Health care systems: the emperor has no clothes.

Stand-alone hospitals are becoming something of a rarity on the American landscape. While hospital boards have repeatedly voted to form systems in the last 10 to 20 years, they have been just as likely to neglect to identify specific, measurable benefits that a merger would bring to their institution. An even if they did, they frequently discontinued evaluating whether system formation brought the hoped-for benefits, thereby justifying ongoing system participation. It is an incumbent fiduciary obligation to continually ask the question: Does continued participation make sense; that is, are we appropriately exercising stewardship over the hospitals' or system's assets by participating in this system? In a sense, boards are in danger of becoming like the emperor in the children's fairy tale, believing they have done the right thing without taking a hard look at today's reality.

Home care and the new economy. Creating a new model for service delivery.

The strategy undertaken by the VNSNY for its survival has been to create a new service delivery model. The design of the SDM is based on a study of organizations, within and outside of health care, that face common challenges in the home health industry today: increased competition, declining reimbursement with escalating costs, and demands for improved outcomes and customer satisfaction. The model that emerged contained several important strategies in its design, including the alignment of team goals with organizational strategic objectives, restructuring teams as multidisciplinary units, redefining the work of teams to include practice improvement and supporting team learning, increasing members' accountability for team not individual performance. The SDM continues to evolve and improve during the process of implementation as lessons emerge from our experience with teams. Preliminary results indicate that the efforts have begun to show improvements in outcomes.

Health care systems: the emperor has no clothes.

Hospitals that merged and joined systems in the last 10 years need to revisit their decisions and determine whether their good intentions have actually paid off.

A model for improving medication use in home health care patients.

OBJECTIVES: (1) To develop a model for the identification and resolution of problems associated with suboptimal medication use in elderly patients receiving home health care; (2) To select the most important identifiable problems and develop structured procedures for their resolution. DESIGN: Expert panel review, problem selection, and development of a problem resolution model and guidelines. SETTING: Home health care. PARTICIPANTS: A panel with expertise in home health nursing, pharmacy, clinical pharmacology, gerontology, pharmacoepidemiology, and health services research. INTERVENTIONS: A list of potential problems associated with the most frequently used classes of drugs was compiled for review by the panel. Problems that were controversial or that could not be identified in the home care setting were excluded. Panel members individually ranked the remainder. Detailed procedures for identification and resolution of the 15 top-ranking problems were developed. MAIN OUTCOME MEASURES: Not applicable. RESULTS: Potential medication problems were defined by both drug use and symptoms or clinical signs associated with specific adverse effects, to ensure that clinically relevant problems would be identified. The model developed for problem assessment and resolution was centered on the drug utilization review (DUR) coordinator and the attending home health nurse. Following guidelines developed by the panel, the DUR coordinator advises the home health nurse about identified problems and how to resolve them. One of these practitioners, usually the nurse, then contacts the attending physician to explain their concerns, offer potential solutions, and request instructions. CONCLUSION: A potentially useful model for the identification and resolution of medication problems in the home health care setting was developed. This model is currently being evaluated in a randomized controlled trial.

Legal issues in accepting capitation.

The effort to reduce the cost of medical, hospital, and ancillary services increasingly focuses on shifting the financial risk for the cost of these services to those who provide them. Shifting arrangements include capitation for physicians classified as "primary care" physicians; capitation arrangements that include primary and specialty services; risk shifting to medical groups, IPAs, and other physician organizations; as well as the packaging of physician and hospital services on a "full risk," "per case," or other basis. Accepting financial risk for the cost of medical and other health care services, as well as the responsibility for managing the provision of services, may very well be the only remaining opportunity for providers to maximize reimbursement and maintain administrative and clinical self-direction. However, physicians must work with managed care organizations (MCOs) through negotiation of contracts and throughout the relationship to make sure: Unnecessary financial and legal risks to the MCO and physicians are eliminated. Risks that cannot be eliminated are apportioned between the MCO and physicians. All risks are managed in a coordinated fashion between the MCO and physicians.

The real world experience: death of homebound elderly persons. Staff views from the front lines.

If advance directives are implemented properly, this could, in the long term, be a vehicle for more appropriate utilization of health care services and health care technology. Yet in our own large agency we find few patients and families making the choice to have advance directives. This confirms that real change in this area is not being achieved through legislative or regulatory mandate but rather through an interactive process. Home care agencies are in a strong position to effect this change. Next we need to move beyond compliance and into an understanding of how advance directive requirements must be integrated with a patient, the family, and their culture, along with the ongoing relationships that evolve between the nurse and the patient over time.

Guidelines for physician contracting with alternative delivery systems.

The rapid proliferation of alternative healthcare delivery systems--particularly health maintenance organizations (HMOs) and preferred provider organizations (PPOs)--means that physicians contemplating participation in one of these entities must obtain, at the least, information about the group's ability to operate efficiently and effectively. For physicians who are contracting directly with a specific HMO, PPO, or independent practice association (IPA), issues that are relevant in all situations include termination, submission of data, discipline procedures, no solicitation covenants, arbitration clauses, rights to discontinue treatment, use of consultants, compliance with state and federal laws, and exclusivity.