Innovative Service Delivery Models Research Articles

Digital Health in Response to COVID-19 in Low- and Middle-income Countries: Opportunities and Challenges.

COVID‐19 has pulled back the curtain on health system fragility to expose persistent and deepening inequities worldwide. The limited capacity of low‐ and lower‐middle income countries (LMICs) to respond to the pandemic and its impact on the health of populations – particularly the most vulnerable – presents a marked challenge. In this context, countries face the enormous task of rethinking the way essential services will be delivered. A critical and essential part of solving these challenges will be using information and communication technology and digital health to enhance direct communication with the public; scale proven and innovative service delivery models; and empower the frontlines. However, if the deployment, adaptation, or expansion of these innovations are not user‐centered for the most marginalized or do not learn from past lessons, it could be highly wasteful at best. At worst, such shortcomings could exacerbate pre‐existing weaknesses in the health care system such as exclusion of peripheral populations, disempowerment of health workers, and proliferation of unregulated private providers. We provide recommendations of which innovations should be prioritized and implementation principles to address the current challenges while responding to the need to fundamentally change service delivery for accelerated impact.

How policy is shaping the macro healthcare delivery supply chain: The emergence of a new tier of retail medical clinics

The healthcare industry continues to face substantial pressure to simultaneously improve costs and patient centricity. Much of the focus to date has concerned policy interventions capable of improving these performance measures for traditional healthcare providers, such as hospitals. But recently, nontraditional healthcare providers like Walmart Health and Amazon have made forays into the industry by establishing retail medical clinics (RMCs). These efforts constitute a redistribution of how services are organized across the macro healthcare delivery supply chain. While RMCs stand to bring innovative models of service delivery to patients, the policy environment can both enable and inhibit their involvement in the industry. We develop a framework that explains how structural and conduct regulations have historically influenced demand for and supply of healthcare services. We then describe how these regulatory factors can support nontraditional healthcare providers as they launch innovative service delivery models aimed at efficiency and customer centricity.

A Machine Learning Approach to Uncovering Hidden Utilization Patterns of Early Childhood Dental Care Among Medicaid-Insured Children

Background: Early childhood dental care (ECDC) is a significant public health opportunity since dental caries is largely preventable and a prime target for reducing healthcare expenditures. This study aims to discover underlying patterns in ECDC utilization among Ohio Medicaid-insured children, which have significant implications for public health prevention, innovative service delivery models, and targeted cost-saving interventions.Methods: Using 9 years of longitudinal Medicaid data of 24,223 publicly insured child members of an accountable care organization (ACO), Partners for Kids in Ohio, we applied unsupervised machine learning to cluster patients based on their cumulative dental cost curves in early childhood (24–60 months). Clinical validity, analytical validity, and reproducibility were assessed.Results: The clustering revealed five novel subpopulations: (1) early-onset of decay by age (0.5% of the population, as early as 28 months), (2) middle-onset of decay (3.0%, as early as 35 months), (3) late-onset of decay (5.8%, as early as 44 months), (4) regular preventive care (67.7%), and (5) zero utilization (23.0%). Patients with early-onset of decay incurred the highest dental cost [median annual cost (MAC) = $9,499, InterQuartile Range (IQR): $7,052–$11,216], while patients with regular preventive care incurred the lowest dental cost (MAC = $191, IQR: $99–$336). We also found a plausible correlation of early-onset of decay with complex medical conditions diagnosed at 0–24 months. Almost one-third of patients with early-onset of decay had complex medical conditions diagnosed at 0–24 months. Patients with early-onset of decay also incurred the highest medical cost (MAC = $7,513, IQR: $4,527–$12,546) at 0–24 months.Conclusion: Among Ohio Medicaid-insured children, five subpopulations with distinctive clinical, cost, and utilization patterns were discovered and validated through a data-driven approach. This novel discovery promotes innovative prevention strategies that differentiate Medicaid subpopulations, and allows for the development of cost-effective interventions that target high-risk patients. Furthermore, an integrated medical-dental care delivery model promises to reduce costs further while improving patient outcomes.

Characteristics of Mental Health and Substance Use Service Facilities for Older Adults: Findings from U.S. National Surveys

ABSTRACT Objectives To describe the characteristics of U.S. mental health and substance use service programs dedicated/tailored for older adults (age 65+). Methods Data came from the 2012 and 2019 National Mental Health Services Survey (N-MHSS) and the National Survey of Substance Abuse Treatment Services (N-SSATS). Using Pearson χ2 and Fisher’s exact tests, we compared the numbers/proportions of older-adult programs in 2012 and 2019 and examined differences between facilities with or without an older-adult program in 2019. Results From 2012 to 2019, the percent of all mental health and substance use service facilities for adults that had a dedicated/tailored program for older adults increased significantly, from 20.7% to 28.9% for mental health facilities and from 7.1% to 24.8% for substance use facilities, with 101 mental health facilities and 53 substance use facilities serving older adults exclusively in 2019. Compared to facilities without an older-adult program, higher percentages of facilities with such a program offered treatment for co-occurring mental and substance use disorders and supplemental health and social care services. Conclusions Given the rapidly aging society, more accessible and affordable programs dedicated/tailored for older adults are needed. To achieve this goal and better meet older adults’ needs, more detailed data on facility characteristics are needed to build the knowledge base on improving the treatment environment. Clinical Implications Programs for older adults should be designed to meet the complex needs of those with mental health and/or substance use problems and incorporate innovative service delivery models that can improve older adults’ access.

Exploring the roles of advanced practice nurses in the care of patients following fragility hip fracture: A systematic review.

This study aimed to explore the role and impact of advanced practice nurses (APNs) in care of patients following fragility hip fracture by systematically reviewing the available evidence. Systematic review. A search of the databases Ovid Medline, CINAHL, Embase, Emcare, Cochrane Library, and Google Scholar was conducted from January-February 2019. This systematic review adhered to The PRISMA Statement. Study selection was managed using the Covidence software platform and quality was assessed using JBI Critical appraisal tools. Studies included adults >18years and described the role and impact of APNs in care of patients following fragility hip fracture on clinical and non-clinical outcomes. There were 19 papers identified that met the inclusion/exclusion criteria. Quality was graded as moderate to low risk of bias. Six characteristics of APNs were identified: (1) coordination; (2) collaboration; (3) education; (4) assessment, investigation and treatment recommendations; (5) discharge planning, support and follow up; and (6) documentation. Overall mortality and LOS improved when characteristics of the APN role were present. Key findings from this systematic review showed: (1) The APN title and role are not clearly defined, but characteristics of the APN role are evident; (2) characteristics of APNs promote the delivery of best practice hip fracture care and have a positive impact on mortality and LOS; and (3) innovative service delivery models involving APNs should be considered to address future projections of hip fracture rates and improve outcomes. This systematic review provides evidence of the role characteristics of APNs in fragility hip fracture and the impact of the role on outcomes. Findings from this research could be used to develop service delivery models using APNs to care for patients following fragility hip fracture and to inform practice where APN roles may improve outcomes for other patient cohorts.

Retention and predictors of attrition among children living with HIV on antiretroviral therapy (ART) in Côte d’Ivoire between 2012 and 2016

Background: In Côte d’Ivoire a retrospective national-level cohort study conducted in 2009 indicated that 77%, 72% and 75% of children living with HIV (CLHIV) remained in care at 12, 36, and 48 months after starting ART, respectively. The CDC-sponsored Improving HIV Surveillance and Program Evaluation in Côte d’Ivoire project assessed retention progress since that study. Methods and materials: A retrospective review of medical records was conducted using 2-stage cluster sampling. HIV care and treatment centers (CTC) were sampled based on patient caseload, then records of patients under 15 years of age who initiated ART between 2012–2016 were randomly selected. Time-to-event analysis was performed to estimate the cumulative attrition rates per total number of person-years (PYs) of observation. Cox proportional hazard regressions were conducted to identify factors associated with attrition. Results: 1198 patient records from 33 CTC were reviewed. At time of ART initiation, CLHIVs’ mean age was 5.8 years, 609 (51%) were male, median CD4 count was 529 cells/μL (interquartile range: 270-910), and 210 (21%) were severely undernourished. Retention was 91%, 84%, 74%, 72%, and 70% at 12, 24, 36, 48 and 60 months after ART initiation, respectively. 309 attrition events occurred over 3,169 PYs of follow-up, with 266 lost to follow-up (LTFU), 29 transfers and 14 deaths. Multivariate analyses showed determinants for LTFU included attending a CTC with a mixed (public-private) status [adjusted hazard ratio (aHR) 6.05, 95% confidence interval (CI): 4.23–8.65], a CTC with no on-site laboratory (aHR 4.01, 95% CI: 1.70–9.46), and a CTC without an electronic medical record system (aHR 2.22, 95% CI: 1.59–3.12). Age, clinical and immunological status at ART initiation, and parent's HIV status were not related to attrition. Conclusion: Attrition rates were high, with no substantial improvement since 2009 for time periods longer than 12 months since ART initiation. Retention improvements in Cote d’Ivoire would require a focus on scaling up innovative service delivery models such as decentralization of services to the community, coordination with local or regional labs for facilities without an on-site laboratory, and rigorous tracking systems for patients in care.

Implementing innovative service delivery models in genetic counseling: a qualitative analysis of facilitators and barriers.

Given the increasing demand for genetic counseling, implementation of innovative service delivery models (SDMs) has been proposed to improve access and increase the efficiency of genetic counseling services. This study investigated the key considerations in genetic counseling practices that impact the decision to implement innovative SDMs, as well as barriers and facilitators to implementation. A cross-sectional, qualitative research design was employed, using focus groups. Genetic counselors (GCs) were recruited from respondents to an online survey about SDMs and by posting an invitation to the National Society of Genetic Counselors (NSGC) listserv. A total of 30 participants participated in either in-person (n=3) or online (n=5) focus groups, facilitated by members of the Service Delivery Model subcommittee of the NSGC Access and Service Delivery Committee. Transcribed audio and written notes from the focus groups were coded, utilizing an inductive thematic analysis method. Five overarching themes that impact decisions to implement and use innovative SDMs were identified: (a) Patient volume and efficiency are key motivators in trying innovative SDMs; (b) the decision to change is facilitated by available resources; (c) the implementation of innovative SDMs is multidimensional and complex process; (d) there is concern about the impact on patient-provider relationships with the utilization of innovative SDMs; and (e) measuring outcomes of innovative SDM facilitates acquisition of additional resources and support. Approaches to innovative SDM selection and implementation vary by institution needs, resources, and population as demonstrated by the variety of approaches to similar barriers. Outcomes related to the implementation of innovative SDMs in genetic counseling practice should be measured to demonstrate the value of innovative genetic counseling SDMs, improvement of access to care, and to justify need for additional resources to support implementation of these models.

Genetic counseling service delivery models: A study of genetic counselors’ interests, needs, and barriers to implementation

As demand for genetic services grows, innovative genetic counseling service delivery models (SDMs) are needed. However, there is limited research on the barriers and needs of genetic counselors (GCs) interested in implementing new SDMs into their practice. In fall 2017, the National Society of Genetic Counselors (NSGC) Access and Service Delivery Committee's SDM Subcommittee sent an online survey to the NSGC membership regarding the use of SDMs, which aimed to update the understanding of current SDM use and how this has changed over time. The survey included several questions with open-response components assessing the need for new SDMs and barriers to implementation. Inductive thematic analysis was used to identify common themes. Among 517 usable responses (16% response rate), more than half (54.4%) of respondents indicated their current SDM was inadequate to address the patient need in their area. Nearly two-thirds (64.8%) indicated they were in the process of or planning to make changes to their SDM, although 40.6% did not have a specific timeline. Three major themes related to expanding access, reimbursement for services, and lack of support were identified from responses to questions about implementation of additional SDMs. Access included subthemes of geographic and physical location limitations, addressing long wait times, and the need to expand services. Reimbursement for services included issues with billing, genetic counselor licensure, and limitations due to the need for physician involvement in billing. The lack of support was evident with issues related to understaffing; difficulty gaining support at the administrative, institutional, or physician level; time constraints; and funding concerns. This study shows that GCs need education, tools, and resources to overcome barriers in implementing new or adapting current SDMs, and there is a need for policy change, including new billing and coverage models.

Mechanisms to achieve a successful rural physiotherapy public-private partnership: a qualitative study.

Longstanding gaps in physiotherapy service delivery exist in rural areas across Australia. In response to this, a large public rural health organisation contracted a private physiotherapy business to implement a public-private partnership (PPP) to supply physiotherapy to hospital inpatients, aged care facility residents and outpatients in four outer regional Australian towns. Treatment rooms were provided by the health organisation for the private physiotherapists to see clients. This study explored how stakeholders defined the success of a PPP model of service delivery in a rural setting and examined if the model was successful according to stakeholder definitions. Barriers and enablers (mechanisms) were identified and linked to stakeholder-defined success measures. A qualitative study was conducted using a constructive inquiry design. Participants were purposively recruited, via email invitation and telephone follow-up. Participants comprised managers and clinicians from the rural public health organisation and the private physiotherapy business involved in setting up, working within or alongside the partnership. Semi-structured interviews were undertaken with all participants. Data were transcribed verbatim and analysed using framework analysis. Program logic was used to synthesise all information. Individual interviews were conducted with five staff from each partnering organisation, including managers and clinicians (total n=10). Two main themes and three subthemes were identified. All participants described the model as being successful. Elements of success included improved access to local services, and satisfied stakeholders. There were three mechanisms identified to successfully implement the service delivery model. The first mechanism was the provision of human and several other resources, which included the workforce model and the use of several resources for the partnership. The second mechanism was stakeholder engagement, which included having motivated stakeholders and consistent stakeholders. The third mechanism was streamlined processes, which included the content of the contract and referral schedule, streamlined administration processes for contracting and accounting, having processes for managing private therapists in a public setting as well as processes for communication. This study demonstrates that an innovative physiotherapy PPP model of service delivery can be a successful way to improve access to physiotherapy services in rural areas. Success of service models varies depending on the viewpoint of the stakeholder and achieving success for all stakeholders is contingent on mechanisms such as those identified in this study. PPPs have potential to address service gaps in hospitals, residential aged care and primary care in rural areas.

Rural-Urban Differences in Dental Service Utilization and Dental Service Procedures Received Among US Adults: Results From the 2016 Medical Expenditure Panel Survey.

To assess rural-urban differences in dental service use and procedures and to explore the interaction effects of individual- and county-level factors on having dental service use and procedures. Data were from the 2016 Medical Expenditure Panel Survey (MEPS). We assessed rural-urban differences in 3 outcome variables: number of dental visits (1, 2, or 3+ visits), preventive care procedures (Yes/No), and treatment procedures (Yes/No). The study sample included 8,199 adults ≥ 18 years of age who reported at least 1 dental visit in the past year. Sampling weights embedded in MEPS were incorporated into all the analyses. A significant interaction between residential location and race/ethnicity (P = .030) suggested limited access to dental visits for minority groups, especially for blacks in the more rural areas. Adults from a more rural area were less likely to have received a preventive procedure (AOR = 0.55, 95% CI: 0.35-0.87) than those from an urban area. Adults of racial/ethnic minority groups, with lower SES, and without dental insurance were less likely to have received a preventive procedure (all P < .01) but were more likely to have received a treatment procedure (all P < .05). The study showed rural adults were less likely to have received preventive dental procedures than their urban counterparts. Racial/ethnic minority groups living in a more rural area had even more limited access to dental services. Innovative service delivery models that integrate telehealth and community-based case management may contribute to addressing these gaps in rural communities.

Childhood cancer survivorship and late effects: The landscape in India in 2020.

Survivorship care is a major area of focus in the holistic management of childhood cancer with current knowledge and information almost exclusively from high-income countries. In this review, we summarize the state of scientific knowledge, service delivery, advocacy initiatives, and research efforts in this field in India. Twenty-one single-center studies published until today (20 in the last decade) confirm some of the well-documented issues in childhood cancer survivors and highlight the high prevalence of hepatitis B and hepatitis C infection in our survivors. Heterogeneity in methodology, outcome metrics, and quality precludes drawing further conclusions, and the ongoing multicenter Indian Pediatric Oncology Group study would address this. Besides the usual model of follow-up clinics in hospital settings, innovative models of service delivery led by not-for-profit organizations are being developed. Advocacy initiatives driven by survivors and support groups are also under way. All of these portend a promising future.

Evaluating the Level of the Household Water Service Provided by a Private Water Enterprise in Ghana

Innovative service delivery models are attempting to more consistently provide clean water to communities in developing countries. It is imperative that these approaches be evaluated for their performance in these contexts while understating potential consequences. A private service delivery model in Ghana utilizing solar-powered water treatment, circuit rider principles, pre-paid metering, and a district-wide approach was assessed for three years. A quasi-experimental design used key informant surveys, household surveys, and water quality testing to investigate the service received by households under various management schemes. Service indicators were compared using logistic regression analysis. Private customers were shown to have significantly improved quality, annual reliability, and satisfaction ratings (p &lt; 0.05) compared with control households, while maintaining the quantity of water collected. However, private customers were more reliant upon multiple water sources to meet domestic needs and suffered from lower affordability scores. About 38% of households used private water services, with no significant relationship with socioeconomic class. It is important for policy-makers and implementers to understand that some people will be unwilling or unable to take advantage of this model, and a transition from free improved sources to paid piped schemes will likely require a period of supporting both systems in order to reach everyone.

Evaluating the sustainability of differentiated service delivery interventions for stable ART clients in sub-Saharan Africa: a systematic review protocol

IntroductionIn 2015, WHO recommended immediate treatment for people living with HIV (PLHIV). As a result, the number of PLHIV needing antiretroviral therapy (ART) in sub-Saharan Africa (SSA) doubled from 12...

Use of Outpatient Care Services by People with Dementia: Results of the Bavarian Dementia Survey (BayDem)

The increasing prevalence of dementia raises challenges concerning the care of people with dementia (pwd). The care of pwd is mainly conducted by informal caregivers who are faced with several burdens; however, use of care services is generally low. The aim of this study was to identify predictors of the use of outpatient care services. The Bavarian Dementia Survey (BayDem) is a multi-centre, longitudinal study that was conducted at 3 different sites in Bavaria, Germany. Participants were people with dementia (pwd) (according to ICD-10) and their informal caregivers. Data were collected by standardised face-to-face interviews using well-designed instruments in cooperation with local partners. Logistic regression analysis was carried out in order to identify predictors of the use of outpatient care services. In total, 364 pwd and 339 informal caregivers were included at the beginning of the study BayDem. The use of supportive care services was generally low. One-third of all participants used outpatient care services. In the logistic regression analysis, the following significant predictors for the use of outpatient care services 6 months after baseline were identified: severity of cognitive impairment of the pwd; use of outpatient care at the beginning of the study. The low use of outpatient care services is a well-known paradoxical phenomenon. Such services can help give relief to informal caregivers. In order to enhance the use of supportive outpatient care services, there should be more focus on innovative health service delivery models with a low access threshold barrier. Besides more public campaigns, more guidance for existing offers is needed.

Reducing maternal and newborn mortality in Nigeria\u2014a qualitative study of stakeholders\u2019 perceptions about the performance of community health workers and the introduction of community midwifery at primary healthcare level

BackgroundRural communities in Nigeria account for high maternal and newborn mortality rates in the country. Thus, there is a need for innovative models of service delivery, possibly with greater community engagement. Introducing and strengthening community midwifery practice within the Nigerian primary healthcare system is a clear policy option. The potential of community midwifery to increase the availability of skilled care during pregnancy, at birth and within postpartum periods in the health systems of developing countries has not been fully explored. This study was designed to assess stakeholders’ perceptions about the performance of community health workers and the feasibility of introducing and using community midwifery to address the high maternal and newborn mortality within the Nigerian healthcare system.MethodsThis study was undertaken in two human resources for health (HRH) project focal states (Bauchi and Cross River States) in Nigeria, utilizing a qualitative research design. Interviews were conducted with 44 purposively selected key informants. Key informants were selected based on their knowledge and experience working with different cadres of frontline health workers at primary healthcare level. The qualitative data were audio-recorded, transcribed and then thematically analysed.ResultsSome study participants felt that introducing community midwifery will increase access to maternal and newborn healthcare services, especially in rural communities. Others felt that applying community midwifery at the primary healthcare level may lead to duplication of duties among the health worker cadres, possibly creating disharmony. Some key informants suggested that there should be concerted efforts to train and retrain the existing cadres of community health workers via the effective implementation of the task shifting policy in Nigeria, in addition to possibly revising the existing training curricula, instead of introducing community midwifery.ConclusionApplying community midwifery within the Nigerian healthcare system has the potential to increase the availability of skilled care during pregnancy, at birth and within postpartum periods, especially in rural communities. However, there needs to be broader stakeholder engagement, more awareness creation and the careful consideration of modalities for introducing and strengthening community midwifery training and practice within the Nigerian health system as well as within the health systems of other developing countries.

Integration of Gender-Affirming Primary Care and Peer Navigation With HIV Prevention and Treatment Services to Improve the Health of Transgender Women: Protocol for a Prospective Longitudinal Cohort Study.

BackgroundPublic health strategies are urgently needed to improve HIV disparities among transgender women, including holistic intervention approaches that address those health needs prioritized by the community. Hormone therapy is the primary method by which many transgender women medically achieve gender affirmation. Peer navigation has been shown to be effective to engage and retain underserved populations living with HIV in stable primary medical care.ObjectiveThis study aims to assess the feasibility and acceptability of an integrated innovative HIV service delivery model designed to improve HIV prevention and care by combining gender-affirming primary care and peer navigation with HIV prevention and treatment services.MethodsA 12-month, nonrandomized, single-arm cohort study was implemented in Lima, Peru, among adult individuals, assigned a male sex at birth, who identified themselves as transgender women, regardless of initiation or completion of medical gender affirmation, and who were unaware of their HIV serostatus or were living with HIV but not engaged in HIV treatment. HIV-negative participants received quarterly HIV testing and were offered to initiate pre-exposure prophylaxis. HIV-positive participants were offered to initiate antiretroviral treatment and underwent quarterly plasma HIV-1 RNA and peripheral CD4+ lymphocyte cell count monitoring. All participants received feminizing hormone therapy and adherence counseling and education on their use. Peer health navigation facilitated retention in care by visiting participants at home, work, or socialization venues, or by contacting them by social media and phone.ResultsPatient recruitment started in October 2016 and finished in March 2017. The cohort ended follow-up on March 2018. Data analysis is currently underway.ConclusionsInnovative and culturally sensitive strategies to improve access to HIV prevention and treatment services for transgender women are vital to curb the burden of HIV epidemic for this key population. Findings of this intervention will inform future policies and research, including evaluation of its efficacy in a randomized controlled trial.Trial RegistrationClinicalTrials.gov NCT03757117; https://clinicaltrials.gov/ct2/show/NCT03757117International Registered Report Identifier (IRRID)DERR1-10.2196/14091

Alternative Payment Models in Total Joint Arthroplasty

» The U.S. Patient Protection and Affordable Care Act (Affordable Care Act or “Obamacare”) represents a comprehensive initiative to improve health insurance coverage, affordability, and access, while minimizing health-care spending and improving upon the quality of care provided.» The U.S. Center for Medicare &amp; Medicaid Innovation, one of the important components of the Affordable Care Act, has developed new innovative payment and service delivery models, commonly referred to as alternative payment models, to reduce health-care expenditures.» Alternative payment models have undergone several iterations over the past decade, including the Acute Care Episode (ACE) demonstration, the Bundled Payments for Care Improvement (BPCI) initiative, the BPCI Advanced initiative, and the Comprehensive Care for Joint Replacement (CJR) program.» The goal of this article was to review the logistics, performance, and limitations of these 4 alternative payment models and to discuss what the future of health-care reimbursements may hold.

Unintended Bundled Payments for Care Improvement Consequences After Removal of Total Knee Arthroplasty From Inpatient-Only List

BackgroundThe Centers for Medicare and Medicaid Services beginning in 2013 introduced the Bundled Payments for Care Improvement (BPCI) initiative to test innovative payment and service delivery models. Early implementers of the BPCI program have shown decreased hospital length of stays, discharges to inpatient facilities, and readmission rates with overall cost savings. Removal of total knee arthroplasty from the Medicare inpatient-only list may potentially cause substantial changes in patients included in BPCI bundles in 2018. MethodsThe 2017 Centers for Medicare and Medicaid Services data were used to compare total expenditures of diagnosis-related groups 469 and 470. Medicare patients who underwent total knee arthroplasty between January 2017 and December 2017 were defined as group one (n = 1024) and expenditures were compared to group two patients (n = 631) that included only those patients staying greater than 24 hours. Postacute events within the 90-day episode including admission to an inpatient rehabilitation facility/skilled nursing facility (SNF), home health (HH), and readmissions were analyzed. Expenditures were converted to 2018 dollars using Consumer Price Index. Statistical analysis of expenditures was performed with Wilcoxon Tests. ResultsMedian expenditures were $15,587 (interquartile range [IQR] $13,915-$17,684) for group 1 and $16,706 (IQR $15,333-$19,247) for group 2 (P < .001). Median postacute care spend was $3817 (IQR $2431-$5057) for group 1 and $4195 (IQR $3049-$6064) for group 2 patients (P < .001). Compared with group 1 patients, group 2 patients had a higher rate of SNF admissions (21% vs 13%), inpatient rehabilitation facility admissions (0.16% vs 0.1%), HH (72% vs 69%), and readmissions (5% vs 4%). ConclusionImplications of the removal of total knee arthroplasty from the inpatient-only list could potentially remove up to 40% of patients from the BPCI program leading to substantially less savings on average $1100 per patient. Remaining bundle patients are also more likely to require HH and SNF after discharge.

Innovative Service Delivery Models for Serving Children with Speech Sound Disorders.

Service delivery variables that may have an impact on the treatment outcomes of children with speech sound disorders include the number and duration of intervention sessions, distribution of the sessions over time, and the format (group intervention or individual intervention). In this article, we briefly review these variables and the recommendations for the most effective service delivery components for children with speech sound disorders. We then describe innovative, collaborative service delivery models for preschoolers and school-age children with speech sound disorder. The models include "Quick Articulation!" conducted in a local elementary school by clinical MS-SLP students from Purdue University, as well as Summer Speech and Literacy Laboratory, which takes place in the department of Speech, Language, and Hearing Sciences at Purdue and involves participation from clinical and research faculty, and graduate and undergraduate students. The article provides useful information to help guide clinicians and clinical supervisors in implementing components of these models into their practice with children with speech sound disorder.

Towards a Municipal Infrastructure and Finance Model for Local Government: a Case of uMgungundlovu District Municipality

Local government institutions in South Africa have had to endure a perpetual bout of service delivery protests. Protests are a public manifestation of conflict; hence the terms 'conflict' and 'protest' are used interchangeably in this article. Local government is a key element in the reconstruction and development effort in South Africa. This article proposes an infrastructure and finance model for service delivery by evaluating service delivery at uMgungundlovu District Municipality as a case study. The objective of the article is to analyse elements that contribute to municipal distress, assess municipal service delivery mechanisms and evaluate the Local Government Turnaround Strategy. The complex process of service delivery is viewed to be of national importance and requires an immediate developmental solution through innovative service delivery models. An attitudinal survey determined the perceptions of local communities on levels of service delivery. Another survey was conducted on officials to ascertain the root causes and elements contributing to municipal distress. The findings here reveal that national government grants are not sufficient in addressing service delivery backlogs. Timely delivery of municipal infrastructure is constrained by limited municipal resources. Therefore, municipalities can form Municipal Service Partnerships (MSP) with the private sector. The article underlines the need for a holistic approach to development planning through service delivery models and well-structured planning and implementation strategies for municipalities to fulfil their mandates. Finally, the article recommends that municipal services must be sustainable and that municipal business models remain at the core of sustainable service delivery.