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.
Frank W. Garrison, Valorie Dearmon, Rebecca Graves
FigureA nursing shortage, whether at the individual market level or the national level, profoundly impacts healthcare delivery.1 Nurse administrators continually seek ways to address nursing shortages by attracting new nurses to the profession and supporting their success as novice practitioners. Nurse residency programs (NRPs) are commonly employed to develop and support new graduate RNs (NGRNs), reducing vacancy and turnover.2-4 Putting an effective NRP into practice can be challenging in any setting, but particularly so for smaller hospitals where resources are seriously limited. In 2015, our 100-bed community hospital hurriedly implemented an NRP to address the facility's critical nursing shortage. Predictably, we identified opportunities for improvement of the newly developed NRP soon after implementation. Here, we explain how we optimized our NRP at minimal cost to achieve sustained improvements in nursing vacancy and turnover. A quick fix Our hospital implemented its original NRP in response to a 2014 nursing vacancy rate of 17% and a turnover rate of 37%. We needed a solution to provide immediate relief from our nursing shortage, but a policy was in place that prohibited hiring nurses with less than 2 years of experience. The CNO and management team decided to revise the policy to allow the hiring of NGRNs contingent on their completion of an NRP, which the hospital quickly developed and implemented. Although the NRP brought significant relief to the nursing vacancy crisis, the CNO and nurse managers feared that the program was only a quick fix. They wanted to replace it with a well-developed and evidence-based solution able to sustain vacancy reduction and prevent future turnover. For the NRP to be most effective, the team believed that it needed greater emphasis on competence development of NGRNs and preceptors alike to support the hospital's mission of excellence. However, with substantial capital already investedâapproximately $20,000 per NGRN over traditional orientation, predominantly for salary dollarsârequesting further funds to enhance the NRP presented a challenge. Identifying best practices The CNO and project team, which included nurse managers, nurse educators, and recent graduates from the hospital's NRP, conducted a comprehensive literature review to identify NRP best practices. The use of NRPs to improve competence and reduce vacancy and turnover is well documented in the literature, but program variations make it difficult to define best-practice strategies.4,5 Agencies such as the American Association of Colleges of Nursing have established guidelines for NRPs, and accreditation status is awarded for a fee to organizations meeting the established guidelines.6 However, as with our organization, resource limitations prevent some facilities from seeking accreditation. Nonetheless, criteria found within the accreditation standards underscore best practices and can guide the selection of evidence-based strategies within the context and constraints of any organization. Our literature review identified that competent preceptors are essential to NGRN development.2,7 The preceptor-NGRN bond is vital to NGRN confidence and skill building.8 Effective preceptors possess clinical expertise combined with the knowledge and ability to facilitate another's competence.2,7 Interprofessional collaboration is also key to NGRN success.9,10 Engaging NGRNs in collaborative work promotes decision making, confidence, and communication.9-11 Simulation can facilitate competence and help develop collaborative skills.8,9,12 It allows novice nurses to practice skills without fear or risk of hurting patients, honing critical-thinking and decision-making abilities.12-14 A recent landmark study validated the effectiveness of high-fidelity simulation as a substitute for up to half of traditional clinical hours for nursing students.14 Lastly, studies repeatedly find that socialization and long-term support are vital to NGRN competence, retention, and professional commitment.2,5,7 Other strategies, such as extending the duration of NRP class time, are recommended, but these were eliminated by our team due to prohibitive cost. The project team carefully examined the evidence and selected best practices appropriate to our setting and circumstances. Three measurable objectives guided NRP improvement: 1) increase NGRN competence through practical skill-building methods; 2) increase preceptor competence, with NGRN competence correlating with preceptors' teaching and mentoring skills; and 3) develop a social and professional support system for NGRNs to promote competence and foster professional and organizational loyalty. Getting to work The project team formalized the competence development plan, obtained institutional review board approval, and set out to implement the NRP improvements for an incoming 2016 class of NGRNs (N = 6). The team began the implementation process by partnering with a local university's school of nursing for simulation lab use with faculty instruction. Next, the team purchased validated assessment tools from a national company for NGRN and preceptor pre- and posttraining competence assessment. The instruments consisted of an NGRN clinical competence assessment tool and a preceptor clinical and precepting competence tool. Assessment findings were analyzed by the contracted company, providing detailed reporting of each individual's strengths and weaknesses. A group of seven preceptor nurses within the facility completed the nurse preceptor competence assessments; the project team used the assessment results to tailor the preceptors' education to areas of needed improvement. The hospital hadn't previously assessed preceptor competence, and the new approach allowed for customized education to improve preceptors' abilities. The hospital's education department conducted the training; afterward, the preceptors took a posttraining assessment. During the course of the project, three of the preceptors had to be replaced due to unforeseen circumstances. The substitute preceptors received training but weren't in the initial preassessment group, so only the assessments of the remaining four preceptors from the original group were considered as part of the study results. The costs for assessments for both the preceptors and NGRNs were minimal, as shown in Table 1.Table 1:: Annual NRP improvement project expensesThe enhanced NRP commenced a few weeks after the preceptors completed training. Each of the six NGRNs took nationally validated NGRN-specific nursing competence assessments aligned to clinical specialty areas of interest to establish pre- and posttraining competence; three of the six NGRNs took an additional pre- and posttraining competence assessment necessary for the combined clinical focus of their selected department. The NGRNs completed an initial hospital orientation and then began the competence development curriculum consisting of simulation lab training, didactic interprofessional collaboration training, preceptor-guided nursing shifts, and social and professional support group meetings. (See Table 2.) Many of the simulation scenarios and the didactic interprofessional collaboration lessons were based on findings from the NGRNs' baseline competence assessments and feedback from the hospital's recent NRP graduates. The project team analyzed this information to identify areas of needed improvement and allocated didactic instruction time accordingly to those areas.Table 2:: NGRN competence development curriculum examplesCollaborative skills were practiced during interprofessional simulation scenarios. Furthermore, numerous NGRN classes were taught by various hospital leaders, again focusing on improvement areas identified from the baseline assessments and the previous NRP class feedback. Class time included a variety of role-play scenarios, allowing the NGRNs to practice the skills necessary to communicate accurately, effectively, and collaboratively. Faculty from the nursing school also taught classes on time management skills and the impact of effective collaboration on overall time management. The NGRNs worked scheduled shifts to care for patients under the direction and guidance of their preceptors, observing and/or participating in all nursing activities, including multidisciplinary rounds. As the NRP progressed, the amount of nursing work performed independently by the NGRNs increased steadily as preceptors observed improvement in the NGRNs' skills and readiness. The importance of socialization and professional support to the NGRNs' success can't be understated. Providing social and professional support requires a time investment as opposed to capital. During each NRP class day, a 1-hour catered lunch was scheduled as social and professional support time. Some of these lunch meetings focused on strengthening NGRN peer relationships, whereas others included preceptors and managers for fostering social and professional networks outside of the NGRNs' peer group. When the didactic portion of the NRP was complete, the social and professional functions were changed to a breakfast meeting at morning shift change. The breakfast meetings continue for a full year to provide time for NGRNs to engage with each other, their preceptors, the CNO, and other nurse leaders by asking questions, resolving challenges, making suggestions, and sharing successes in their transition to professional practice. Success! The project was an enormous success from the perspective of the project team and hospital administration. The best practices integrated into the existing NRP markedly strengthened the program. Incorporating simulation lab training was highly valuable, but even more efficacious was the relationship between our hospital and the university. Developing the infrastructure for the partnership between the hospital and university required a significant time commitment for both parties because a number of meetings were required to understand each other's needs and goals. As the parties grew to understand what each had to offer, a mutually beneficial contractual agreement for simulation training was formalized. The contract established a partnership with the school for use of its high-fidelity simulation lab and faculty instruction in the lab to facilitate NGRN skill building. The fees for simulation training required an investment that was significant to the hospital's budget, but the resulting partnership between the hospital and university was well worth it. The relationship helped meet the hospital's need for nursing staff and the school's need for NGRN placement in the workforce. Faculty also volunteered a significant amount of time, at no additional cost to the hospital, to assist the project team in educating the NGRNs during the NRP didactic class times. The partnership led to an agreement for the school's family NP students to perform clinical rotations in the hospital and its clinics, and for the hospital to be the school's sole provider for women's services clinical rotations. The relationship even resulted in the CNO's placement on a university advisory council. Competence assessment data also revealed project success. Pre- and posttraining assessment data were analyzed using statistics software. Measures of central tendency and variance were evaluated and, because of the normal distribution of all variables, differences in the means were analyzed by paired-samples t tests. The itemized score reports from the preceptors' initial competence assessments revealed opportunities for improvement in the areas of communication, critical thinking and problem solving, and orientation plans. The competence assessment group mean score for the four preceptors who participated in the entire project increased from a pretraining score of 77.00 (SD = 2.94) to a posttraining score of 79.00 (SD = 4.55); however, statistical significance wasn't found (t(3) = -.608, P = .586). Also, the reassessment itemized score reports for the individual preceptors revealed an improvement in the pre- and posttraining mean score in the three identified areas of need. Similarly, the NGRN competence development curriculum, as informed by the NGRNs' baseline assessments and feedback from the hospital's recent NRP graduates, led to improved NGRN competence. The posttraining assessments demonstrated a statistically significant improvement in overall NGRN competence. The mean for the nine baseline tests was 72.11 (SD = 6.03) and for the nine reassessment tests, 81.22 (SD = 3.59). A significant increase from the baseline assessment to the reassessment was found (t(8) = -3.833, P = .005). The NGRNs also completed the Casey-Fink Graduate Nurse Experience Survey at the end of didactic training. The Casey-Fink survey is a valid and reliable self-assessment of NGRN competence, with content validity established by expert review and a Cronbach's alpha coefficient of 0.89 after repeated measures.15,16 The survey findings provided additional insight into project effectiveness by revealing the NGRNs' self-perceptions of nursing competence after the NRP. For example, in the 24-question Likert scale portion of the survey, 83.3% of the responses from the six NGRNs demonstrated a favorable view of the transition experience. The survey results were also useful in departmental placement of the NGRNs at the end of didactic training and for planning additional education for individual NGRNs in areas of self-perceived need. The hospital's nursing vacancy continued to improve during the enhanced NRP. The current vacancy rate dropped from 17% at the end of 2014 to 7.5% by mid-2016, and that reduction has occurred even as the hospital has increased nursing positions by 20% to account for growth since the inception of the NRP. The vacancy rate is impacted by a variety of factors; implementation of an NRP is one such factor. In our case, the NRP resulted in an impactful reduction in vacancies. Although the small cohort size for the NRP improvement project limits the generalizability of our study, the improvements significantly increased NGRN competence, which has been linked to increased retention.3 Whether improvements in the NRP will impact nurse retention and sustain lower vacancy rates downstream is yet to be determined, but early findings are promising. In summary, at the onset of the NRP, a valuable partnership was established benefitting all parties involved. Areas of preceptor weakness were identified and successfully addressed in preparation for the NRP, although the improvement in preceptor competence wasn't statistically significant. However, NGRN competence did significantly improve from baseline after the NRP. The Casey-Fink survey indicated a favorable view of the NGRNs' transition experience and identified areas to target individualized education going forward. Finally, the facility's nursing vacancy rate improved, decreasing by more than half. In progress The costs of implementing and operating an NRP are considerable, but the expenses required to make impactful best-practice improvements to an existing NRP are far less substantial. With the exception of the simulation lab fees, the overall costs of the improvement project were minimal. Although simulation added to the costs, the long-term benefits of the relationship between the hospital and university, along with improved NGRN competence, were deemed a solid return on investment. The expense for the competence assessment tools and analysis of findings wasn't an additional cost to the improvement project because our parent company was already requiring us to use an outside company to measure new employee competence. A hospital interested in NGRN competence assessment but lacking the resources to engage an outside company can use other assessment instruments free of charge, such as the Casey-Fink survey or an internally developed tool. Nurse leaders in community hospitals with limited capital for NGRN recruitment and retention need to evaluate the in-house resources available to support NGRNs and strategize ways to optimize those resources. For example, the project team realized that a tactic as simple as involving various hospital departments in NGRNs' education can improve their interdepartmental knowledge and collaboration. We also learned that purposefully designed social and professional support activities are a far more productive use of lunch and breakfast hours than unstructured break times. Nurse leaders also need to consider looking beyond the four walls of the hospital for any available resources.7 Not every community hospital has access to a nearby university or nursing school, but other community resources may be available. For example, a long-term acute care facility may be willing to conduct educational in-services for NGRNs on how the facilities work collaboratively for safe care transitions. Learning from and partnering with sister hospitals can also serve as an excellent NRP improvement resource. Perhaps partnering with a sister hospital can allow for specialty training of NGRNs that one facility's NRP isn't equipped to provide. Even pharmaceutical and medical representatives may be willing to provide in-services on medications and equipment to increase NGRNs' knowledge about the nursing care they provide and further their understanding of how hospitals work with these entities. By identifying both the internal and external resources available, hospitals with limited capital to direct toward recruitment and retention of NGRNs can work smarter to increase nursing competence and support long-term retention.
Setting the context The constitution of Finland stipulates that society must guarantee adequate social, health and medical services for each of its 5.3 million inhabitants, and promote the health of the population. Due to decentralized governance, responsibility for financing long-term care for older people rests heavily on the shoulders of 336 relatively independent local authorities (municipalities), as does the delivery of long-term care services. Obliged by law to provide long-term care services for older dependent people, these municipalities are free either to provide services themselves or to purchase them from various for-profit or not-for-profit providers. Historically, municipalities have tended to rely on providing their own services. According to the Statistical Yearbook on Social Welfare and Healthcare (National Institute for Health and Welfare, 2010), 87 per cent of all long-term care days in residential facilities were produced in public facilities, 10 per cent in not-for-profit private facilities and only 3 per cent in for-profit private facilities. In contrast, when it comes to sheltered housing for older people, officially known as âservice housesâ or âsheltered housingâ, only 42 per cent of long-term care days were furnished by public providers while the private sector provided 32 per cent of care days in not-for-profit facilities and 26 per cent in for-profit facilities. Chronic care hospitals, known as âhealth centresâ, are predominantly public (95 per cent). Recent statistics are not available for home care. In all these types of facilities municipalities are responsible for monitoring care but they are aided in this task by other entities. The National Supervisory Authority for Welfare and Health (known as Valvira), supervised by the Ministry of Social Affairs and Health, undertakes a national supervisory role, together with six Regional State Administrative Agencies (AVI).
The emerging Austrian long-term care system in the context of a federal constitution In Austria, long-term care started to become acknowledged as a specific field of social and health policies during the 1980s, when a debate about long-term care allowances was initiated by people with disabilities acquired during their working age. The ensuing reform was marked by the legacies of the traditional Austrian welfare regime, by the federal constitution and the clear-cut distinction between the health and social care systems. The decentralized governance of health and social care in Austria has been based on two distinct principles. On the one hand, healthcare is a part of the social insurance system that is primarily regulated by the federal government, financed by contributions and administered by the self-governed health insurance agencies at federal and regional levels. The regional governments ( BundeslÀnder ) are involved as planners, managers and co-financers of hospitals (Hofmarcher and Quentin, 2013). On the other hand, the principle of subsidiarity has been applied to the areas of disability, social and long-term care with respective responsibilities assigned by constitutional law to the nine regional governments. Their activities are funded from general taxes that are centrally levied and distributed according to defined criteria. In practice, this means that, if patients have been assessed as being in need of long-term care, they have to rely on their own assets and/or means-tested social assistance from the local or regional authorities (Ganner, 2008).
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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Home care is the fastest growing sector of medicine today. It has increased at approximately 20% per year since 1989, and this double-digit growth is expected to continue into the future. In 1990, The Prospective Payment Assessment Commission (DHHS) reported that Medicare expenditures for home healthcare services were $3.5 billion. This increased nearly fivefold, to $16.9 billion, in 1996, and it is expected to have reached $19 billion in 1997.1 Estimates by the Congressional Budget Office estimate the spending for home health services will exceed $30 billion by 2002.2 In 1996, 10% of the Medicare population received in-home services for a total of 280 million visits to 3.8 million beneficiaries.1 Most of the patients (75%) who receive in-home services are 65 years of age or older, with an average age of 70 years, and according to the 1992 National Home and Hospice Care Survey conducted by the National Center for Health Statistics, for every resident in a nursing facility, there are three to four patients of equal debility residing in the community with the assistance of family, friends, and the intermittent services of home healthcare agencies. The comparison between the institutionalized and home-bound populations and the most frail patients in ambulatory practice is especially instructive in exposing the level of involvement of the medical community. The discrepancies between the different settings are striking. In the care of chronically ill patients, it is usually the physician who recommends the frequency of visits for follow-up and monitoring. These are the patients in the office in âfair to poorâ health who see their physicians an average of 11 times a year3; in the nursing home, these patient are seen a minimum of 6 times a year, and often 12 or more. The homebound patient is often among the highest users of acute medical services, at great risk for complications, and among the most ethically challenging. Their care demands the highest degree of coordination with other health care providers as well as counseling of family members. Yet in 1994, when 3.1 million Medicare beneficiaries were provided with home care services, only 1.5 million home visits were made by physicians. On average, homebound patients get one visit every 2 years, even though 90% of primary care physicians who answered recent surveys agreed that house calls are important in their management.4 The reason cited most commonly for the low numbers of home visits has been the poor payment for these services. A 1990 AMA telephone survey of a nationally representative sample of 1161 family physicians and internists found that 88% felt that reimbursement was inadequate for physician services in the home.4 The Physician Payment Review Commission stated in their 1994 report to Congress: âFirst, the homebound represent perhaps one of the most vulnerable Medicare populations. Declines in primary care services to this population might, therefore, merit more attention than would changes in services to other Medicare beneficiaries. Second, home visit services take a considerable amount of physician time but are relatively poorly paid⊠Advisors to the Commission have suggested that the combination of time and low hourly remuneration along with financial pressures on providers' practices might make home visits a service that is curtailed by providers.â The Office of Inspector General, in their June 1995 report, The Physician's Role in Home Health Care found: âFourteen percent of physicians report making home visits; most of them say these visits are infrequent and only when absolutely necessary. They add that since Medicare pays so little for a home visit, it is not affordable for them to see patients in their homes.â6 Then there is the lack of medical education. In the past 30 years, medical schools and residency training programs have provided few, if any, home care training experiences. As a result, the majority of physicians in practice today are unaware of the opportunities and âbest practiceâ models for caring for patients in the home. See also p 174 But the times they are a'changin'. Through the persistent efforts of a small committed group, led by the American Academy of Home Care Physicians, the Health Care Financing Administration agreed to reassess the value of physician involvement in the home care arena.7 As of January 1998, Medicare has made extensive revisions to the rules for home visits. These modification are likely to stimulate a profound reconfiguration of the delivery of health care to the chronically ill in this country. The current procedural terminology codes for house calls have been expanded to more closely reflect those used in ambulatory care, and there has been a significantly improved reimbursement structure that makes house calls a financially viable alternative setting for medical practice. Most importantly, the upper level codes allow for the comprehensive assessment of complex patients in the home for both new and established patients. It is now feasible to provide an appropriate level of service for the more seriously ill patients who wish to eschew the hospital and are often too frail to travel to the office. It is also more practicable for acute care services to be brought to the home, avoiding the emergency department and the inevitable hospital admission. It is now conceivable that a growing number of physicians, as recently demonstrated in Chicago and Detroit, will embrace the home as their principle setting for providing care. The second major change is the expansion of nurse practitioner and physician assistant services into the home, without on-site supervision by the physician, and at 85% of the reimbursement.7 This change will allow physicians and mid-level practitioners to work in partnership in the management of the chronically ill, sharing the monitoring visits and using the physician more effectively in unsettled or more complex situations. Nurse practitioners and physician assistants have proven themselves highly capable in the management of frail patients in the institutional setting through such programs as EverCare and Elder Health as well as through the personal experiences of many physicians in a variety of settings. Similarly, this extension of the partnership into home care should lead to a successful augmentation of the array of services provided by larger group practices. In this issue of JAGS, Dr. Fried describes the population of patients most likely to benefit from physician home visits and an academic ambulatory care practice that demonstrates many of the principles needed to incorporate a house call program.8 The patients are typical of the frail and highly impaired older patients followed by home care agencies; 30 to 40% were actively receiving care at the time of the survey. The range of illnesses is also typical of that seen in the clinic and is managed in much the same way, except that the patients were in a setting more conducive to their needs. Many were quite adamant in their refusal to allow hospitalization and obviously tested the acute care capabilities of the practice, which proved very adept at responding to their needs despite the limited resources. One of the three geriatricians took primary responsibilities for the house call program along with the nurse practitioner, who handled the bulk of the visits and telephone calls. They defined a reasonable catchment area to decrease travel time and time away from the practice, and they made both regularly scheduled visits for those patients unable to come to the practice and acute care visits during the day as time permitted. Office procedures established the house call practice as a separate, but highly integrated, part of the overall service. The limitations were driven predominantly by the lack of reimbursement for the nurse practitioner visits and the constraints of an academic affiliation. Nevertheless, the care was clearly highly valued by both the patients and the staff. Much can also be learned from the recognized weaknesses of this program. The network of home care providers and the integration of services across disciplines were not as developed as in other models. Often a home care agency will assign nurses to a larger house call practice and encourage regularly scheduled meetings to facilitate care coordination. Social workers, therapists, and nutritionists from the agency may also participate. The benefits to the agency in improved communication, efficiency in completion of the documentation and orders, and the increase in referrals more than offsets the costs of the personnel. Similar benefits can entice participation by a local pharmacy that delivers medications to the home, a durable medical equipment vendor, and an infusion company. The mutual interests and ability to complement each other's services promote a strong sense of teamsmanship and can result in a more profitable business. A second area that was not fully developed in the program described was the use of newly available, highly portable diagnostic instruments and therapeutic technologies. Advances in miniaturization and automation give the physician on-site access to a wide range of equipment for analyzing blood and urine samples, simple radiography, oximetry, and electrocardiography. Digital processing allows for easy transmission of the results and telecommunication with consultants. Other specialized adjunctive services, which may be available in larger metropolitan areas, include ultrasonography, echocardiography, and Doppler studies. Therapeutic modalities include infusion devices for enteral and parenteral therapies, oxygen delivery devices and ventilators, peritoneal and hemodialysis devices, and specialty support surfaces for wound management. In a well organized program, virtually any service available in a hospital room can be provided in a patient's home. With the changes in Medicare policies and regulations, the opportunities in home care are enormous and the future bright for both the healthcare industry and academia. Visionary leaders in healthcare organizations and physicians' groups recognize that the overwhelming majority of chronically ill patients can be successfully cared for in the home, and nearly everyone would choose care at home to admission to a nursing home. Several studies both here and abroad show that a well organized program of home-centered care for frail older people and vulnerable younger patients can be the most cost-effective, efficient, and most preferred healthcare alternative.9, 10 In addition, the Hartford Foundation has supported a select group of medical schools in the development of home care curricula to educate physicians in training. For those physicians already in practice, the American Academy of Home Care Physicians is providing ongoing education in the administrative and clinical aspects of home care. Many challenges still lay ahead. A decentralized system of health care is highly dependent on information management technologies that are not yet fully standardized or implemented. Increasing numbers of widely disbursed patients will require us to investigate alternative methods of healthcare delivery using less expensive personnel with more focused skills and the training and management strategies to supervise their care.11 However, only with the continuing support of federal, state, and private insurance will the knowledge gained from these experiences lead to the development of a comprehensive spectrum of services in a seamless system of care.
Advanced industrial countries around the world are making or contemplating major reforms of their systems for financing and organizing long-term care for the elderly. The paper describes major reform efforts including: the pursuit of cost efficiencies from further differentiation of the acute and long-term care delivery systems, promotion of home and community-based care alternatives to traditional institutions, and âsystems integrationâ involving consolidation of responsibility for long-term care at one level of government. The paper concludes by discussing the special relevance to the long-term care reform debate in the U.S. of recent British and German decisions to, respectively, decentralize versus centralize responsibility for long-term care.
The frail elderly have special multidimensional housing needs beyond affordability, including shelter that is more adaptive to reduced function and offers supportive services. Suitable housing for this population comprises three policy areasâhousing, health care, and social services. In a federal system, development and implementation of policies in these areas involves participation of several levels of government and the nongovernmental sector. This paper uses federalism as a conceptual framework to examine and compare these policy areas in Canada and the United States. In both countries, general national housing policiesârelying heavily on the nongovernmental sector and characterized by joint federalâprovincial programs in Canada and by important local government roles and ageâspecific programs in the United Statesâhave benefited the elderly. The effects of such policies on the frail elderly, however, have been less positive because of the general lack of essential human services and, to a lesser degree, health care that enables them to live outside institutions. This is especially true in the United States, where health care policy is fragmented and is dominated by a private insurance system, partial federal financing of health insurance for the elderly, and tense federalâstate relations in financing health care for the poor. Although Canadian policies and programs operate autonomously and more uniformly within a national health plan, neither country has a universal, comprehensive longâterm care system. Geographically diverse patterns of social services, funded by grants to states and provinces and the nonprofit sector, are common to both countries. However, the United States has inadequately funded ageâspecific programs and has relied on a growing commercial service provision. Housing outcomes for frail elders are moving in the right direction in both countries; however, Canada seems to be better positioned, largely because of its health care system. As increased decentralization continues to characterize the three policy areas that affect suitable housing for frail elders, the United States can learn from Canada's negotiated federalism approach to more uniform solutions to merging housing and longâterm care.
In the United Kingdom, despite a stated commitment to community care, centralized planning and financing through the Social Security System, rather than the Social Services Department, resulted in a serious distortion in policy. Social Security funded care in residential and nursing homes, and not community care. As in the United States, central government expenditures for expensive institutional care rose dramatically in the 1980s as a result. By the end of the decade, changes were implemented to decentralize the provision and funding of social care. Several projects were undertaken to demonstrate effective means of applying the new policies. In each instance, case managers worked with relatively small caseloads of the frail elderly and were responsible for allocating funds to purchase the services needed within a fixed budget. In all settings, there was a reduction in the use of institutional care facilities; the quality of life of both the clients and their caregivers improved significantly; and these gains were achieved at no greater cost than for individuals receiving the traditional services without case management. Despite the fact that issues such as what happens to costs when the system is expanded to other target clienteles remain to be resolved, the success of the projects highlights the significant gains to be achieved with case managers who have control of both service selection and budgets.