A randomized trial of nurse specialist home care for women with high-risk pregnancies: outcomes and costs.

OBJECTIVE: To examine prenatal, maternal, and infant outcomes and costs through 1 year after delivery using a model of prenatal care for women at high risk of delivering low-birth-weight infants in which half of the prenatal care was provided in women's homes by nurse specialists with master's degrees. STUDY DESIGN: Randomized clinical trial. PATIENTS AND METHODS: A sample of 173 women (and 194 infants) with high-risk pregnancies (gestational or pregestational diabetes mellitus, chronic hypertension, preterm labor, or high risk of preterm labor) were randomly assigned to the intervention group (85 women and 94 infants) or the control group (88 women and 100 infants). Control women received usual prenatal care. Intervention women received half of their prenatal care in their homes, with teaching, counseling, telephone outreach, daily telephone availability, and a postpartum home visit by nurse specialists with physician backup. RESULTS: For the full sample, mean maternal age was 27 years; 85.5% of women were single mothers, 36.4% had less than a high school education, 93.6% were African American, and 93.6% had public health insurance, with no differences between groups on these variables. The intervention group had lower fetal/infant mortality vs the control group (2 vs 9), 11 fewer preterm infants, more twin pregnancies carried to term (77.7% vs 33.3%), fewer prenatal hospitalizations (41 vs 49), fewer infant rehospitalizations (18 vs 24), and a savings of more than 750 total hospital days and $2,496,145 [corrected]. CONCLUSION: This model of care provides a reasoned solution to improving pregnancy and infant outcomes while reducing healthcare costs.

Combining accounting approaches to practice valuation.

Healthcare organizations that wish to acquire physician or ambulatory care practices can choose from a variety of practice valuation approaches. Basic accounting methods assess the value of a physician practice on the basis of a historical, balance-sheet description of tangible assets. Yet these methods alone are inadequate to determine the true financial value of a practice. By using a combination of accounting approaches to practice valuation that consider factors such as fair market value, opportunity cost, and discounted cash flow over a defined time period, organizations can more accurately assess a practice's actual value.

A randomized trial of early discharge and nurse specialist transitional follow-up care of high-risk childbearing women.

In a randomized clinical trial, quality of health care as reflected in patient outcomes and cost of health care was compared between two groups of high-risk childbearing women: women diagnosed with diabetes or hypertension in pregnancy. The control group (N = 52) was discharged routinely from the hospital. The intervention group (N = 44) was discharged early using a model of clinical nurse specialist transitional follow-up care. During pregnancy, the intervention group had significantly fewer rehospitalizations than the control group. For infants of diabetic women enrolled in the study during their pregnancy, low birth weight (< or = 2,500 g) was three times more prevalent in the control group (29%) than in the intervention group (8.3%). The postpartum hospital charges for the intervention group were also significantly less than for the control group. The mean total hospital charges for the intervention group were 44% less than for the control group. The mean cost of the clinical specialist follow-up care was 2% of the total hospital charges for the control group. A net savings of $13,327 was realized for each mother-infant dyad discharged early from the hospital.

Avoiding managed care pricing pitfalls.

Healthcare providers, concerned about competing as managed care proliferates, have attempted to negotiate as many contracts as possible to secure market share. Economic theory suggests that, in the short run, any contract that yields incremental revenues in excess of incremental costs is desirable. However, the marginal costs associated with managed care contracts can have serious financial consequences. Maimonides Medical Center (MMC), New York, New York, had negotiated a variety of payment terms and methods for inpatient healthcare services--including discounts off the Federal DRG rate, discounts off the state-regulated case-payment rate for managed care companies, global pricing, per-diem rates, and capitation--with more than 15 managed care companies. As market incentives changed, however, contract decisions that had been made either "on the margin" or in response to market-driven prices did not always improve financial performance over the long term. Some of the unexpected pitfalls MMC encountered were dual discounting and adverse risk selection.

Downsizing administrative staff without causing burnout.

In sum, the most direct route to avoiding burnout in downsizing is to change the philosophy of the department and organization. Narrowly defined jobs cannot persist when positions are being eliminated. Managers need to find ways to accomplish the goals of the hospital within the available financial resources. To gain the staff support and commitment for doing that, the hospital must become much more receptive to seeking advice from the employees themselves on how it can be done.

Implementation of a variety of computerized bedside nursing information systems in 17 New Jersey hospitals.

This article examines issues of implementing nursing information computer systems in 17 hospitals in New Jersey and the initial effects of such systems as perceived by users. Unlike previous studies that examined the effects of one system in one hospital, this study examines the effects of several major systems in a variety of settings. Many of the hospitals experienced major delays or other problems with implementation; the hospitals in which timely implementation occurred were the ones that had purchased a commercially available stand-alone nursing system and did not try to develop interfaces or do extensive development. While these hospitals did meet with difficulties and needed some software customization, the problems were not so severe as to impede timely implementation. On the other hand, most of the hospitals that had major delays had planned more ambitious projects. These hospitals either required development work with vendors or were implementing a nursing information system while simultaneously putting in place a hospital system. Initial staff impressions of the effects of the system were positive; nursing department staffs reported that they liked the nursing systems. They said that documentation was better (more readable, complete, and timely) and they also believed that care was improved because the computer prompted nurses on what to look for and what to do. Support for these systems from hospital administration, outside of nursing, was cautious and based primarily on cost/benefit results.

The financial impact of management innovations by health centers.

The primary goal of The Program to Strengthen Primary Care Health Centers was to identify innovations that could improve the financial viability of health centers. This article describes the impact of program-related innovations on financial indicators. During the study period, all of the participant centers continued in existence, whereas one of the comparison centers went bankrupt. Total revenue and net income both improved significantly for the study centers relative to the comparison group. Centers that received audits of their operational systems prior to program commencement fared less well than those that did not.

Management techniques at primary care health centers: the impact of management innovation.

Long-term financial viability was a goal of The Program to Strengthen Primary Care Health Centers. To accomplish this, it was expected that participant centers would increase their management capabilities. We evaluated 32 management techniques in five principal areas: budgeting, strategic planning, general financial management, collections, and general health services management. Eight of the techniques showed change over the course of the demonstration (six increases and two decreases). It appears that there was somewhat more improvement among study centers than in a comparison group. Management sophistication has been expanding among health centers in general; Program participation appears to have accelerated this growth.

Case studies of management innovation at primary care health centers.

This article discusses the experiences of four individual health centers that participated in The Program to Strengthen Primary Care Health Centers. These centers were attempting "typical" initiatives, were considered highly likely to succeed, and were located in geographically diverse areas. Given these characteristics, it is likely that other centers could replicate their endeavors and could gain valuable knowledge from their implementation experiences. This article presents each center's characteristics, history, and mission; describes the environment in which the center operates; and discusses the barriers to implementation of selected innovations.

Innovations by primary care health centers: lessons for managers and policy makers.

This article highlights results from the evaluation of The Program to Strengthen Primary Care Health Centers, and suggests some directions for public policy. Program participants reported substantial improvements in financial viability, given the relatively small monetary investment. Technical assistance in the development of innovations, however, appears to dampen creativity and ultimately hinder financial gains. Recommendations address improved physician retention, the development of professional expertise, the importance of attention to long-range objectives, the related problems of excess capacity and surplus patient demand, and the integration of primary care health centers into managed care systems and health networks.

Improving the financial viability of primary care health centers.

This article presents findings from a national demonstration program to improve the long-term financial viability of small not-for-profit primary care health centers. The program initiatives and their implementation are described in some detail. A standard pre/post study design was used to measure the impact of the initiatives on general outcome measures, financial ratios, and the utilization of management techniques. Overall, demonstration centers showed improvement over the study period. Notable short-term improvements included significant growth in the volume of patient visits and increased profit. Observed changes also revealed an increased use of sophisticated management techniques, expected to positively affect longer-term financial health. The findings suggest that improving the financial viability of health centers need not be expensive.

Innovation in nursing: a benefit/cost analysis.

This study found that costs of implementing projects aimed at improving nurse recruitment and retention vary substantially. At 37 hospitals the costs ranged from a mean of $1,029 per bed for shared governance to $8,399 per bed for computer projects. For a typical 30-bed unit implementing a non-computer project, an average of 1,800 hours of personnel time was devoted to implementation. In most cases, hospitals found that the projects took more resources than expected to get off the ground. The benefit/cost results indicate that the potential annual savings in hospital operation costs associated with reduced length of stay were approximately $3,015 for each $1,000 of one-shot implementation costs spent per bed.

Nursing care delivery models and nurse satisfaction.

The relative impact of various nursing care delivery models and management interventions on nurse satisfaction was assessed in 37 New Jersey hospitals. Nurses ranked pay as the most important factor, followed by autonomy and professional status. Changes in scores between pilot and comparison units were significantly different for satisfaction with interactions and task requirements. Change in satisfaction with interaction was significant for all initiatives in aggregate, as well as for each of the five types of initiatives separately. The change in satisfaction with task requirements was significant for all initiatives taken as a group and for those units that implemented reorganization, computer, and education initiatives. Even among nurses who eventually liked the new environment there was a period of initial dissatisfaction.

A comparison of work-sampling and time-and-motion techniques for studies in health services research.

OBJECTIVE: This study compares results and illustrates trade-offs between work-sampling and time-and-motion methodologies. DATA SOURCES: Data are from time-and-motion measurements of a sample of medical residents in two large urban hospitals. STUDY DESIGN: The study contrasts the precision of work-sampling and time-and-motion techniques using data actually collected using the time-and-motion approach. That data set was used to generate a simulated set of work-sampling data points. DATA COLLECTION/EXTRACTION METHODS: Trained observers followed residents during their 24-hour day and recorded the start and end time of each activity performed by the resident. The activities were coded and then grouped into ten major categories. Work-sampling data were derived from the raw time-and-motion data for hourly, half-hourly, and quarter-hourly observations. PRINCIPAL FINDINGS: The actual time spent on different tasks as assessed by the time-and-motion analysis differed from the percent of time projected by work-sampling. The work-sampling results differed by 20 percent or more of the estimated value for eight of the ten activities. As expected, the standard deviation decreases as work-sampling observations become more frequent. CONCLUSIONS: Findings indicate that the work-sampling approach, as commonly employed, may not provide an acceptably precise approximation of the result that would be obtained by time-and-motion observations.

Changing the delivery of nursing care. Implementation issues and qualitative findings.

Faced with a shortage of professional nurses, 37 hospitals in New Jersey implemented a variety of approaches to changing the delivery of nursing care. Implementation issues, including the positive and negative effects of the changes, are discussed. Most project coordinators reported that implementation was more difficult than they had anticipated.