Health online: the future isn't what it used to be

Over the next 10 years, the healthcare system will change to focus more on preventive medicine and healthcare in the home, with fewer doctors and a new class of home healthcare providers. Healthcare professionals need to debate how best to manage these changes.

The potential impact of home telecare on clinical practice

Home telecare, in which the health status of patients at home is monitored remotely, has the potential to improve care and reduce costs. Its widespread implementation would require fundamental changes in the healthcare system.

Home telecare in the United States

Telecare has the potential--to extend home-care services normally delivered by conventional means. In the USA, government reductions in health-care financing have been matched by a growing interest, on the part of commercial health-care insurers, in cost reductions and cost-effective care planning. This review identifies emerging trends in home care. Several telecare demonstration projects have been undertaken with patients with coronary heart disease and HIV/AIDS. These projects have attempted to develop new methods of providing cost-effective care for a growing patient population with chronic disease.

Home health at the crossroads

Entire classes of Medicare beneficiaries that previously had been served under the home health benefit are now absent from the care rolls. Anecdotal reports indicate that these beneficiaries are being forced to opt for higher-cost skilled nursing facility or hospital care. Some people are simply going without needed care. Before "expanding" the Medicare benefit into new coverage areas, it only makes good policy and good sense to repair some of the unintended consequences of the Balanced Budget Act of 1997 (BBA).

Ethical dilemmas in the pediatric hemophilia community

How can pediatric nurses best advocate appropriately and knowledgeably for patients with hemophilia in our rapidly changing health care system. This commentary raises many questions, questions that can provide the basis for discussion among parents, providers, and payors. Children with hemophilia have benefited greatly by the creation of comprehensive care teams that support home treatment (Butler, 1998). Ongoing excellence in home care can be achieved by parents' and patients' self-advocacy. The hemophilia community's self-advocacy has been so successful as demonstrated by the move to home care, self-infusion, and the Ricky Ray legislation. This community has an ownership of its preventive care and recognizes that federally funded centers of excellence exist by the use of the family's tax dollars and the patient's patronage. Hemophilia programs are a model for further examination for preventive self-care in other chronic disease states.

The family role in the context of long-term care

Current long-term care policy and practices are built on the premise that family is and should be the primary party responsible for impaired older persons. This article presents evidence that this premise and the resulting policies and practices are (a) built on myth; (b) fueled by gender, income, and ethnic inequalities; and (c) largely responsible for the creation of a service system that has inadequate capacity to meet current and future needs. An alternative paradigm, which places primary responsibility for long-term care needs on the individual, is proposed here and implications for new policy direction are outlined. The projected benefits of this shift in paradigm will be the development of a more viable and more equitable long-term care system that has the capacity to provide high quality care to meet the expanding need.

Tools, methods, and strategies. Do innovative models of health care delivery improve quality of care for selected vulnerable populations? A systematic review

BACKGROUND

A criticism of conventional office or clinic-based models of care is that they focus on patients' urgent problems and do not provide the comprehensive assessments, education, and psychosocial support that vulnerable patients also need. Innovative models have emerged to address these needs. A systematic review of prospective studies involving searches of computerized databases, reviews of reference lists, and contacts with authors, was conducted to determine whether multidisciplinary teams, outreach or home care, and case management improve the quality of the care in two vulnerable populations-the terminally ill and the mentally ill.

RESULTS

Literature searches identified 730 citations. 52 original articles met screening standards, and 24 studies fulfilled all criteria. Patient and caregiver satisfaction was consistently higher with innovative models. In no study was satisfaction lower. Functional, clinical, or psychological improvements were not consistently demonstrated. For mentally ill patients, multidisciplinary outreach strategies were effective in reducing inpatient hospitalizations. Costs were inadequately assessed in the studies to draw a summary conclusion.

DISCUSSION

Like other interventions, health care delivery models can be assessed from an evidence-based perspective. More needs to be learned about the costs and health improvements of innovative models before we can determine whether the increased patient and caregiver satisfaction found justifies widespread use of these models. Development of a uniform set of quality outcome measures and encouragement to evaluate efforts and disseminate results will help accomplish this goal.

"High-tech" home care at the VNA of Texas

The term "high tech" was made popular in the United States by John Naisbitt in his book, Mega Trends. Today, advanced technology may allow an individual to be cared for at home, although often both professional and family support is required to utilize the technology. The VNA of Texas is using high tech applications in the home to better serve its patients.

Efficiency of home care: notes for an economic approach to resource allocation

Home-delivered health-related services are not valued for themselves but are, rather, highly customized inputs that can be used in the production of several alternative "commodities" ultimately demanded by consumers. These valued commodities are the restoration, improvement, or maintenance of health and functional status that can be produced by home-delivered care (and by alternative services) and the everyday support of daily functioning at home. If we can describe how inputs into the production of these two commodities are allocated, it may be possible to make judgments about whether home-delivered care and other services would produce more value if they were allocated differently.