RESUMEN
OBJECTIVE: Building on the original taxonomy of hospital-based health systems from 20 years ago, we develop a new taxonomy to inform emerging public policy and practice developments. DATA SOURCES: The 2016 American Hospital Association's (AHA) Annual Survey; the 2016 IQVIA Healthcare Organizations and Systems (HCOS) database; and the 2017-2018 National Survey of Healthcare Organizations and Systems (NSHOS). STUDY DESIGN: Cluster analysis of the 2016 AHA Annual Survey data to derive measures of differentiation, centralization, and integration to create categories or types of hospital-based health systems. DATA COLLECTION: Principal components factor analysis with varimax rotation generating the factors used in the cluster algorithms. PRINCIPAL FINDINGS: Among the four cluster types, 54% (N = 202) of systems are decentralized (-0.35) and relatively less differentiated (-0.37); 23% of systems (N = 85) are highly differentiated (1.28) but relatively decentralized (-0.29); 15% (N = 57) are highly centralized (2.04) and highly differentiated (0.65); and approximately 9 percent (N = 33) are least differentiated (-1.35) and most decentralized (-0.64). Despite differences in calculation, the Highly Centralized, Highly Differentiated System Cluster and the Undifferentiated, Decentralized System Cluster were similar to those identified 20 years ago. The other two system clusters contained similarities as well as differences from those 20 years ago. Overall, 82 percent of the systems remain relatively decentralized suggesting they operate largely as holding companies allowing autonomy to individual hospitals operating within the system. CONCLUSIONS: The new taxonomy of hospital-based health systems bears similarities as well as differences from 20 years ago. Important applications of the taxonomy for addressing current challenges facing the healthcare system, such as the transition to value-based payment models, continued consolidation, and the growing importance of the social determinants of health, are highlighted.
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Prestación Integrada de Atención de Salud/clasificación , Prestación Integrada de Atención de Salud/organización & administración , Hospitales Generales/clasificación , Hospitales Generales/organización & administración , Prestación Integrada de Atención de Salud/economía , Prestación Integrada de Atención de Salud/normas , Hospitales Generales/economía , Hospitales Generales/normas , Humanos , Propiedad , Estados UnidosRESUMEN
Background: Nurses and others have used various terms to describe our caring/healing approach to practice. Because terms used can influence our image of ourselves and the image others have of us, we sought to clarify their meanings. Questions: How are the terms holistic nursing, integrative health care, and integrative nursing defined or described? Do we identify with these definitions/descriptions? Are the various terms the same or are they distinct? Method: We conducted an integrated review of peer-reviewed literature following the process described by Whittemore and Knafl. Using standard search methods, we reviewed full texts of 94 published papers and extracted data from 58 articles. Findings: Holistic describes "whole person care" often acknowledging body-mind-spirit. Holistic nursing defines a disciplinary practice specialty. The term integrative refers to practice that includes two or more disciplines or distinct approaches to care. Both terms, integrative and holistic, are associated with alternative/complementary modalities and have similar philosophical and/or theoretical underpinnings. Conclusions: There is considerable overlap between holistic nursing and integrative nursing. The relationship of integrative nursing to integrative health care is unclear based solely on definitions. Consideration of terms used provides opportunities for reflection, collaboration, and growth.
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Prestación Integrada de Atención de Salud/clasificación , Enfermería Holística/clasificación , Prestación Integrada de Atención de Salud/métodos , Prestación Integrada de Atención de Salud/tendencias , Enfermería Holística/métodos , Enfermería Holística/tendencias , HumanosRESUMEN
INTRODUCTION: Rheumatic heart disease (RHD) is a preventable chronic condition affecting the valves of the heart. RHD prevention and care programmes have historically originated in more developed countries, implemented in a targeted (or vertical) manner and evaluated using non-controlled approaches. Taking a broad view of the integration of RHD activities within the whole system is critical for health planning in low-income regions with a high burden of RHD and less robust health systems. Therefore, we propose to conduct a systematic review to assess RHD programme models in order to gain a better understanding of the extent of integration within relevant health systems. METHODS AND ANALYSIS: A predefined search strategy will be used to search for relevant articles published in English from January 1990 to December 2017. Electronic databases PubMed, Scopus, Web of Science, Africa Wide, CINAHL, Cochrane Central Register of Controlled Trials, Google Scholar and Global Index Medicus will be searched, as well as reference lists of relevant articles published. A standardised data extraction form will be used to obtain information for analysis from the included studies. The quality, reliability and risk of bias of included studies will be assessed using design-specific criteria. Programme integration will be analysed according to stewardship and governance, financing, planning, service delivery, monitoring and evaluation, and demand generation. Programme inputs, outputs and impact will also be described. ETHICS AND DISSEMINATION: No ethical approval is required. Findings will be disseminated in a peer-review journal in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines. PROSPERO REGISTRATION NUMBER: CRD42017076307.
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Prestación Integrada de Atención de Salud , Servicios Preventivos de Salud , Cardiopatía Reumática/prevención & control , Prestación Integrada de Atención de Salud/clasificación , Prestación Integrada de Atención de Salud/métodos , Prestación Integrada de Atención de Salud/organización & administración , Humanos , Servicios Preventivos de Salud/métodos , Servicios Preventivos de Salud/organización & administración , Proyectos de Investigación , Revisiones Sistemáticas como AsuntoRESUMEN
BACKGROUND: Medicare was an early innovator of accountable care organizations (ACOs), establishing the Medicare Shared Savings Program (MSSP) and Pioneer programs in 2012-2013. Existing research has documented that ACOs bring together an array of health providers with hospitals serving as important participants. PURPOSE: Hospitals vary markedly in their service structure and organizational capabilities, and thus, one would expect hospital ACO participants to vary in these regards. Our research identifies hospital subgroups that share certain capabilities and competencies. Such research, in conjunction with existing ACO research, provides deeper understanding of the structure and operation of these organizations. Given that Medicare was an initiator of the ACO concept, our findings provide a baseline to track the evolution of ACO hospitals over time. METHODOLOGY/APPROACH: Hierarchical clustering methods are used in separate analyses of MSSP and Pioneer ACO hospitals. Hospitals participating in ACOs with 2012-2013 start dates are identified through multiple sources. Study data come from the Centers for Medicare and Medicaid Services, American Hospital Association, and Health Information and Management Systems Society. RESULTS: Five-cluster solutions were developed separately for the MSSP and Pioneer hospital samples. Both the MSSP and Pioneer taxonomies had several clusters with high levels of health information technology capabilities. Also distinct clusters with strong physician linkages were present. We examined Pioneer ACO hospitals that subsequently left the program and found that they commonly had low levels of ambulatory care services or health information technology. CONCLUSION: Distinct subgroups of hospitals exist in both the MSSP and Pioneer programs, suggesting that individual hospitals serve different roles within an ACO. Health information technology and physician linkages appear to be particularly important features in ACO hospitals. PRACTICE IMPLICATIONS: ACOs need to consider not only geographic and service mix when selecting hospital participants but also their vertical integration features and management competencies.
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Organizaciones Responsables por la Atención/clasificación , Hospitales/clasificación , Medicare/organización & administración , Organizaciones Responsables por la Atención/organización & administración , Análisis por Conglomerados , Prestación Integrada de Atención de Salud/clasificación , Prestación Integrada de Atención de Salud/organización & administración , Administración Hospitalaria , Servicios Hospitalarios Compartidos/organización & administración , Humanos , Estados UnidosRESUMEN
Attention deficit hyperactivity disorder (ADHD) is a common behavioral health disorder in childhood that causes significant impairments in quality of life, home relationships, and school success. Despite a substantial evidence base and corresponding practice guidelines established by the American Academy of Pediatrics that support use of behavioral therapy to treat ADHD, affected patients infrequently receive therapy. This article will review the causes of underuse of behavioral therapy and methods to overcome these barriers such as integrating behavioral health care, thereby creating a pediatric patient-centered medical home. Additionally, a novel practice model of a behavioral health care collaboration being piloted in a rural pediatric office will be presented, including methods to screen, assess, and treat ADHD patients and families within the comfort of the primary care office.
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Trastorno por Déficit de Atención con Hiperactividad/terapia , Terapia Conductista/organización & administración , Prestación Integrada de Atención de Salud/organización & administración , Atención Primaria de Salud/organización & administración , Salud Rural , Población Rural , Trastorno por Déficit de Atención con Hiperactividad/fisiopatología , Niño , Conducta Cooperativa , Prestación Integrada de Atención de Salud/clasificación , Adhesión a Directriz , Investigación sobre Servicios de Salud , Humanos , Innovación Organizacional , Guías de Práctica Clínica como Asunto , Calidad de Vida , Salud Rural/normasRESUMEN
Background: Comprehensive Geriatric Assessment (CGA) is now the accepted gold standard for caring for frail older people in hospital. However, there is uncertainty about identifying and targeting suitable recipients and which patients benefit the most. Objectives: our objectives were to describe the key elements, principal measures of outcome and the characteristics of the main beneficiaries of inpatient CGA. Methods: we used the Joanna Briggs Institute umbrella review method. We searched for systematic reviews and meta-analyses describing CGA services for hospital inpatients in the Cochrane Database of Systematic Reviews, Database of Reviews of Effectiveness (DARE), MEDLINE and EMBASE and a range of other sources. Results: we screened 1,010 titles and evaluated 419 abstracts for eligibility, 143 full articles for relevance and included 24 in a final quality and relevance check. Thirteen reviews, reported in 15 papers, were selected for review. The most widely used definition of CGA was: 'a multidimensional, multidisciplinary process which identifies medical, social and functional needs, and the development of an integrated/co-ordinated care plan to meet those needs'. Key clinical outcomes included mortality, activities of daily living and dependency. The main beneficiaries were people ≥55 years in receipt of acute care. Frailty in CGA recipients and patient related outcomes were not usually reported. Conclusions: we confirm a widely used definition of CGA. Key outcomes are death, disability and institutionalisation. The main beneficiaries in hospital are older people with acute illness. The presence of frailty has not been widely examined as a determinant of CGA outcome.
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Prestación Integrada de Atención de Salud/métodos , Fragilidad/terapia , Evaluación Geriátrica/métodos , Geriatría/métodos , Admisión del Paciente , Factores de Edad , Anciano , Prestación Integrada de Atención de Salud/clasificación , Femenino , Anciano Frágil , Fragilidad/diagnóstico , Fragilidad/fisiopatología , Fragilidad/psicología , Evaluación Geriátrica/clasificación , Geriatría/clasificación , Humanos , Vida Independiente , Masculino , Persona de Mediana Edad , Grupo de Atención al Paciente , Participación Social , Terminología como AsuntoRESUMEN
BACKGROUND: In January 2015, we created a multidisciplinary Aortic Center with the collaboration of Vascular Surgery, Cardiac Surgery, Interventional Radiology, Anesthesia and Hospital Administration. We report the initial success of creating a Comprehensive Aortic Center. METHODS: All aortic procedures performed from January 1, 2015 until December 31, 2016 were entered into a prospectively collected database and compared with available data for 2014. Primary outcomes included the number of all aortic related procedures, transfer acceptance rate, transfer time, and proportion of elective/emergent referrals. RESULTS: The Aortic Center included 5 vascular surgeons, 2 cardiac surgeons, and 2 interventional radiologists. Workflow processes were implemented to streamline patient transfers as well as physician and operating room notification. Total aortic volume increased significantly from 162 to 261 patients. This reflected an overall 59% (P = 0.0167) increase in all aorta-related procedures. We had a 65% overall increase in transfer requests with 156% increase in acceptance of referrals and 136% drop in transfer denials (P < 0.0001). Emergent abdominal aortic cases accounted for 17% (n = 45) of our total aortic volume in 2015. The average transfer time from request to arrival decreased from 515 to 352 min, although this change was not statistically significant. We did see a significant increase in the use of air-transfers for aortic patients (P = 0.0041). Factorial analysis showed that time for transfer was affected only by air-transfer use, regardless of the year the patient was transferred. Transfer volume and volume of aortic related procedures remained stable in 2016. CONCLUSIONS: Designation as a comprehensive Aortic Center with implementation of strategic workflow systems and a culture of "no refusal of transfers" resulted in a significant increase in aortic volume for both emergent and elective aortic cases. Case volumes increased for all specialties involved in the center. Improvements in transfer center and emergency medical services communication demonstrated a trend toward more efficient transfer times. These increases and improvements were sustainable for 2 years after this designation.
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Aorta/cirugía , Enfermedades de la Aorta/cirugía , Procedimientos Quirúrgicos Cardíacos , Servicios Centralizados de Hospital/organización & administración , Prestación Integrada de Atención de Salud/organización & administración , Radiólogos/organización & administración , Radiología Intervencionista/organización & administración , Cirujanos/organización & administración , Centros Traumatológicos/organización & administración , Procedimientos Quirúrgicos Vasculares/organización & administración , Procedimientos Quirúrgicos Cardíacos/clasificación , Servicio de Cardiología en Hospital/organización & administración , Servicios Centralizados de Hospital/clasificación , Conducta Cooperativa , Bases de Datos Factuales , Prestación Integrada de Atención de Salud/clasificación , Procedimientos Quirúrgicos Electivos , Urgencias Médicas , Florida , Humanos , Comunicación Interdisciplinaria , Grupo de Atención al Paciente/clasificación , Grupo de Atención al Paciente/organización & administración , Transferencia de Pacientes/organización & administración , Evaluación de Programas y Proyectos de Salud , Radiólogos/clasificación , Servicio de Radiología en Hospital/organización & administración , Radiología Intervencionista/clasificación , Derivación y Consulta/organización & administración , Estudios Retrospectivos , Cirujanos/clasificación , Terminología como Asunto , Factores de Tiempo , Tiempo de Tratamiento/organización & administración , Centros Traumatológicos/clasificación , Procedimientos Quirúrgicos Vasculares/clasificación , Flujo de Trabajo , Carga de TrabajoRESUMEN
Insufficient knowledge exists regarding how to measure the presence and degree of integrated care. Prior estimates of integration levels are neither grounded in theory nor psychometrically validated. They provide scant guidance to inform improvement activities, compare integration efforts, discriminate among practices by degree of integration, measure the effect of integration on quadruple aim outcomes, or address the needs of clinicians, regulators, and policymakers seeking new models of health care delivery and funding. We describe the development of the Practice Integration Profile (PIP), a novel instrument designed to measure levels of integrated behavioral health care within a primary care clinic. The PIP draws upon the Agency for Health care Research & Quality's (AHRQ) Lexicon of Collaborative Care which provides theoretic justification for a paradigm case of collaborative care. We used the key clauses of the Lexicon to derive domains of integration and generate measures corresponding to those key clauses. After reviewing currently used methods for identifying collaborative care, or integration, and identifying the need to improve on them, we describe a national collaboration to describe and evaluate the PIP. We also describe its potential use in practice improvement, research, responsiveness to multiple stakeholder needs, and other future directions. (PsycINFO Database Record
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Prestación Integrada de Atención de Salud/clasificación , Atención Primaria de Salud/normas , Evaluación de Procesos, Atención de Salud/tendencias , Humanos , Atención Primaria de Salud/métodos , Atención Primaria de Salud/tendencias , Mejoramiento de la CalidadRESUMEN
INTRODUCTION: Type 2 diabetes is often comorbid with internalizing mental health disorders and associated with greater psychiatric treatment resistance. Integrating psychotherapy into primary care can help treat internalizing disorders generally. We explored whether such treatment had comparable effectiveness in patients with and without Type 2 diabetes. METHOD: Participants were 468 consecutive adults (23% male; 62% Hispanic, Mage = 41.46 years) referred by medical staff for psychotherapy appointments to address internalizing symptoms (e.g., depression). After each visit, patients completed a self-report measure and clinicians assessed patient symptom severity. These data and demographics extracted from electronic medical records were analyzed using descriptive and multilevel modeling analyses. RESULTS: Patients with and without diabetes were similar in types of internalizing disorders experienced and baseline clinician- and self-reported symptomology. Multilevel modeling suggested improvements in self-reported symptomology was comparable across patient groups; however, only patients without diabetes significantly improved according to clinician reports. DISCUSSION: Although findings suggested integrated psychotherapy resulted in comparable patient-reported reductions of internalizing symptoms, these effects were not evident in clinician reports of diabetic patients. Possible reasons for this discrepancy (e.g., reporting biases) are discussed. Integrated psychotherapy for internalizing disorders may be effective for Type 2 diabetic patients, though caution is warranted. (PsycINFO Database Record
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Medicina de la Conducta/métodos , Prestación Integrada de Atención de Salud/normas , Diabetes Mellitus Tipo 2/psicología , Trastornos Mentales/terapia , Adulto , Terapia Conductista , Prestación Integrada de Atención de Salud/clasificación , Depresión/diagnóstico , Depresión/terapia , Diabetes Mellitus Tipo 2/terapia , Femenino , Humanos , Masculino , Persona de Mediana EdadRESUMEN
BACKGROUND: Developing integrated service models in a primary care setting is considered an essential strategy for establishing a sustainable and affordable health care system. The Rainbow Model of Integrated Care (RMIC) describes the theoretical foundations of integrated primary care. The aim of this study is to refine the RMIC by developing a consensus-based taxonomy of key features. METHODS: First, the appropriateness of previously identified key features was retested by conducting an international Delphi study that was built on the results of a previous national Delphi study. Second, categorisation of the features among the RMIC integrated care domains was assessed in a second international Delphi study. Finally, a taxonomy was constructed by the researchers based on the results of the three Delphi studies. RESULTS: The final taxonomy consists of 21 key features distributed over eight integration domains which are organised into three main categories: scope (person-focused vs. population-based), type (clinical, professional, organisational and system) and enablers (functional vs. normative) of an integrated primary care service model. CONCLUSIONS: The taxonomy provides a crucial differentiation that clarifies and supports implementation, policy formulation and research regarding the organisation of integrated primary care. Further research is needed to develop instruments based on the taxonomy that can reveal the realm of integrated primary care in practice.
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Clasificación/métodos , Prestación Integrada de Atención de Salud/clasificación , Atención Primaria de Salud , Técnica Delphi , Humanos , Cooperación Internacional , Modelos Organizacionales , Países Bajos , Atención Primaria de Salud/métodos , Atención Primaria de Salud/organización & administraciónRESUMEN
OBJECTIVE: To use industrial organisation and organisational ecology research methods to survey industry structures and performance in the markets for private dental services and the effect of competition. DESIGN: Data on practice characteristics, performance, and perceived competition were collected from full-time private dentists (n = 1,121) using a questionnaire. The response rate was 59.6%. Cluster analysis was used to identify practice type based on service differentiation and process integration variables formulated from the questionnaire. RESULTS: Four strategic groups were identified in the Finnish markets: Solo practices formed one distinct group and group practices were classified into three clusters Integrated practices, Small practices, and Loosely integrated practices. Statistically significant differences were found in performance and perceived competitiveness between the groups. Integrated practices with the highest level of process integration and service differentiation performed better than solo and small practices. Moreover, loosely integrated and small practices outperformed solo practises. Competitive intensity was highest among small practices which had a low level of service differentiation and was above average among solo practises. CONCLUSIONS: Private dental care providers that had differentiated their services from public services and that had a high number of integrated service production processes enjoyed higher performance and less competitive pressures than those who had not.
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Servicios de Salud Dental/organización & administración , Sector de Atención de Salud/organización & administración , Práctica Privada/organización & administración , Prestación Integrada de Atención de Salud/clasificación , Prestación Integrada de Atención de Salud/economía , Prestación Integrada de Atención de Salud/organización & administración , Servicios de Salud Dental/clasificación , Servicios de Salud Dental/economía , Competencia Económica , Honorarios Odontológicos , Administración Financiera/economía , Administración Financiera/organización & administración , Finlandia , Práctica Odontológica de Grupo/clasificación , Práctica Odontológica de Grupo/economía , Práctica Odontológica de Grupo/organización & administración , Reforma de la Atención de Salud/economía , Reforma de la Atención de Salud/organización & administración , Sector de Atención de Salud/economía , Humanos , Comercialización de los Servicios de Salud/economía , Comercialización de los Servicios de Salud/organización & administración , Administración de la Práctica Odontológica/economía , Administración de la Práctica Odontológica/organización & administración , Práctica Privada/economíaAsunto(s)
Prestación Integrada de Atención de Salud/clasificación , Atención Ambulatoria , California , Prestación Integrada de Atención de Salud/economía , Prestación Integrada de Atención de Salud/organización & administración , Eficiencia Organizacional , Encuestas de Atención de la Salud , Humanos , Informática Médica , Estados UnidosAsunto(s)
Prestación Integrada de Atención de Salud/organización & administración , Eficiencia Organizacional/clasificación , Sistemas Multiinstitucionales/organización & administración , Benchmarking , Prestación Integrada de Atención de Salud/clasificación , Directorios como Asunto , Encuestas de Atención de la Salud , Humanos , Auditoría Administrativa , Sistemas Multiinstitucionales/clasificación , Integración de Sistemas , Estados UnidosRESUMEN
More needs to be done to improve safety and quality and to manage risks in health care. Existing processes are fragmented and there is no single comprehensive source of information about what goes wrong. An integrated framework for the management of safety, quality and risk is needed, with an information and incident management system based on a universal patient safety classification. The World Alliance for Patient Safety provides a platform for the development of a coherent approach; 43 desirable attributes for such an approach are discussed. An example of an incident management and information system serving a patient safety classification is presented, with a brief account of how and where it is currently used. Any such system is valueless unless it improves safety and quality. Quadruple-loop learning (personal, local, national and international) is proposed with examples of how an exemplar system has been successfully used at the various levels. There is currently an opportunity to "get it right" by international cooperation via the World Health Organization to develop an integrated framework incorporating systems that can accommodate information from all sources, manage and monitor things that go wrong, and allow the worldwide sharing of information and the dissemination of tools for the implementation of strategies which have been shown to work.
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Prestación Integrada de Atención de Salud/normas , Sistemas de Información Administrativa/normas , Administración de la Seguridad/normas , Seguridad/normas , Australia , Prestación Integrada de Atención de Salud/clasificación , Humanos , Cooperación Internacional , Errores Médicos/clasificación , Informática Médica , Integración de Sistemas , Gestión de la Calidad Total , Organización Mundial de la SaludRESUMEN
There is a growing need to better understand and address the consequences of an increasing reliance on networks used to enhance health services delivery. Networks seem to have emerged as the definitive solution for tackling complex healthcare problems together that we have not been able to adequately address separately. Emphasizing the collective and the collaborative, networks are assumed to address healthcare issues in ways that are superior to previous service-delivery models. While this assumption would appear to be sound theoretically, we have little empirical information available to actually understand what networks are, what they do and whether they achieve their stated goals--truly making a difference in the delivery of care and the maintenance of health. With a diversity of networks within Canada focused on health services delivery, this paper offers a multi-dimensional framework for conceptualizing how these complex inter-organizational relationships generate both challenges and opportunities. We identify six paradoxes that the networks create when used to enhance the delivery of health services and posit several propositions concerning the evaluative work that needs to be done to enhance our understanding of and confidence in this inter-organizational form. Unless these paradoxes are adequately recognized and addressed, the value and costs associated with developing and using networks in healthcare contexts will remain unclear at best. Given the broad interest in and use of networks proliferating in health-related arenas, it is time to amass the evidence and than align the perspectives. Are networks here to stay in healthcare because they make a difference or because we got tired of talking about the need for greater collaboration and so gave it a new name and frame? At the very least, it will be important to build on what we have already learned through research into collaboration in healthcare and related fields, and even more critical to be mindful of the pitfalls and possibilities of using networks as the solution of choice as we move forward.
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Redes Comunitarias/organización & administración , Prestación Integrada de Atención de Salud/organización & administración , Modelos Organizacionales , Canadá , Redes Comunitarias/clasificación , Conducta Cooperativa , Prestación Integrada de Atención de Salud/clasificación , Eficiencia Organizacional , Política de Salud , Investigación sobre Servicios de Salud , Humanos , Relaciones Interinstitucionales , Innovación Organizacional , Política Organizacional , Política , Apoyo SocialRESUMEN
Networks of collaborating organizations have become critical mechanisms for the effective delivery of healthcare and related human services. Despite their importance, there is much about health networks that is not understood. The article by Huerta, Casebeer and VanderPlaat is an effort to discuss the importance of health services delivery networks and to point out ways in which such networks might best be studied. Their article offers a number of useful and interesting ideas for both practice and research. Many of these ideas are not, however, well organized, integrated or fully developed. This commentary provides a critique of their work, while offering some of our own suggestions about how the study of health delivery networks might be advanced.