StrangerR wrote:Bluebonnet wrote:StrangerR wrote:А с гос страховкой будет понятно что. Следующим шагом будет (как уже в некоторых штатах) сказано - идите вы доктора нафиг со своими счетами - вот мои 10 миллионов граждан которым нужна медицина, я вам буду платить фиксированную сумму за каждого, ваше дело лечить. .
Макет этой идеи запущен под эгидой patient care medical home, с таким хорошим провалом и пока врачей желающих туда попасть немного
Как раз там не провал а ОЧЕНЬ НЕПЛОХИЕ результаты. Но там снова та же песня - из за искуственного ограничение числа докторов они начинают тратить по 3 минуты на пациента (компенсируя это работой медсестер), вместо того, чтобы скажем ВЕСЬ начальный прием вести PA, чтобы ВРАЧ из другой страны мог ЛЕГКО сдать на PA (и работать под руководством другого врача в США). Была статья в Business Week, сама идея как раз работает прекрасно, и как только ограничат аппетиты врачей по биллингу - они пойдут туда работать толпами.
HMO в целом похожая система - работает прекрасно. И врачи почти все в ней учавствуют. Потому как не участвовать - просто потерять пациентов. Но она не во всех штатах и реально доступна лишь через рабочие страховки.
Business Week - безусловно курутая экономическая пресса, круче только New York Times
На самом деле, вот что пишут медицинские источники про опыт перехода традиционных практик в Patient-Centered Medical Home
Annals of Family Medicine
Initial Lessons From the First National Demonstration Project on Practice Transformation to a Patient-Centered Medical Home
Paul A. Nutting, MD, MSPH; William L. Miller, MD, MA; Benjamin F. Crabtree, PhD; Carlos Roberto Jaen, MD, PhD; Elizabeth E. Stewart, PhD; Kurt C. Stange, MD, PhD
Published: 06/09/2009
Change is hard enough; transformation to a PCMH requires epic whole-practice reimagination and redesign. It is much more than a series of incremental changes. Since the early 1990s, theories of quality improvement emphasizing sequential plan-do-study-act cycles have dominated change efforts within primary care practices.[19] Many NDP practices initially chose to take this incremental approach -- literally checking off each model component as completed. They were soon overwhelmed with complications. Whereas the traditional quality improvement model works for clearly bounded clinical process changes, the NDP experience suggests that transformation to a PCMH requires a continuous, unrelenting process of change. It represents a fundamental reimagination and redesign of practice, replacing old patterns and processes with new ones. Transformation includes new scheduling and access arrangements, new coordination arrangements with other parts of the health care system, group visits, new ways of bringing evidence to the point of care, quality improvement activities, institution of more point-of-care services, development of team-based care, changes in practice management, new strategies for patient engagement, and multiple new uses of information systems and technology.
These multiple components of a PCMH are highly interdependent.[20] Each component, when implemented, ripples throughout the practice, affecting all other work processes and individual roles. Prior changes require adjustment as new ones are made and practice systems and relationships begin to operate in different ways. Roles of individuals and the practices, sense of identity, and imagination about the meaning of patient care are changed. Most current practice models are designed to enhance physician workflow. The PCMH should be designed to enhance the patient experience. This shift requires a transformation, not an incremental change.
Technology Needed for the PCMH Is Not Plug and Play
Although most participating practices had an electronic medical record (EMR) at the beginning of the project, an initial strategy of the NDP was to implement further technological enhancements supporting a PCMH (eg, registries, e-prescribing, patient portals, etc) and to use them to reconfigure work patterns. These added features included a range of components, some of which were enhancements to EMR.[17] New technology implementation was more difficult and time consuming than originally envisioned. The hodgepodge of information technology marketed to primary care practices resembles more a pile of jigsaw pieces than components of an integrated and interoperable system. A function as seemingly simple as a disease registry was either absent from EMR systems or extremely awkward to activate and required complicated workarounds. Even with discounted pricing and more than usual technical support from vendors, the challenges proved daunting. Making the tasks more difficult was the need to redefine work processes before implementation rather than after. Technology often foundered on the shoals of practice work redesign. This lesson resonates well with the emerging research literature about the EMR in primary care practices.[21-24]
Transformation to the PCMH Requires Personal Transformation of Physicians
Transformation to a PCMH requires not only implementing new, sophisticated office systems, but also adopting substantially different approaches to patient care. Such a fundamental shift nearly always challenges doctors to reexamine their identity as a physician. For example, transformation involves a move from physician-centered care to a team approach in which care is shared among other adequately prepared office staff.[25] To function in this team-based environment, physicians need facilitative leadership skills instead of the more common authoritarian ones. A PCMH requires expanding the clinical focus from 1 patient at a time to a proactive, population-based approach, especially for chronic care and preventive services.[26,27] In addition, physician-patient relationships need to shift toward a style of working in relationship-centered partnerships to achieve patients' goals rather than merely adhering to clinical guidelines.[28-30]
Change Fatigue Is a Serious Concern Even Within Capable and Highly Motivated Practices
The magnitude and pace of change required to transform into a PCMH produced change fatigue midway through the first year. Transformation occurs, not at a steady and predictable pace, but in fits and starts. After the strenuous task of implementing a particular PCMH component, the practice had to simultaneously manage the ripple effects, maintain the change, and prepare for the next. The work is daunting and exhausting and occurring in practices that already felt as if they were running as fast as they could. This type of transformative change, if done too fast, can damage practices and often result in staff burnout, turnover, and financial distress. ...participants found it challenging to pass this energy on to colleagues when they returned home.
Transformation to a PCMH Is a Developmental Process
As the NDP progressed, we began to see a distinction between what we have named the practice's "core structure" and its "adaptive reserve." Core structure includes capabilities to manage basic finances and clinical and practice operations during times of stability and modest change. A practice's ability to keep pace with rapid development and change, however, was largely a function of the practice's adaptive reserve. A strong adaptive reserve includes such capabilities as a strong relationship system within the practice, shared leadership, protected group reflection time, and attention to the local environment.[31] In the beginning of the NDP, practices varied considerably in their adaptive reserve, and that capability was a major determinant of a practice's initial progress. None of the practices, at baseline, had a systematic change management process in place, and few preserved time for planning and reflection. In many practices, change began as an initial flurry of physician-led, just-do-it, top-down actions. Although initially successful in some practices, this approach proved ineffective in the long-term. The intense pace and magnitude of change soon revealed and exacerbated deeper dysfunction within the relationship infrastructure of practices, including tension among physicians and among practice staff, ineffective communication patterns, and avoidance of potential conflict and difficult conversations that produced stalemate. Transformation toward a PCMH appears to require a strategic developmental approach that starts with assuring a strong structural core, and then implements smaller changes that help to build the adaptive reserve. Only then can larger, more complex changes begin. Such transformation takes more time than the 2 years allocated to the NDP.
Transformation Is a Local Process
We observed multiple pathways toward the PCMH, each highly dependent on initial conditions at the local practice, health care system, and community level. Even among the highly motivated NDP practices (both facilitated and self-directed) there was considerable variation in need for assistance, depending on specific challenges and previous experience with change. Facilitated practices received a spectrum of assistance, including a combination of consultation (providing specific information), coaching (assisting physicians and others in personal transformation), and facilitation (addressing a practice's adaptive reserve.)
По поводу ВЕСЬ начальный прием вести РА - это, извините, откровенная чушь. Как раз во время первоначального приема очень важно не упустить детали, которых РА просто не обучают. Поэтому многие сейчас протестуют против приема РА вместо специалистов - могу накидать тыщи возмущенных врачебных откликов по поводу доверия экспертизе так называемого специалиста, к которому отправляют пациента на консультацию, а там RN или РА.
Ничего не имею против помощи в ведении хронических и повторных больных
А ведь они тоже бедные болеют - Вы думаете лечить их будем в космос отправлять - как это там на сороковой по-моему странице, чтобы не раздувать аппетиты тех, кто того себе не может позволить. И вообще, пора создавать отдельные поселения на Луне дабы эти последние новуриши не позорили людской род и не селили своими богатствами сметения в пролетарские души 
).. Gowri lives in Rhode Island with her husband and three children.
- надо же какаие новости - это Вам Ваш РА такое про этот тест рассказывал 
