BACKGROUND Home- and community-based services funded through the Medicaid program account for $125 billion in annual federal and state expenditure (Center for Medicare Services, 2023), serving millions of elderly and disabled individuals who receive care in private residences rather than institutional settings. The decentralized nature of home care delivery creates fundamental accountability challenges: services occur in private homes largely beyond direct supervisory oversight, making home care one of the highest-risk categories for Medicaid fraud. Nationwide investigations by the HHS Office of Inspector General from 2011 through 2015 recovered $975 million in fraudulent home health claims (OIG, 2016). A 2024 New York State Comptroller audit documented $14.5 billion in Medicaid personal care payments made without required electronic visit verification (Office of the New York State Comptroller, 2024). In Massachusetts, a 2024 federal conviction established that a home health agency co-owner defrauded MassHealth of at least $100 million over four years through billing for services never rendered (U.S Department of Justice, 2024). Electronic visit verification was mandated under the 21st Century Cures Act (Pub. L. No. 114-255, § 12006, 2016) to address these vulnerabilities by requiring real-time electronic capture of six data elements at each Medicaid-billable visit: service type, recipient identity, date, location, provider identity, and start and end times. MassHealth selected Sandata Technologies as the Commonwealth's designated EVV aggregator, with hard billing edits scheduled no earlier than July 2026 (MassHealth, 2025). Despite widespread EVV implementation nationally, no published peer-reviewed study has empirically characterized visit-level EVV anomaly patterns from operational agency data or documented the industry-wide pre-submission exception management infrastructure through which GPS verification failures are converted into billing-ready records before aggregator transmission. Direct telephone communication with Axxess customer support on June 16, 2026 confirmed that most agencies use the EVV Exception Center and that through this workflow an agency can achieve 100% compliance (Axxess, personal communication, June 16, 2026). WellSky customer support confirmed on the same date that flagged visits can be changed to verified visits prior to state aggregator transmission (WellSky, personal communication, June 16, 2026). OBJECTIVE This study had two primary objectives. First, to characterize the prevalence, typology, and distribution of EVV anomalies through quantitative analysis of 15,172 de-identified visit records from an operational Massachusetts Medicaid home care agency during the pre-enforcement window preceding MassHealth hard billing edits. Second, to document the industry-wide pre-submission exception management infrastructure across six major documentation platforms through direct vendor communication and systematic platform review, and to characterize the response pattern of Massachusetts home care agencies to voluntary research participation requests. METHODS This study employed a five-agency mixed-methods comparative design. Agency A: cross-sectional observational analysis of 15,172 de-identified Sandata EVV visit records from January 1 through May 20, 2026 (140 days; 120 unique patients; 52 caregivers; 11 procedure codes). Written data use authorization was obtained from Agency A leadership. Six anomaly categories were analyzed: GPS location exceptions (GPS_EXCEPTION field); non-verified visit status (VISIT_STATUS field); systematic minimum-time patterns (ACTUAL_TIME = 8.0 minutes exactly); manual time adjustments (both ADJUSTED_IN_TIME and ADJUSTED_OUT_TIME populated); batch backdating (entry creation timestamps versus visit dates); and geographic impossibility (Haversine formula applied to sequential GPS coordinates). Financial exposure was calculated by applying verified 2026 MassHealth fee schedule rates from 101 CMR 350.00 to actual billing units in non-verified visit records. Agency B: operational observation of Axxess Exception Center pre-submission workflows. Agencies C, D, and E: structured professional interviews and research participation solicitation. Twenty additional Massachusetts Medicaid-enrolled agencies were contacted by telephone for voluntary participation between June 15 and 16, 2026. Direct primary source telephone communication was conducted with Axxess and WellSky customer support on June 16, 2026, including step by step exception center workflow on how to correct a mismatched visit. Systematic review of published technical documentation was conducted for six major documentation platforms: Axxess, WellSky/Kinnser, HHAeXchange, AlayaCare, AxisCare, and Alora Health. All analyses were conducted in Microsoft Excel using raw Sandata export data. RESULTS Agency A: GPS exception flags were present in 12,683 of 15,172 visits (83.6%). The GPS_CALL_IN_DISTANCE field, available for 4,983 records, revealed a mean clock-in distance of 12,922 meters from the patient address, a median of 391 meters, and a maximum of 156,956 meters (97.5 miles). A total of 1,410 visits (9.3%) recorded distances exceeding 10 kilometers and 516 visits (3.4%) exceeded 50 kilometers. Non-verified visits totaled 3,333 (22.0%), with estimated potential financial exposure of $246,610 for the five-month period applying verified 2026 MassHealth rates (101 CMR 350.00), annualizing to approximately $642,948 at this single agency. A total of 1,992 visits (13.1%) were documented at exactly eight minutes duration, appearing across four procedure codes including G0299 registered nurse and G0300 licensed practical nurse. Employee E18 recorded 1,304 of 1,441 visits (90.5%) at exactly eight minutes â 6.9 times the agency-wide rate â across four service types, sustained over five months without attenuation. Manual time adjustments affected 601 records (4.0%), with five employees accounting for 299 of 601 adjusted visits (49.8%). Sequential visit records required implied travel speeds of 87 to 230 miles per hour between Massachusetts communities, constituting mathematical proof of fabricated location entries. A weekly batch backdating pattern was identified in which no real-time EVV entries were generated Monday through Thursday, followed by retroactive bulk entry on Friday. Agency B demonstrated systematic use of the Axxess Exception Center to normalize GPS exceptions before Sandata submission, self-reporting 96% compliance â illustrating the EVV Compliance Paradox. Agency C quality assurance professionals identified Drive-By Clock-In Fraud, in which caregivers clock in from within GPS geofence range of a patient's address without entering the premises. Agency D identified a theoretical Complicit Patient vulnerability through dual-device registration. Agency E declined research participation, stating their EVV data was problematic and they did not wish attention called to their records. Of 20 additional agencies approached, zero agreed to participate; responses included -direct refusals, non-responses, and one representative who stated no staff member had any knowledge of EVV. Vendor communication confirmed that most agencies use pre-submission exception management and that flagged visits can be reclassified as verified prior to aggregator transmission (Axxess, personal communication, June 16, 2026; WellSky, personal communication, June 16, 2026). Further documented photographic evidence from Axxess help system showing: The Exception Center workflow step by step, their own template example with a geographically mismatched visit, including a four- day visit error and correction steps: âselect a reason code, type clinician signature, click update visit.â Upon completion, the visit is a verified record regardless of the original GPS mismatch or duration anomaly. CONCLUSIONS EVV data contains substantially more actionable fraud intelligence than current practice extracts. Six anomaly categories affecting thousands of visits in a single Massachusetts agency over five months reflect systemic rather than isolated non-compliance. Geographic impossibility requiring 87 to 230 mph implied travel speeds constitutes mathematical proof of GPS location fabrication. Employee E18's sustained eight-minute visit pattern across 1,441 visits and four procedure codes including licensed skilled nursing is statistically impossible as a naturally occurring clinical pattern. The estimated $246,610 in potential financial exposure over five months illustrates the scale of program integrity risk operating within apparently compliant EVV systems. The EVV Compliance Paradox - confirmed by direct vendor communication - demonstrates that compliance rates in GPS-based systems may reflect exception management sophistication rather than care delivery integrity, including the step by step exception center correction workflow that verifies a patient visit with clear original GPS mismatch. The 0% research participation rate across 21 Massachusetts agencies approached, including one that explicitly cited concern about its own EVV data, suggests widespread institutional awareness of compliance vulnerabilities. GPS-based EVV is necessary but structurally insufficient. Hardware-anchored verification requiring physical presence inside the patient's home, supervised biometric enrollment, and cryptographic visit records are the architectural requirements that GPS-based systems cannot meet. Six f
In Spain, the public National Health Service provides care to Spaniards and other residents and is tailored for a decentralized state of autonomies. Each Autonomous Community has legislative capacity in its organization and management. We study the case of the collaboration between private hospitals and the public health service in La Rioja, an Autonomous Community of Spain located in the North of the Iberian Peninsula, due to the importance that this relationship has in health systems, in general. We applied the case study method as a methodological tool in a long-term local study. The interpretation was carried out within a national context, which allows us to understand its meaning and the historical keys to hospital development in this region. Primary sources have been reviewed (mainly reports, catalogs, and censuses of hospitals from the Ministry of Health and the Government of La Rioja) and other secondary sources, located in archives, libraries, Institute of Rioja Studies, and Department of Health. The hospital system in La Rioja was characterized by a predominance of public beds compared with private ones, although there has been a growing trend in the number of private beds from 2013 onwards due to the incorporation of health and social care convalescent hospitals (two). La Rioja has been promoting public-private collaboration (seen as a strategic alliance) and focusing on agreements in the socio-health space, particularly using the management service agreement and the concession of work formulas. The development of the public health service in La Rioja, from 1986 to 2019, has been determined by a progressive lower dependence on specialized hospitals from other health services of neighboring Autonomous Communities and by a mixed public-private hospital system.
The introduction of Voluntary Assisted Dying (VAD) legislation across Australia has presented challenges to clinicians, who have had to learn about new processes and, in some cases, to consider ethical and legal issues they have not previously encountered. For the most part, the adjustments have been managed smoothly, even if not all misgivings or uncertainties have been resolved. Where innovative changes are being introduced, it is important to identify and monitor concerns that arise in the community, including those of practitioners. This can be achieved by the conduct of surveys, the results of which may be used to guide further action on institutional, community and individual levels. This is especially important while the change process is getting underway, as is the case in New South Wales (NSW), where VAD legislation has only recently come into effect. The study by Light et al.1 of attitudes to VAD amongst clinicians in NSW provides such useful information. It shows â reassuringly for supporters â that most agree with the legislation. However, the value of this study is not that a majority in favour of VAD resolves the surrounding issues for all time. Rather, its main utility derives from the questions it raises but leaves unanswered and which will undoubtedly stimulate community discussion. These questions, moreover, have relevance not just for NSW but also across other jurisdictions, including Victoria, where a review of the VAD legislation is currently in progress. Light et al.'s study shows that the support for VAD amongst clinicians is not only widespread but also extends across all disciplines, even if levels of actual support vary somewhat between different areas of work, and it provides an indication of how perceptions have changed over time. Although in this case direct comparisons may be imprecise, it seems clear that acceptance of VAD amongst Australian health professionals has increased significantly over the past decade during the period in which legislation has been progressively introduced in various jurisdictions. On the other hand, it also shows that, despite such positive expressions, only a small proportion of practitioners is prepared to become directly involved, signalling potential problems for attempts to establish the expertise required to ensure the effective operation of the new system. In Victoria, this small number of participating practitioners has been shown to have an impact on the burden of care shouldered by the practitioners, as well as on the ability for patients to access their services.2 Despite the revealing nature of the figures, as with quantitative research in general, the numerical data cannot capture all consequential nuances of opinion, for which a more detailed, fine-grained analysis of qualitative investigation would be needed to fill in the details. It cannot show, for example, how or why individual clinicians make their choices, the nature of their interactions with patients and families or the impact of their experiences on their own future practice. Nor can a survey resolve ethical disagreements. This fact has not prevented polls from being used to exert political pressure on policymakers in the past: indeed, some studies have been instrumental towards this very outcome, provoking critical reflections on how the wording of a question can increase the chances of obtaining a desired outcome.3, 4 Nonetheless, the existence of a body of opinion about certain ethical issues can help clarify what is at stake and stimulate debate in affected communities. As obvious as it may sound, numerical studies cannot resolve questions of truth or ethical validity. Even widespread agreement at the level of public opinion cannot be taken as proof that a question has been, or can be, settled. High levels of unanimity cannot substitute for or circumvent ongoing, ethical discourse, in which all questions, including those claimed by some protagonists to be closed, are potentially subject to rigorous scrutiny. One of the main sources of ethical complexity about VAD arises from the multiplicity of cultural and religious perspectives within the community. Such differences can sometimes be recognised by subgroup analysis of sufficiently large quantitative data sets. However, even here, results may be misleading because responses can vary widely within population groups, which often lack homogeneity and consensus. Notwithstanding this, it is important for policymakers and health professionals to remain alert to issues of cultural sensitivity, in relation to which both principles and practices may need to be adjusted. Numerous studies have drawn attention to the array of possible concerns, which may vary according to cultural backgrounds, professional roles, religious beliefs and family contexts.5, 6 These considerations lead to an important conclusion about VAD and the ways in which it is understood, applied and evaluated. VAD is not just one thing; it is not just a piece of legislation or a single moral act. Rather, it is a focal point for a vast array of issues and concerns, ranging from the meanings attached to life and death, grief and bereavement, pain and suffering, the importance of trust, loyalty and care, and fears of abandonment and dependency. It raises questions about the relationship between law and ethics and the processes available in a society for resolving, or accommodating, ethical differences. For this reason, it cannot be summarised or evaluated in relation to just one set of variables. It is truly multidimensional, a kind of palimpsest of accumulated voices and views from multiple perspectives. For the same reason, it is worth noting that the ferment does not cease after a law has been passed. On the contrary, legislation itself should be regarded as an invitation for ongoing discussion and ethical reflection, which legislators should welcome as important for the refinement of the system. This is not always recognised, as appears to be the case at present in Victoria, where the terms of reference for the mandated review appear to have been set in a manner seeking to limit rather than stimulate public debate. So, what is the important message? That we need to continue to monitor attitudes to and beliefs about VAD, not just in the health professional community but more broadly, and to ensure that the multidimensional conversations continue. Even where VAD programmes appear to be functioning effectively, there is an unending need for ongoing review, using quantitative surveys and other research methodologies, and critical discussion. The establishment of a legal framework for VAD is not the end point: if it is successful it will open up fecund new territory within which ethical experience can continue to be deepened and enriched.
Workforce challenges are a persistent feature of the long-term care landscape, while the landscape itself is shifting. In the United States, from 1985 to 2015, a decline in the proportion of low-acuity residents has occurred in concert with the growth of assisted living (Silver et al., 2018) and a shift of Medicaid-financed long-term care toward home- and community-based services (Eiken, 2015). As a result, nursing homes serve a larger proportion of people who are admitted from hospitals and paid for by Medicare (Fashaw et al., 2019). As acuity of care needs increases in these settings, the industry increasingly depends on a complex myriad of direct care and specialized workers. Workforce issues intersect with provider and policy interests: The workforce is the providersâ largest cost, whereas policymakers see the workforce as a lever to influence the quality of care. Workforce issues also intersect with larger social issues. For example, immigration policy influences the long-term care workforce, as do state and federal minimum wage laws. The larger economic environment and prevailing wages in other service industries affect the labor supply, especially in long-term care. As we saw in 2020, existing workforce concerns collided with infection control and acute illness care during the pandemic of coronavirus disease 2019 (COVID-19). Lastly, but not least in importance, workforce issues affect the quality of life for the people who live in long-term care settings. In short, workforce issues are the most significant challenges facing the long-term care industry. Although considerable research attention has been paid to long-term care workforce topics, the editorial team at The Gerontologist recognized that important questions remain, prompting the call, in the fall of 2019, for this special issue on workforce issues in long-term care. We little knew when the call for papers went out that a pandemic would throw a bright spotlight on long-term care, especially nursing homes, making this issue even more timely. The articles in this issue paint a picture of stagnated progress and thorny challenges, but their rich and varied methodologies and perspectives also offer the field some glimpses of optimism that we can leverage diverse approaches to improve long-term care. Taking a broad perspective, Foley and Luz (2021) evaluate progress on the workforce development goals set forth in the 2008 Institute on Medicine (IoM) report âRetooling for an Aging Americaâ (IoM, 2008). They highlight the continuing shortages of both geriatricians, a workforce sector that appears to be shrinking despite the increasing need, and direct care workers. Their conclusions are disturbing: Since 2008 only one of the IoM report recommendations has been completely met, and several have not been addressed at all. As the numbers of older patients grow, the United States, at least, has made little progress on meeting the workforce pressures to meet their care needs. Scalesâ (2021) Forum article summarizes the current state of the direct care workforce, highlighting the preponderance of women of color and emphasizing how the work of caring continues to be devalued, as manifested in poor compensation, heavy workloads, and inadequate training and support. Despite these ongoing challenges, Scales offers optimism and a call to action, noting the opportunity to leverage the emergency responses to the COVID-19 pandemic and the crisis in long-term care settings it engendered. She calls for disseminating tested interventions, especially upskilling and empowering direct care workers and changing to value-based payment models. Two studies in our collection support these recommendations. Wu et al. (2021) studied the impact of a policy change in Taiwan that instituted a new payment system for home care services. The policy shifted payment from a per-hour rate to a per-service rate, increasing flexibility of home care workersâ time and allowing the opportunity for higher reimbursement for more efficient service delivery, leading to an increase in the workforce. Gleason and Miller (2021) found that supervisor support and degree of control on the job were associated with home health aidesâ job satisfaction and intention to leave among respondents to the 2017 Massachusetts Home Care Aide Survey. Together these two studies illustrate how policy and workplace practices might influence workforce size by attracting workers, on the one hand, and retaining them, on the other. Articles by Castle (2021) and Kennedy et al. (2021) are also relevant to the important challenge of retaining direct care workers. Castle points out that the problem cannot be studied adequately if the concept of retention is not operationalized adequately. In this useful measurement study, he compared different definitions of retention, integrating data from the Nursing Home Compare and Certification and Survey Provider Enhanced Reporting databases. He concludes that the best indicators of care quality are 3- and 5-year retention rates. Kennedy et al. compared retention rates for direct care workers in assisted living and nursing homes using an Ohio data set. Their results showed comparable retention rates across settings, but predictors of retention differed. Retention strategies should take into account context, including work settings and their attendant resources and regulation. Although long-term care workforce policy is often associated with standardized quality indicators, these are only indirectly associated with resident quality of life. Using a novel, hermeneutic approach to policy analysis, Hande et al. (2021) examined the connections between decentralized Canadian long-term care regulations and resident quality of life. They found that newer regulations tended to provide more flexibility for staff to promote resident quality of life. Despite the overall tendency of regulations to be rigid and safety-oriented, the findings offer some optimism that more flexible regulations might support the goal of empowering staff to emphasize quality of life for residents. Whereas the aforementioned articles approached the direct care workforce from a policy and large data set perspective, three qualitative papers privilege the perspectives of those workers. Douglas et al. (2021) explored the pressures associated with mealtime assistance, a burdensome task that is often an âextraâ duty for nursing assistants. Their findings show the importance of training for this task, emphasizing the importance of verbal and nonverbal communication skills to this intimate social interaction. Cooke and Baumbusch (2021) further examined the interpersonal climate of the care facility in their critical ethnographic study of two Canadian nursing homes. This work documents power dynamics among nursing home staff, showing how incivility and bullying relate to team collaboration, and how these dynamics affect care delivery. Cooke and Baumbusch conclude that, although increasing staffing numbers may alleviate some care burdens and improve quality of care, considering who is working and how they interact may be equally important. Themes of managing time pressures cut across these qualitative analyses and are the focus of a study of Swedish nursing assistants (Lundin et al., 2021). The workersâ accounts depict nursing assistants as a collective âwe,â facing, on the one hand, the âtheyâ of residents, largely drawn as passive recipients of care, and, on the other hand, the âtheyâ of administrators who impose burdens that are not always related to direct care of residents. This paper explored how workers prioritize their time among these demands, the values that they use for prioritizing, and how those values are compromised. Together these three qualitative studies enrich our understanding of the day-to-day experiences of direct care workers and emphasize how institutional contexts may affect the link between workers and quality of care. The challenges faced by direct care workers are compounded by an external environment that devalues this work. The systematic review by Machha et al. (2021) found that work in aging care remains highly stigmatized. This review applied a linguistic framework to English-language articles addressing stigma in aging care. The analysis demonstrates how the work of caring for older people and the workers who do this work are stigmatized, although the nature of that stigmatization depends on the social position of the people studied. Unsurprisingly, such stigma affects recruitment, job satisfaction, and worker well-being. The joint import of support and training connects the quantitative and qualitative work in this collection; enhancing the direct care workforce involves increasing numbers and increasing their skills. A key skill needed in all long-term care settings is the ability to work with people living with dementia. McKay et al. (2021) address training directly in their comparison of a traditional skills training approach to an approach based on an occupational adaptation (OA) framework. Although both groups improved in skills mastery, the OA-based group showed greater gains, developing more cooperative approaches to solving the complex problems typical in dementia care. This exploratory study suggests that OA-based training has the potential to address climate and skills issues that challenge worker satisfaction and effectiveness in long-term care settings. As Foley and Luz (2021) point out, the increasing acuity of nursing home residents demands changing models of medical care delivery. Katz et al. (2021) review current models, noting that shortages of geriatricians have led to greater proportions of care delivered by nurse practitioners, physician assistants, and skilled nursing facility specialists. At the patient care level, involvement of these nonphysician professionals may lead to higher quality of care, but Katz et al. argue that there is insufficient research to determine which models of care are ideal. They call for rigorously testing these models in the future. As a start, Wagner et al. (2021) regressed Nursing Home Compare quality measures onto provider and institutional characteristics. They found that having a staff physician was associated with fewer emergency room admissions, but greater use of antipsychotic medication for long-stay residents. Their findings suggest that policies that favor a particular model may not yield unambiguously positive outcomes. Further research is needed to compare different care models directly to one another. McGilton et al. (2021) demonstrated how, during the COVID-19 crisis, nurse practitioners in rural and urban Canadian nursing homes took on the burdens of containing the spread of the virus, stepping in to cover gaps across the workforce spectrum from nursing to medical care, providing support for staff and families, and creating linkages across health care systems such as emergency medicine and psychiatry. Nurse practitioners in this qualitative study demonstrated flexibility in being able to span the complex needs of postacute care systems, supporting McGilton et al.âs call for increasing the formal involvement of nurse practitioners in these systems. Clearly, administrative structures, workplace climate, training, and support are important factors in creating a thriving workforce for long-term care. Missing thus far in the articles discussed is a focus on the individuals with the most administrative power within these settings: administrators and directors of nursing. A scoping review by Siegel and Young (2021) reveals important gaps in our knowledge about these key players. They found no studies of how administrators and directors of nursing work together to navigate the complexity of demands they face, although anecdotal evidence suggests that this relationship is critical. This review suggests that there is a great need for theory-based studies of the organizational process to understand how to improve important workplace characteristics to make long-term care jobs more appealing. Overall, this collection of articles spans the long-term care workforce from the front line to the back office, from rigid hierarchies to flexible models that promote creativity. When we started on the path to producing this collection, we knew that the way forward would have to negotiate a complex and changing landscape. If the shared goal is that long-term care should provide both high-quality care and the opportunity for a good life, the resulting articles lay out many of the challenges faced by policymakers, practitioners, and providers. At the same time, new models of care and new ways of thinking about and defining âworkâ have perhaps moved us a few steps down the path. The COVID-19 pandemic has laid bare the need to reinvest in the long-term care workforce, and we hope that this collection will provide positive guidance for future research and policy.
INTRODUCTION Scenario 1 An elderly female, aged 78, had a fall at home. The family called the emergency ambulance service, and she was sent to the nearest acute care hospital. She sustained fractures of her superior and inferior pubic rami and experienced pain with movement and ambulation. She was hospitalized, and an orthopedic surgeon was her primary doctor. In the ward, she was referred to the physiotherapist for rehabilitation and exercises, a pain specialist for pain control, as oral medications were not sufficient to control her pain, and the endocrinologist was called in to help with her Diabetes Mellitus (DM) management, as her sugar levels were always beyond 15 mmol/l while she was in the ward. The medical officer also asked the dietitians to review her and talk to her family about her food intake and regulation. Her blood tests which were done at admission showed renal impairment, likely from her many years of DM and thus, diabetic nephropathy. A renal physician was also asked to provide consultation and inputs. When a ward nurse noticed she was not relevant in her responses and keeps forgetting instructions, she highlighted this to the medical officer who felt a psychiatry consult would be relevant. The latter came to see her and thought that as there were signs of dementia, she should be seen by the geriatrician. 1 week had passed, and she was still getting consultations with multi-disciplinary health-care professionals. Her family was concerned about her hospital bill, and they approached the nurses, who told them to meet the administrator at the Business Office. Scenario 2 A 78-year-old female sustained a fall at home and landed on her back. Her neighbours heard her and they activated the neighborhood Family Physician (FP) who visited her at home to assess her. He found tenderness in her pubic bone area. She was prescribed analgesia, and he then called her daughter who was at work, to explain the situation. He explained also that he would be taking her down to the Family Medicine Center (FMC: in Singapore, this represents a group of family medicine clinics, laboratories, and radiology services all in one locale or vicinity, readily accessible to the community living in the area) across from her block of flats, to have X-rays performed. In the meantime, he also organized the physiotherapist and care coordinator from the FMC to visit her at home. The neighbors activated their befrienders' network, and several females came down to help out with her meals, household chores, and administration of her prescribed medication. They kept her daughter updated as she was unable to leave work. What does it take to move from a model in Scenario 1 to that in Scenario 2? Scenario 1 is a hospital-based, hospital-centric, multi-disciplinary model. It is also conventionally, a physician-centric model. Scenario 2 is a community-based model which is patient-centric, in alignment with the notion that the patient should always be at the heart of our care delivery. Scenarios 1 and 2 involved a specialist and an FP playing a central role, coordinating care, respectively. Is one model of care superior to the other? Is there too much focus on acute care and less on community-based care? Are we ready to challenge the status quo and ensure health-care affordability for our population in the long term? Which model will be able to meet the expectations of our population? Importantly, countries also have to review which model is economically sustainable in the medium to long term, especially to meet the needs of their populace, which in some countries include a rapidly aging population? Some of the considerations that need to be taken into account in coming to a decision include: Disease prevalence and burden in the country The existing health-care model and system The ratio of health-care providers to patient Cost and health-care funding in the country The current and projected health-care demand and needs The perception of the population on FP s and primary care providers versus that of specialists in hospitals and The networks and strengths of the primary care model in the country. For many countries, including developed nations, the model of care provision is very similar to Scenario 1. How do we prepare our paradigm shift toward the model depicted in Scenario 2? HEALTH-CARE SYSTEMS: THE ISSUES OF THE DAY Today, healthcare is evolving faster than ever before. Care models are changing. Governments are seeking better outcomes and lower costs. Insurers and other agencies are asking for more metrics for reimbursements. Physicians and providers are seeking for better patient engagement, as the shift is now more focused on care in the community.[12] Health is influenced by a complex interplay of physical, social, economic, cultural and environmental factors; thus the need to view it in a broader context and perspective. Holistic healthcare requires effective partnerships between health-care providers, patients, and their families as well as caregivers. Health-care systems around the world continue to struggle to keep up with issues related to patient safety, quality, responsiveness to the needs of the people, and managing the ever-changing expectations of consumers. Economic, demographic, and even social forces will continue to put pressure on health-care systems. Thus, there is a need to have ongoing robust review processes and effective resources support for capacity building. There is a need to ensure health-care services are planned, designed and delivered in ways that respect people's rights, their choices, needs, and preferences for receiving information and care. Some of the critical areas that pose challenges to health-care systems today include;[134] The prevalence and ubiquity of chronic illnesses Aging population care needs Health-care inflation and also financing Cost of health-care labor and attracting/retaining talent Planning relevant and effective health-care education and training Managing expectations and mindsets of consumers and the population. With all these in mind, can Scenario 2 or a community-based healthcare model work? Will it be sustainable? There are good points to support its implementation. This model of care can enhance delivery efficiency, and is more sustainable and affordable in the longer term. As community-based care means providing more decentralized care closer to patients and families, connectivity will certainly be a major consideration. The state of technological development today allows us this connectivity, even with the decentralization of care. Video-conferencing and video telecommunications are relatively widely available these days. In Singapore for example, there is the national electronic health record; one patient, one health-care record. This way, there can be data and resource sharing, and every health-care provider can be on the âsame pageâ in managing a particular patient. Of course, all these access will be password guarded for maintenance of confidentiality. Guidelines of the Personal Data Protection Act must also be adhered to.[15] The decentralization and enhanced connectivity model can be seen to be able to contribute positively toward patient care and ease of care nearer to their homes, thus stepping up regarding convenience. This model of care can also help give patients more autonomy, independence, and more empowerment as well as self-control in their own care. Afterall, one patient is a whole, holistic person who will usually have multi-dimensional needs.[356] Nations can also explore innovative models of community care and customize these to work for their population and suit their local culture. For example in the management of chronic illnesses such as hypertension and DM, there can be more counseling, demonstration (of proper food choices and cooking models) and compassionate care, more up close and personal interaction, to meet their needs. This way, family members, and caregivers are free to join in and actively participate as well. Most importantly, the needs of these long-term care patients with terminal and chronic diseases are met. This type of model can help manage the rigid fee-for-service use of emergency departments and tertiary hospitals, by these patients for a variety of common complications that they can potentially develop. A community-based palliative care model is also better and more receptive for the end of life or terminal care. The emphasis with these is really on the quality of life, the interactions and personal relationships of these patients. In fact, with this model, it may be possible to push the envelope toward more âproactive careâ with the empowerment of the people/patients. DECENTRALIZATION AND CONNECTIVITY The decentralization model of community based care can help expand outreach, across geographic areas. This can be very useful in larger states or countries. In most countries health-care delivery continues to remain very local. Even with Academic Medical Centres (AMC), often the most immediate patients in their vicinity are served. If the value of health-care delivery is to be enhanced and cover a larger scale and area, far more patients need to be served. Thus, the need to plan capacity and strategic expansion. Building more hospitals is not the most cost-effective solution for this, thus the proposed community based care, use of FMC, and the decentralization models. For large parent hospitals or AMCs to have oversight and execute the necessary surveillance and monitoring, a hub and spoke model could be considered. Satellite centers staffing, rotation of staff, collaborative teams practice and engagement by leadership can be planned and executed. AMCs and hospitals should also continually strengthen their partnership with community partners and FMCs, empower them and work closely to achieve the best possible outcomes together. The integration that cuts across horizontally as well as vertically is important to strive for. To ensure connectivity with decentralization, community-based care must be properly and adequately planned with feedback from all stakeholders, to ensure its main goals are met. It should be evidence-based and customized to the local context. Platforms for knowledge sharing and information, even if readily accessible to care, providers, must be guarded to maintain confidentiality. Importantly, there should also be a means to continuously educate and influence mindsets as well as the behavior of the health-care consumers. The model may serve as a framework such as a clinical community in practice model. To start off these community-based care teams, there should be sufficiently credible, inter-professional, committed personnel to form the care teams. These teams comprise not just doctors and nurses but also allied health personnel, social workers, and counselors. Some models also add in community volunteers and befrienders as well as a neighborhood network. These groups may be ad hoc, but with the training, they can be a part of the care network model too. These community-based care teams should not be viewed as providing inferior care, as compared to that in an AMC or hospital. They represent high functioning teams with specialists in different aspects of care provision. This model of community-based care must also not be confused with community nursing, which is more commonly available in many countries. Community-based care will have more case management and case coordination, and relevant staff or managers will have to be employed to help with coordination of care and services. It will be a value-add if these teams and staff have support and backing, from a reputable institution such as an AMC or a secondary, or tertiary hospital. This kind of decentralization model will fit the analogy of a hub and spoke. The teams must be steeped in strong inter-professional care values with a high level of empowerment. The care planning, implementation and finally, execution, with a certain expected level of responsiveness and flexibility should be inculcated. With more widespread community-based care, there may be unintended and indirect benefits which can come about. Health literacy may increase, even if just from the fact that more education and awareness is generated. Interventional programs through community at large education and outreach are other reasons for this. As the model also emphasizes the very close and increased frequency of interactions between care providers and patients, education/counseling can be done more often too. All these also help enhance the level of self-reliance, self-management, and self-care among the more able patients. With the maturation of the model and a more established infrastructure, more elements can be added. This may include the befrienders, community leaders, and voluntary groups. Even students from institutions of higher learning (e.g., from medical, nursing, allied health, dental, and social work schools) can come together for their inter-professional education projects and offer services and care in the community as well. Thus, there are many spin-offs that can amalgamate and strengthen the networks. POPULATION TO BENEFIT Healthcare is more effective when patients are engaged in their own care. Moving forward in a society with aging population, a community based model of care has many benefits. It can be tapped on in the management of patients with long-term chronic diseases and especially those with complications. An example would be an elderly old, who has the complications of many years of DM, needing regular follow-up and care. Not only the elderly but also adults and children with chronic illnesses, congenital diseases, and those needing long-term care will also benefit. At risk individuals, such as patients with fall risks, living alone without family support, those with frailty issues (frailty syndrome can be under-recognized and underdiagnosed) and those with noncompliance issues are other examples of those who will benefit with this type of care model. It may even help reduce readmissions and re-attendance rates among regular attendees in emergency departments and hospitals clinics.[234] Another group of patients who will find this model useful will be those with end-stage diseases, advanced cancer, as well as those needing palliative and end of life care. The dignity, family, and community support it can offer is a welcome to them as they may wish to spend their last days in familiar environments with loved ones in close proximity. Even those with recent discharge from hospitals needing intermediate care support will benefit. In certain context, the medical care teams need to be supplemented with social support teams as well and this can be made available on a demand basis. With this, society can be offered the multi-dimensional, multifaceted, integrated care they need, with all the necessary social and emotional/psychological support. Patient centered care is a focus by the healthcare model on the needs, preferences, and outcomes relevant to patients and families. There is both organizational and individual commitment to ensure patients are motivated, cared for and prepared for the different stages of their medical care or injury. With any model of care, responsiveness is critical to meet the expectations of the public and patients as well as instill confidence. At the end of the day, both health-care providers, and consumers, in the system, would like to see: Improved quality of care Better care outcomes Higher levels of satisfaction Easier and faster accessibility Better coordination and Cost kept within certain limits of affordability. INNOVATIVE TECHNOLOGY IN COMMUNITY-BASED CARE Consumer health wearable technology is becoming more widespread and starting to make an impact on patients and patient care. In the proposed area of community-based care, how can these be incorporated? It needs careful, strategic planning, and implementation to supplement the care provided and simplify monitoring and oversight. With digital diversification, this is possible today. Data can be obtained with personalized health analytics, as well as customized advice and preventive practices for different groups of people and patients in the community. Some of the modalities that can be used include tele-care/telehealth, with the remote and wireless transmission of data and information, specific interventions and also monitoring (e.g., electrocardiogram, vital signs, falls, and motion). The instant feedback and individualized approach are very attractive. There is a strong potential for a big market in this, and the community-based care model has the potential to drive the wearable and health-care technology industry.[78910] On the other hand, as with any other health-care technology, issues with information guarding and maintenance of confidentiality is important. Some systems that utilize GPS, the internet and social media can be at risk to hackers, and thus the necessary technological, as well as cybersecurity considerations, are needed. CONCLUSION To advance true systems integration with community-based care, the following are crucial considerations: Definition of the scope of the service Defining the extent of the service; perhaps, concentrating volume in selected and focused locations, which have to be carefully chosen. Piloting may be one way to have a trial covering certain areas first before subsequent expansion with the necessary modifications The integration of care across locations to ensure seamlessness. This calls for a model with a certain degree of dynamism and flexibility. For any community-based care model to work, there must be collaboration bringing together citizens, consumers, health-care providers, innovators and the government. Each of these groups plays a significant role to ensure an optimized model of care in the community is implemented. Healthcare of the future is taking a more significant push towards preventive, primary and community-based care. It pays for nations and states to explore these early, even before many have reached the critical threshold of embarking on the silver tsunami, as in some rapidly aging nations. Life's journey in health and disease requires different sensitivities and types of care delivery during each chapter or phase. The final phase, whereby death is certain and imminent is best addressed with extracare and support not only physically but also spiritually and emotionally. The right model ensures people get the right care, at the right time, by the right team, in the right place.
With successive English governments extolling the virtues of greater choice and control within welfare services, there is growing debate about concepts such as direct payments and personal budgets (in the UK and in many developed countries). With the evidence base inevitably patchy and incomplete, there have been increasing criticisms of these approaches from the social care trade press and from academic policy commentators alike. Against this background, this paper reviews the concerns that are emerging and explores some of the limitations of current debatesâmany of which make an implicit appeal to âthe evidenceâ in order to justify increasingly polarised views. In particular, the paper argues that many current accounts are based on an imperfect understanding of the principles at stake; on a failure to apply the same burden of proof to the old system as well as the new; on prior attitudes to state services and to current social care; and on a potentially limited adherence to more traditional forms of evidence-based practice.
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