Hospitality and service: leading real change

A patient's decision to recommend a health care organization and the patient's loyalty scores are largely determined by the interaction patients and their families have with the nurses. Hospitality is how the delivery of that product makes the person feel and is a dialogue that requires the server to be "on the guest's side" throughout the experience. The challenge for health care is to help our patients and their families transcend the usual routine care of our health care world and to experience an emotional connection that provides that sense of affiliation and emotional kinship with the organization and the staff. Moving from the service mindset in health care to the hospitality mindset that engages people positively and emotionally is what healing is all about.     

The art of leading with grace

Uncivilized environments take their toll on people who work there. Cultures of distrust are created and there is no warmth, reverence, or love available for the healing work of health care. We can blame the staff, or we can look at ourselves and recognize that the staff is merely a reflection of ourselves. Gracious leaders create a gracious and loving staff who care for patients and their families in extraordinary ways.     

Quality in life and death: can we have the conversations?

As nurses, we participate in providing social justice through the delivery of health care. While much of what we do supports healthier lifestyles and healing, we must also acknowledge that for an increasing number of our patients, life may have become irreversibly painful and unwanted. Nurses have acute sensitivity to the dilemmas faced by dying patients and their families. Our empathy and know-how in such cases dictates that we make an effort to relieve such suffering. Easing suffering will require assessments of the changing terrain of end-of-life care and the populations receiving that care. Dialogues can bridge the interest of patients, providers, and policymakers and ultimately legislation that reinforces ethical end-of-life care and ensures a voice for those who will be most affected.     

Technicity in nursing and the dispensation of thinking

While technology and health care delivery are inextricably and increasingly intertwined and technology has driven major advances in quality and efficiency in health care, technology does not replace the need for a thinking human being in care delivery. The term "technicity" refers to the tension created by the ability of humans to think versus their risk of being exploited as objects subservient to technologies. Drawing upon the philosophical works of Thoreau, Heidegger, and others, the authors pause on the conundrum created by expanding technology with the assumption that technological "improvements" should be evaluated with caution. Health care information systems are an example of tools that have improved our ability to collect and store information, but when systems "go down," staff can be rendered helpless. Similarly, technology can impose personal distance between the patient and provider in instances where staff are positioned as a mechanism for collecting data rather than a person interacting with another person. In some cases, health care providers function as navigators helping patients reach the correct pharmaceutical, rather than as teachers helping patients seek better health. Lastly, the tendency toward systems analysis in the context of the complex hospital environment leads solely toward uniform solutions rather than instances where a customized solution is warranted.     

Complex home care: Part 2- family annual income, insurance premium, and out-of-pocket expenses

Annual costs paid by families for intravenous infusion of home parenteral nutrition (HPN) health insurance premiums, deductibles, co-payments for health services, and the wide range of out-of-pocket home health care expenses are significant. The costs of managing complex chronic care at home cannot be completely understood until all out-of-pocket costs have been defined, described, and tabulated. Non-reimbursed and out-of-pocket costs paid by families over years for complex chronic care negatively impact the financial stability of families. National health care reform must take into account the long-term financial burdens of families caring for those with complex home care. Any changes that may increase the out-of-pocket costs or health insurance costs to these families can also have a negative long-term impact on society when greater numbers of patients declare bankruptcy or qualify for medical disability.     

Childhood preventive care,adult healthcare and economic growth: The role of healthcare financing

We analyze the impact of healthcare financing on economic growth, focusing on the issue of the joint public–private financing of healthcare (co-payment). We use an overlapping-generations model with endogenous growth based on health human capital accumulation, where families pay for childhood preventive care and the government can either fully finance or co-finance adulthood curative care. From a growth maximizing perspective, distortionary taxes give an advantage to co-financing. Nevertheless, we prove that, if agents are assumed to be heterogeneous in preferences, full financing can become the best option.     

The AACN Synergy Model for Patient Care: a nursing model as a Force of Magnetism

One of the 14 Forces of Magnetism requires a health care organization to have a professional model of care. The eligibility requirements stipulate that this model must be utilized throughout the health care system and that the same philosophy must be used throughout the system. The American Association of Critical-Care Nurses Synergy Model for Patient Care describes nursing practice based on eight patient characteristics, and also describes eight nurse competencies. The core concept of the model is that the needs or characteristics of patients and families influence and drive the characteristics or competencies of nurses. Synergy results when the needs and characteristics of a patient, clinical unit, or system are matched with a nurse's competencies. The synergy model is an excellent framework to organize the work of patient care throughout the health care system. It can be used and applied in various ways and provides a comprehensive framework for assuring success in building a philosophy that supports the Forces of Magnetism.     

Complex home care: Part I--Utilization and costs to families for health care services each year

As many as 120 persons per million people in the United States are dependent on the lifelong, complex, technology-based care of home parenteral nutrition (HPN) infusions. However, data for costs paid by families for HPN-related health care services and for non-reimbursed expenditures are rarely tabulated and most often underestimated. The goals of this study were to describe health care services used by families to manage HPN, report the frequency of each service used annually, and estimate the average annual non-reimbursed costs to families for these health services. The numerous and varied types of services reported and the time required to coordinate and access HPN services illustrates the challenges faced by patients and their family caregivers. The lack of a coordinated and efficient system for delivering complex chronic care results in poorer outcomes for HPN patients and their families on-reimbursed costs and the extensive amount of time required to coordinate multi-professional services negatively impacts the clinical outcomes and quality of life of complex chronic home care.     

INSURANCE‐INDUCED MORAL HAZARD: A DYNAMIC MODEL OF WITHIN‐YEAR MEDICAL CARE DECISION MAKING UNDER UNCERTAINTY

This study quantifies the moral hazard effect of health insurance on medical expenditure by estimating a dynamic model of within‐year medical care consumption that allows for insurance selection, endogenous health transitions, and individual uncertainty about medical care prices in an environment where insurance has nonlinear cost‐sharing features. The results suggest that moral hazard accounts for 53.1%, on average, of total annual medical expenditure when insured. This estimate is significantly different, and generally larger, than that produced by an alternative model that is representative of the annual medical care decision‐making models commonly found in the literature.     

Ethics and economics

The author suggests that one way to better manage the burgeoning costs in acute care settings and improve patient care is by the earlier use of ethics case consultations and end-of-life support from ethics teams. This study determined that, in several very diverse clinical scenarios, timely facilitation of meaningful communication and decision making between patients, families, and health care providers can result in the more appropriate use of health care resources. While few of the patients in this study had recorded advanced directives in place, and there was initially a lack of family consensus in some cases, compliance with the ethics team recommendations led to a more appropriate clinical unit placement; and improved family support helped manage the costs of care and focus on the patients' quality of life. The decrease in the use of medical interventions and therapies after ethics consultations was consistent in all cases presented here.     

Social and family load of Alzheimer’s disease

As the World Health Organization reports, mental illnesses have a serious impact on more than 25% of all population people worldwide at some time during their lives. Mental illnesses are universal; they affect people of any age, both women and men, the rich and the poor, no matter from which urban and rural environment they come from. Mental illnesses have an enormous economic effect on societies and on the quality of people’s life, including their families. The purpose of this study is to describe social and economic aspects of Alzheimer’s disease (AD) with respect to the early diagnosis. The authors provide an analysis of costs of treatment and care in the selected countries where the data from the available studies are recalculated into comparable quantities. Furthermore, the authors analyse aspects and possibilities of care for patients with AD in the informal (home) environment in compliance with individual phases of this disease. In the article, the method of research of available sources focusing on social and economic issues of AD is used. In order to compare costs of treatment and care of the AD patients, the Qualitative Comparative Analysis Method is exploited. The analyses have shown that the metric systems for monitoring the direct and indirect costs for the individual phases of AD are different.     

How work environment impacts retention

Work environment is a major aspect of the day-to-day grind that drives the retention (or turnover) of RNs. When opportunities abound, it is easy to jump ship, and when turnover begins, it is usually the best and brightest who are first to depart. Recent research reported a whopping 27.1% average voluntary turnover rate among new graduate nurses during their first year of employment. Aging of the nurse workforce may be the largest factor impacting health care work environments, as employers struggle to diminish the physical effect of lifting thousands of pounds and walking several miles during each shift. Every influence on the work environment (management, peer behavior, patient acuity, equipment availability, the physical plant) should be assessed for impact on the workforce. While we cannot hope to create paradise in each work setting, we can promote an environment that is healing both to patient and to caregiver.     

INVESTMENT IN HOSPITAL CARE TECHNOLOGY UNDER DIFFERENT PURCHASING RULES: A REAL OPTION APPROACH

Quality of health care is the product of several factors as the literature has long recognized. In this paper we focus on the relationship between quality and investment in health technology by analysing the optimal investment decision in a new health care technology of a representative hospital that maximizes its surplus in an uncertain environment. The new technology allows the hospital to increase the quality level of the care provided, but the investment is irreversible. The paper uses the framework of the real option literature to show how the purchaser might influence the quality level by setting a quality‐contingent long‐term contract with the hospital.The investment in new technology is in fact best incentivated within a long‐term contract where the number of treatments reimbursed depends on the level of investment made when the technology is new. In this way, asymmetry of information does not affect the outcome of the contract. In our model in fact the purchaser can verify the level of the investment only at the end of each period but the purchasing rule has an anticipating effect on the decision to invest.     

Courage, leadership, and end-of-life care: when courage counts

As leaders, we must feel a sense of moral obligation to implement evidence about end-of-life care in our practice setting. Nurse leaders can help patients and families orchestrate a beautiful experience that is an alternative to futile, expensive end-of-life care. Preparation is key in helping staff provide the best level of care. A plan built around the best care for patients can integrate with many diverse positions and people. Courageous nurse leaders are well adapted to maneuvering through political traps and advocating for patients and their families. Everyone benefits personally and financially, including our communities and nation, when courageous leaders advocate successfully for effective end-of-life care.     

GROWTH OF U.S. HEALTH CARE SPENDING

The share of output allocated to health care has more than doubled since 1960. This paper models the growth in this ratio and finds that the increase in the elderly population whose medical spending is heavily subsidized is a key factor behind this growth. Technological change is a symptom of the medical market structure rather than a cause of medical spending growth. The econometric model in the analysis here is based on a micro model composed of two groups. The first group is a healthier group that makes income transfers in order to finance the sicker group's health insurance premiums. In this model, a technical constraint places an upper bound on the healing ability of the medical good. This upper bound changes through an unobservable endogenous process. Estimating the health care model involves using estimation techniques that bypass the need to make any a priori assumptions about the functional form of the regressions or about the distribution of the residuals. The results suggest that technical change cannot indefinitely induce health care spending growth if no subsidies exist that provide full health care coverage with premiums fully paid by the subsidy. If subsidies provide full coverage and pay the entire premium, then new technical discoveries can induce constantly expanding medical expenditures.     

Governing for improved quality and patient safety

Board members have a critical oversight role to play in monitoring and providing direction to improve health care quality and safety. In the emerging environment of health care reform, the board's role in overseeing quality and safety on behalf of stakeholders will become as or even more important than its financial oversight role. Nurses can expand their impact by joining the ranks of health care organization governing boards to lead and guide the entire health care enterprise to realize the goal of improved care and outcomes for all patients.     

Staffing for end of life: challenges and opportunities

What would staffing look like if we committed to end-of-life experiences that were designed to honor the needs of the person dying, their loved ones, and the needs of the nurses and care team involved in the dying experience? When we think about the experience of death in a health care setting, it is essential we look at the needs of both patients and caregivers. Attending to the needs of patients and their families facing death, even if well defined, can be difficult to design into staffing plans and budgets in a way that would not put an organization at further financial risk. If we are going to commit to staffing practices that honor dying, in all it's dimensions and for all who are potentially impacted, we will most likely have to step outside traditional thinking to find answers.     

The cost of imperfect agency in health care: Evidence from rural Cameroun

Health is a pressing problem facing Africans today, yet health care systems in Africa are inadequate and under-funded. We show that pervasive imperfect agency means that they are also inefficient. Imperfect agency (due to unobservable medical effort) is a recognized market failure in health care, but its impact is difficult to measure. We take an indirect approach to estimation and infer the cost of unobservable effort from the behavior of utility-maximizing patients, specifically their willingness to incur measurable costs to avoid practitioners who shirk. We use a unique data set from rural Cameroun where patients choose between the government health system, church-operated (mission) health facilities and, importantly, traditional healers. Traditional healers provide health services on an outcome–contingent basis where patients pay only if they are cured. Both government and mission facilities, in contrast, are paid on a fee-for-service basis. Patients' choices of practitioners, combined with quantitative information about patients' illnesses, permit a structural estimation of the value of unobservable medical effort. The results allow investigation into the nature of agency, its costs, and the manner in which contracts reduce and patient behavior mitigates those costs. We estimate that in the absence of imperfect agency, utility from health care would increase by at least 160%. Even in the face of imperfect agency, the sophistication of patients in choosing between existing contracts for different illnesses increases utility by up to 20%.     

Palliative care: a paradigm of care responsive to the demands for health care reform in America

Palliative care is poised to become a universally available approach to health care which addresses both the needs of patients and families experiencing serious, progressive, and life-threatening illness, and also the costs of delivering such needed services. Palliative care and hospice are part of a continuum of care with palliative care provided at any time during the illness trajectory, while hospice care is offered at the end of life. Within the context of health care reform, we believe palliative care addresses critical economic imperatives while enhancing quality of life even as death approaches. As leaders in health care, advance practice nurses, specifically, and the nursing community in general are best positioned with the knowledge, expertise, and commitment to advance the specialty of palliative care and lead the way in the reform of America's health care system.     

Regulating internal markets for hospital care

Internal markets have been created in an attempt to shift power from producers to consumers in a context where consumers have very weak incentives to seek out low-cost producers and have little knowledge about the quality of health care. The idea is that by establishing public agencies to act as the sole purchasers on behalf of consumers in their area of jurisdiction, the asymmetry of information can be moderated and a more competitive environment created in which costs will be minimized and quality enhanced. Whether these aspirations can be fulfilled will depend on how the internal market is organized. In this article the cost-minimizing properties of alternative market structures where hospitals do not share the same objectives are examined. The scheme is designed from the standpoint of a benevolent regulator that provides services using two hospitals with fixed locations. The paper shows that price discrimination is a superior instrument. Finally some market forms are always dominated and should be avoided.

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