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1.
Salud Colect ; 17: e3338, 2021 02 24.
Artigo em Espanhol | MEDLINE | ID: mdl-33822539

RESUMO

Drawing on multiple sources, this article presents an analysis of a national survey implemented by Street Clinic teams in Brazil on the homeless population and the COVID-19 pandemic. Through the lens of certain ethical-political principles and methodological decisions, we focus our analysis on discourses about who lives and works on the streets during the pandemic, connecting discourse with experience. From the perspective of governmentality and biopolitics, we seek to shed light on power relations that reveal modes of government embodied at the street level - mainly related to isolation measures and social distancing - to create tensions surrounding the emergence of the notion of the homeless population in the midst of the pandemic. We conclude with a discussion of the precariousness that circumscribes life on the streets as a shared condition, and search for ways to comprehend forms of resistance and the right to exist.


Assuntos
COVID-19/prevenção & controle , Regulamentação Governamental , Política de Saúde , Pessoas em Situação de Rua , Distanciamento Físico , Provedores de Redes de Segurança/legislação & jurisprudência , Populações Vulneráveis , Brasil/epidemiologia , COVID-19/epidemiologia , Atenção à Saúde/legislação & jurisprudência , Atenção à Saúde/organização & administração , Pesquisas sobre Serviços de Saúde , Humanos , Pandemias , Provedores de Redes de Segurança/organização & administração , Justiça Social
2.
Soc Work Health Care ; 60(2): 146-156, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-33749534

RESUMO

Primary care systems are a mainstay for how many Americans seek health and behavioral health care. It is estimated that almost a quarter of behavioral health conditions are diagnosed and/or treated in primary care. Many clinics treat the whole person through integrated models of care such as the Primary Care Behavioral Health (PCBH) model. COVID-19 has disrupted integrated care delivery and traditional PCBH workflows requiring swift adaptations. This paper synthesizes how COVID-19 has impacted clinical services at one federally qualified health center and describes how care has continued despite the challenges experienced by frontline behavioral health providers.


Assuntos
COVID-19/epidemiologia , Serviços de Saúde Mental/organização & administração , Administração dos Cuidados ao Paciente/organização & administração , Atenção Primária à Saúde/organização & administração , Provedores de Redes de Segurança/organização & administração , Agendamento de Consultas , Humanos , Equipe de Assistência ao Paciente , Papel Profissional , SARS-CoV-2 , Autocuidado , Telemedicina/organização & administração , Fluxo de Trabalho
3.
J Subst Abuse Treat ; 124: 108244, 2021 05.
Artigo em Inglês | MEDLINE | ID: mdl-33339632

RESUMO

Following the rising crisis of COVID-19 and the Oregon governor's stay-at-home orders, members of the Oregon Health and Science University (OHSU) inpatient addiction consult service recognized that local addiction treatment and recovery organizations were operating at limited capacity. As a result, discharge planning, patient access to local community-based treatment, and safety-net programming were affected. Given structural and intersectional risk vulnerabilities of people with substance use disorders (SUDs), the OHSU members felt that COVID-19 would disproportionately impact chronically marginalized members of our community. These inequities inspired the formation of the Oregon substance use disorder resources collaborative (ORSUD) led by four medical students. ORSUD's mission is to support the efforts of local safety-net organizations that and front-line providers who serve chronically marginalized community members in the midst of the global pandemic. We operationalized our mission through: 1) collecting and disseminating operational and capacity changes in local addiction and harm reduction services to the broader treatment community, and 2) identifying and addressing immediate resource needs for local safety-net programs. Our program uses a real-time public-facing document to collate local programmatic updates and general community resources. COVID-19 disproportionately burdens people with SUDs; thus, ORSUD exists to support programs serving people with SUDs and will continue to evolve to meet their needs and the needs of those who serve them.


Assuntos
Medicina do Vício/tendências , COVID-19 , Acesso aos Serviços de Saúde , Alocação de Recursos , Provedores de Redes de Segurança/organização & administração , Transtornos Relacionados ao Uso de Substâncias/reabilitação , Redução do Dano , Humanos , Oregon , Quarentena , Encaminhamento e Consulta , Telemedicina
5.
Health Aff (Millwood) ; 39(10): 1752-1761, 2020 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-33017237

RESUMO

Safety-net programs improve health for low-income children over the short and long term. In September 2018 the Trump administration announced its intention to change the guidance on how to identify a potential "public charge," defined as a noncitizen primarily dependent on the government for subsistence. After this change, immigrants' applications for permanent residence could be denied for using a broader range of safety-net programs. We investigated whether the announced public charge rule affected the share of children enrolled in Medicaid, the Supplemental Nutrition Assistance Program, and the Special Supplemental Nutrition Program for Women, Infants, and Children, using county-level data. Results show that a 1-percentage-point increase in a county's noncitizen share was associated with a 0.1-percentage-point reduction in child Medicaid use. Applied nationwide, this implies a decline in coverage of 260,000 children. The public charge rule was adopted in February 2020, just before the coronavirus disease 2019 (COVID-19) pandemic began in the US. These results suggest that the Trump administration's public charge announcement could have led to many thousands of eligible, low-income children failing to receive safety-net support during a severe health and economic crisis.


Assuntos
Serviços de Saúde da Criança/organização & administração , Infecções por Coronavirus/prevenção & controle , Assistência Alimentar/estatística & dados numéricos , Disparidades em Assistência à Saúde/economia , Medicaid/economia , Pandemias/prevenção & controle , Pneumonia Viral/prevenção & controle , Pobreza/estatística & dados numéricos , Adolescente , Criança , Saúde da Criança , Pré-Escolar , Estudos de Coortes , Infecções por Coronavirus/epidemiologia , Bases de Dados Factuais , Medo , Feminino , Política de Saúde/legislação & jurisprudência , Humanos , Cobertura do Seguro/estatística & dados numéricos , Masculino , Inovação Organizacional , Pandemias/estatística & dados numéricos , Pneumonia Viral/epidemiologia , Formulação de Políticas , Estudos Retrospectivos , Provedores de Redes de Segurança/organização & administração , Estados Unidos
6.
Surgery ; 168(3): 404-407, 2020 09.
Artigo em Inglês | MEDLINE | ID: mdl-32624225

RESUMO

BACKGROUND: The coronavirus disease 2019 pandemic has claimed many lives and strained the US health care system. At Boston Medical Center, a regional safety-net hospital, the Department of Surgery created a dedicated coronavirus disease 2019 Procedure Team to ease the burden on other providers coping with the surge of infected patients. As restrictions on social distancing are lifted, health systems are bracing for additional surges in coronavirus disease 2019 cases. Our objective is to quantify the volume and types of procedures performed, review outcomes, and highlight lessons for other institutions that may need to establish similar teams. METHODS: Procedures were tracked prospectively along with patient demographics, immediate complications, and time from donning to doffing of the personal protective equipment. Retrospective chart review was conducted to obtain patient outcomes and delayed adverse events. We hypothesized that a dedicated surgeon-led team would perform invasive bedside procedures expeditiously and with few complications. RESULTS: From March 30, 2020 to April 30, 2020, there were 1,196 coronavirus disease 2019 admissions. The Procedure Team performed 272 procedures on 125 patients, including placement of 135 arterial catheters, 107 central venous catheters, 25 hemodialysis catheters, and 4 thoracostomy tubes. Specific to central venous access, the average procedural time was 47 minutes, and the rate of immediate complications was 1.5%, including 1 arterial cannulation and 1 pneumothorax. CONCLUSION: Procedural complication rate was less than rates reported in the literature. The team saved approximately 192 hours of work that could be redirected to other patient care needs. In times of crisis, redeployment of surgeons (who arguably have the most procedural experience) into procedural teams is a practical approach to optimize outcomes and preserve resources.


Assuntos
Betacoronavirus , Infecções por Coronavirus/epidemiologia , Transmissão de Doença Infecciosa/prevenção & controle , Pandemias , Equipamento de Proteção Individual/provisão & distribuição , Pneumonia Viral/epidemiologia , Provedores de Redes de Segurança/organização & administração , Cirurgiões/normas , Adulto , Idoso , Idoso de 80 Anos ou mais , Infecções por Coronavirus/transmissão , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Segurança do Paciente , Pneumonia Viral/transmissão , Estudos Retrospectivos , Estados Unidos/epidemiologia , Adulto Jovem
7.
Biodemography Soc Biol ; 65(3): 257-267, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32727275

RESUMO

In the United States, obesity has increased in prevalence over time and is strongly associated with subsequent outcomes such as diabetes mellitus (DM) and nonalcoholic fatty liver disease (NAFLD). It is unclear, however, as to how the magnitude of NAFLD risk from obesity and DM is increased in safety-net health system settings. Among the San Francisco Health Network (SFHN) patients (N = 47,211), we examined the association between Body Mass Index (BMI) and elevated liver enzyme levels, including interaction by DM status. Our findings revealed that 32.2 percent of SFHN patients were obese, and Pacific Islanders in the safety-net had the highest rates of obesity compared to other racial groups, even after using higher race-specific BMI cutoffs. In SFHN, obesity was associated with elevated liver enzymes, with the relationship stronger among those without DM. Our findings highlight how obesity is a stronger factor of NAFLD in the absence of DM, suggesting that practitioners consider screening for NAFLD among safety-net patients with obesity even if DM has not developed. These results highlight the importance of directing efforts to reduce obesity in safety-net health systems and encourage researchers to further examine effect modification between health outcomes in such populations.


Assuntos
Obesidade/terapia , Provedores de Redes de Segurança/métodos , Adolescente , Adulto , Idoso , Índice de Massa Corporal , California/epidemiologia , Comorbidade , Diabetes Mellitus/epidemiologia , Diabetes Mellitus/etiologia , Registros Eletrônicos de Saúde/estatística & dados numéricos , Feminino , Insuficiência Hepática/epidemiologia , Insuficiência Hepática/etiologia , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Obesidade/epidemiologia , Prevalência , Fatores de Risco , Provedores de Redes de Segurança/organização & administração , Provedores de Redes de Segurança/estatística & dados numéricos
8.
Health Aff (Millwood) ; 39(8): 1437-1442, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32525705

RESUMO

New York City Health + Hospitals is the largest safety-net health care delivery system in the United States. Before the coronavirus disease 2019 (COVID-19) pandemic, NYC Health + Hospitals served more than one million patients annually, including the most vulnerable New Yorkers, while billing fewer than five hundred telehealth visits monthly. Once the pandemic struck, we established a strategy to allow us to continue to serve our existing patients while treating the surge of new patients. Starting in March 2020, we were able to transform the system using virtual care platforms through which we conducted almost eighty-three thousand billable televisits in one month, as well as more than thirty thousand behavioral health encounters via telephone and video. Telehealth also enabled us to support patient-family communication, postdischarge follow-up, and palliative care for patients with COVID-19. Expanded Medicaid coverage and insurance reimbursement for telehealth played a pivotal role in this transformation. As we move to a new blend of virtual and in-person care, it is vital that the major regulatory and insurance changes undergirding our COVID-19 telehealth response be sustained to protect access for our most vulnerable patients.


Assuntos
Controle de Doenças Transmissíveis/organização & administração , Infecções por Coronavirus/epidemiologia , Atenção à Saúde/organização & administração , Pandemias/estatística & dados numéricos , Pneumonia Viral/epidemiologia , Provedores de Redes de Segurança/organização & administração , Telemedicina/organização & administração , Infecções por Coronavirus/prevenção & controle , Feminino , Humanos , Comunicação Interdisciplinar , Masculino , Cidade de Nova Iorque , Avaliação de Resultados em Cuidados de Saúde , Pandemias/prevenção & controle , Pneumonia Viral/prevenção & controle
10.
Acad Med ; 95(4): 559-566, 2020 04.
Artigo em Inglês | MEDLINE | ID: mdl-31913879

RESUMO

PURPOSE: Changing market forces increasingly are leading academic medical centers (AMCs) to form or join health systems. But it is unclear how this shift is affecting the tripartite academic mission of education, research, and high-quality patient care. To explore this topic, the authors identified and characterized the types of health systems that owned or managed AMCs in the United States in 2016. METHOD: The authors identified AMCs as any general acute care hospitals that had a resident-to-bed ratio of at least 0.25 and that were affiliated with at least one MD- or DO-granting medical school. Using the Agency for Healthcare Research and Quality 2016 Compendium of U.S. Health Systems, the authors also identified academic-affiliated health systems (AHSs) as those health systems that owned or managed at least one AMC. They compared AMCs and other general acute care hospitals, AHSs and non-AHSs, and AHSs by type of medical school relationship, using health system size, hospital characteristics, undergraduate and graduate medical education characteristics, services provided, and ownership. RESULTS: Health systems owned or managed nearly all AMCs (361, 95.8%). Of the 626 health systems, 230 (36.7%) met the definition of an AHS. Compared with other health systems, AHSs included more hospitals, provided more services, and had a lower ratio of primary care doctors to specialists. Most AHSs (136, 59.1%) had a single, shared medical school relationship, whereas 38 (16.5%) had an exclusive medical school relationship and 56 (24.3%) had multiple medical school relationships. CONCLUSIONS: These findings suggest that several distinct types of relationships between AHSs and medical schools exist. The traditional vision of a medical school having an exclusive relationship with a single AHS is no longer prominent.


Assuntos
Educação de Pós-Graduação em Medicina/organização & administração , Educação de Graduação em Medicina/organização & administração , Hospitais de Ensino/organização & administração , Centros Médicos Acadêmicos/organização & administração , Pesquisa Biomédica , Hospitais Gerais/organização & administração , Hospitais Pediátricos/organização & administração , Hospitais com Fins Lucrativos/organização & administração , Hospitais Públicos/organização & administração , Hospitais Filantrópicos/organização & administração , Humanos , Qualidade da Assistência à Saúde , Provedores de Redes de Segurança/organização & administração , Faculdades de Medicina/organização & administração
11.
Am J Surg ; 219(2): 299-303, 2020 02.
Artigo em Inglês | MEDLINE | ID: mdl-31928779

RESUMO

BACKGROUND: Safety-net hospitals frequently underperform on surgical quality measures. To achieve equitable surgical care, creative strategies are needed to improve care for this vulnerable population. METHODS: We designed a trainee-led quality improvement (QI) program to promote evidence-based analgesia prescribing. The program included a collaborative resident leadership model and used educational interventions and performance feedback. RESULTS: Before the QI program, 48% of patients were discharged on acetaminophen post-operatively, and 0% were discharged on ibuprofen. In the most recent month since the QI program was launched, 100% of patients were discharged on acetaminophen, and 81% on ibuprofen. CONCLUSION: Our trainee-led quality improvement program demonstrates that surgical trainees can accelerate change and may be a powerful force for improving health equity through safer post-operative discharge prescribing practices at a safety-net hospital.


Assuntos
Analgésicos Opioides/uso terapêutico , Medicina Baseada em Evidências/educação , Epidemia de Opioides/prevenção & controle , Dor Pós-Operatória/tratamento farmacológico , Melhoria de Qualidade , Provedores de Redes de Segurança/organização & administração , Adulto , Uso de Medicamentos , Educação de Pós-Graduação em Medicina/métodos , Feminino , Humanos , Internato e Residência/métodos , Masculino , Manejo da Dor/métodos , Dor Pós-Operatória/diagnóstico , Guias de Prática Clínica como Assunto , Medição de Risco , Estados Unidos
12.
J Surg Res ; 247: 163-171, 2020 03.
Artigo em Inglês | MEDLINE | ID: mdl-31776023

RESUMO

BACKGROUND: Care teams on complex surgical services face a growing list of competing expectations. Approaches to quality improvement must use minimal resources and address both system and human requirements to meet expectations without compromising care. The purpose of this study was to demonstrate that iterative prototyping, combined with a rigorous quantitative evaluation approach, can effectively improve system and stakeholder efficiency on daily trauma surgical rounds at an academic safety-net hospital and level 1 trauma center. MATERIALS AND METHODS: This study occurred between May 2017 and October 2017 at the Zuckerberg San Francisco General Hospital and Trauma Center. Care team members rounding on the trauma service included attending trauma surgeons, fellows, residents, interns, nurse practitioners, pharmacists, and medical students. We used human-centered design to develop and test solutions to improve the surgical rounding process. Each prototype was evaluated using qualitative design research methods, which informed the next iteration. Time observations of rounding activities were adopted from the Lean methodology and tracked before and after implementation. Intern work hours, on-time operative starts, and discharge order times were also tracked before and after implementation. RESULTS: Four prototypes were designed and iteratively implemented, producing care team satisfaction by the end of the implementation period. Discharge order times decreased by a median of 58 min, intern work hours were decreased by 97 min/d, and first operative case on-time starts increased from 40% to 63% (P < 0.05). The time spent on clarifications decreased by 4.7% (P < 0.05), allowing for more time to discuss care plans with the patients themselves. CONCLUSIONS: Iterative prototyping as part of a human-centered design methodology is a powerful tool to address complex systems with diverse interests and competing priorities. Rapid, in-context prototyping is feasible on a complex trauma surgical service and can result in improved workflows and efficiency for the system and its stakeholders.


Assuntos
Eficiência Organizacional , Equipe de Assistência ao Paciente/organização & administração , Melhoria de Qualidade , Visitas com Preceptor/organização & administração , Centros de Traumatologia/organização & administração , Centros Médicos Acadêmicos/organização & administração , Humanos , Motivação , Estudos Prospectivos , Pesquisa Qualitativa , Provedores de Redes de Segurança/organização & administração , Participação dos Interessados , Design Universal , Fluxo de Trabalho
15.
J Interprof Care ; 34(1): 27-35, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-31381470

RESUMO

The objective of this manuscript is to describe the results of a pharmacist-driven, Type 2 diabetes targeted, collaborative practice within an urban, underserved federally qualified health center. Pharmacists within a primary care team managed patients with chronic illnesses utilizing a collaborative practice agreement. Pharmacists, pharmacy residents, and supervised students provided care for patients with Type 2 diabetes. The first visit incorporated past medical history, medication reconciliation, determination of adherence and patient knowledge of diabetes pathophysiology, care plan, including diet and exercise, medications, and possible complications. Pharmacists had the authority to optimize medications and order laboratory tests and referrals. Diabetes, hypertension, and medication use outcomes data were collected and analyzed to assess the impact of clinical pharmacy services. Patient and provider satisfaction were assessed via surveys and focus group interviews. Ninety-nine patients were included in the evaluation. The mean A1c level was 9.8% at baseline and 8.4% at follow-up (p< .05). There were significant improvements in patient attainment of A1c <9%, ACE Inhibitor/angiotensin receptor blocker and statin use, and tobacco cessation at follow-up (p< .05). Eleven providers who responded to the satisfaction survey answered 73% of the questions with strongly agree. The seven patients who participated in the satisfaction survey, and focus group were satisfied with the care they received from the pharmacists. The focus group highlighted similar personal goals, barriers, and interests in nutrition education. Working as part of a collaborative care team, pharmacists were able to have a significant impact on improving the health outcomes of patients with Type 2 diabetes and patient and provider perceptions of the vital role of pharmacists.


Assuntos
Diabetes Mellitus Tipo 2/terapia , Gerenciamento Clínico , Relações Interprofissionais , Farmacêuticos/organização & administração , Provedores de Redes de Segurança/organização & administração , Adulto , Idoso , Idoso de 80 Anos ou mais , Animais , Fármacos Cardiovasculares/administração & dosagem , Feminino , Hemoglobina A Glicada , Conhecimentos, Atitudes e Prática em Saúde , Estilo de Vida Saudável , Humanos , Inibidores de Hidroximetilglutaril-CoA Redutases/administração & dosagem , Masculino , Área Carente de Assistência Médica , Pessoa de Meia-Idade , Equipe de Assistência ao Paciente/organização & administração , Pectinidae , Atenção Primária à Saúde/organização & administração , Abandono do Hábito de Fumar/estatística & dados numéricos , Fatores Socioeconômicos , População Urbana , Populações Vulneráveis
16.
PLoS One ; 14(12): e0225540, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31851666

RESUMO

BACKGROUND: Current treatment options for chronic pain and depression are largely medication-based, which may cause adverse side effects. Integrative Medical Group Visits (IMGV) combines mindfulness techniques, evidence based integrative medicine, and medical group visits, and is a promising adjunct to medications, especially for diverse underserved patients who have limited access to non-pharmacological therapies. OBJECTIVE: Determine the effectiveness of IMGV compared to a Primary Care Provider (PCP) visit in patients with chronic pain and depression. DESIGN: 9-week single-blind randomized control trial with a 12-week maintenance phase (intervention-medical groups; control-primary care provider visit). SETTING: Academic tertiary safety-net hospital and 2 affiliated federally-qualified community health centers. PARTICIPANTS: 159 predominantly low income racially diverse adults with nonspecific chronic pain and depressive symptoms. INTERVENTIONS: IMGV intervention- 9 weekly 2.5 hour in person IMGV sessions, 12 weeks on-line platform access followed by a final IMGV at 21 weeks. MEASUREMENTS: Data collected at baseline, 9, and 21 weeks included primary outcomes depressive symptoms (Patient Health Questionnaire 9), pain (Brief Pain Inventory). Secondary outcomes included pain medication use and utilization. RESULTS: There were no differences in pain or depression at any time point. At 9 weeks, the IMGV group had fewer emergency department visits (RR 0.32, 95% CI: 0.12, 0.83) compared to controls. At 21 weeks, the IMGV group reported reduction in pain medication use (Odds Ratio: 0.42, CI: 0.18-0.98) compared to controls. LIMITATIONS: Absence of treatment assignment concealment for patients and disproportionate group attendance in IMGV. CONCLUSION: Results demonstrate that low-income racially diverse patients will attend medical group visits that focus on non-pharmacological techniques, however, in the attention to treat analysis there was no difference in average pain levels between the intervention and the control group. TRIAL REGISTRATION: clinicaltrials.gov NCT02262377.


Assuntos
Dor Crônica/terapia , Depressão/terapia , Medicina Integrativa/métodos , Atenção Plena/métodos , Visita a Consultório Médico , Centros Médicos Acadêmicos/organização & administração , Adulto , Idoso , Idoso de 80 Anos ou mais , Dor Crônica/diagnóstico , Dor Crônica/psicologia , Centros Comunitários de Saúde/organização & administração , Depressão/diagnóstico , Depressão/psicologia , Feminino , Humanos , Medicina Integrativa/organização & administração , Masculino , Pessoa de Meia-Idade , Medição da Dor , Questionário de Saúde do Paciente , Atenção Primária à Saúde/métodos , Atenção Primária à Saúde/organização & administração , Provedores de Redes de Segurança/organização & administração , Índice de Gravidade de Doença , Método Simples-Cego , Centros de Atenção Terciária/organização & administração , Resultado do Tratamento , Adulto Jovem
17.
Rev. psicol. trab. organ. (1999) ; 35(3): 183-193, dic. 2019. tab
Artigo em Inglês | IBECS | ID: ibc-188136

RESUMO

In three studies we examined, from an attachment perspective, the utility and the validity of a scale assessing followers' perceptions of leaders as security providers (LSPS). Based on the literature, we designed a 15-item scale tapping the five functions of a security-enhancing attachment figure (secure base, safe haven, proximity seeking, emotional ties, and separation distress) within organizational contexts. The scale showed acceptable reliability and a one-factor structure in all the studies. In Study 1 (N = 237), the LSPS was positively associated with transformational leadership and inversely associated with passive-avoidant leadership. Moreover, employees' perceptions of their leader as a security provider made a unique contribution to their satisfaction with the manager and perception of the manager's efficacy. In Study 2 (N = 263), the LSPS was positively associated with authentic leadership. Employees' ratings of their leader on the LSPS were positively associated with employees' organizational identification, work engagement, and work satisfaction. In Study 3 (N = 263), we found that employees' perceptions of their leader as a security provider had a protective effect on their job burnout. The findings indicate that research on the follower-leader relationship can benefit from the adoption of an attachment perspective


A través de tres estudios examinamos desde una perspectiva basada en la teoría del apego la utilidad y la validez de una escala que mide la percepción que los seguidores tienen de sus líderes como proveedores de seguridad LSPS. Con base en estudios previos, se diseñó una escala de 15 elementos que cubrían las cinco funciones de la figura de apego que aumenta la seguridad (base segura, puerto seguro, búsqueda de proximidad, lazos emocionales y malestar por la separación) en contextos organizativos. En todos los estudios la escala mostraba una fiabilidad aceptable y una estructura unifactorial. En el estudio 1 (N = 237), se encontró que las puntuaciones en la escala LSPS estaban positivamente relacionadas con el liderazgo transformacional y negativamente con el liderazgo pasivo-evitador. En el estudio 2 (N = 263), se encontró que la escala LSPS estaba positivamente relacionada con el liderazgo auténtico y con la identificación organizacional, la implicación en el trabajo y la satisfacción en el trabajo de los empleados. Finalmente, en el estudio 3 (N = 263) se encontró que las percepciones de los empleados de su líder como proveedor de seguridad tenían un efecto protector sobre el burnout. Estos hallazgos en su conjunto indican que la investigación de las relaciones entre líderes y seguidores puede beneficiarse si se adopta una perspectiva basada en el apego


Assuntos
Humanos , Masculino , Feminino , Adulto Jovem , Adulto , Pessoa de Meia-Idade , Liderança , Gestão da Segurança/organização & administração , Provedores de Redes de Segurança/organização & administração , Engajamento no Trabalho , Esgotamento Profissional/prevenção & controle , Relações Trabalhistas , Processos Grupais , Esgotamento Profissional/epidemiologia , Autorrelato/estatística & dados numéricos , Inquéritos e Questionários/estatística & dados numéricos
19.
Jt Comm J Qual Patient Saf ; 45(12): 798-807, 2019 12.
Artigo em Inglês | MEDLINE | ID: mdl-31648946

RESUMO

BACKGROUND: Guidelines urge primary care practices to routinely provide tobacco cessation care, but quality indicators for the provision of advice and assistance to quit smoking lag. This study evaluated the implementation of a systems-based strategy to improve performance of tobacco cessation care in primary care clinics. METHODS: Changes to the electronic health record (EHR) facilitated staff to document when they ask about tobacco use, advise the patient to quit, offer to connect the patient to a quitline (QL) counselor, and refer interested patients to receive a call from a QL. Medical assistants (MAs) were trained to use the new sections of the EHR, and their roles were expanded to include the provision of brief cessation advice and activation of the QL referral. Primary outcomes were change in tobacco cessation processes preimplementation vs. one, three, and six months postimplementation of the strategy. RESULTS: The increase in performance of tobacco cessation care was significant and sustained at six months postimplementation for assessing smoking status (50.9% vs. 76.3%; odds ratio [OR] = 3.04; 95% confidence interval [CI] = 2.80-3.31), providing advice (15.1% vs. 92.7%; OR = 69.3; 95% CI = 51.88-92.60), assessing readiness to quit (22.8% vs. 76.6%; OR = 10.80; 95% CI = 8.92-13.08), and accepting a referral to the QL (1.3% vs. 21.7%; OR = 20.31; 95% CI = 4.91-84.05). CONCLUSION: Key stakeholder engagement informed a system change intervention that includes an EHR-supported role expansion of MAs for QL referrals; these changes substantially increased the provision of tobacco cessation care.


Assuntos
Registros Eletrônicos de Saúde/organização & administração , Atenção Primária à Saúde/organização & administração , Papel Profissional , Provedores de Redes de Segurança/organização & administração , Abandono do Uso de Tabaco/métodos , Adolescente , Adulto , Idoso , Registros Eletrônicos de Saúde/normas , Feminino , Pessoal de Saúde/educação , Humanos , Masculino , Pessoa de Meia-Idade , Avaliação de Processos e Resultados em Cuidados de Saúde , Projetos Piloto , Atenção Primária à Saúde/normas , Melhoria de Qualidade/organização & administração , Encaminhamento e Consulta/organização & administração , Provedores de Redes de Segurança/normas , Fatores Socioeconômicos , Adulto Jovem
20.
JAMA Netw Open ; 2(8): e198577, 2019 08 02.
Artigo em Inglês | MEDLINE | ID: mdl-31390034

RESUMO

Importance: No consensus exists on how to define safety-net hospitals (SNHs) for research or policy decision-making. Identifying which types of hospitals are classified as SNHs under different definitions is key to assessing policies that affect SNH funding. Objective: To examine characteristics of SNHs as classified under 3 common definitions. Design, Setting, and Participants: This cross-sectional analysis includes noncritical-access hospitals in the Healthcare Cost and Utilization Project State Inpatient Databases from 47 US states for fiscal year 2015, linked to the Centers for Medicare & Medicaid Services Hospital Cost Reports and to the American Hospital Association Annual Survey. Data were analyzed from March 1 through September 30, 2018. Exposures: Hospital characteristics including organizational characteristics, scope of services provided, and financial attributes. Main Outcomes and Measures: Definitions of SNH based on Medicaid and Medicare Supplemental Security Income inpatient days historically used to determine Medicare Disproportionate Share Hospital (DSH) payments; Medicaid and uninsured caseload; and uncompensated care costs. For each measure, SNHs were defined as those within the top quartile for each state. Results: The 2066 hospitals in this study were distributed across the Northeast (340 [16.5%]), Midwest (587 [28.4%]), South (790 [38.2%]), and West (349 [16.9%]). Concordance between definitions was low; 269 hospitals (13.0%) or fewer were identified as SNHs under any 2 definitions. Uncompensated care captured smaller (200 of 523 [38.2%]) and more rural (65 of 523 [12.4%]) SNHs, whereas DSH index and Medicaid and uncompensated caseload identified SNHs that were larger (264 of 518 [51.0%] and 158 of 487 [32.4%], respectively) and teaching facilities (337 of 518 [65.1%] and 229 of 487 [47.0%], respectively) that provided more essential services than non-SNHs. Uncompensated care also distinguished remarkable financial differences between SNHs and non-SNHs. Under the uncompensated care definition, median (interquartile range [IQR]) bad debt ($27.1 [$15.5-$44.3] vs $12.8 [$6.7-$21.6] per $1000 of operating expenses; P < .001) and charity care ($19.9 [$9.3-$34.1] vs $9.1 [$4.0-$18.7] per $1000 of operating expenses) were twice as high and median (IQR) unreimbursed costs ($32.6 [$12.4-$55.4] vs $23.6 [$9.0-$42.7] per $1000 of operating expenses; P < .001) were 38% higher for SNHs than for non-SNHs. Safety-net hospitals defined by uncompensated care burden had lower median (IQR) total (4.7% [0%-9.9%] vs 5.8% [1.2%-11.2%]; P = .003) and operating (0.3% [-8.0% to 7.2%] vs 2.3% [-3.9% to 8.9%]; P < .001) margins than their non-SNH counterparts, whereas differences between SNH and non-SNH profit margins generally were not statistically significant under the other 2 definitions. Conclusions and Relevance: Different SNH definitions identify hospitals with different characteristics and financial conditions. The new DSH formula, which accounts for uncompensated care, may lead to redistributed payments across hospitals. Our results may inform which types of hospitals will experience funding changes as DSH payment policies evolve.


Assuntos
Hospitais/classificação , Hospitais/estatística & dados numéricos , Provedores de Redes de Segurança/classificação , Provedores de Redes de Segurança/organização & administração , Provedores de Redes de Segurança/estatística & dados numéricos , Estudos Transversais , Humanos , Estados Unidos
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