Mount Sinai Journal of Medicine最新文献

Patients with serious illnesses are living longer and with greater disabilities. Palliative-care interventions have been shown to increase quality of life, lower costs, and improve survival. In order to meet the palliative-care needs of patients, it is crucial for primary-care clinicians to understand how they can provide primary palliative care and when they should refer to palliative-care specialists. By working together, many more patients and families will receive the comprehensive, individualized, coordinated care and support that both primary care and palliative care offers to patients. This article will review literature illustrating the benefits of palliative care; discuss why primary-care clinicians are ideally suited to incorporate palliative care into their practice; and provide guidance to primary-care clinicians regarding how and when to access palliative-care specialist services, how to gain more training in palliative care, and how to be reimbursed for palliative-care visits.

Skyrocketing health care costs are burdening our people and our economy, yet health care indicators show how little we are achieving with the money we spend. Federal and state governments, along with public-health experts and policymakers, are proposing a host of new initiatives to find solutions. The Patient Protection and Affordable Care Act is designed to address both the quality and accessibility of health care, while reducing its cost. This article provides an overview of models supported by the Affordable Care Act that address one or more goals of the "Triple Aim": better health care for individuals, better health outcomes in the community, and lower health care costs. The models described below rely on the core principles of primary care: comprehensive, coordinated and continuous primary care; preventive care; and the sophisticated implementation of health information technology designed to promote communication between health care providers, enhance coordination of care, minimize duplication of services, and permit reporting on quality. These models will support better health care and reduced costs for people who access health care services but will not address health outcomes in the community at large. Health care professionals, working in concert with community-based organizations and advocates, must also address conditions that influence health in the broadest sense to truly improve the health of our communities and reduce health care costs.

There is increasing interest in maintaining health and delaying disability for older adults as this population segment expands. And instead of focusing on a traditional disease-specific approach to health maintenance, there is an ongoing shift to a patient-centered approach, and defining outcomes based on the older adults' goals. In this approach, their goals and preferences are central, and other factors such as their health status and prognosis help determine which goals may be realistic. These subjective goals and objective characteristics are then balanced with the risks, benefits, and harms of established evidence-driven health-maintenance recommendations. Hence, older adults share their goals and preferences with clinicians; while clinicians share information on risks, benefits, harms, and uncertainties of existing health-maintenance recommendations, and help guide the older adult through how existing evidence can respond to their health goals and preferences. In this article, the concept of patient-centered care in the context of health maintenance for older adults is discussed; and health maintenance recommendations for older adults are reviewed.

The causes of homelessness are complex and multifactorial and the solutions equally complex. Though homelessness is not a disease process, it is directly linked to poor health outcomes. It is thus incumbent on health care professionals to know the various definitions of homelessness, the ramifications of unstable housing, and the specific living conditions of each homeless patient. These factors needed to be accounted for when designing treatment plans in a way that will increase access to care and promote adherence. Increasing compliance and addressing barriers to care will improve outcomes and may reduce overall health expenditures.

After a diminishing of its ranks following the post-World War II explosion of growth in medical discoveries, advanced medical technology, and the concomitant specialization of the physician workforce, family medicine is re-establishing itself as a leading medical specialty that has garnered growing interest among recent medical-school graduates. Family physicians provide care for patients of all ages, from newborns to the elderly. In addition to its wide scope of practice, family medicine is characterized by its emphasis on understanding of the whole person, its partnership approach with patients over many years, and its command of medical complexity. Family physicians are trained both to use community resources to assist individual patients in meeting medical or social needs and to identify and address community-wide needs. The specialty of family medicine is uniquely positioned to provide a leadership role in health-reform efforts that are accelerating across the country. Health care models that are gaining traction, such as the patient-centered medical home model, health homes, and accountable care organizations, share the characteristics of providing comprehensive, coordinated patient care with an emphasis on disease prevention and health promotion. This model of care, provided in the context of family and community, has been the hallmark of family medicine since its creation as a distinct medical specialty more than 40 years ago. In addition, family physicians' ability to care for patients of all ages make them particularly cost-effective as the new models of care move to improve access to care through expanded hours and locations.

The Meyerhoff Scholars Program at the University of Maryland, Baltimore County is widely viewed as a national model of a program that enhances the number of underrepresented minority students who pursue science, technology, engineering, and mathematics PhDs. The current article provides an overview of the program and the institution-wide change process that led to its development, as well as a summary of key outcome and process evaluation research findings. African American Meyerhoff students are 5× more likely than comparison students to pursue a science, technology, engineering, and mathematics PhD. Program components viewed by the students as most beneficial include financial scholarship, being a part of the Meyerhoff Program community, the Summer Bridge program, study groups, and summer research. Qualitative findings from interviews and focus groups demonstrate the importance of the Meyerhoff Program in creating a sense of belonging and a shared identity, encouraging professional development, and emphasizing the importance of academic skills. Among Meyerhoff students, several precollege and college factors have emerged as predictors of successful entrance into a PhD program in the science, technology, engineering, and mathematics fields, including precollege research excitement, precollege intrinsic math/science motivation, number of summer research experiences during college, and college grade point average. Limitations of the research to date are noted, and directions for future research are proposed.

Psychiatric disorders, particularly depression and anxiety disorders, are common in primary-care settings, though often overlooked or untreated. Depression and anxiety disorders are associated with a poorer course for and complications from common chronic diseases such as diabetes mellitus and coronary heart disease. Integrating psychiatric services into primary-care settings can improve recognition and treatment of psychiatric disorders for large populations of patients. Numerous research studies demonstrate associations between improved recognition and treatment of psychiatric disorders and improved courses of psychiatric disorders, but also with improvements in other chronic diseases such as diabetes. The evidence bases supporting the use of 2 models of integrated care, colocation of psychiatric care and collaborative care, are reviewed. These models' uses in specific populations are also discussed.

This article reviews existing models of physician compensation and presents information about current compensation patterns for primary-care physicians in the United States. Theories of work motivation are reviewed where they have relevance to the desired outcome of satisfied, productive physicians whose skills and expertise are retained in the workforce. Healthcare reforms that purport to bring accountability for healthcare quality and value-rather than simply volume-bring opportunities to redesign primary-care physician compensation and may allow for new compensation methodologies that increase job satisfaction. Physicians are increasingly shunning the responsibility of private practice and choosing to work as employees of a larger organization, often a hospital. Employers of physicians are seeking compensation models that reward both productivity and value.