Quality collaboratives: lessons from research

Quality improvement collaboratives are increasingly being used in many countries to achieve rapid improvements in health care. However, there is little independent evidence that they are more cost effective than other methods, and little knowledge about how they could be made more effective. A number of systematic evaluations are being performed by researchers in North America, the UK, and Sweden. This paper presents the shared ideas from two meetings of these researchers. The evidence to date is that some collaboratives have stimulated improvements in patient care and organisational performance, but there are significant differences between collaboratives and teams. The researchers agreed on the possible reasons why some were less successful than others, and identified 10 challenges which organisers and teams need to address to achieve improvement. In the absence of more conclusive evidence, these guidelines are likely to be useful for collaborative organisers, teams and their managers and may also contribute to further research into collaboratives and the spread of innovations in health care.     

Gender differences in health care access indicators in an urban, low-income community

OBJECTIVES: This study examined factors associated with gender differences in health insurance coverage and having a usual source of medical care. METHODS: In-person interviews were conducted with a community sample of 695 residents of Central Harlem, New York City. Predictors of the 2 outcome variables and the interaction of key variables with gender were analyzed via logistic regression. RESULTS: No strong patterns emerged to explain gender differentials in having insurance coverage and having a usual provider. However, women employed full time had increased odds of insurance coverage, whereas employment had no similar effect among men. Public assistance evidenced a strong relationship with insurance coverage among both men and women. Socioeconomic factors and health insurance were important independent predictors of having a usual source of health care for men but had little effect among women. CONCLUSIONS: Expanding the availability of both public insurance and affordable private coverage for men living in low-income communities is an important means of reducing gender disparities in access to health care. Public assistance is an important means of enabling access to health care for men as well as women.     

Insurance + access not equal to health care: typology of barriers to health care access for low-income families

PURPOSE Public health insurance programs have expanded coverage for the poor, and family physicians provide essential services to these vulnerable populations. Despite these efforts, many Americans do not have access to basic medical care. This study was designed to identify barriers faced by low-income parents when accessing health care for their children and how insurance status affects their reporting of these barriers.     

Improving public health care: lessons on governance from five cities.

Policy-oriented investigations into public health care delivery have been limited, especially during the Reagan era of competition and profit-based health care, when the inner city was essentially forgotten. In this study, policymakers toured five urban public health care systems in different parts of the country to promote consideration of a new governance for Chicago and Cook County's complicated and uncoordinated care for the medically indigent. A comparison of patterns of governance revealed strengths and weaknesses of each model. Local leadership and the political will to evolve a system of care, with clear connections between the public and private sectors, account for each city's relative success in addressing mounting needs of inner-city populations.     

Expanding insurance coverage and access for low-income people

Medicaid provides health insurance for 40 million low-income women and children, elderly, blind, and disabled people. In 1996, state initiatives covered nearly a million more people who have very low incomes but aren't eligible for Medicaid. This issue of States of Health looks at the extent to which such programs to expand insurance coverage actually improve access to care. How many of those who are eligible are enrolled? How many receive appropriate care? And how can we increase those numbers to the limit?     

Partnerships among community development, public health, and health care could improve the well-being of low-income people

Safe, vibrant neighborhoods are vital to health. The community development "industry"-a network of nonprofit service providers, real estate developers, financial institutions, foundations, and government-draws on public subsidies and other financing to transform impoverished neighborhoods into better-functioning communities. Although such activity positively affects the "upstream" causes of poor health, the community development industry rarely collaborates with the health sector or even considers health effects in its work. Examples of initiatives-such as the creation of affordable housing that avoids nursing home placement-suggest a strong potential for cross-sector collaborations to reduce health disparities and slow the growth of health care spending, while at the same time improving economic and social well-being in America's most disadvantaged communities. We propose a four-point plan to help ensure that these collaborations achieve positive outcomes and sustainable progress for residents and investors alike.     

建立和使用健康档案提高社区卫生服务质量

目的为了探讨提高社区卫生服务质量的途径和方法。方法从社区卫生工作的实际出发，参照国内文献，分析建立健康档案的意义、内容、基本要求以及存在的现状．寻求科学管理和有效利用的方法。结果健康档案内容和格式应标准化，管理和利用应计算机化与网络化。结论建立和用活健康档案是提高社区卫生服务质量的基础途径。     

A community expands access to health care: the case of access health in Michigan

Access Health, a Michigan-based "three-share plan," is viewed as a successful community-based approach to expanding health benefits in the workplace. It was the stimulus for recently proposed legislation to federally fund similar plans nationally. The program evolved with the support of the W.K. Kellogg Foundation. Its sustained viability is attributable in part to the creative use of a state statute to draw down federal Medicaid disproportionate-share hospital (DSH) funds. Although it faces obstacles common to programs of its type, the program's greatest financial vulnerability rests on the uncertain continued availability of the monies it uses to subsidize the program.     

Improving access to health care: case management for vulnerable children.

Health care providers are being confronted by a change in childhood morbidity from primarily physical problems to complex problems rooted in the social, family, and environmental conditions that accompany persistent urban poverty. The clustering of multiple problems in one family necessitates redefining preventive and treatment strategies. Yet the lack of coordination among federal, state and local service programs often exacerbates the vulnerability of these beleaguered children and families. Therapeutic case management is a powerful service coordination strategy for increasing access and improving the health of vulnerable children. An ongoing evaluation of one case management model at the Center for the Vulnerable Child at Children's Hospital in Oakland, California is described in this article. Process evaluation data show this model to be effective in improving comprehensiveness and continuity of care among participating families.     

Improving access to and outcomes from mental health care in rural Australia

OBJECTIVE: Rural Australians face particular difficulties in accessing mental health care. This paper explores whether 51 rural Access to Allied Psychological Services projects, funded under the Better Outcomes in Mental Health Care program, are improving such access, and, if so, whether this is translating to positive consumer outcomes. DESIGN AND METHOD: The paper draws on three data sources (a survey of models of service delivery, a minimum dataset and three case studies) to examine the operation and achievements of these projects, and makes comparisons with their 57 urban equivalents as relevant. RESULTS: Proportionally, uptake of the projects in rural areas has been higher than in urban areas: more GPs and allied health professionals are involved, and more consumers have received care. There is also evidence that the models of service delivery used in these projects have specifically been designed to resolve issues particular to rural areas, such as difficulties recruiting and retaining providers. The projects are being delivered at no or low cost to consumers, and are achieving positive outcomes as assessed by standardised measures. CONCLUSION: The findings suggest that the rural projects have the potential to improve access to mental health care for rural residents with depression and anxiety, by enabling GPs to refer them to allied health professionals. The findings are discussed with reference to recent reforms to mental health care delivery in Australia.     

Improving the implementation of cost recovery for health: lessons from Zimbabwe

In the current debate over health financing policy in developing countries, governments are increasingly focusing on cost recovery--having patients pay part or all of their health care costs--as a way to mobilize more resources for health, improve equity by selectively charging the wealthy, and increase efficiency by encouraging reinvestment of fee revenues into cost-effective primary care. Zimbabwe offers an important example of a country with a tradition of levying fees in government health facilities, but where enforcement became lax in the 1980s. In 1991, policymakers resolved to resuscitate and strengthen cost recovery, as part of a broader economic reform program. This paper discusses the strengths and weaknesses of Zimbabwe's cost recovery system, its potential for improvement, and the obstacles to change in revising the fee structure and billing and collection procedures. It argues that cost recovery can help to achieve Zimbabwe's health objectives, but only in conjunction with other measures to redirect public spending to essential public health and clinic care and improve the efficiency of government services. The paper finds that during the 1980s, the fee schedule became badly misaligned with actual medical care costs and created distortions in patient referral patterns. Billing and collection were also weak, because of deficiencies in personnel and information systems and lack of incentives for revenue generation. The paper concludes that if key steps were taken to raise the collections-to-billings ratio, recover fees from privately-insured patients, and adjust fees in line with medical cost inflation, recoveries could increase fourfold, from 5% to 20% of government spending for clinical care. At the same time, access to government health services for the poor could be maintained by improving exemption procedures.     

Primary care for low-income populations: comparing health care delivery systems

Amidst recent policy discussions about the health care safety net there has been relatively little information about whether the actual site of care affects care quality. We therefore used National Health Interview Survey data to describe low-income adults seeking primary care at different types of sites and the quality of access and preventive care at these sites. After adjusting for sociodemographic characteristics and illness burden, hospital-outpatient- department patients were more likely to receive vaccinations for influenza (adjusted odds ratio [AOR] 1.3, 95% confidence interval [CI] 1.0-1.6) and pneumococcus (AOR 1.4, 95% CI 1.1-1.8) than were those at clinics or health centers. Hospital-clinic patients were more likely to report delays in care due to office administrative difficulties (AOR 1.3, 95% CI 1.1-1.7) and more likely to have more than one emergency room visit (AOR 1.9, 95% CI 1.5-2.3). Physicians' office or HMO patients were less likely to report administrative delays in care than those at clinics or health centers, but there were no other differences in quality between these two site types. Policymakers and health care services analysts and providers must monitor quality as they decide how best to deliver care to vulnerable populations.     

Improving access to health care in Latino communities.

Public debate about health care reform often focuses on the need for health insurance coverage, but in Latino communities many other barriers also inhibit access to medical care. In addition, basic public health services often go underfunded or ignored. Thus, health care reform efforts, nationally and in each State, must embrace a broader view of the issues if the needs of Latino communities are to be served. This report reviews and summarizes information about the mounting problems Latino communities face in gaining access to medical care. Access to appropriate medical care is reduced by numerous financial, structural, and institutional barriers. Financial barriers include the lack of health insurance coverage and low family incomes common in Latino communities. More than 7 million Latinos (39 percent) go without health insurance coverage. Latinos without health insurance receive about half as much medical care as those who are insured. Structurally, the delivery system organization rarely reflects the cultural or social concerns of the communities where they are located. Therefore, providers and patients fail to communicate their concerns adequately. These communication problems are exacerbated by the extreme shortage of Latino health care professionals and other resources available. Institutional barriers often reflect the failure to consider what it means to provide good service as well as high-quality medical care. Reducing these barriers to medical care requires modifying governmental and institutional policies, expanding the supply of competent providers, restructuring delivery system incentives to ensure primary care and public health services, and enhancing service and satisfaction with care.     

Commentary: Lessons from Medicaid--improving access to office-based physician care for the low-income population.

Medicaid offers important lessons about providing access to office-based physician services for the poor. First, differentials in physician fees between Medicaid and other payers compromise access to care and are difficult to reverse. Second, managed care alone is not enough to attain equity in access, especially if differentials in payment rates between Medicaid and private patients in managed care settings are allowed to grow. Finally, financing strategies alone are not sufficient to resolve the shortage of health care providers in medically underserved areas. In these areas, payment policy must be combined with resource development to ensure that vulnerable populations have access to care.