High Users Of Health Services Research Articles

What supports are people with intellectual disability living in group homes provided to access health care? A case study

AbstractBackgroundPeople with intellectual disabilities living in group homes often have complex health needs, are high health service users and need support from their service provider to access health services. In Australia, little is known about the types and amounts of these supports.MethodsA case study was conducted on a large Western Australian disability provider of group homes to 160 people with intellectual disability. Over an 18‐month period, including during the COVID‐19 pandemic, the study quantified health service use in hospital‐ and community‐based settings, ways by which the person was supported to access health care and the impact on other people supported by the provider. Economic costs of supporting access to health services were estimated.FindingsOverall, the disability provider supported 160 people in accessing health services an average of 23 times each (n = 3617, median = 20, interquartile range = 10–33) over the 18 months. Support included staff attending with the person (96%), following up with guardian/decision‐maker (50%), additional resourcing via overtime or staff backfills (6%) and transport (94%). The average cost of supporting one health visit was estimated at $78.51 AUD (2021). Impact on the person's household included loss of opportunity for housemates (30%), reduced supervision within the home (79%) and longer timeframes to complete care needs (32%). The impact of COVID‐19 restrictions saw a reduction in allied and mental health service use that did not return to prepandemic levels following the cessation of restrictions. Primary care, specialist, outpatient, pathology and emergency service use was also lower in the postrestriction period compared to the prepandemic period.ConclusionsFor people living in group homes, the disability provider plays an essential role in supporting health service access, primarily through the provision of support staff and transport. The change in health service utilisation following the COVID‐19 restriction period indicates that altered health system priorities can potentially exacerbate access inequality for people with intellectual disability.

Health service use and predictors of high health service use among adults experiencing homelessness: a retrospective cohort study

ObjectiveTo describe the characteristics and cost of health service use of a cohort of 2,140 people attending homeless hostel clinics, and identify predictors of high health service use and time to readmission. MethodA retrospective cohort study of 2,140 adults who attended a homeless hostel clinic and were hospitalised in New South Wales (NSW) using linked clinic, health and mortality data from 1 July 2008 to 30 June 2021. Multivariable logistic regression examined predictors of high health service users. ResultsThere were 27,466 hospital admissions, with a median cost of A$81,481 per person, and a total cost of A$548.2 million. Twenty per cent of the cohort were readmitted within 28 days and 27.4% were classified as high users of health services. Factors associated with high use were age ≥45 years, female (AOR: 1.52; 95%CI 1.05‐2.22), the presence of a mental disorder, substance use disorder (AOR: 1.36; 95%CI: 1.03‐1.82), or if the person had been homeless for >1 year (AOR: 1.31; 95%CI: 1.06‐1.62). Conclusions and implications for public healthThe high health costs generated by homeless adults confirm the need to develop models of supported housing with a focus on integrated care, improved referral pathways and better coordination with community‐based support agencies.

Towards digital health equity - a qualitative study of the challenges experienced by vulnerable groups in using digital health services in the COVID-19 era

BackgroundThe COVID-19 pandemic has given an unprecedented boost to already increased digital health services, which can place many vulnerable groups at risk of digital exclusion. To improve the likelihood of achieving digital health equity, it is necessary to identify and address the elements that may prevent vulnerable groups from benefiting from digital health services. This study examined the challenges experienced by vulnerable groups in using digital health services during the COVID-19 pandemic.MethodsQualitative descriptive design was utilized. Semi-structured interviews were conducted between October 2020 and May 2021. The participants (N = 74) were older adults, migrants, mental health service users, high users of health services, and the unemployed. Qualitative content analysis with both inductive and deductive approach was used to analyze the data. Challenges related to the use of digital health services were interpreted through digital determinants of health from the Digital Health Equity Framework.ResultsFor most of the participants the access to digital health services was hampered by insufficient digital, and / or local language skills. The lack of support and training, poor health, as well as the lack of strong e-identification or suitable devices also prevented the access. Digital services were not perceived to be applicable for all situations or capable of replacing face-to-face services due to the poor communication in the digital environment. Fears and the lack of trust regarding digital platforms were expressed as well as concerns related to the security of the services. Contact with a health care professional was also considered less personal and more prone to misunderstandings in the digital environment than in face-to-face services. Finally, digital alternatives were not always available as desired by participants, or participants were unaware of existing digital services and their value.ConclusionSeveral development needs in the implementation of digital health services were identified that could improve equal access to and benefits gained from digital services in the future. While digital health services are increasing, traditional face-to-face services will still need to be offered alongside the digital ones to ensure equal access to services.

Patients with more comorbidities have better detection of chronic conditions, but poorer management and control: findings from six middle-income countries

BackgroundThe burden of non-communicable diseases (NCDs) is rising rapidly in middle-income countries (MICs), where NCDs are often undiagnosed, untreated and uncontrolled. How comorbidity impacts diagnosis, treatment, and control of NCDs is an emerging area of research inquiry and have important clinical implications as highlighted in the recent National Institute for Health and Care Excellence guidelines for treating patients suffering from multiple NCDs. This is the first study to examine the association between increasing numbers of comorbidities with being undiagnosed, untreated, and uncontrolled for NCDs, in 6 large MICs.MethodsCross-sectional analysis of the World Health Organisation Study of Global Ageing and Adult Health (WHO SAGE) Wave 1 (2007–10), which consisted of adults aged ≥18 years from 6 populous MICs, including China, Ghana, India, Mexico, Russia and South Africa (overall n = 41, 557).ResultsA higher number of comorbidities was associated with better odds of diagnosis for hypertension, angina, and arthritis, and higher odds of having treatment for hypertension and angina. However, more comorbidities were associated with increased odds of uncontrolled hypertension, angina, arthritis, and asthma. Comorbidity with concordant conditions was associated with improved diagnosis and treatment of hypertension and angina.ConclusionPatients with more comorbidities have better diagnosis of chronic conditions, but this does not translate into better management and control of these conditions. Patients with multiple NCDs are high users of health services and are at an increased risk of adverse health outcomes. Hence, improving their access to care is a priority for healthcare systems.

Measuring social determinants of health and their impact on service use and medical complexity

IntroductionPopulation based data on the social determinants of health are not widely available, despite a wide body of evidence pointing to their importance. The Mantioba Population Research Data Repository offers a unique opportunity to leverage data from multiple government departments to assess the relationship between measurable social determinants and health.
 Objectives and ApproachUsing population based data from health, small area level census survey questions, social assisitance, education, social housing, child protective services and justice, linked at the individual level, we measured indicators of social complexity and mapped them in the province of Manitoba. Individuals with high level of social complexity were then compared with indicators of medical complexity and/or high use of medical services to determine the degree of overlap between these attributes of individuals. A matched group of individuals without any of the measured social complexities was developed and the number and reason for visits to primary care providers was compared.
 ResultsThe rate of individuals having three or more social complexities varied from a low of ~7% to a high of 35%, depending on the geographic location. High residential mobiity, involvement with the justice system and history of social assistance were the most frequent (>15%). Individuals with social complexities tended to be younger and live in poorer neighbourhoods than medically complex individuals or high users of health services. Socially complex persons had on average 5.5 primary care visits annually, compared to only ~3.5 for matched individuals with no social complexities. The overlap with high users of health services was slight (14.4%) and depended on the characteristics of the population. The overlap with medically complex patients ws higher (16.2%), particularly when medical complexity included mental health related diagnoses (20.4%).
 Conclusion/ImplicationsThe proportion of individuals with social complexities is large, and a substantial number have multiple risk factors. These individuals are for the most part a unique group, distinct from medically complex patients. Different strategies for care may be necessary to promote and sustain mental and physical health and wellbeing.

Health literacy of the baby boomer generation and the implications for nursing.

To investigate the health literacy of the baby boomer generation and what this means for nursing care. Nurses are encouraged to tailor information and education to the individual's level of understanding or health literacy but there may be generational differences in health literacy due to historical, social, and economic contexts. The baby boomer generation, people born between 1946 and 1966, are projected to be high users of health services as they age, therefore nurses' understanding of their health literacy characteristics is important. Integrative literature review. Database and manual searching for articles occurred in July 2017. Four articles met the criteria. Data were extracted and tabulated, and methodological-quality was assessed. Three categories of relevance emerged from the analysis of study findings: social demographics may predict health literacy, navigation of the health care system is challenging with low health literacy, and mechanisms to translate information into action remain unclear. Although there is limited evidence to guide practice in regard to health literacy for the baby boomer generation, the emergence of the internet may confound nursing assessment of literacy: people from the baby boomer generation may appear to have higher literacy than they actually possess. Sociodemographic information may be used for initial screening for health literacy. Creative questions are recommended to overcome possible stigma associated with individual awareness of low literacy. The mechanisms for translating information into action require further investigation.

Predicting who applies to Public Housing using Linked Administrative Data

ABSTRACT
 ObjectivePublic housing residents, who live in low income government rental housing, are often in poorer health than the rest of the population. However, few studies have been able to untangle the relationships between health and public housing residency, and to assess whether health contributes to the decision to apply. We used linked population-based administrative data from one Canadian province to compare the health and health service use of people who applied to public housing to that of people who did not apply.
 ApproachAdministrative data housed in the Manitoba Centre for Health Policy’s Population Health Research Data Repository were used to identify a cohort of individuals who applied to public housing in 2005 and 2006. They were matched one-to-one to a cohort from the general population using socio-demographic variables. A population registry provided demographic and geographic characteristics. Economic measures included receipt of income assistance and an area-level measure from the Statistics Canada Census. Measures of health and health service use were derived from hospital, physician, emergency department, and prescription drug databases. Conditional logistic regression was used to test the association between a public housing application and health status and health service use, after controlling for income.
 ResultsThere were 10,324 individuals in each of the public housing applicant and matched cohorts; the majority were female (72.4%), young (62% less than 40 years), urban residents (61.2%), and received income assistance (52.8%). A higher percent of the public housing applicant cohort had physician-diagnosed physical and mental health conditions and used more health services compared to the matched cohort. Having a physician-diagnosed respiratory illness (odds ratio [OR] = 1.14, 95% confidence interval [CI] 1.05,1.25), diabetes (OR = 1.24, 95% CI 1.09,1.40), schizophrenia (OR = 1.58, 95% CI 1.30,1.92), affective disorders (OR = 1.37, 95% CI 1.27,1.48), and substance abuse disorders (OR = 1.46, 95% CI 1.25,1.71) were associated with an increased likelihood of applying for public housing, while being diagnosed with cancer (OR = 0.76, 95% CI 0.61,0.96) was associated with a decreased likelihood of applying, after controlling for income differences. High health service users were also more likely to apply for public housing, after controlling for income differences.
 ConclusionIndividuals who move into public housing are in poor health before they apply. Health and social service supports that are co-located with public housing facilities may help to ensure that residents have successful tenancies.

Lifelong Health and Health Services Use: A New Focus for Gerontological Nursing Research and Practice.

It is commonly believed that older adults are often ill and therefore high users of health services. A pilot study involving adults 60 and older living in the Canadian province of Alberta was conducted to (a) raise interest in the concepts of lifelong health and health services use; (b) develop a lifelong health data collection tool; (c) obtain information about lifelong and recent health services use, and self-perceived lifelong and current health; and (d) reveal links (if any) between perceived health and lifelong health services use. A questionnaire was developed, pilot tested, and posted for completion by 100 volunteers. Most older adults reported good or very good current and lifelong health. Comorbidities and low finances were associated with higher health services use. These findings suggest community-dwelling older adults may be healthy currently and throughout their lives. Gerontological nursing research, practice, and advocacy are needed because myths about aging must be addressed to refocus attention on the importance of lifelong health promotion for older adults. [Journal of Gerontological Nursing, 43(2), 28-32.].

Improving access and managing healthcare demand with walk-in clinic

Purpose – Poor access to healthcare and increasing demand for services represent a management dilemma how to balance between needs and costs. Scrutinising the concept of demand management and using a case study from Finnish primary care, the purpose of this paper is to examine the complexities of managing demand for health services. Design/methodology/approach – Convenience has explained the popularity of walk-in clinics (WIC), making it an attractive demand management tool. By analysing the quantitative service utilisation data of frequent attenders at WIC, the paper exemplifies what enhanced access to care means for demand management of public welfare services. Findings – High user rates and satisfaction indicate demand for this type of service; however, the establishment of WIC provided supplementary care for the high users of health services, most suffering chronic diseases. Research limitations/implications – Better understanding of the structure of service demand is needed in order to develop a more coordinated service system and to manage demand for public welfare services. Practical implications – The study demonstrates the importance of identifying service utilisation patterns in managing demand. Instead of single solutions, a wider system-level perspective is essential. Originality/value – Managing demand and facilitating access are core primary care attributes but there is little evidence about the impact of demand management strategies. The paper ties together important healthcare management issues: how to control demand and improve the access? Moreover, few studies have examined the frequent attendance at WIC. This paper presents a practical illustration of demand management tool and indicates some demand management problems to be considered in healthcare management.

G463(P) Determining the health needs of children with special educational needs

Introduction The goal of the SEND reforms is to improve the outcomes of children with special educational needs (SEN) and disabilities. One key strategy is to improve the coordination and integration of education, health and care services through joint commissioning. Commissioning can only be effective when services are designed around the needs of their services users. Little is known about the health needs of disabled children for whom the lack of data for planning purposes is the single biggest challenge to better outcomes. Aim To describe the health problems and services use of children with SEN. To pilot an approach to data collection for services planning. A third objective, to assess the quality of medical reports, is reported separately. Method We reviewed all the medical reports submitted between January and June 2014 for a Statement of Special Educational Needs (SSEN). Additional hospital statistics were collected. Results Data were analysed on 125 children, 78% boys and 22% girls, median age 6.9 years (1.9–14.8). 65% of children were known to community paediatrics and 25% to CAMH services. 6% of children were LAC, 5% on CP plan, and 15% excluded from school. 39% children had autism, 7% ADHD, 26% SEMH, 9% physical needs, 8% sensory impairment (all types), 26% SLCN, 46% learning difficulties (all types), 8% SpLDs. 55% of the children had multiple needs, 6% were complex special needs. In the previous year 62% children attended hospital outpatients (1–16 visits), 10% of children were admitted to hospital (1–4 admissions) and 23% of children had been seen in A&E (1–7 visits). 50% of children were known to hospital specialities, 50% to S&L, 16% physiotherapy, 30% OT services. Many children had associated health problems (19% medical, 18% nutrition, 9% continence). Conclusions Children with SEN have extensive health needs and are high users of health services. Our data is likely to be an underestimate as we only analysed hospital statistics and medical reports whose quality varied. SSEN reports provide important health data. Data collection and analysis from a broader range of services continues. The new Education, Health and Care process provides an opportunity for prospective data collection for services planning.

Global understandings of domestic violence

Global understandings of domestic violence

Examining the relationship between health-related need and the receipt of care by participants experiencing homelessness and mental illness.

BackgroundPeople experiencing homelessness and mental illness face multiple barriers to care. The goal of this study was to examine the association between health service use and indicators of need among individuals experiencing homelessness and mental illness in Vancouver, Canada. We hypothesized that those with more severe mental illness would access greater levels of primary and specialist health services than those with less severe mental illness.MethodsParticipants met criteria for homelessness and current mental disorder using standardized criteria (n = 497). Interviews assessed current health status and involvement with a variety of health services including specialist, general practice, and emergency services. The 80th percentile was used to differentiate ‘low health service use’ and ‘high health service use’. Using multivariate logistic regression analysis, we analyzed associations between predisposing, enabling and need-related factors with levels of primary and specialist health service use.ResultsTwenty-one percent of participants had high primary care use, and 12% had high use of specialist services. Factors significantly (p ≤ 0.05) associated with high primary care use were: multiple physical illnesses [AOR 2.74 (1.12, 6.70]; poor general health [AOR 1.68 (1.01, 2.81)]; having a regular family physician [AOR 2.27 (1.27, 4.07)]; and negative social relationships [AOR 1.74 (1.01, 2.99)]. Conversely, having a more severe mental disorder (e.g. psychotic disorder) was significantly associated with lower odds of high service use [AOR 0.59 (0.35, 0.97)]. For specialist care, recent history of psychiatric hospitalization [AOR 2.53 (1.35, 4.75)] and major depressive episode [AOR 1.98 (1.11, 3.56)] were associated with high use, while having a blood borne infectious disease (i.e., HIV, HCV, HBV) was associated with lower odds of high service use.ConclusionsContrary to our hypotheses, we found that individuals with greater assessed need, including more severe mental disorders, and blood-borne infectious diseases had significantly lower odds of being high health service users than those with lower assessed needs. Our findings reveal an important gap between levels of need and service involvement for individuals who are both homeless and mentally ill and have implications for health service reform in relation to the unmet and complex needs of a marginalized sub-population. (Trial registration: ISRCTN57595077 and ISRCTN66721740).

Healthcare Utilization in Women After Abdominal Surgery for Ovarian Cancer

Women undergoing surgery for ovarian cancer are severely ill and are high users of health services. Contributing to these increased utilization rates are the multiple modalities used to treat ovarian cancer and the complications and side effects from those treatments. The purpose of this study was to evaluate the effectiveness of an intervention provided by advanced practice nurses and a psychiatric consultation-liaison nurse on patients' self-report of healthcare utilization compared with an attention control intervention in women undergoing surgery for a suspected diagnosis of ovarian cancer. A two-group, experimental, longitudinal design was used to compare women who were assigned randomly to the intervention group or to an attention control group at baseline within 48 hours after surgery and 1, 3, and 6 months after surgery. Healthcare utilization was measured as the number of self-reported inpatient admissions and outpatient visits, including emergency room visits, oncology outpatient visits, and primary care visits. Nurse interventions consisted of 16 contacts: symptom management, counseling, education, direct nursing care, coordination of resources, and referrals. The attention control interventions consisted of nine contacts that included instructions on use of a symptom management toolkit and strategies on how to manage symptoms. There were no differences in hospitalizations and oncology outpatient visits between the two groups. The main finding of this study was a significant difference in the number of primary care visits between the two groups. Women in the attention control group went to their primary care providers more often than the intervention group. The women who reported more visits also reported more depressive symptoms. In addition, a trend was found in the number of emergency room visits between the two groups. The intervention group visited the emergency room more often because the nurse instructed patients to go when they recognized symptoms that needed urgent care after hours. Women in the intervention group appropriately used the emergency room to manage their problems after hours, whereas more women in the attention control group reported significantly more primary care visits. These findings highlight the need for healthcare providers representing various disciplines to coordinate services across specialties, especially for women who have depressive symptoms.

Structured review: evaluating the effectiveness of nurse case managers in improving health outcomes in three major chronic diseases

This paper presents the findings of a review and appraisal of the evidence for the effectiveness of nurse case management in improving health outcomes for patients living either with Diabetes, Chronic Obstructive Pulmonary Disease or Coronary Heart Disease. Long term chronic health conditions provide some of the greatest challenges to western health care systems. In the UK, three of the most significant chronic conditions are Diabetes, Chronic Obstructive Pulmonary Disease and Coronary Heart Disease. Patients with these long term conditions are high users of health services who often receive unplanned, poorly co-ordinated, ad-hoc care in response to an exacerbation or crisis. To counter this, the nurse case manager is identified as a central aspect of improving care for these patients. However, the evidence for the effectiveness of nurse case management in improving health outcomes for the chronically ill is scarce. A structured review of the literature. The review was undertaken focussing on studies that evaluated nurse case management with one or all of the three major long term chronic conditions. A total of 108 papers were initially reviewed and filtered to leave 75 citations that were appraised. About 18 papers were finally included in the review and subject to thematic analysis based on the health outcomes evaluated in the studies. Significantly positive results were reported for nurse case management impact on five health outcomes; 'objective clinical measurements', 'quality of life and functionality', 'patient satisfaction', 'adherence to treatment' and 'self care and service use'. The evidence generated in this review suggests that nurse case managers have the potential to achieve improved health outcomes for patients with long term conditions. Further research is required to support role development and create a more targeted approach to the intervention.

Typology of High Users of Health Services Among a Rural Medicaid Population

To identify a typology for high system users among a rural Medicaid population that could assist policy makers and providers in better and more efficiently serving this population. Exploratory secondary data analysis of a large integrated Medicaid database in a western state. Five hundred and thirty-nine Medicaid recipients receiving 2 or more state services and receiving 10 or more unique medications. Data analysis examining health care use, medication use, and demographic characteristics using SAS to identify patterns of use of services in the population. Results were confirmed with a statewide sample of 2,287 Medicaid users. 3 characteristics-(1) use of 36 or more health care services in a year; (2) no gap in health care service use over the entire year; and (3) use of >12 health care services in 1 month-describe high-risk groups of Medicaid users. Public health nurses, particularly as case managers and program planners, can look at service use patterns through client histories and their own agency records, in order to identify high-risk groups who may benefit the most from programs that address their support, education, and coordination of health care needs.

Care Management for Children With Special Needs

This study documents screening methods and services provided by health plan case managers for high need children in a Washington State health plan. Enrollees were screened to identify 315 children who had or were at risk of developing a chronic condition and were high users of health services. From this group, 46 children/families could be contacted and needed case management. Services included assessment of physical/social needs, patient education, referral to community resources, and benefit utilization. These services were different from care coordination provided in primary care practices.

Clinical Patterns of Obstructive Sleep Apnea and Its Comorbid Conditions: A Data Mining Approach

Obstructive sleep apnea often results in a wide range of comorbid conditions. Although some conditions have been clearly identified as comorbid, a full clinical pattern of associated diseases has not been systematically documented. This research aimed to reveal the full pattern of comorbid conditions associated with OSA by employing a data mining technique. A large data repository (the New South Wales inpatient Data Collection) collected between 1999 and 2004 was mined, and all clinical diagnoses were coded with ICD-10-AM codes. A total of 60,197 cases (4% of total records) were identified as related to OSA (72.2% males, 27.8% females). OSA occurrence showed 2 peaks at 0-4 years and 55-59 years. A strikingly low occurrence was observed for the adolescent years. Conditions comorbid with OSA in adults by descending frequency were essential hypertension, obesity, hypercholesterolemia, type 2 diabetes, past or current tobacco use, and ischemic heart conditions. Obesity and OSA showed a similar time course of onset, with a latent period of 5 years for hypertension and type 2 diabetes and 15 years for chronic ischemic heart conditions. Comorbid conditions were predominantly of the cardiovascular, endocrine/metabolic and respiratory systems. The data also indicated OSA patients are high users of health services. The data mining technique confirms the prevalence of the disease, describes the age distribution patterns and time courses of disease development from obesity and OSAto comorbid conditions, and implicates possible interrelationships among these conditions and high cost of treating OSA patients.

The Comprehensive Care Clinic

Management of chronic diseases has been a recent focus of health care because of its effect on quality of life, health care use, and cost (Holman & Lorig, 2000). However, most of the interventions geared toward chronic disease management have been disease specific and do not address the issue of comorbidity, defined as an additional disease beyond the condition under study that increases a patient's total burden of (Klabunde, Warren, & Legler, 2002, p. 26). Previous studies of older adults have demonstrated the importance of comorbidity in affecting the number and type of health care services sought (Westert, Satariano, Schellevis, & van den Bos, 2001), functional abilities (Dunlopp, Manheim, Sohn, Liu, & Chang, 2002), and general health (Wensing, Vingerhoests, & Grol, 2001). In a review of current management strategies for chronic diseases, Davis, Wagner, and Groves (2002) stated that people with chronic comorbid diseases have common concerns and face similar challenges, such as coping with anger and dealing with role function changes, that are not often addressed in disease-specific self-management programs (Lorig et al., 1996). Disease-management vendors, such as case managers, who provide services specific to a disease or syndrome, are now finding it necessary to merge with other companies to provide comprehensive all-disease management to patients with multiple chronic comorbid conditions (Carroll, 2002). The problem of comorbidity is well represented in the elderly veteran population. Given its rapid growth, an important goal for the Department of Veterans Affairs (VA) is to develop effective interventions to help elderly veterans better cope with their chronic comorbid conditions. This article describes a clinical demonstration project, the Comprehensive Care Clinic (CCC) in the West Los Angeles VA Medical Center, implemented by its Geriatric Research, Education, and Clinical Center (GRECC) outpatient clinic staff that aimed to serve this need. The CCC was an interdisciplinary team effort to serve the psychosocial and medical needs of a population of elderly veterans with chronic comorbid conditions and who were perceived as high users of health services by their GRECC providers. The CCC consisted of a monthly group clinic supplemental to the patients' outpatient primary care clinic appointments and provided increased access to their health care team, closer monitoring of chronic illness symptoms, and education for self-care and encouraged social support among its members. It began in January 2001 and ended in December 2001. METHOD Sample The sampling method for the CCC was based on the Kaiser Permanente Cooperative Health Care Clinic model (Kaiser Permanente, 1993). The GRECC clinic interdisciplinary staff, composed of physicians, a nurse practitioner, a social worker, a pharmacist, a psychologist, a nutritionist, and a program assistant, was given rosters of the clinic patients and asked to recommend patients for the CCC based on eligibility criteria developed from the Kaiser Permanente model: * Frequent flyers or those who sought unscheduled care at least 10 times per year (phone calls, emergency room visits, urgent care, unscheduled primary care visits) as determined by GRECC interdisciplinary staff * Minimum of two chronic disorders * No terminal illness * No cognitive impairment as measured by a Mini-Mental State Examination (Folstein, Folstein, & McHugh, 1975) score of at least 24 * Able to transfer and toilet independently * No active substance abuse problem * Living in the community (no nursing home residents) * Primary care providers were GRECC staff Twenty-two patients were identified by the clinic staff as potential participants from a roster of 200. Procedures and Interventions Telephone Needs Assessment. The identified patients were contacted by telephone, introduced to the concept of the CCC, and asked about their health care needs, patterns of VA services use, and interest in attending a group clinic, using a needs assessment instrument developed for this pilot program (see Table 1). …

Another way to look at high service utilization: the contribution of disability

High users of health services are usually identified in terms of their health complications stemming from the coincidence of a number of chronic conditions. Instead, this analysis attempts to characterize high users in terms of disability, based on the belief that disability provides a more detailed and accurate representation of functional needs and health consequences. The study compares the characteristics of high users of health services among Canadian adults (aged 20-65) with those of low to moderate users and non-users. Secondary analysis of data collected for the National Population Health Survey, a cross-sectional public-use population-based national survey, conducted in 1998-99. No matter how disability is conceptualized and measured, it has the strongest association of all the variables considered with health service utilization. Whether looking at the simple presence of a disability or at specific impairments or activity restrictions, there is at least a two-fold increase in the risk of high use over the non-disabled. The present study challenges the clinical wisdom that high users should be the target for efforts to reduce the overall consumption of health services. Many high users consume on the basis, not of choice, but of need rooted in disability. Moreover, when compared with low or moderate service users, their clinical condition is exacerbated by social factors, including lower income, less education and less immediate family support. Equity cannot be achieved by focusing on reducing consumption by this clinically and socially vulnerable group.

Patterns of Service Use Among Persons With Schizophrenia and Other Psychotic Disorders

This study assessed 12-month service use patterns among people with psychotic disorders and sought to identify determinants of service use. As part of a large two-phase Australian study of psychotic disorders, structured interviews were conducted with a stratified random sample of adults who screened positive for psychosis. Demographic characteristics, social functioning, symptoms, mental health diagnoses, and use of psychiatric and nonpsychiatric services were assessed. Data were analyzed for 858 persons who had an ICD-10 diagnosis of a psychotic disorder and who had been hospitalized for less than six months during the previous year. People with psychotic disorders had high levels of use of health services, both in absolute terms and relative to people with nonpsychotic disorders. Those with psychotic disorders were estimated to have an average of one contact with health services per week. Use of psychiatric inpatient services was associated with parenthood, higher symptom levels, recent attempts at suicide or self-harm, personal disability, medication status, and frequency of alcohol consumption. Services provided by general practitioners (family physicians) were more likely to be obtained by older people, women, people with greater availability of friends, those with fewer negative symptoms, and those whose service needs were unmet by other sources. People who were high users of health services also reported having more contact with a range of non-health agencies. The predictors of service use accounted for small proportions of the variance in overall use of health services. The role of general practitioners in providing and monitoring treatment programs and other psychosocial interventions needs to be acknowledged and enhanced.