Alternative Service Delivery Models Research Articles

Persistent high fertility in Uganda: young people recount obstacles and enabling factors to use of contraceptives

BackgroundHigh fertility among young people aged 15-24 years is a public health concern in Uganda. Unwanted pregnancy, unsafe induced abortions and associated high morbidity and mortality among young women may be attributed to low contraceptive use. This study aims at exploring reasons for low contraceptive use among young people.MethodsIn 16 focus group discussions, the views of young people about obstacles and enabling factors to contraceptive use in Mityana and Mubende districts, Uganda were explored. The groups were homogeneously composed by married and unmarried men and women, between the ages of 15-24. The data obtained was analyzed using qualitative content analysis.ResultsYoung men and women described multiple obstacles to contraceptive use. The obstacles were categorized as misconceptions and fears related to contraception, gender power relations, socio-cultural expectations and contradictions, short term planning, and health service barriers. Additionally, young people recounted several enabling factors that included female strategies to overcome obstacles, changing perceptions to contraceptive use, and changing attitude towards a small family size.ConclusionsOur findings suggest changing perceptions and behavior shift towards contraceptive use and a small family size although obstacles still exist. Personalized strategies to young women and men are needed to motivate and assist young people plan their future families, adopt and sustain use of contraceptives. Reducing obstacles and reinforcing enabling factors through education, culturally sensitive behavior change strategies have the potential to enhance contraceptives use. Alternative models of contraceptive service delivery to young people are proposed.

New Documents Reflect Expansion in Schools Practices

New Documents Reflect Expansion in Schools Practices

Primary care and dementia: 2. long‐term care at home: psychosocial interventions, information provision, carer support and case management

To write a narrative review of the role of primary care physicians in the long-term care of people with dementia living at home, with a focus on psychosocial interventions, the provision of information and carer support, behavioural and psychological symptoms and case management. The systematic review carried out for the NICE/SCIE Guidelines was updated from January 2006, Cochrane Reviews were identified and other publications found by consultations with experts. In primary care, the long-term care of people with dementia living at home can be structured around several key themes: reframing dementia with a focus on a social model of disability; active use of information sources; supporting carers (caregivers); the management of behavioural and psychological symptoms and a structured case management approach. Caring for people with dementia in primary care demands the same systematic approach as the management of other long-term conditions. The systematic follow-up of both people with dementia and their carers should be integrated into primary care. Reframing dementia, with an emphasis on abilities retained may allow people with dementia and their families to develop more effective coping strategies; an increase in skill mix within primary care is required to deliver this and may also improve the management of behavioural problems. The potential benefits of person-centred interventions, like advance care planning, and alternative models of service delivery, such as a structured, collaborative care approach which promotes integrated case management within primary care, require further evaluation.

The Contradictions in ‘Alternative’ Service Delivery: Governance, Business Models, and Sustainability in Municipal Water Supply

Restructuring municipal water supply using ‘alternative service delivery’ models is a growing trend. The author examines potential contradictions between ‘alternative service delivery’ business models, on the one hand, and goals of good governance and sustainability on the other. A case study of water conservation and efficiency programs implemented by municipal water utilities in Canada is used to show that specific alternative service delivery (ASD) models which seek greater distance between management and government can create incentives which deter utilities from pursuing important social and environmental goals. The neoliberal governance reform that commonly accompanies and encourages ASD tends to exacerbate its deficiencies vis-à-vis conservation in the water sector. Still, the prevalent government-led service delivery model can impose trade-offs of its own. Strategic (rather than ideological) improvements in governance can enable municipalities to reap the benefits of a variety of business models (including ASD) without compromising sustainability objectives.

Co-Location of Services for Refugees: An Evaluation of a Pilot Program in Western Australia

In recent years newly arrived refugees from Africa, Burma and Middle Eastern nations have dominated the refugee intake to Australia. Coming from war torn nations, extremely poor economies and rural areas, their transition into Australia has not been easy. This paper is based on the evaluation of the Integrated Services Centre Pilot Project (ISC) which assessed co-location as an alternative service delivery model. The evaluation focused on project staff, service providers and a small sample of the refugees themselves. The objectives of the research did not warrant a greater focus on the clients as the evaluation centered on co-location as an alternate service delivery model. Data gathered from the evaluation indicated that the basic support needs of African refugees were not being met by traditional refugee services, but that the ISC Project was meeting these needs. Data also showed that African refugees had a higher level of need than other refugee groups. The article concludes with some recommendations on how current service provision can be more responsive to the needs of African refugees.

A pilot telerehabilitation program: delivering early intervention services to rural families.

The enTECH Telerehabilitation Program explored the use of telerehabilitation as an alternative service delivery model for early intervention therapy services. Utilizing the Kentucky Telehealth Network, two families living in rural Kentucky received occupational therapy services over a 12-week period. Following program implementation, qualitative data was collected using participant journals and interviews. Data analysis identified three thematic categories related to the program: benefits/strengths, challenges/weaknesses, and recommendations for program improvement. Results of the program evaluation indicated that telerehabilitation has the potential to cost-effectively meet the therapeutic needs of children living in rural areas where provider shortages exist. The enTECH Telerehabilitation Program serves as a model for how telerehabilitation can be used to deliver early intervention services to ameliorate health disparities and improve access to rehabilitation services.

Improving Inpatient and Follow-Up TBI Services

Improving Inpatient and Follow-Up TBI Services

The Politics of Choice and Competition in Public Services

The politics of choice and competition in public services are complex. Only public service users seem basically to want choice. Providers prefer alternative models of service delivery especially those that rely upon trust. Social democrats prefer voice and trust; conservatives want choice and competition to be exercised in the context of a full private market. Yet, so long as they are properly designed, policies aimed at promoting choice and competition can serve the interests of all these groups better than the alternatives.

Village Savings and Loan Associations: experience from Zanzibar

The continuing failure of MFIs to reach remote and rural areas, especially in Africa, has renewed interest in finding alternative models of service delivery that can achieve this goal. The Village Saving and Loan Association model promoted by CARE is an accumulating savings and credit association that is timebound, with a periodic action audit at which all the funds are paid out. The approach was implemented in Zanzibar in 2001–2002 and CARE then left the area. This article reports findings from a follow-up study to assess the performance of the groups. The number of groups had grown and overall outreach had expanded to some 4,500 members. The financial performance of the groups was strong with returns on savings of 53 per cent. The context for this strong performance is a relatively well-off and well-educated population that is likely to have favoured strong group governance.

Is the organisation and structure of hospital postnatal care a barrier to quality care? Findings from a state-wide review in Victoria, Australia

Objective to describe the structure and organisation of hospital postnatal care in Victoria, Australia. Design postal survey sent to all public hospitals in Victoria ( n = 71 ) and key-informant interviews with midwives and medical practitioners ( n = 38 ). Setting Victoria, Australia. Participants providers of postnatal care in Victorian public hospitals. Findings there is significant diversity across Victoria in the way postnatal units are structured and organised and in the way care is provided. There are differences in numerous practices, including maternal and neonatal observations and the length of time women spend in hospital after giving birth. Although the benefits of continuity of care are recognised by health care providers, continuity is difficult to provide in the postnatal period. Postnatal care is provided in busy, sometimes chaotic environments, with many barriers to providing effective care and few opportunities for women to rest and recover after childbirth. The findings in this study can, in part, be explained by the lack of evidence that has been available to guide early postnatal care. Key conclusions and implications for practice current structures such as standard postnatal documentation (clinical pathways) and fixed length of stay, may inhibit rather than support individualised care for women after childbirth. There is a need to move towards greater flexibility in providing of early postnatal care, including alternative models of service delivery; choice and flexibility in the length of stay after birth; a focus on the individual with far less emphasis on care being structured around organisational requirements; and building an evidence base to guide care.

Alternative models for academic family practices

BackgroundThe Future of Family Medicine Report calls for a fundamental redesign of the American family physician workplace. At the same time, academic family practices are under economic pressure. Most family medicine departments do not have self-supporting practices, but seek support from specialty colleagues or hospital practice plans. Alternative models for academic family practices that are economically viable and consistent with the principles of family medicine are needed. This article presents several "experiments" to address these challenges.MethodsThe basis of comparison is a traditional academic family medicine center. Apart of the faculty practice plan, our center consistently operated at a deficit despite high productivity. A number of different practice types and alternative models of service delivery were therefore developed and tested. They ranged from a multi-specialty office arrangement, to a community clinic operated as part of a federally-qualified health center, to a team of providers based in and providing care for residents of an elderly public housing project. Financial comparisons using consistent accounting across models are provided.ResultsAcademic family practices can, at least in some settings, operate without subsidy while providing continuity of care to a broad segment of the community. The prerequisites are that the clinicians must see patients efficiently, and be able to bill appropriately for their payer mix.ConclusionExperimenting within academic practice structure and organization is worthwhile, and can result in economically viable alternatives to traditional models.

Models of primary care service delivery in Ontario: Why such diversity?

A surprisingly large and ever-growing number of alternative models of primary care service delivery have been developed in Ontario. The models are relatively poorly understood, and it is unclear why there are so many of them. What needs of providers and of government as payer are they attempting to address? Through a literature review and interviews with key informants, we sought to explain why there are so many models.

Evaluating the clinical effectiveness of neonatal nurse practitioners: an exploratory study

The aim of the investigation was to establish if there was any preliminary evidence to indicate if the quality of care and clinical outcomes for premature birth babies are affected by the type of practitioner (i.e. nurse practitioner vs. medical practitioner) responsible for the initial assessment, treatment and management of neonates during the first 6-12 hours following admission to a neonatal intensive care unit. The United Kingdom (UK) has seen a proliferation in the number of nurse practitioners in the past decade. While there is a growing body of evidence to suggest that nurse practitioners in primary care settings are able to provide a high quality and effective level of clinical service comparable with many of their medical counterparts, there has been relatively little evaluation of the nurse practitioner role in acute or high dependency hospital settings. The study design used a mixed method approach combining a retrospective examination and quality assessment of nursing and medical records. A random sample of 61 sets of medical records, relating specifically to the initial management and treatment of neonates were criterion assessed by an experienced consultant neonatologist and a variety of patient outcome data collated and analysed. The analysis of the patient outcome data and quality assessment of nursing and medical records revealed that there was no statistical difference in the standard and quality of care provided between nurse practitioners and medical staff in the vast majority of areas evaluated. However, trends in the data suggest that Advanced Neonatal Nurse Practitioners (ANNPs) did not perform as well as their medical counterparts in terms of the overall completeness or comprehensiveness of the standard care provided in a number of areas. Neonatal nurse practitioners provide an alternative model of service delivery in the initial admission and management of premature birth babies. While the results of the study suggest that ANNPs do not perform as well as medical staff, in the majority of cases, they still performed to an acceptable standard. Nonetheless, some deficits in the standard of care provided by both groups of practitioners were identified which in turn have implications for ongoing training and skills development. Relevance to clinical practice. The findings suggest that ANNPs are capable of taking on an advanced role in the assessment and management of neonates.

A Brief Consultation and Advisory Approach for use in Child and Adolescent Mental Health Services: A Pilot Study

In England, the demand for, and access to Child and Adolescent Mental Health Services (CAMHS) have led to endemic and intractable problems: long waiting lists, non-attendance and complaints of inaccessibility from both users and referrers. The dilemma facing CAMHS is how best to respond to rising demand without compromising the quality of specialist secondary care services. As a pilot, we developed an alternative model of service delivery that provided a brief (2+1) consultation. We also created a manual as a guide to this process. This was evaluated with 50 families, who were seen within four weeks of their returned questionnaire. Strengths and Difficulties Questionnaire (SDQ) scores showed that 72% of families improved and 95% of parents were satisfied with the service they received. This approach is brief and empowering, and is sufficient to produce change. Implications for services using this approach would include: (i) informing referrers of the alternative model, (ii) training requirements, (iii) increasing the number of mental health workers so that secondary care services are able to function effectively, and (iv) allowing more specialist services to deal with the more severely disturbed cases.

A randomised controlled trial of patient self management of oral anticoagulation treatment compared with primary care management

Background: The increase in numbers of patients receiving warfarin treatment has led to the development of alternative models of service delivery for oral anticoagulant monitoring. Patient self management for oral...

Service Quality Variation across Urban Space: First Steps Toward a Model of Citizen Satisfaction

There is currently a strong focus on alternative service delivery models and improved government service in the urban and public administration fields. A key aspect of this has been the institutionalization of performance measurement and benchmarking as core tools necessary to reinvent government and make agencies run like businesses. However, the focus on performance measurement has been limited to evaluations of inputs and outputs. Advocates have not successfully tackled the more difficult challenge of integrating good internal measures with service outcomes, which can best be measured by soliciting feedback from the customer through citizen surveys. In this article, we examine 96 neighborhoods across 12 cities and counties and find significant variation in the distribution of service satisfaction outcomes. We argue that such neighborhood– level feedback is useful and illustrates the importance to administrators of disaggregating traditional performance measures to the same neighborhood level to target scare resources more effectively where needed.

Alternative Service Delivery Models

This article is part of a continuing series that draws on the findings from the recently completed AWWA Research Foundation project, “A Strategic Assessment of the Future of Water Utilities.” The project team worked in conjunction with water industry leaders to identify internal and external trends expected to influence the water industry, develop a set of scenarios for the operating environment that water utilities might face in the future, and identify the attributes of the successful utility of the future. One of the key findings of the project was that alternative service delivery models can significantly improve productivity. This article describes the challenges and opportunities that alternative service delivery modes create for water utilities.

Making it fit: A provocative look at models of early intensive behavioral intervention for children with autism.

Abstract Recommendations for ABA for children with Autism have exponentially increased, creating a shortage of qualified ABA consultants. The increase in demand, lack of financial support for in-home programs and difficulty of maintaining in-home staff create a need for alternative delivery models for Early Intensive Behavioral Intervention (EIBI). We present a preliminary analysis of learning rates and psychometric outcomes for children in 3 different delivery models--Home based EIBI, only; and Home and School EIBI; Home Based EIBI with alternative school methods. ********** An impressive body of research exists that supports the effectiveness of early intensive behavioral intervention (EIBI) programs based on principles of applied behavior analysis (ABA) implemented with preschool age children diagnosed with autism and PDD-NOS (see New York State Department of Health Early Intervention Program, 1999a, 1999b, 1999c). Traditionally, these programs have included 40+ hours per week of programming conducted by trained therapists in home settings over a period of 2-3 years. Given the daunting financial and logistical demands inherent in organizing and implementing programs of this type, it is often necessary to implement different service delivery models. Some of these models have included school-based programs (often housed in special needs schools), combined home/school programs, and partial home programs - among others. Relatively little research has been done comparing the outcomes and relative effectiveness of these program variants. Effective EIBI programs can significantly increase the quality of life of children and families, and can significantly reduce costs to society (Jacobson, Mulick, & Green, 1998). Increased knowledge of the comparative efficacy of EIBI program variants can be of benefit to school districts and parents of autistic children attempting to balance limited resources with effective intervention. This study is viewed as a pilot project. Data are presented for children in 3 different service delivery models: Home based EIBI, only; Home based and School EIBI; and Home based EIBI and alternative school program. The intent of the study is to obtain initial data to be used in formulating follow-up studies of the efficacy of alternative EIBI service delivery models. Method Participants This study was conducted with children of preschool age (N = 5) initially diagnosed with autism or PDD-NOS currently in EIBI programs followed by the psychology department of Columbus Children's Hospital. Participants were between 3 and 6 years of age, who received a comprehensive psychological evaluation at least twice by the Psychology Department, have received at least 10 hours per week of EIBI intervention over the past 18 months (or more), and have tutors other than parents. Exclusionary criteria included diagnoses of Asperger's, Rett's, Fragile X without Mental Retardation, Mental Retardation without Autism, and Tuberous Sclerosis. See Table 1 for a brief description of each participant. Materials Because of age and skill differences, children received a variety of standardized cognitive and language measures. These measures included: Cognitive measures: 1. Bayley Scales of Infant Development Second Edition (Bayley; Bayley, 1993) The Bayley was designed to assist professionals in early identification of developmental delays. Standardized scores for cognitive, motor, and behavioral development are available. Correlations with measures of cognitive ability (e. g. IQ tests) are adequate for estimates of developmental delay (correlation with WPPSI-R Full Scale IQ = .73). Test-retest reliability for the mental scale was also adequate (.87). 2. Mullen Scales of Early Learning Manual (Mullen; Mullen, 1995) The Mullen was designed to provide estimates of cognitive development for young children. …

The impact of genetic counselling about breast cancer risk on women's risk perceptions and levels of distress.

Women referred to a familial breast cancer clinic completed questionnaires before and after counselling and at annual follow-up to assess their risk estimate and psychological characteristics. The aims were to determine whether those who attended the clinic overestimated their risk or were highly anxious and whether counselling influenced risk estimates and levels of distress. Women (n = 450) at this clinic were more likely to underestimate (39%) than overestimate (14%) their risk. Mean trait anxiety scores were higher than general population data (t = 4.9, n = 1059, P < 0.001) but not significantly different from published data from other screening samples. Overestimators (z = 5.69, P < 0.0001) and underestimators (z = –8.01, P < 0.0001) reported significantly different risk estimates (i.e. increased accuracy) after counselling, but significant inaccuracies persisted. Over- (n = 12) and underestimators (n = 60) were still inaccurate in their risk estimates by a factor of 2 after counselling. Thirty per cent of the sample scored above the cut-off (5/6) for case identification on a screening measure for psychological distress, the General Health Questionnaire (GHQ). GHQ scores were significantly lower after counselling (t = 3.6, d.f. = 384, P = 0.0004) with no evidence of increasing risk estimate causing increased distress. The risk of distress after counselling was greater for younger women and those who were more distressed at first presentation. The counselling offered was effective in increasing the accuracy of risk perceptions without causing distress to those who initially underestimated their risk. It is worrying that inaccuracies persisted, particularly as the demand for service has since reduced the consultation time offered in this clinic. Further work is needed to evaluate alternative models of service delivery using more sophisticated methods of assessing understanding of risk. © 1999 Cancer Research Campaign

The European model of service delivery: a partnership approach in Northern Ireland

The volatile political and security environment of Northern Ireland has for 26 years focused attention on tackling the, so far, intractable constitutional question of its position within the United Kingdom and the island of Ireland. The collapse of the IRA ceasefire in February 1996 and fears of a possible return to violence by Protestant paramilitaries have heightened tensions. This protracted period of violence has deflected attention away from a system of public service administration in Northern Ireland characterized by serious problems of accountability. Essential public services operate under the aegis of appointed boards, and the major repository of power, under a system of Direct Rule from Westminster, is the Secretary of State for Northern Ireland, a British Cabinet Minister. Under a recent European initiative (the EC Peace and Reconciliation Programme, 1995) an alternative model of service delivery provides a major opportunity for administrative reform in Northern Ireland. This model is based on a partnership approach in which councillors, the private and voluntary sectors collaborate to deliver services. Although still in its early stages, this approach could sever the link between political progress and administrative change which has contributed for too long to the ‘democratic deficit’ in Northern Ireland. © 1998 John Wiley & Sons, Ltd.