University of Phoenix HLT 610 Medical Care in Rural Areas Research Paper

University of Phoenix HLT 610 Medical Care in Rural Areas Research Paper ORDER NOW FOR CUSTOMIZED AND ORIGINAL ESSAY PAPERS ON University of Phoenix HLT 610 Medical Care in Rural Areas Research Paper In 750-1,000 words, identify and describe the issues affecting standards of practice related to competency of medical care identified in the Lyckholm and Hackney article. Which is at the link in the bottom of the page In addition to summarizing the relevant points of the article, explain the relevance that standards of practice have (or will have) to you as a practitioner. University of Phoenix HLT 610 Medical Care in Rural Areas Research Paper Prepare this assignment according to the APA style 7 guidelines found in the APA Style Guide. An abstract is not required. This assignment uses a grading rubric. The rubric is attached. Instructors will be using the rubric to grade the assignment; therefore, students should review the rubric prior to the beginning of the assignment to become familiar with the assignment criteria and expectations for successful completion of the assignment. https://pdf.sciencedirectassets.com/271153/1-s2.0-… attachment_1 attachment_2 attachment_3 Critical Reviews in Oncology/Hematology 40 (2001) 131– 138 www.elsevier.com/locate/critrevonc Ethics of rural health care Laurie J. Lyckholm , Mary Helen Hackney *, Thomas J. Smith Department of Medicine and the Di6ision of Hematology/Oncology, Massey Cancer Center, Virginia Commonwealth Uni6ersity School of Medicine, 401 College Street, Richmond, VA 23298 -0037, USA Accepted 6 February 2001 Contents 1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 132 2. Program description: The Rural Cancer Outreach Program (RCOP) . . . . . . . . . . . . . . . . . . . . . 132 3. Program analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.1. Impact of the program on the clinical care provided . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.2. Impact of the program on health care professional recruitment and retention . . . . . . . . . . . . . 132 132 133 4. Economic analysis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 133 5. Other programs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 134 6. Applicability to other settings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 134 7. Ethical issues in rural health care. . . . . . . . . . . . . . 7.1. Justice issues: access to and delivery of health care . 7.2. Competency of medical care . . . . . . . . . . . . . . 7.3. Confidentiality and privacy. . . . . . . . . . . . . . . 7.4. Institutional ethics committees . . . . . . . . . . . . . . . . . . 134 134 135 136 136 8. Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137 Reviewers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137 Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137 Biographies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 138 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Abstract One quarter of the US population live in areas designated as rural. Delivery of rural health care can be difficult with unique challenges including limited access to specialists such as oncologists. The Rural Cancer Outreach Program is an alliance between an academic medical center and five rural hospitals. Due to the presence of this program, the appropriate use of narcotics for chronic pain has increased, the number of breast conserving surgeries has more than doubled and accrual to clinical trials has gone from zero to nine over the survey period. An increase in adjuvant chemotherapy has been noted. The rural hospitals and the academic center have seen a positive financial impact. The most prominent ethical issues focus on justice, especially access to * Corresponding author. Tel.: + 1-804-8280450; fax: + 1-804-8288453. E-mail addresses: [email protected] (L.J. Lyckholm), [email protected] (M.H. Hackney). 1040-8428/01/$ – see front matter © 2001 Elsevier Science Ireland Ltd. All rights reserved. PII: S 1 0 4 0 – 8 4 2 8 ( 0 1 ) 0 0 1 3 9 – 1 132 L.J. Lyckholm et al. / Critical Re6iews in Oncology/Hematology 40 (2001) 131–138 health care, privacy, confidentiality, medical competency, and the blurring of personal and profession boundaries in small communities. As medical care has become more complex with an increasing number of ethical issues intertwined, the rural hospitals have begun to develop mechanisms to provide help in difficult situations. The academic center has provided expertise and continued education for staff, both individually and within groups, regarding ethical dilemmas. © 2001 Elsevier Science Ireland Ltd. All rights reserved. Keywords: Care of the poor; Cost analysis; Medically under-served; Rural; Strategic alliances 1. Introduction One quarter of the US population lives in areas designated as rural, or fewer than 2500 people per town boundary, and frontier, or fewer than 6.6 people per square mile [1]. The geographical and socioeconomic features of rural America present unique challenges to delivery of health care resources, especially delivery of oncology care. Rural patient health is often poorer than urban or suburban patient health. The long distances make some types of care difficult. There is increasing evidence that high volume produces high quality cancer care [2,3] and many rural hospitals will always have low volume. This article will explore the ethical issues related to rural health care, particularly oncology care. It will describe the rural cancer outreach program of the Massey Cancer Center (MCC) including a clinical and financial analysis of the program; the ethics of the program; applicability to other settings; and what we have learned in 10 years of creating access to care. from the rural site come to the academic center for specialized cancer nursing, then receive annual updates. Many of the rural nurses have become certified in oncology nursing. The program is administered by the Massey Cancer Center of the Medical College of Virginia, Virginia Commonwealth University, and each of the rural hospitals. Support for this program comes from the Commonwealth of Virginia. 3. Program analysis 3.1. Impact of the program on the clinical care pro6ided We have analyzed three important index conditions in our first two rural hospitals [6]. We chose these conditions because there was documented wide variation in practice, and poor medical outcomes if optimal process was not followed (Table 2). It was difficult to Table 1 Goals of the rural cancer outreach program 2. Program description: The Rural Cancer Outreach Program (RCOP) The rural cancer outreach started as a ‘strategic alliance’ [4] between academic centers and rural nonfor-profit hospitals.University of Phoenix HLT 610 Medical Care in Rural Areas Research Paper The goal was to establish a model of care that would provide state of the art care in rural areas, increase the access to care, generate services and revenue for both the rural and academic center, train health care professionals [5], and serve as a laboratory for intervention. (Table 1). The RCOP has grown from one program in 1988 to five programs operating at five rural hospitals. Briefly, the majority of cancer care is provided at the rural hospital. A team of two– three oncologists and two nurse practitioners or nurse clinical specialists travel to each site weekly. While there, they see new consultations and patients under treatment. They work with primary care doctors at the rural sites who have expressed an interest in care of cancer patients; this typically includes two– three surgeons and two–four primary care internists or family physicians. Nurses Goal Establish a model of care for rural Virginia Deliver state of the art care in rural areas Comment Virginia is typical rural US state See what care could be delivered at the rural site, what should be centralized Increase access to clinical trials Allow access to new drugs; increase accrual to clinical trials for the academic center Train health care professionals Help recruit and retain primary care and specialist physicians and nurses for the rural area. Provide a specialty service that makes rural practice more attractive Link academic and rural Make regional policy, not hospitals in strategic alliance hospital against hospital, to solve problems of indigent care. Help finances of both hospital Help support unprofitable partners small rural hospitals. Serve as a entry point for Use the program for tobacco community based interventions and nutrition interventions if in prevention desired by rural community. L.J. Lyckholm et al. / Critical Re6iews in Oncology/Hematology 40 (2001) 131–138 133 Table 2 Index condition Morphine use in chronic pain Breast conserving therapy Clinical trial accrual Adjuvant therapy for early breast cancer Level before RCOP 0 B20% 0 Unknown. Probably high for affluent patients who could travel, low for the poor analyze the type of care because the volume of any one condition, e.g. use of adjuvant chemotherapy in Stage I–III breast cancer, was always low and usually less than ten cases per year. However, the importance of high quality care to those individuals is as important as in other settings. There is often reluctance to analyze care patterns if it is likely to show less than optimal care; for instance, a hospital that reports excess mortality from routine myocardial infarction may find that patients avoid that hospital for all cardiac care, especially troublesome for a small hospital that depends on retaining a large percentage of its market for survival. Also, there is often no financing available to support an in depth look at practice patterns and survival or recurrence. The use of morphine for cancer pain was studied in one hospital. In the preceding 3 years before RCOP, there had been almost no morphine prescribed; within 2 years the amount of oral and intravenous morphine increased by over 500%. In addition, the use of meperidine declined. Breast conservation, considered the desired treatment for early stage breast cancer, had been rarely used before RCOP. By the 3rd year of operation at our first hospital, over 60% of patients were routinely treated with breast conservation. In addition, before the RCOP, all breast cancer patients were not routinely offered adjuvant treatment, because many could not see an oncologist due to distance or cost. In other studies, the referral of patients to a medical oncologist — rather than treatment by a surgeon alone — was significantly correlated with the likelihood of receiving adjuvant chemotherapy [7]. Clinical trial accrual to Cancer and Leukemia Group B (CALGB), National Surgical Adjuvant Breast and Bowel Program (NSABP) and other trials increased from essential zero to 9% of eligible patients. This compares favorably with the 2% national average in the US. 3.2. Impact of the program on health care professional recruitment and retention The RCOP has been successful in helping to recruit and retain good physicians to rural areas. Physicians commonly mention the increased academic linkage Level after RCOP +500% 60% 9 Offered to all patients regardless of ability to pay and ease of referral to the academic center. These rural doctors have noted that the concentration of complex cancer care in the hands of a few local doctors rather than many has allowed them to increase their expertise.University of Phoenix HLT 610 Medical Care in Rural Areas Research Paper There has also been continued centralization of some complex procedures such as radiation and leukemia treatment that are not feasible to perform at a rural center. 4. Economic analysis Pre- and post-RCOP financial data were collected on 1745 cancer patients treated at the participating centers, two rural community hospitals, and MCC. The main outcome measures were costs (estimated reimbursement from all sources), revenues, contribution margins, and profit (or loss) of the program. Key results are shown in Table 3, modified from the full report in the Journal of Rural Health [8]. The RCOP had a positive financial impact on the rural and academic medical center hospitals. The RCOP was associated with an increased number of referrals of 330% more cancer patients and 9% more other medical/surgical patients. The MCC had increased receipts of 6.2%. The rural hospitals each had over a million dollars in new charges and over $500 000 US new profit each year. In total, the receipts for both centers increased by 137%. Most of this additional income was from ‘ancillary’ services such as increased use of the computerized axial tomography (CAT) or magnetic resonance imaging (MRI) scan, laboratory, and pharmacy. All patients were treated regardless of ability to pay, and the program generated sufficient profit to allow increased indigent care. The net annual cost per patient fell from $10 233 to $3862 (? 62%) associated with more use of outpatient services, more efficient use of resources, and the shift to a less expensive locus of care. The cost for each rural patient admitted to MCV fell by 40%, compared to only an 2% decrease for all other cancer patients consistent with other programs that have increased coordination among providers [9]. L.J. Lyckholm et al. / Critical Re6iews in Oncology/Hematology 40 (2001) 131–138 134 5. Other programs 7. Ethical issues in rural health care Similar results of improved clinical care process, equal or better patient outcomes and cost savings have been reported from the Manitoba Cancer Outreach Program, but final results have not yet been published. The Manitoba Cancer Research and Treatment Program was started in 1984 with similar goals [10]. It works on a similar model of consultation with the academic center, then all the care is delivered in one of six regional centers. Insurance is not an issue in Manitoba since there is a single universal payer. However, there are limited funds for cancer and dollars that can be saved by off loading to a regional center preserve dollars for research. Distance is even more problematic, with some centers 8 h by train, impassible by cars, and air transport too costly. Key rural primary care doctors and surgeons are identified, and given an initial training program followed by yearly updates. All protocols are specified in a central care plan, and the central hub audits dictations from the rural centers. Similar clinical results have been obtained, with excellent clinical care and less overall cost to the province [11]. (personal communication, Harvey Schipper 1999) The challenge is to provide high quality, affordable, accessible care for all. In the US, the absence of a single payer system allows exclusion of whole segments of the population. Combined with the dispersed poor population in rural areas, these issues represent significant obstacles to delivery of care. In Virginia, one third of the population is rural and most of these people are medically underserved for both primary and specialty care. The rural population has more federal Medicare and state Medicaid health insurance coverage with a low rate of reimbursement compared to most insurance, so rural hospitals and providers have less income than urban centers. ‘Negative marketing’ or locating services in affluent areas so that the poor do not have access is widespread. The ethical issues most prominent in rural health care include justice issues, especially those involving access to and delivery of health care, related issues of medical competency, confidentiality and privacy issues, and conflicts of interest related to blurring of personal and professional boundaries. Finally, institutional ethics committees at rural hospitals are evolving, but may not have the necessary elements of expertise that are more accessible in urban centers. 6. Applicability to other settings 7.1. Justice issues: access to and deli6ery of health care We have not identified other similar programs that have published their clinical and economic results.University of Phoenix HLT 610 Medical Care in Rural Areas Research Paper The closest is the Centre Bernard Lyon that has shown good adoption of clinical practice guidelines and better clinical practice [12,13]. This program should be applicable to other centers that serve rural, dispersed populations. The main problems have been sustaining the medical innovation part of the program, and not ‘burning out’ the doctors and nurses who must travel the distance. The continued travel can be a major problem for health professionals. The principle of justice calls for equitable distribution of health care resources, meaning that health care is distributed according to need rather than to the ability of a person to obtain it. Challenges to this principle in the rural health care setting include geographical and financial barriers. In some rural communities health care may be hours away. Nonmetro and frontier areas possess far less physician coverage than more urbanized areas even after controlling for population size. For example, in 1988, the ratio of primary care physicians per 100 000 persons for re- Table 3 Impact of RCOP on rural and academic programs Cancer patients from RCOP areas seen at MCC All patients from RCOP areas seen at MCC Estimated receipts, MCC Estimated receipts, RCOP Total estimated receipts Net annual cost per patient in the system Inpatient admission, MCC a b Represents average values of 1988 and 1989 financial data. Represents average values of 1992 and 1993 financial data. Pre-RCOPa Post-RCOPb Change (%) 173 6958 $1 770 256 NA $1 770 256 $10 233 $12 268 743 7572 1 879 542 $2 314 516 $4 194 058 $3862 $7370 330% 9% 6.2% – 137% ?62% ?40% L.J. Lyckholm et al. / Critical Re6iews in Oncology/Hematology 40 (2001) 131–138 mote rural areas was 38.2; for the more inclusive nonmetro areas it was 51.3. In comparison, metro areas had a ratio of 95.9 [14,15]. This problem will be compounded as more independent community hospitals close their doors due to the lack of funding. The poor and elderly without access to transportation may receive little to no health care. The traffic and complexity of urban centers may intimidate those who have always lived in rural areas. Financial barriers are similar to those experienced by the poor urban population. The community, however, may actually be a positive factor in overcoming these barriers. In a review of these issues, Purtilo and Sorrell remarked that in times of hardship, rural community members often help those of their community who are most financially strapped [16]. Among those community members are the physicians, who are also ‘expected’ to contribute their services and advocacy for the patient. Physicians are part of the community, and ‘‘the high probability that the physician will see a rejected patient at the drug store, Lions Club dinner, or next PTA meeting makes saying ‘no’ practically impossible’’ [17]. This situation may create a tremendous conflict of interest between the physicians’ allegiance to their community and their hospital, which may not have the financial resources to provide care for indigent members of the community. Improved access to oncology care is at the heart of our rural cancer outreach program. Oncology care in the rural setting is equivalent, or sometimes better, in terms of convenience, than that in the academic medical center. The most important aspect of the program is improving financial and geographic access to subspecialty care and consultation. Transportation is provided for patients who have daily radiation treatments. Although we cannot impact direct costs of the patients’ oncology care, reducing out-of-pocket spending, which is significant, appears to be of great assistance to many of the patients. Finally, by providing care close to home, we hope to offer comfort and a greater sense of security to patients who are frightened or feel threatened by the diagnosis of cancer and the therapy they must endure. 7.2. Competency of medical care Several issues surrounding competency of medical care exist in the rural setting, and some are particular to our rural outreach oncology setting. The first concerns competency to provide specialty care. Many rural areas have few primary care providers, and no specialists. There is increasing evidence that high volume produces high quality and many rural hospitals will always have low volume [ … Get a 10 % discount on an order above $ 100 Use the following coupon code : NURSING10

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