[Transfer of the AGnES concept to the regular German health-care system: legal evaluation, reimbursement, qualification]

Task-Sharing Between Pediatricians and Non-Physician Healthcare Professionals in Outpatient Child Health Care in Germany: Assessment of Need and Acceptance for Concept Development

Although pediatricians in Germany work as general practitioners for children, they are planned and trained as medical specialists. In consequence, distances between practices and residences of patients can be very large. The implementation of task-sharing models is a promising option to sustain pediatric outpatient care in rural regions. In this study we assessed the need for and acceptance of delegation of tasks in outpatient pediatric healthcare to non-physician healthcare professionals and developed a task-sharing concept. A standardized questionnaire was developed and addressed a wide range of healthcare professionals. On the basis of the results of the questionnaire and a subsequent workshop involving representatives of the various fields of pediatric care a delegation-concept was developed. A total of 206 questionnaires were answered (response rate: 17%). About 70% of the respondents (n = 145) agreed with the delegation of counseling on prevention, 66% (n = 135) with the delegation of tasks in the transition process into adult medicine. All proposed tasks were conceivable for at least a third of the respondents. Mostly, pediatricians could envision delegation more than the non-physician health care professionals. A three-dimension-delegation-concept was developed: which tasks can be delegated to whom in which setting. Basically, if nurses or medical practice assistants are adequately qualified, all tasks can be delegated to both. The delegation was approved by most of the respondents. Implementation of task-sharing provides a new option to support pediatricians and create better access to outpatient pediatric health care in rural regions. The next step should be the implementation of the delegation concept in pilot projects.

Cognitive impairment in primary ambulatory health care: pharmacotherapy and the use of potentially inappropriate medicine

OBJECTIVE

Drug intake is associated with a risk of drug-related problems, for example, the intake of potentially inappropriate medication (PIM), especially for cognitively impaired individuals. The proportion of PIM taken by immobile individuals, especially patients with suspicion of dementia in the AGnES studies (German: Arzt-entlastende Gemeinde-nahe E-Health-gestützte Systemische Intervention), and possible determinants were analyzed.

METHODS

In a community-based, prospective cohort study in the ambulatory healthcare sector, a sample of 342 patients aged ≥65 years were screened for dementia and received a home medication review. The screening for dementia was positive in 111 cases (32.5%). Data assessment included sociodemographic variables and medical diagnoses. The German PRISCUS list was used to detect PIM and drug-condition interactions.

RESULTS

Potentially inappropriate medication in dementia was identified in 22 (19.8%) patients with suspicion of dementia. A multivariate binary logistic regression revealed that the number of drugs taken (one to four drugs: OR = 0.059; 95% CI 0.006-0.55, p = 0.0133; Ref.: >9 drugs) and female gender (OR = 10.362; 95% CI: 1.28-83.87) were risk factors for PIM intake in patient with suspicion of dementia.

CONCLUSIONS

Inappropriate medication use in a community-based sample positively screened for dementia appears to be determined by sex and the number of drugs taken. The intake of fewer than five drugs and receiving support with regard to drug intake protects from the intake of PIM. Patients could benefit from medication management in a collaborative network of healthcare professionals. The implementation of systematic medication review and drug documentation should be extended and standardized in both research studies and routine primary health care.

[Qualification concept for delegation of medical tasks to nonmedical professional groups. The "Greifswalder 3-level model"]

To manage the current demographics and the expected medical, nursing, and social care needs of the population, structural changes are needed in the German health care system. On the regional level, there is a shortage of general practitioners in Germany. In the future, the number of affected regions will likely increase. These trends require new support strategies, which include the delegation of medical tasks to nonphysician professionals of which nurses and medical assistants are the primary profession. Thus, they will expand their traditional scope of work. However, their traditional training does not qualify them to perform medical tasks responsibly and with high quality. Hence, there is a need for further development of advanced training programs. The goal is to tailor modular advanced training to the specific support needs of the patients. A recent law (GKV-Versorgungsstrukturgesetz, GKV-VStG, 1 January 2012) was passed that specifies and extends the delegation options of medical tasks beyond the restrictions defined in previous German legislation (§ 63, SGB V in 2008). In this article, we present a three-stage model for qualifying nonphysician medical professionals for defined ranges of medical tasks.

Home visit delegation in primary care: acceptability to general practitioners in the state of Mecklenburg-Western Pomerania, Germany

BACKGROUND

Shortages and maldistribution of primary care physicians (PCPs) are affecting many countries today, including in Germany. As has been suggested, the ensuing problems might be alleviated by delegating some medical tasks to physicians' assistants (PAs). This was tried in three regions of the German state of Mecklenburg-Western Pomerania under a pilot project entitled AGnES (Arztentlastende gemeindenahe E-Health-gestützte Systemische Intervention, i.e., a community-based, e-health-assisted, systemic intervention to reduce physicians' workloads). We conducted a survey of all practicing PCPs in the state to assess their overall attitude toward the delegation of home visit tasks, and to determine what they would prefer as the job description and type of employment contract for a PA who would be hired to assist them.

METHODS

All PCPs practicing in Mecklenburg-Western Pomerania were asked in a quantitative survey about their willingness to delegate home visits, their perceived barriers to and benefits of home visit delegation to a qualified assistant, the skills they would require of a PA who would be hired to carry out home visits, and their preferred type of employment contract for the PA.

RESULTS

47% of the PCPs (515/1096) responded to the survey. 46% of the respondents were already informally delegating home visit tasks to qualified PAs. Female PCPs were more likely to do so (odds ratio [OR] 1.70), as were PCPs practicing in rural areas (OR 1.63) and those working in individual practice (OR 1.94). Most PCPs were in favor of delegating home visits to qualified PAs (77%). Main advantages were seen in reducing physicians' workloads (70%) and in increasing their job satisfaction (48%). 34% of PCPs said they would not cover the cost of training PAs.

CONCLUSION

Acceptance of home visit delegation among PCPs in the state of Mecklenburg-Western Pomerania is high, mainly among the younger physicians. Perceived barriers and benefits of delegation of home visits to qualified PAs should be taken into account in the design of future health-care reforms, so that practice in rural areas can be made more attractive for the incoming generation of PCPs.

[Delegation and substitution of specific medical tasks as a future model of health care supply]

Changing health care needs caused by changing demographics lead to an increasing demand for medical and nursing care in Germany. A declining number of general practitioners will soon cause a lack of health care supply in a growing number of regions. Nurses constituting the largest occupational group in the health care system contribute by filling the resulting gap. Internationally, models have been developed to incorporate new responsibilities for nursing professionals. However, nursing education needs to be adapted as well. Presently nurses are not qualified to take on medical tasks. The current nursing curriculum needs to include medical skills and content to reach a qualification status comparable to other European countries. The transition towards a more team-oriented medical care will have to be supervised and evaluated by health services research in both nursing and clinical care. The aim is to also provide a basis for the further development of the relevant socio-legal framework.

Delegation of GP-home visits to qualified practice assistants: assessment of economic effects in an ambulatory healthcare centre

Background

Against the background of a decreasing number of general practitioners (GPs) in rural regions in Germany, the AGnES-concept (AGnES = GP-supporting, community-based, e-health-assisted, systemic intervention) supports the delegation of regular GP-home visits to qualified practice assistants. The concept was implemented and evaluated in different model projects in Germany.

To explore the economic effects of this concept, the development of the number of home visits in an ambulatory healthcare centre was analysed and compared with the number of home visits in the surrounding county.

Methods

Information about GP-home visits was derived from reimbursement data of the ambulatory healthcare centre and a statutory health insurance. Information about home visits conducted by AGnES-practice assistants was collected from the project documentation over a time period of 12 consecutive quarter years, four quarter years before the beginning of the project and 8 quarter years while the project was implemented, considering background temporal trends on the population level in the study region.

Results

Within the ambulatory healthcare centre, the home visits by the GPs significantly decreased, especially the number of medically urgent home visits. However, the overall rate of home visits (conducted by the GPs and the AGnES-practice assistants together) did not change significantly after implementation of the AGnES-concept. In the surrounding county, the home visit rates of the GPs were continuous; the temporal patterns were approximately equal for both usual and urgent home visits.

Conclusion

The results of the analyses show that the support by AGnES-practice assistants led to a decrease of GP-home visits rather than an induction of additional home visits by the AGnES-practice assistants. The most extended effect is related to the medically urgent home visits rather than to the usual home visits.