Nursing Services

Questions on health service utilization in the KORA-Age study covered inpatient services, outpatient services, drug utilization, and long-term care services according to the scope of compulsory long-term care insurance (LTCI)
[20 (link),21 ] The first three domains are covered by the Statutory Health Insurance (SHI) and the last by LTCI, which is a separate branch within the German social security system covering various community-based and institutional nursing care services. LTCI defines three care levels reflecting the applicant’s need for support in activities of daily living. Each level is connected to a fixed monthly tariff for community-living and institutionalized beneficiaries.
Long-term care utilization in the KORA-Age study was assessed by asking ‘Did you use services covered by the LTCI in the past 12 months?’ and, if ‘yes’, ‘Which care level are you assigned to?’.
For inpatient services, the number of hospital days was assessed by asking ‘Have you been hospitalized in the past 12 months?’ and, if ‘yes’, ‘How many days have you been hospitalized in the past 12 months?’. Outpatient services were assessed by asking the question, ‘How often did you see a physician (general practitioner or specialist) in the past 3 months?’. Finally, drug consumption was assessed in the postal questionnaire and covered the medications taken in the past 7 days including both prescribed and over-the-counter (OTC) drugs. Participants were asked to write down the exact name and central pharmaceutical number (PZN) for each medication. The PZN is a nationwide standardized identification number for proprietary medical products in Germany enabling a well-defined attribution of a pharmaceutical product including, for example, name, package size and defined daily dose (DDD).

Data from the administration of Version 1 of the HLQ in the initial phase of a large multi-centre service improvement trial, the Ophelia (OPtimising HEalth LIteracy and Access) project [9 (link)] were used. The data were provided by 813 clients of 8 diverse community-based agencies in Victoria, Australia who were administered the HLQ during the needs assessment stage of the project. The settings and questionnaire respondents who were recruited for the study are described in detail elsewhere [9 (link), 10 (link)]. Briefly, 8 organisations providing Home and Community Care (HACC) services, Hospital Admission Risk Programs (HARP) or community nursing and other chronic disease services from 4 of 8 Department of Health (now Department of Health and Human Services) regions in Victoria were invited to participate in the Ophelia project through an expression of interest process. The respondents comprised people attending one of these 8 participating organisations. Each organisation selected a target group of clients based on a service-provision priority. The majority of the participants were expected to have a chronic health condition although this was not a pre-requisite for inclusion. Trained staff from each organisation collected data from a representative sample of clients within their target group using consecutive methods of recruitment where feasible and employing various strategies for recruiting clients who are traditionally ‘harder to reach’. Selection criteria required that participants should be cognitively able to provide informed consent to participate, and be over the age of 18 years.
Numbers in the selected organisations available for data analysis were:

A Melbourne metropolitan municipal community service = 102 cases;

A rural coastal community health service = 70;

A regional city case management service for chronic and complex clients = 132;

A Melbourne metropolitan community health service = 90;

A Melbourne outer metropolitan community health service = 108;

A Melbourne outer metropolitan municipal community service = 97;

A regional community health service = 99;

A Melbourne metropolitan domiciliary nursing service = 115.

In Bangladesh, the programme aimed to develop a streamlined and easily scaled‐up package of activities. A&T partnered initially with the Essential Health Care (EHC) programme of BRAC, a respected national non‐governmental organization (NGO) operating large community‐based public health, education and microfinance programmes. Programme design involved four components: advocacy, interpersonal counselling and community mobilization, mass communication and the strategic use of data (Box 1 and Fig. 1). All strategic decisions were evidence based. After programme launch, ongoing data from programme monitoring, assessments, small studies and quantitative surveys were used to adjust strategies. The programme thus evolved during the process of scale‐up. Summarized thereafter are the categories and timing of research conducted.

Advocacy to promote child nutrition and accelerate scale‐up of programmes:

Local, regional and national decision makers and stakeholders: Advocacy video shows on IYCF, meetings with the national alliance of over 20 stakeholders under the Institute of Public Health Nutrition (IPHN)/Government of Bangladesh (GOB), dissemination of government‐branded materials to implementing stakeholders.

Engaging journalists: Orientations and scholarships for journalists, TV talk shows and newspaper supplements.

Individualized dialogue with government decision makers and donors: MOUs, task forces and sharing evidence.

Interpersonal counselling and community mobilization

Mothers: Counselling provided through home visits at specific ages of the child on breastfeeding, complementary feeding and handwashing before feeding, and group community meetings of pregnant and lactating women with trained community workers.

Community opinion leaders: Mobilization of support for child nutrition and IYCF through orientations, video shows, seminars and forums to reach doctors, religious leaders, fathers, local government and NGOs working at community level.

Health providers: 3‐ to 5‐day in‐service training, pre‐service medical/nursing curriculum through partnerships with medical associations, mass media and print materials, messages through national and regional newspapers, wall posters for government and private clinics, job aids for government staff and materials tailored for formal and informal health practitioners.

Mass media

Families, frontline workers and opinion leaders: TV and radio spots on key topics for mothers, fathers, frontline workers and opinion leaders at all levels.

Rural community members in media dark areas: Interactive community events including village theatre, community video showings and quiz shows on IYCF and handwashing topics.

This retrospective study utilized the diagnosis procedure combination (DPC) and severity of a patient’s condition and the extent of a patient’s need for medical/nursing care (SCNMN) databases.
The DPC is a patient classification method for acute inpatients developed in Japan as a tool to make acute medical care transparent and visible. In 2003, the Ministry of Health, Labour, Welfare implemented this as a lump-sum per-diem payment system, and it is used for acute inpatient medical care and medical resource allocation. Acute care hospitals in Japan are part of this system and report medical information on medical procedures to the Ministry of Health, Labour, and Welfare.^{[20 (link),21 (link)]} As of 2020, the DPC database had been applied to 1757 facilities and 483,180 beds, accounting for 24.5% of Japan’s general hospitals and 54.4% of its beds. This DPC database collects the following information: patient age and sex; main diagnoses, preexisting comorbidities, postadmission complications linked with the international classification of diseases, and 10^th revision codes; dates of admission and discharge; route of hospital admission; discharge destination; discharge outcome; and surgical procedure.^{[20 (link),22 (link)]}The SCNMN database is an index developed in Japan for measuring the nursing services required by inpatients. It is now mainly used as a standard for paying medical expenses such as basic hospital charges for acute care. This index consists of 21 items divided into 3 categories. Item A (7 items) refers to highly specialized nursing care, including monitoring and treatment. Item B (7 items) refers to patients’ functional status, such as activities of daily living (ADL), which influence medical care. Item C (7 items) refers to medical management, such as surgical treatment and emergency care. These items are evaluated daily for each patient and compiled into a database.^{[23 (link)]}

The setting for this research was the Western Cape province where existing public–private contracting for caesarean delivery services was occurring due to human resource shortages in rural district hospitals. Five rural district hospitals within one rural district were chosen following engagement with provincial managers and obstetric clinical managers.
In SA, women with low-risk pregnancies receive antenatal care at primary care clinics and community health centres. District hospitals provide level 1 (generalist) services to inpatients and outpatients including obstetric care for women with low-risk pregnancies. District hospitals have between 30 and 200 beds, a 24-hour emergency service and an operating theatre. Generalists (medical officers) provide the services together with nursing staff and allied health professionals; some district hospitals have specialist family physicians serving as clinical managers but there are no obstetric or anaesthetic specialists at district hospital level. Most district hospitals also have community service doctors. These are doctors who have completed a 2-year internship and are required to complete a further 1 year of community service.13 None of the five hospitals had newly qualified intern medical doctors who are generally not placed within district hospitals.
For obstetric services at district hospital level, normal vaginal deliveries are performed by midwives, assisted vaginal deliveries are performed by advanced midwives or medical officers and caesarean deliveries (surgery and anaesthesia) are performed by medical officers. Pregnant women with pre-existing morbidities such as diabetes, autoimmune disorders, thyroid disease, and cardiac disease or obstetric complications such as anticipated preterm delivery, suspected intrauterine growth restrictions, pre-eclampsia, placenta praevia, abruptio placentae, multiple pregnancy, two previous caesarean sections, body mass index over 35–40 kg/m², and severe anaemia are referred for delivery to a secondary or tertiary level hospital.
Public health facilities are permitted to contract the services of private providers where needed. There are three mechanisms by which private providers can be contracted to the public service: through a locum agency, through a sessional contract which is limited to a maximum of 39 hours per month or as a service provider in response to a tender for specific services. In all three contracting models, the remuneration is time based and not related to the number of patients or theatre cases performed. In the case of obstetric services, private providers are mainly used for theatre services either as a GP surgeon or GP anaesthetist to undertake caesarean deliveries or for obstetric surgery including ectopic pregnancy, termination of pregnancy and dilatation and curettage following spontaneous miscarriage. They may also be called for an assisted delivery if the establishment doctor is unable to manage a complicated delivery. For GPs contracted through a sessional contract, medicolegal indemnity is provided by the state but for those contracted as locums or through a service provider tender, they are required to have their own medicolegal indemnity cover. In these five hospitals, the private GPs did not have medical indemnity for private obstetric practice and only performed caesarean deliveries during their public sector contracted time.