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.     

Primary health care delivery and public health departments: a model and simulation

Describes development of a computer simulated design of primary care service delivery within a complex organization. Data for the model was obtained by interview, from financial records, patient charts, personnel files, and by questionnaire. The design regards primary health care need as a variable dependent on population characteristics and disease incidence rates, with delivery of care being determined by community needs. By extension of this line of thought, the most appropriate organizational design for the institution must necessarily be based on the specific environment in which it operates. The model and the simulation of primary health care activity in a health department supported the hypothesis that staff assignment is a function of community need for the service, and is also a function of the resources available. Changes in lag time for feedback regarding goal attainment did not produce any changes in performance, and political support was not found to be directly related to staffing of a particular program. An important conclusion to be drawn from this research is that resource administration and allocation requires skills in community diagnosis and internal management which health administrators would do well to include in their education.     

Primary health care teams. Opportunities and challenges in evaluation of service delivery innovations

Quality of service and corporate productivity may be improved when employees are formed into semi-autonomous teams that are empowered to be innovative in service and are rewarded for attaining performance goals. This article describes the planned staffing and implementation strategies for three models of primary health care teams (HCTs) in a managed care organization (MCO). Implementation of each model focussed on (1) changes to primary care staffing mix (structural integration of roles) and (2) development of teamwork (functional integration of roles). Evidence from other industries suggests that the planned changes to structural and functional integration of existing primary care delivery models could improve system productivity, patient satisfaction, clinical quality, and employee morale. Retrospective evaluations of whether the planned improvements were achieved, and whether these achievements can be attributed to changes in staffing mix or teamwork, are now being conducted. Opportunities and limitations in conducting these retrospective evaluations are discussed, particularly with reference to use of existing data sources. The article concludes with recommendations for evaluation of natural experiments in primary care redesign.     

Training and challenges for the health care system in Brazil: an analysis of investments to expand health care service delivery

The goal of this study is to discuss the investments made by the Brazilian government to expand health care service delivery in the Unified National Health System (SUS) from 1995 to 2001. The data indicate a mismatch between investments to increase service delivery and maintenance and optimization of the health service network's capacity. The paper concludes that there is a need to guarantee financial maintenance of the system and conduct new investments based on an analysis of the installed capacity and the financial possibilities to guarantee resources for continuous delivery of this additional services supply.     

Pregnant women and listeriosis: preferred educational messages and delivery mechanisms

OBJECTIVE: To characterize pregnant women's food safety practices, to evaluate the impact of existing educational messages on the risks and prevention of listeriosis, and to identify preferred delivery methods for educational initiatives. DESIGN: Eight focus group discussions conducted with pregnant women in 4 locations. SETTING: Focus group discussions led by moderators using a prepared moderator guide. PARTICIPANTS: Purposeful sampling was used to select the 63 pregnant women who participated in this study. The focus groups were segmented by location and education level. PHENOMENON OF INTEREST: Food safety knowledge and food-handling practices, food safety practices during pregnancy, attitudes toward listeriosis brochure, and preferred delivery methods. ANALYSIS: Focus group discussions were videotaped and audiorecorded. Detailed summaries of each discussion were prepared and systematically analyzed to identify common themes within and across groups. RESULTS: Participants were not aware of the risks of listeriosis and recommended practices for listeriosis prevention; thus, they were not taking precautions during their pregnancy to prevent listeriosis. CONCLUSIONS AND IMPLICATIONS: The study identified the need to develop educational materials on listeriosis targeted specifically to pregnant women and to partner with obstetricians and other health care providers to deliver these materials to pregnant women.     

Elderly self care education: a low technology primary health care option for developing countries.

This article presents a number of perspectives on the curriculum building processes as well as the methodology and content of a self care training curriculum and information packet that were prepared and field for the development of a model self care education program for older persons. Course content and topical areas are outlined, and various training agenda and educational materials are described. Although this program was undertaken as part of the national goal to develop a health promotion and disease prevention strategy for older people in the United States, a number of insights, principles and implications drawn from the curriculum development activities and field testing experiences are applicable to other countries, especially developing nations where the problems and needs of the aged are becoming increasingly apparent in the face of ever shrinking resources.     

The relationship between self-rated health and health care service use among women veterans in a primary care clinic.

This study examined whether self-rated health predicted health service use among women in an equal access primary care clinic setting. Women veterans (n = 139), 23-76 years of age were administered the PRIME-MD questionnaire at their outpatient clinic (OPC) visit which included a self-rated health item and assessment of symptoms. Number of prospective OPC visits was the outcome variable. Women who had poor/fair health were significantly more likely (OR = 3.25) to have more (>12) OPC visits than women who reported excellent/very good health. We conclude that poor perception of one's health is an important predictor of health care use among women veterans.     

Designing a comprehensive service for a health care group: a framework for planning

This article describes an exercise which was designed by a multidisciplinary group, including a community physician, health economist, clinician and operational research practitioner, to explore the essential nature of planning services for a particular health care group. The first programme, described in the article, was concerned with psychogeriatric services, including both community and hospital provision, but it is indicated that the exercise can be adapted to all other services, and has already been used to evolve a comprehensive accident and emergency service in a particular health area. Participants came from a wide variety of disciplines, including community medicine, psychiatry, geriatrics, hospital and community nursing and non-medical administration. The tutors to the course were those who had been involved in its planning and they spent the time working with the participants to explore the concepts involved and to produce some practical solutions that could be used in the field.     

Ambulatory care: a decade of change in health care delivery

While the need to realign the continuum and change the delivery system is one of the many factors driving health care reform, it is clear that a major transformation of the delivery system is already under way and that ambulatory care and home care are at the forefront of that movement. This trend is likely to continue regardless of the pace of health reform.     

Approach to sustainable primary health care service delivery for rural and remote South Australia

ABSTRACT: We describe the operation of four University Teaching Practices established by the South Australian Centre for Rural and Remote Health (SACRRH) and the Adelaide University Department of General Practice. These practices were established in response to the acknowledged difficulty in recruiting and retaining GPs in rural South Australia. The practices are co-located with a hospital or accident and emergency service and community based nurses and allied health professionals. They provide integrated health care and multidisciplinary health care student placements in a learning environment where students experience rural multidisciplinary practice and country life. The study found that although the sites differed in significant ways, they all provided integrated care and effective placements for students. This style of health care delivery is flexible and broadly applicable. Sustainability is achieved through financially viability, attracting and retaining health care professionals and the development of electronic information systems, to support integrated practice.     

Training health workers for primary care in a developing health service

To provide primary health care in a thinly populated mountainous country with few doctors presents great difficulties. The Royal Government of Bhutan decided to base their primary medical care service on appropriately trained medical auxilliaries. The training programme is described, and the problems of assessing the field activities discussed.     

The ethics of health service delivery: a challenge to public health leadership

The ethical distribution of health care is a central issue now that AIDS has started to be a drain on health care resources. If the worst predictions are true, the next half century will be capitalized by a great stress of the health care delivery system in the Pacific. The critical challenges that face the current leadership are: sustaining commitment to all levels of administration to reduce social and health inequities; making sound decisions on policies, priorities and goals that are based on valid information; strengthen health infrastructure, based on the principle of primary health care, including appropriate distribution of staffing, skills, technology and resources. The goals of the Pacific Health Promotion and Development center must not focus exclusively on AIDs. Hepatitis B control measures, hypertension and diabetes, primary care in remote areas, and rehabilitation initiatives must be kept in place. Humanitarian interests for AIDs patients must be balanced with the pragmatic reality of saving children's hearing, or extending useful lives. The attributes of respect, accountability, leadership, judgement, fairness, integrity and honesty controlled by principles of social justice must be part of the administrative decision making process. The 2 major issues facing public health professional are: (1) the financial considerations involved with increasingly expensive technology, services and research, contrasted against the need to prioritize their use and development; (2) pragmatic and ideological needs must be balanced to maximize preventative and curative services and make them available to those who can benefit from them.     

Customer service in health care: a new era

Intensified competition in healthcare is stimulating an enhanced focus on consumer satisfaction. Critical barriers to customer service are being dismantled and hospitals are instituting comprehensive models to promote consumer-oriented environments.     

Disruptive innovation in health care delivery: a framework for business-model innovation

Disruptive innovation has brought affordability and convenience to customers in a variety of industries. However, health care remains expensive and inaccessible to many because of the lack of business-model innovation. This paper explains the theory of disruptive innovation and describes how disruptive technologies must be matched with innovative business models. The authors present a framework for categorizing and developing business models in health care, followed by a discussion of some of the reasons why disruptive innovation in health care delivery has been slow.