Rethinking workforce planning for integrated care: using scenario analysis to facilitate policy development.

BACKGROUND: A goal of health workforce planning is to have the most appropriate workforce available to meet prevailing needs. However, this is a difficult task when considering integrated care, as future workforces may require different numbers, roles and skill mixes than those at present. With this uncertainty and large variations in what constitutes integrated care, current health workforce policy and planning processes are poorly placed to respond. In order to address this issue, we present a scenario-based workforce planning approach. METHODS: We propose a novel mixed methods design, incorporating content analysis, scenario methods and scenario analysis through the use of a policy Delphi. The design prescribes that data be gathered from workforce documents and studies that are used to develop scenarios, which are then assessed by a panel of suitably qualified people. Assessment consists of evaluating scenario desirability, feasibility and validity and includes a process for indicating policy development opportunities. RESULTS: We confirmed our method using data from New Zealand's Older Persons Health sector and its workforce. Three scenarios resulted, one that reflects a normative direction and two alternatives that reflect key sector workforce drivers and trends. One of these, based on alternative assumptions, was found to be more desirable by the policy Delphi panel. The panel also found a number of favourable policy proposals. CONCLUSIONS: The method shows that through applying techniques that have been developed to accommodate uncertainty, health workforce planning can benefit when confronting issues associated with integrated care. The method contributes to overcoming significant weaknesses of present health workforce planning approaches by identifying a wider range of plausible futures and thematic kernels for policy development. The use of scenarios provides a means to contemplate future situations and provides opportunities for policy rehearsal and reflection.

Building a Primary Care Community of Practice: SCOPE as a Platform for Care Integration and System Transformation.

Strong primary care plays a foundational role in a high-functioning health system. Primary care is the main entry point to the healthcare system for patients, but in many health systems, the majority of primary care practices and physicians are functionally disconnected from, and not meaningfully integrated with, specialist care, hospital resources or team-based allied professionals. Here, we detail how a grassroots program in the Greater Toronto Area, known as SCOPE (Seamless Care Optimizing the Patient Experience), has worked to build and grow a community of practice among physicians who were previously "unaffiliated" to provide streamlined access to specialist care and virtual team-based resources. Notably, through purposeful engagement efforts, this community of practice has led to new patient-facing initiatives that respond to primary care needs. This improved integration of primary care with both hospital-based resources and specialty services, along with the initiation of new services that address population needs, demonstrates the value of this type of purposeful engagement to develop a primary care community of practice.

Job satisfaction of the primary healthcare providers with expanded roles in the context of health service integration in rural China: a cross-sectional mixed methods study.

OBJECTIVE: Against the backdrop of integrating public health services and clinical services at primary healthcare (PHC) institutions, primary healthcare providers (PCPs) have taken on expanded roles. This posed a potential challenge to China as it may directly impact PCPs' workload, income, and perceived work autonomy, thus affecting their job satisfaction. This study aimed to explore the association between the expanded roles and job satisfaction of the PCPs in township healthcare centers (THCs), the rural PHC institutions in China. METHODS: A cross-sectional study using mixed methods was conducted in 47 THCs in China's Shandong province. Based on a sample of 1146 PCPs, the association between the proportion of PCPs' working time spent on public health services and PCPs' self-reported job satisfaction was estimated using the logistic regression. Qualitative data were also collected and analyzed to explore the mechanism of how the expanded roles impacted PCPs' job satisfaction. RESULTS: One hundred eighty-four physicians and 146 nurses undertook increased work responsibilities, accounting for 15.91% and 12.61% of the total sample. For those spending 40-60%, 60-80%, and more than 80% of the working time providing public health services, the time spent on public health was negatively associated with job satisfaction, with the odds ratio being 0.199 [0.067-0.587], 0.083 [0.025-0.276], and 0.030 [0.007-0.130], respectively. Qualitative analysis illustrated that a majority of the PCPs with expanded roles were dissatisfied with their jobs due to the heavy workload, the mismatch between the income and the workload, and the low level of work autonomy. PCPs' heavier work burden was mainly caused by the current public health service delivery policy and the separation of public health service delivery and regular clinical services delivery, a significant challenge undermining the efforts to better integrate public health services and clinical services at PHC institutions. CONCLUSION: The current policies of adding public health service delivery to the PHC system have negative impacts on PCPs' job satisfaction through increased work responsibilities for PCPs, which have led to low work autonomy and the mismatch between the income and the workload. The fundamental reason lies in the fragmented incentives and external supervision for public health service delivery and clinical service delivery. Policy-makers should balance the development of clinic and public health departments at the institutional level and integrate their financing and supervision at the system level so as to strengthen the synergy of public health service provision and routine clinical service provision.

Policy paradox and political neglect in community health services.

Community health services (CHSs) have never had a settled organisational existence but the turmoil has intensified since the publication of Transforming Community Services in 2009. CHSs are now beset by three dilemmas: ongoing organisational fragmentation; the extension of competition law and the spread of privatisation; inadequate workforce development and lack of clarity on the nature of CHS activity. This has left the services in a position of policy and political vulnerability. The solution may be for the service to be part of horizontal integration models such as the accountable care organisation, with a focus on locality and multi-professional teams wrapped around patient pathways.

Aligning Organizational Culture and Infrastructure to Support Evidence-Based Practice.

Standardized nursing practice based on the foundations of evidence-based practice leads to high-quality patient care and optimal outcomes. Despite knowing the benefits of evidence-based practice, health care organizations do not consistently make it the standard of care; thus, implementation of evidence-based practice at the system level continues to be challenging. This article describes the process adopted by a facility in the Southwest that took on the challenge of changing the organizational culture to incorporate evidence-based practice. The organization met the challenges by identifying perceived and actual barriers to successful implementation of evidence-based practice. The lack of standardized practice was addressed by developing a group of stakeholders including organizational leaders, clinical experts, and bedside providers. Changing the culture required a comprehensive process of document selection and development, education, and outcome evaluation. The ultimate aim was to implement an integrated system to develop practices and documents based on the best evidence to support patient outcomes.

Principles of clinical management: connecting management, healthcare and education in health. / Princípios para a gestão da clínica: conectando gestão, atenção à saúde e educação na saúde.

This paper aims at proposing validated principles to underpin clinical management as a means to transform healthcare for integrated healthcare systems. The starting point was the conception of clinical management based on structuring elements that do not separate management, care and education. The authors' proposal was submitted to specialists so that a consensus could be reached. At the end of the process, the following principles of clinical management were presented: (1) Focus on health needs and comprehensive care, (2) Quality and safety in healthcare, (3) Articulation and legitimation of different health practices and types of knowledge to face health problems, (4) Power sharing and co-accountability among managers, health professionals and citizens in healthcare production; (5) Education of people and organizations; (6) Focus on outcomes that add value to health and life; (7) Transparency and accountability regarding collective interests. It is concluded that the principles of clinical management express connections that shed new light on management, healthcare, and education in integrated healthcare systems, requiring critical awareness in relation to the simultaneity of "permanence" and change in practices.

O artigo objetiva propor princípios validados que norteariam uma gestão da clínica voltada à transformação da atenção à saúde, para sistemas integrados de saúde. Partiu-se da concepção de gestão da clínica configurada a partir de certos elementos estruturantes que não separam gestão, cuidado e educação. A proposta dos autores passou por processo de estabelecimento de consenso entre especialistas convidados. Como resultados, são apresentados os seguintes princípios da gestão da clínica: (1) Orientação às necessidades de saúde e à integralidade do cuidado; (2) Qualidade e segurança no cuidado em saúde; (3) Articulação e valorização dos diferentes saberes e práticas em saúde para o enfrentamento dos problemas de saúde; (4) Compartilhamento de poder e corresponsabilização entre gestores, profissionais de saúde e cidadãos na produção da atenção em saúde; (5) Educação de pessoas e da organização; (6) Orientação aos resultados que agreguem valor à saúde e à vida e (7) Transparência e responsabilização com os interesses coletivos. Conclui-se que os princípios da gestão da clínica expressam conexões que lançam uma nova luz sobre a gestão, atenção à saúde e educação em sistemas integrados e demandam uma consciência crítica em relação à simultaneidade de permanências e mudanças de práticas.

[A large network of integrated medical care: the example of Kaiser Permanente in California. First-hand report by a physician]. / Un grand réseau de soins médicaux intégrés: l'exemple de Kaiser Permanente en Californie. Témoignage d'un praticien.

The Kaiser Permanente (KP) system of integrated medical care is a unique model of medical organization in the USA which achieves the twin goals of economic efficiency and first-rate care. Organizationally, it is quite different from most health maintenance organizations (HMOs). The doctors remain independent, but in an exclusive marriage with the Kaiser Hospitals and the Kaiser insurance, both of which are non-profit. KP cares for over 8 million members. KP ensures continuity of patient care whether at home, as an outpatient, or when hospitalized, and promotes prevention among healthy members. The integration of all services produces very high indices measuring quality of care, as investigated by both the press and official government agencies at a surprising low cost. The system also was found to be more cost-effective than the National Health System in the United Kingdom.

Prehospital care in Indonesia.

BACKGROUND: Indonesia is a huge, diverse, and developing country that until recently had no public ambulance service let alone a system of prehospital care. It commonly experiences many natural disasters, manmade conflicts, and violence as well as the daily emergencies seen worldwide. CURRENT SYSTEM: Hospitals of varying standards are widespread but have no system of emergency ambulance or patient retrieval. Indonesia's only public emergency ambulance service, 118, is based in five of the biggest cities and is leading the way in paramedic training and prehospital care. CHALLENGES AND DEVELOPMENTS: There are many challenges faced including the culture of acceptance, vast geographical areas, traffic, inadequate numbers of ambulances, and access to quality training resources. Recently there have been a number of encouraging developments including setting up of a disaster response brigade, better provision of ambulances, and development of paramedic training. CONCLUSIONS: An integrated national regionalised hospital and prehospital system may seem fantastic but with the enthusiasm of those involved and perhaps some help from countries with access to training resources it may not be an unrealistic goal.

Health workforce governance: Processes, tools and actors towards a competent workforce for integrated health services delivery.

A competent health workforce is a vital resource for health services delivery, dictating the extent to which services are capable of responding to health needs. In the context of the changing health landscape, an integrated approach to service provision has taken precedence. For this, strengthening health workforce competencies is an imperative, and doing so in practice hinges on the oversight and steering function of governance. To aid health system stewards in their governing role, this review seeks to provide an overview of processes, tools and actors for strengthening health workforce competencies. It draws from a purposive and multidisciplinary review of literature, expert opinion and country initiatives across the WHO European Region's 53 Member States. Through our analysis, we observe distinct yet complementary roles can be differentiated between health services delivery and the health system. This understanding is a necessary prerequisite to gain deeper insight into the specificities for strengthening health workforce competencies in order for governance to rightly create the institutional environment called for to foster alignment. Differentiating between the contribution of health services and the health system in the strengthening of health workforce competencies is an important distinction for achieving and sustaining health improvement goals.

Managed care and market power: physician organizations in four markets.

Physicians and other providers have responded to the spread of managed care by adapting structures and strategies to accommodate or resist the pressures exerted on them to reduce costs. In this paper we examine how physician organizations have evolved in four markets and whether their features represent attempts to improve efficiency or resist change. The strategies adopted by physicians in terms of alignment with other providers and development of independent medical management capabilities appear to be sensitive to opportunities to reap cost savings and the competitiveness of physician, hospital, and health plan markets.

Physician practice management organizations: their prospects and performance.

As physician organizations adapt their incentives, processes, and structures to accommodate the demands of an increasingly competitive and performance-sensitive external environment, the development of more effective administrative and managerial mechanisms becomes critical to success. The emergence of physician practice management companies (PPMCs) represents a potentially positive step for physician practices seeking increased economies of scale through consolidation, as well as enhanced access to financial capital. However, economic and finance theory, coupled with some empirical "arithmetic" regarding the financial and operational performance of leading publicly traded PPMCs, suggest caution in one's forecasts of the future prospects for these evolving corporate forms.

Integrating lay and nurse-midwifery into the U.S. and Canadian health care systems.

The integration of midwifery into the health care systems in the U.S. and Canada has invoked scholars to speak of a "rise of midwifery". Despite the gains that the profession of midwifery has made in both countries, there are some interesting differences in how midwifery is organized and practised in these two settings. Briefly, in the U.S. midwifery currently exists as a profession divided between nurse- and non-nurse-midwives, or "lay" midwives, with greater acceptance and legitimacy garnered by the former, whereas midwifery in some jurisdictions in Canada has gained legitimacy as a unified profession separate from nursing. An analysis of the differences in the development and organization of lay and nurse-midwifery in Canada and the U.S. highlights the importance of differences in the system of health professions in these two countries, the role of the state in this system, and the relationship between feminism, midwifery and the state on the outcome of efforts to integrate midwifery.

Advanced practice nurses in integrated health care systems.

Changes in the health care delivery system are discussed with a view to those affecting the role and use of advanced practice nurses and particularly nurse practitioners who provide primary and reproductive care to women. Nurse practitioners are particularly well suited to function within integrated systems. They accomplish cost-containment strategies because of lower salaries or fees, fewer invasive procedures, greater compliance by patients, and increased nonpharmacologic treatments. They collaborate with all providers of primary care and enhance communication with patients. They develop clinical pathways for professionals and for patients and their families and support the use of guidelines and protocols to enhance standards of practice. It is suggested that women will become powerful consumers and that nurse practitioners are especially versed, not only in providing routine screening and episodic care, but also in teaching self-care, providing developmental and emotional support, and increasing compliance for health promotion and disease prevention. A high demand exists for education as an advanced practice nurse. Although many educational programs are moving to the master's degree, standardized educational levels are urged as a means for professionals and consumers to better understand advanced practice nursing roles. The need for nurse practitioners in the primary care market-place is demonstrated, but the system is in a state of flux, and the roles may not be used appropriately. Nurse practitioners should help to define new jobs and be assertive in negotiating for positions.