) Health Plan Focus (83 firms with large scope and providing health plans), and (5) Entrepreneur (55 firms with the largest scope offering both a core set of services and investing in a variety of new noncore business opportunities including many for-profit ventures). Significant differences in financial performance among the strategies were found when controlling for payer reimbursement conditions. Specifically, in an unfavorable condition with high Medicaid and low commercial insurance, the Mission Based strategy performs significantly worse while the Entrepreneur strategy performs surprisingly well, in comparison with the other strategies. CONCLUSIONS: Findings suggest: (a) scope can be used to classify a large number of multibusiness health care firms into a taxonomy representing a small group of distinct corporate strategies, which are recognizable by senior management in the health care industry, (b) no single strategy dominates in performance across different payer profiles, instead there appears to be complementarities or fit between strategy and payer profiles that determines which firms perform well and which do not under different conditions, and (c) senior management of nonprofit health care firms are cross-subsidizing unprofitable patient care through ownership of nonpatient care businesses including for-profit ventures.     

Point-of-care systems, informatics, and health care delivery

Evolving information technology has had profound effects on business operations and the marketplace. The health care services industry, particularly hospitals, clinics, and medical offices, has historically lagged behind other industries in the implementation of comprehensive, integrated, computerized data management tools. Health care reformers are looking to the promises of the information technology "revolution" as a means of improving systemic efficiency and health care quality. This study discusses the impact of informatics, or information technology, on the delivery of health care services. We present the evolution of informatics and the predicted future benefits of integrated computerized patient records and point-of-care systems.     

Improving adolescent pregnancy outcomes and maternal health:a case study of comprehensive case managed services

Our findings indicate how health outcomes regarding adolescent pregnancy and maternal and infant health care are intertwined with a case management process that fosters measures that are social in nature-the provision of direct services, as well as the encouragement of informal social supports systems. They also show how case managed services in a small, nongovernmental organization (NGO) with a strong commitment to its clients may provide the spontaneity and caring which results in a "match" between client needs and the delivery of services-and positive outcomes for pregnant women, early maternal health and infant health. The delivery of such case managed services in a manner which is intensive, comprehensive, flexible and integrated contributes significantly to such improved health outcomes.     

In ten california counties, notable progress in system integration within the safety net, although challenges remain

When fully implemented, the Affordable Care Act will expand insurance coverage to the currently uninsured, and experiments in delivery and payment under the law's auspices could produce greater efficiencies in how care is delivered. Both factors may accelerate the development of one viable model to streamline care, integrated delivery systems-coordinated care networks that deliver all needed health services to a defined population. Through interviews and surveys, we examined ten California counties that participated in two federally and locally funded initiatives to redesign how care is delivered to predominantly poor and uninsured populations. We found substantial progress in assessing and managing access to specialists, monitoring and promoting quality, and offering disease management and care coordination training in a majority of counties. However, efforts to coordinate care, electronically disseminate patient information, and align financial incentives were less successful or more difficult to assess. We posit that integrated delivery systems could improve care efficiency and quality and make countywide safety-net systems a desirable source of care for newly insured patients under health reform.     

Development of integrated care in England and the Netherlands: managing across public-private boundaries

This paper addresses the impact of the public-private mix in the Dutch and English health and social care systems on the development and delivery of integrated care. Integrated care is conceived of as an organisational process of coordination which seeks to achieve seamless and continuous care, tailored to the patients' needs and based on a holistic view of the patient. We describe both systems' structures and characteristics from a historical perspective, which means that developments and processes within the systems are put in the spotlight. We demonstrate that the dividing- or fault-lines, such as the financial split between short-term and long-term care in the Netherlands and the divisions between health and social care as well as between the public, private and voluntary sectors in England have hindered integrated care development and delivery in both countries. Contradictory interests, differences in professional and organisational cultures, power relations, and mistrust between and within these sectors have had a clear impact on integrated care development and delivery within networks of public authorities and public and/or private providers. We explain these phenomena in terms of network theory as a basis for drawing lessons for policy makers and those developing integrated care networks.     

Developing effective policy and practice for health promotion in Scotland

Scotland has recently embarked on a new phase of policy and infrastructure development for improving population health and reducing health inequalities that broadly conforms to the Ottawa Charter and WHO's strategic framework for the prevention and control of non-communicable diseases. The new phase is characterised by an integrated, cross-government approach to improving health with strengthened political and Scottish Executive leadership and investment since devolution. A comprehensive policy framework for improving young people's health and reducing inequalities has been developed across education, health, environment and social justice. It builds on an earlier phase of relative stability and continuity in the health promotion infrastructure with policy focused on CVD and cancer prevention and tackling the behavioural risk factors (smoking, alcohol, diet, physical activity) as well as sexual health and mental health and wellbeing. These national strategies are currently being implemented across Scotland. They combine promotion, prevention, treatment and protection goals and target both population-level and high-risk groups. Crosscutting government objectives and headline targets for addressing poverty, disadvantage and health inequalities now supplement the NHS health improvement targets on smoking, alcohol, physical activity, teenage pregnancy and child immunization. Within the health service, prevention efforts are largely concerned with primary care development (anticipatory care) and health system reform to maximize their impact on reducing health inequalities. Efforts to tackle the social determinants of health and reduce inequalities in health outcomes are beginning to be connected and mainstreamed across local government with Community Planning Partnerships as the main vehicle. National level mechanisms for integrated funding, planning and performance reporting to deliver shared priority outcomes have yet to be developed. The development of health improvement strategies has been founded upon a rich source of population health data to monitor changes and improvements, epidemiological studies and evaluation work. The key issues have been to find ways of intervening to accelerate the rate of improvement and to stem the growing health inequalities. A further challenge is to ensure that the lessons from reviews and evaluations of past programmes and strategies are not lost, but help to guide improvements in the complex delivery system and to inform future policy direction. Within the health service, prevention efforts are largely concerned with primary care development and health system reform. Efforts to reduce inequalities in health outcomes are beginning to be connected and mainstreamed across local government.     

System-Based Participatory Research in Health Care: An Approach for Sustainable Translational Research and Quality Improvement

Translational research seeks to improve health care by promoting action and change in real-world health care settings. Although translational research advocates a break from the traditional researcher-initiated approach to science, strategies to successfully engage clinicians and leaders of health care delivery organizations in research are still under development. We propose that applying the principles of community-based participatory research in a way that considers delivery systems—including their leaders, clinicians, and staff—as a focal community can enhance the ability of translational research to improve health care. Applying participatory research methods, such as engaging in collaborative partnerships, building on existing community strengths, investing in long-term relationships, and engaging in research as a cyclical, iterative process, can be a successful approach to sustainable quality improvement at the systems level.     

Study protocol: national research partnership to improve primary health care performance and outcomes for Indigenous peoples

Background

Strengthening primary health care is critical to reducing health inequity between Indigenous and non-Indigenous Australians. The Audit and Best practice for Chronic Disease Extension (ABCDE) project has facilitated the implementation of modern Continuous Quality Improvement (CQI) approaches in Indigenous community health care centres across Australia. The project demonstrated improvements in health centre systems, delivery of primary care services and in patient intermediate outcomes. It has also highlighted substantial variation in quality of care. Through a partnership between academic researchers, service providers and policy makers, we are now implementing a study which aims to 1) explore the factors associated with variation in clinical performance; 2) examine specific strategies that have been effective in improving primary care clinical performance; and 3) work with health service staff, management and policy makers to enhance the effective implementation of successful strategies.

Methods/Design

The study will be conducted in Indigenous community health centres from at least six States/Territories (Northern Territory, Western Australia, New South Wales, South Australia, Queensland and Victoria) over a five year period. A research hub will be established in each region to support collection and reporting of quantitative and qualitative clinical and health centre system performance data, to investigate factors affecting variation in quality of care and to facilitate effective translation of research evidence into policy and practice. The project is supported by a web-based information system, providing automated analysis and reporting of clinical care performance to health centre staff and management.

Discussion

By linking researchers directly to users of research (service providers, managers and policy makers), the partnership is well placed to generate new knowledge on effective strategies for improving the quality of primary health care and fostering effective and efficient exchange and use of data and information among service providers and policy makers to achieve evidence-based resource allocation, service planning, system development, and improvements of service delivery and Indigenous health outcomes.     

Towards integrated care for chronic conditions: Dutch policy developments to overcome the (financial) barriers

Chronic non-communicable diseases are a major threat to population health and have a major economic impact on health care systems. Worldwide, integrated chronic care delivery systems have been developed to tackle this challenge. In the Netherlands, the recently introduced integrated payment system - the chain-DTC - is seen as the cornerstone of a policy stimulating the development of a well-functioning integrated chronic care system.The purpose of this paper is to describe the recent attempts in the Netherlands to stimulate the delivery of integrated chronic care, focusing specifically on the new integrated payment scheme and the barriers to introducing this scheme. We also highlight possible threats and identify necessary conditions to the success of the system. This paper is based on a combination of methods and sources including literature, government documents, personal communications and site visits to disease management programs (DMPs).The most important conditions for the success of the new payment system are: complete care protocols describing both general (e.g. smoking cessation, physical activity) and disease-specific chronic care modules, coverage of all components of a DMP by basic health care insurance, adequate information systems that facilitate communication between caregivers, explicit links between the quality and the price of a DMP, expansion of the amount of specialized care included in the chain-DTC, inclusion of a multi-morbidity factor in the risk equalization formula of insurers, and thorough economic evaluation of DMPs.     

?konomische Aspekte der integrierten Versorgung

For more than 10?years integrated care has been an inherent part of the German healthcare system. The aims of selective contracts are to minimize interface problems between outpatient and inpatient sectors, generalist und specialist care as well as to intensify competition. Despite repeated efforts by the legislator, comprehensive integrated healthcare is still limited to a few flagship projects. This is mainly due to low incentives on the part of both suppliers and customers. Therefore, this article focuses on the economic aspects of integrated care. From a theoretical perspective, integrated care improves efficiency in the healthcare sector by reducing interface problems and asymmetric information as well as by intensifying competition. In practice, however, there are a number of obstacles to implementation. Particularly noteworthy are the financial difficulties in addition to problems regarding sectoral budgeting and the long-term nature of investments. However, the political environment and thus the financial arrangements within the statutory health insurance seem to be more important for further development of integrated care in Germany than the financing issues.     

整合医学模式在肿瘤专科医院管理中的应用实践

整合医学被视为重塑全球和各国卫生体系的关键。结合北京某三甲肿瘤专科医院的管理实践,探讨在整合医学模式下运用具体策略和管理措施,提高医疗服务质量和患者健康收益的可能方案。实践表明,医疗机构可以从学科建设、医院管理和社会服务3个维度进行整体设计,通过多学科综合诊疗等一系列管理措施,突破医、教、研、防的传统管理架构和思维模式,推动医院实现整合型发展。     

Research evidence on strategies enabling integration of electronic health records in the health care systems of low‐ and middle‐income countries: A literature review

Integration of electronic health records (EHRs) in the national health care systems of low‐ and middle‐income countries (LMICs) is vital for achieving the United Nations Sustainable Development Goal of ensuring healthy lives and promoting well‐being for all people of all ages. National EHR systems are increasing, but mostly in developed countries. Besides, there is limited research evidence on successful strategies for ensuring integration of national EHRs in the health care systems of LMICs. To fill this evidence gap, a comprehensive survey of literature was conducted using scientific electronic databases—PubMed, SCOPUS, Web of Science, and Global Health—and consultations with international experts. The review highlights the lack of evidence on strategies for integrating EHR systems, although there was ample evidence on implementation challenges and relevance of EHRs to vertical disease programs such as HIV. The findings describe the narrow focus of EHR implementation, the prominence of vertical disease programs in EHR adoption, testing of theoretical and conceptual models for EHR implementation and success, and strategies for EHR implementation. The review findings are further amplified through examples of EHR implementation in Sierra Leone, Malawi, and India. Unless evidence‐based strategies are identified and applied, integration of national EHRs in the health care systems of LMICs is difficult.     

Integrated patient-centered computing: operations optimization for the 21st century

Over the last few years, health care providers have increasingly recognized that health care is an information business. In fact, the restructuring now being contemplated by many in the context of reform cannot be done without proper information management support. The unfortunate concentration of the health care industry over the last 20 years on administrative and financial data capture has obscured the fact that the important focus should be on patient care and health care operations information. Information on patient care has, unfortunately, largely been relegated to the paper chart and other ad hoc pieces of paper. New systems should focus on health care operations optimization, with specific design features to address failings in the paper system. To be successful, such systems must be integrated and patient centered. This is especially clear in the new enterprise-based world of health care delivery, where patients are the only common factor among venues. Health record professionals, the primary caretakers of patient care information, should be deeply involved in helping institutions move to this new world.     

Expanding access to antiretroviral therapy in sub-saharan Africa: avoiding the pitfalls and dangers, capitalizing on the opportunities

We describe a number of pitfalls that may occur with the push to rapidly expand access to antiretroviral therapy in sub-Saharan Africa. These include undesirable opportunity costs, the fragmentation of health systems, worsening health care inequities, and poor and unsustained treatment outcomes. On the other hand, AIDS "treatment activism" provides an opportunity to catalyze comprehensive health systems development and reduce health care inequities.However, these positive benefits will only happen if we explicitly set out to achieve them. We call for a greater commitment toward health activism that tackles the broader political and economic constraints to human and health systems development in Africa, as well as toward the resuscitation of inclusive and equitable public health systems.     

Evolution of computer-based information systems and networks to support integrated health care delivery systems

As health care delivery systems become more integrated with an emphasis on community wellness and prevention, well-developed information infrastructures will be needed to support their activities. The article introduces several previously published independent models for the evolution of integrated delivery systems, computer-based patient records (CPRs), and health information networks as well as a summary model that illustrates the relationship among these entities and their somewhat parallel development.     

GOBI versus PHC? Some dangers of selective primary health care

This article enters the debate concerning comprehensive versus selective primary health care by focussing on UNICEF's 'child survival revolution'. It is argued that UNICEF is dangerously mistaken in believing that its present emphasis on selective primary health care is a precursor or 'leading edge' of comprehensive primary health care. The approach of UNICEF--diffusion of a package of technologies by campaigns organized from the top down--is more likely to undermine the social basis for comprehensive care. The kinds of implementation UNICEF has chosen in order to minimize costs and maximize impact on child mortality, namely 'social marketing' via mass media and massive, ad hoc delivery systems seriously undermine the development of grassroots organization among parents and primary health care workers. Indigenuous, local organizations are distorted and limited to conduits of a delivery system. Needs are defined outside the communities affected. In addition, UNICEF's so-called revolution has in common with other selective approaches an ideology accepting as inevitable the health effects of economic crisis in the 1980s, further undermining the confidence of local groups and health workers who might otherwise conceive of their desire to control health conditions as a right. The UNICEF interventions popularly known as GOBI-FFF are 'targetted' at individuals, in particular 'ignorant' mothers. As such they are especially destructive to the process of group formation and self-organization of the poor around their just demands for water and sanitation, land, shelter, and employment. This article concludes that UNICEF's GOBI should either be abandoned or integrated into comprehensive primary health care programs that put parents and local workers in control and that emphasize continuing political struggle for health rights.     

MSO development: progress versus pitfalls

Physicians and hospitals are rapidly organizing integrated systems to compete more successfully in the new health care business arena. The preferred parent structure has been the management services organization (MSO). Notable factors have produced significant progress or pitfalls. Success is driven by the thoughtfulness of planning, the depth of management, and the quality of care.