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Background: It seems to be a truth universally acknowledged that pathways to care for people with eating disorders are inconsistent and difficult to navigate. This may, in part, be a result of the complex nature of the illness comprising both mental and medical ill-health across a broad range of severity. Care therefore is distributed across all parts of the health system resulting in many doors into the system, distributed care responsibility, without well developed or integrated pathways from one part of the system to another. Efforts in many parts of the world to redesign health service delivery for this illness group are underway, each dependent upon the local system structures, geographies served, funding sources and workforce availability. Methods: In NSW—the largest populational jurisdiction in Australia, and over three times the size of the UK—the government embarked six years ago on a program of whole-of-health system reform to embed identification and treatment of people with eating disorders across the lifespan and across the health system, which is largely publicly funded. Prior to this, eating disorders had not been considered a 'core' part of service delivery within the health system, meaning many patients received no treatment or bounced in and out of 'doorways'. The program received initial funding of $17.6 million ($12.5 million USD) increasing to $29.5 million in phase 2 and the large-scale service and workforce development program has been implemented across 15 geographical districts spanning almost one million square kilometres servicing 7.75 million people. Conclusions: In the first five years of implementation there has been positive effects of the policy change and reform on all three service targets—emergency departments presentations, hospital admissions and community occasions of service as well as client hours. This paper describes the strategic process of policy and practice change, utilising well documented service design and change strategies and principles with relevance for strategic change within health systems in general. Plain English summary: This review outlines a $30 million health system reform to eating disorder treatment implemented by the NSW State Government six years ago which has seen large-scale service and workforce development across 15 geographical districts. This spans almost one million square kilometres and services 7.75 million people in Australia. The reform is very large in scale and is now in its second phase of implementation. Here outlined is the strategic process of policy and practice change of the entire reform and initial findings from an external review of phase one, which demonstrates positive effects on all three service targets—emergency departments presentations, hospital admissions and community occasions of service—including increased rates of treatment provision, improved perception of eating disorders amongst health professionals, improved pathway options and better communication within multidisciplinary teams. This type of whole-of-health system government led reform has relevance and learnings for health systems internationally. [ABSTRACT FROM AUTHOR]

The health of any nation, and the Bulgarian one in particular, is extremely important for the economy, security and development of the country. Unlike other European countries, due to defects in the structure and functioning, the Bulgarian health system could not achieve satisfactory final results in a number of important aspects of public health. One part of the essential problems includes high rates of morbidity, mortality, wide spread of health risk factors, and on the other - insufficient satisfaction of medical professionals (doctors, nurses, support staff) and patients. This, combined with the changes in the political administration of Bulgaria, led to a decision for a radical reform in the health care system. Conditionally, the changes can be divided, according to their nature, into 6 large groups: 1) Reforms leading to democratization of the system; 2) Reforms related to liberalization; 3) Reforms in the status of primary care practices; 4) Reforms in the organization, construction and structure of the system; 5) Reforms in financing and payment methods; 6) Reforms in the management of the primary care system and practices. The purpose of this review article is to present the theoretical framework, grounds and goals for the reform of the health care system in Bulgaria carried out in the past, with a focus on primary care and the current state. [ABSTRACT FROM AUTHOR]

Background: Ensuring equal access to medicines and their appropriate and safe use at reasonable costs are core functions of health systems. Despite that, few descriptions of national medicines policies' development processes and implementation strategies have been published. This study aimed to describe the government program-based development of the Rational Pharmacotherapy Action Plan in Finland as a part of the undergoing major health and social service system reform, also covering the implementation of rational pharmacotherapy in the reformed system and processes. Methods: The data of this qualitative study consisted of public reports and Steering Group meeting memos related to the development of the national Rational Pharmacotherapy Action Plan that the Ministry of Social Affairs and Health coordinated. Qualitative content analysis applying systems theory and the conceptual framework of integrated services as theoretical frameworks was used as an analysis method. Results: The national Rational Pharmacotherapy Action Plan covering 2018–2022 was created in a bottom-up development process involving a wide range of stakeholders. Rational pharmacotherapy was redefined by adding equality as the fifth pillar to complement the previously defined pillars of being effective, safe, high-quality, and cost-effective. The Action Plan formed a normative framework for long-term development, with a vision and principles focusing on people-centeredness, better coordination and management of the medication use processes, the continuity of treatment paths and the flow of patient and medicines information through partnerships, and evidence-informed policies and practices. Conclusion: Through intensive stakeholder participation, the bottom-up approach created a national vision and principles of rational pharmacotherapy along with strong commitment to implementing the goals and measures. The concern lies in ensuring the continuity of the Action Plan implementation and achieving a balanced long-term development aligned with the integrated and reformed national social and health services system. The development of the pharmaceutical system has several national and EU-level dependencies requiring political long-term commitment. While the Action Plan differs from the national medicines policy, it forms a good basis for long-term development covering important parts of medicine policy at the micro, meso, and macro levels of the service system. [ABSTRACT FROM AUTHOR]

Recent changes to US reimbursement policies are increasingly holding providers financially accountable for patients' health. Providing nonmedical services in conjunction with primary care--known as wraparound services--is one strategy to improve patient outcomes and reduce overall health care spending. These services leverage additional providers to address patients' social determinants of health. Eskenazi Health--an Indianapolis, Indiana, safety-net provider--introduced wraparound services at its federally qualified health center sites. Behavioral health, social work, dietetics, patient navigation, and other services that address patients' social and behavioral needs are co-located with primary care services. In an eleven-year panel of primary care patients, receipt of any wraparound service was negatively associated with subsequent hospitalizations and emergency department visits. The estimated cost savings from potentially avoided hospitalizations alone was $1.4 million annually. Under value-based payment, wraparound services may be one part of a portfolio of strategies to address the social, behavioral, and environmental factors that drive poor patient health and increase costs. [ABSTRACT FROM AUTHOR]

There have been numerous initiatives for a long period of time to enhance integration in healthcare in many countries, but these processes still prove to be challenging. More research is needed to understand the interplay between different factors and different collaboration contexts, and this paper makes a contribution in this respect. We explore how collaboration can be established and sustained across organizational boundaries. Theory and methods: We draw on the concept of sense-making (Weick) as we investigate the complex interplay between structure and agency in facilitating or constraining collaboration across organizational boundaries. The empirical material consists of 35 interviews with health personnel participating in three different collaboration initiatives between primary and secondary care regarding obesity and diabetes in Norway. The health care providers involved are all public. The aim of the collaboration is to enhance knowledge sharing and to improve prevention and treatment across primary and secondary care providers tailored to the needs of the patient. The study is part of The Research Council of Norway's evaluation program of The Coordination Reform, a reform addressing coordination and collaboration in healthcare. Results: We find that structure, competence, equality and commitment are important elements to establish and sustain collaboration across organizational boundaries. Discussion: Organizational, technological and financial structures can both facilitate and constrain collaboration. When participants determine their scope of action, they do so by interpreting the latitude provided by structural frames, but also by how they interpret the interaction with others. When participants in primary and secondary care each interpret each other as competent professionals, this enhances collaboration. Furthermore, when participants in both organizations experience the relationship between them as equal, this also enhances collaboration. Likewise, if one part interprets the other part as regarding them as less competent or superior in the relationship, this represents a barrier for collaboration. Many collaboration initiatives have one or several dedicated persons who are highly committed to the collaboration and who drive the work forward in spite of many challenges. However, if not other participants in the collaboration initiatives, as well as in their local community, interpret the collaboration as meaningful and commit themselves to the work, this represents a barrier for collaboration over time. Conclusions: Collaboration depends on participants finding collaboration meaningful. Development of integrated care in our study is neither a result of structural adaptation alone, nor of strategic action alone, but a result of the interactions between concerned actors and their interpretations of structural frames and the actions of others. Implications for policy makers and practitioners are to pay attention to both agency and structure when planning for integration of healthcare services. Limitations: The majority of the informants come from primary care. This could possibly imply a bias towards perspectives from primary care. On the other hand, informants from secondary care are included, and the collaboration initiatives are originally initiated by secondary care. Suggestions for future research: Possible future research includes focusing on how different groups of patients and their carers experience these and other collaboration initiatives. [ABSTRACT FROM AUTHOR]

The author comments on the problems facing state health care reform and coverage in the U.S. He says health insurance in the country is generally accessed through employer-provided benefits and 82 percent of Americans without health insurance are in families with at least one part time worker. He discusses the Employee Retirement Income Security Act (ERISA) of 1974, which was enacted to regulate the increasing size and complexity of private pension plans provided by employers to their employees. Alternatives to mandated health insurance are explored.

Introduction: Health systems are a complex web of interacting and interconnected parts; introducing an intervention, or the allocation of resources, in one sector can have effects across other sectors and impact the entire system. A prerequisite for effective health system reorganisation or transformation is a broad and common understanding of the current system amongst stakeholders and innovators. Chronic obstructive pulmonary disease (COPD) and heart failure (HF) are common chronic diseases with high health care costs that require an integrated health system to effectively treat.Study Description: This case study documents the first phase of system transformation at a regional level in Ontario, Canada. In this first phase, visual representations of the health system in its current state were developed using a collaborative co-creation approach, and a focus on COPD and HF. Multiple methods were used including focus groups, open-ended questionnaires, and document review, to develop a series of graphical and visual representations; a health care ecosystem map.Results: The ecosystem map identified key sectoral components, inter-component interactions, and care requirements for patients with COPD and HF and inventoried current programs and services available to deliver this care. Main findings identified that independent system-wide navigation for this vulnerable patient group is limited, primary care is central to the accessibility of nearly half of the identified care elements, and resources are not equitably distributed. The health care ecosystem mapping helped to identify care gaps and illustrates the need to resource the primary care provider and the patient with system navigation resources and interdisciplinary team care.Conclusion: The co-created health care ecosystem map brought a collective understanding of the health care system as it applies to COPD and HF. The map provides a blueprint that can be adapted to other disease states and health systems. Future transformation will build on this foundational work, continuing the robust interdisciplinary co-creation strategies, exploring predictive health system modelling and identifying areas for integration. [ABSTRACT FROM AUTHOR]

The article discusses strategies to understand and resolve the complex health care system issues in the U.S. and to introduce reform in the sector as of June 2019. Topics include such theories as Systems Thinking, the book "General Systems Theory" published by Ludwig von Bertalanffy, and the field of complexity science that covers such areas as health care and management science.

Improving nursing home care has been a central legislative focus since the 1980s; The major response effort to address these reports of poor-quality care was first met with a federal rule in 1987, the Nursing Home Reform Act (NHRA). Since enactment of the NHRA in 1987, and despite an increasing utilization of nursing home care by aging minorities, the standardization of care practice, or quality indicators (e.g., structural, process, and outcome measures), within long-term nursing home care have remained relatively unchanged. This paper reports a value-critical policy analysis of the most recent final action rule, effective on November 28 of 2016 by the Centers for Medicare and Medicaid Services (CMS) with a particular focus on its impact on African-American and Latino older adults. This paper presents results of two policy analyses. Taken together, this merged analysis focuses on an overview of the problem, the groups most affected by the problem, current program goals and objectives, forms of benefits and services, and a current state of the social problem. Following the analysis, we present changes and improvements to be made, as well as proposals for reform and recommendations for policy changes. [ABSTRACT FROM AUTHOR]

The concept of commissioning is starting to gain traction in the Australian health system. Primary Care Networks began operations in July 2015 with a remit around commissioning health services. Despite the centrality of this concept, we know relatively little about commissioning in Australia. Other systems have experimented with it for some time, and this paper reviews the evidence and lessons inherent within the international literature. The study defines commissioning, and explores experiences of others who have adopted commissioning approaches and the evidence concerning the outcomes of these experiments. Commissioning is a difficult topic in many senses and its application to a complex area such as health reform can make it even more challenging. Ultimately, this evidence suggests that commissioning is more than simply a technical or operational process, but one that is value-based and relational. This is not to downplay the technical aspects, which in many jurisdictions have resulted in explicit and evidenced-based approaches to planning and priority setting. However, if new commissioning organisations, such as Primary Health Networks, are to have an impact, they need to balance the operational and relational elements of commissioning. [ABSTRACT FROM AUTHOR]

In tune with much international practice, the English National Health Service has been striving to transform health care provision to make it more affordable in the face of rising demand. At the heart of a set of recent radical reforms has been the launch of ‘clinical commissioning’ using the vehicle of local groups of General Practitioners (GPs). This devolves a large portion of the total healthcare budget to these groups. National government policy statements make clear that the expectation is that the groups will ‘transform’ the organisation and provision of health services. In this article, we draw upon interviews, observations and analysis of internal documents to make an assessment of the extent to which clinical leaders have seized the opportunity presented by the creation of these groups to attempt transformative service redesign. [ABSTRACT FROM AUTHOR]

There have been two major attempts to introduce market mechanisms into England's National Health Service: the 'internal market' reform project of the 1990s, and the 'quasi-market' of the 2000s. Despite their similarities, the former attempt was on balance unsuccessful while the latter succeeded. This article examines and compares the outcomes of the two periods, analysing the reasons for their relative successes and failures. It goes on to highlight options for future reforms that would build on those achievements. [ABSTRACT FROM AUTHOR]

In this Article, I argue that while the Patient Protection and Affordable Care Act of 2010 (PPACA and the Act) addresses health care fragmentation, it does not go far enough. In doing so, I further develop my theory of health care fragmentation--the disjunction between the legally-represented and lived experience of patients--as well as examine the meta-level issues absent from legal scholarship about the social assumptions that shape health care legislation and contribute to fragmentation. These social views fail to recognize vulnerability to illness as universal and constant across a lifetime and are reflected in legal responses to health care delivery. I examine fragmentation both before and after PPACA and offer suggestions to bring the lived and legal experiences of patients into alignment. My conception of the lived experience fits within the public policy debate about patient-centered health care, since vulnerability to illness-- while universal--is experienced and often best addressed on an individual level. [ABSTRACT FROM AUTHOR]

Young adults between the ages of 18-34 are most likely to lack health insurance in the United States. The Affordable Care Act (ACA), a federal statute signed into law in 2010, contains provisions specific to increasing access to health insurance for young adults including the provision that persons under 26 can stay on their parents' insurance. While the reasons for uninsurance among young adults have been documented, how they operate and are perceived on an individual level have not been explored in great detail. Further, it is poorly understood how the ACA policies and the state health insurance exchanges can serve young adults. Thus, we interviewed uninsured young adults aged 18-35 in northeastern Minnesota and northwestern Wisconsin and used inductive thematic analysis to explore these issues. Findings suggest that young adults don't feel at risk for health problems and therefore have low levels of health insurance literacy and place little value on health insurance. Multiple barriers to health insurance coverage, including the provision about staying on a parent's policy, persist despite the ACA. Our findings also suggest valuable lessons for state health insurance exchanges on how to better serve this population. Keywords: Health Care Access; Health Insurance; Health Policy; Young Adults; Interviews; Inductive Thematic Analysis [ABSTRACT FROM AUTHOR]

This article reviews existing models of physician compensation and presents information about current compensation patterns for primary-care physicians in the United States. Theories of work motivation are reviewed where they have relevance to the desired outcome of satisfied, productive physicians whose skills and expertise are retained in the workforce. Healthcare reforms that purport to bring accountability for healthcare quality and value-rather than simply volume-bring opportunities to redesign primary-care physician compensation and may allow for new compensation methodologies that increase job satisfaction. Physicians are increasingly shunning the responsibility of private practice and choosing to work as employees of a larger organization, often a hospital. Employers of physicians are seeking compensation models that reward both productivity and value. Mt Sinai J Med 79:490-496, 2012 © 2012 Mount Sinai School of Medicine [ABSTRACT FROM AUTHOR]

The article focuses on the failure of the U.S. Patient Protection and Affordability Act (PPACA), the health care reform signed into law in March 2010, to respect human life borne out of the abortion-funding aspects of the bill. The provisions of the Hyde Amendment and its vulnerability to political pressure are presented. Several bills that prohibit federal funding of abortions are discussed including the Capps Amendment and House Resolution (HR) 3962.

The article focuses on federal budget and Medicare. It states that 20 percent of overall health care spending in the U.S. was accounted to Medicare. It says that the share of Medicare for national health expenditures (NHE) in federal actuaries project could be stable or decline between 2011 and 2019. It mentions that viewing health care costs through the lens of federal budgeting has been conventional. It adds that three major approaches to Medicare reform have been in reality including the voucher program, proposals to moderate program spending such as the Accountable Care Organizations (ACOs), and the protection of federal budget through the direct reduction of program benefits.

In 1991, the Philippines joined a growing list of countries that reformed health planning through decentralization. Reformers viewed decentralization as a tool that would solve multiple problems, leading to more meaningful democracy and more effective health planning. Today, nearly two decades after the passage of decentralization legislation, questions about the effectiveness of the reforms persist. Inadequate financing, inequity, and a lack of meaningful participation remain challenges, in many ways mirroring broader weaknesses of Philippine democracy. These concerns pose questions regarding the nature of contemporary decentralization, democratization, and health planning and whether these three strategies are indeed mutually enforcing. [ABSTRACT FROM PUBLISHER]

Scand J Caring Sci; 2010; 24; 427–435 Left alone – Swedish nurses’ and mental health workers’ experiences of being care providers in a social psychiatric dwelling context in the post-health-care-restructuring era. A focus-group interview study The professional role of nurses and mental health workers in social psychiatry is being re-defined towards a recovery, client-focused perspective. Approximately 0.7 percent of the adult population in Sweden suffers from severe mental illness leading to a need for community services. The primary aims of the Mental Health Reform in 1995 in Sweden were to improve the quality of life for people with severe, long-term mental illness and, through normalization and integration, enhancing their opportunities to communicate with and participate in society. This study examines nurses’ and mental health workers’ views and experiences of being care providers in a municipal psychiatric group dwelling context when caring for clients suffering from severe mental illness. Three focus group interviews were made and thematic content analysis was conducted. Four themes were formulated: ‘Being a general human factotum not unlike the role of parents’, ‘Having a complex and ambiguous view of clients’, ‘Working in a mainly ‘strangled’ situation’, and ‘Feeling overwhelming frustration’. The staff, for instance, experienced a heavy workload that highly involved themselves as persons and restricted organization. The individual relational aspects of the nursing role, the risk of instrumentalizing the staff due to an organizational economical teleopathy (meaning a pathological desire to react goals), and the high societal demands on accomplishing the Mental Health Reform goals are discussed. To redefine the professional role of nurses and mental health workers in the community, in Sweden known as municipality, they need support in the form of continuously education, supervision, and dialogue with politicians as well as the public in general. [ABSTRACT FROM AUTHOR]

Israel's enactment of national health insurance was clearly a breakthrough. However, other aspects of reform that were supposed to be implemented simultaneously were stymied, in particular, the conversion of government hospitals to independent trusts and removing the Ministry of Health from the direct provision of services such as mental health and long-term care. This article explores how punctuated equilibrium and path dependency coexist in the Israeli case. In doing so, it examines the relevance of concepts provided by various theories of social and institutional change. Aside from path dependency and punctuated equilibrium, we discuss other notions derived from related theories, such as political leadership and the role of ideas. Applying these theories to the Israeli case helps better understand the coexistence of punctuated equilibrium and path dependency. [ABSTRACT FROM AUTHOR]

The article presents the conversation between David Wilsford and Lawrence D. Brown regarding the health care policy change. Wilsford shares that his view of the analytical task in looking at health policy over time is about the search for the general properties across cases. He notes that the perspective of Brown on the policy change stresses the uselessness of searching for theories to explain over time or across cases.

In 2005, New Mexico implemented a unique reform in managed behavioral health services that seeks to ensure delivery of consumer-driven, recovery-oriented care to low-income individuals. Distinguishing features of the reform are the Local Collaboratives (LCs), regionally based community organizations designed by state government to represent behavioral health concerns of New Mexico's diverse cultural populations. We examine community response to the LCs, focusing on two broad sets of themes derived from 18 months of ethnographic fieldwork. The first set—structure and function—encompasses several issues: predominance of provider versus consumer voice; insufficient resources to support internal operations; imposition of state administrative demands; and perceived lack of state response to LC efforts. The second set—participation and collaboration—reveals how problems of information flow and other logistical factors impact involvement in LCs and how the construction of “community” introduced under this initiative exacerbates tensions across localities with varied histories and populations. [ABSTRACT FROM AUTHOR]

The benefits of community partnerships have been well established in the health service literature. However, measuring these benefits and associated outcomes is relatively new. This paper presents an innovative initiative in the application of a balanced scorecard framework for measuring and monitoring partnership activity at the community level, while adopting principles of evidence-based practice to the partnership process. In addition, it serves as an excellent example of how organizations can apply scorecard methodology to move away from relationship-based partnerships and into new collaborations of which they can select - using a formal skill and competency assessment for partnership success. [ABSTRACT FROM AUTHOR]

Widespread global migration is occurring at the same time that health care delivery systems in Western nations are undergoing major restructuring. The call for health care to be more efficient, economical, and responsive to diverse cultural populations has come from several sectors, including governments and researchers. This has led to policies to address perceived deficiencies in health care services. The authors draw on their research at health care institutions in a western Canadian city to probe, first, how the concept of culture is interpreted within organizations; and second, how culture is "written into health systems" as they undergo restructuring. Meanings and interpretations of culture are not transparent; moreover, "writing in" culture is not simply a matter of health care providers learning about their clients' "belief systems" and being sensitive to these beliefs. Belief systems and people's experiences of the care they receive are negotiated within highly complex "organizational cultures," located in broader macroeconomic and political structures, and discourses that shape how health care systems are organized. The authors consider whether current discourses on cost containment are in competition with providing equitable health care services to diverse client populations. [ABSTRACT FROM AUTHOR]

Systems change has emerged as a dominant frame through which local, state, and national funders and practitioners across a wide array of fields approach their work. In most of these efforts, change agents and scholars strive to shift human services and community systems to create better and more just outcomes and improve the status quo. Despite this, there is a dearth of frameworks that scholars, practitioners, and funders can draw upon to aid them in understanding, designing, and assessing this process from a systemic perspective. This paper provides one framework—grounded in systems thinking and change literatures—for understanding and identifying the fundamental system parts and interdependencies that can help to explain system functioning and leverage systems change. The proposed framework highlights the importance of attending to both the deep and apparent structures within a system as well as the interactions and interdependencies among these system parts. This includes attending to the dominant normative, resource, regulative, and operational characteristics that dictate the behavior and lived experiences of system members. The value of engaging critical stakeholders in problem definition, boundary construction, and systems analysis are also discussed. The implications of this framework for systems change researchers and practitioners are discussed. [ABSTRACT FROM AUTHOR]

Based on an analysis of the articles in this special issue, the authors propose five operating principles for systems change work. These principles are: clarifying the purpose of the systems change; identifying whether the change is one to an existing system or the change is to create a new system; conceptualize the work as systems change from the beginning; use an eclectic approach; and be open to opportunities that emerge while also undertaking forma analysis to identify leverage points. The authors argue that the time is now ripe to develop such principles and encourage community change agents to engage in a dialogue to explore, revise, eliminate or expand on these principles. [ABSTRACT FROM AUTHOR]