Specialized managed care for children with cystic fibrosis: Resource use patterns and rate design for a high cost Medicaid population

Objective. This research study had two goals: (1) to describe resource consumption patterns for Medi-Cal children with cystic fibrosis, and (2) to explore the feasibility from a rate design perspective of developing specialized managed care plans for such a special needs population.^ Background. Children with special health care needs (CSHN) comprise about 2% of the California Medicaid pediatric population. CSHN have rare but serious health problems, such as cystic fibrosis. Medicaid programs, including Medi-Cal, are enrolling more and more beneficiaries in managed care to control costs. CSHN, however, do not fit the wellness model underlying most managed care plans. Child health advocates believe that both efficiency and quality will suffer if CSHN are removed from regionalized special care centers and scattered among general purpose plans. They believe that CSHN should be "carved out" from enrollment in general plans. One alternative is the Specialized Managed Care Plan, tailored for CSHN.^ Methods. The study population consisted of children under age 21 with CF who were eligible for Medi-Cal and California Children's Services program (CCS) during 1991. Health Care Financing Administration (HCFA) Medicaid Tape-to-Tape data were analyzed as part of a California Children's Hospital Association (CCHA) project.^ Results. Mean Medi-Cal expenditures per month enrolled were $2,302 for 457 CF children, compared to about \$1,270 for all 47,000 CCS special needs children and roughly $60 for almost 2.6 million ``regular needs'' children. For CF children, inpatient care (80\%) and outpatient drugs (9\%) were the major cost drivers, with {\it all\/} outpatient visits comprising only 2\% of expenditures. About one-third of CF children were eligible due to AFDC (Aid to Families with Dependent Children). Age group explained about 17\% of all expenditure variation. Regression analysis was used to select the best capitation rate structure (rate cells by age and eligibility group). Sensitivity analysis estimated moderate financial risk for a statewide plan (360 enrollees), but severe risk for single county implementation due to small numbers of children.^ Conclusions. Study results support the carve out of CSHN due to unique expenditure patterns. The Specialized Managed Care Plan concept appears feasible from a rate design perspective given sufficient enrollees. ^

Indigent care and infant mortality in Texas

Infant Mortality has been made a point of emphasis by the Department of Health and Human Services in the Healthy People 2000, 2010, and 2020 priorities. This study used the Behavioral Model for Vulnerable Populations to consider a number of factors which impact infant mortality in the indigent populations in the State of Texas. The primary focus of this study was the enabling factor of community resources, specifically the program used by each county to provide care to their indigent population. The Legislature of the State of Texas requires that each state have a program set up within a Hospital District, Public Hospital or develop a County Indigent Health Care Program (CIHCP) in order to provide the basic health care needs of their most vulnerable residents. We sought to determine whether the development of a CICHP without an appointed hospital to provide the care would have an adverse effect on residents seeking care and increase infant mortality. A Poisson Regression Analysis was used to analyze incidence rate ratios adjusting for race/ethnicity and wealth/poverty variables. Our study showed that counties using a CIHCP had significantly lower infant mortality rates when compared to counties using a hospital district and were statistically equivalent to counties using a public hospital program or a combination of service programs. This relationship was maintained when adjusted incidence rate ratios were calculated. This may give evidence that counties struggling to fund a public hospital or hospital district may be able to find a more cost-effective alternative in the CIHCP without adversely affecting the health status of their residents. More cost-benefit analysis and controlling analysis must be done to further characterize this relationship. ^

Correlates of prenatal care initiation among low -income Hispanic women

Because Hispanic women are even less likely than women of other ethnic groups to receive early prenatal care, the purpose of this study was to identify factors that may influence these women to initiate care. After giving consent, 300 Hispanic women (100 who initiated first trimester care, 100 who initiated second trimester care, and 100 who initiated third trimester care or received no care) were interviewed in the post partum unit of a local public hospital. The interview included recollection of events leading to the first prenatal appointment, including first physical indicators of pregnancy, confirmation of pregnancy, feelings about the pregnancy, appointment making behavior, and system barriers encountered. The Health Belief Model was used as the theoretical framework for determining psychosocial variables. Using this model, perceived susceptibility to problems during pregnancy, perceived seriousness of possible problems, perceived benefits of prenatal care, perceived barriers to care, and cues to action were assessed. Time of entry into prenatal care was assessed by interview.^ In this sample of low-income Hispanic women, a higher perception of barriers to care was associated with later initiation of care and non-use of care, higher perceived benefits of care for the baby were associated with earlier care, especially in women without a card to access hospital district services, and having a card to access hospital district services was associated with earlier care. Several barriers to care were mentioned by women on open-ended questioning including long waiting times, embarrassment, and lack of transportation.^ Recommendations for practice included decreasing the number of visits for low-risk women while increasing the time spent with the provider, decreasing the number of vaginal exams for low-risk women, increasing the use of midwives, training lay workers to do risk assessment, giving specific messages about benefits of care to baby, and increasing general health motivation through community intervention methods. More research on the psychosocial and cultural factors associated with initiation of care is needed. In the meantime, the recommendations for practice can be implemented now to increase the use of prenatal care by low-income Hispanic women. ^

Attitudes of health-care workers toward pregnant, HIV -positive women

The management of HIV infection with antiretroviral drugs has succeeded in increasing survival rates, but the subject of pregnancy in HIV-positive women continues to garner debate. Discrimination and stigma have been identified as barriers to health care, suggesting that women with HIV may be disinclined to seek prenatal care if health-care workers exhibit negative attitudes toward the women's pregnancies. To optimize prenatal and medical care for women with HIV infection, it is important to understand the general social conditions and cultural context in which these women have children. Goffman's treatise on stigma, Foucault's discussion of the knowledge/power matrix, and Bandura's Social Cognitive Theory offer theoretical perspectives by which we can evaluate the gender, race, and class issues that are inherent in pregnancy decision-making for women with HIV infection. It is also necessary to evaluate prevailing attitudes on childbearing toward HIV-positive women and to review the historical background of prejudice in which HIV-positive women make decisions regarding childbearing. ^ This qualitative study used a survey instrument and one-on-one interviews with HIV-infected women to elicit their perceptions of how they were treated by care providers when they became pregnant. It also included interviews with health-care workers to determine what their feelings are about pregnancy within the context of HIV infection. Results of the ethnographic inquiry reveal that most of the women had negative experiences at some point during a pregnancy, but that the situation improved when they sought care from a provider who was familiar with HIV infection. The health-care providers interviewed were firm in their belief that HIV-positive women deserved optimal care and treated the women with respect, but these are individuals who are also experts in providing care to HIV-positive patients. The question remains as to what kind of care HIV-positive women are receiving generally and what types of attitudes they are being subjected to if they see less experienced providers. Further research is also needed to determine whether HIV-positive women from a broader ethnic representation and higher socioeconomic status experience similar negative attitudes. ^

Minors’ Access to Contraceptive Services

Over the past 30 years, states have expanded minors’ authority to consent to health care, including care related to sexual activity. This trend reflects U.S. Supreme Court rulings extending the constitutional right to privacy to a minor’s decision to obtain contraceptives and concluding that rights do not “come into being magically only when one attains the state-defined age of majority.” It also reflects the recognition that while parental involvement is desirable, many minors will remain sexually active but not seek services if they have to tell their parents. As a result, confidentiality is vital to ensuring minors’ access to contraceptive services. Even when a state has no relevant policy or case law, physicians may commonly provide medical care to a mature minor without parental consent, particularly if the state allows a minor to consent to related health services.

Trauma Treatment in Forensic Settings: Clinicians' Perspectives, Barriers to Effective Treatment, and Suggestions for Clinical Practice

Between 30% and 90% of the prison population is estimated to have survived traumatic experiences such as sexual, emotional, and physical abuse prior to incarceration (Anonymous, 1999; Fondacaro, Holt, & Powell, 1999; Messina & Grella, 2006; Pollard & Baker, 2000; Veysey, De Cou, & Prescott, 1998). Similarly, information from the Bureau of Justice Statistics (as reported in Warren, 2001) estimated that more than half of the women in state prisons have experienced past physical and sexual abuse. Thus, given the astonishing number of inmates who appear to be victims of some kind of trauma, it seems likely that those who work with these inmates (e.g., prison staff, guards, and treatment providers) will in some way encounter challenges related to the inmates' trauma history. These difficulties may appear in any number of forms including inmates' behavioral outbursts, increased emotionality, sensitivity to triggering situations, and chronic physical or mental health needs (Veysey, et al., 1998). It is also likely that these individuals with trauma histories would benefit greatly from treatment while incarcerated. This treatment could be utilized to minimize symptoms of posttraumatic stress, decrease behavioral problems, and help the inmate function more effectively in society when released from incarceration (Kokorowski & Freng, 2001; Tucker, Cosio, Meshreki, 2003). Few studies have explored the types of trauma treatment that are effective with inmate populations or made specific suggestions for clinicians working in forensic settings (Kokorowski & Freng, 2001). Essentially, there appears to be a large gap in terms of the need for trauma treatment for inmates and the lack of literature addressing what to do about it. However, clinicians across the country seem to be quietly attempting to fulfill this need for trauma treatment with incarcerated populations. They are providing this greatly needed treatment every day. in the face of enormous challenges and often without recognition or the opportunity to share their valuable work with the larger community.

Hospital care of children in four countries

Background. While perceptions of parents and staff about care of hospitalized children have been explored in developed countries, little research has examined these in developing countries. Assumptions about family-centred care are often based on Western values, with little evidence of how cultural constructs affect care delivery in developing nations. Aim. This paper reports a study to provide evidence from which culturally-appropriate hospital care for children can be delivered. Methods. Using a rigorously devised and trialed questionnaire, attitudes of staff and parents about the way children are cared for in children's hospitals in four countries were examined and subjected to a four way analysis: parents and staff within and between developed and developing countries. Results. There were no questions where all parents and staff in both developed and developing country groups were in complete agreement. However, there was some indication that, while culture plays a major role in paediatric care delivery, basic concepts of family-centred care are similar. Conclusions. The findings are limited by the sampling strategy. Nevertheless, while differences were found between parents' and staff's expectations of the delivery of care to children in hospitals, similarities existed and the influence of culture cannot be ignored. Education programmes for staff and parents should reflect these influences to ensure the optimum delivery of family-centred care, regardless of where the hospital is situated.

Family centred care: a review of qualitative studies

Aim. To review systematically qualitative studies, which were found during a literature search for a Cochrane systematic review of the use of family centred care in children's hospitals. Background. Family centred care has become a cornerstone of paediatric practice, however, its effectiveness is not known. No single definition exists, rather a list of elements that constitute family centred care. However, it is recognized to involve the parents in care planning for a child in health services. A new definition is presented here. Methods. The papers were found in wide range of databases, by hand searching and by contacting the authors where necessary, using terms given in detail in the protocol in the Cochrane Library, in 2004. Qualitative studies could not be used for statistical analysis, but are still important to the review and so are described separately in this paper. Results. Negotiation between staff and families, perceptions held by both parents and staff roles influenced the delivery of family centred care. A sub-theme of cost of family centred care to families and staffs was discovered and this included both financial and emotional costs. Conclusion. Further research is needed to generate evidence about family centred care in situations arising from modern models of care in which family centred care is thought to be an inherent part, but which leave families with the care of sick children with little or no support. Relevance to clinical practice. Family centred care is said to be used widely in practice. More research is needed to ensure that is it being implemented correctly.

Pain relief for neonates in Australian hospitals: A need to improve evidence-based practice

Objective: To ascertain the extent to which neonatal analgesia was used in Australia for minor invasive procedures as an indicator of evidence-based practice in neonatology. Methods: A cross-sectional telephone survey of hospitals in all Australian states and territories with more than 200 deliveries per year was carried out. Questions were asked regarding awareness of the benefits and the use of analgesia for minor invasive procedures in term and near term neonates. Analysis was undertaken according to state and territory, annual birth numbers and the level of neonatal nursery care available. Results: Data were available from 212 of 214 eligible hospitals. Of the total respondents, 51% and 70% respectively were aware of the benefits of sucrose and breast-feeding for neonatal analgesia. Eleven per cent of units administered sucrose before venepuncture and 25% of units used breast-feeding. Ten per cent of units used sucrose before heel prick with 49% utilizing breast-feeding. Expressed breast milk was used in 10% of units. Analgesia was given less frequently before intravenous cannulation compared to venepuncture and heel prick. Awareness and implementation of neonatal analgesia varied widely in the states and territories. There was a trend for hospitals providing a higher level of neonatal care to have a greater awareness of sucrose as an analgesic (P < 0.0001) and the use of sucrose for venepuncture (P = 0.029), heel prick (P = 0.025) and intravenous catheter insertion (P = 0.013). Similar trends were found on analysis according to birth number of the maternity units. Smaller units had a greater usage of breast-feeding as an analgesic for heel prick (P = 0.017). Conclusion: Despite good evidence for the administration of sucrose and breast milk in providing effective analgesia for newborn infants, it is not widely used in Australia. It is imperative that the gap between research findings and clinical practice with regard to neonatal analgesia be addressed.

The experiences and perceptions of fathers attending the birth and immediate care of their baby

Fathers in the United Kingdom (UK) usually attend the birth and immediate care of their baby. They also have an increasing presence during complicated and preterm childbirth, newborn resuscitation and early neonatal unit(NNU) care. However, there is limited evidence about the effect of these experiences on them. The aim of this study was to gain an understanding of the experiences of fathers encountering these situations. The study consisted of three phases and was undertaken in one National Health Service trust in the UK. Qualitative semi-structured interviews using a phenomenological approach were undertaken with 20 first-time fathers present at the delivery, resuscitation and/or admission of their baby to the NNU. Direct observations were made of 22 normal and complicated deliveries and initial newborn care and qualitative semi-structured interviews using the critical incident approach were undertaken with 37 health care professionals (HCPs). The study generated qualitative and quantitative data that were analysed accordingly. The findings show that most fathers were involved for at least some of the time and often spontaneously initiated their involvement. Their most important need was for information. They were usually more concerned about their partner, irrespective of the baby?s need for resuscitation and NNU care. To facilitate their involvement, fathers needed guidance and support from HCPs, particularly delivery suite midwives. Most HCPs recognised the needs of fathers and ways in which they could be helped to connect with their experience. However, these needs were not always met, usually because of inadequate staffing levels, a lack of resources or a mother-centred philosophy of care. The findings suggest the service often determines the extent to which fathers are involved. It is anticipated that these findings will inform HCP education and training and the development of both policy and health education thereby enhancing the quality of care provision for fathers.

Photodynamic therapy with verteporfin for juxtafoveal choroidal neovascularisation secondary to pathological myopia

The treatment of choroidal neovascularisation (CNV) secondary to pathological myopia has presented a number of problems to ophthalmologists over the years, but the advent of photodynamic therapy (PDT) with verteporfin has changed how we manage these patients. Until PDT became available, the use of laser photocoagulation for extra and juxtafoveal lesions had been shown to be effective in the short term in preventing loss of vision, although the risk of regrowth of CNV and undertreatment were well recognised. However, even in apparent successful cases of photocoagulation, laser scar enlargement and creepage into the fovea in the mid-to-long term often occurred with resulting loss of central vision.1 Other options for treatment were very limited with little evidence that other modalities such as transpupillary thermotherapy or submacular surgery and macular transplantation surgery would be successful in highly myopic eyes. The evidence for the role of PDT and verteporfin CNV secondary to pathological myopia comes from the verteporfin in photodynamic therapy (VIP) study that has shown how effective this treatment is in eyes with subfoveal CNV.2, 3 Now in this publication, Lam et al4 from Hong Kong have shown that PDT is also effective in juxtafoveal CNV, with high myopia. They performed a small prospective study of 11 patients of mean age 44.8 years, with 12 months of follow-up. They found that there was a mean improvement of 1.8 lines of LogMAR best-corrected visual acuity (BCVA) at 12 months, with a mean number of 2.3 PDT treatments. The most rapid improvement occurred within the first 3 months of treatment and by 12 months none of the patients had suffered a deterioration in BCVA from baseline. There were no cases of adverse effects from the infusion or laser treatment. For ophthalmologists dealing with patients with CNV secondary to causes other than AMD, this is further evidence of the effectiveness of PDT with verteporfin in maintaining vision. These patients are likely to be younger than those with AMD and are likely to be in active employment and supporting families, and clearly the preservation of best vision possible is imperative in this group. It is therefore encouraging for ophthalmologists in the United Kingdom that the verteporfin in PDT Cohort Study (VPDT Study) includes the ability to treat patients with subfoveal CNV secondary to high myopia if they fulfill National Institute of Clinical Excellence guidelines, and will allow representations to be made on an individual basis for treatment of juxtafoveal lesions.5 For those ophthalmologists used to juggling increased patient expectations with scarce NHS resources, this is promising news and will allow us to offer a better standard of care to our patients.

Patients' and health professionals' views on primary care for people with serious mental illness:focus group study

Objective: To explore the experience of providing and receiving primary care from the perspectives of primary care health professionals and patients with serious mental illness respectively. Design: Qualitative study consisting of six patient groups, six health professional groups, and six combined focus groups. Setting: Six primary care trusts in the West Midlands. Participants: Forty five patients with serious mental illness, 39 general practitioners (GPs), and eight practice nurses. Results: Most health professionals felt that the care of people with serious mental illness was too specialised for primary care. However, most patients viewed primary care as the cornerstone of their health care and preferred to consult their own GP, who listened and was willing to learn, rather than be referred to a different GP with specific mental health knowledge. Swift access was important to patients, with barriers created by the effects of the illness and the noisy or crowded waiting area. Some patients described how they exaggerated symptoms ("acted up") to negotiate an urgent appointment, a strategy that was also employed by some GPs to facilitate admission to secondary care. Most participants felt that structured reviews of care had value. However, whereas health professionals perceived serious mental illness as a lifelong condition, patients emphasised the importance of optimism in treatment and hope for recovery. Conclusions: Primary care is of central importance to people with serious mental illness. The challenge for health professionals and patients is to create a system in which patients can see a health professional when they want to without needing to exaggerate their symptoms. The importance that patients attach to optimism in treatment, continuity of care, and listening skills compared with specific mental health knowledge should encourage health professionals in primary care to play a greater role in the care of patients with serious mental illness.

A multi-agency perspective to disaster preparedness

The increasing number of victims from disasters in recent years results in several challenges for authorities aiming to protect and provide support to affected people. Humanitarian logistics represents one of the most important fields during preparedness and response in cases of disaster, seeking to provide relief, information and services to disaster victims. However, on top of the challenges of logistical activities, the successful completion of operations depends to a large extent on coordination. This is particularly important for developing countries, where disasters occur very often and resources are even scarcer. This paper assumes a multi-agency approach to disaster preparedness that combines geographical information systems (GIS) and multi-objective optimization. The purpose of the tool is to determine the location of emergency facilities, stock prepositioning and distribution allocation for floods. We illustrate the application and the results using a case study centred on Acapulco, México.

A planning model for needs analysis for subacute care

The purpose of this study is to produce a model to be used by state regulating agencies to assess demand for subacute care. In accomplishing this goal, the study refines the definition of subacute care, demonstrates a method for bed need assessment, and measures the effectiveness of this new level of care. This was the largest study of subacute care to date. Research focused on 19 subacute units in 16 states, each of which provides high-intensity rehabilitative and/or restorative care carried out in a high-tech unit. Each of the facilities was based in a nursing home, but utilized separate staff, equipment, and services. Because these facilities are under local control, it was possible to study regional differences in subacute care demand.^ Using this data, a model for predicting demand for subacute care services was created, building on earlier models submitted by John Whitman for the American Hospital Association and Robin E. MacStravic. The Broderick model uses the "bootstrapping" method and takes advantage of high technology: computers and software, databases in business and government, publicly available databases from providers or commercial vendors, professional organizations, and other information sources. Using newly available sources of information, this new model addresses the problems and needs of health care planners as they approach the challenges of the 21st century. ^

Nurses' spiritual well-being: Its influence on attitudes and level of practice in providing spiritual care

The purpose of this study was to examine the relationship between the spiritual well-being of nurses and its influence on their attitudes toward providing spiritual care to patients. Two research instruments and a demographic data form were used for the survey. Using a descriptive design, tbe Spiritual Well-Being Scale, the Health Professional's Spiritual Role Scale, and the demographic data form were administered to 100 registered nurses from a large South Florida teaching hospital. The findings indicated a significantly positive correlation between the overall Spiritual Well-Being Scale and the Health Professional's Spiritual Role Scale (r = 0.52; p =.005). Significant differences were found between correlation of nurses' levels of spiritual well-being and all sociodemographic factors except for the three Age Groups and for religious affiliations. Findings have implications for how nurses should be trained in meeting patients total needs. ^