A Service Model For Delivering Care Closer to Home.

Upton Surgery (Worcestershire) has developed a flexible and responsive service model that facilitates multi-agency support for adult patients with complex care needs experiencing an acute health crisis. The purpose of this service is to provide appropriate interventions that avoid unnecessary hospital admissions or, alternatively, provide support to facilitate early discharge from secondary care. Key aspects of this service are the collaborative and proactive identification of patients at risk, rapid creation and deployment of a reactive multi-agency team and follow-up of patients with an appropriate long-term care plan. A small team of dedicated staff (the Complex Care Team) are pivotal to coordinating and delivering this service. Key skills are sophisticated leadership and project management skills, and these have been used sensitively to challenge some traditional roles and boundaries in the interests of providing effective, holistic care for the patient. This is a practical example of early implementation of the principles underlying the Department of Health’s (DH) recent Best Practice Guidance, ‘Delivering Care Closer to Home’ (DH, July 2008) and may provide useful learning points for other general practice surgeries considering implementing similar models. This integrated case management approach has had enthusiastic endorsement from patients and carers. In addition to the enhanced quality of care and experience for the patient, this approach has delivered value for money. Secondary care costs have been reduced by preventing admissions and also by reducing excess bed-days. The savings achieved have justified the ongoing commitment to the service and the staff employed in the Complex Care Team. The success of this service model has been endorsed recently by the ‘Customer Care’ award by ‘Management in Practice’. The Surgery was also awarded the ‘Practice of the Year’ award for this and a number of other customer-focussed projects.

Dialysis residential care : a future dialysis service model

People with chronic kidney disease are ageing and have increasing co-morbidities. The current delivery of renal replacement therapy, dialysis and transplantation, needs to adjust to changing patient needs. This paper proposes a potential future service delivery model featuring a dialysis residential care facility and a care coordination focus. The residential care facility would be composed of four levels of care; high, hostel, independent and outpatient. The paper argues that this model may result in decreased morbidity, improved patient quality of life and may prove cost effective. Patients' nutritional status, medication adherence and transport efficiency may be improved. We propose this model to stimulate further debate in order to meet the needs of current and future chronic kidney disease patients.

Managing risks of violence in a youth mental health service: a service model description

There is a significant relationship between experiencing a severe mental illness, particularly psychosis, and exhibiting violent or offending behaviour. Reducing, if not preventing, the risks of violence among patients of mental health services is clinically warranted, but models to address this are limited

Intensive case management for high-risk patients with first-episode psychosis: service model and outcomes

Background : The first episode of psychosis is a crucial period when early intervention can alter the trajectory of the young person's ongoing mental health and general functioning. After an investigation into completed suicides in the Early Psychosis Prevention and Intervention Centre (EPPIC) programme, the intensive case management subprogramme was developed in 2003 to provide assertive outreach to young people having a first episode of psychosis who are at high risk owing to risk to self or others, disengagement, or suboptimal recovery. We report intensive case management model development, characterise the target cohort, and report on outcomes compared with EPPIC treatment as usual.

Methods : Inclusion criteria, staff support, referral pathways, clinical review processes, models of engagement and care, and risk management protocols are described. We compared 120 consecutive referrals with 50 EPPIC treatment as usual patients (age 15–24 years) in a naturalistic stratified quasi-experimental real-world design. Key performance indicators of service use plus engagement and suicide attempts were compared between EPPIC treatment as usual and intensive case management, and psychosocial and clinical measures were compared between intensive case management referral and discharge.

Findings : Referrals were predominately unemployed males with low levels of functioning and educational attainment. They were characterised by a family history of mental illness, migration and early separation, with substantial trauma, history of violence, and forensic attention. Intensive case management improved psychopathology and psychosocial outcomes in high-risk patients and reduced risk ratings, admissions, bed days, and crisis contacts.

Interpretation : Characterisation of intensive case management patients validated the clinical research focus and identified a first episode of psychosis high-risk subgroup. In a real-world study, implementation of an intensive case management stream within a well-established first episode of psychosis service showed significant improvement in key service outcomes. Further analysis is needed to determine cost savings and effects on psychosocial outcomes. Targeting intensive case management services to high-risk patients with unmet needs should reduce the distress associated with pathways to care for patients, their families, and the community.

Homeless access to dental health care: Creation of a dental service model

This project involved developing a model for planning a dental emergency treatment center that could function as an embedded component of a shelter for the homeless population. The dental services provided by such a clinic should include treatment for tooth pain, dental caries or cavities, chipped or broken teeth, broken partials, abscessed teeth, emergency cleanings, periodontal disease or gum disease and fillings. These are the dental services that are most often sought by homeless people in hospital emergency rooms.^ The underlying assumption for this project was that the oral health needs of the homeless community can most effectively be addressed by implementing small dental clinics in existing facilities that provide shelter and other services for this population. The model described in this project identifies oral health care services that would be provided by the clinic, facility (physical plant) requirements and associated infrastructure to operate an embedded dental clinic, methods for obtaining funding, strategies of recruiting dental professionals to staff the facility, and methods to assess the outcomes of the embedded clinic strategy. As an example, this project describes a strategy for developing such an embedded clinic at San Antonio Metropolitan Ministries SAMM shelter based on recommendations from community health care leaders, managers of homeless shelters, members of the homeless community and dental professionals^

A profile of low vision services in England the Low Vision Service Model Evaluation (LOVSME) project

In the UK, low vision rehabilitation is delivered by a wide variety of providers with different strategies being used to integrate services from health, social care and the voluntary sector. In order to capture the current diversity of service provision the Low vision Service Model Evaluation (LOVSME) project aimed to profile selected low vision services using published standards for service delivery as a guide. Seven geographically and organizationally varied low-vision services across England were chosen for their diversity and all agreed to participate. A series of questionnaires and follow-up visits were undertaken to obtain a comprehensive description of each service, including the staff workloads and the cost of providing the service. In this paper the strengths of each model of delivery are discussed, and examples of good practice identified. As a result of the project, an Assessment Framework tool has been developed that aims to help other service providers evaluate different aspects of their own service to identify any gaps in existing service provision, and will act as a benchmark for future service development.

A medical data reliability assessment model

There is currently a strong focus worldwide on the potential of large-scale Electronic Health Record (EHR) systems to cut costs and improve patient outcomes through increased efficiency. This is accomplished by aggregating medical data from isolated Electronic Medical Record databases maintained by different healthcare providers. Concerns about the privacy and reliability of Electronic Health Records are crucial to healthcare service consumers. Traditional security mechanisms are designed to satisfy confidentiality, integrity, and availability requirements, but they fail to provide a measurement tool for data reliability from a data entry perspective. In this paper, we introduce a Medical Data Reliability Assessment (MDRA) service model to assess the reliability of medical data by evaluating the trustworthiness of its sources, usually the healthcare provider which created the data and the medical practitioner who diagnosed the patient and authorised entry of this data into the patient’s medical record. The result is then expressed by manipulating health record metadata to alert medical practitioners relying on the information to possible reliability problems.

A University Support Model for eResearch

Queensland University of Technology (QUT) is faced with a rapidly growing research agenda built upon a strategic research capacity-building program. This presentation will outline the results of a project that has recently investigated QUT’s research support requirements and which has developed a model for the support of eResearch across the university. QUT’s research building strategy has produced growth at the faculty level and within its research institutes. This increased research activity is pushing the need for university-wide eResearch platforms capable of providing infrastructure and support in areas such as collaboration, data, networking, authentication and authorisation, workflows and the grid. One of the driving forces behind the investigation is data-centric nature of modern research. It is now critical that researchers have access to supported infrastructure that allows the collection, analysis, aggregation and sharing of large data volumes for exploration and mining in order to gain new insights and to generate new knowledge. However, recent surveys into current research data management practices by the Australian Partnership for Sustainable Repositories (APSR) and by QUT itself, has revealed serious shortcomings in areas such as research data management, especially its long term maintenance for reuse and authoritative evidence of research findings. While these internal university pressures are building, at the same time there are external pressures that are magnifying them. For example, recent compliance guidelines from bodies such as the ARC, and NHMRC and Universities Australia indicate that institutions need to provide facilities for the safe and secure storage of research data along with a surrounding set of policies, on its retention, ownership and accessibility. The newly formed Australian National Data Service (ANDS) is developing strategies and guidelines for research data management and research institutions are a central focus, responsible for managing and storing institutional data on platforms that can be federated nationally and internationally for wider use. For some time QUT has recognised the importance of eResearch and has been active in a number of related areas: ePrints to digitally publish research papers, grid computing portals and workflows, institutional-wide provisioning and authentication systems, and legal protocols for copyright management. QUT also has two widely recognised centres focused on fundamental research into eResearch itself: The OAK LAW project (Open Access to Knowledge) which focuses upon legal issues relating eResearch and the Microsoft QUT eResearch Centre whose goal is to accelerate scientific research discovery, through new smart software. In order to better harness all of these resources and improve research outcomes, the university recently established a project to investigate how it might better organise the support of eResearch. This presentation will outline the project outcomes, which include a flexible and sustainable eResearch support service model addressing short and longer term research needs, identification of resource requirements required to establish and sustain the service, and the development of research data management policies and implementation plans.

The impact of software-as-a-service on business models of leading software vendors : experiences from three exploratory case studies

The number of software vendors offering ‘Software-as-a-Service’ has been increasing in recent years. In the Software-as-a-Service model software is operated by the software vendor and delivered to the customer as a service. Existing business models and industry structures are challenged by the changes to the deployment and pricing model compared to traditional software. However, the full implications on the way companies create, deliver and capture value are not yet sufficiently analyzed. Current research is scattered on specific aspects, only a few studies provide a more holistic view of the impact from a business model perspective. For vendors it is, however, crucial to be aware of the potentially far reaching consequences of Software-as-a-Service. Therefore, a literature review and three exploratory case studies of leading software vendors are used to evaluate possible implications of Software-as-a-Service on business models. The results show an impact on all business model building blocks and highlight in particular the often less articulated impact on key activities, customer relationship and key partnerships for leading software vendors and show related challenges, for example, with regard to the integration of development and operations processes. The observed implications demonstrate the disruptive character of the concept and identify future research requirements.

Software as a service (SaaS) for small and medium enterprises (SMEs) : the role of intermediaries

Software as a Service (SaaS) is anticipated to provide significant benefits to small and medium enterprises (SMEs) due to ease of access to high-end applications, 7*24 availability, utility pricing, etc. However, underlying SaaS is the assumption that SMEs will directly interact with the SaaS vendor and use a self-service model. In practice, we see the rise of SaaS intermediaries who support SMEs with using SaaS. This paper reports on an empirical study of the role of intermediaries in terms of how they support SMEs in sourcing and leveraging SaaS for their business. The knowledge contributions of this paper are: (1) the identification and description of the role of SaaS intermediaries and (2) the specification of different roles of SaaS intermediaries, in particular a more basic role with technology orientation and operational alignment perspective and (3) a more added value role with customer orientation and strategic alignment perspective.

Specialist versus generic models of psychiatry training and service provision for people with intellectual disabilities

Background  Models of service provision and professional training differ between countries. This study aims to investigate a specialist intellectual disabilities model and a generic mental health model, specifically comparing psychiatrists’ knowledge and competencies, and service quality and accessibility in meeting the mental health needs of people with intellectual disabilities. Method  Data were collected from consultant and trainee psychiatrists within a specialist intellectual disabilities model (UK) and a generic mental health model (Australia). Results  The sample sizes were 294 (UK) and 205 (Australia). Statistically significant differences were found, with UK participants having positive views about the specialist intellectual disabilities service model they worked within, demonstrating flexible and accessible working practices and service provision, responsive to the range of mental health needs of the population with intellectual disabilities, and providing a wide range of treatments and supports. The UK participants were knowledgeable, well trained and confident in their work. They wanted to work with people with intellectual disabilities. In all of these areas, the converse was found from the Australian generic mental health service model. Conclusions  The specialist intellectual disabilities model of service provision and training has advantages over the generic mental health model.

Profiling emergency nurse practitioner service

The aim of this study was to investigate the practice profile of emergency nurse practitioners across Australia. Nurse practitioners have been providing health service in the emergency setting internationally for more than 30 years, and evidence supports the value of this role in terms of patient satisfaction, effectiveness in improving service indicators, and acceptability of the role. The introduction of this service model has been instrumental in reducing waiting times for low-acuity patients and impacting positively on emergency department service delivery. Recent rapid uptake of this role internationally has outpaced development of the service model to inform education and ongoing service development. This was a national study that used interpretive research methods to identify the practice profile of emergency nurse practitioners. Data were collected from December 2012 to February 2013 through in-depth interviews. An inductive approach was used in data analysis to identify conceptual themes and develop an analysis framework. The study participants worked in a range of service models and managed patient presentations across all levels of acuity and complexity. The findings show that although there is no single definable model of the emergency nurse practitioner role in Australia, there are practice features that are common across all service models; these have been conceptualized as "modes of practice." This study has produced new knowledge about the practice profile of emergency nurse practitioners. The findings will inform development of practice standards for education and continuing professional development for emergency nurse practitioners and facilitate standardized operational definitions for ongoing research into this growing service model.

Effectiveness of an emergency nurse practitioner service for adults presenting to rural hospitals with chest pain : Protocol for a multicentre, longitudinal nested cohort study

Introduction Chest pain is common in emergency department (ED) patients and represents a considerable burden for rural health services. Health services reforms to improve access to care need appropriately skilled and supported clinicians in the delivery of safe and effective care, including the use of emergency nurse practitioners (ENPs). Despite increasing use of ENPs, little is known about the safety and quality of the service in the rural ED context. The aims of this study are (1) to examine the safety and quality of the ENP service model in the provision of care in the rural environment and (2) to evaluate the effectiveness of the service in the management of patients presenting with undifferentiated chest pain. Methods and analysis This is the protocol for a prospective longitudinal nested cohort study to compare the effectiveness of ENP service with that of standard care. Adults presenting to three rural EDs in Queensland, Australia with a primary presenting complaint of atraumatic chest pain will be eligible for enrolment. We will measure (1) clinician's use of evidence-based guidelines (2) diagnostic accuracy of ECG interpretation for the management of patients with suspected or confirmed ACS (3) service indicators of waiting times, length-of-stay and did-not-wait rates and (4) clinician's diagnostic accuracy as measured by rates of unplanned representation within 7 days (5) satisfaction with care, (6) quality-of-life and (7) functional status. To assess these outcomes we will use a combination of measures collected from routinely collected data, medical record review and questionnaires (with 30-day follow-up). Ethics and dissemination Queensland Health Human Research Ethics Committee (HREC) has approved this protocol. The results will be published in peer-reviewed scientific journals and presented at one or more scientific conferences.