Effects of Paying Physicians Based on their Relative Performance for Quality

Background Studies examining the effectiveness of pay-for-performance programs to improve quality of care primarily have been confined to bonus-type arrangements that reward providers for performance above a predetermined threshold. No studies to date have evaluated programs placing providers at financial risk for performance relative to other participants in the program. Objective The objective of the study is to evaluate the impact of an incentive program conferring limited financial risk to primary care physicians. Participants There were 334 participating primary care physicians in Rochester, New York. Design The design of the study is a retrospective cohort study using pre/post analysis. Measurements The measurements adhere to 4 diabetes performance measures between 1999 and 2004. Results While absolute performance levels increased across all measures immediately following implementation, there was no difference between the post- and pre-intervention trends indicating that the overall increase in performance was largely a result of secular trends. However, there was evidence of a modest 1-time improvement in physician adherence for eye examination that appeared attributable to the incentive program. For this measure, physicians improved their adherence rate on average by 7 percentage points in the year after implementation of the program. Conclusions This study demonstrates a modest effect in improving provider adherence to quality standards for a single measure of diabetes care during the early phase of a pay-for-performance program that placed physicians under limited financial risk. Further research is needed to determine the most effective incentive structures for achieving substantial gains in quality of care.     

The ministry of nursing

Historically, the nursing profession has roots in the Christian concept of ministry. A caring ministry called for persons to serve their neighbours who were in need physically or spiritually. Persons were seen as wholes. As caring professions developed into separate and distinct entities, many continued to share a holistic view of people and to address similar needs. Nursing and pastoral care workers especially share concern for meeting common client patient needs; for example, providing concern and comfort, assisting persons to find meaning in their situation, responding to spiritual distress, and helping persons to experience hope. Many of the caring qualities of today's nurses are pastoral in nature, and contribute richly to healing. Examining nursing as ministry provides an opportunity to consider the nature of nursing as it moves into the 21st century.     

Chaplaincy and Narrative Theory: A Response to Risk's Case Study

The response of a clinical chaplain to a case study of chaplaincy with an elderly African-American male with Parkinson's disease is presented. The case study offers two novel aspects: first, it explicitly describes interventions by the chaplain, and second, the chaplain's clinical approach was guided throughout by an underlying theory (narrative theory). The case study seeks to shift the paradigm from chaplains as “agenda-less” companions to clinicians with a repertoire of interventions which they should claim. The chaplain's use of narrative theory is examined. Future case studies may draw on narrative theory in chaplaincy with older males with different chronic disease, with women who have Parkinson's, and may seek to develop a theory of chaplaincy from within the profession.     

Transitions Model: Melding of Psychotherapy and Palliative Care Using Teams

This article explains a hospital palliative model called the Transitions and Palliative Care Therapy (TPCT) and provides data. In addition, the Geriatric Interdisciplinary Team Treatment (GITT) program, using its experience with hospice and research based knowledge, applied key principles of teamwork to enhance the TPCT team approach. GITT was applied to TPCT for 1 year. The TPCT model is a transitions counselors–based model that is a hospital-centered, interdisciplinary consult service, with a focus on the patient and the family. It employs master's level counselors and mid-level providers, with a much smaller group of palliative care physicians who supervise mid-level practitioners and provide medical input and leadership. Outcomes evaluated were hospital cost, family and staff satisfaction, and number of consults that led to de-escalating treatment. In all cases the GITT model was effective; it assisted with improved cost, better satisfaction, and an increased number of consults.     

The Role of Forgiveness in Rehabilitation

This article proposes that unresolved forgiveness issues may affect rehabilitation patients' motivation to participate in their physical therapy, and that their therapeutic outcomes may benefit from working through a forgiveness process. I also suggest that chaplains have a role in helping patients address their unresolved forgiveness issues and lowered motivation by helping the patients work through a forgiveness process. For patients with conditions caused at least in part by their own behavior, or even by someone else, this article offers a case study of pastoral care provided in light of unresolved forgiveness issues and a working through of a forgiveness process. Also presented is a revised model of a forgiveness process that informs the pastoral care provided in the case study.     

Resilience and Professional Chaplaincy: A Paradigm Shift in Focus

Research into the area of resilience provides a challenge and a great opportunity for professional chaplaincy. In this article, we will consider the challenge that the research primarily of George Bonanno of Columbia University offers to the traditional, clinical perspectives and assessments of professional chaplains serving in health care. Secondly, we will propose the practical implications for a wider paradigm and an expanded focus on intentionality and interventions of chaplains. Resilience is seen as a positive response possibility for those facing potentially traumatic events. It is understood to be a predominant response to traumatic events more often than the grief recovery model usually presumed to be active. Resilience has heuristic value and merits being factored in to professional chaplaincy as it relates to patient assessment, interventions, interdisciplinary care, staff and corporate support, and transcultural usefulness.