Role divergence and complexity in gerontological home care.

This study documents high levels of role complexity and functional overlap in the field of home health care. Personnel perform a wide range of "professional/organizational" and "community/familial" service functions though the emphasis is on the delivery of a battery of pseudo family-like tasks. The importance of a familial orientation does not significantly decline when controlling for length of employment or organizational rationality. Role orientation is, however, significantly associated with a worker's chronological age. Results lead to program planning recommendations meant to influence staff training paradigms in home health care.     

Job stress and job dissatisfaction of home care workers in the context of health care restructuring.

Changes in the social organization of home care work due to health care restructuring have affected the job stress and job dissatisfaction of home care workers. This article reports the results of a survey of 892 employees from three nonprofit home care agencies in a medium-sized city in Ontario, Canada. Survey results are complemented by data from 16 focus groups with 99 employees. For the purposes of this study, home care workers include both office workers (managers, supervisors, coordinators, office support staff, and case managers) and visiting workers (nurses, therapists, and visiting homemakers). Focus group participants indicated that health care restructuring has resulted in organizational change, budget cuts, heavier workloads, job insecurity, loss of organizational support, loss of peer support, and loss of time to provide emotional laboring, or the "caring" aspects of home care work. Analyses of survey data show that organizational change, fear of job loss, heavy workloads, and lack of organizational and peer support lead to increased job stress and decreased levels of job satisfaction.     

Understanding coordination of care from the consumer's perspective in a regional health system

OBJECTIVE: To understand and develop a model about the meaning of coordination to consumers who experienced a transition from acute care to home care. STUDY DESIGN: A qualitative, exploratory study using Grounded Theory. DATA SOURCES/ANALYSIS: Thirty-three consumers in the Calgary Regional Health Authority who had experienced the transition from an acute care hospital back into the community with home care support were interviewed. They were asked to describe their transition experience and what aspects of coordination were important to them. Interviews were recorded, transcribed, and analyzed using constant comparison. The coding and retrieval of information was facilitated by the computer software program Nud*ist. PRINCIPAL FINDINGS: The resulting model has four components: (1) the meaning of coordination to consumers; (2) aspects of health care system support that are important for coordination; (3) elements that prepared consumers to return home; and (4) the components of a successful transition experience. Consumers appeared to play a crucial role in spanning organizational boundaries by participating in the coordination of their own care. CONCLUSIONS: Consumers must be included in health care decisions as recipients of services and major players in the transition processes related to their care. Health care providers need to ensure that consumers are prepared to carry out their coordination role and managers need to foster a culture that values the consumer "voice" in organizational processes.     

Community health: integration of primary care and public health competencies. SESPAS report 2010

Primary care and public health have run on parallel tracks with scarce points of contact or coordination in community action to improve the population's health. If community health is defined as the "health of individuals and groups in a defined community, determined by the interaction of personal and familial factors and by the socioeconomic-cultural and physical environments" and of community intervention is defined as local action to improve community health, primary care and public health are the key players to implement this aim. However, their actions should take into account other local actors, including the population. The inclusion of community health as an objective of the health system highlights the need to achieve more coordinated and comprehensive action, and to introduce advances in several areas, which include training for health professionals, contracts to service providers, systems for defining service portfolios, and organizational aspects of services.     

Social work services in home health care: challenges for the new prospective payment system era

The implementation of the Prospective Payment System (PPS) provides a unique opportunity for social workers to be better integrated into home health care. To do so, it is important for social workers to define their roles and eliminate any barriers to providing social workers services, which may improve patient outcomes. Two focus groups with home health nurses (n = 10) and social workers (n = 8) were conducted in a large urban home health agency to define social work roles and identify barriers to providing social work services. This paper categorizes the barriers to providing social work services into informational, systems/organizational, and inter-professional barriers and presents possible solutions to these barriers as home health agencies strive to provide care under PPS.     

Organizational adaptation in the VNA: paradigm change in voluntary sector.

The organizational history of the visiting nurse association (VNA) is reviewed from the perspective of paradigm change. A paradigm is a behavioral and structural model that comes to characterize a field because of its compatibility with environmental conditions. The concept is applied to interpreting adaptation among the VNA's. Four distinct paradigms are identified which comprise the overlapping but sequential course of VNA adaptation to changing circumstances. These paradigms are "public health nursing," "community nursing service," "the home health agency," and the "home care enterprise." The emergence of each is examined with emphasis on the continuity and discontinuity of elements. Particular focus is given to the durability to date of the voluntary auspice and its future prospects in light of ongoing paradigmatic change is discussed.     

Organizational Adaptation in the VNA

The organizational history of the visiting nurse association (VNA) is reviewed from the perspective of paradigm change. A paradigm is a behavioral and structural model that comes to characterize a field because of its compatibility with environmental conditions. The concept is applied to interpreting adaptation among the VNA's. Four distinct paradigms are identified which comprise the overlapping but sequential course of VNA adaptation to changing circumstances. These paradigms are "public health nursing," "community nursing service.," "the home health agency," and the "home care enterprise." The emergence of each is examined with emphasis on the continuity and discontinuity of elements. Particular focus is given to the durability to date of the voluntary auspice and its future prospects in light of ongoing paradigmatic change is discussed.     

Health IT–Enabled Care Coordination: A National Survey of Patient-Centered Medical Home Clinicians

PURPOSE

Health information technology (IT) offers promising tools for improving care coordination. We assessed the feasibility and acceptability of 6 proposed care coordination objectives for stage 3 of the Centers for Medicare and Medicaid Services electronic health record incentive program (Meaningful Use) related to referrals, notification of care from other facilities, patient clinical summaries, and patient dashboards.

METHODS

We surveyed physician-owned and hospital/health system–affiliated primary care practices that achieved patient-centered medical home recognition and participated in the Meaningful Use program, and community health clinics with patient-centered medical home recognition (most with certified electronic health record systems). The response rate was 35.1%. We ascertained whether practices had implemented proposed objectives and perceptions of their importance. We analyzed the association of organizational and contextual factors with self-reported use of health IT to support care coordination activities.

RESULTS

Although 78% of the 350 respondents viewed timely notification of hospital discharges as very important, only 48.7% used health IT systems to accomplish this task. The activity most frequently supported by health IT was providing clinical summaries to patients, in 76.6% of practices; however, merely 47.7% considered this activity very important. Greater use of health IT to support care coordination activities was positively associated with the presence of a nonclinician responsible for care coordination and the practice’s capacity for systematic change.

CONCLUSIONS

Even among practices having a strong commitment to the medical home model, the use of health IT to support care coordination objectives is not consistent. Health IT capabilities are not currently aligned with clinicians’ priorities. Many practices will need financial and technical assistance for health IT to enhance care coordination.     

The Health Care Home Model: Primary Health Care Meeting Public Health Goals

In November 2010, the American Public Health Association endorsed the health care home model as an important way that primary care may contribute to meeting the public health goals of increasing access to care, reducing health disparities, and better integrating health care with public health systems. Here we summarize the elements of the health care home (also called the medical home) model, evidence for its clinical and public health efficacy, and its place within the context of health care reform legislation. The model also has limitations, especially with regard to its degree of involvement with the communities in which care is delivered. Several actions could be undertaken to further develop, implement, and sustain the health care home.THE AMERICAN PUBLIC HEALTH Association (APHA) has 3 overarching policy priorities: rebuild the public health infrastructure, ensure access to care, and reduce health disparities.1,2 The health care home model contributes to these goals by improving health care delivery at the patient level through redesigning and expanding the scope of primary health care services and improving the interface between primary care practices and public health agencies.In November 2010, APHA endorsed the health care home model of primary care for its public health value. Health care home, a term used by the National Association of Community Health Centers, is a model also referred to as the medical home.3,4 The health care home is a vehicle by which patient- and family-level care at the point of delivery may contribute to meeting population-level goals of improving access to care, reducing health disparities, increasing preventive service delivery, and improving chronic disease management.5 Here we summarize the APHA health care home policy statement and suggest next steps for moving the model forward.     

The changing US health care system: challenges for responsible public policy

The "managed care backlash" arguably topped the list of media and policy concerns in 1998. Yet, against the background of the highly charged environment in which the future of our health care system continues to be debated, there is a dearth of concrete, "objective" facts on the nature of the changes, the reasons for them, and their meaning. An analysis of five important themes that emerged from a review of the recent literature on health system change concludes that an inherent tension exists between the interest in rapidly driving down health care costs through organizational change and the long time frames that are required to make fundamental changes in structure, process, and orientation. Unfortunately, in an environment in which purchasers are driven to seek cost savings and the political will supports a pluralistic and mixed public/private system, the health system may chart an alternative course, with the result that purchasers may rely increasingly on individual cost sharing and continue to cut back the amount of coverage they are willing to offer. The real challenge for public policy makers is to confront the issues directly, avoiding political incentives to adopt easy and fast solutions for these complex matters.     

Reflection in action in caring for the dying: applying organizational learning theory to improve communications in terminal care.

Currently, single loop learning is the predominant method of problem solving orientation engaged in by healthcare institutions. This mode of learning is not conductive to fostering needed communications between health care providers and terminal patients. Reflection in action, second loop learning, focuses on deep listening and dialogue and can be critical in opening communications paths between the dying patient and his or her caregivers. This article discusses organizational learning theory and applies the theories double loop learning technique of reflection in action to end-of-life care. The article further explores an exemplar of reflection in action in a Palliative Care Program, and end-of-life home care program at Kaiser Permanente. In order to more effectively meet the needs of terminally ill patients, greater efforts are needed to incorporate second loop learning into the practice of those caring for these patients.     

Hospice: staffing and cost implications for home health agencies

The authors describe a study done to evaluate the implementation of a home health agency-based hospice program. Forty-one hospice patients were compared with a group of terminally ill patients receiving standard home care treatment. The differences in the type, frequency, and intensity of services required by the two groups were evaluated. While hospice care was found to be slightly more staff intensive than standard home care treatment, the differences were minimal. The results suggest that a home health agency with a multidisciplinary staff could implement a hospice program without making dramatic organizational, administrative, or resource change.     

Availability and Primary Health Care Orientation of Dementia-Related Services in Rural Saskatchewan,Canada

Community-based services are important for improving outcomes for individuals with dementia and their caregivers. This study examined: (a) availability of rural dementia-related services in the Canadian province of Saskatchewan, and (b) orientation of services toward six key attributes of primary health care (i.e., information/education, accessibility, population orientation, coordinated care, comprehensiveness, quality of care). Data were collected from 71 rural Home Care Assessors via cross-sectional survey. Basic health services were available in most communities (e.g., pharmacists, family physicians, palliative care, adult day programs, home care, long-term care facilities). Dementia-specific services typically were unavailable (e.g., health promotion, counseling, caregiver support groups, transportation, week-end/night respite). Mean scores on the primary health care orientation scales were low (range 12.4 to 17.5/25). Specific services to address needs of rural individuals with dementia and their caregivers are limited in availability and fit with primary health care attributes.     

HOSPICE

The authors describe a study done to evaluate the implementation of a home health agency-based hospice program. Forty-one hospice patients were compared with a group of terminally ill patients receiving standard home care treatment. The differences in the type, frequency, and intensity ofservices required by the two groups were evaluated. while hospice care waa found to be ali-e htlv- more staff intensive than standard home care treatment. the differences were minimal. The resulta suggest that a home health agency with a multidisciplinary staff could implement a hospice program without making dramatic organizational, administrative, or resource change.     

Reflection in Action in Caring for the Dying: Applying Organizational Learning Theory to Improve Communications in Terminal Care

ABSTRACT

Currently, single loop learning is the predominant method of problem solving orientation engaged in by healthcare institutions. This mode of learning is not conducive to fostering needed communications between health care providers and terminal patients. Reflection in action, second loop learning, focuses on deep listening and dialogue and can be critical in opening communications paths between the dying patient and his or her caregivers. This article discusses organizational learning theory and applies the theories double loop learning technique of reflection in action to end-of-life care. The article further explores an exemplar of reflection in action in a Palliative Care Program, and end-of-life home care program at Kaiser Permanente. In order to more effectively meet the needs of terminally ill patients, greater efforts are needed to incorporate second loop learning into the practice of those caring for these patients.     

Vers des nouvelles perspectives d'appui à la Prévention au Système National de la Santé, en Tunisie

"Prevention", a component of primary health care since Alma Atas declaration (1978), has been a strategic axis of health policy in Tunisia for four decades. If the Tunisian Revolutionary Constitution (2014) declared in its Article 38 that "the State guarantees prevention", the regulatory texts, organizing preventive structures and its operational programs, have today become ill-suited with the global burden of disease and current scientific evidence. The analysis of current preventive practices in Tunisia, based on the "health continuum", the taxonomy of "preventive strategies" and the identification of "vulnerable populations", has shown the need to implement prevention activities. "Primordial" and "quaternary" (for the management of cardiovascular diseases and cancers), extension of the fields of health education and epidemiological surveillance, towards Therapeutic Education of Patients / Health Promotion, and health monitoring, and coverage of new groups at risk: adolescents and the elderly. Faced with the multitude of prevention structures and the fragmentation of health programs, the reform of the national preventive policy and its practices should be based on the principles of integration, relevance and efficiency, through the establishment of a National Health Protection Agency (NHPA). This ANP is called upon to launch new prevention support projects including integrated preventive medicine centers (providing periodic health examinations), hospital patient therapeutic education services and home care units. Such a reform, announcing the birth of a new generation of preventive basic health care activities in Tunisia, should be reinforced by a legal, organizational and educational basis.     

Home hospitalization: background, current situation, and future prospects]

OBJECTIVE: To establish the different forms that the concept of home care has taken over time as a modality for providing health care, so as to contribute to the debate on the circumstances affecting health care management in the face of future challenges. METHODS: The literature is reviewed on home care as a method for delivering health care, by researching publications indexed during the period of 1995-2000 in three medical bibliographical databases: MEDLINE, LILACS (Latin American and Caribean Health Sciences) and the Indice Médico Espa?ol (Spanish Medical Index). RESULTS: Home hospitalization has developed differently over time in various countries, with an assortment of models for this type of care, each with its respective advantages and disadvantages. CONCLUSIONS: There are some criteria and proposals that could provide a framework for home care that is innovative, effective, and of high quality. Home care could help in the design and creation of a consensus on an organizational and financing model that fits in harmoniously between primary care and care in a hospital.     

A model for the integration of community-based health and social services.

This article describes a program designed by a case management organization and home health agency to improve the delivery of home care to the elderly. The results of a modified experimental-control study indicate that the cost of the services to the experimental group, who received comprehensive assessments, consolidated case management and joint monitoring, was less than the control group with an accompanying improvement in the quality of care. It is suggested that the program may be a practical model for local, community social service and health agencies seeking a way to increase continuity of care, improved quality, and reduce costs without difficult organizational and system changes.     

Defining cultural competence: a practical framework for addressing racial/ethnic disparities in health and health care

OBJECTIVES: Racial/ethnic disparities in health in the U.S. have been well described. The field of "cultural competence" has emerged as one strategy to address these disparities. Based on a review of the relevant literature, the authors develop a definition of cultural competence, identify key components for intervention, and describe a practical framework for implementation of measures to address racial/ethnic disparities in health and health care. METHODS: The authors conducted a literature review of academic, foundation, and government publications focusing on sociocultural barriers to care, the level of the health care system at which a given barrier occurs, and cultural competence efforts that address these barriers. RESULTS: Sociocultural barriers to care were identified at the organizational (leadership/workforce), structural (processes of care), and clinical (provider-patient encounter) levels. A framework of cultural competence interventions--including minority recruitment into the health professions, development of interpreter services and language-appropriate health educational materials, and provider education on cross-cultural issues--emerged to categorize strategies to address racial/ethnic disparities in health and health care. CONCLUSIONS: Demographic changes anticipated over the next decade magnify the importance of addressing racial/ethnic disparities in health and health care. A framework of organizational, structural, and clinical cultural competence interventions can facilitate the elimination of these disparities and improve care for all Americans.     

A Model for the Integration of Community-Based Health and Social Services

This article describes a program designed by a case management organization and home health agency to improve the delivery of home care to the elderly. The results of a modified experimental-control study indicate that the cost of the services to the experimental group, who received comprehensive assessments, consolidated case management and joint monitoring, was less than the control group with an accompanying improvement in the quality of care. It is suggested that the program may be a practical model for local, community social service and health agencies seeking a way to increase continuity of care, improved quality, and reduce costs without difficult organizational and system changes.