Background: During the last decades, advancements has been made in medicine and medical technology which has made it possible to care for elderly persons with multi morbidity in their own homes. The fact that the average length of in-hospital stay has become shorter is also a factor in that home health care has become more common. The medical responsibility for patients in home health care is divided between the home health care organization and the primary care provider, which makes collaboration between these two organizations an important and necessary part of the nurses' job. Ongoing care coordination and collaboration between primary care and home health care is generally described as poor and as an area that requires improvement. Therefore it is important to study nurses' experiences of collaboration in practice. Aim: To describe nurses' experiences of collaboration between primary care and home health care. Method: A semi-structured interview study was conducted with eleven nurses from four health centers and five home health care units in western Sweden. Qualitative content analysis was used to analyze the data.Results: The nurses' experiences of collaboration in practice showed that the medical rounds were a central part of collaboration, that there was a lack of distinct ways of communication and that both organizations were dependent on each other. The results also showed that regulatory systems affected collaboration, that there were boundaries and grey zones between the organizations, that the organizations used different solutions to replace collaboration and that it was important to have knowledge of the other organization. Conclusion: Because the organizations were dependent on each other to give care to the patient and there was a lack of distinct ways of communication, personal relationships became a facilitator for collaboration. Different strategies were used to bypass the obstacles in collaboration. / Andelen äldre personer och personer med kroniska sjukdomar i befolkningen ökar, samtidigt som vårdtiderna i slutenvården förkortas. På grund av den medicintekniska utvecklingen finns det ökade möjligheter att få avancerad sjukvård i hemmet. Hemsjukvården delar det medicinska ansvaret för dessa patienter med primärvården och samverkan dem emellan är därför grundläggande för att kunna ge en god och sammanhållen vård till patienten. Skyldigheten att samverka är reglerat genom lagar och författningar. Trots detta finns det betydande brister i samverkan och vårdkoordinering mellan primärvård och hemsjukvård. För att få en ökad förståelse av detta är det av vikt att ta reda på sjuksköterskors upplevelse av hur samverkan fungerar i praktiken. Resultatet i den här studien bygger på intervjuer med elva sjuksköterskor inom primärvård och hemsjukvård, där de fått beskriva sina upplevelser av samverkan mellan primärvård och hemsjukvård. Resultatet av studien visade att ronden var en central del av samverkan. Det framkom också att sjuksköterskorna ansåg att det saknades tydliga formella kommunikationsvägar, vilket i kombination med att de var beroende av varandra för att ge vård till patienterna gjorde att personliga relationer och olika strategier användes för att förenkla samverkan. Organisationerna kunde också skapa olika alternativa lösningar för att ersätta samverkan mellan primärvården och hemsjukvården. I resultatet framkom att sjuksköterskorna även ansåg att regelverk påverkade samverkan. De tyckte att det var nödvändigt att ha en ram att förhålla sig till, men de ville också kunna vara flexibla vid behov. Detta eftersom de ansåg att det fanns ett gränsland mellan primärvård och hemsjukvård som upplevdes som en gråzon där uppgifter och behov ibland överlappade varandra.

Diante do incremento das Organizações Sociais e outras entidades do Terceiro Setor atuantes de gestão de serviços públicos de saúde, a partir da previsão do Plano Diretor de Reforma do Aparelho do Estado na década de 1990, surgiram críticas doutrinárias de que não existe controle efetivo dessas entidades na sua atuação. Entendeu-se como componentes do Terceiro Setor: as Organizações Sociais, as Organizações da Sociedade Civil de Interesse Público, as Fundações de Apoio e os Serviços Sociais Autônomos. Assim, este trabalho, ao pesquisar e analisar a legislação que regulamenta a matéria e a doutrina que a estuda, identificou a tipificação das formas de controle existentes em três esferas governamentais, no nível Federal, no Estado de São Paulo e no Município de São Paulo, apontando, quando pertinentes, as comparações. Diferenças e semelhanças foram encontradas nas diferentes formas de controle existentes, na perspectiva do Controle Interno e do Controle Externo, este, pormenorizado no exercício decorrente dos Poderes constituídos (Executivo, Legislativo, Judicial). No controle externo pelo legislativo, prevalece o realizado pelo auxílio do Tribunal de Contas. No controle externo jurisdicional, além da centralidade do controle judicial, ainda há a marcante atuação do Ministério Público. Ainda encontrou-se relevante registro do valorizado controle externo exercido pela sociedade civil, comumente conhecido como controle social. A discussão foi pautada na interpretação jurídica, a qual tem implicações patentes nas instituições existentes e na Vida dos indivíduos que às leis estão submetidos. Essa análise, por importante à sociedade, dispôs-se a trazê-la à Saúde Coletiva / The increasing presence of Social Organizations and other Third Sector entities in the management of public health care services in Brazil, foreseen with the implementation of the Master Plan for State Reform in the 1990s has led to criticism as to the absence of effective controls of these entities performance. We studied and compared legislation regulating control mechanisms for Social Organizations in Health and other Third Sector entities in three government spheres, Federal, State and City of São Paulo. We identified similarities and dissimilarities in existing control mechanisms from an Internal and External Control perspective. External Control mechanisms are executed by the Executive, Legislative and Judiciary. In the Legislative the main control mechanism are the Auditory Courts, and in the Judiciary the Prosecutors. The legislation also mentions the importance of external control by the population, as part of social control mechanisms. The analysis is referenced by juridical knowledge, and demonstrates the contributions of this type of analysis for a Public Health perspective

In a context where technology is increasingly being incorporated into health care practice, many U.S. health care providers and organizations are finding it challenging to connect disparate electronic documentation systems to retrieve patient information when coordinating care across providers and heath care entities. Local and regional health information exchange (HIE) systems were created to facilitate collecting information into one integrated patient record to address information transfer between heath care providers. Yet, adoption and use of HIEs have been low. The purpose of this study was to review the predictive factors accounting for physicians' use of a HIE in the U.S. state of Hawaii. Key factors from the technology acceptance model were evaluated to determine the behavioral intention resulting in actual use of the Hawaii health information exchange (HHIE). Physician characteristics (medical specialty, age, and gender) and location characteristics were also assessed. The total population of the study contained 1034 Hawaii physicians who have signed up to use the HHIE. Linear and logistic regression models were structured to evaluate the predictive nature of (a) use to determine if a physician has ever logged into the HIE and (b) usage to evaluate the extent to which a physician is logging into the HIE. Findings from the study reveal a predictive relationship between the characteristic of medical specialty and HHIE use when comparing primary care and emergency department physicians to physician specialists. Using study results, health care leaders can improve physician outreach and review barriers when using the HIE systems to coordinate care. Policy implications include the possible formulation of future requirements surrounding HIE physician participation.

Collaborative efforts between medical and behavioral health professionals is required to simultaneously treat individuals with medical and mental health disorders. However, there is lack of focus on the competencies and trainings needed by behavioral health clinicians (BHCs) transitioning to integrated primary care (IPC) settings. The purpose of this qualitative interpretive phenomenological study was to describe the lived experiences of BHCs who have transitioned from specialty outpatient behavioral healthcare settings to IPC settings. Semi-structured interview questions were used to collect data. Using interpretive phenomenological data analysis approach, themes and the shared meanings and experiences of 8 licensed BHCs were explored. Seven participants had graduate degrees and 1 participant had post-graduate degree. All participants had at least a year of experience working in IPC settings, worked full-time in North Carolina, and had over a year of experience in traditional behavioral healthcare settings. Results indicated that participants shared experiences in 5 themes: (a) clinical experience, (b) effective communication, (c) collaboration with primary care providers(PCPs), (d) continued education and trainings, and (e) care coordination. The outcome of this research will inform institutions, administrators, and credentialing boards to consider implementation of defined competencies for BHCs in community health centers that operate on IPC principles to ensure collaborative efforts between BHCs and PCPs in order to help provide effective holistic and affordable health care in a systems-based approach.

Care Coordination Home Telehealth (CCHT) maintains a positive impact on the delivery of patient care in the primary care clinic at the Department of Veterans Administration Medical Center (VAMC). This quality improvement initiative targets patients with chronic conditions such as diabetes, hypertension, heart failure, and chronic obstructive pulmonary disease. These patient are frequently seen in the emergency room, and are often admitted to the hospital, where they saturate the outpatient clinics' waiting room with multiple walk-ins. CCHT has, to some extent, reduced walk-ins, emergency room visits, and hospitalization while minimizing the strain on access to care at the VAMC. Sustaining self-management skills of veterans with chronic conditions at the VAMC continues to impose challenges. In this project, retrospective data from 95 randomly selected charts reviewed during a 2-year period were used to compare hospitalizations, emergency room visits, and primary care visits. The findings of the study indicate veterans enrolled in Home Telehealth show positive social change. The social change is evidenced by change in behavior patterns, such as maintaining a healthy diet, performing daily physical activity, and compliance with medication administration. Enrolled veterans had better outcomes regarding hospitalization, emergency room visits, and primary care visits. The data highlighted the need for incorporating disease-specific protocols guiding care coordinators at first point of contact with the veteran patient. Following these protocols may enhance communication style that matches the patient's stage of behavioral change with interventions.

Despite the federal government’s $1.5 billion investment between 1993 and 2010 to fund 164 separate community-based systems of care, there has been an extremely limited attempt to measure the impact of system of care. The impetus for this research is the struggle for how the value based concept of system of care is communicated within a community. While child mental health services researchers have published a number of randomized control trials to explore individual level supports for youth served in a system of care community, researchers have struggled to devise a way to measure system of care philosophy diffusion. While system of care is a system level intervention, this study explored the role of the system of care value: family voice as it pertains to direct practice for children and families. The goal was to assess whether specific direct practices regularly associated with system of care (i.e., wraparound or home-based services) lead to greater family voice or if the mere presence of a high-functioning system of care community leads to equal family voice for all receiving community-based services. The primary finding was a relationship between the perception of family functioning and perceived empowerment/self-efficacy. This finding suggests that as functioning improves, so does a caregiver’s perception of their personal empowerment/ self-efficacy. While the framing of this study was to “unpack” the system of care value of family voice, the findings do not support any clear cut explanation for how family voice is promoted or communicated to families. Based on the findings, it appears as if families feel more empowered as their child improves. Additional research needs to be done on the application of family voice within the practice setting to better understand how to best instruct staff to infuse family voice in their daily practice.

abstract: Rapid advance in sensor and information technology has resulted in both spatially and temporally data-rich environment, which creates a pressing need for us to develop novel statistical methods and the associated computational tools to extract intelligent knowledge and informative patterns from these massive datasets. The statistical challenges for addressing these massive datasets lay in their complex structures, such as high-dimensionality, hierarchy, multi-modality, heterogeneity and data uncertainty. Besides the statistical challenges, the associated computational approaches are also considered essential in achieving efficiency, effectiveness, as well as the numerical stability in practice. On the other hand, some recent developments in statistics and machine learning, such as sparse learning, transfer learning, and some traditional methodologies which still hold potential, such as multi-level models, all shed lights on addressing these complex datasets in a statistically powerful and computationally efficient way. In this dissertation, we identify four kinds of general complex datasets, including "high-dimensional datasets", "hierarchically-structured datasets", "multimodality datasets" and "data uncertainties", which are ubiquitous in many domains, such as biology, medicine, neuroscience, health care delivery, manufacturing, etc. We depict the development of novel statistical models to analyze complex datasets which fall under these four categories, and we show how these models can be applied to some real-world applications, such as Alzheimer's disease research, nursing care process, and manufacturing. / Dissertation/Thesis / Ph.D. Industrial Engineering 2012

Diante do incremento das Organizações Sociais e outras entidades do Terceiro Setor atuantes de gestão de serviços públicos de saúde, a partir da previsão do Plano Diretor de Reforma do Aparelho do Estado na década de 1990, surgiram críticas doutrinárias de que não existe controle efetivo dessas entidades na sua atuação. Entendeu-se como componentes do Terceiro Setor: as Organizações Sociais, as Organizações da Sociedade Civil de Interesse Público, as Fundações de Apoio e os Serviços Sociais Autônomos. Assim, este trabalho, ao pesquisar e analisar a legislação que regulamenta a matéria e a doutrina que a estuda, identificou a tipificação das formas de controle existentes em três esferas governamentais, no nível Federal, no Estado de São Paulo e no Município de São Paulo, apontando, quando pertinentes, as comparações. Diferenças e semelhanças foram encontradas nas diferentes formas de controle existentes, na perspectiva do Controle Interno e do Controle Externo, este, pormenorizado no exercício decorrente dos Poderes constituídos (Executivo, Legislativo, Judicial). No controle externo pelo legislativo, prevalece o realizado pelo auxílio do Tribunal de Contas. No controle externo jurisdicional, além da centralidade do controle judicial, ainda há a marcante atuação do Ministério Público. Ainda encontrou-se relevante registro do valorizado controle externo exercido pela sociedade civil, comumente conhecido como controle social. A discussão foi pautada na interpretação jurídica, a qual tem implicações patentes nas instituições existentes e na Vida dos indivíduos que às leis estão submetidos. Essa análise, por importante à sociedade, dispôs-se a trazê-la à Saúde Coletiva / The increasing presence of Social Organizations and other Third Sector entities in the management of public health care services in Brazil, foreseen with the implementation of the Master Plan for State Reform in the 1990s has led to criticism as to the absence of effective controls of these entities performance. We studied and compared legislation regulating control mechanisms for Social Organizations in Health and other Third Sector entities in three government spheres, Federal, State and City of São Paulo. We identified similarities and dissimilarities in existing control mechanisms from an Internal and External Control perspective. External Control mechanisms are executed by the Executive, Legislative and Judiciary. In the Legislative the main control mechanism are the Auditory Courts, and in the Judiciary the Prosecutors. The legislation also mentions the importance of external control by the population, as part of social control mechanisms. The analysis is referenced by juridical knowledge, and demonstrates the contributions of this type of analysis for a Public Health perspective

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