High-risk Clients Research Articles

A Nursing Case Management Program for Low-Income High-Risk Diabetic Clients

Case management has been widely promoted as a method that can improve clinical outcomes and reduce healthcare costs. This article describes a cost-benefit analysis for a proposed nursing case management program that provides care for a low-income high-risk diabetic population in a rural county. Industry trends, objectives and functions of the case management program, timeline, financial plan, and cost analysis are described. The analysis indicated a potential net savings of 149,544 dollars annually. This would be a significant cost savings for the healthcare provider and funding source.

A Nursing Case Management Program for Low-Income High-Risk Diabetic Clients

A Nursing Case Management Program for Low-Income High-Risk Diabetic Clients

HCV (Hepatitis C Virus) Pre-Test and Post-Test Counseling Services at Drug Treatment Programs: Missed Opportunities for Primary Prevention

Although drug users are at risk for hepatitis C virus (HCV) infection, many clients in drug treatment programs remain uninformed about their HCV serostatus. Consistent with established Human immunodeficiency virus (HIV) testing and counseling guidelines, recommendations for HCV testing procedures include the delivery of prevention messages targeting all high-risk clients. However, little research has determined whether HCV testing in these programs is accompanied by counseling for HCV antibody negative clients. In this article, we examine staff and client perceptions of pre-test and post-test counseling services at five drug treatment programs in the U.S. Some clients were dissatisfied with pre-test counseling at their programs and some HCV antibody negative clients indicated that they received minimal post-test counseling. Other participants reported that their programs did not offer any post-test counseling for HCV antibody negative clients. Gaps in the pre-test and post-test counseling services at drug treatment programs represent missed opportunities to communicate primary prevention messages to uninfected clients.

Dutch community midwives’ views on preconception care

to explore the opinions of midwives on the desirability of preconception care for all couples contemplating pregnancy, their willingness to introduce preconception care to midwifery practice and, if it were to be implemented, the necessary conditions, including knowledge, postgraduate education and referral possibilities for successful implementation in the community. all community midwives (n = 129) working in 49 midwifery practices that refer their high-risk clients to the Erasmus University Medical Centre, Rotterdam (the Netherlands). Rotterdam and its immediate surrounding communities. midwives working at the midwifery practices were recruited by telephone. All agreed to participate, and subsequently received a questionnaire by post. 102 (79%) questionnaires were returned. Ninety-five (93%) of the 102 midwives were familiar with the concept of preconception care, and 71 (70%) of them already provided it to some extent. Of the 102 respondents, 84 (83%) seemed to be willing to provide such care in the future, and 56 (55%) felt that preconception care should be part of their professional domain. Midwives, however, lack time and knowledge to do so. community midwives already provide counselling, although not on a structural basis, and usually not earlier than in the first trimester of pregnancy. Midwives seem willing to play an active role in the provision of preconception care in the future. There is, however, great need for postgraduate training.

Do auditor resignations reduce uncertainty about the quality of firms’ financial reporting?

We assess the conditions under which auditor resignations reduce uncertainty about the quality of financial reporting of former and continuing clients of the resigning auditor. Our analysis is based on a sample of 109 auditor resignations in the period 1994–1998. Approximately one-quarter of these resignation announcements are accompanied by disclosure of a disagreement over accounting treatment or over the adequacy of internal controls—factors that point toward diminished credibility of former client’s financial statements—and are associated with negative abnormal returns for the former client. In contrast, we find no stock market effect for the remaining firms (i.e., three-quarters of our sample) for which the auditor resignations are “unexplained”, suggesting that the act of resignation, by itself, is not informative. Further, we find that these unexplained resignations, which likely result from auditors’ periodic risk-related reviews of their client portfolios, transfer value-relevant information to another class of investors. In particular, we find that industry matched continuing clients of the auditor that also have poor performance experience positive abnormal returns in the days surrounding media-announced resignations from former clients. This suggests that in an environment where poorly performing, high-risk audit clients are screened contemporaneously, an auditor’s unexplained resignation from one client, but not from a similar client in its portfolio, helps reduce uncertainty about the credibility of continuing clients’ financial reporting.

Hospital Readmission From Home Health Care Before and After Prospective Payment

To describe and compare clients who were readmitted to the hospital during an episode of home health care, before and after the inception of the prospective payment system (PPS). A longitudinal mixed design was used to replicate a study conducted 9 years previously (pre-PPS) in the same home care agency in the central part of the United States. Seventy-six closed-case medical records from a not-for-profit hospital-affiliated home care agency were retrospectively reviewed and compared to pre-PPS data. The same data collection tool, the Hospital Readmission Inventory, was used for both pre- and post-PPS studies. Nurse administrators at the data collection agency were interviewed concerning comparative results. Currently readmitted clients were sicker than were those in the previous research report, they were readmitted sooner for a different diagnosis, and they had less continuity of services. The home health care industry has undergone a dramatic change in payment for services, from fee-for-service to PPS. Of particular concern is the adverse patient outcome of an unplanned hospital readmission. Prior studies have characterized such patients in home health care, but no comparative reports were found in a literature search since the inception of PPS. Findings from this study indicated that an increased emphasis on cost containment and higher-risk clients appear to have changed patterns of care delivery.

Empowering high‐risk clients to attain a better quality of life: a career resiliency framework

Career counselors frequently encounter clients who are at high risk for career and life development difficulties. Research suggests there is a connection between resiliency and successful career development in high‐risk clients. Many high‐risk individuals have poor decision‐making skills and lack motivation to succeed in life and career development. This article describes a career resiliency framework in which career resiliency is best understood within the context of psychological resiliency. Specifically, this article explicates how career counseling from a resiliency theory perspective may promote successful career development for populations dealing with multiple barriers.

The STIRR model of best practices for blood-borne diseases among clients with serious mental illness.

Persons with severe mental illness have a markedly elevated risk of several blood-borne infections, including HIV, hepatitis B, and hepatitis C. Prevention, early detection, and treatment of these disorders are crucial interventions for high-risk populations. However, because of a number of barriers, most clients with severe mental illness do not receive these basic best-practice services. The authors describe a public health model intervention designed to deliver basic best-practice services for blood-borne diseases, as specified by the Centers for Disease Control and Prevention, to clients with severe mental illness and co-occurring substance use disorders. The intervention, called STIRR (for screen, test, immunize, reduce risk, and refer), is brief (requiring approximately one hour per client) and is delivered at the site of mental health care by a mobile team of specialists. Clients are provided with risk screening, testing for HIV and hepatitis, immunization for hepatitis A and B, risk-reduction counseling, and treatment referral for blood-borne infections. Also described is a pilot study to evaluate this model in two publicly funded community mental health centers. At the first site, 137 (79 percent) of clients with severe mental illness were tested and immunized. At the second site, more than two-thirds of the clients of a dual diagnosis team participated (67 clients, or 68 percent). Intervention costs per client ranged from 194 dollars to 262 dollars. S: The STIRR approach has the potential to provide a basic, best-practice package of interventions for high-risk clients with severe mental illness.

Client-related predictors of early treatment drop-out in a substance abuse clinic exclusively employing individual therapy

The present study examined predictors of early drop-out in a heterogeneous male and female outpatient sample enrolled in an addiction program. Clients who failed to attend five or more individual therapy sessions were considered “non treatment-engaged.” Sixty-four percent of the sample engaged in initial treatment, compared to 36% who were early drop-outs. The latter group, compared to the former group, was significantly less educated and was more likely to be African American, female, report cocaine as the primary drug of choice, and be referred from outside the larger medical center ( p < .05). In multivariate models, female gender and African American ethnicity were independent predictors of early treatment drop-out ( p < .00001). Although substance-related factors influenced treatment outcomes, their effects were weakened when taken into consideration with demographic factors such as gender and ethnicity. Continued examination of ethnicity, gender, and other potential negative prognostic factors for attendance in various addiction treatment milieus may aid in provision of appropriate services especially for high-risk clients.

Program, Practice, and Vision: Standardized Nursing Language and the Computerized Patient Record

BACKGROUNDIn 1997, the community‐based Nurse Case Management program of Aurora Health Care in Milwaukee, WI, was created to coordinate care for highrisk clients. Advanced practice nurse case managers partner with clients, families, and providers to establish goals and support efficient and effective use of healthcare resources. Clients referred to the program have evidence of suboptimal self‐management, complex health conditions, multiple specialty providers, or a history of high or inappropriate service utilization. Clients are typically seen in their homes, medical clinics, outpatient or other community sites.MAIN CONTENT POINTSFrom the start, the program was designed to provide coordinated care across the entire care continuum. Access to patient encounters, clinical, and financial data was identified as an essential component to providing and evaluating individual and program outcomes. The staff also needed a way to input data into the system. The program director was able to justify educational and information system support for the creation of a program‐specific documentation program. She valued the use of standardized nursing language as a way to capture and retrieve data about the discipline‐specific aspects of care. The NANDA, NIC, and NOC taxonomies were selected as the cornerstone for the nursing department of the largest Aurora hospital and the nurse case manager program. Administration further provided support for the department to partner with the established information system vendor in the creation of new software specifically designed to function within the integrated healthcare delivery system.The program was established based on the American Nurses Association standards for advanced practice and literature‐based best practice guidelines for patient care. Prior to implementation, the staff had basic computer access and limited standardized nursing language experience with NANDA diagnoses. The group set out to learn more about the NANDA/NIC/NOC taxonomies by attending a conference, using self‐study techniques from texts, and applying the concepts in their clinical practice. Several common patient problems and nursing interventions were recognized immediately. Sample plans with suggested NANDA/NIC/NOC linkages were developed for staff to use as a framework to tailor to the unique needs of their patients. Networking with colleagues provided an avenue to build confidence and consensus regarding taxonomy application.The documentation system was designed on paper and evolved into the program‐specific component of the systemwide computerized patient record. In addition to education, the staff invested much time in designing and developing expertise in computer use. Care Manager, the program‐specific software, went live in January 2000 and provided the case managers with a vehicle to access data, enter clinical notes and care plans, share data between providers, and track patient outcomes over time.CONCLUSIONSIt is important for users to have a clear vision of the functionality needed for practice. Significant educational and information system resources are needed. “Superusers” and focused education can increase the speed and efficiency of design and implementation processes.Because standardized nursing language is used to describe practice, staff members must develop expertise in using this terminology language to describe assessments, diagnoses, outcomes, and interventions in their daily practice. The next steps involve increasing system functionality to allow for more efficient documentation of assessments and interventions on the care plan and improve the ability to prescribe specific interventions within a NIC label. In regard to research, standardized nursing language provides a framework for descriptive and correlational studies that identify those interventions most effective in achieving best practice outcomes. Case managers need to use change theory to identify stage of readiness, appropriate NOCs to describe incremental change, and most effective NICs to promote patient movement toward action.

Integrating substance abuse treatment and criminal justice supervision.

Proponents of a pure public safety perspective on the drug problem hold that drug-involved offenders require consistent and intensive supervision by criminal justice authorities in order to stay off drugs and out of trouble. In contrast, proponents of a thoroughgoing public health perspective commonly argue that clients perform better if they are left alone to develop an effective therapeutic alliance with counselors. Both may be correct, but with respect to different groups of offenders. One approach has shown consistent promise for reducing drug use and criminal recidivism: an integrated public health-public safety strategy that combines community-based drug abuse treatment with ongoing criminal justice supervision. This article presents promising findings from programs implementing this strategy and discusses best treatment practices to meet the needs of both low-risk and high-risk clients.

Client characteristics, abnormal accruals and auditor switches: An empirical study

This paper investigates the associations among client characteristics, abnormal accruals and auditor switches. Working within a framework that categorises switches as resulting from auditor-client realignments, disagreements over accounting decisions, or dissatisfaction with auditor/client service quality, we find that auditor switches are associated with smaller, higher risk clients. Several other factors such as the issuance of securities and the existence of a modified opinion also increase the probability of an auditor switch. Notably, testing a subsequent time period to DeFond and Subramanyam (1998), we do not replicate their findings that clients with negative prior year abnormal accruals are more likely to switch auditors once other controls are in place. Further, our evidence suggests that clients that switch auditors move closer to the industry norm abnormal accruals in the subsequent period than non-switching clients, regardless of the sign of the prior period abnormal accruals. This result differs from DeFond and Subramanyam (1998) who report larger income increasing abnormal accruals for switchers. In general, we find that abnormal accruals add little explanatory power to models of auditor switching in our sample. © City University of Hong Kong.

Early psychosis identification and intervention.

Early psychosis identification and intervention.

Responsivity: The value of providing intensive services to high-risk offenders

Tests of the importance of service matching have had varying results, yet little attention has been given to testing the hypotheses about outcomes for clients based on differing risks to recidivate. We set out to test the risk and responsivity principles using a sample of clients from one site of a four-site randomized block experimental design study examining the effectiveness of a seamless system approach vs. traditional criminal justice supervision. Findings from our preliminary examination of official and self-report data from this site suggest the importance of the risk and responsivity concepts in providing substance abuse treatment, particularly for high-risk clients. Because of the relatively low statistical power of the tests employed in this exploratory analysis, many observed relationships were not statistically significant. Nonetheless, findings offer important implications for the delivery of substance abuse treatment. Future analyses are also recommended to further explore the impact of different service delivery systems.

Cross-sectional survey of the extent and indicators of hepatitis C virus infection in Houston Department of Health and Human Services' sexually transmitted disease clinics.

To evaluate the prevalence and indicators of hepatitis C virus (HCV) infection in Houston and determine the effectiveness of targeted HCV screening in sexually transmitted disease (STD) clinics. We performed a cross-sectional survey in low-risk and high-risk groups in Houston. This included a blinded survey of HCV conducted in 1010 STD clinic clients having serological syphilis tests, and 1885 multi-speciality group practice patients having metabolic blood work. This was followed with a targeted hepatitis C survey of 822 high-risk clients from STD clinics. The seroprevalence of hepatitis C infection in the blinded survey was 3.9% (95% CI 3.0-4.8) in the multi-speciality group and 5.0% (95% CI 3.7-6.3) in the STD clinics. Prevalence of hepatitis C infection among targeted STD clinic clients was significantly higher at 15.3% (95% CI 12.7-17.7). Risk factors that correlated with HCV infection after logistic regression included: injection drug use (OR = 10, 95% CI = 3.4-30.3), heroin use (OR = 6.6, 95% CI = 2.2-20.5), non-transfusion/ transplantation blood exposure (OR = 3.0, 95% CI = 1.3-6.9), sharing equipment to snort drugs (OR = 2.5, 95% CI 1.2-5.4), and age above 25 years (OR = 51, 95% CI = 9-47). This study demonstrates that targeting clients in STD clinics for known risk behaviours is an effective way to identify cases of HCV infection. STD clinics allow access to clients with both drug use and sexual risk behaviours and are a useful location for targeting hepatitis C screening and prevention efforts.

Mental health support for youth offending teams: a qualitative study.

The objective of the present study was to examine the views of professionals working in youth offending teams (YOTs) on a new model for providing mental health service support within the context of an interagency setting. Focus groups were used and data were analysed according to the constant comparative method. The setting consisted of two YOTs, one in an inner-city area and the other in a rural/semi-urban area, where primary mental health workers operate at the interface between YOTs and the specialist child and adolescent mental health services. Seventeen YOT professionals participated in four focus groups. Four themes were identified: previous experiences of specialist mental health services; issues of interagency working; the role of the primary mental health worker within the YOT; and recommendations for the future. Overall, the clinical component of the role (assessment and intervention), and the accessibility and responsiveness of the mental health staff were consistently valued, while there were mixed responses on role definitions within the team, consultation and training. It is concluded that mental health service provision through primary mental health workers is a useful model for interagency partnerships for high-risk client groups with multiple and complex mental health needs.

Unrestricted access to mental health services

This study examines referrals to a nurse-led, community-based, acute psychiatric assessment and treatment centre in the north west of England which operates an open referral system. Data were collated over 12 months and the total number of assessments was 1,544. It focused on the appropriateness of emergency assessments, which accounted for 29 per cent (n = 446) of the total. In considering 'appropriateness' the authors examined each assessment by source, risk, diagnosis and outcome. The results show that professionals and non-health professionals, such as the patient themselves, carers or a voluntary group, are equally likely to make inappropriate referrals, but, overall, open access was used efficiently by both groups. The results also indicate that open access to the service enabled early intervention for high-risk client groups. Implications for professionals and services are discussed.

The Effects of Decision Aid Orientation on Risk Factor Identification and Audit Test Planning

In auditing, risk management involves identifying client facts or issues that may affect engagement risk, and planning evidence-gathering strategies accordingly. The purpose of this paper is to examine whether auditors' identification of risk factors and planning of audit tests is affected by decision aid orientation, i.e., a “negative” focus wherein client risk and its consequences are emphasized, or a “positive” focus where such factors are not emphasized. Specifically, we expect that auditors will identify more risk factors using a negatively oriented risk identification decision aid, but only when engagement risk is relatively high. We address this issue in the context of auditors' knowledge of actual clients, manipulating decision aid orientation as negative or positive in a matched-pair design. Results show that auditors using the negative decision aid orientation identify more risk factors than do those using a positive orientation, for their higher-risk clients. We also find that decisions to apply substantive tests are more directly linked to specific risk factors identified than to direct risk assessments. Further, our results show that auditors with repeat engagement experience with the client identify more risk factors. The findings of this study imply that audit firms may improve their risk management strategies through simple changes in the design of decision aids used to support audit planning.

The Importance of Business Risk in Setting Audit Fees: Evidence from Cases of Client Misconduct

Previous research (Bell, Landsman and Shackelford, Journal of Accounting Research, 2001) provides survey evidence that, for the clients of a large audit firm, audit clients with higher perceived business risk bear the expected costs of this risk with higher audit fees. We examine this relation between audit fees and business risk for audit clients doing business in developing countries where bribery of top government officials is accepted business practice. We hypothesize that bribery-paying clients impart potential legal and reputation costs on auditors and hence have higher business risk. Our evidence indicates that audit fees were higher for clients that disclosed paying bribes and for those that had not disclosed paying bribes but had operations in developing countries in which bribery was an acceptable form of business conduct. We conclude that the evidence is consistent with an audit market where audit firms knowingly assess business risk at the client level, then pass its expected costs to the client in the form of higher audit fees. Our evidence is inconsistent with an audit market that does not price business risk, or where auditors cross-subsidize fees between high and low risk clients as modeled by Morgan and Stocken (Review of Accounting Studies, 1998).

Gun violence and children: factors related to exposure and trauma.

The study discussed in this article investigated the relationship between access to firearms and parental monitoring on rural youths' exposure to gun violence and examined the effect of gun violence exposure on the mental health of these youths. A survey was administered to rural students who participated in a student assistance program (n = 162) that provided in-school support groups for students in grades 6 through 12. Results indicated that a substantial number of students were exposed to gun violence and exposure was significantly related to firearm access and parental monitoring. Furthermore, gun violence exposure was significantly associated with trauma among the youths. Implications for social workers include advising high-risk clients and their families on gun removal and safe storage practices.