Shared Health Care Research Articles

Sustainable chronic disease management in remote Australia

The Sharing Health Care Initiative (SHCI) demonstration project, which aimed to improve management of chronic diseases, was implemented in four small remote communities in the Katherine region which are serviced by the Katherine West Health Board, a remote Aboriginal-community-controlled health organisation in the Northern Territory. We reviewed the project proposal, final report, evaluation reports and transitional funding proposal, and supplemented these with in-depth interviews with key individuals. We determined factors critical to the sustainability of the SHCI project in relation to context, community engagement, systems flexibility and adaptability, the availability and effect of information systems, and the human nature of health care and policy. The project had a significant impact on community awareness of chronic disease and an improvement in clinic processes. We found that a number of interrelated factors promoted sustainability, including: An implementation strategy sufficiently flexible to take account of local conditions; A high level of community engagement; Appropriate timeframes, timing and congruence between national policy and local readiness to implement a chronic disease project; Effective communication between participating organisations; Project champions (key individuals) in participating organisations; Effective use of monitoring and evaluation data; and Adequate and ongoing funding. The absence of a number of these factors, such as poor communication, inhibited sustainability. Other factors could both promote and inhibit. For example, the impact of key individuals was important, but could be idiosyncratic and have negative effects.

Flexible information storage in MUDR II EHR

An important research task of the EuroMISE Centre is the applied research in the field of electronic health record (EHR) design including electronic medical guidelines and intelligent systems for data mining and decision support. The research in this field was inspired by several European projects. We have proposed a mathematical meta-description of a flexible information storage model based on the experience gathered in cooperation in those projects. In this model, we use two basic structures called a knowledge base and data files. We describe those two structures using the graph theory concepts. Furthermore, we use logical formulas to express conditions that should be valid. Additionally, we present a description of a global system architecture of a 3-tier EHR application with interfaces based on the latest technologies; predominately on Web Services, SOAP, XML, HTTP, CORBA, etc. According to our experience and test results gained from the MUDR EHR usage, we describe an open universal solution, which can be applied as the EHR kernel of hospital information systems. To realize this approach in a daily practice for health professionals we have started a co-operative project with clinical information systems developers. Within that project we are developing a new system for continual shared health care.

Pregnant women's social representations of oral health: a reference to rethink mother-baby dental assistance

Assuming that a better understanding is crucial to a better practice, we searched for pregnant women’s knowledge about oral health, seeking to understand the social representations (SR) that influence their practice, from the perspective of the Social Representation Theory purposed by Moscovici (1961). The subjects of this qualitative research were 12 pregnant women enrolled in prenatal care services. Each woman was assessed by means of a semistructured interview, which was recordered and transcripted. Pre-categories came out from the data analysis and were gathered in 14 thematic clusters: profile, seeking for dental care, learned issues, self-care, concepts and values on oral health, pregnancy versus dental care, need for professional information, relationship between mother and child ́s oral health, responsibility, wishes, child care and other issues. Four major themes were extracted from latter grouping of these clusters: pregnant woman profile, SR of pregnant woman’s oral health, SR of relationship between oral health and pregnancy and SR of child’s oral health. In our data analyzes and discussion we intended highlight topics that could contribute to enhance the health workers’ skills by providing reflections about the ongoing model for pregnant women dental care. To do so, we outlined issues as the representation of dental care during childbearing as harmful to the child, the representation of the influence of mother’s oral health on child’s health, mediated by the sense of unity between pregnant women and their babies, and the persistence of this intimacy after labor, by the shared health care issues and by the examples extended from the mothers to their children. The beginning of a promising cycle of a better oral health promotion depends on a closer approach of dentistry to pregnant women. Therefore it is necessary to rethink the human resources training (specially in dentistry) and the dental practice in health care systems, emphasizing inquisitive education, interdisciplinary prenatal assistance and comprehensive dental assistance to the pregnant woman. We also outlined suggestions attempting to provide issues for research and to contribute for the improvement of mother-baby dental care.

Are depressed patients more likely to share health care decisions with others?

To determine whether psychological variables, particularly depression, influence patients' willingness to share medical decisions with family members or friends. Cross-sectional interviews. Oncology and general geriatrics outpatient clinics of an urban VA medical center. Ninety-five patients with a Charlson comorbidity index score greater than 5. Subjects described the way that they make health care decisions with friends or family as a dichotomous variable ("shared" versus "not shared") and as a 5-point ordinal variable (the degree to which they share decisions). Patients also completed the 15-item version of the Geriatric Depression Scale (GDS), the Global Distress Index of the Memorial Symptom Assessment Scale, and selected tests of cognitive function and health literacy. Patients with a GDS score higher than 5 were more likely to share decision-making (16/26 versus 26/69; odds ratio 2.58; p = 0.040), as were patients who were married (23/35 versus 19/60; odds ratio 3.63; p = 0.001). In multivariable regression models, a short form GDS score higher than 5 was independently associated with a willingness to share decision with others. These results suggest that depression may have a clinically significant influence on patients' willingness to share health care decisions with others. Health care providers should be alert to this possibility, particularly when the decision at hand is significant.

Are Depressed Patients More Likely to Share Health Care Decisions with Others?

Objectives: To determine whether psychological variables, particularly depression, influence patients' willingness to share medical decisions with family members or friends. Design: Cross-sectional interviews. Setting: Oncology and general geriatrics outpatient clinics of an urban VA medical center. Participants: Ninety-five patients with a Charlson comorbidity index score greater than 5. Measurements: Subjects described the way that they make health care decisions with friends or family as a dichotomous variable ("shared" versus "not shared") and as a 5-point ordinal variable (the degree to which they share decisions). Patients also completed the 15-item version of the Geriatric Depression Scale (GDS), the Global Distress Index of the Memorial Symptom Assessment Scale, and selected tests of cognitive function and health literacy. Results: Patients with a GDS score higher than 5 were more likely to share decision-making (16/26 versus 26/69; odds ratio 2.58; p = 0.040), as were patients who were married (23/35 versus 19/60; odds ratio 3.63; p = 0.001). In multivariable regression models, a short form GDS score higher than 5 was independently associated with a willingness to share decision with others. Conclusion: These results suggest that depression may have a clinically significant influence on patients' willingness to share health care decisions with others. Health care providers should be alert to this possibility, particularly when the decision at hand is significant.

Shared mental health care: The Calgary model--A commentary.

Shared mental health care: The Calgary model--A commentary.

Shared mental health care: The Calgary model.

Shared mental health care: The Calgary model.

Small-scale rural pilot programs in chronic illness management - what next?

In recent years, rural SA has been the recipient of significant funding to support a range of new primary health care initiatives. Much of this funding, additional to normal recurrent budgets in our health system, has facilitated effective change and development through demonstration and research projects across the state. The resultant work involves programs such as: ? coordinated care trials (COAG) ? more allied health services (MAHS) ? Commonwealth regional health service initiatives (CRHS) ? quality use of medicines (QUM) ? community packages for aged care services ? Indigenous chronic disease self-management pilot programs (CDSM) ? chronic disease self-management (CDSM) programs - Sharing Health Care SA ? chronic disease self-management (CDSM) programs in Indigenous communities. In addition to the resources listed above, funding was also provided by the Commonwealth to establish the South Australian Centre for Rural and Remote Health (SACRRH) and develop the University Department of Rural Health in Whyalla. While this new funding has led to substantial developmental work in chronic illness management in particular, one needs to ask whether the time might not be right now for these hitherto small-scale change initiatives to be transformed into ongoing mainstream programs, informed and guided by research outcomes to date. Is it time to move beyond tentative chronic illness programs and into mainstream reform? We have shown that there is much to be gained, both for patients and for the system, from improved coordination of primary care services and initiatives such as self-management programs for patients with chronic conditions. Better management leads to improved patient health outcomes and can reduce demand for unplanned hospital and emergency services. Many admissions to rural hospitals requiring expensive services, in terms of infrastructure and staffing, could be either prevented, or patients could be managed more effectively in the community as part of a wider primary health care program.

Section 4 Introduction: Demonstration Projects

Frendin?s article in the previous section describes the funding of 12 self-management demonstration projects under the Commonwealth?s Sharing Health Care Initiative. The first two papers in this section, by Lishman and Mansfield, provide some insight into the nature and conduct of demonstration projects in lower SES areas of Perth and South West Sydney respectively. The next two papers discuss demonstration projects with Indigenous people in Katherine (Mobbs et al.) and Port Lincoln (Ah Kit et al.).

The chronic disease self-management project at Katherine West Health Board Aboriginal Corporation in the Northern Territory: A report of the first year

Katherine West Health Board Aboriginal Corporation (KWHB) at Katherine in the Northern Territory is an Aboriginal health service delivery organization directed by the Indigenous Board. The Chronic Disease Self-Management Demonstration Project (CDSM) commenced in April, 2002 at KWHB with funding from the Commonwealth Department of Health and Ageing Sharing Health Care initiative, as one of eight demonstration projects across the country. The project is under the direction of the KWHB Board, which is made up of 18 members elected by their own communities that lie within the KWHB service sector. The full Board or the Board Executive meet routinely throughout each year and members are actively involved with the project at both community and Board levels. The project governance structure also includes a Steering Committee and the Project Management Group that meets monthly. The project is well supported by the various management and administrative sections of KWHB. In the communities, the project reports to the local health committees that have been established by KWHB with community support, and to the local CDSM committees made up of members of the target group.

The role of self-help groups in chronic illness management: A qualitative study

Self-help groups offer a unique form of support based on mutual understanding and the experiential knowledge of members. They constitute a potentially valuable resource for assisting people to manage chronic illness and its impacts. We conducted in-depth interviews with 15 members and the leaders of five chronic illness-related self-help groups in Newcastle, New South Wales. The focus was on small, voluntary groups with little or no external funding; agencies that are often overlooked in terms of their contribution to the health care system. Those interviewed readily identified benefits relating to quality of life, illness management, and interactions with health care professionals. Increased emotional and social support, access to an expanded information base, a better understanding of their illness, and a greater sense of confidence and control in relation to it seemed to enhance the capacity of members to engage in active self-management of their conditions. Along with such benefits, group leaders also highlighted some of the challenges faced by volunteers who run these agencies. Self-help groups are effective structures that can serve as an adjunct to clinical care and provide tangible benefits to their members. Further investigation and better recognition of these groups is warranted given their potential to assist those with chronic illness and to contribute to national policy objectives for chronic disease management such as those identified in the Sharing Health Care Initiative.

The sharing health care initiative: Issues in design of the evaluation of a national program of demonstration projects for self-management of chronic conditions

This paper aims to consider the key issues in defining and measuring elements for evaluation of the national program of the Sharing Health Care Initiative (SHCI), and to describe the design of the national evaluation framework. Key parts of the chronic disease self-management literature and the evaluation literature were reviewed. The implications of the literature for design of the national evaluation are outlined. Three key issues needed to be addressed in the national evaluation of the SHCI - a program of diverse demonstration projects funded to develop generic self-management approaches. First, a guiding principle of the national evaluation was identification of common project features for analysis against some standard impact and outcome measures, to allow aggregated and comparative analysis. Second, strong emphasis on process evaluation was critical in order to allow analysis of which elements were successful and which were not. Third, the national evaluation was focused more broadly than efficacy at the program participant level; it also covered factors that are likely to contribute to development of self-management programs in the Australian context. The focus of the national evaluation of the SHCI was clearly defined in line with its national role, and reflecting its focus on providing information for future policy options to most effectively develop chronic condition self-management approaches in Australia. Comprehensive evaluation of a range of factors beyond efficacy at the individual client level is needed to assist in understanding the potential effectiveness of population-based implementation of interventions with well-demonstrated efficacy.

An International Partnership: Impacting Wound Care in Brazil

The purpose of this article is to review nursing literature about international partnerships, describe nursing and nursing education in Brazil, and describe an international partnership about chronic wound prevention and treatment in Brazil. Because countries often share health care concerns, nursing knowledge is greater than any one country's health care trends or clinical issues. Although the literature has numerous articles about pressure ulcers and other chronic wounds, much of this information is lacking for nurses in Brazil because it is primarily written in English. This project provided educational programs in Portuguese to nurses and nursing students in Brazil, involved them in the development of wound care protocols, allowed practice with dressings, and stimulated discussions on improvement of home care to patients and families. WOC nurses have a critical global role in sharing wound care knowledge. (J WOCN 2002;29:287-94.)

An International Partnership

The purpose of this article is to review nursing literature about international partnerships, describe nursing and nursing education in Brazil, and describe an international partnership about chronic wound prevention and treatment in Brazil. Because countries often share health care concerns, nursing knowledge is greater than any one country's health care trends or clinical issues. Although the literature has numerous articles about pressure ulcers and other chronic wounds, much of this information is lacking for nurses in Brazil because it is primarily written in English. This project provided educational programs in Portuguese to nurses and nursing students in Brazil, involved them in the development of wound care protocols, allowed practice with dressings, and stimulated discussions on improvement of home care to patients and families. WOC nurses have a critical global role in sharing wound care knowledge.

A randomized trial of a computerized versus an audio-booklet decision aid for women considering post-menopausal hormone replacement therapy

Decision aids (DAs) are increasingly being developed to help patients make shared health care decisions with their practitioners. There are no formal comparisons of the efficacy of different delivery methods. Interactive computerized delivery methods have the advantage of allowing patients control over flow of information and to receive feedback on their comprehension. The purpose of this study was to compare the efficacy of an interactive computerized DA for women considering long-term hormone replacement therapy, to that of a validated audio-booklet version of the same intervention. Fifty-one peri-menopausal women were randomized to use either the computerized or the standard audio-booklet version of the DA. The computerized version presented identical information with the addition of feedback modules to reinforce the participant’s understanding. The patients were interviewed with a pre- and post-intervention questionnaire. The computerized DA improved realistic expectations by 52.7% over baseline versus 27.6% with the audio-booklet ( P=0.015). Knowledge (Kn) scores improved by 17.5 and 8.4% for the computer and standard DA groups, respectively ( P=0.019). The results of this study have implications for future DA design, and other areas where patient Kn and understanding are important, such as in the setting of informed consent.

Using financial incentives to promote shared mental health care.

To consider the most common primary care reimbursement structures, to identify incentives inherent in each, and to discuss how each could be used to encourage a shared-care approach to treating mental disorders at the primary care level. Three major financial reimbursement models--fee-for-service, capitation, and blended payment mechanisms--are examined. Each is considered in terms of its risk-sharing elements and the consequent incentives. We offer several scenarios to illustrate how the shared-care practice model might be encouraged under each financing mechanism. The current fee-for-service system does not encourage shared care. For wide adoption of the shared-care practice model, there must be a change in the reimbursement system's incentives. While none of the financing mechanisms offers a perfect solution, each has potential. Each, however, must be carefully tailored to its environment. Financial considerations are just one aspect to achieving shared care. Nevertheless, in designing a system to encourage collaborative, coordinated care for those suffering from mental illness, decision makers should be wary of creating or maintaining obstacles (financial or otherwise) to provision of accessible, high-quality care.

Hospital discharge letter --Clinical information for the family physician

There are aspects related with the proportion and quality of discharge letters which may influence the management of shared health care after hospital discharge; we describe them taking into consideration that no changes regarding the usual way of giving hospital discharge took place. To determine the proportion of cases in which the hospital discharge of inpatients was accompanied with a discharge letter and to measure its quality. A descriptive and transverse observation study referring to the year of 1996. The authors observed, in the clinical files of this Department, the total cases of discharge of inpatients with ischaemic heart disease (123 cases). Besides measuring the variable "discharge letter existence", we studied the composed variable discharge letter quality (existence of clinical history data, objective observation data, complementary test results, diagnosis, therapeutic procedures, and also the readability of the clinical information and the existence of the legible name of the specialist). From the study of 121 cases of discharge of inpatients with ischaemic heart disease, 90.2% presented discharge letters. When studied, their quality was considered sufficient in 57.7% and insufficient in the rest of the cases. We point out that 29.7% of the discharge letters did not present objective observation data. The clinical information provided in this Department, at the time of hospital discharge, presents a higher proportion and quality than that observed in other studies.

New Connections Between Public Health and Social Services

New public health policies present social services with new opportunities and challenges. A shared public health and social care agenda is emerging around health improvement, social exclusion and regeneration. Early signs of synergy indicate that social services have a key role to play in shaping the public health agenda and in acting as a bridge between the NHS and the wider local authority.

Widening Regional Inequality in Premature Mortality Rates in Manitoba

To describe regional trends in premature mortality in Manitoba. Comparison of all-cause and cause-specific mortality of persons less than age 75 in 11 Regional Health Authority populations over two time periods: 1985-89 and 1990-94. The provincial premature mortality rate declined over the two time periods (4.00/1,000 to 3.72/1,000). Declines were also observed in 9 of 11 regional populations. Premature mortality increased, however, in the 2 regional populations with the highest mortality rates in the first observation period. Declining premature mortality in low mortality populations and rising premature mortality in high mortality populations has resulted in a widening of regional mortality rates in Manitoba. Recent policy initiatives in many provinces, including the devolution of authority for the management and delivery of health services and the implementation of population need-based funding formulas to share health care resources among regional health authorities, if implemented, have the potential to partially mitigate the processes producing these widening regional health inequalities.

Promoting shared health care decision making using the analytic hierarchy process

Recent developments in medical technology and bioethics have led to a shift in the traditional framework of physician–patient responsibility in health care decision making. Patients are increasingly participating in serious health care decisions, resulting in a “shared decision-making model“ that both patients and their doctors agree is a significant improvement over the traditional system in which a doctor served as the primary decision maker. However, patients are finding they need to develop strategies that allow them to understand and evaluate their health care options in a clear manner. T.L. Saaty’s “Analytic Hierarchy Process” (AHP) is a decision methodology that has been successfully applied to a wide variety of situations and has great potential as a methodology for improved shared health care decision making. This paper reports the results of an experimental use of AHP as a tool to facilitate shared decision making for two specific health care populations. Both groups of patients were deciding amongst their options in terms of two important elective health care procedures: estrogen replacement therapy and cosmetic eyelid surgery. After using AHP, the majority of both patients and physicians agreed that this technique improved physician–patient communication, thus greatly assisting shared health care decisions. When considering other criteria in addition to physician–patient communication, including the entire physician–patient relationship, the patients felt that AHP was preferable to the conventional doctor-patient mode of decision making.