Changing the chronic care system to meet people's needs.

Persons who are likely to be the heaviest users of medical and supportive care services--those with chronic illnesses, disabilities, and functional limitations--are often forced to navigate a system that requires them to perform most of the coordination functions themselves and is generally not organized around their needs. In 1996 an estimated 128 million Americans had at least one of these three conditions, and 9.5 million had all three. This paper examines the current programs designed to assist these persons and suggests changes in eligibility rules, coverage policies, and educational programs to provide a system more oriented to people's chronic care needs.

Predictors of homelessness among families in New York City: from shelter request to housing stability.

OBJECTIVES: This study examined predictors of entry into shelter and subsequent housing stability for a cohort of families receiving public assistance in New York City. METHODS: Interviews were conducted with 266 families as they requested shelter and with a comparison sample of 298 families selected at random from the welfare caseload. Respondents were reinterviewed 5 years later. Families with prior history of shelter use were excluded from the follow-up study. RESULTS: Demographic characteristics and housing conditions were the most important risk factors for shelter entry; enduring poverty and disruptive social experiences also contributed. Five years later, four fifths of sheltered families had their own apartment. Receipt of subsidized housing was the primary predictor of housing stability among formerly homeless families (odds ratio [OR] = 20.6, 95% confidence interval [CI] = 9.9, 42.9). CONCLUSIONS: Housing subsidies are critical to ending homelessness among families.

Factors important in the purchase of partnership long-term care insurance.

OBJECTIVE: To understand the factors important in the purchase of long-term care insurance through the Robert Wood Johnson Foundation Partnership for Long-Term Care. DATA SOURCES: Information on the Partnership programs, telephone surveys, data on Partnership purchasers, and random sample frames. STUDY DESIGN: Logistic regression analysis is used to examine characteristics associated with the purchase of a Partnership insurance policy. Independent variables are health status, demographic and financial characteristics, knowledge, and attitudes. DATA COLLECTION: A telephone survey of Partnership purchasers and a random sample of the population in each Partnership state were conducted. Survey questions included health status, opinions about long-term care and long-term care insurance, financial planning, demographic characteristics, and income and assets. PRINCIPAL FINDINGS: Important in the purchase of a Partnership policy were variables associated with education and knowledge about long-term care. Other important factors include attitudes and health status. Partnership purchase is associated with higher income and asset levels up to a point, with the effect plateauing and decreasing at the highest income and asset levels. CONCLUSIONS: Improved education and knowledge are important in increasing long-term care insurance purchase. Attitudes about having a caregiver, and about the government's role in paying for long-term care as well as the potential purchaser's willingness to consider nursing home care affect policy purchase. Also associated with Partnership policy purchase are better health and middle income and asset levels.

Tracking consumers' reactions to the changing health care system: early indicators.

A survey in fifteen communities and nationwide of consumers' opinions about changes in their local health care system reveals that Americans are surprisingly positive about recent changes in their personal access to and quality of care and consistently negative about changes in the cost of care. Although many consumers think that changes in the system are making things worse, they are optimistic about the trend toward managed care. Subgroup analysis shows that uninsured persons and persons with health problems reported high rates of concern about many of the health system issues we explored, while Medicaid recipients, Hispanics, and African Americans reported positive changes in their access to and quality of care.

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.

Reflections from The Robert Wood Johnson Foundation on The Program to Strengthen Primary Care Health Centers.

Given the modest amount of resources provided by the Foundation through The Program to Strengthen Primary Care Health Centers, the grantees undertook a high level of activity. Perhaps centers were aided by the momentum and focus of the Program in addition to financial resources. Such grants seem to move longer-range projects onto the daily agendas of managers. It might be worthwhile to convert some portion of federal community health center funding to support financial and managerial innovations. Generally, positive evaluation findings should encourage centers to explore some of the demonstrated initiatives. Evolution and innovation are considered key to the survival of primary care health centers.

RUG-II (Resource Utilization Group, Version II) impacts on long-term care facilities in New York.

This article observes changes during the first 5 years of Resource Utilization Group, Version II (RUG-II) system utilization by the New York State Department of Health (NYDOH) for Medicaid program reimbursement. Findings include a dramatic increase in the number of residents scoring in the highest intensity resident-care categories, a substantial increase in staffing and expenditures for rehabilitation therapies, and a possible negative impact on the financial performance of New York long-term care (LTC) facilities. RUG-II appears to have been successful in improving access to nursing homes for individuals with heavy-care needs and in encouraging the appropriate utilization of institutionalized skilled nursing care.

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.

Predictors of shelter use among low-income families: psychiatric history, substance abuse, and victimization.

For poor housed and homeless families in New York City, NY, we examined the degree to which psychiatric and substance-abuse problems and victimization placed the families at elevated risk of requiring emergency housing, and we documented the prevalence of such problems. These problems were infrequently reported by both groups. However, past mental hospitalization, treatment in a detoxification center, childhood sexual abuse, and adult physical abuse were associated with increased risk of homelessness.

Connecting the disconnected: adult day care for people with AIDS in New York City.

Despite pressing need, the development of a continuum of long-term-care services for people with acquired immune deficiency syndrome (AIDS) has been hampered by the dearth of information on the characteristics and service needs of patients eligible for such care. This article presents findings from a process evaluation of an outpatient day care program for people with AIDS in New York City. The AIDS clients were highly functional but had a diverse range of needs and problems related to housing, substance abuse, medical care, and social support. The majority of clients reported being very satisfied with the level of staff support and with the overall program. The findings of the study suggest that day care is a valuable addition to the continuum of services and that the creative dissemination of this program may improve the delivery of services to people with AIDS.

The potential for using non-physicians to compensate for the reduced availability of residents.

Both the number of residents and the amount of time existing residents have in which to carry out their activities may soon be decreasing. To consider the potential for alternative ways of staffing teaching hospitals, it is necessary to know how residents spend their time. The authors sought to learn this by conducting a time-motion study of eight internal medicine residents at two urban hospitals in New York City in 1988. The residents' activities were observed and coded by premedical students, and the authors independently classified the possible activities into (1) those that had to be done by a physician, (2) those that were educational only, and (3) those that could be done by a non-physician. A total of 1,726 activities of 67 kinds were coded, averaging 7.75 minutes each. The authors analyze and project their data using two models--the traditional model of care in which the physician is the primary medical manager of the patient, and an alternative model in which a midlevel practitioner, such as a nurse practitioner, would perform the day-to-day monitoring of patients. For example, the data indicate that in the traditional model, almost half of a resident's time is spent in activities that must be done by a physician, meaning that another kind of physician would be needed to do those activities if the resident were unavailable; but in the midlevel practitioner model, only around 20% of the activities would require a physician. The authors give detailed breakdowns of their data, estimate the kinds and numbers of non-physician health care professionals necessary to substitute for residents in appropriate activities, and review possible difficulties in implementing such substitutions.