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This economy is to account translates into higher reimbursement categories buy provera 10mg on-line menstrual ultrasound, known for long stays so the chart can contain a lengthy record as Resource Utilization Groups (RUGS) discount provera 10 mg on line breast cancer yeti,5 a classiﬁca- without thinning. Most of the sections that follow are tion system analogous to the Diagnosis-Related Group nursing driven, with care plans, the MDS, and each (DRG) system in hospitals and similar in that it dictates discipline (physical therapy, occupational therapy, re- prospective payment. The reader will note, however, that creational therapy, social services, medication delivery the prospective payment in the nursing home is not built records, treatment records, etc). Although it is not neces- on medical diagnoses, but rather on the level of debility sary for the physician to read completely the entire chart implicit in the nursing diagnoses. This fundamental prin- of every patient, it pays to do so for a substantial minor- ciple highlights the importance of nursing function and ity to get an impression of the total care rendered. In lingo in the SNF, and many physicians practicing in the aggregate, the total nursing home record of patient care SNF are slow to understand the pervasiveness of this captures the comprehensiveness of the experience better principle; it is much like learning a foreign language than a typical hospital chart, certainly with regard to care while living abroad. The Nursing Home Medical Record Patient Autonomy Physicians are often struck by the volume of the typical nursing home medical record; it is huge. The ﬁrst reaction The second fundamental principle that pervades nursing of doctors when confronted with the patient record is, home practice is that of patient autonomy. It is nearly conceivable effort is expended to ensure this principle in impossible to be admitted to the modern nursing home the SNF. For example, patients are not to be restrained without declaring one’s code status. Admitting history in any way, whether chemically (via sedatives or neu- and physical examination, orders, and progress notes roleptics) or physically, without extensive documentation usually follow. Most nursing homes ﬁnd it far easier to ﬁnd creative ways to avoid restraint through behavior management than to use restraints. For instance, lap trays on wheelchairs and bed Advance Directive/Code Status rails are considered restraints. Not only are residents not Orders to be restrained; they are also encouraged to participate History and Physical Admission Records (from previous care, e. By Total Parenteral Nutrition regulation, this autonomy and independence is to be Active Care Plans fostered, which implies that it must be assessed in the ﬁrst Progree Notes place. Residents are strongly encouraged to take meals Resolved Care Plans Care Conference Records in groups, to see movies or watch television together, to Vital Signs attend musical events, and to vote. These activities are Lab and Special Reports either brought to them in the facility or arranged in Medication Administration Record (MAR) "ﬁeld-trip" fashion. Again, physicians may be slow to Treatments comprehend this fundamental atmosphere of patient Dietary Occupational Therapy autonomy. Physicians are used to meting out admonitions Physical Therapy and directives to patients in the ofﬁce, clinic, or hospital. Speech Therapy Patients are referred to as "residents" in the SNF—this is Quality of Life/Activities their home, where they are boss. The admonitions and Social Work directives are supposed to come from them to the staff Miscellaneous and physicians, not the other way around. Acute psychotic episodes imposed or psychoactive drug administered for purposes of 6. Brief reactive psychosis discipline or convenience and not required to treat the resident’s 7. Tourette’s disorder mechanical device, material, or equipment attached or adjacent 10. Huntington’s disease to the resident’s body that the individual cannot remove easily 11. Organic mental syndromes (including dementia) with which restricts freedom of movement or access to one’s body associated psychotic and/or agitated features as (includes leg and arm restraints, hand mitts, soft ties or vest, deﬁned by wheelchair safety bars, and gerichairs). There must be a trial of less restrictive measures unless the scratching) documented by the facility which causes physical restraint is necessary to provide lifesaving treatment. The resident or his/her legal representative must consent to the —Present a danger to themselves use of restraints. Residents who are restrained should be released, exercised, —Actually interfere with staff’s ability to provide care toileted, and checked for skin redness every 2 h. Each resident’s drug regimen must be free from unnecessary drugs nausea, vomiting, or pruritus (1) "Unnecessary drugs" are drugs that are given in excessive (b) Antipsychotics should not be used if one or more of the fol- doses, for excessive periods of time, without adequate moni- lowing is/are the only indication toring, or in the absence of a diagnosis or reason for the drug. Impaired memory (2) In deciding whether an unnecessary drug is being used, sur- 7. Uncooperativeness (1) Residents who have not used antipsychotic drugs are not given 15. Any indication for which the order is on an "as needed" these drugs unless antipsychotic drug therapy is necessary to basis treat a speciﬁc condition. Summary of new federal regulations relevant to primary physicians and medical directors in nursing homes: 1987 Omnibus Budget Reconciliation Act (OBRA).
The solution-focused orientation descends from the Mental Research Institute (MRI) Brief Therapy model and yet departs from the latter buy provera 10 mg otc pregnancy 40 weeks. Solution-focused therapists help clients con- centrate exclusively on solutions that have worked in the past or will work in the future purchase 5 mg provera mastercard seven hills womens health center, while MRI therapists zoom in on the interactional context of the presenting problems with an eye on discovering problematic attempted solutions. Albeit immensely effective with individual clients, SFT cannot be blindly applied to couples and the family. For instance, when applying SFT to a couple, the therapist may still maintain an individual focus. She may interview each person sequentially and lack knowledge and skills to facilitate the interactions between the couple. Moreover, the therapist may not have the proficiency to help the couple negotiate and resolve their dif- ferences. Consequently, SFT must be tailored or modified to be used effec- tively in couples therapy. The specific details of how SFT can be tailored for effective couples therapy are beyond the scope of this discussion. Nonethe- less, suffice it to say that the following caveat and warning should be heeded. SFT can be applied to couples and families, only if the therapist constantly maintains a balanced view of each person’s needs, resources, and characteristics in the family system, and promotes the use of their re- sources for the well-being of all the persons involved. Strategic and Solution-Focused Couples Therapy 199 UNDERLYING ASSUMPTIONS AND KEY CONCEPTS The SFT approach begins with some refreshing assumptions. They have the capability to construct solutions that can enhance their lives, but have lost sight of these abilities because their problems emerge so large to them that their strengths are crowded out of the picture. The solution-focused therapist ardently adheres to the belief that a simple shift in focus from what is not going well to what the clients are already doing that works can remind them of, and expand their use of, their re- sources (Berg & Miller, 1992; de Shazer, 1985, 1988, 1991, 1994; O’Hanlon & Weiner-Davis, 1989). Like the Constructivists who believe in the notion of no true reality, solution-focused therapists believe that they should not impose what they think is normal on their clients. They disagree with the Structuralists’ claims that symptoms are a sign of some underlying problem (e. They focus only on the complaints clients themselves present, and help the clients reexamine the ways they describe themselves and their problems. Due to individual dif- ferences, therapy is highly individualized (Berg & de Shazer, 1993; Berg & Miller, 1992; de Shazer, 1994; O’Hanlon & Weiner-Davis, 1989). THERAPEUTIC CONTENT, PROCESS, AND TECHNIQUES The goals and contents of therapy revolve around resolution of the client’s presenting complaints. To do that: Efforts are made to create an atmosphere in therapy where the individuals are helped to reorient themselves from focusing on their problems to recog- nizing and utilizing their strengths to resolve their problems. Better goals can get you out of your stuck places and can lead you into a more fulfilling future. Much of the work for SFT lies in the negotiation of an achievable goal (Berg & de Shazer, 1993; Berg & Miller, 1992). Instead of changing personality and psychopathology types, SFT therapists help clients construct well-defined goals (Berg & Miller, 1992; de Shazer, 1991; Walter & Peller, 1992). Instead of having negative goals such as "I will get rid of my depression," the goals should be positive. A solution-focused therapist may ask, "Instead of being depressed, what will you be doing? A simple question to ask is "As you leave my office today, and you are on track, what will you be doing or saying differently to yourself? In so doing, the therapist em- powers the client to succeed and avoid disappointment. To help the client put his or her global, abstract, and ambiguous goals in specific, concrete, and objectively measurable terms, questions such as "How specifically will you be doing this? Use the client’s words for formulating goals rather than the therapist’s theoretical jargon (Prochaska & Norcross, 2003, pp. After the goal for therapy is set, solution-focused therapists play an active role in shifting the focus as quickly as possible from problem talk to solution talk. To capitalize on the client’s existing strengths and resources, a question like this is asked: It is our experience that many people notice that things are better be- tween the time they set up an appointment and the time they come in for the first session. Rather than rigidly adhering to the format of immediately asking a direct question about any presession changes in the beginning of the first session, this question, like any useful ques- tion, should be asked in a timely fashion. The task goes like this: Between now and the next time we meet, I would like you to observe, so you can describe to me next time, what happens in your (pick one: Strategic and Solution-Focused Couples Therapy 201 family, life, marriage, relationship) that you want to continue to have happen. This question prevents clients’ global and persistent perception of their problems and directs their attention to times in the past or present when they did not have the problem, when ordinarily they would have: Can you think of a time when you didn’t have the problem? This is an example of such a question: "Suppose one night, while you were asleep, there was a miracle and this problem was solved. The question is used to activate a positive problem-solving mind-set as well as to steer the client to articulate a clear vision of the goal in treatment. It further helps the client look beyond his or her problem to what the solution would look like (Berg & Miller, 1992).
How- ever order 10mg provera fast delivery breast cancer uptodate, we found no change in the prescribing of muscle relaxants during the demonstration cheap 10 mg provera overnight delivery menopause at 80. A total of 15,570 patients were prescribed muscle relaxants, and there were no observable trends in prescrip- tion rates over time for either demonstration or control sites or for any individual demonstration site (Table 6. Statistical tests (see Appendix C) confirmed that trends for the demonstration and control sites were not significantly different. The absence of declines in use of muscle relaxants indicates that the demonstration sites did not address this provision of the guideline at all. Given that an average of 33 percent of acute low back pain patients at the demonstration sites had been prescribed narcotics during the baseline period (see Chapter Three), we hypothesized there would be a decline in the percentage of pa- tients prescribed narcotics during the conservative treatment period. A total of 10,113 low back pain patients were prescribed narcotics, representing almost one-third of the patients. We found modest rates of reductions in narcotic prescription rates during the demonstration period for both the demonstration and control sites. This result indicates that providers’ prescribing pat- terns were changing in the desired direction, as recommended by the guideline, but introduction of the guideline at the demonstration MTFs did not affect the trends at those sites (Table 6. Statistical tests (see Appendix C) confirmed that trends for the Effects of Guideline Implementation 91 Table 6. Of the four demonstration sites, Site C had the lowest narcotics pre- scription rates, and Site D had the largest reduction in narcotics pre- scriptions during the demonstration period (Figure 6. With this information available to the sites, we hypothesized that use of high-cost NSAIDs at the demonstration sites would decline during the demonstration period. However, the percentages of high- cost NSAIDs increased substantially at one demonstration site (Site D) and moderately at one control site (Site C1) during the demon- stration period (Table 6. Also of note, the percent- age of high-cost NSAIDs prescribed at one of the demonstration sites (Site C) steadily decreased in the period following introduction of the guideline, although this probably was coincidental because the site had not defined actions on this issue in its implementation action plan. We examined trends in use of high-cost NSAIDs for all the demonstration and control sites as well as for the two groups after removing episodes of care for patients at the two MTFs with increas- ing use of the high-cost NSAIDs (Figure 6. No significant change in the rate of prescription of high-cost NSAIDs is observed for the demonstration or control sites during the demonstration period, and statistical tests confirmed that trends for the demonstration and control sites were not significantly different (see Appendix C). For example, providers re- ported they increased physical therapy referrals, while some sites reported declines in referrals, and we found trends of declining refer- ral rates in the encounter data. Others reported rates of follow-up visits that were consistent with those estimated from the encounter data. For pain medications, providers correctly reported no change in use of muscle relaxants, but their perceptions of use of NSAIDs and narcotics were not confirmed by the pharmacy data. Most sites in this demonstration generated fairly limited objective data on their utilization trends, which precluded greater compar- isons between such local data and the centralized encounter data (SADR, Standard Inpatient Data Record, and pharmacy data from the PharmacoEconomic Center). The local data were limited in part because low back pain metrics were not established until later in the demonstration. Other factors also contributed to limited monitoring by the sites, including competing demands for the implementation team members’ time, mixed reactions by providers and clinic staff to using the guideline, and lack of mandates from MTF commands. Effects of the demonstration on care for low back pain patients were limited during the first year the sites worked with the practice guide- line, and effects that were found were for patterns of service delivery rather than for prescribing of pain medications. The only overall ef- fect for the demonstration was a decline in physical therapy referrals during the demonstration period. The decline in numbers of follow- up primary care visits in the last quarter of the demonstration may be an early sign of a trend, but additional data for later months would be needed to verify such a trend was real. Despite not finding overall effects, effects were observed from the encounter data that were specific to individual sites and consistent with their implementation strategies. The strongest of these were the Site A strategy to use back classes to reduce use of physical therapy, which was observed in the data as declines in physical therapy referrals; and the Site D strategy to establish the physical medicine clinic as gatekeeper and reduce inappropriate specialty referrals, which were observed in the data as 96 Evaluation of the Low Back Pain Practice Guideline Implementation shifts of referrals to the physical medicine clinic from other special- ties. The implications of these evaluation findings for ongoing implemen- tation of practice guidelines in AMEDD are considered in Chapter Seven. Chapter Seven LESSONS FROM THE LOW BACK PAIN DEMONSTRATION This first demonstration to field test methods for implementation of clinical practice guidelines yielded rich information and insights even as it struggled to achieve lasting new practices. Despite disap- pointing results in terms of the effects on treatment of acute low back pain, the demonstration contributed to improvements in methods for subsequent guideline demonstrations, and ultimately, for imple- mentation of the low back pain guideline in all Army health facilities as of the spring of 2000. In this chapter, we synthesize the factors influencing the successes and limitations of the low back pain guideline demonstration. We begin by examining how well the demonstration performed on the six critical success factors presented in the beginning of this report and reintroduced throughout, and we assess how this performance contributed to the demonstration results. Then we identify a number of issues for the MTFs that emerged from the demonstration that are likely to affect other MTF guideline implementation efforts. Finally, we discuss implications for MEDCOM with respect to approaches and methods as it moves forward with implementation of a number of DoD/VA practice guidelines in the Army health system. PERFORMANCE ON SIX CRITICAL SUCCESS FACTORS Research on practice guideline implementation has documented that a commitment to the implementation process, including use of multiple interventions, is required to achieve desired changes to 97 98 Evaluation of the Low Back Pain Practice Guideline Implementation clinical practices. Below are the six critical success factors that are es- sential for making lasting changes in the MTFs’ clinical and adminis- trative processes.
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