Evaluation of mandated memoranda of understanding between local health departments and Medicaid managed care plans.

The success of mandating memoranda of understanding (MOU) in promoting collaboration between Medicaid managed care (MCMC) plans and local health departments (LHDs) was examined in this research project. The mandate resulted in MOUs that contributed to increases in collaborative activities, increased perceived quality of health care, and successful management of reimbursement to LHDs. Factors associated with success included a local initiative type of health plan, longer length of time that the MOUs were in place, and higher interorganizational collaborativeness. Concerns related to the MOU approval process and lack of contribution of the MOUs to quality of public health services were identified. MOUs promote collaborative relationships between MCMC plans and LHDs on health care issues important to both sectors.     

Gesundheitsförderung in der stationären Altenbetreuung

Background

Implementation research is an emerging topic in the field of health promotion research. It aims to translate innovative and efficacious health programs into practice and to ensure their effective implementation. In the setting of residential aged care, to date, there has been little research on factors which enable or hinder the implementation of health promotion programs.

Methods

In a qualitative study, the implementation of a physical activity program for the elderly in three Viennese residential care homes were investigated. Twelve semi-structured interviews with persons responsible for program implementation (executives and adopters) were conducted.

Results

The strategic anchoring of the program and therewith the strong adoption of leadership roles by executive staff proved as facilitating factors. The program was compatible with the role identity and expertise of the occupational group responsible for implementation. Furthermore, it offered opportunities for professional development and autonomy. An obstacle was a simultaneously occurring organizational restructuring process; thus, the implementation of the program was perceived as an additional burden by all person surveyed. Moreover, structures for exchange and cooperation were missing.

Conclusion

Beside strategic commitment, successful implementation of a mobility program relies on an operative management that adopts coordinating tasks and creates supporting structures (for collaboration and exchange).     

Disease prevention and health promotion programs: benefits, implementation, quality assurance and open questions??a summary of the evidence

Aim

Disease prevention and health promotion programs are standardized behavioral interventions that may be combined with contextual interventions. With optimized methods, they offer proven efficacy, efficiency, transparency, manageability, and rapid transfer of knowledge.

Subject and methods

This review summarizes their central barriers and success factors based on current research.

Results

Important barriers to effective use of disease prevention and health promotion programs are low implementation fidelity, exaggerated flexibility subject to political change, inadequately trained and overworked personnel, disregard of context, change of implementation frameworks, lack of supportive contextual interventions, a plethora of programs, scarce resources and weak organizational support, resistance to social technologies, choices based on marketing criteria instead of effectiveness, and research gaps. Solutions include robust intervention plans, clear and comprehensive manuals, definition of intervention core and periphery, organizational and leadership support, qualification of users, systematic adaptation to local conditions, and quality assurance/monitoring of acceptance and effectiveness.

Conclusion

Both users and decision-makers should demand proof of effectiveness of program choices and should adhere to quality assurance procedures during implementation. Program development and evaluation should ensure (1) the definition of core intervention components, (2) instructions for adaptation of programs to specific contexts, (3) basic data on resources required for implementation, and (4) evidence of program effectiveness.     

Hospital adaptation to risk-bearing: managerial implications of changes in purchaser-provider contracting

A number of countries have adopted contracting reforms in which hospitals are placed at financial risk. This risk has stimulated a number of adaptive strategies to achieve organizational success. This paper presents a model of six forms of contracting relationships and reviews the adaptation strategies observed in three health systems: the USA, England and the Netherlands. These strategies include service diversification, improved management information systems, the employment of marketing and contract managers, the use of clinical pathways, case management and concurrent/retrospective review of hospital stays, quality management and quality assurance programs, pre-admission authorization, discharge planning, and physician profiling and participation in management. These adaptive strategies have three implications for managers: increased 'partnering', with purchasers, collaboration with medical staff, and assumption of managed care roles. Two groups of institutions are at risk from the changes in hospital contracting: university teaching hospitals and inner-city hospitals serving socially deprived populations. The paper ends with implications for the education of hospital managers and research on hospital management and adaptation to contracting.     

Measuring the extent of gerontological home care staff participation in agency policy making and planning.

A survey study of the work experience and views of administrative and direct service program staff (N = 91) in both small scale and large scale Older Americans Act-funded home care programs in New York City sheds light on the extent to which various categories of personnel in the field of community home care have opportunities to participate in a range of agency policy making and planning functions. Findings reveal that home care staff in small scale programs were more directly involved in both client-centered and program-centered policy/making activities. In particular, these workers felt they were significantly more active in: changing service plans; discussing changes that need to be made in how the agency operates; planning new services and programs at the agency; and helping to train or orient new workers in the program. A strong negative correlation between level of organizational complexity and worker participation rates was discovered. Additional data suggest that all staff, regardless of their status or work responsibility, would like to be granted more of a voice in planning decision. Those who participate least in such activities were most adamant over being given a greater role in this aspect of program life. Heightened levels of job satisfaction were also associated with greater measures of worker involvement in organizational decision-making. Study findings are seen to have implications for the design of more equitable decision-making mechanisms in gerontological home care specifically and human service programs generally.     

Measuring the Extent of Gerontological Home Care Staff Participation in Agency Policy Making and Planning

A survey study of the work experience and views of administrative and direct service program staff (N=91) in both small scale and large scale Older Americans Act-funded home care programs in New York City sheds light on thc extent to which various categories of personnel in the field of community home care have opportunities to participate in a range of agency policy making and planning functions. Findings reveal that home care staff in small scale programs were more directly involved in both client-centered and program-centered policy planning activities. In particular, these workers felt they were significantly more active in: 1) changing service plans; 2) discussing changes that nced to be made in how the agency operates; 3) planning new services and programs at the agency; and 4) helping to train or orient new workers in the program. A strong negative correlation between level of organizational complexity and worker participation rates was discovered. Additional data suggest that all staff, regardless of their status or work responsibility, would like to be granted more of a voice in planning decisions. Those who participate least in such activities were most adamant over being given a greater role in this aspect of program life. Heightened levels of job satisfaction were also associated with greater measures of worker involvcment in organizational decision-making. Study findings are seen to have implications for the design of more equitable decision-making mechanisms in gerontological home care specifically and human service programs generally.     

Staff perception of the impact of health care transformation on quality of care.

OBJECTIVES: To study how medical professionals perceived recent organizational changes and financial cut-backs in terms of organizational and health care quality. DESIGN: A cross-sectional questionnaire survey. SETTING: County council of Stockholm. PARTICIPANTS: A random sample (n=936; 70% response rate) of physicians and nurses employed by the county council of Stockholm. MAIN OUTCOME MEASURES: Staff perception of how recent changes impacted on staff-perceived quality of care, staffs' skills development, management, and perceived organizational efficacy. RESULTS: Over 60% of the respondents rated that patients' access to health care had diminished as a result of ongoing changes. A similar percentage also perceived a decline in the quality of health care delivered in general. However, fewer staff rated a decline during the last year in the quality of care provided by their own department (44%). Staff rating that quality of care in their own department had worsened during the last year also scored substantially lower on all counts of organizational well-being. The most important determinants of staff-perceived quality of care were staff access to pertinent information concerning their daily work and organizational changes, participatory management, performance management, and job commitment. Job satisfaction was more strongly associated with organizational well-being than staff-perceived quality of care. CONCLUSION: Staff perception should be used as an additional indicator of quality of care. To improve quality of care further, management should encourage staff involvement in everyday management issues, including up-to-date information about organizational goals and mission.     

The primary health center as a social system: PHC, social status, and the issue of team-work in South Asia

Primary health care ideology is considered from the vantage point of health center field staff in South India and Sri Lanka. It is argued that professional and organizational role conflicts are fostered by primary health care inspired programs introduced without regard to the status and motivations of existing cadres of staff. Attention is focused on the health center as a social system and the need for social systems analysis as a preliminary step in planning for team-work at the health center-community level. Inasmuch as team-work is the cornerstone of PHC implementation, more thought need be given to staff response to potential programs.     

Readiness for Medicaid Managed Care Reform Initiatives: A Profile of Rural Family Physicians

Medicaid managed care is now an important factor in the financing of rural health care delivery. The participation of rural family physicians in Medicaid managed care is vital for the rural poor to access health services. This study examined 855 family physicians practicing in nonmetropolitan counties across the United States to determine their readiness to participate in Medicaid managed care. Physicians were asked about their experience with prepaid programs and the factors that would influence their participation in such a program. A shortage of health care providers and low reimbursement rates were most frequently cited as barriers to successful implementation. Physicians who had participated in prepaid programs in the past but were no longer participating had the most negative opinions about the potential for Medicaid managed care programs to enhance care for the poor in their communities. Overall, physicians reported potential for the program to improve access and quality of care, but they also expressed reservations about the financial and administrative effects on their practices. These results reveal that negative attitudes were associated with prepaid programs that failed to meet expectations, but physicians also expressed an optimism about the potential to serve the poor within a managed care model.     

Does managed care restrictiveness affect the perceived quality of primary care? A report from ASPN. Ambulatory Sentinel Practice Network

BACKGROUND: The competitive managed care marketplace is causing increased restrictiveness in the structure of health plans. The effect of plan restrictiveness on the delivery of primary care is unknown. Our purpose was to examine the association of the organizational and financial restrictiveness of managed care plans with important elements of primary care, the patient-clinician relationship, and patient satisfaction. METHODS: We conducted a cross-sectional study of 15 member practices of the Ambulatory Sentinel Practice Network selected to represent diverse health care markets. Each practice completed a Managed Care Survey to characterize the degree of organizational and financial restrictiveness for each individual health care plan. A total of 199 managed care plans were characterized. Then, 1475 consecutive outpatients completed a patient survey that included: the Components of Primary Care Instrument as a measure of attributes of primary care; a measure of the amount of inconvenience involved with using the health care plan; and the Medical Outcomes Study Visit Rating Form for assessing patient satisfaction. RESULTS: Clinicians' reports of inconvenience were significantly associated (P < .001) with the financial and organizational restrictiveness scores of the plan. There was no association between plan restrictiveness and patient report of multiple aspects of the delivery of primary care or patient satisfaction with the visit. CONCLUSIONS: Plan restrictiveness is associated with greater perceived hassle for clinicians but not for patients. Plan restrictiveness seems to be creating great pressures for clinicians, but is not affecting patients' reports of the quality of important attributes of primary care or satisfaction with the visit. Physicians and their staffs appear to be buffering patients from the potentially negative effects of plan restrictiveness.     

Past and future priorities in health promotion in the United States: a survey of experts

BACKGROUND. The purpose of this study was to determine past and future priorities of the health promotion industry. Parameters included target markets, program staff, ethical issues, corporate programs, and program sites. METHODS. This study focused on the predictive perceptions of 76 prominent health and fitness professionals. Participants completed an inventory designed to compare past and future practices in health promotion. The Wilcoxon rank-sign test was used to determine changes in perceived importance from past to future periods. RESULTS. The most important markets in the future were women and the elderly. Predictions regarding staffing included an expected increase in staff size in many program settings, a high importance rating for marketers and health educators, and standardized training and certification for health promotion personnel. Many employers in the future were predicted to link medical care costs and reimbursements with lifestyle behaviors, support confidentiality of health status information, and offer voluntary participation in health promotion programs to all employees. Employers were also predicted to provide more healthful work environments. DISCUSSION. Future success of these projected programs will depend upon administrative flexibility, creativity, and strategic planning.     

Perceptions of evidence-based programs among community-based organizations tackling health disparities: a qualitative study

Dissemination of prevention-focused evidence-based programs (EBPs) from research to community settings may improve population health and reduce health disparities, but such flow has been limited. Academic-community partnerships using community-based participatory research (CBPR) principles may support increased dissemination of EBPs to community-based organizations (CBOs). This qualitative study examined the EBP-related perceptions and needs of CBOs targeting underserved populations. As part of PLANET MassCONECT, a CBPR study, we conducted six key informant interviews with community leaders and four focus groups with CBO staff members in Boston, Worcester and Lawrence, Massachusetts, in 2008. Working definitions of EBPs among CBO staff members varied greatly from typical definitions used by researchers or funders. Key barriers to using EBPs included: resource constraints, program adaptation challenges and conflicts with organizational culture. Important facilitators of EBP usage included: program supports for implementation and adaptation, collaborative technical assistance and perceived benefits of using established programs. This exploratory study highlights differences among key stakeholders regarding the role of evidence in program planning and delivery. An updated perspective should better incorporate CBO perspectives on evidence and place greater, and much needed, emphasis on the impact of context for EBP dissemination in community settings.     

Total quality management in health: making it work

Many health organizations are trying total quality management (TQM). This approach represents a total paradigm shift in health care management and presents a series of potential conflict areas in the way health organizations are managed. These areas include TQM's participatory approach versus professional and managerial authority, collective versus individual responsibility, quality assurance and standards versus continuous improvement, and flexible versus rigid objectives and plans. This article reviews the areas of conflict and suggests a number of action guidelines for the successful implementation of TQM.     

Planning for program effectiveness in quality assurance

Quality assurance programs are now a fact of life in health care institutions, yet the effectiveness of these programs in improving care is unproven. Reports of quality assurance activities rarely discuss "remedy implementation" or the outcome of such attempts. Effectiveness does not flow naturally from sound methodology or documentation but is the most challenging part of the program. This article examines reasons for this difficulty, and the authors recommend strategies for improving problem resolution and increasing the influence of the program in the organization. They urge attention to program implementation and emphasize active participation by clinicians, patients, administration, and staff. This broad representation promotes examination of a wide range of patient care issues as well as medical audits, allows the program to enlist support for change, and enables the program to anticipate and make timely contributions to the decisions of policymaking groups.     

What are Medicare managed care plans doing to measure and improve quality of care?

To explore managed care plans' efforts to assess and improve quality of care for Medicare beneficiaries, the authors surveyed managed care plans with risk contracts for Medicare beneficiaries in 20 large metropolitan areas in January 1998. The survey inquired about: (1) the health plans' efforts to assess and improve quality of care for specific underuse, overuse, and misuse problems; (2) how the health plans assessed functional status of enrollees, and (3) the quality improvement program they believed had the greatest impact on the health of enrollees. The managed care plans reported a heterogeneous mix of quality improvement activities ranging from poorly developed to very sophisticated. The vast majority of the more sophisticated programs addressed problems with underuse of services rather than overuse or misuse.     

The Interventions to Reduce Acute Care Transfers (INTERACT) Quality Improvement Program: An Overview for Medical Directors and Primary Care Clinicians in Long Term Care

Interventions to Reduce Acute Care Transfers (INTERACT) is a publicly available quality improvement program that focuses on improving the identification, evaluation, and management of acute changes in condition of nursing home residents. Effective implementation has been associated with substantial reductions in hospitalization of nursing home residents. Familiarity with and support of program implementation by medical directors and primary care clinicians in the nursing home setting are essential to effectiveness and sustainability of the program over time. In addition to helping nursing homes prevent unnecessary hospitalizations and their related complications and costs, and thereby continuing to be or becoming attractive partners for hospitals, health care systems, managed care plans, and accountable care organizations, effective INTERACT implementation will assist nursing homes in meeting the new requirement for a robust quality assurance performance improvement program, which is being rolled out by the federal government over the next year.     

"This clinic is number one": a qualitative study of factors that contribute toward "successful" care at a South African Pediatric HIV/AIDS clinic

HIV/AIDS has significantly affected health care practices. The need for high adherence and regular clinic visits places pressure on health care providers and patients. Poor quality of care has been described in many contexts, but some clinics have achieved excellent treatment results. Using a success case approach, this study aimed to understand factors which contribute to successful care at a South African pediatric HIV/AIDS clinic with documented high patient adherence and follow-up rates. Data included over 50 hours of ethnographic observations and interviews with a total of 35 clinic staff and caregivers. Thematic analysis highlighted strong congruence between caregiver and staff perceptions. Factors which seemed to contribute to successful care included organizational routines, staff-patient relationships, communication, teamwork, leadership, job commitment, caregivers' negative experiences at other clinics, and faith in the "life-saving" care at this clinic. Results suggest the need for all factors to be present in order to promote quality of care. Recommendations for other clinic settings are discussed.     

Reconciling practice and theory: challenges in monitoring Medicaid managed-care quality

The massive shift to managed care in many State Medicaid programs heightens the importance of identifying effective approaches to promote and oversee quality in plans serving Medicaid enrollees. This article reviews operational issues and lessons from the ongoing evaluation of a three-State demonstration of the Health Care Financing Administration's (HCFA) Quality Assurance Reform Initiative (QARI) for Medicaid managed care. The QARI experience to date shows the potential utility of the system while drawing attention to the challenges involved in translating theory to practice. These challenges include data limitations and staffing constraints, diverse levels of sophistication among States and health plans, and the practical limitations of using quality indicators for a population that is often enrolled only on a discontinuous basis. To overcome these challenges, we suggest using realistically long timeframes for system implementation, with intermediate short-term strategies that could treat States and managed-care plans differently depending on their stage of development.     

Using diffusion of innovations theory to guide diabetes management program development: an illustrative example

BACKGROUND: Optimal management of type 2 diabetes requires achievement of optimal glucose, blood pressure and lipid targets through promotion of prudent diet, regular physical activity and adherence to necessary medication. This may require the development of new programs for the coordination of required multidisciplinary services. Diffusion of innovations theory offers a conceptual framework that may facilitate the implementation of such programs. METHODS: To illustrate this, we have re-examined the implementation experiences previously reported by the developers of an actual diabetes management pilot program in Montreal, with an eye toward identifying potentially important process factors that could effectively increase adoption and sustainability. RESULTS: Physician participation in the program appeared to be influenced by perceived advantages of participation, compatibility of the program with own perspective and perceived barriers to participation. Organizational features that may have influenced participation included the extent of the program's integration within the existing health care system. CONCLUSION: A thorough consideration of process factors that impact system and team integration must equally include a focus on ensuring ongoing partnerships among the producers of the model, governments, nongovernmental organizations, private industry, user professionals and patients. This can only be achieved when a knowledge transfer action plan is developed to guide program development, implementation and sustainability.     

Liability for managed care decisions: the Employee Retirement Income Security Act (ERISA) and the uneven playing field.

As managed care organizations expand their programs of quality assurance and physician evaluation, more medical malpractice lawsuits may be brought against managed care organizations on the ground that, like hospitals, they are legally responsible for negligent corporate acts that injure patients. However, the federal Employee Retirement Income Security Act (ERISA) shields managed care organizations from liability when they are part of an employee group health plan governed by ERISA. Unlike patients with other types of insurance, patients in ERISA health plans do not have a malpractice remedy for a managed care organization's negligence. A few federal appeals courts recently recognized that ERISA plans can be vicariously liable for their physicians' medical malpractice, but only if the physician is the plan's employee or agent. Yet ERISA still prohibits negligence claims against ERISA health plans for injuries resulting from denial of plan benefits, failure to use qualified physicians, utilization review, or improper plan administration. Current managed care operations do not neatly distinguish between administering benefits and controlling quality of care. Neither should the law. ERISA should be amended to provide employees with the same remedies that patients in non-ERISA plans enjoy.