The Hospice journal最新文献

Since the inception of the Medicare hospice benefit, hospice has marked a new approach to managed care. Its focus on cost-effectiveness has made it one of Medicare's most successful managed care options. Various restrictions were placed on the hospice program; but, in return for these limitations, advocates of the program received an opportunity to create a program entirely different from other Medicare providers. The challenges of operating a hospice include electing hospice care, candid communication, and the relationship with other providers. These challenges will continue to burden hospices until discussions of death can be direct, clear, and knowledgeable.

Despite the apparent advantages of hospice care, several barriers exist in terms of patient referral. Physicians' prognoses play a large role in determining when hospice care should begin. Predicting patient survival is a subjective decision dependent on several factors that vary before and after hospice enrollment. Currently, the stay of patients in hospice is very short; this can be attributed to late referral by physicians. Additional research on physician behavior and prognostication could help optimize the use of hospice as a valuable health care resource, thereby improving end of life care for terminally ill patients.

Premium adjustors to neutralize risk selection among health plans are the weakest component in the technology for assuring competitive markets. It will be many years before we have adjustors adequate to free health plans to invest in and market improved managed care to predictably high-cost chronically ill persons. For want of a fair premium, health plans are driven by risk selection to underinvest in and otherwise "demarket" care to these very employees and beneficiaries whose costs and care most need to be managed. To achieve best value for the chronically ill, large employer coalitions, Medicare, and Medicaid should consider radical new approaches, such as establishing separate prices for care to people with specific chronic conditions and purchasing such care both from health plans and directly from provider systems.

This article asserts that in light of changing conditions in the healthcare environment, transformational leadership is the most appropriate leadership style for the hospice registered nurse case manager. The author defines transformational leadership and, tracing from early leadership theories, demonstrates how the transformational-transactional leadership paradigm emerged from preceding leadership theories. The components of transformational leadership--transformational behavior and transformational characteristics--are linked to hospice theory and hospice-specific nursing practices. The expanding role of the hospice R.N. case manager is addressed in light of transformational leadership and culture building. Specific actions are proposed in the arenas of research, education, and community, corporate, and legislative involvement.

This paper presents summaries of initiatives and demonstration programs developed by professional and patient care organizations to improve care at the end of life.

Pain among cancer patients is a common distressing symptom that frequently affects physical functioning, social interaction, psychological status, and quality of life. Despite the extensive body of knowledge available regarding cancer pain assessment and management, it often remains untreated, thereby diminishing the quality of patient care at the end of life. Recommendations on how to remove these barriers, as well as to improve care of the dying in general, need to be implemented by the U.S. government.

Although designed to respond to acute illness, the current health care system must increasingly provide care for people living longer with chronic diseases. Evaluation of the quality of this care must utilize appropriate measurements, study populations, and outcomes. Current quality measures and major studies of quality of care are highlighted. A framework for measuring quality of care is outlined.

The purpose of this study is to examine the turning points volunteers found important in their hospice training and volunteer experiences. Seventeen individuals who had recently completed hospice training were asked about the turning points in their training and volunteering that were important in their becoming and remaining a hospice volunteer. The study finds that volunteers have a wide variety of intrapersonal, interpersonal, and group reasons for becoming and remaining a hospice volunteer. The findings suggest that hospice staff need to create a wide variety of events which volunteers can identify with to help people want to become and remain volunteers.

People in the last phase of life often need a very different care system than the one currently available. MediCaring extends the hospice model to a larger population with a wider array of services over a longer period of time with an emphasis on symptom management, maintenance of function, comfort and family counseling. This model requires simultaneous efforts to secure longer life and to make the patient and family ready for dying. Services range from psychological and spiritual counseling for the patient and family, to emergency care access, to inpatient respite care. MediCaring would accomplish these goals without increasing costs, primarily by diminishing the use of acute care interventions that may no longer serve the patient.

The purposes of this study were (1) to describe both religious and nonreligious appraisals of caregiving for a terminally ill patient and (2) to explore the relationship between these appraisals with situational outcomes, mental health outcomes, and spiritual health outcomes in the caregivers. Ninety-two caregivers completed a questionnaire consisting of religious and nonreligious appraisals, general and religious outcomes, depression, anxiety, and purpose in life. Caregivers who appraised their situation as part of God's plan or as a means of gaining strength or understanding from God reported positive outcomes while caregivers who viewed their situation as unjust, as unfair punishment from God, or as desertion from God had low scores on mental and spiritual health outcomes. Religious appraisals made a significant and unique contribution to the prediction of situational outcomes and mental and spiritual health outcomes above and beyond the effects of nonreligious appraisals.