Caseload profiling in district nursing: a systematic literature review.

This systematic literature review aims to identify and appraise current evidence to establish if caseload profiling (CP) provides a strategy to support district nurses to evidence and manage increasingly complex caseloads. A total of 17 studies where thematically synthesised and recurrent themes were identified and summarised under the headings of: defining caseload profiling; caseload profiling in the context of caseload management; workload analysis and its relationship to caseload profiling; potential impact of caseload profiling; and potential barriers to caseload profiling. The literature review showed CP is a robust method of articulating the complexity of care and practitioners could use it to help manage their own caseloads. However, the literature is mainly founded on expert opinion and further research is needed to strengthen the validity of the evidence.

Regional healthcare delivery and demographic change in Germany - scenarios for dermatological care in 2035.

BACKGROUND: The 'demand planning guidelines' issued by the Federal Joint Committee are meant to ensure nationwide delivery of healthcare in Germany. The calculatory variable used to reflect the actual care situation in relation to a given geographical entity is referred to as 'adjusted supply rate'. Against the backdrop of demographic change and already existing problems in replacing retiring physicians, the question arises as to how future dermatological care will evolve at the regional level. METHODS: Using current 'demand planning guidelines' as well as nationwide data on the location of dermatologists and current and projected population figures at the county level, the adjusted supply rate - in terms of dermatological care - was calculated for the year 2035 based on three possible scenarios (scenario 1: 100 % replacement of retiring dermatologists; scenario 2: non-replacement of one dermatologist per planning area; and scenario 3: non-replacement of two dermatologists in rural areas). RESULTS: While scenario 1 shows an actual improvement in regional dermatological care in certain areas between 2014 and 2035 (n = 3 no longer undersupplied), the more likely scenarios 2 and 3 are potentially associated with considerable regional undersupply. CONCLUSIONS: Taking demographic change into account, it is safe to assume that the geographical heterogeneity of dermatological care will increase. This requires greater effort not only in terms of demand planning but also with regard to offering alternative methods of delivering healthcare and intercommunal cooperation. In this context, the objective will be to adapt healthcare delivery to changes both in demography as well as in the plans young physicians have for their own lives.

Challenges of Recruitment and Retention in Rural Areas.

There have long been rural health care workforce shortages; however, the urgency to find real solutions has increased with the changing health care landscape. The evidence makes a compelling case to be intentional in the candidates we support and to align educational resources across multiple systems. Programs need to continually evolve, utilizing workforce data, best practices, and new technological advances. This leads the Office of Rural Health (ORH) to secure funding for therapists practicing in integrated settings and to expand loan repayment to general surgeons and providers creating access through telehealth. While access is ORH's core mission, North Carolina's rural health plan reframed the discussion around creating healthy rural communities. This will require further refinement of the critical workforce definition, and it brings to the forefront the fact that a variety of new partnerships will be key to achieving the objective of healthy rural communities.

Forecasting future needs and optimal allocation of medical residency positions: the Emilia-Romagna Region case study.

OBJECTIVES: Italian regional health authorities annually negotiate the number of residency grants to be financed by the National government and the number and mix of supplementary grants to be funded by the regional budget. This study provides regional decision-makers with a requirement model to forecast the future demand of specialists at the regional level. METHODS: We have developed a system dynamics (SD) model that projects the evolution of the supply of medical specialists and three demand scenarios across the planning horizon (2030). Demand scenarios account for different drivers: demography, service utilization rates (ambulatory care and hospital discharges) and hospital beds. Based on the SD outputs (occupational and training gaps), a mixed integer programming (MIP) model computes potentially effective assignments of medical specialization grants for each year of the projection. RESULTS: To simulate the allocation of grants, we have compared how regional and national grants can be managed in order to reduce future gaps with respect to current training patterns. The allocation of 25 supplementary grants per year does not appear as effective in reducing expected occupational gaps as the re-modulation of all regional training vacancies.

District health managers' perceptions of supervision in Malawi and Tanzania.

BACKGROUND: Mid-level cadres are being used to address human resource shortages in many African contexts, but insufficient and ineffective human resource management is compromising their performance. Supervision plays a key role in performance and motivation, but is frequently characterised by periodic inspection and control, rather than support and feedback to improve performance. This paper explores the perceptions of district health management teams in Tanzania and Malawi on their role as supervisors and on the challenges to effective supervision at the district level. METHODS: This qualitative study took place as part of a broader project, "Health Systems Strengthening for Equity: The Power and Potential of Mid-Level Providers". Semi-structured interviews were conducted with 20 district health management team personnel in Malawi and 37 council health team members in Tanzania. The interviews covered a range of human resource management issues, including supervision and performance assessment, staff job descriptions and roles, motivation and working conditions. RESULTS: Participants displayed varying attitudes to the nature and purpose of the supervision process. Much of the discourse in Malawi centred on inspection and control, while interviewees in Tanzania were more likely to articulate a paradigm characterised by support and improvement. In both countries, facility level performance metrics dominated. The lack of competency-based indicators or clear standards to assess individual health worker performance were considered problematic. Shortages of staff, at both district and facility level, were described as a major impediment to carrying out regular supervisory visits. Other challenges included conflicting and multiple responsibilities of district health team staff and financial constraints. CONCLUSION: Supervision is a central component of effective human resource management. Policy level attention is crucial to ensure a systematic, structured process that is based on common understandings of the role and purpose of supervision. This is particularly important in a context where the majority of staff are mid-level cadres for whom regulation and guidelines may not be as formalised or well-developed as for traditional cadres, such as registered nurses and medical doctors. Supervision needs to be adequately resourced and supported in order to improve performance and retention at the district level.

Regionalisation of general practice training--are we meeting the needs of rural Australia?

The concept of "social accountability" has underpinned the development of many medical education programs over the past decade. Success of the regionalisation of the general practice training program in Australia will ultimately be measured by the ability of the program to deliver a sufficient rural general practice workforce to meet the health needs of rural communities. Regionalisation of general practice training in Australia arose from the 1998 recommendations of the Ministerial Review of General Practice Training. The resultant competitive structure adopted by government was not the preferred option of the Review Committee, and may be a negative influence on rural workforce, as the competitive corporate structure of regional training providers has created barriers to meaningful vertical integration. Available data suggest that the regionalised training program is not yet providing a sustainable general practice workforce to rural Australia. The current increase in medical student and general practice training places provides an opportunity to address some of these issues. In particular, it is recommended that changes be made to registrar selection processes, the rural pipeline and vertical integration of training, and training for procedural rural practice. To achieve these goals, perhaps it is time for another comprehensive ministerial review of general practice training in Australia.

The licensed practical nurse workforce in the United States: one state's experience.

BACKGROUND: Licensed practical nurses (LPNs) are employed in multiple health care settings in the United States, with the largest portion providing nursing care in long-term care, skilled nursing, and nursing home facilities, which largely provide custodial care and rehabilitative services to elderly residents. Rapid growth in the size of the elderly population in the U.S., combined with retirements from an aging LPN workforce, are expected to increase the demand for LPNs in the coming decades. This paper describes the characteristics of LPNs in one state, Washington, and makes projections of LPN supply and demand in the state through 2026. METHODS: The study uses data from a 2007 survey of LPNs with Washington State licenses to describe the demographic, education, and practice characteristics of the workforce. The projections of LPN supply and demand were built from the baseline survey data and changes over time were estimated using available data and literature from a variety of sources. RESULTS: Of the 14,446 LPNs with Washington licenses in 2007, 72% practiced in the state. The work setting in which the largest percentage worked was long-term care (37%). Of the average 37 hours worked per week by LPNs, 25 hours were spent in direct patient care. The average age of practicing LPNs was 46 and 12% of LPNs were male. The racial/ethnic distribution of Washington's LPNs resembled that of the overall state population, with 17% non-White and 4% Hispanic. Nearly three quarters obtained their LPN education within Washington. If the 2007 number of completions from LPN schools in Washington is sustained, the projected supply of practicing LPNs in 2026 will be more than 3,500 (24%) below estimated demand. If the current education completion number increased by 200 LPNs (nearly 20%) in 2011, and this number was maintained through 2026, the projected supply of practicing LPNs would increase but would still be 2,052 LPNs below estimated demand in 2026. Neither projection scenario produces enough LPNs to maintain the 2007 LPN-to-population ratio through 2026. CONCLUSIONS/POLICY IMPLICATIONS: It is not known precisely whether or how LPN workforce roles will change in the future, but the projected LPN shortages in Washington State mirror similar findings from other parts of the U.S., with major growth in projected LPN demand due to increases in, and aging of the state's population. The number of LPNs completing education programs in the state is unlikely to keep pace with the decline in supply from retirements unless a significant expansion of education programs takes place. The LPN profession is an important entry point into the nursing profession, and increasing the number of LPNs educated in-state could expand the pipeline leading to registered nurse (RN) careers, another nursing profession for which major shortages are predicted. Carefully articulated LPN-to-RN education programs could improve the attractiveness of the profession and increase the supply of LPNs.

Toward a methodology for substate projections of registered nurse supply and demand in New York.

Even as concerns about nursing shortages continue nationwide and for individual states in the United States, there is little information on the impact of nursing shortages at substate levels, such as counties or groups of small counties. National and state level assessments can mask wide geographic variation in the distribution of registered nurses (RNs). The Center for Health Workforce Studies at the School of Public Health, University at Albany, developed a practical approach to projecting RN supply and demand at substate levels. The experimental model used in this research was adapted from a methodology utilized for the RN National Supply Model and National Demand Model developed by the Health Resources and Services Administration in the department of Health and Human Services to make RN supply and demand projections at the broader national and state levels. The Center's research highlighted the value of substate analyses in the identification of RN supply and demand gaps and found that supply and demand gaps vary greatly by region and within regions. This study also provided an in-depth understanding of the dynamics that drive substate labor markets for RNs as well as the need for substate analyses to help policymakers better allocate scarce resources to address nursing shortages.

Effectiveness of occupational injury prevention policies in Spain.

OBJECTIVE: We examined the effectiveness of preventive interventions against occupational injuries (preferential action plans [PAPs]) developed by Spanish regional governments starting in 2000. METHODS: We included 3,252,028 occupational injuries with sick leave due to mechanical causes occurring between 1994 and 2004 in manufacturing and private service companies. Time trends for occupational injury rates were estimated before and after implementation of PAPs in each region, with a control group defined for those regions in which no PAPs were implemented (e.g., Galicia, Madrid, and Cataluña). We determined annual change percentages and their 95% confidence intervals (CIs) through a negative binomial regression model. Regions were grouped into three categories according to formal quality of their PAPs. RESULTS: The regions with the best PAPs (Andalucia, Aragon, Valencia, and Murcia) showed annually increasing occupational injury rates (2.3%, 95% CI -2.5, 7.4) before implementation of PAPs. After PAPs were implemented, occupational injury rates decreased significantly to -7.4% (95% CI -10.2, -4.5). Similar results were also found for regions with PAPs of lower quality and even for regions that didn't implement a PAP (control group). These results did not vary substantially in stratified analysis by gender, age, type of contract, or length of sick leave. CONCLUSION: PAPs are not related to a general decline in occupational injury rates in Spain starting in 2000. Reinforcement of Spanish health and safety regulations and labor inspection activities since 2000, resulting from a social agreement between central government and social agents, remains an alternative hypothesis requiring additional research.

Human resource development: new assessments and new directions.

The National Health Plan (NHP) 2001-2010 required a health workforce situation analysis and strategy to match the NHP's priorities and strategies. This paper is based on the work that was done in 2001 to support the preparation of a Health Human Resource Development Strategy for Papua New Guinea (PNG). The analysis showed that changes in health sector financing, population growth and changing health needs had created many human resource problems and challenges. This paper focuses on the main categories of health worker in PNG: doctors, health extension officers, nurses and community health workers. It presents analyses of workforce numbers and costs, and discusses future health system and human resource strategies based on the 2001 study and subsequent developments.

[Physicians' commuting in five health regions in São Paulo, Brazil: patterns and intervening factors]. / A circularidade dos médicos em cinco regiões de São Paulo, Brasil: padrões e fatores intervenientes.

The article aims to analyze physicians' commuting from a new perspective, verifying their movement and work supply between health regions, specifically in five regions in the state of São Paulo, Brazil. This movement was referred to as physicians' commuting, defined as the diversity of job situations over the course of a given time period in given geographic territories. The methodology used was a multiple case study with quantitative and qualitative approaches. All the physicians registered in the National Registry of Healthcare Establishment (CNES) in March 2015 were categorized as either "exclusive physicians", with employment contracts exclusively in the target health region or "non-exclusive physicians", with employment contracts both in that region and in other regions. We analyzed the region's socioeconomic and health characteristics and healthcare structure. The region's dependence on external physicians, namely those residing in other regions, varied from 30 to 40%; dependence was higher in the more economically developed regions and less in the less developed regions. Internal dependence, among municipalities, was close to 40% in the regions with higher economic development and reached 60% in the less developed regions. Non-exclusive physicians tended to be more specialized, working more in surgical and diagnostic specialties, while exclusive physicians worked more in basic and clinical specialties, suggesting that the commuting patterns are associated with the organization of different arrangements of healthcare provision. We identified a growing share of outsourced arrangements and the importance of regionally negotiated actions. Such studies can better orient more integrated redistributive policies.

O artigo objetiva analisar a movimentação dos médicos, sob nova perspectiva, verificando seu deslocamento e oferta de trabalho entre as Regiões de Saúde, especificamente em cinco regiões do Estado de São Paulo, Brasil. Denominou-se essa movimentação como circularidade médica, definida pela diversidade de vínculos constituintes do exercício profissional observada ao longo de um determinado período em determinados espaços geográficos. A metodologia usada foi de estudo de casos múltiplos com aplicação de abordagens quantitativas e qualitativas. Todos os médicos cadastrados na base do Cadastro Nacional de Estabelecimentos de Saúde (CNES), em março de 2015, foram categorizados em: "médicos exclusivos", com vínculos exclusivamente na região em foco; e "médicos não exclusivos", com vínculo na região e em outras. Analisaram-se os dados socioeconômicos e de saúde da região e a estrutura assistencial de saúde. A dependência regional de médicos externos variou de 30% a 40%, mais elevada nas regiões mais desenvolvidas e menor nas menos desenvolvidas. A dependência interna, entre municípios, fica próxima de 40% nas regiões com maior desenvolvimento econômico e chega a 60% nas as regiões menos desenvolvidas. Médicos não exclusivos são mais especializados, com maior atuação em especialidades cirúrgicas e de diagnóstico, e os exclusivos atuam mais em especialidades básicas e clínicas, indicando que a movimentação pode estar associada à organização da prestação da assistência, nos seus diferentes arranjos. Identifica-se uma crescente participação de arranjos terceirizados e a importância de ações pactuadas regionalmente. Tais estudos podem orientar melhor as políticas redistributivas mais integradas.

El objetivo de este artículo es analizar el movimiento de los médicos, desde una nueva perspectiva, verificando su desplazamiento y oferta de trabajo entre regiones de salud, específicamente, en cinco regiones del estado de São Paulo, Brasil. Se denominó este movimiento circularidad médica, y se definió por la diversidad de los vínculos que se constituyen durante el ejercicio profesional, observado a lo largo de un determinado período, en determinados espacios geográficos. La metodología utilizada fue la del estudio de casos múltiples con aplicación de abordajes cuantitativos y cualitativos. Todos los médicos registrados en la base del Registro Nacional de Establecimientos (CNES), en marzo de 2015, se categorizaron como: "médicos exclusivos", con vínculos exclusivamente en la región en cuestión; y "médicos no exclusivos", con vínculos en esta región y en otras. Se analizaron los datos socioeconómicos y de salud de la región y la estructura asistencial de salud. La dependencia regional de médicos externos varió de un 30 a un 40%, fue más elevada en las regiones más desarrolladas y menor en las menos desarrolladas. La dependencia interna, entre municipios, es cercana al 40% en las regiones con mayor desarrollo económico, y llega a un 60% en las regiones menos desarrolladas. Los médicos no exclusivos están más especializados, con una mayor actuación en especialidades quirúrgicas y de diagnóstico, mientras que los exclusivos actúan más en especialidades básicas y clínicas, indicando que el movimiento puede estar asociado a la organización de la prestación de la asistencia, en sus diferentes configuraciones. Se identifica una creciente participación de soluciones tercerizadas, así como la importancia de las acciones consensuadas regionalmente. Este tipo de estudios pueden orientar mejor las políticas redistributivas e integrarlas más.

Utilization of Functional Exercises to Build Regional Emergency Preparedness among Rural Health Organizations in the US.

Rural communities face barriers to disaster preparedness and considerable risk of disasters. Emergency preparedness among rural communities has improved with funding from federal programs and implementation of a National Incident Management System. The objective of this project was to design and implement disaster exercises to test decision making by rural response partners to improve regional planning, collaboration, and readiness. Six functional exercises were developed and conducted among three rural Nebraska (USA) regions by the Center for Preparedness Education (CPE) at the University of Nebraska Medical Center (Omaha, Nebraska USA). A total of 83 command centers participated. Six functional exercises were designed to test regional response and command-level decision making, and each 3-hour exercise was followed by a 3-hour regional after action conference. Participant feedback, single agency debriefing feedback, and regional After Action Reports were analyzed. Functional exercises were able to test command-level decision making and operations at multiple agencies simultaneously with limited funding. Observations included emergency management jurisdiction barriers to utilization of unified command and establishment of joint information centers, limited utilization of documentation necessary for reimbursement, and the need to develop coordinated public messaging. Functional exercises are a key tool for testing command-level decision making and response at a higher level than what is typically achieved in tabletop or short, full-scale exercises. Functional exercises enable evaluation of command staff, identification of areas for improvement, and advancing regional collaboration among diverse response partners. Obaid JM , Bailey G , Wheeler H , Meyers L , Medcalf SJ , Hansen KF , Sanger KK , Lowe JJ . Utilization of functional exercises to build regional emergency preparedness among rural health organizations in the US. Prehosp Disaster Med. 2017;32(2):224-230.

Demografia médica em municípios em extrema pobreza no Brasil / Medical demographics in municipalities in extreme poverty in Brazil / Demografía médica en municipios de extrema pobreza en Brasil

Resumo O objetivo deste artigo foi analisar a distribuição de profissionais médicos vinculados ao Sistema Único de Saúde em municípios em extrema pobreza do Brasil. Trata-se de estudo observacional, longitudinal e retrospectivo, desenvolvido com base em dados secundários disponibilizados pelo Departamento de Informática do Sistema Único de Saúde. Foram contabilizados 16.267 médicos, dos quais 1.360 atendiam na rede privada e 14.907 na rede pública. Dentre estes, 1.284 atendem na região Norte; 9.186, no Nordeste; 3.071, no Sudeste; 837, no Sul; e 529, no Centro-Oeste. Entre os municípios brasileiros em extrema pobreza, 12,2% dispõem de três médicos; 10,7%, de dois médicos; e 9,2%, de apenas um médico. Os desfechos primários relativos à demografia médica dos municípios em extrema pobreza afirmam a desproporção na distribuição de profissionais entre as cidades brasileiras. Sugere-se a implementação de políticas em saúde que promovam a equidade da demografia médica no país.

Abstract This article aimed to analyze the distribution of medical professionals linked to the Brazilian Unified Health System in municipalities in extreme poverty in the country. This is an observational, longitudinal and retrospective study based on secondary data provided by the Department of Informatics of the Unified Health System. In total, 16,267 physicians were identified, of which 1,360 worked in the private network and 14,907 in the public network. The regional distribution is as follows: 1,284 in the North; 9,186 in the Northeast; 3,071 in the Southeast; 837 in the South; and 529 in the Midwest. Among Brazilian municipalities in extreme poverty, 12.2% have three physicians; 10.7% of two physicians; and 9.2% of only one. The primary outcomes related to the demographics of medical personnel municipalities in extreme poverty show the disproportion in the distribution of professionals among Brazilian cities. The implementation of health policies that promote the equity of such demographics in the country is suggested.

Resumen Este artículo analizó la distribución de los profesionales médicos vinculados al Sistema Único de Salud en municipios en extrema pobreza en Brasil. Se trató de un estudio observacional, longitudinal y retrospectivo, realizado con datos secundarios provenientes del Departamento de Informática del Sistema Único de Salud. De un total de 16.267 médicos; 1.360 estaban en la red privada y 14.907 en la red pública. De estos, 1.284 trabajaban en la región Norte; 9.186, en el Nordeste; 3.071, en el Sudeste; 837 en el Sur; y 529, en el Centro-Oeste. En tal condición, el 12,2% de los municipios tenía tres médicos; el 10,7%, dos; y el 9,2% solo uno. Los resultados primarios relacionados con el tema permiten atestar la desproporción en la distribución de profesionales entre las ciudades brasileñas. Se sugiere implementar políticas de salud que promuevan la equidad en la demografía médica en el país.

Size and performance of planning agencies.

A preliminary analysis of the 1973-74 national assessment of comprehensive health planning [P.L. 89-749, sections 314 (a) and (b)] agencies is reported. The analysis suggests that agency staff size and budget are more strongly related to high performance scores than is size of population served. Complete analysis of the 1973-74 assessment data was not possible because of time constraints; it is argued that plans should be made for detailed analysis of data from future assessments of planning agencies under P.L. 93-641 so that factors relevant to performance may be identified more precisely and incorporated into agency structure.

The regional distribution of doctors in Mexico, 1930-1990: a policy assessment.

The results of the doctor distributional policy in Mexico is evaluated. Despite the government's efforts to achieve a better distribution of doctors throughout the country between 1930 and 1990, important disparities still exist among geographic areas. Diverse factors ranging from the underdevelopment of some areas, to the resistance of doctors to leave the urban areas, are related to this unequal distribution. Early programmes aimed at redressing the original distribution in the 1930's had limited effects. In subsequent years, additional programmes were implemented. However, a lack of coordination and the short time span of many programmes produced only minor changes to the distributional pattern. Although in recent years the distribution has improved, southern states still suffer an acute scarcity while northern states have a relative abundance. Finally, the paper discusses how economic, political and social variables, as well as the structure of the health system, have shaped the current distribution of Mexican doctors.

Physician recruitment in rural Canada: programs in New Brunswick, Newfoundland, and Nova Scotia.

This paper examines programs used in the Atlantic provinces of New Brunswick, Newfoundland, and Nova Scotia to recruit and retain physicians in rural areas. The provinces have many similarities but have unique characteristics that have shaped recruitment methods. The total number of physicians in each province has grown at a faster rate than the population. Each has problems attracting physicians to underserved areas, although the magnitude of the problems vary. The data for this paper were gathered from documents available from various agencies in each province and a series of personal interviews conducted in the spring of 1993. The provinces have chosen different avenues in attempting to solve the maldistribution of physician resources, ranging from regulatory methods in New Brunswick to moves in Newfoundland to encourage graduates of the province's medical school to locate in the rural areas and lessen the dependence on foreign medical graduates. Nova Scotia, with fewer areas needing physicians, has been able to focus its efforts on selected locations. Reviewing the methods used in the three provinces provides an insight into the attempts to solve the shortage of physicians in rural areas.

The Northland Health Scheme.

The Northland Health Scheme, proposed by the Special Advisory Committee on Health Service Organisation (Sachso), is about to become a reality. On 20 February 1978 cabinet approved the setting up of a steering committe in Northland to propose a Health Board structure, establish further working parties to consider local aspects of the scheme, initiate the formation of service development groups, assist SACHSO in developing legislation, and take any other steps that seemed appropriate. The chairman of this committee was named on 1 March and others who have agreed to serve are listed in the New Zealand Medical Journal of 22 March (News, 1978). It is now, therefore, an appropriate moment to scrutinise carefully what is proposed and the principles that underlie the proposals.