IDENTIFICACIÓN DE LAS PLANTAS HOSPEDANTES

The American system of health care is based on health insurance programmes for the public to cover the cost of health care (Boult et al, 2000:1011). Two major insurance programmes, Medicaid and Medicare, bear two-thirds of the health care costs for older people (Moneyham and Scott, 1997:68).

In the mid 1980s Medicare began looking to ‘managed care’ to help control high expenditure. Under managed Medicare, an insurance company known as a health maintenance organisation (HMO) accepts a fee from the Medicare programme for each person it enrols. The HMO agrees to provide him or her with, at the very least, the standard package of Medicare benefits (Boult et al, 2000:1011). However, Medicaid and

47

Medicare have been criticised for focussing too much on acute services at the expense of long-term and community-based options that assist older people to remain in the community, to prevent illness or to maintain the highest level of health possible (Marek and Rantz, 2000:1). Care Management has therefore been promoted as an alternative approach to addressing the long-term care needs of older people (Moneyham and Scott, 1997:69). Many managed health care organisations are now utilising Care Management as a mechanism for improving the quality of care, reducing inappropriate use of services, and controlling costs (Hawkinset al, 1998:15; Hicks et al, 1993:49). As a result of increasing dissatisfaction with the managed care model, a number of models of Care Management have been developed in the US in recent years. These are summarised next.

2.5.1 Ageing In Place (Marek and Rantz, 2000)

Marek and Rantz developed this model of care as an alternative to nursing home care. This model offers care co-ordination (or Case Management (sic)) and health care services to older people with the aim of allowing them to ‘age in place’ (Marek and Rantz, 2000:2). This entails the delivery of services to older people either in their own homes or in sheltered housing developed as part of the project. The timing and intensity of health and personal care services are directed by the clients themselves. Case Managers, or ‘care co-ordinators’ as they are described, are nurses specially trained in Case Management. Their role is to assess and reassess the needs of clients, develop and implement a care plan, monitor the quality and efficiency of service delivery, and ensure throughout the process that clients receive quality services that continually meet the needs of clients and support informal carers (Marek and Rantz, 2000:4). On admission, clients receive a comprehensive assessment of their functional and cognitive capacity, strengths, abilities, limitations, existing resources and supports. A plan is developed in partnership with the client based on the results of the

assessment. In the plan, services are ‘bundled’ in packages designed specifically to meet the needs of the client. Clients are monitored and services altered as clients’ health care needs change. Reassessment is conducted as needed or at least every three to six monhs depending on the client’s needs. In-home services are provided by

professional and non-professional staff including: assistance with daily living activities such as bathing, dressing and shopping; assistance with medications; social services; recreational activities; skilled nursing services; communication with other health care providers, and rehabilitation therapy such as physical, occupational and speech therapy (Marek and Rantz, 2000:4). In addition ‘wellness centres’ have been designed that are located in sheltered housing sites which provide a range of health services including screening and educational programs.

An evaluation is planned for the ‘Ageing in Place’ study. Individuals in the project will be compared to clients of similar case-mix in nursing homes as well as to clients in the community receiving services but not participating in the project. Both quality of care and costs of care will be investigated during the evaluation.

2.5.2 Community-Based Nurse Care Management Of Older Adults

(Moneyham and Scott, 1997)

Moneyham and Scott devised a model for nurse-based Care Management. It targets older adults living in the community and consists of:

comprehensive assessment care planning

information and referral directed nursing care services

co-ordination and monitoring of services.

(Moneyham and Scott 1997:70-71)

The goal of this approach to Care Management is to provide services at various points along the health care continuum to decrease fragmentation while improving the quality of life and reducing costs (American Nurses Association, 1988). Moneyham and Scott (1997:71) have identified three critical aspects of service delivery according to this model. Firstly, comprehensive assessments should be carried out which include evaluation of the client’s physical, social, functional and cognitive/mental status, available resource systems, financial resources and environmental conditions. Such assessment should not be regarded as a once-off occurrence, but rather an ongoing intervention. Secondly, the authors place great emphasis on the importance of a good long-term relationship between clients and service providers, as the therapeutic

relationship is viewed as one of the key routes by which older people, their families and informal carers can be supported in practising self care:

‘It is the relationship that creates a foundation for therapeutic intervention by providing older adults and their families the sense of support, security, confidence and competence which is needed to perform self-care.’

(Moneyham and Scott 1997:71)

Finally, information and referral services, although somewhat ‘invisible’, are viewed to be an integral function of nurse-based Care Management. The authors believe that experienced Case Managers should know that older people are capable of making changes to maintain and improve their health and social independence if relevant information and knowledge are made available to them (Moneyham and Scott, 1997). They view nursing Case Managers as being in a strategic position to provide information on health concerns and community resources before problems arise. Such people may also be in a position to give older people and their families the knowledge and skills they need to act as advocates for themselves:

‘The nurse Care Manager may intervene in various ways including doing for and doing with the client and family, while at the same time modeling and teaching self-care, negotiation, and self-advocacy skills’

(Moneyham and Scott, 1997:72)

The model proposed by Moneyham and Scott had not been tested in the field at the time of publication, and the authors point to the lack of evidence of demonstrated effectiveness of the nurse-based Care Management model. In a small number of descriptive studies, nurse-based Care Management has been associated with improved quality and access to health care services and reduced costs (Cohen, 1991; Etheridge and Lamb, 1989; Lamb and Stempel, 1994; Newmanet al, 1984; Parker and Secord, 1988; Rogerset al, 1991; Zander, 1988). These studies indicate that individuals who work with nurse Case Managers spend fewers days in the hospital and intensive care unit, have fewer hospital admissions and use accident and emergency facilities less frequently. However, there have been few efforts to examine the effectiveness of specific interventions carried out by nurse Case Managers (Moneyham and Scott 1997:73).

2.5.3 The Biopsychosocial Individual And Systems Intervention Model (BISIM)

(Hawkins, Veeder and Pearce, 1998)

Hawkins, Veeder and Pearce propose a model for nurse-social worker collaboration known as the Biopsychosocial Individual and Systems Intervention Model, or BISIM. This model encompasses both the Care and Case Management levels in that it:

‘… derives from a combination of the most workable inter- disciplinary collaboration models at the organisational and administrative levels and a broadly conceived case

management intervention approach with individuals and [families]’.

(Hawkins, Veeder and Pearce, 1998:56)

This model assumes nurses and social workers to collaborate as equal partners and involves initial client contact, assessment of services required, development of a plan of care, linking clients to services and community resources, implementation and co-ordination of effort to ensure that the plan is implemented efficiently with an equal distribution of health and social aspects, and advocacy where necessary.

The design of the BISIM model was based on a qualitative study of thirty-three nursing and social work leaders in 1995 and 1996. In-depth interviews were carried out with these participants, lasting for approximately thirty minutes. The major topics explored included:

the history of collaboration between social workers and nursing in a variety of agencies and institutions

the advantages and disadvantages of the ways in which social workers and nurses interact, and how they evaluate the outcomes of their practices or interventions the opportunities that a managed care system could offer to nurses, social workers and their clients and informal carers for access to care, a holistic approach to care, health promotion, disease prevention and integration of alternative or

complementary therapies

new opportunities for collaboration between these two professions.

The model is currently being tested in practice in two arenas: a social work-police team project in the area of domestic violence, and with a coalition of social workers, nurses and teachers addressing violence in a semi-urban community (Veeder, 2001).