In vitro metabolism of cyanohydroxybutene: formation of a glutathione-S-transferase catalyzed product

This paper examines the financing of elderly health care in Japan for medical institutions, nursing homes, and at home. The analysis demonstrates that the conventional figures for elderly health expenditures in Japan systematically underestimate the real costs by excluding the costs of uninsured services, nursing homes, and home health care. The paper estimates these costs and shows that they add about 10% to the conventional figure for elderly health care costs in Japan. This inquiry also shows how government policy for health care financing shaped distinctive Japanese patterns of elderly care provision. The financing system provided a hidden subsidy--through national health insurance coverage of long-term hospitalization--that encouraged high institutionalization rates of elderly in medical facilities. Public financing for long-term elderly hospitalization, however, has not been matched by government attention to quality of care, resulting in serious quality problems and reflecting a social trade-off between cost and quality. Also, until recently the financing system rarely reimbursed home health care, thereby creating strong disincentives to the development of formal home health care services. This analysis has important implications for reforms now being considered by the Japanese government in the financing and provision of health care for the elderly, especially the limitations of relying on reimbursement price policy. The reforms could have unintended negative consequences for equity, efficiency, and quality of care.     

A geriatric medical residency program. A four-year experience

Geriatricians are needed to further improve the health care of elderly Americans. The first formalized geriatric residency program in the United States was developed at the Mount Sinai City Hospital Center in New York, and this has produced a second program at the Jewish Institute for Geriatric Care at Long Island Jewish-Hillside Medical Center, New Hyde Park, New York. The goals of this training are to develop special clinical skills to deal with the medical and psychosocial problems of the elderly, and to achieve the ability to develop health care systems for the elderly. Emphasis is on a multileveled system, including home, outpatient, acute hospital, convalescent unit, and long-term institution care. The training period is 12 to 24 months, after an initial 24 to 36 months of standard internal medicine, thus fulfilling the requirements for board eligibility in internal medicine.     

The health and welfare system for elderly in France

Dichotomy is the main characteristic of the Health and Welfare system in France. This system lies on two distinct fields, the medical field which is managed by the National Government, and the social field managed by the Local Government. The French home care policy for the elderly has developed a large number of services to assist in activities of daily living, to provide nursing and medical care at home, to improve living conditions, to maintain social relationships, and to postpone institutionalization and hospitalization, respectively. The main home care service is represented by "home helpers" who provide maid Notiniralics services. The second widely used service is the "home care service" performed by a team of nurses, assistant-nurses, psychologists, physiotherapists. This team provides nursing care and assistance in activities of daily living. As for institutions for the elderly, they are divided into welfare and medical institutions. The welfare institutions include social establishments like shelter homes and nursing homes. The medical institutions are mostly represented by long-term care hospitals. One of the main goals of the aging policy is to create medical wards in welfare institutions in response to the increased dependency of the institutionalized elderly. Recent experimental and innovative concepts have been established, such as "shelter homes for dependent elderly" for physically or cognitively impaired elderly.     

Prognostic indicators and early home rehabilitation in elderly patients with hip fractures

A program for early mobilization in the hospital and rehabilitation at home after hip fracture was developed in cooperation with local health and social authorities and applied to 103 consecutive patients having a mean age of 75 years. All were admitted to the hospital from their own homes. Three fourths of the patients returned home directly after postoperative mobilization periods of usually two to three weeks in hospital. Four months after the fracture 81 of 99 surviving patients were at home, most of them having regained their prefracture functional status. One year after the fracture 91 patients were alive, and 78 of these were at home with no functional loss, compared with their condition at four months. Some of the social and medical factors which may already be pertinent to the recovery outcome at the time of fracture are identified. Eight to nine of ten patients with two or three positive factors ("healthy," living with someone, and ability to walk two weeks postsurgery) returned directly home. This study suggests the importance of intensive support, in the form of information to patients and relatives, and close cooperation between hospital staff and community care authorities. By this means, a continuity of care and early permanent independence can be achieved for elderly hip fracture patients and institutionalized rehabilitation can be reduced with benefit for both the individual and society.     

A study on estimation of early discharge day for home health care and medical expense for inpatients

This report was done mid way through the study "A Demonstration-Cum-Research on the Reimbursement system and cost-effectiveness of Home Health Care Program in Korea". It focused on developing an estimation of early discharge day to home health care based on analysis medical records and on an analysis of medical expenses based on a detailed statement of treatment for inpatients who were hospitalized at S General Hospital in 1991. Two research methods were adopted for estimation of the early discharge day. One was micro-analysis from the medical records and the other was macro-analysis to clarify the estimated early discharge day to home health care for patients with four diseases judged from need assessment to be candidates for this type of program, namely patients with, Cesarean Section, Hypertension, Diabetes Mellitus, Chronic Obstructive Pulmonary Disease (COPD). Estimation of early discharge day to home health care were developed through many aspects of analysis of the signs and symptoms by disease in a micro-analysis in addition to a decrease in the amount of treatment, drugs, tests and changes in the test consistency, drug methods, and client's condition in the macro-analysis. Accordingly, an early discharge day for inpatients was finally estimated through the analysis of the client's conditions and treatment, drugs, tests, and nursing care activities that the patient received during hospitalization. From the research findings, the following summarized conclusions have drawn. First, for patients with Cesarean Sections, after assessing each items using the two analysis methods, the mean period of hospitalization was 8.8 days, but the mean period of hospitalization was estimated at 4.1 days if early discharge to home health care could be done. Second, for patients with Hypertension, the same method as for the patients with the Cesarean Sections was used and the result was reduction from a mean period of the hospitalization of 9.9 days to a mean period of the hospitalization of 5.2 days. Third, for patients with Diabetes Mellitus there was a decrease from a mean period of the hospitalization of 11.7 days to a mean period of hospitalization of 8.4 days if early discharge to home health care could be done. Fourth, for patients with Chronic Obstructive Pulmonary Disease, the mean period of the hospitalization was 14.3 days, but the mean period of the hospitalization could be 8.1 days if early discharge to home health care could be done.(ABSTRACT TRUNCATED AT 400 WORDS)     

The Circle Model--support for relatives of people with dementia

Home care for cognitively impaired elderly puts tremendous stress and burden on their families. Therefore it is important to search for effective care models in order to provide support for this group. In this study, an intervention model--the Circle Model--was developed, tested and evaluated in six places in Sweden. The model is unique in that family caregivers and volunteers were trained together in study circles. After their training, the volunteers replaced the caregivers in the homes on a regular basis, which permitted the caregivers some relief from the demands of caregiving. Interviews were conducted with the participants to gather information about their training and relief care experiences. The caregivers reported that the study circle provided opportunity to exchange experiences with other people in similar situations. They felt a spirit of community with other relatives, and were able to increase their knowledge in care providing and coping strategies. The emphasis in temporary relief care by the volunteers was placed on providing the relatives with feelings of security and relaxation. The satisfaction among the Circle Model participants was reciprocal. The volunteers also reported high satisfaction and appreciation of the knowledge which they acquired from the caregivers. The Circle Model brings new dimensions to the home care situation and should be seen as a complement to social services support.     

Localization of extracellular matrix molecules, integrins and their regulators, TGF betas, is correlated with axon pathfinding in the spinal cord of normal and Danforth''s short tail mice

We present a local Dissemination of EPIC, a project which has been devised to support health and social primary care by an information system. One key point of the EPIC project was a standardization effort at European level, providing a standardized basis for the management system based on client needs for planning and manpower control. Whilst EPIC has been designed as a general community information system, the main EPIC applications focus is on the care of the elderly. Savona is a middle size Italian town with a high percentage of elderly people and has already had an experience of integration of health and social care within an Italian project. It has therefore been regarded as a suitable site for the dissemination of EPIC. The EPIC application solved some of the information problems which emerged during the validation of the previous Italian project, such as the definition of the requirements; the collection, processing and retrieval of the clinical/social data; the definition of responsibilities and relations of the operators.     

Coping behaviors of the elderly with positive physical examination results in Kaohsiung City

The objectives of this study were as follows: first, to investigate the coping behaviors of the elderly facing the stress of disease after free physical examination; Second, to identify personal and disease characteristics, and the social support that influences coping behaviors in the elderly. The study sample consisted of 661 elderly patients who were found to have abnormal findings during a free physical examination provided by 11 regional health stations in Kaohsiung City. Data were collected with questionnaires through home interview. Four hundred and eighty-four subjects completed the questionnaires. Data were analyzed using SAS computer program. The major findings were as follows: 1.Problem-oriented coping behaviors were the more frequently used. The most frequently used coping behaviors were "accepting the situation as it is", "reling on myself to solve problems", "hoping that things would get better", "seeking professional help", and "letting things follow their natural cause". 2. The relative variables for problem-oriented coping were marital status, religion, medical insurance, educational level, disease characteristics, and social support. Sex, marital status, religion, medical insurance, perceived disease severity, characteristics of health problem, and newly found abnormality at this free physical examination were the relative variables for affective-oriented coping. 3. The best predictive variables for using problem-oriented coping behaviors were medical insurance, self-esteem support from family and friends, tangible support from health professionals, emotional support from health professionals, and whether it was the first time the patients knew their health problems. Findings from this study had implications for development of nursing care plans for elderly clients, as well as for collaborative team exploration of coping behaviors in the elderly.     

Nursing homes as a setting for psychological practice: Public policy perspectives.

Recent federal legislation has provided renewed interest in improving the quality of nursing home care. The lack of both funding and personnel are significant barriers that may keep psychology's disciplinary expertise from being fully used in nursing homes. Nursing homes may be forced to undertake mandated activities (e.g., preadmission screening, nurses aides' training, and evaluation) without psychologists' expertise, relying either on medical practitioners with little knowledge of mental health interventions or on minimally qualified, entry-level mental health workers. Advocates for improved nursing home care must see the links among basic disciplinary skills, interdisciplinary collaboration, and improved care for mentally impaired elderly individuals. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Geriatric assessment in oncology

With the anticipated growth in the numbers of elderly persons, a higher prevalence of cancers among older persons is expected; as a result, oncologists will treat larger numbers of older persons in their practices. Clinicians caring for older persons with cancer must recognize the heterogeneity of the elderly population and focus their assessments and care plans accordingly. The author reviewed literature and drew conclusions regarding geriatric assessment in several key areas: the medical, cognitive, affective, functional economic, and environmental status of patients; social support for patients; and advance directives. They concluded that for younger and healthier seniors, simple probes for the presence of common geriatric problems may suffice, but traditional means of medical assessment should be supplemented by brief screening for common geriatric conditions and nonmedical issues that are of particular relevance to the health of older persons. Assessment instruments can be used to guide these brief evaluations, but results must be interpreted in the context of the limitations of the instruments used. Patients who are frail or at high risk for functional decline or nursing home placement should receive more extensive evaluation by individual practitioners or by a multidisciplinary team of health care professionals who can provide comprehensive geriatric assessment. By broadening their assessment skills to include domains that are beyond traditional internal medicine and oncology training, oncologists can better serve their older cancer patients.     

Painless dentistry. Fact or fiction?

The complex chronic health problems and functional limitations common in the elderly population place them at risk for complicated hospitalizations and discharge planning. The purpose of this study was to investigate the effectiveness of a discharge planning protocol in identifying elderly patients' home care needs. The sample in this quasiexperimental study consisted of 507 hospitalized patients age 65 years or older. The control group received the usual hospital discharge planning protocol. In the experimental group, nurse/social worker teams coordinated the discharge planning process, using an adapted form of the Discharge Planning Questionnaire (DPQ) to identify the home care needs of elderly patients. Thirty days after hospital discharge, both patient groups participated in a telephone survey to obtain information about health care problems they experienced during home recovery and their use of health care resources. The findings indicated that the majority of the elderly patients had functional dependencies, which required the help of another person to carry out daily household duties and provide assistance with basic needs, especially ambulation. These functionally dependent patients only received home care referrals about 50% of the time. These findings raise questions about current reimbursable services. Logistic regression analysis indicated that patients with increased functional dependency and patient problems during home recovery had a greater likelihood of rehospitalization and emergency department usage. This information about the home care of elderly patients after hospitalization supports the need for comprehensive functional assessment as part of discharge planning. This study also suggests that the nurse/social worker team can provide effective screening and discharge planning coordination of home care. Physician involvement and effective communication networks must be in place.     

The impact of payor/provider type on health care use and expenditures among the frail elderly

OBJECTIVES: This study examined whether health care expenditures and usage by the frail elderly differ under three payor/provider types: Medicare fee for service, Medicare health maintenance organization (HMO), and dual Medicare-Medicaid enrollment. METHODS: In-home interviews were conducted among 450 frail elderly patients of a San Diego, Calif, health care system. Cost and use data were collected from providers. RESULTS: Analyses revealed no difference in total expenditures between fee-for-service and HMO enrollees, but Medicare-Medicaid beneficiaries' expenditures were 46.8% higher than those for HMO enrollees and 52.2% higher than those for the fee-for-service group. Fee-for-service participants were less than half as likely as HMO enrollees to have two or more hospital admissions, but hospital usage rates between those two payor/provider groups did not differ. Not were there payor/provider differences in access to home health care, but HMO home health care users received significantly fewer services than the others. CONCLUSIONS: The care provided to these HMO beneficiaries resulted in a combination of restricted home health use and higher multiple hospitalizations. This raises compelling questions for future research. For the dually enrolled, stronger cost containment may be required.     

Morphological characteristics of hyperplastic and adenomatous stomach polyps

The growing percentage of Americans who are elderly and the prevalence of chronic medical conditions will soon necessitate an expanded system of home health care. Presently, the financial and physical burden of this care falls on the elder and the family. This article discusses the issues surrounding elder caregiving.     

Randomised controlled trial comparing hospital at home care with inpatient hospital care. II: cost minimisation analysis

OBJECTIVES: To examine the cost of providing hospital at home in place of some forms of inpatient hospital care. DESIGN: Cost minimisation study within a randomised controlled trial. SETTING: District general hospital and catchment area of neighbouring community trust. SUBJECTS: Patients recovering from hip replacement (n=86), knee replacement (n=86), and hysterectomy (n=238); elderly medical patients (n=96); and patients with chronic obstructive airways disease (n=32). INTERVENTIONS: Hospital at home or inpatient hospital care. MAIN OUTCOME MEASURES: Cost of hospital at home scheme to health service, to general practitioners, and to patients and their families compared with hospital care. RESULTS: No difference was detected in total healthcare costs between hospital at home and hospital care for patients recovering from a hip or knee replacement, or elderly medical patients. Hospital at home significantly increased healthcare costs for patients recovering from a hysterectomy (ratio of geometrical means 1.15, 95% confidence interval 1.04 to 1.29, P=0.009) and for those with chronic obstructive airways disease (Mann-Whitney U test, P=0.01). Hospital at home significantly increased general practitioners' costs for elderly medical patients (Mann-Whitney U test, P<0.01) and for those with chronic obstructive airways disease (P=0.02). Patient and carer expenditure made up a small proportion of total costs. CONCLUSION: Hospital at home care did not reduce total healthcare costs for the conditions studied in this trial, and costs were significantly increased for patients recovering from a hysterectomy and those with chronic obstructive airways disease. There was some evidence that costs were shifted to primary care for elderly medical patients and those with chronic obstructive airways disease.     

Teaching Rwandan families to care for people with AIDS at home

AIDS causes disabling symptoms during its chronic and terminal phases. Families throughout the world, whether related to the patient by blood or affection, provide most of the personal care for him or her at home during these phases. Whether the family has access to advanced medical care or not, they can be taught simple comfort measures and nursing care skills that will improve the well-being of the patient. In Rwanda, a small country in east-central Africa, Red Cross volunteers were trained to teach these skills. The volunteers then returned to their villages to help local families. Six months later, 24 of these families were interviewed about the impact of the volunteers' visits. Families indicated they had benefited from being taught the caregiving skills. They also appreciated the emotional support attendant to the volunteers' visits. In summary, the training course enabled volunteers both to enhance family nursing care skills and to provide emotional support to families caring for people with AIDS at home. This training can also be used by volunteers to assist families caring for members ill with other endemic chronic infectious diseases.     

A military application of a medical self-care program

The cost of health care is a growing concern to the military. Many military clinic appointments and emergency department visits are unnecessary; they are for minor, self-limiting illnesses and injuries that could be treated at home. Military health care can no longer afford the luxury of treating minor illnesses and injuries in the hospital setting. This paper examines one method for military beneficiaries to obtain health care services appropriately. A selected group of military family members received a medical self-care book and an education session, which resulted in more appropriate decision-making about when to use the health care system. This was a 6-month, experimental study using control and experimental groups, with surveys before and after the study period. The self-care book was used 628 times to help make more informed decisions about when to seek medical care. The mean number of clinic and emergency room visits (p = 0.02) decreased for those using the medical self-care book.     

The virtual visit: using telecommunications technology to take care of patients

Telephone-Linked Care (TLC) technology has been developed and applied as an alternative to and a supplement for office visits as a means to deliver ambulatory care. TLC is used to monitor patients with chronic diseases, counsel patients on important health behaviors, and provide information and support to home caregivers of patients with disabling conditions. TLC speaks to patients over the telephone in their homes using computer-controlled digitized human speech. Patients use their telephone keypad to communicate. TLC conversations last 2-15 minutes per call and take place weekly for periods of at least 3 months. The conversations consist of a salutation, password verification, the core clinical part, and a closing. The structure of the clinical part is similar for each of the application groups: chronic disease, health behavior, and caregiver support. The system architecture consists of linked voice and database components and their subcomponents. Preliminary evaluation indicates that TLC is well accepted by patients and their providers and can improve clinical outcomes.     

A model for improving medication use in home health care patients

OBJECTIVES: (1) To develop a model for the identification and resolution of problems associated with suboptimal medication use in elderly patients receiving home health care; (2) To select the most important identifiable problems and develop structured procedures for their resolution. DESIGN: Expert panel review, problem selection, and development of a problem resolution model and guidelines. SETTING: Home health care. PARTICIPANTS: A panel with expertise in home health nursing, pharmacy, clinical pharmacology, gerontology, pharmacoepidemiology, and health services research. INTERVENTIONS: A list of potential problems associated with the most frequently used classes of drugs was compiled for review by the panel. Problems that were controversial or that could not be identified in the home care setting were excluded. Panel members individually ranked the remainder. Detailed procedures for identification and resolution of the 15 top-ranking problems were developed. MAIN OUTCOME MEASURES: Not applicable. RESULTS: Potential medication problems were defined by both drug use and symptoms or clinical signs associated with specific adverse effects, to ensure that clinically relevant problems would be identified. The model developed for problem assessment and resolution was centered on the drug utilization review (DUR) coordinator and the attending home health nurse. Following guidelines developed by the panel, the DUR coordinator advises the home health nurse about identified problems and how to resolve them. One of these practitioners, usually the nurse, then contacts the attending physician to explain their concerns, offer potential solutions, and request instructions. CONCLUSION: A potentially useful model for the identification and resolution of medication problems in the home health care setting was developed. This model is currently being evaluated in a randomized controlled trial.     

Linking level of care to level of need: Assessing the need for mental health care for nursing home residents.

What are the mental health status and active treatment needs of nursing home residents? A stratified random sample of 828 residents in 25 facilities serving Medicaid recipients was assessed for levels of physical and psychosocial functioning. Although 91.2% had sufficiently high levels of medical and physical care needs to justify nursing home placement, 79.6% also had moderate to intense needs for mental health care. Older residents, relative to their younger counterparts, had more intense medical and mental health care needs. It was also found that psychiatric diagnosis was a poor indicator of mental health service needs, particularly among elderly individuals. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

A cystic fibrosis handbook for teachers

Hope is an important concept to nursing. It is a powerful human response seen in every age group, across all demographic lines, and within all health care settings. Hope is a component of virtually every nurse-patient relationship developed in every field of nursing. Nowhere is the significance of hope more visible than in the home care setting. Whether it is a hospice visit or a postpartum follow-up visit with a new mother and infant, the home care nurse instinctively searches for evidence of hope in the patient and his or her support system. Hope has long been recognized by nurses as not only valuable but also essential to health.