Home care for the chronically ill: a self-care health system

This article focuses on home care for chronically ill adults and seniors. According to our thesis, home care should be understood as a self-care system, and its aim is to guarantee the individual's social and bodily survival. Home care consists of three areas, related to illness, the home, and to life history. Caregiving, usually under women's responsibility, is present throughout the history of the illness and the health-seeking process. The article analyzes these issues in light of the ageing process, the epidemiological changes occurring worldwide, and the urgency to incorporate this analysis into the heath care research agenda.     

Integrated care programmes for chronically ill patients: a review of systematic reviews.

OBJECTIVE: To investigate effectiveness, definitions, and components of integrated care programmes for chronically ill patients on the basis of systematic reviews. DESIGN: Literature review from January 1996 to May 2004. MAIN MEASURES: Definitions and components of integrated care programmes and all effects reported on the quality of care. RESULTS: Searches in the Medline and Cochrane databases identified 13 systematic reviews of integrated care programmes for chronically ill patients. Despite considerable heterogeneity in interventions, patient populations, and processes and outcomes of care, integrated care programmes seemed to have positive effects on the quality of patient care. No consistent definitions were present for the management of patients with chronic illnesses. In all the reviews the aims of integrated care programmes were very similar, namely reducing fragmentation and improving continuity and coordination of care, but the focus and content of the programmes differed widely. The most common components of integrated care programmes were self-management support and patient education, often combined with structured clinical follow-up and case management; a multidisciplinary patient care team; multidisciplinary clinical pathways and feedback, reminders, and education for professionals. CONCLUSION: Integrated care programmes seemed to have positive effects on the quality of care. However, integrated care programmes have widely varying definitions and components and failure to recognize these variations leads to inappropriate conclusions about the effectiveness of these programmes and to inappropriate application of research results. To compare programmes and better understand the (cost) effectiveness of the programmes, consistent definitions must be used and component interventions must be well described.     

Educating family physicians to care for the chronically mentally ill

More than 50 percent of the chronically mentally ill receive their medical, psychiatric, and social support services from primary care physicians in the general health sector. Despite this high level of involvement with these patients, the majority of family physicians consider their training in the management of patients with mental disorders to be inadequate. This paper describes six categories of critical competencies that should be included in the mental health curricula of family physician training programs: therapeutic attitudes and skills, diagnosis and differential diagnosis, functional assessment, psychopharmacology, management of emergencies, and psychosocial treatments. It outlines the manner in which specific competencies could be incorporated in medical school, in family practice residency training, and in postgraduate continuing medical education as well as the specific elements included in each. The discussion is based on the assumption that more effective participation by family physicians in the treatment of chronic psychiatric illness requires active attention throughout the continuum of medical education.     

A residential continuum for the chronically mentally ill: a Markov probability model

The movement of a group of chronically mentally ill clients among various facilities for residential care was described with a Markov probability model. The results of a goodness-of-fit test indicated that the model accurately captured the flow of clients among the state psychiatric hospital, the in-patient units, the community, and three types of group homes. The model was then used to answer several policy-relevant questions about the functioning of the continuum of residential care, such as how often vacancies can be expected to arise and how efficiently clients are progressing along the continuum.     

Psychological care of the chronically physically ill

Disease prevalence and health priorities have changed, with increasing emphasis on chronic degenerative problems. Health care for the chronically physically ill needs to focus on realistic and often modest goals. This article presents the case for greater consideration of psychological factors, and outlines an example of a system of psychological care.     

Economic evaluation of care for the chronically ill: A literature review

Financial problems of governments and the consequent urge toset limits on health care growth have increased the importanceof economic rationalization. A systematic review of the presentbody of knowledge might facilitate the need to set prioritiesin health care policies and research in an ageing society withgrowing numbers of the elderly and chronically ill. After explainingthe purpose and methods of full economic evaluation, we reviewthe literature on 3 major chronic diseases, diabetes mellitus(20 publications), rheumatoid arthritis (15) and chronic obstructivepulmonary disease (COPD) and asthma (8). This review serves2 objectives: to review the existing literature and to assessits quality. The review reveals a lack of full economic evaluationin this sector of health care. The total number of referencesto the specified chronic diseases covers 5% of all economicliterature and 44% of all references under Index Medicus' heading‘economics’, while the burden of illness is substantial,resulting in high indirect costs to the patients themselvesand to society. The dominant approach is cost-effectivenessanalysis (71%), followed by cost-benefit analysis (20%). Cost-utilityanalysis is rare (9%), partly because it is still in the phaseof development. However, this approach can deal better withthe objectives of many interventions in chronic care, i.e. increasingthe quality rather than the quantity of life. We make a pleafor full economic evaluation of chronic care programmes andfor the development of quality of life measures which coverthe broad domain of well-being of the chronically ill.     

Comprehensive care of the chronically ill cancer patient: an inter-agency model

The article identifies continuity of care between hospital and community as the key element of comprehensive health care for the chronically ill cancer patient. It describes the collaborative effort of the Michigan Cancer Foundation and the Metropolitan Detroit Cancer Control Program to provide this continuity. The structure, process, and outcome of the inter-agency model is presented and illustrated through case example. The authors believe that this model is applicable to treatment of persons with other chronic diseases which require frequent hospitalization.     

A model of the willingness to use telemedicine for routine and specialized care

We examined factors associated with the willingness to use telemedicine for routine and specialized care within a theoretical framework. The conceptual model proposed that willingness to use telemedicine is associated directly with attitudes to telemedicine, attitudes to the patient-physician relationship, and to satisfaction with current health-care. In addition, technology anxiety and past behaviour were both assumed to affect willingness to use telemedicine indirectly. Telephone interviews were conducted with a national sample of 1204 Jewish, non-institutionalized adults in Israel. Structural equation modelling was used to examine the hypothesized relationships. Participants were more willing to use telemedicine for routine than for specialized care. Overall, willingness to use telemedicine was affected by attitudes to telemedicine, attitudes to the patient-physician relationship and by level of technology anxiety. Educational interventions aimed at encouraging the use of telemedicine should target potential users' attitudes, as well as feelings of uneasiness and anxiety regarding technology.     

Satisfaction with and access to community care of the chronically ill in Israel's health system

One goal of Israel's National Health Insurance Law was to improve services for vulnerable populations. However, it was feared that this goal would not be reached for the chronically ill, due to the regulations governing health plan reimbursement and to amendments to the law that authorize additional co-payments for services. OBJECTIVE: To examine the satisfaction with and organizational and financial access to services of chronically ill patients, and compare them to those of healthy consumers. METHODS: In autumn 2001, telephone interviews were conducted with a random sample of 1790 permanent residents of Israel over age 22, 512 (28%) of whom reported having a chronic illness. RESULTS: No significant differences were found between chronically ill and healthy respondents in satisfaction with services, and few differences were found in organizational access to services. However, differences were found in financial access to services. Specifically, chronic illness had an independent positive effect on the burden of co-payments for health services and the likelihood of forfeiting care or medication due to cost. CONCLUSIONS: Increased co-payments for services may restrict access to care. To lighten the burden on vulnerable populations, it is necessary to consider discounts and lower ceilings on co-payments.