Paper series (United Hospital Fund of New York)最新文献

Responding to changes in health care financing, government policy, technology, and clinical judgment, and the rise of managed care, hospitals are shifting services from inpatient to outpatient settings and moving them into the community. Institutions are evolving into integrated delivery systems, developing the capacity to provide a continuum of coordinated services in an array of settings and to share financial risk with physicians and managed care organizations. Over the past several years, hospitals in New York City have shifted considerable resources into ambulatory care. In their drive to expand and enhance services, however, they face serious challenges, including a well-established focus on hospitals as inpatient centers of tertiary care and medical education, a heavy reliance upon residents as providers of medical care, limited access to capital, and often inadequate physical plants. In 1995, the United Hospital Fund awarded $600,000 through its Ambulatory Care Services Initiative to support hospitals' efforts to meet the challenges of reorganizing services, compete in a managed care environment, and provide high-quality ambulatory care in more efficient ways. Through the initiative, 12 New York City hospitals started projects to reorganize service delivery and build an infrastructure of systems, technology, and personnel. Among the projects undertaken by the hospitals were:--broad-based reorganization efforts employing primary care models to improve and expand existing ambulatory care services, integrate services, and better coordinate care;--projects to improve information management, planning and testing new systems for scheduling appointments, registering patients, and tracking ambulatory care and its outcomes;--training programs to increase the supply of primary care providers (both nurse practitioners and primary care physicians), train clinical and support staff in the skills needed to deliver more efficient and better ambulatory care, prepare staff for practicing in a managed care environment, and help staff communicate with a culturally diverse patient population and promote the importance of primary care within the community. Significant innovations and improvements were realized through the projects. Several hospitals expanded the availability of primary care services, trained new primary care providers, and helped patients gain access to primary care clinicians for the first time. Better methods for documenting ambulatory care were introduced. To increase efficiency and improve service to patients, some of the hospitals instituted automated appointment systems and improved medical record services. To reduce fragmentation and contain personnel costs, support staff positions were redesigned, and staff were retrained to carry out new multi-tasked responsibilities. Many of the components vital to high-quality ambulatory care can take years to develop, and significant investments of capital. Increased primary care capacity, n

Between 1992 and 1995, the United Hospital Fund engaged two groups of New York City hospitals in collective efforts to address crucial issues of length of stay and patient-centered care; the three-year, $1.1-million Length of Stay Initiative, which supported projects in seven New York City hospitals to identify and change practices that unnecessarily prolong inpatient stays; and the two-year, $700,000 Patient-Centered Care Consortium, through which 15 hospitals surveyed patients and received grants and technical support to design, implement, and evaluate improvements in meeting patients' expressed needs for more personalized care. Specific strategies and interventions developed and tested through the Length of Stay Initiative included continuous quality improvement programs to reduce delays and prevent duplication of diagnostic tests; clinical pathways to reduce unnecessary and inefficient variations in the treatment of common conditions and diseases; and a variety of other techniques, such as work redesign, diagnostic-specific clustering of patients, interdisciplinary design teams, and interdisciplinary rounds. Activities undertaken by the hospitals participating in the Patient-Centered Care Consortium included an initial survey of 3,423 patients and subsequent focus groups, individual interviews, and additional surveys to better understand the nature and causes of problems with care and to target, design, and test small-scale improvements. Among the first products to the consortium were patient education and information programs; daily treatment plans; improvements in the coordination of care and in teamwork among health care professionals; redesigned interpreter services, and improved methods of providing emotional support. Through their projects in the Length of Stay Initiative and Patient-Centered Care Consortium the participating hospitals learned some important lessons about what it takes to increase efficiency, improve the quality of patient care, and provide better service to patients. Strong leadership, institutional support, the involvement of medical staff, an interdisciplinary approach, an investment in staff training, the ability to work through resistance to change, systems and support for collecting performance data, and ways to evaluate how well improvements work were found to be especially key.

Recent surveys of patients in New York and Cleveland, among other cities, indicate that there is substantial room for improvement in meeting patients' needs and preferences, particularly in the areas of emotional support, coordination of care, discharge preparation, and the involvement of family and friends. Hospitals are using a variety of techniques to improve patient care and organizational efficiency in this challenging environment. One prominent approach, reengineering, offers a means by which hospitals can integrate highly specialized departmental structures and functions by focusing on interdisciplinary teamwork and organizing the delivery of care around patients. Key elements of successful hospital reengineering efforts have included: - the involvement and commitment of senior management and other key stakeholders, particularly physicians, nurses, and union representatives; - investment in staff training and retraining, and the redesign of staff evaluation and compensation systems; - timely, unit-specific measures of patient satisfaction and the clinical quality of care; - consistent and frequent internal communication between staff and leadership; and - treatment that emphasizes communication among caregivers, patients, and their family members. Several basic issues need to be addressed if hospitals are to offer technically sophisticated medical care that is also responsive to their patients' personal needs, including: - variations among patients regarding the amount of information they want and need, and the amount of involvement they want in their care; - the means by which patients will get information about their medical care, and who will provide any additional support that may be needed by non-English-speaking or socioeconomically disadvantaged patients; and - the specific changes in medical practice and hospital processes that will promote the involvement of patients in their care.

This paper focuses on providing quality care in the paraprofessional home care industry. Despite government policies that have encouraged home-based care for 20 years, home health care still remains relegated to second-class status by the rest of the health care industry. Home care is unique because it relies primarily on paraprofessional care delivered by a home care aide working alone, essentially as a guest in the client's home. The resulting interpersonal dynamic between patient and caregiver--which develops far from the eyes of the primary physician, regulators, and third-party payers--is one unlike any other patient-caregiver relationship in the health care system. The quality of care received by the client is linked directly to the quality of the paraprofessional's job: "good jobs" are prerequisite for "good service." Good jobs, however, are not enough. They must be supported by paraprofessional agencies that add real value to the home care service. Part I We define quality home care as meeting the client's needs. Unfortunately, since home care is provided in dispersed, minimally supervised settings, measuring quality of service is very difficult. For this reason, we suggest that it is the front-line employee--the home care aide who is present for hours every visit--who can best determine if the client's needs are being met, and who is best positioned to respond accordingly. Part II To best meet client needs, paraprofessional home care must be built around the home care aide. This requires that home care aides (1) be carefully selected during the hiring process, (2) be well trained, and (3) be empowered with considerable responsibility and capacity to respond to the daily needs of the clients. This Model, one that emphasizes the front-line employee, is in full keeping with the "total quality management" innovations that are currently reorganizing America's service industries. Unfortunately this model is not typically reflected in current paraprofessional home health care practice. Part III Building the home care service around home care aide requires redesigning the paraprofessinal's job in 5 ways: 1. Make work pay, by providing a minimum of $7.50 per hour and a decent benefits package.(ABSTRACT TRUNCATED AT 400 WORDS)

Emergency department overcrowding may not be so much a result of inappropriate use of the emergency department as it is a problem of the unavailability and inaccessibility of primary care services in the community. The prevailing theory that people use the emergency department because they cannot afford care elsewhere does not hold true. The vast majority of patients surveyed as part of the Emergency Services Initiative had some type of coverage, primarily Medicare or Medicaid. Without additional primary care capacity to accommodate walk-in patients and to make appointments available within one to two weeks, emergency departments will remain over-crowded. In addition to increasing primary care capacity, services must be structured to be as convenient and amenable to patient use as the emergency department. The findings of the Emergency Services Initiative supports the Preferred Primary Care Provider guidelines for the assignment of a primary practitioner or team to each patient, 24-hour telephone access for medical advice, evening and weekend hours, accommodation of walk-in patients, and the provision of nonurgent appointments within a maximum of two to four weeks. In addition, easy access to ancillary services for lab tests and X rays is beneficial for attracting patients. Patient education is also necessary. Questioning by counselors indicated that patients often do not understand that primary care settings are more appropriate than the emergency department for treatment of minor health problems. The most effective way to implement change in the health care system may not be through broad, generic prescriptions but through well-designed programs tailored to specific sites and communities. Changing staff behavior is often as challenging as changing patient behavior. Pre-project planning and communication about purpose, scope, and procedures are necessary if projects are to begin and continue smoothly. Ongoing evaluation is also key.

As the number of Americans who volunteer grows, the definition of "volunteer" is becoming more broad. In addition to the traditional volunteer opportunity, there are community service, student internship, and court-ordered service programs, all of which pose a set of complicated managerial questions for those charged with designing and running volunteer programs. Today, volunteers' motives may extend further than the simple desire to help their neighbor. For example, given the tough job market, some individuals are volunteering as a possible bridge to employment, and are eager to learn skills and gain experience that they might transfer to a new work setting. The growth in the number of volunteers is not without its down side, however. As governments have cut back on service programs, some responsibilities traditionally assumed by government are being shunted to volunteer organizations, an inappropriate solution. Although volunteer programs deserve support, governments cannot be let off the hook. Volunteers cannot and should not replace paid staff. There are a number of exciting and innovative approaches to recruiting, managing, and motivating volunteers. Some programs are responding to the new kinds of volunteers by restructuring the volunteer opportunity to make it more accessible to those who work from 9 to 5. Others are responding to the diversity of the communities they serve by seeking training in cultural sensitivity and recruiting volunteers from the community. Whatever the volunteer opportunity, the screening and placement interview is a crucial first step. It should be used to clarify expectations--of the volunteer and of the volunteer administrator. Once volunteers are on board, the key to managing and retaining volunteers is to recognize what motivates the individual volunteer--whether it is the desire to acquire job-related skills, to socialize, or simply to learn new things--and to provide the volunteer with these opportunities. Continuing education, training, and feedback are essential ingredients of any volunteer program. Another key to retaining volunteers is appropriate recognition. Although volunteers may appreciate the traditional pin or letter of thanks, volunteer administrators should explore other means of recognition that are tied in to the individual volunteer's motives for volunteering in the first place. Involving volunteers in the development and refinement of the volunteer program and considering their suggestions for improvements are important ways of keeping them involved and signaling recognition of their expertise and value.(ABSTRACT TRUNCATED AT 400 WORDS)

In 1989, almost 10 percent of all patients--or nearly 100,000 patients--hospitalized at facilities located in New York City were not city residents. Nonresidents are attracted to the city by the prestige and expertise of the city's hospitals; they are more likely than residents to require the hospitals' most sophisticated and specialized services, ranging from transplantation and coronary bypass surgery to treatment of malignant conditions. The largest numbers of nonresident patients, however, receive care for conditions that are relatively routine, care which would seem to be generally available at suburban hospitals. Although New York City hospitals continued to serve a substantial number of patients residing outside the city, the flow of nonresident patients seems to be slowly diminishing, particularly at the city's academic medical centers. (The specialty hospitals, on the other hand, seem to be attracting an increasing share of nonresident patients.) This decline occurred despite the one-third increase in population since 1960 in the New York State counties surrounding the city. To complicate matters, many New Yorkers are leaving the city for care. Almost 40,000 New York City residents were admitted to hospitals elsewhere in New York State, and perhaps another 20,000 to 40,000 may be receiving hospital care in other states. These trends have obvious implications for the city's hospital in their dual role as leaders in advanced and sophisticated medical care and as providers of vital patient care services to the city's population. The most highly specialized services can maintain clinical expertise and remain financially viable only if a sufficient number of patients can be attracted from throughout the metropolitan area and beyond. Likewise, the city's hospitals can be confident of fulfilling basic patient care needs only as long as New Yorkers do not look elsewhere for care. With the myriad pressures on our hospitals, the challenge of keeping them inviting and responsive will be formidable, but the construction of modern facilities, emphasis on patient-centered care, cultivation of strong relationships with communities and practitioners, and careful monitoring of patient flows and patient satisfaction should help the city's hospitals continue to attract patients, both from within the city and beyond the city limits.