Providers’ Perspectives on High-Quality Dementia Care in Long-Term Care

ObjectivesTo understand dementia care providers’ perspectives on high-quality care for persons living with dementia (PLWD) in long-term care (LTC).DesignA qualitative study using a directed content analysis approach.Setting and ParticipantsNine national LTC dementia care providers.MethodsWe facilitated 5 listening sessions centered around dementia care philosophies, models, and practices. Two researchers first mapped qualitative data to the Holistic Approach to Transformational Change (HATCh) model for dementia care using a directed content analysis approach. They then identified themes and subthemes emerging from the data using a conventional analysis approach. They coded data iteratively and solicited input from 3 additional researchers to reach consensus where needed. Member checks were performed to ensure the trustworthiness of the data during 2 follow-up listening sessions.ResultsThe 9 participants described the importance of understanding the experiences of PLWDs in order to provide high-quality dementia care and to deliver such care with the residents and their preferences as the focus. They emphasized experiential education as essential for families and all staff, regardless of role. They noted the need to balance safety with resident choice, as well as the corresponding need for facility leadership and regulators to support such choices. The listening sessions revealed areas to foster person-centered care for PLWD, but also highlighted barriers to implementing this philosophy in LTC settings.Conclusions and ImplicationsEmergent themes included care practices that center on resident preferences and are supported by staff with the experiential education and communication skills necessary to relate to and support PLWD. These findings provide contextual information for researchers seeking to identify and test interventions that reflect LTC providers’ priorities for PLWD and emphasize the need to align research priorities with provider priorities.     

Is Home Health Care a Substitute for Hospital Care?

A previous study used aggregate (region-level) data to investigate whether home health care serves as a substitute for inpatient hospital care and concluded that “there is no evidence that services provided at home replace hospital services.” However, that study was based on a cross-section of regions observed at a single point of time and did not control for unobserved regional heterogeneity. In this article, state-level employment data are used to reexamine whether home health care serves as a substitute for inpatient hospital care. This analysis is based on longitudinal (panel) data—observations on states in two time periods—which enable the reduction or elimination of biases that arise from use of cross-sectional data. This study finds that states that had higher home health care employment growth during the period 1998–2008 tended to have lower hospital employment growth, controlling for changes in population. Moreover, states that had higher home health care payroll growth tended to have lower hospital payroll growth. The estimates indicate that the reduction in hospital payroll associated with a $1,000 increase in home health payroll is not less than $1,542, and may be as high as $2,315. This study does not find a significant relationship between growth in utilization of home health care and growth in utilization of nursing and residential care facilities. An important reason why home health care may serve as a substitute for hospital care is that the availability of home health care may allow patients to be discharged from the hospital earlier. Hospital discharge data from the Healthcare Cost and Utilization Project are used to test the hypothesis that use of home health care reduces the length of hospital stays. Major Diagnostic Categories with larger increases in the fraction of patients discharged to home health care tended to have larger declines in mean length of stay (LOS). Between 1998 and 2008, mean LOS declined by 4.1%, from 4.78 to 4.59 days. The estimates are consistent with the hypothesis that this was entirely due to the increase in the fraction of hospital patients discharged to home health care, from 6.4% in 1998 to 9.9% in 2008. The estimated reduction in 2008 hospital costs resulting from the rise in the fraction of hospital patients discharged to home health care may have been 36% larger than the increase in the payroll of the home health care industry.     

Who Will Take Care of Us? Exploring Differences in Respondents’ Satisfaction with Primary Care vs Specialty Care Physicians

ObjectiveOur study explored perceived patient satisfaction with either primary care or specialist physicians to identify factors accounting for the differences.Study DesignThe data were collected from an Internet-based survey, DrScore.com, for measuring patient satisfaction with physicians. Participants found their doctors through the DrScore search engine and rated their physicians with anonymity. A total satisfaction score was the sum of scores based on 9 physician rating items and then was scaled to the range of 0-100. Logistic regressions were used to analyze associations between patient satisfaction (score ≥70) and various factors.ResultsThe mean satisfaction score was 79.4 for primary care (n = 11,558) and 75.5 for specialty care (n = 11,068) (P > .05). Nearly 50% of primary care patients waited for 0-2 days to get an appointment, while more than 50% of specialty care patients waited for more than 6 days. As waiting days became longer than 2 weeks, patient ratings of specialty care were lower than those of primary care. Patients (≥45 years) were 24% less likely to be satisfied with primary care (P < .01) but 40% more likely with specialty care (P < .01) than patients (<25 years).ConclusionsAlthough differences in overall patient satisfaction with primary and specialty care were not observed, more specialists obtained extremely low satisfaction scores than primary care providers did. Age and factors related to waiting time for the visit or time spent with a doctor were associated with patient satisfaction with physicians.     

Communicating Chaplains’ Care: Narrative Documentation in a Neuroscience-Spine Intensive Care Unit

Chaplaincy care is different for every patient; a growing challenge is to ensure that electronic health records function to support personalized care. While ICU health care teams have advanced clinical practice guidelines to identify and integrate relevant aspects of the patient’s story into whole person care, recommendations for documentation are rare. This qualitative study of over 400 free-text EHR notes offers unique insight into current use of free-text documentation in ICU by six chaplains integrated into the healthcare team. Our research provides insight into the phenomena chaplains record in the electronic record. Content analysis shows recurrent report of patient and family practices, beliefs, coping mechanisms, concerns, emotional resources and needs, family and faith support, medical decision making and medical communications. These findings are important for health care team discussions of factors deemed essential to whole person care in ICUs, and, by extension have the potential to support the development of EHR designs that aim to advance personalized care.     

We Care Don't We?

Abstract

The HIV/AIDS epidemic has impacted all levels of society from the individual to the macro-economic. The continuing spread of infection around the world means that traditional methods of care and support are put under extreme pressure and many families lose their capacity to cope. Social workers are involved in providing care, counseling and support to those affected, and in developing programmes and other interventions to prevent the spread of the disease. Prevention and behaviour change are vital, but access to treatment is an ethical imperative, particularly in developing countries where the epidemic is most prevalent. Social work is a profession uniquely situated to demonstrate leadership in multi-sectoral collaboration in responding to this pandemic. Consequently this paper briefly reviews the scale and current nature of the epidemic and then considers how social workers can help build more compassionate policies at an international level. Social workers can help to create awareness of the negative effects of poverty, tackle gender inequity, help build more effective coalitions and partnerships, and work with other concerned groups and organisations to end stigma and discrimination. Using case examples the paper considers how social workers can help develop caring strategies that improve the lives of those living with HIV and AIDS.     

Whom Should We Profile? Examining Diabetes Care Practice Variation among Primary Care Providers,Provider Groups,and Health Care Facilities

OBJECTIVE: To evaluate the amount of variation in diabetes practice patterns at the primary care provider (PCP), provider group, and facility level, and to examine the reliability of diabetes care profiles constructed using electronic databases. DATA SOURCES/STUDY SETTING: Clinical and administrative data obtained from the electronic information systems at all facilities in a Department of Veterans Affairs' (VA) integrated service network for a study period of October 1997 through September 1998. STUDY DESIGN: This is a cohort study. The key variables of interest are different types of diabetes quality indicators, including measures of technical process, intermediate outcomes, and resource use. DATA COLLECTION/EXTRACTION METHODS: A coordinated registry of patients with diabetes was constructed by integrating laboratory, pharmacy, utilization, and primary care provider data extracted from the local clinical information system used at all VA medical centers. The study sample consisted of 12,110 patients with diabetes, 258 PCPs, 42 provider groups, and 13 facilities. PRINCIPAL FINDINGS: There were large differences in the amount of practice variation across levels of care and for different types of diabetes care indicators. The greatest amount of variance tended to be attributable to the facility level. For process measures, such as whether a hemoglobin A1c was measured, the facility and PCP effects were generally comparable. However, for three resource use measures the facility effect was at least six times the size of the PCP effect, and for inter-mediate outcome indicators, such as hyperlipidemia, facility effects ranged from two to sixty times the size of the PCP level effect. A somewhat larger PCP effect was found (5 percent of the variation) when we examined a "linked" process-outcome measure linking hyperlipidemia and treatment with statins). When the PCP effect is small (i.e., 2 percent), a panel of two hundred diabetes patients is needed to construct profiles with 80 percent reliability. CONCLUSIONS: little of the variation in many currently measured diabetes care practices is attributable to PCPs and, unless panel sizes are large, PCP profiling will be inaccurate. If profiling is to improve quality, it may be best to focus on examining facility-level performance variations and on developing indicators that promote specific, high-priority clinical actions.     

Should Programs of All-Inclusive Care for the Elderly Use Community-Based Primary Care Physicians?

The program of All-inclusive Care for the Elderly (PACE) is a community-based, long-term care model designed for older adults that are nursing home eligible. Bound by original design and regulations, these programs have primarily utilized a center-based ("staff") primary care physician model. However, some believe that this might hinder expansion of the PACE model. In response to this concern, three PACE programs have explored the use of "community-based" primary care physicians (CBPCPs). In an attempt to evaluate the impact of this variation in the model, we surveyed the medical director, 2 community-based primary care physicians and 6 non-physician staff members at one of these sites. Responders generally support the use of CBPCPs as a useful and productive alternative way to expand PACE services to a wider audience of eligible patients. Because some staff members perceive that CBPCPs utilize hospital and NH services at a higher rate, continued education of both CBPCPs and staff members regarding the expectations from this relationship is needed.     

Pediatric Primary Care Providers’ Relationships with Mental Health Care Providers: Survey Results

Background

As many as 20 % of children have diagnosable mental health conditions and nearly all of them receive pediatric primary health care. However, most children with serious mental health concerns do not receive mental health services. This study tested hypotheses that pediatric primary care providers (PPCPs) in relationships with mental health providers would differ in their care of patients with mental health concerns when compared to PPCPs not in such relationships.

Objective

To explore differences between PPCPs who have relationships with mental health care providers and those who do not with regard to their care of children with mental health concerns.

Methods

Seventy-two PPCPs completed a mailed survey addressing topics such as comfort levels diagnosing and managing patients with behavioral health disorders, perceived barriers to care, activity related to prescribing psychotropic medications, and availability of consultation with mental health specialists. More than one-third (19 providers) of providers reported no specialized training in behavioral pediatrics and nearly 45 % (32 providers) indicated having a relationship or partnership with a mental health specialist.

Results

Those providers who reported relationships indicated greater availability of consultation and communication with psychiatric providers as well as telephone consultation with non-psychiatric mental health providers. All providers were more comfortable assessing as opposed to treating children with disorders, with the exception of attention disorders, which providers were comfortable with both treating and assessing. For all conditions, there was no main effect for partnership.

Conclusion

While partnerships may be associated with greater availability of consultation and communication, for this sample of PPCPs there was no evidence of advantage with respect to diagnosis and management. The paper concludes with a discussion of study limitations, the need for further research, and suggestions for practice.     

Health Care Students’ Differing Conceptions of Expertise: A Challenge for Inter-Professional Care

The aim of the study was to examine do health care students, who study at different programs, value similar expert qualities. To investigate this issue, a questionnaire was administered among health care students in a Finnish polytechnic (two cohorts, total n = 466), consisting of a scale for rating the importance of different expert qualities. The questionnaire resulted in the following dimensions of the conceptions of expertise: (1) social skills, (2) scientific skills, (3) innovativeness, (4) continuing self-development, and (5) problem-solving skills. Also the Inventory of General Study Orientations (IGSO) was applied to analyse possible motivational explanations for different conceptions of expertise. In addition to the scales, an open-ended writing task was used to explore in depth students’ conceptions of expertise. It appeared that study orientations were a minor factor in the study, while study environment (study programs) clearly differentiated students’ conceptions of expertise. Thus, the study argues that health care students’ conceptions of expertise are constituted mainly on domain-specific bases and that students who graduate from different programs may possess very diverse ideas about their profession. Consequently, different conceptions captured during the education form a major challenge for inter-professional care later in work-life. This phenomenon should be taken into account when organising health care education.     

Creating “Well-Functioning” Residential Care and Defining Its Place in a System of Care

This article presents a model for understanding the elements and dynamics of a well-functioning residential group care resource based upon the study of 10 group care residences over a 14-month period. In addition, seven characteristics related to the differential use of foster care and residential care are presented. Finally, five key processes suggested as necessary for the creation of a system of care for young people are offered for consideration.