what are the types of health services research

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NCBI Bookshelf. A service of the National Library of Medicine, National Institutes of Health.

Hughes RG, editor. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Rockville (MD): Agency for Healthcare Research and Quality (US); 2008 Apr.

Patient Safety and Quality: An Evidence-Based Handbook for Nurses.

Chapter 8 health services research: scope and significance.

Donald M. Steinwachs ; Ronda G. Hughes .

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The provision of high-quality, affordable, health care services is an increasingly difficult challenge. Due to the complexities of health care services and systems, investigating and interpreting the use, costs, quality, accessibility, delivery, organization, financing, and outcomes of health care services is key to informing government officials, insurers, providers, consumers, and others making decisions about health-related issues. Health services researchers examine the access to care, health care costs and processes, and the outcomes of health services for individuals and populations.

The field of health services research (HSR) is relied on by decisionmakers and the public to be the primary source of information on how well health systems in the United States and other countries are meeting this challenge. The “goal of HSR is to provide information that will eventually lead to improvements in the health of the citizenry.” 1 Drawing on theories, knowledge, and methods from a range of disciplines, 2 HSR is a multidisciplinary field that moves beyond basic and applied research, drawing on all the health professions and on many academic disciplines, including biostatistics, epidemiology, health economics, medicine, nursing, operations research, psychology, and sociology. 3

In 1979, the Institute of Medicine defined HSR as “inquiry to produce knowledge about the structure, processes, or effects of personal health services” 4 (p. 14). This was expanded upon in 2002 by AcademyHealth, the professional organization of the HSR field, with the following definition, which broadly describes the scope of HSR:

Health services research is the multidisciplinary field of scientific investigation that studies how social factors, financing systems, organizational structures and processes, health technologies, and personal behaviors affect access to health care, the quality and cost of health care, and ultimately our health and well-being. Its research domains are individuals, families, organizations, institutions, communities, and populations. 5

More specifically, HSR informs and evaluates innovations in health policy. These include changes in Medicare and Medicaid coverage, disparities in access and utilization of care, innovations in private health insurance (e.g., consumer-directed health plans), and trends among those without health insurance. 6–10 The health care industry continues to change, and HSR examines the impact of organizational changes on access to care, quality, and efficiency (e.g., growth in for-profit hospital systems). As new diagnostic and treatment technologies are introduced, HSR examines their impact on patient outcomes of care and health care costs.

The definition of HSR also highlights the importance of examining the contribution of services to the health of individuals and broader populations. HSR applied at the population level is particularly important in understanding health system performance and the impact of health policy on the public’s health. In the United States, the National Healthcare Quality Report, 11 National Healthcare Disparities Report, 12 and Healthy People Year 2010 13 exemplify our capacity for monitoring quality and assessing change. These reports tell us that the American quality of care is inconsistent and could be substantially improved. The associated cost of health care services is monitored by the Centers for Medicare & Medicaid Services (CMS). CMS reports tell us that American health care is the most expensive in the world, consuming approximately 16 percent of America’s gross domestic product. 14

Beyond health policy, HSR examines the process of care and the interactions of patients and providers. For example, HSR methods have been developed to describe doctor-patient communication patterns and examine their impact on patient adherence, satisfaction, and outcomes of care. 15–17

Advances in HSR measurement methodologies have made possible policy innovations. Prospective payment of hospitals, nursing homes, and home health care by Medicare became possible with the development of robust case-mix measurement systems. 18 CMS was able to initiate a pay-for-performance demonstration, rewarding hospitals with better quality performance, using valid and robust measures of quality. 14 Innovations in health care policy are frequently made possible by advances in measurement of indicators of health system performance.

History of Health Services Research

The history of HSR is generally considered to have begun in the 1950s and 1960s with the first funding of grants for health services research focused on the impact of hospital organizations. 19 , 20 On the contrary, HSR began with Florence Nightingale when she collected and analyzed data as the basis for improving the quality of patient care and outcomes. 21 Also significant in the history of HSR was the concern raised about the distribution, quality, and cost of care in the late 1920s that led to one of the first U.S. efforts to examine the need for medical services and their costs, undertaken in 1927 by the Committee on the Costs of Medical Care. 22 The committee published a series of 28 reports and recommendations that have had a significant impact on how medical care is organized and delivered in the United States. 23 Other key reports of historical importance to HSR were, for example, the national health survey in 1935–1936 by the Public Health Service, the inventory of the nation’s hospitals by the American Hospital Association’s Commission on Hospital Care in 1944, and studies by the American Hospital Association’s Commission on Chronic Illness on the prevalence and prevention of chronic illness in the community. 23

In 1968, the National Center for Health Services Research and Development was established as part of the U.S. Public Health Services to address concerns with access to health services, quality of care, and costs. The Center funded demonstration projects to measure quality and investigator-initiated research grants. In 1989, Congress created the Agency for Health Care Policy and Research and broadened its mission to focus attention on variations in medical practice, patient outcomes of care, and the dissemination of evidence-based guidelines for the treatment of common disorders. Later Congress reauthorized and renamed the agency, Agency for Healthcare Research and Quality (AHRQ). AHRQ provides Federal leadership for the field, investing in methods for quality measurement, development of patient safety methods, and health information technology (e.g., electronic health records and decision support systems).

The Federal role in HSR has expanded over time, and investments in HSR are made by multiple Federal agencies. In addition to AHRQ, the U.S. Department of Veterans Affairs, Centers for Disease Control and Prevention, the National Institutes of Health, CMS, and other Federal agencies fund HSR. The diversification of funding comes, in part, from the recognition that HSR is important in managing health care systems, such as the Veterans Health Administration, and provides essential information on the translation of scientific discoveries into clinical practice in American communities, such as those funded by National Institutes of Health. It is estimated that total Federal funding of HSR was $1.5 billion in 2003, of which AHRQ was responsible for approximately 20 percent. 24

Private funding of HSR has also grown over time. Funding by private foundations has a significant role and complements Federal funding. Among the many foundations funding HSR are the Robert Wood Johnson Foundation, Commonwealth Fund, Kaiser Family Foundation, Kellogg Foundation, and Hartford Foundation. Other private funding sources include the health care industry, for example, pharmaceutical companies, health insurers, and health care systems.

Goals for Health Services and Patient Outcomes

The goal of health services is to protect and improve the health of individuals and populations. In a landmark 2001 report, Crossing the Quality Chasm: A New Health System for the 21 st Century, 25 the Institute of Medicine (IOM) of the National Academy of Sciences proposed that the goals for health services should include six critical elements:

Patient Safety: Patients should not be harmed by health care services that are intended to help them. The IOM report, To Err Is Human , 26 found that between 46,000 and 98,000 Americans were dying in hospitals each year due to medical errors. Subsequent research has found medical errors common across all health care settings. The problem is not due to the lack of dedication to quality care by health professionals, but due to the lack of systems that prevent errors from occurring and/or prevent medical errors from reaching the patient.
Effectiveness: Effective care is based on scientific evidence that treatment will increase the likelihood of desired health outcomes. Evidence comes from laboratory experiments, clinical research (usually randomized controlled trials), epidemiological studies, and outcomes research. The availability and strength of evidence varies by disorder and treatment.
Timeliness: Seeking and receiving health care is frequently associated with delays in obtaining an appointment and waiting in emergency rooms and doctors’ offices. Failure to provide timely care can deny people critically needed services or allow health conditions to progress and outcomes to worsen. Health care needs to be organized to meet the needs of patients in a timely manner.
Patient Centered: Patient-centered care recognizes that listening to the patient’s needs, values, and preferences is essential to providing high-quality care. Health care services should be personalized for each patient, care should be coordinated, family and friends on whom the patient relies should be involved, and care should provide physical comfort and emotional support.
Efficiency: The U.S. health care system is the most expensive in the world, yet there is consistent evidence that the United States does not produce the best health outcomes 27–30 or the highest levels of satisfaction. 31 The goal is to continually identify waste and inefficiency in the provision of health care services and eliminate them.
Equity: The health care system should benefit all people. The evidence is strong and convincing that the current system fails to accomplish this goal. The IOM report, Unequal Treatment , 32 documented pervasive differences in the care received by racial and ethnic minorities. The findings were that racial and ethnic minorities are receiving poorer quality of care than the majority population, even after accounting for differences in access to health services.

Crossing the Quality Chasm concludes that for the American health care system to attain these goals, transformational changes are needed. 25 The field of HSR provides the measurement tools by which progress toward these goals is assessed, as seen in the National Healthcare Quality Report. 11 Equally important, health services researchers are developing and evaluating innovative approaches to improve quality of care, involving innovations in organization, financing, use of technology, and roles of health professionals.

Evaluating the Quality of Health Care

HSR evaluation of quality of care has proven to be an inexact science and complex, even though its definition is relatively simple: “Quality of care is the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.” 1 This definition draws attention to the importance of the application of current professional knowledge in the diagnostic and treatment processes of health care. The goal of quality care is to increase the likelihood of achieving desired health outcomes, as expressed by the patient.

The complexity in measuring quality comes from gaps in our knowledge regarding which services, for which patients, will actually improve the likelihood of desired health outcomes. Also, patients need not have the same desired health outcomes and therefore might not receive the same care for an identical health problem, further complicating the measurement of quality of care. Quality measurement has advanced substantially, but it remains early in its development.

The conceptual framework widely applied in evaluating quality comes from years of research and the insightful analysis of Avedis Donabedian. 33 He formalized the conceptual model for describing, analyzing, and evaluating the quality of care using three dimensions: (1) structure, (2) process, and (3) outcome. This model is applied in the evaluation of health services and the accreditation of health care providers and organizations.

Seminal research about variation in the quality of care patients received brought to focus the need to monitor and improve the quality of health care. Wennberg and Gittelsohn 34 , 35 found wide variation in practice patterns among community physicians, surgical procedures, and hospitals. Brook and colleagues 36 found that a small number of physicians were responsible for a large number of improperly administered injections. This was the precursor to research on the appropriateness of procedures and services under specific circumstances 36 , 37 as well as the development of practice guidelines and standards for quality care. 38 Yet the challenge of research on variations in care is the implication of the inappropriateness of care. The challenge is determining whether there is a direct relationship between rates of utilization, variations in appropriateness, and quality of care.

One of the challenges in understanding quality, how to measure it, and how to improve it is the influence of physical, socioeconomic, and work environments. Income, race, and gender—as well as individuals within society and organizations—influence health and risks to health. 40 Researchers have found that differences in internal factors, such as collaborative relationships with physicians, decentralized clinical decisionmaking, and positive administrative support, impact nurse and patient outcomes 41 , 42 and the quality and safety of care. 43 Differences in external factors, such as insurance and geographic location, can influence access to available health care professionals and resources, what type of care is afforded patients, and the impact of care on patients. The structure, process, and outcome dimensions of quality are influenced by both internal and external factors.

Structure of Health Care

The structure of health care broadly includes the facilities (e.g., hospitals and clinics), personnel (e.g., number of nurses and physicians), and technology that create the capacity to provide health services. Structural characteristics are expected to influence the quality of health care services. One component in the accreditation of health care facilities (e.g., hospitals, nursing homes) is the review of the adequacy of structural characteristics, including staffing, on-call resources, technology, and support services (laboratory, pharmacy, radiology). The structural resources of health care facilities and organizations are the foundation upon which quality health care services are provided.

Process of Care

The interactions between the health care providers and patients over time comprise the process of health care. The process of care may be examined from multiple perspectives: the sequence of services received over time, the relationship of health services to a specific patient complaint or diagnosis, and the numbers and types of services received over time or for a specific health problem. Examining the time sequence of health care services provides insights into the timeliness of care, organizational responsiveness, and efficiency. Linking services to a specific patient complaint or diagnosis provides insights into the natural history of problem presentation and the subsequent processes of care, including diagnosis, treatment, management, and recovery. Examining the natural history of a presenting health complaint across patients will reveal variations in patterns of care. For example, presenting complaints for some patients never resolve into a specific diagnosis. An initial diagnosis may change as more information is obtained. Patients may suffer complications in the treatment process. Also, the process of care may provide insights into outcomes of care (e.g., return visit for complications). Generally it is not possible to examine the process of care and determine how fully the patient has recovered prior health status by the end of the episode of treatment. For this reason, special investigations are needed to assess outcomes of care.

Evaluation of the process of care can be done by applying the six goals for health care quality. 25 Was the patient’s safety protected (i.e., were there adverse events due to medical errors or errors of omission)? Was care timely and not delayed or denied? Were the diagnosis and treatments provided consistent with scientific evidence and best professional practice? Was the care patient centered? Were services provided efficiently? Was the care provided equitable? Answers to these questions can help us understand if the process of care needs improvement and where quality improvement efforts should be directed.

Outcomes of Care

The value of health care services lies in their capacity to improve health outcomes for individuals and populations. Health outcomes are broadly conceptualized to include clinical measures of disease progression, patient-reported health status or functional status, satisfaction with health status or quality of life, satisfaction with services, and the costs of health services. Historically, quality assessment has emphasized clinical outcomes, for example, disease-specific measures. However, disease-specific measures may not tell us much about how well the patient is able to function and whether or not desired health outcomes have been achieved. To understand the patients’ outcomes, it is necessary to ask patients about their outcomes, including health status, quality of life, and satisfaction with services. HSR has developed valid and robust standardized questionnaires to obtain patient-reported information on these dimensions of health outcomes. As these are more widely applied, we are learning about the extent to which health care services are improving health.

Public Health Perspective on Health Services

Another perspective on health care services comes from the field of public health in which preventive health services are conceptualized at three levels: primary, secondary, and tertiary prevention. 44 Primary prevention includes immunizations, healthy lifestyles, and working and living in risk-free environments. Primary prevention seeks to prevent disease or delay its onset. Examples of primary prevention include immunizations against infectious disease; smoking prevention or cessation; and promotion of regular exercise, weight control, and a balanced diet. Secondary prevention includes the range of interventions that can reduce the impact of disease morbidity once it occurs and slow its progression. With the increasing burden of chronic diseases, much of the health care provided is directed at secondary prevention. Tertiary prevention is directed at rehabilitation for disabilities resulting from disease and injury. The goal of tertiary prevention is to return individuals to the highest state of functioning (physical, mental, and social) possible. The public health framework expands the structure, process, and outcome conceptual model by identifying the role and value of health services at three stages: prior to onset of disease, disease management, and disease recovery and rehabilitation.

Methodologies and Data Sources Used in Health Services Research

The interdisciplinary character of HSR draws on methods and data sources common to the many disciplines that form the intellectual underpinnings of the field. This section discusses the measurement of effectiveness and efficacy of health services and some of the methods and data sources used to understand effectiveness. Effectiveness is one of the six goals of health services. Effectiveness is interrelated with the other five goals, and some of these interrelationships are discussed.

Efficacy and Effectiveness

An important distinction is made between efficacy and effectiveness of health services. Efficacy is generally established using randomized controlled trial (RCT) methods to test whether or not clinical interventions make a difference in clinical outcomes. A good example is the series of studies required for Food and Drug Administration approval of a new drug before it is certified as safe and efficacious and allowed to be used in the United States. Efficacy research is generally done with highly select groups of patients where the impact of the drug can be validly measured and results are not confounded by the presence of comorbid conditions and their treatments. The efficacy question is: What impact does a clinical intervention have under ideal conditions?

In contrast, effectiveness research is undertaken in community settings and generally includes the full range of individuals who would be prescribed the clinical intervention. Many of these individuals will have multiple health problems and be taking multiple medications, unlike those who were recruited to the RCT. Effectiveness research is seeking to answer the question: Who will benefit from the clinical intervention among all those people in the community who have a specific health problem(s)?

Both efficacy and effectiveness questions are important. Logically, effectiveness research would be conducted after finding the clinical intervention to be efficacious. However, there are many treatments for which no efficacy information exists; the treatments are accepted as common practice, and it would not be ethical to withhold treatments from a control group in an RCT. As a result, effectiveness research may not have the benefit of efficacy findings.

The routine use of an RCT to evaluate efficacy began in the 1960s and is the accepted procedure for evaluating new medications. However, this standard is not applied across all health care services and treatments. Most surgical procedures are not evaluated using an RCT. Intensive care units have never been evaluated using an RCT, nor are nurse staffing decisions in hospitals or the evaluation of many medical devices. We currently accept different standards of evidence depending on the treatment technology. As a result, the level of evidence guiding clinical and public health decisionmaking varies.

Methods for Effectiveness Research

A variety of methods are used to examine effectiveness of health services. RCT methods are not usually applied in effectiveness research because the intervention being studied has demonstrated efficacy or is acknowledged as accepted clinical practice. When this is true, it would be unethical to randomly assign individuals who would be expected to benefit from the intervention to a control group not receiving an efficacious treatment. We will discuss when RCT methods can be used to test effectiveness and provide several examples. More commonly, effectiveness research uses statistical methods for comparing treatments across nonequivalent groups.

RCT and Policy Research

RCT study methods can be used to compare the effectiveness and costs of services across randomly assigned representative population groups. In an RCT, study participants are randomly assigned to two or more groups to ensure comparability and avoid any selection bias. At least one group receives an intervention (clinical, organizational, and/or financial), and usually one group serves as a control group, receiving a current standard of care, sometimes referred to as “usual care.” Two examples of effectiveness research using an RCT methodology to answer policy questions are described.

Health insurance experiment

Probably the first application of RCT methods in effectiveness research was undertaken in the 1970s as a health insurance experiment. The experiment was designed to test the impact on cost and health outcomes of different levels of insurance deductibles and copayment rates. A total of 3,958 people, ages 14–61, were randomized to a set of insurance plans and followed over 3 to 5 years. 45

The economic impact of receiving free care in one plan versus being in a plan requiring payment out-of-pocket of deductibles and co-insurance had the expected impact on utilization. Those paying a share of their medical bills utilized approximately one-third fewer doctor visits and were hospitalized one-third less frequently.

The impact on 10 health measures of free health insurance versus paying a portion of medical care costs out of pocket was evaluated. The findings were that there was largely no effect on health as measured by physical functioning, role functioning, mental health, social contacts, health perceptions, smoking, weight, serum cholesterol, diastolic blood pressure, vision, and risk of dying. 46 The exceptions were that individuals with poor vision improved under free care, as did low-income persons with high blood pressure.

Medicare preventive services experiment

A more recent example of RCT methods applied in HSR is the Baltimore Medicare Preventive Services Demonstration. The study evaluated the impact on cost and outcomes of offering a defined preventive services package to Medicare beneficiaries. This was compared to usual Medicare coverage, which paid for few preventive services. The preventive services coverage being evaluated included an annual preventive visit with screening tests and health counseling. The physician could request a preventive followup visit during the year, which would also be covered. Medicare beneficiaries (n = 4,195) were randomized to preventive services (the intervention group) or usual care (the control group). Sixty-three percent of those in the intervention group had at least one preventive visit. Significant differences were found in health outcomes between intervention and control groups. Among the 45 percent with declining health status, as measured by the Quality of Well-Being scale, 47 the decline was significantly less in the group offered preventive services. Mortality was also significantly lower in the intervention group. There was no significant impact of preventive services on utilization and cost. 48

Comparative Clinical Effectiveness and RCTs

The passage of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA) included provisions for the funding of comparative effectiveness studies. AHRQs’ Effective Health Care Program (authorized under MMA Section 1013) informs comparative clinical effectiveness efforts by conducting and supporting research and evidence syntheses on priority topics to CMS.

Comparative effectiveness studies ask the question: Which of the alternative treatments available is best and for whom? Interest in this question reflects how advances in science have provided multiple treatment options for many conditions. Currently, there is no systematic process by which treatment options are compared and matched to the needs of different types of patients. Frequently, patients are started on one treatment and then may be prescribed alternative treatments if they cannot tolerate the treatment or if it is not as effective as expected. RCT methods can be used to evaluate comparative effectiveness of an intervention in treatment and control populations. This is ethical to do when there is no evidence that the treatments are not equivalent.

An example of a comparative effectiveness study using RCT methods is the CATIE study, testing alternative antipsychotic medications in the treatment of schizophrenia. A study of 1,493 persons with schizophrenia compared five of the newer antipsychotic medications (second generation) and also compared them against one of the first-generation antipsychotic medications. 49 , 50 The findings were surprising to many. The second-generation antipsychotics were no more effective in controlling psychotic symptoms than the first-generation drug. There was one exception, the drug Clozapine. 51 Furthermore, second-generation medications showed significant side effects that can affect health outcomes. These included weight gain, metabolic changes, extrapyramidal symptoms, and sedation effects. Each medication showed a somewhat different side-effect risk profile. From a positive perspective, the findings indicated that the clinician and patient can choose any of these medications as first-line treatment except Clozapine, which is generally used for treatment-resistant cases due to more intensive clinical monitoring requirements. The ultimate choice of treatment will depend on the patient’s ability to tolerate side effects that vary by drug.

The conduct of any RCT is resource intensive, requiring the recruitment of participants, and participants must give informed consent to be randomized. The rationale for making this investment may depend on the importance of the policy or practice issue. As shown, RCT methods can be applied to address policy and clinical care concerns with effectiveness. To the extent that the RCT includes a broad cross-section of people who would be affected by a policy or receive a clinical treatment, this methodology provides robust effectiveness findings.

Comparing Effectiveness and Costs Across Nonequivalent Groups

A range of statistical methods can be used to compare nonequivalent groups (i.e., groups receiving different treatments or exposures when there has been no random assignment to ensure comparability of group membership). It is not practical to review all the specific statistical approaches that can be applied. In general, the statistical methods seek to adjust for nonequivalent characteristics between groups that are expected to influence the outcome of interest (i.e., make the comparisons fair). Statistical adjustment for nonequivalent characteristics is referred to as “risk adjustment.” The foundations for risk adjustment come from multiple disciplines. Epidemiologic methods are routinely used to identify and estimate disease and outcomes risk factors. These methods are applicable in comparative effectiveness evaluations. 52

Operations research uses methods for creating homogeneous groups predictive of cost or disease outcomes. These methods are used to make fair comparisons across provider practices and health plans and to control the cost of health care. They also have been used in designing payment systems, including diagnostically related groups used in Medicare’s Prospective Payment System to reimburse hospitals for care rendered to Medicare beneficiaries, and resource-based relative value scales used in Medicare’s physician payment system. Diagnostically related groups are used to standardize and rationalize patient care in hospitals—provided largely by nurses and other health professionals—and resource-based relative value scales are used to standardize and rationalize patient care in outpatient settings—care provided largely by physicians and nurse practitioners. Other disciplines also contribute to our understanding of risk factors for the range of health outcomes, including mortality, health and functional status, quality of life, and rehabilitation and return to work

The basic form of a nonequivalent group comparison includes adjusting the outcomes of each group for the risk factors that are known to affect the occurrence and/or severity of the outcomes being evaluated. 53 For many disease outcomes, risk factors include demographic characteristics (age, gender), disease-specific risk factors (e.g., health behaviors, environmental exposures, and clinical indicators of risk), and indicators of health status (e.g., presence of comorbid conditions). After adjustment for risks factors, variations in access to care and quality of care (e.g., choice of treatment and adherence to treatment) would be expected to explain the remaining observed variation in outcomes. Ideally, the nonequivalent group comparison makes it possible to compare the effectiveness of alternative treatments and assess the impact of poor access to care. One limitation of this methodology is the limit of current knowledge regarding all relevant disease risk factors. Even when risk factors are known, limits on data availability and accuracy of risk factor measurement have to be considered.

Risk adjustment methods are also used to make cost comparisons across health care providers to determine which providers are more efficient. Instead of adjusting for disease risk factors, adjustments are made for the costliness of the patient mix (case mix) and differences in costs of labor, space, and services in the local area. Comparisons may be made to assess efficiency of providing specific services (e.g., hospitalization, office visit, or laboratory test). These comparisons would use case-mix measures that adjust for the costliness of different mixes of hospital episodes. 18 Comparisons of the total cost of care for insured populations would apply case-mix measures that adjust for disease and health factors that affect total cost of care. 54

Data Sources for Effectiveness Research

A range of data sources is used in effectiveness research, including administrative and billing data, chart reviews and electronic health records, and survey questionnaires. The following discussion identifies major attributes of each category of data source.

Medical records

Medical records document the patient’s presenting problem or condition, tests and physical exam findings, treatment, and followup care. The medical record is generally the most complete source of clinical information on the patient’s care. However, medical records are generally not structured to ensure the physician or other provider records all relevant information. The completeness of medical record information can vary considerably. If the patient does not return for followup care, the medical record may provide no information on outcomes of care. If a patient sees multiple providers during the course of treatment, each with its own separate medical record, complete information on treatment requires access to all the records. Lack of standardization of medical records also can make abstracting records for research very resource intensive.

Administrative and billing data

Health care providers generally have administrative and billing data systems that capture a limited and consistent set of data on every patient and service provided. These systems uniquely identify the patient and link information on insurance coverage and billing. Each service received by the patient is linked to the patient using a unique patient identifier. Services are identified using accepted codes (e.g., ICD9-CM, CPT), together with date of service, provider identifier, and other relevant information for billing or management reporting. Administrative data make it possible to identify all individual patients seen by a provider and produce a profile of all services received by each patient over any defined time period. Administrative data are comprehensive and the data are generally complete (i.e., no problems with missing data). The primary limitation is the data set collected by administrative systems is very limited and lacks the detail of the medical record.

Administrative data systems can provide some insights into quality and outcomes of care. AHRQ has developed software that provides quality indicators and patient safety measures using one administrative data set, hospital discharge abstracts. 55 , 56 Utilization-based indicators of outcome include rehospitalization, return to surgery during a hospitalization, and incidence of complications; some systems include information on death. Administrative data can efficiently provide quality and outcomes indicators for defined populations and for health systems. Other applications of administrative data include assessing efficiency, timeliness, and equity. The limitation is that there are many health conditions and health outcomes that cannot currently be measured using administrative data.

Survey questionnaires

Neither the medical record nor the administrative data capture information on the patient’s experience in health or patient-reported outcomes of care. Survey questionnaires are routinely used to obtain information on patient satisfaction in health plans. A widely used example is the Consumer Assessment of Healthcare Providers and Systems or CAHPS. 57

Information on the impact of health conditions on health and functional status has to come from the patient. This may be obtained at the time of a visit or hospitalization. However, to assess patient outcomes of care, systematic followup of patients after the completion of treatment is generally required. This can be done using mail questionnaires, telephone interviews, or in-person interviews. The HSR field has developed health-status and quality-of-life measures that can be used no matter what health conditions the patient has. 47 , 58–60 Numerous condition-specific measures of outcome are also used. 53

Effectiveness research relies on a range of data sources. Some are routinely collected in the process of medical care and patient billing. Others may require special data collection, including medical record abstracts to obtain detailed clinical data and survey questionnaires to gain information on the patient’s perspective on treatment and outcomes. Efficient strategies for examining effectiveness may use administrative data to examine a limited set of data on all patients, and a statistically representative sample of patients for in-depth analysis using data from chart abstracts and survey questionnaires.

Using HSR Methods To Improve Clinical Practice

HSR research tools can be applied in clinical settings to improve clinical practice and patient outcomes. These tools are used as part of quality improvement programs in hospitals, clinics, and health plans. Two examples illustrate applications to improve quality-of-care performance.

Evidence-based treatment

For many chronic medical conditions, clinical research has evaluated the efficacy of diagnostic methods and treatment interventions. As a result, evidence-based reviews of research literature can provide a basis for establishing quality-of-care criteria against which to judge current practice. In a national study of quality of medical care, it was found that only 55 percent of patients received evidence-based treatments for common disorders and preventive care. 61 The researchers examined treatment for a range of health conditions, using a national sample of medical records abstracts. For each quality criterion, a classification was applied to determine if the quality-of-care deficiency was one of underuse, overuse, or misuse. Greater problems were found with underuse (46 percent) than with overuse (11 percent). Quality of care varied by condition: senile cataracts scored highest, 78 percent of recommended care received, and alcohol dependence scored lowest, 10 percent of recommended care received. Overall, only about half of recommended care was received, frequently due to underuse of services.

Researchers have sought to identify why rates of conformance with evidence-based treatments are low. Frequently cited barriers to evidence-based practice include physician disagreement with the evidence, perception that patients will not accept treatment, low ratings of self-efficacy as a provider of the treatment, and difficulty of integrating the evidence-based treatment into existing practice. 62 More needs to be learned how to assist health care providers to overcome barriers to the adoption of evidence-based practices.

The described data sources and methods can be applied in clinical settings to assess conformance to evidence-based quality criteria and provide feedback to clinicians. If electronic health records are available, the feedback and reminders may be directly incorporated into the medical record and seen by the clinician at the time of a visit. Intermountain Health Care utilizes its electronic health records to monitor adherence to evidence-based quality standards and to provide decision support to clinicians when seeing patients. This strategy has contributed to substantial improvements in their quality performance. 63

Outcomes management system

In 1988, Paul Ellwood proposed the adoption of outcomes management system (OMS) as a method to build clinical intelligence on “what treatments work, for whom, and under what circumstances.” 64 OMS would require linking information on the patient’s experience with outcomes of care and information on diagnosis and treatment that would usually come from the medical record.

In 1991, the Managed Health Care Association, an employer organization, brought together a group of employers and their health plan partners who were interested in testing the OMS concept in health plans. 65 To do so would require a set of methods that could be widely applied across health plans with differing information systems. The methodology chosen was for each of 16 health plans to identify all adult enrollees with at least two diagnoses of asthma over the previous 2 years. A stratified sample was chosen with half of the enrollees having more severe asthma (e.g., hospitalization or emergency room visit in the past 2 years) and the other enrollees having less severe asthma (outpatient visits only). Each adult received a questionnaire asking about their asthma treatment and health status. Followup surveys were done in each of 2 successive years to track changes over time.

The findings were compared to national treatment recommendations for adult asthma. 66 Across the health plans, 26 percent of severe asthmatics did not have a corticosteroid inhaler, and 42 percent used it daily, as recommended. 67 Only 5 percent of patients reported monitoring their asthma using a home peak flow meter. Approximately half of adults with asthma reported having the information they needed to avoid asthma attacks, to take appropriate actions when an asthma flare-up occurs, and to adjust medications when their asthma gets worse. Health plans used the baseline findings to develop quality-improvement interventions, which varied across health plans. Followup surveys of the patient cohort provided feedback to health plans on their success in improving asthma treatment and outcomes over time.

This chapter has provided a definition and history of the field of health services research and discussed how this field is examining quality-of-care issues and seeking to improve quality of care. Comparisons of current practice to evidence-based standards with feedback to clinicians and the integration of patient-reported outcomes are two examples of how HSR tools can be used to provide quality-improvement information for health care organizations. These examples utilize multiple data sources, including medical records, patient surveys, and administrative data. The opportunities for nurse researchers to provide invaluable contributions to the growing field of health services research are innumerable.

Cite this Page Steinwachs DM, Hughes RG. Health Services Research: Scope and Significance. In: Hughes RG, editor. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Rockville (MD): Agency for Healthcare Research and Quality (US); 2008 Apr. Chapter 8.
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Research Training in the Biomedical, Behavioral, and Clinical Research Sciences (2011)

Chapter: 8 health services research, 8 health services research.

Health services research (HSR) provides the information needed to understand the effectiveness and efficiency of our health care delivery system and its impact on the health and well-being of individuals and populations. 1 Health services research documents deficiencies in patient and population health and in the provision of health services and seeks to identify contributing factors. There are many examples: being uninsured in America reduces access to health care and contributes to poorer health outcomes (Institute of Medicine [IOM] reports on uninsured); medical errors too frequently occur in hospitals and many patients suffer injury or death (IOM, 1999); and in the community, only half of the time are individuals receiving preventive and chronic disease care consistent with scientific evidence (McGlynn, 2003).

Health services researchers seek solutions to these and other problems that adversely affect access to care, quality, safety, and cost of care. Health services research evaluates the impact of government and private-sector health policies, designs and evaluates innovations in health care organization and financing, and examines the effects of new technologies or new uses of existing technologies. Assessing the impact of health services on population health requires health services researchers to go beyond disease outcomes to examine health status and health-related quality of life outcomes, assess delivery system quality and efficiency, as well as focus attention on prevention and health promotion services.

The contributions of health services research to policy, management, and clinical care have been diverse. Planners and policy makers, for example, are frustrated by the inability to generalize and use findings from efficacy studies: persons recruited to randomized control trials testing new treatments typically are not representative of the larger population expected to benefit from the treatment. Thus, it is up health services research to fill this information gap by assessing the impact of diagnostic and treatment technologies on patient outcomes and costs across real-world practice settings and diverse populations.

Translational research has emerged as an important dimension of health services research design and analysis; translational research provides the knowledge base to move scientific discoveries from laboratory, clinical, or population studies into clinical applications at the National Cancer Institute. Yet translation alone is generally not sufficient to ensure these services are available across America. Implementation research is needed to effectively adapt new clinical applications to diverse real-world practice settings in which programs, tools, and guidelines will be utilized and need to be integrated into the existing hospitals and community practice settings (Rubenstein and Pugh, 2006). Together translation and implementation research are gaining greater visibility as we have come to recognize that many Americans are failing to receive consistent high-quality health care based on the latest scientific knowledge. Meeting the challenges of translation and implementation research requires additional disciplinary breadth, drawing on areas of organizational and operations research, psychology, marketing, education, and adult learning. Also expanded applications of health information technology are needed in support of consumer-patient decision making and real-time decision support for health care providers. The rapid growth and continuing change in scientific health information will result in the translation and implementation processes being continual and not one-time or infrequent events. The capacity to achieve this goal may require fundamental re-thinking of information flow and how it supports all aspects of health services.

Central to advances in all scientific fields are measurement tools, and for health services research measurement tools span payment and financing, appropriateness of utilization (overuse, underuse, and misuse; IOM, 2001), quality of care, and patient outcomes of care. Health services research

has provided the measurement tools being used in payment for inpatient hospital services, outpatient services, and nursing home care, as well as capitation payment methods for persons enrolled in health plans. Improved payment methods are making it possible to adjust payment for quality of care and to better reward efficiency. These measurement tools, and others to be developed, will be needed to monitor and evaluate the impact of the 2010 Health Reform legislation and how well it achieves its goals. Examples of quality-of-care measures that will require further development include: assessing the timeliness of health care, measuring coordination of patient care when multiple providers are involved in diagnosis and treatment, providing patient-centeredness of care, and equity of health care. Although these are not new, there are few if any accepted measurement tools to assess deficiencies and progress toward the goals of health reform. The training and support of researchers who focus on measurement is a continuing and growing need in health services research.

Since 2003 Congress has provided support to the Agency for Healthcare Research and Quality (AHRQ) to develop and fund comparative effectiveness research (CER). In 2009, the American Recovery and Reinvestment Act (ARRA) augmented CER support with $1.1 billion for research and training through AHRQ, the National Institutes of Health, and the Office of the Secretary of Health and Human Services (HHS). CER as defined by HHS combines key elements of health services and clinical research:

Comparative effectiveness research is the conduct and synthesis of research comparing the benefits and harms of different interventions and strategies to prevent, diagnose, treat and monitor health conditions in “real world” settings. The purpose of this research is to improve health outcomes by developing and disseminating evidence-based information to patients, clinicians, and other decision-makers, responding to their expressed needs, about which interventions are most effective for which patients under specific circumstances.

To provide this information, comparative effectiveness research must assess a comprehensive array of health-related outcomes for diverse patient populations and sub-groups.

Defined interventions compared may include medications, procedures, medical and assistive devices and technologies, diagnostic testing, behavioral change, and delivery system strategies.

This research necessitates the development, expansion, and use of a variety of data sources and methods to assess comparative effectiveness and actively disseminate the results.

The expectation is that CER will provide new information that is not currently available about what treatments and services work best for individuals across America’s diverse populations, taking into consideration the person’s circumstances and the timing of services. The new CER mandate complements the initiatives discussed above in translation and implementation research, intensifying the focus on research driving health system transformation to achieve better health outcomes for all Americans and greater efficiency.

FEDERAL SUPPORT OF HEALTH SERVICES RESEARCH

In 1968, Congress recognized the emerging role of health services research for improving health care delivery in the United States and created the National Center for Health Services Research and Development (NCHSRD) in the Department of Health, Education, and Welfare (DHEW). During the years 1968-1989, NCHSRD sought to develop research on issues of access, cost, and quality, and to develop data systems to support research on utilization and cost of care. 2 However, over time the budget for NCHSRD declined and the future of the NCHSRD became uncertain. Private foundations played a critical role in sustaining the health services research field during these years. 3

In 1989, health services research once again found strong support in Congress and a new vision for health services research was created in the authorization of the Agency for Health Care Policy and Research (AHCPR). Congress directed the Agency—subsequently renamed the Agency for Healthcare Quality and Research—to undertake research on patient outcomes, develop practice guidelines, and disseminate the research to change the practice of medicine. 4 The agency placed greater emphasis than previously on the examination of clinical practice, decision making, and comparative effectiveness of alternative approaches to diagnosis and treatment. The funding for AHRQ has grown over the years from $128 million in fiscal year 1993 to $397 million in fiscal year 2010, plus $300 million in CER funding from the ARRA appropriation.

While the National Research Service Awards (NRSA) program included support for health services research from its inception (see, for example, NRC, 1977), Congress specified in 1989 that one-half of 1 percent of the NRSA budget for training be allocated for training health services researchers through AHRQ, subsequently expanding that

allocation to 1 percent of NRSA funding in 1999, which has remained unchanged.

It should be noted that in the early 1990s Congress authorized a 15 percent set-aside for both research and NRSA training in service-related research supported by the National Institute of Mental Health (NIMH), the National Institute of Drug Abuse (NIDA), and the National Institute of Alcohol Abuse and Alcoholism (NIAAA) as part of the reorganization of the former Alcohol, Drug Abuse and Mental Health Administration into the National Institutes of Health. Even with this congressionally mandated set-aside for these NIH institutes, AHRQ remained the lead agency for health services research. NIH funding has been directed at HSR focused on questions related to the delivery of health care for specific diseases/disorders. AHRQ and NIH fund complementary research and in many instances have co-funded major health services research studies.

HEALTH SERVICES RESEARCH WORKFORCE

No national statistical system reports on the size and composition of the health services research workforce (Moore and McGinnis, 2009; Pittman and Holve, 2009). Obtaining information on the workforce in this field is a challenge. Identifying scientists who primarily do health services research is complicated by the interdisciplinary nature of the field. Health services research is an applied field, and so most health services researchers have another unique discipline or profession that they bring to health services research. Workforce data usually classify health services researchers by their primary discipline or profession and often are unable to identify the field of scientific inquiry as health services research. As NIH moves more toward trans-disciplinary research, the problem of not having multiple classifications incorporating both discipline and field of application may be an issue faced by many basic sciences and clinical researchers, as well as health services research.

In addition, anecdotal evidence suggests that some investigators involved in health services research studies do not identify themselves as health services researchers, nor do they necessarily belong to the only national professional association in this area, namely AcademyHealth. This partial or part-time involvement of many scientists in health services research only further complicates efforts to estimate the size and composition of the health services research workforce.

McGinnis and Moore addressed this issue in their study on the current status of the health services research workforce. In a conservative estimate of the field, counting HSRProj investigators (since 2004), speakers from AcademyHealth’s Annual Research Meeting in 2007, and AcademyHealth members whose membership has lapsed or joined in 2000 or later, Moore and McGinnis found that the field has more than doubled in size since the IOM’s estimate in 1995, growing from approximately 5,000 health services researchers to more than 13,000 researchers in 2007. Using a more expansive definition of the field by including researchers in disciplinary associations with subgroups that sometimes do health services research, such as the American Public Health Association, the American Society of Health Economists, the American Statistical Association, and the American Sociological Association, there could be an additional 6,000 intermitted members of the field (Moore and McGinnis, 2009).

The best data available on the composition of health services research workforce 5 likely comes from the most recent AcademyHealth membership survey in 2008 (AcademyHealth, 2008). AcademyHealth draws its members from both health services research and health policy, and includes student memberships. Although this database more than likely underestimates the total size of the workforce, it does provide some insights into its composition.

As of 2008, 51 percent of AcademyHealth’s 3,500 individual members report having a Ph.D., Sc.D., or other doctoral-level training in science. There are another 12 percent reporting an M.D. Table 8-1 shows the distribution of health services researchers by employment sector.

AcademyHealth membership has greater female representation (60.7 percent) than male (39.3 percent). This representation has changed slightly from AcademyHealth’s survey of members in 2002, when 55 percent of the respondents were women and 45 percent were men. Of note is that the youngest members were twice as likely to be female as to be male, while the oldest respondents were twice as likely to be male as to be female. The ethnic mix of members is 21 percent from minority ethnic backgrounds, including Asian/Pacific Islanders (10.6 percent), African Americans (5.2 percent), and Hispanics/Latinos (2.6 percent), plus 79 percent Caucasian and 2.5 percent other. Representation of all minorities has increased since 2002—to 21 percent from 12.8 percent.

Table 8-2 shows the primary field of interest by the members of AcademyHealth, and the largest share of the members classify their primary discipline as public health (21.5 percent). Only 13.3 percent of members identify their primary discipline as health services research.

In a study on the demand for health services researchers, Thornton and Brown (2009) found that the demand from both universities and non-academic employers is expected to increase. Based on their work one can anticipate there will be a growing demand for “people who can analyze the effectiveness of health service systems from disease management firms; investment firms with a large stake in the health care sector; state and local government; hospitals and providers that will be implementing quality reporting systems and pay-for-performance systems;” and the health

TABLE 8-1 Setting of Primary Employment, 2008

TABLE 8-2 Primary Field of AcademyHealth Members, 2008

industry including equipment manufacturers, pharmaceutical firms, and insurers.

Graduate Programs in Health Services Research

Graduate programs in health services research are not separately accredited, and because many graduates could come from doctoral programs with a different specialty than health services research, there is no accurate tally of doctoral students earning degrees in health services research (Ricketts, 2009). However, in its 2009 online directory of master’s and doctoral programs in HSR, AcademyHealth reports that there are now 41 schools providing HSR doctoral programs and 22 schools with postdoctoral training programs. Doctoral programs are mainly Ph.D. programs, including both disciplinary (e.g., health economics, medical sociology) and general training in health services research. An example of additional training opportunities is illustrated by Veterans Administration’s description of a new fellowship program:

VA Advanced Fellowship Program in Health Services Research and Development (HSR&D): This includes 16 training sites for Ph.D. associated health professionals, 8 training sites for post-residency physician associated health professionals, and 3 sites for post-doctoral physician associated health professionals. HSR&D also participates in the VA Advanced Fellowship Program in Medical Informatics which includes 7 training sites for post-doctoral and physician health professionals in medical informatics.

The NRSA program provides support for training in health services research. As discussed above, the AHRQ has received funding equal to one percent of all NRSA funds for NIH. AHRQ supplements NRSA funding with $500,000 annually. As shown in Table 8-3 , both NIH and AHRQ are funding HSR training at predoctoral and postdoctoral levels. Taken together, there were 107 predoctoral training positions in 2008, 68 percent of them funded by AHRQ. There were also a total of 85 postdoctoral positions, of which 49 percent were funded by AHRQ. The agency accepts new and renewal training grant applications every 5 years. In general, the agency has been able to fund only two-thirds of the requested training positions, and this is very similar to the rate for all NIH training awards. In addition, several NIH institutes provide NRSA awards in health services research, including NIMH, NIAAA, and NIDA. Overall, the total number of trainees is likely less than 2 percent of all NRSA training positions. No data are available on graduates of doctoral programs who are not funded by the NRSA program but who plan to pursue health services research careers. It would be expected that these numbers far exceed NRSA recipients, as they do in other health research fields.

Although there is incomplete information on the characteristics and careers of all individuals with training in health services research, there is some information of NRSA trainees supported by AHRQ. In particular, AHRQ commissioned an outcome study in 1999 of NRSA trainees between 1986 and 1997, which used information from the curricula vitae (CV) of the traimees. The results of this study were reported in the last assessment of the NRSA program. These data were updated in 2005 when data on trainees from 1998 to 2003 were added and data on the earlier trainees were made current to 2003. From 1986 to August 2003, AHRQ supported more than 1,000 individuals through different funding mechanisms. The NRSA program T32 institutional awards supported 346 predoctoral and 435 postdoctoral trainees through 27 university-based or university-affiliated training sites. Another 81 AHRQ F32 individual NRSA postdoctoral fellowships and 5 predoctoral fellowships were awarded. Some individuals had multiple awards under different mechanisms. A total of 854 individuals had support.

TABLE 8-3 Health Services Research Training Positions Funded by AHRQ and the NIH

In 2000, AHRQ launched its career development (K) award program and by August 2003 had made 48 awards. The majority of AHRQ-supported NRSA trainees and fellows between 1986 and 2003 were female (502 of 854, or 59 percent), a difference especially evident among T32 predoctoral trainees (229 of 346, or 66 percent) and F32 fellows (45 of 76, or 58 percent). There were almost even numbers of males (203) and females (225) with T32 postdoctoral trainees during this period.

The CVs of 709 trainees provided information on career progression and research productivity. CVs were received from 850: 346 had T32 predoctoral support, 428 had T32 postdoctoral support, and 76 had F32 fellowships. Of those who earned a doctorate by 2003, about 75 percent or 244 of the doctorates with a known degree field earned their doctorate in a health science field, including: health services research (81); related multidisciplinary health fields such as health policy, health administration, or public health (118); or one of the other health sciences (45). Over 90 percent of the T32 predoctoral trainees earned their baccalaureate degrees in one of the sciences, with 42 percent in the social sciences, 15 percent in the health sciences, and 19 percent in other scientific fields, including the physical and mathematical sciences. The degrees of those with baccalaureate degrees in non-sciences were either in education, humanities, or professional fields. Length of time in training for T32 and F31 predoctoral students averaged about 20 months, but 36 percent were only in training for 12 months. There was some difference in length of training by gender, with 81 percent of females in training for 24 months or less and 75 percent of males for this period. At the postdoctoral level, 84 percent of F32 fellows were in training for 24 months or less, and 86 percent of the T32 awardees were in training for this period. For both the T32 and F32 trainees, about half were in training for 24 months.

Half of the AHRQ NRSA T32 postdoctoral trainees with research doctorates earned them in the social sciences (sociology, economics, or the other social sciences); the remainder earned them in a variety of health or other fields. The other half of the AHRQ NRSA T32 postdoctoral trainees had clinical doctorates, and about half of these were earned in internal medicine; another 20 percent were earned in pediatrics and another 6 percent were earned in family practice, with the remainder earned in a wide variety of other clinical specialties. About 20 percent, or 59, of the 241 clinical doctorates with CV information earned a joint M.D./Ph.D. Just over half of the AHRQ NRSA F32 fellows held clinical doctorates, and more were in internal medicine.

The study also showed that the AHRQ NRSA trainees and fellows actively pursue research careers through a variety of employment paths. Most AHRQ NRSA T32 predoctoral trainees who completed their doctorates by 2003 did not pursue formal postdoctoral research training. First employment data were available for 555 of the predoctoral and postdoctoral trainees, and a large majority of both groups where employed in academic institutions. For the postdoctorates, 71 percent of 382 trainees were in academe, 23 percent were in for-profit or non-profit organizations, and 5 percent were in government. Of those in academic positions, 76 percent were Ph.D.s and 72 percent had clinical degrees. Most of the clinical doctorates that complete training began their academic career as an instructor. The percentage for the 165 predoctoral trainees formed a similar pattern, but only 57 percent had an academic position and 29 percent were in for-profit or non-profit organizations. The current employment of postdoctoral trainees at the end of 2003 closely resembles their first employment with 79 percent in academic positions and 13 percent in health-related employment. The remaining 8 percent were in for-profit or other organizations. For T32 predoctoral trainees, academic employment was almost as high at 67 percent, with 21 percent in health-related employment and the remaining 11 percent in for-profit or other organizations.

Of the employed NRSA T32 predoctoral trainees, about half (48 percent) reported having received post-training research support, and about 77 percent reported at least one post-training scientific journal publication. For NRSA T32

postdoctoral trainees with research doctorates, 72 percent reported having received post-training research support, and 85 percent listed at least one scientific journal publication following training. About 60 percent of the employed NRSA T32 postdoctoral trainees with clinical doctorates reported having received post-training research support, and about 78 percent had at least one scientific journal publication following training. Two-thirds of the employed former AHRQ NRSA F fellows reported having received grant support. In general, 90 percent of all trainees had at least one post-training scientific journal publication.

FEDERAL HEALTH SERVICES RESEARCH FUNDING

The broad relevance of health services research has contributed to federal funding through multiple agencies, unlike the funding of most other areas of health research. AHRQ’s research is expected to address cross-cutting issues such as access, quality and cost issues that are faced by the entire American health care system. Other funding sources seek to fund health services research in support of their organizational missions. The VA and DoD focus on their delivery systems, CMS on financing Medicare and Medicaid, CDC on prevention, and the NIH on delivery of services for specific diseases. These funding sources are complemented by private sources, including major foundations (e.g., Robert Wood Johnson Foundation, Commonwealth Fund, MacArthur Foundation, Kellogg Foundation, Kaiser Family Foundation, and a number of state-based foundations) and private corporations. The following discussion will be limited to federal funding of health services research.

In 2001 the Coalition for Health Services Research (CHSR), the advocacy affiliate of AcademyHealth, began an initiative to document health services research funding levels across the federal government. The first report was completed in 2003 and now there are annual updates. As of FY 2009, the Coalition estimates that a total of $1.48 billion was expended for health services research and related activities by the federal government in as shown below:

Agency for Healthcare Research and Quality (AHRQ)—$372 million;

Centers for Disease Control and Prevention (CDC):

National Center for Health Statistics (NCHS)—$125 million;

Extramural Prevention Research Program—$31 million;

Prevention Research Centers—$31 million;

Centers for Medicare and Medicaid Services (CMS)—$39 million; 6

Health Resources and Services Administration (HRSA)—$9 million;

National Institutes of Health (NIH) (All Institutes)—$779 million;

Veterans Health Administration (VHA)—$75 million; and

The Department of Defense (DoD)—$17 million.

Despite repeated calls from the Coalition for Health Services Research that federal agencies use a standard definition or uniform categories to report their expenditures, the data presented above are measured by these agencies using their own unique definition for what constitutes health services research. Only with a uniform definition and standard categories, would it be possible to assess how the current funding meets emerging needs.

Comparing the health services research funding of $1.5 billion to total federal health research funding of $35 billion in 2005 (Global Forum for Health Research, 2005) shows that approximately 4 percent of total funding is being devoted to health services research, based on classifications used within each agency and institute.

NIH institutes report funding health services research as shown in Table 8-4 . NIMH, NIDA, and NCI have the largest programmatic commitment, ranging from 17 to 23 percent of budget. Other institutes report smaller commitments of budget to health services research.

In summary, AHRQ provides 25 percent of all health services research funding as reported by federal agencies. Other federal agencies support more focused program-specific and disease-specific health services research. Private funding of health services research is substantial but no comprehensive source of information is available on non-federal sources.

CAREERS IN HEALTH SERVICES RESEARCH

The employment opportunities and careers in health services research are widely varied. Academic careers may be in schools of medicine, nursing, public health, and other health professional schools, as well as engineering and traditional arts and sciences departments, along with business and public policy schools. To effectively manage interdisciplinary research, academic institutions usually have organizational structures such as centers or institutes for health services research that cross school and departmental boundaries. At some institutions there are multiple centers reflecting different areas of specialization and the availability of funding for specialized centers from federal and private sources.

Private-sector health services research careers are available in many areas. Federal contract work evaluating major public policy initiatives are primarily done by private research firms. These organizations include RAND, Mathematica, Abt Associates, Westat, and others. These organizations are organized to do short-term large-scale studies that are not as easily organized and managed in most academic settings.

TABLE 8-4 NIH Institute Health Services Research Budgets Health Services Research FY 2008 Estimate (Dollars in Thousands)

Other private-sector health services research careers are in research organizations sponsored by HMOs and health plans, hospital systems, pharmaceutical firms, insurers, and other major stakeholders in health care. Health services research positions may involve directing research, translating research into practice and products, and managing and evaluating health care operations.

Associations for professional groups, manufacturers, and advocacy groups recruit people trained in health services research to strengthen their capacity to use information com-ing from health services research to advance their advocacy objectives and meet the needs of their members. As efforts to translate science into practice accelerate, the demand for individuals skilled in health services research and communication to users is likely to grow.

Government agencies recruit substantial numbers of health services research professionals to lead and manage research programs, to support policy analysis and development, and to work with managers and providers in the VA and DoD health care delivery systems.

New career paths for health services research professionals may emerge as research into effective translation of knowledge into practice grows. The 2003 Medicare prescription drug legislation mandated in Section 1013 that comparative effectiveness studies of health care services including prescription drugs increased the need for health services researchers trained in pharmaco-economics. The ARRA provided a substantial increase in CER funding for both research and investment in research infrastructure including methods and data. The development of tools and techniques to support translation is likely to become an industry that will require research skills in the design, evaluation, and testing of new technologies. Translation of knowledge for clinicians may be the initial priority, but priorities will likely expand to include managers, patients, and the public. The passage of the 2010 Affordable Health Care Act for America brings new and increased demands to monitor the success of health reform and identify unintended consequences. To achieve goals of greater efficiency in American health care and better quality, additional investments in health services research and translation and implementation in practice will be needed. The future demand for well-trained health services researchers is currently strong and growing.

RECOMMENDATIONS

Recommendation 8–1: Health services research training should be expanded and strengthened within each NIH institute and center.

Biomedical research has created a growing gap between research advances in biomedical science and the ability to apply them effectively to improve the health of the public. Thus there is a need for more effective health care delivery practices to ensure effective and evidence-based care, and to reduce waste and unnecessary risk to patients.

Recommendation 8–2: AHRQ training programs should be expanded, at a minimum commensurate with the growth in total federal spending on health services research, including comparative effectiveness research.

Recognition of the rising costs of care, with concerns about quality and consistency, have driven increases in services research. Health services research has established an important evidence base to enable patients and health care organizations to evaluate benefits and risks of diagnostic and therapeutic intervention and to compare relative values of older and newer approaches as choices proliferate. This field can also evaluate different approaches to health care delivery and financing, which will allow the nation to get more benefit from the dramatic advances in biomedical science. Ideally, the total numbers of persons being trained in HSR should grow at the same rate as national health

care expenditures. The NRSA program provides funding for a fraction of all trainees, which is divided among NIH institutes and AHRQ. Since NRSA funding is expected to ensure an adequate supply of research personnel for health research, it is reasonable to expect the proportion of NRSA funding for HSR trainees to approximate the proportion of the federal health research that is HSR. This guideline suggests the need to roughly double NRSA funding of HSR training, from the current level of approximately 2 percent of NRSA funds to 4 percent.

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Comprehensive research and a highly-trained workforce are essential for the improvement of health and health care both nationally and internationally. During the past 40 years the National Research Services Award (NRSA) Program has played a large role in training the workforce responsible for dramatic advances in the understanding of various diseases and new insights that have led to more effective and targeted therapies. In spite of this program, the difficulty obtaining jobs after the postdoc period has discouraged many domestic students from pursuing graduate postdoc training. In the United States, more than 50 percent of the postdoc workforce is made up of individuals who obtained their Ph.D.s from other countries. Indeed, one can make a strong argument that the influx of highly trained and creative foreigners has contributed greatly to U.S. science over the past 70 years.

Research Training in the Biomedical, Behavioral, and Clinical Research Sciences discusses a number of important issues, including: the job prospects for postdocs completing their training; questions about the continued supply of international postdocs in an increasingly competitive world; the need for equal, excellent training for all graduate students who receive NIH funding; and the need to increase the diversity of trainees. The book recommends improvements in minority recruiting, more rigorous and extensive training in the responsible conduct of research and ethics, increased emphasis on career development, more attention to outcomes, and the requirement for incorporating more quantitative thinking in the biomedical curriculum.

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This is research that engages community partners as equal participants in the research.

Genetic Studies

These are studies to find the role of genes in different diseases.

Observational Studies

These are studies in which a group of people is observed for many years.

Physiological Studies

These are studies to better understand how the human body functions.

Prevention Studies

These are studies that test ways to prevent specific conditions or diseases.

Public Health Research

This type of research can be one or a combination of the types of research mentioned above. Public health research tries to improve the health and well-being of people from a population-level perspective.

More Information about Clinical Trials

Clinical trials are often done in a "randomized" way. These are sometimes called RCTs for "randomized clinical trials." In an RCT, some people will be chosen at random to receive a treatment or intervention, such as a new drug. The rest of the participants will be given a "placebo," such as a sugar pill. In other cases, when two interventions are being compared, one group will receive one of the interventions and the other group will be given a different one. Some clinical trials are also "blinded." This means that both the volunteers and the doctors do not know if people are taking the new medicine or the placebo. Only at the end of the study will this be revealed. Since people are chosen at random (similar to a coin toss) in an RCT, people who receive the treatment should be no different than those who do not. For instance, there should be an equal number of males who receive treatment compared with those who do not. This helps reduce bias due to something like gender in a study.

New drugs are first developed in research labs, and then tested in animals. Only then are clinical studies done in humans. Clinical trials of new drugs are done in different phases:

Phase I studies test a new drug for the first time in a small group of people (about 20-80) to see if it safe, to find the right dose, and to know the side effects.
Phase II studies are done in more people (about 100-300) to see how well the new drug treats a disease.
Phase III studies are done in large groups of people (about 1000 to 3000) to see if the new drug works well, has side effects, and how it compares to other drugs.
Phase IV studies are done after the treatment is approved by the U.S. Food and Drug Administration (FDA).
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Understanding Clinical Research

Clinical research helps doctors and other healthcare providers learn new ways to prevent and treat illness in people and find answers to questions about health, disease, and human behavior. Clinical research leads to the development of new drugs, new ways to treat old and new illnesses, and new ways to prevent diseases in people at risk of developing them.

Types of Clinical Research

There are many different types of clinical research.

Epidemiology studies improve the understanding of a disease by studying patterns, causes, and effects of health and disease in specific groups of people.
Behavioral studies improve the understanding of human behavior and how it relates to health and disease.
Health services studies examine how people access health care providers and health care services, how much care costs, and what happens to patients as a result of the care they receive.
Community-based participatory research engages the local community in all phases of the research process.
Genetic studies examine the potential role of genes in different diseases.
Observational studies observe a group of people for many years, usually without any specific intervention. These studies can help scientists understand the natural history of a disease or the transition from wellness to illness.
Physiological studies attempt to shed more light on how the human body functions.
Public health research tries to improve the health and well-being of people from a population-level perspective. It may combine one or more types of clinical research.
Clinical trials study the effects of an intervention or treatment on health outcomes.

What Is a Clinical Trial?

Scientists and doctors use clinical trials to discover new ways to safely and effectively prevent, detect, and treat diseases. During a clinical trial, researchers may study:

New drugs or new combinations of drugs
New surgical procedures
New medical devices
New ways to use existing treatments
How to change behaviors to improve health
New methods to detect diseases and health conditions
New ways to improve quality of life for people with serious health conditions

A Clinical Trial Is a Scientific Test

When conducting a clinical trial, doctors want to answer one or more of the following questions:

Does this treatment work?
Does it work better than what we’re using now?
What side effects does it cause?
Do the benefits of the treatment outweigh the risks?
Which patients or groups of patients are most likely to find this treatment helpful?

Because a clinical trial is a scientific test, the answer to the research question is unknown. While it is possible you may not receive a direct benefit from your participation in the clinical trial, your involvement will add valuable information to the study findings.

The Difference Between Clinical Research, Clinical Trials, and Medical Care

You may find the distinction between clinical research and your medical care a bit unclear, especially if your doctor or other health care provider is also a researcher. When you receive medical care, you and your provider develop a personalized treatment plan. When you take part in a type of clinical research, you and the researcher must follow a specific plan called the “protocol.” Typically, your provider or the researcher cannot change the protocol. However, the protocol will outline steps to follow if you aren’t doing well.

Searching for Health Sciences Research

Getting Started
Formulating Your Question

Types of Research

Study design glossary.

Selecting a Database
Controlled Vocabulary / Subject Headings
PubMed: Medical Subject Headings (MeSH)
CINAHL: Subject Headings
Building Your Search
Refining Your Search
Pubmed's Clinical Queries
Search the Citations!
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Resources & Tutorials

In the Health Sciences, we generally categorize evidence into two main types: Filtered and Unfiltered resources. When you look at the traditional evidence pyramid, we are looking at the research cycle: starting with unfiltered information (the original research), once a body of work is established, we can start analyzing and synthesizing the existing research, creating filtered information (i.e., systematic reviews and meta-analyses).

Image from https://openmd.com/guide/levels-of-evidence

Unfiltered (Primary / Original Research)

In the sciences, a primary source is a source that includes original research that's documented at the time of study. A primary source will often have a Methods section that describes the researchers' procedures and materials. Primary sources can take the form of:

original research article
data / original findings from a research study
thesis or dissertation
conference paper
lab notebook

Filtered (Secondary Sources / Reviews)

Secondary sources offer analysis, evaluation, interpretation and/or synthesis of primary sources. A secondary source could be:

review article / literature review
systematic review or meta-analysis
monograph (book) or book chapter
conference proceedings (collections of conference papers)

Filtered (Tertiary Sources)

Tertiary sources offer summaries or compilations of information from primary and secondary sources. A tertiary source could be:

encyclopedia, dictionary or handbook
evidence-based textbook
clinical practice guidelines
monograph from a point of care tool (such as DynaMed or UpToDate)
evidence-based care sheet

Systematic Review A summary of the clinical literature. A systematic review is a critical assessment and evaluation of all research studies that address a particular clinical issue. The researchers use an organized method of locating, assembling, and evaluating a body of literature on a particular topic using a set of specific criteria. A systematic review typically includes a description of the findings of the collection of research studies. (AHRQ Glossary of Terms)

Meta-Analysis A work consisting of studies using a quantitative method of combining the results of independent studies (usually drawn from the published literature) and synthesizing summaries and conclusions which may be used to evaluate therapeutic effectiveness, plan new studies, etc. It is often an overview of clinical trials. It is usually called a meta-analysis by the author or sponsoring body and should be differentiated from reviews of literature. (PubMed)

Randomized Controlled Trial A controlled clinical trial that randomly (by chance) assigns participants to two or more groups. There are various methods to randomize study participants to their groups. (AHRQ Glossary of Terms)

Controlled Clinical Trial A type of clinical trial comparing the effectiveness of one medication or treatment with the effectiveness of another medication or treatment. In many controlled trials, the other treatment is a placebo (inactive substance) and is considered the "control." (AHRQ Glossary of Terms)

Cohort Study A clinical research study in which people who presently have a certain condition or receive a particular treatment are followed over time and compared with another group of people who are not affected by the condition. (AHRQ Glossary of Terms)

Case Control Study The observational epidemiologic study of persons with the disease (or other outcome variable) of interest and a suitable control (comparison, reference) group of persons without the disease. The relationship of an attribute to the disease is examined by comparing the diseased and nondiseased with regard to how frequently the attribute is present or, if quantitative, the levels of the attribute, in each of the groups. (OCEBM Table of Evidence Glossary)

Case Series A group or series of case reports involving patients who were given similar treatment. Reports of case series usually contain detailed information about the individual patients. This includes demographic information (for example, age, gender, ethnic origin) and information on diagnosis, treatment, response to treatment, and follow-up after treatment. (OCEBM Table of Evidence Glossary)

Case Study An investigation of a single subject or a single unit, which could be a small number of individuals who seem to be representative of a larger group or very different from it. (Dictionary of Nursing Theory and Research, Fourth Edition)

Editorial Work consisting of a statement of the opinions, beliefs, and policy of the editor or publisher of a journal, usually on current matters of medical or scientific significance to the medical community or society at large. The editorials published by editors of journals representing the official organ of a society or organization are generally substantive. (PubMed)

Opinion A belief or conclusion held with confidence but not substantiated by positive knowledge or proof. (The Free Dictionary)

Animal Research A laboratory experiment using animals to study the development and progression of diseases. Animal studies also test how safe and effective new treatments are before they are tested in people.(NCI Dictionary of Cancer Terms)

In Vitro Research In the laboratory (outside the body). The opposite of in vivo (in the body). (NCI Dictionary of Cancer Terms)

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Last Updated: May 29, 2024 10:01 AM
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Open access
Published: 29 May 2024

The implementation of person-centred plans in the community-care sector: a qualitative study of organizations in Ontario, Canada

Samina Idrees 1 ,
Gillian Young 1 ,
Brian Dunne 2 ,
Donnie Antony 2 ,
Leslie Meredith 1 &
Maria Mathews 1

BMC Health Services Research volume 24 , Article number: 680 ( 2024 ) Cite this article

Metrics details

Person-centred planning refers to a model of care in which programs and services are developed in collaboration with persons receiving care (i.e., persons-supported) and tailored to their unique needs and goals. In recent decades, governments around the world have enacted policies requiring community-care agencies to adopt an individualized or person-centred approach to service delivery. Although regional mandates provide a framework for directing care, it is unclear how this guidance is implemented in practice given the diversity and range of organizations within the sector. This study aims to address a gap in the literature by describing how person-centred care plans are implemented in community-care organizations.

We conducted semi-structured interviews with administrators from community-care organizations in Ontario, Canada. We asked participants about their organization’s approach to developing and updating person-centred care plans, including relevant supports and barriers. We analyzed the data thematically using a pragmatic, qualitative, descriptive approach.

We interviewed administrators from 12 community-care organizations. We identified three overarching categories or processes related to organizational characteristics and person-centred planning: (1) organizational context, (2) organizational culture, and (3) the design and delivery of person-centred care plans. The context of care and the types of services offered by the organization were directly informed by the needs and characteristics of the population served. The culture of the organization (e.g., their values, attitudes and beliefs surrounding persons-supported) was a key influence in the development and implementation of person-centred care plans. Participants described the person-centred planning process as being iterative and collaborative, involving initial and continued consultations with persons-supported and their close family and friends, while also citing implementation challenges in cases where persons had difficulty communicating, and in cases where they preferred not to have a formal plan in place.

Conclusions

The person-centred planning process is largely informed by organizational context and culture. There are ongoing challenges in the implementation of person-centred care plans, highlighting a gap between policy and practice and suggesting a need for comprehensive guidance and enhanced adaptability in current regulations. Policymakers, administrators, and service providers can leverage these insights to refine policies, advocating for inclusive, flexible approaches that better align with diverse community needs.

Peer Review reports

The community-care sector facilitates the coordination and administration of in-home and community-based health and social services. Community-care services include supports for independent living, residential services, complex medical care, and community-participation services to support personal and professional goals (e.g., education, employment, and recreation-based supports) [ 1 ]. There is substantial heterogeneity in the clinical and demographic characteristics of the community-care population, including individuals with physical and developmental disabilities, and complex medical needs [ 2 ]. We refer to the individuals served by these organizations as ‘persons-supported’ in line with person-first language conventions [ 3 , 4 ].

In recent decades, governments across the world have enacted policies requiring community-care agencies to adopt an individualized or person-centred approach to service delivery [ 5 , 6 , 7 , 8 ]. Person-centred care encompasses a broad framework designed to direct care delivery, as opposed to a singular standardized process. In the context of community-care, person-centred planning refers to a model of care provision in which programs and services are developed in collaboration with persons-supported and tailored to their unique needs and desired outcomes [ 9 , 10 ].

In Ontario, Canada, community-care services are funded by the Ministry of Health (MOH) and the Ministry of Children, Community and Social Services (MCCSS). Service agreements between these ministries and individual agencies can be complex and contingent on different factors including compliance with a number of regulatory items and policies [ 7 , 11 ]. MOH provides funding for health-based services including in-home physiotherapy, respiratory therapy, and personal support services, among several others. MOH funds Home and Community Care Support Services (HCCSS), a network of organizations responsible for coordinating the delivery of in-home and community-based care in the province. MCCSS funds social service agencies including those providing community participation and residential support for people with intellectual and developmental disabilities (IDDs).

Several tools and resources have been developed to aid organizations in providing person-centred care and organizations may differ in their use of these tools and their specific approach. Although regional mandates provide a framework for directing care delivery, it is unclear how this guidance is implemented in practice given the diversity and range of organizations within the sector. In addition, as noted by a recent scoping review, there is limited literature on the implementation process and impact of person-centred planning on individual outcomes [ 12 ]. Using a pragmatic, qualitative, descriptive approach [ 13 ], we outline how community-care organizations enact a person-centred approach to care and the factors that shape their enactment. By describing existing practices in the context of the community-care sector, we aim to provide insight on how to optimize care delivery to improve outcomes and inform current policy. This study is part of a larger, multi-methods project examining the implementation of person-centred care plans in the community-care sector. This project encompasses qualitative interviews with representatives from different community-care organizations, as well as staff and persons-supported at a partner community-care organization. This paper focuses on analyzing data from interviews with representatives from different community-care organizations.

We conducted semi-structured interviews with administrators from community-care organizations in Southwestern Ontario (roughly the Ontario Health West Region) between October 2022 and January 2023. We included community-care organizations funded by MOH or MCCSS. We excluded organizations that did not provide services in Southwestern Ontario. We identified eligible organizations and participants by searching online databases, including community resource lists, as well as through consultation with members of the research team.

We used maximum variation sampling [ 14 ], to recruit participants from organizations with a wide range of characteristics including location (i.e., urban, rural), organization type (i.e., for-profit, not-for-profit), and types of services provided (e.g., residential, recreation, transportation, etc.) We contacted eligible organizations via email, providing them with study information and inviting them to participate. We recruited until the data reached saturation, defined as the point at which there was sufficient data to enable rigorous analysis [ 14 , 15 ].

In each interview, we asked participants about their organization’s approach to developing and updating individual service agreements or person-centred care plans, and the supports and barriers (e.g., organizational, funding, staffing, etc.) that facilitate or hinder the implementation of these plans (Supplementary Material 1 : Interview Guide). We also collected information on relevant participant and organizational characteristics, including participant gender, position, years of experience, organization location, type (i.e., for-profit, not-for-profit), services offered, years in operation, and client load. The interviews were approximately one hour in length and conducted virtually via Zoom (Zoom Video Communications Inc.) or by telephone. The interviews were audio-recorded and transcribed verbatim. Interviewer field notes were also used in data analysis.

We analyzed the data thematically [ 16 ]. The coding process followed a collaborative and multi-step approach. Initially, three members of the research team independently reviewed and coded a selection of transcripts to identify key ideas and patterns in the data, and form a preliminary coding template. We then met to consolidate individual coding efforts. We compared coding of each transcript, resolving conflicts through discussion and consensus. In coding subsequent transcripts and through a series of meetings, we worked together to finalize the codebook to reflect more analytic codes. We used the finalized template to code all interview transcripts in NVivo (QSR International), a software designed to facilitate qualitative data analysis. We refined the codebook on an as-needed basis by incorporating novel insights gleaned from the coding of additional transcripts, reflecting the iterative nature of the analysis.

We increased the robustness of our methodology by pre-testing interview questions, documenting interview and transcription protocols, using experienced interviewers, and confirming meaning with participants in interviews [ 14 , 15 , 16 ]. We kept detailed records of interviews, field notes, and drafts of the coding template. We made efforts to identify negative cases and provided rich descriptions and illustrative quotes [ 17 ]. We included individuals directly involved in the administration of community-care services on our research team. These individuals provided important context and feedback at each stage of the research process.

This study was approved by the research ethics board at Western University. We obtained informed consent from participants prior to the onset of interviews. We maintained confidentiality through secure storage of interview data (e.g., audio recordings), password-protection of sensitive documents, and the de-identification of transcripts.

Positionality

The authors represent a multidisciplinary team of researchers, clinicians, and community-care leaders. The community-care leaders and clinicians on our team provided key practical expertise to inform the development of interview questions and the analysis of study findings.

We interviewed administrators across 12 community-care organizations in Southwestern Ontario. The sample included representatives from seven organizations that received funding from MCCSS, three organizations that received funding from MOH, and two organizations that received funding from both MCCSS and MOH (Table 1 ). Eleven organizations were not-for-profit, one was a for-profit agency. The organizations provided care in rural ( n = 3), urban ( n = 4), or both rural and urban populations ( n = 5). Seven of the 12 participants were women, nine had been working with their organization for more than 11 years, and all had been working in the community-care sector for more than 12 years (Table 2 ).

We identified three key categories or processes relating to organizational characteristics and their impact on the design and delivery of person-centred care plans: (1) organizational context, (2) organizational culture, and (3) the development and implementation of person-centred care plans.

Organizational context

Organizational context refers to the characteristics of persons-supported, and the nature of services provided. Organizational context accounts for the considerable heterogeneity across organizations in the community-care sector and their approach to person-centred care plans.

Populations served

The majority of organizations included in the study supported individuals with IDDs: “all of the people have been identified as having a developmental disability. That’s part of the eligibility criteria for any funded developmental service in Ontario.” [P10]. Participants described how eligibility was ascertained through the referral process: “ the DSO [Developmental Services Ontario] figures all of that out and then refers them to us .” [P08]. These descriptions highlighted a common access point for publicly-funded adult developmental services in the province. Accordingly, these organizations were primarily funded by MCCSS. Other organizations focused on medically complex individuals including those with acquired brain injuries or those unable to access out-patient services due to physical disabilities: “the typical reason for referral is going to be around a physical impairment… But, with this medically complex population, you’re often seeing comorbidities where there may be some cognitive impairment, early dementia.” [P04]. In these organizations, eligibility and referral were usually coordinated by HCCSS. These insights highlighted the diverse characteristics of community-care populations, emphasizing the need to consider both physical and cognitive health challenges in care provision approaches.

Services offered

The characteristics of persons-supported informed the context of care and the type of services offered by the organization. The different dimensions of services offered within this sector include social and medical care, short and long-term care provision, in-home and community-care, and full and part-time care.

Nature of care: social vs. medical

Many organizations serving individuals with IDDs employed a holistic, psychosocial model of care, designed to support all areas of an individual’s life including supports for independent-living, and community-based education, employment, and recreation services to support personal and professional goals: “we support people in their homes, so residential supports. We also support people in the community, to be a part of the community, participate in the community and also to work in the community.” [P06]. These descriptions reflect a comprehensive approach to care, aiming to address needs within and beyond residential settings to promote active participation within the broader community. In contrast, some organizations followed a biomedical model of care, designed to support specific health needs: “We provide all five therapies… physiotherapy, occupational therapy, speech, social work, and nutrition. In some locations we provide visiting nursing, at some locations shift nursing. We have some clinic-nursing… and we provide personal support and home-making services in a number of locations as well.” [P04]. These organizations adopted a more clinically-focused approach to care. In either instance, the care model and the nature of services offered were largely determined by an organization’s mandate including which gaps they aimed to fill within the community. Many organizations described providing a mixture of social and medical care for individuals with complex needs. However, the implementation of care plans could be impacted by the lack of integration between social and medical care sectors, as some participants spoke to the importance of “[integrating] all of the different healthcare sector services… [including] acute care and public health and home and community care and primary care, and mental health and addictions.” [P04].

Duration of care: short-term vs. long-term

The duration of care also varied based on the needs of persons-supported. Organizations serving individuals with IDDs usually offered support across the lifespan: “We support adults with developmental disabilities and we support them from 18 [years] up until the end of their life.” [P06]. Some organizations provided temporary supports aimed at addressing specific health needs: “For therapies – these are all short-term interventions and typically they’re very specific and focused on certain goals. And so, you may get a referral for physiotherapy that is authorized for three visits or five visits” [P04], or crisis situations (e.g., homelessness): “Our services are then brought in to help provide some level of support, guidance, stabilization resource, and once essentially sustainability and positive outcomes are achieved—then our services are immediately withdrawn.” [P12]. One organization employed a model of care with two service streams, an initial rehabilitation stream that was intended to be short-term and an ongoing service stream for individuals requiring continuing support.

In-home vs. community-based care

Many organizations provided in-home care and community-based supports, where residential supports were designed to help individuals lead independent lives, and community-based supports encouraged participation in community activities to further inclusion and address personal and professional goals. One participant spoke about the range of services offered in the home and community:

“There’s probably two big categories of [services we offer]: community support services—so that includes things like adult day programs, assisted living, meals on wheels, transportation, friendly visiting … and things like blood pressure clinics, exercise programs… and then on the other side we do home care services. In the home care basket, we provide personal support, and we also provide social work support.” [P05].

Likewise, another participant spoke in further detail on the types of services that allow individuals to live independently within their homes, or in community-based residential settings (e.g., long-term care facilities):

“We provide accommodation supports to about 100 people living in our community—which means that we will provide support to them in their own homes. So, anywhere from an hour a week to 24 hours a day. And that service can include things from personal care to home management to money management, cooking, cleaning, and being out and about in communities—so community participation. We also provide supports for about 50 people living in long-term care facilities and that is all community participation support. So, minus the last 2 and a half years because of the pandemic, what that means is that a person living in a long-term care facility with a developmental disability can have our support to get out and about for 2 or 3 hours a week, on average.” [P10].

Full-time vs. part-time support

The person-supported’s needs also determined whether they would receive care within their homes and if they would be supported on a full-time (i.e., 24 h a day, 7 days a week) or part-time basis:

“ It really does range from that intensive 24- hour/7 day a week support, which we actually do provide that level of intense support in the family home, if that’s needed. And then, all the way through to just occasional advocacy support and phone check-in.” [P01].

Organizational Culture

Organizational culture was described as a key influence in the development and implementation of person-centred care plans. The culture of the organization includes their perceptions, attitudes and beliefs surrounding persons-supported; their model of care provision; as well as their willingness to evolve and adapt service provision to optimize care delivery.

Perceptions, attitudes, and beliefs regarding persons-supported

Participants described their organization’s view of persons-supported, with many organizations adopting an inclusionary framework where persons-supported were afforded the same rights and dignities as others in the community. This organizational philosophy was described as being deeply intertwined with an organization’s approach to personalizing programs and services:

“…an organization needs to be able to listen to the people who are receiving the service… and support them, to learn more, figure out, articulate, whatever it is, the service or the supports that they need in order to get and move forward with their life.” [P10].

The focus on the person-supported, their needs, likes, and dislikes, was echoed across organizations, with an emphasis on the impact of “culture and trying to embed for each person who delivers service the importance of understanding the individual.” [P05]. Participants also described their organization’s approach to allowing persons-supported to take risks, make mistakes, and live life on their own terms:

“You have to go and venture out and take some [risks]… We try to exercise that philosophy - people with disabilities should have the same rights and responsibilities as other people in the community. Whether that’s birthing or education, getting a job, having a house they can be proud of, accessing community supports, whether that be [a] library or community centre, or service club, whatever that is.” [P03].

Model of care provision

The model of care provision was heavily influenced by the organization’s values and philosophy. Several organizations employed a flexible model of care where supports were developed around the needs, preferences, and desired outcomes of the person-supported:

“…if we don’t offer [the program they want], we certainly build it. Honestly, most of our programs were either created or built by someone coming to us [and] saying ‘I want to do this with my life,’ or …‘my son would like to do art.’” [P02].

Although there were similarities in models across the different organizations, one participant noted that flexibility can be limited in the congregate care setting as staff must tend to the needs of a group as opposed to an individual:

“Our typical plan of operation outside of the congregate setting is we design services around the needs of the person. We don’t ask them to fit into what we need, we build services for what they need. Within the congregate care setting, we have a specific set of rules and regulations for safety and well-being of the other people that are here.” [P11].

Evolving service orientation

In organizations serving individuals with IDDs, many described shifting from program-based services to more individualized and community-based supports: “The goal was always to get people involved in their community and build in some of those natural supports … [we] are looking to support people in their own communities based on their individual plans.” [P07]. One participant described this model as a person-directed approach as opposed to person-centred, citing the limitations of program-based services in meeting individual needs:

“[Persons-supported] couldn’t [do] what they wanted because they were part of a bigger group. We would listen to the bigger group, but if one person didn’t want to go bowling … we couldn’t support them because everybody had to go bowling.” [P06].

The focus on individualized support could potentially lead to increased inclusion for persons-supported in their communities:

“… people go to Tim Horton’s, and if they go every day at 9 they probably, eventually will meet other people that go at 9 o’clock and maybe strike up a conversation and get to know somebody and join a table … and meet people in the community.” [P02].

By creating routines centred on individual preferences, the person-supported becomes a part of a community with shared interests and values.

Person-centred care plans

Community-care organizations enacted a person-centred approach by creating person-centred care plans for each person-supported. Although all participants said their organization provided person-centred services, there was considerable variation in the specific processes for developing, implementing, and updating care plans.

Developing a person-centred care plan

The development of a care plan includes assessment, consultation, and prioritization. The initial development of the care plan usually involved an assessment of an individual’s needs and goals. Participants described agency-specific assessment processes that often incorporated information from service referrals: “ In addition to the material we get from the DSO [Disability Services Ontario] we facilitate the delivery of an intake package specifically for our services. And that intake package helps to further understand the nature and needs of an individual.” [P12]. Agency-specific assessment processes differed by the nature of services provided and the characteristics of the population. However, most organizations included assessments of “not only physical functioning capabilities, but also cognitive.” [P01]. Assessment also included an appraisal of the suitability of the organization’s services. In instances where persons-supported were seeking residential placements or independent-living support, organizations assessed their ability to carry out the activities of daily living:

“[Our internal assessment] is an overview of all areas of their life. From, ‘do they need assistance with baking, cooking, groceries, cleaning, laundry? Is there going to be day program opportunities included in that residential request for placement? What the medical needs are?’” [P02].

In contrast, the person-supported’s community-based activities were primarily informed by their interests and desired outcomes: “We talk about what kinds of goals they want to work on. What kind of outcomes we’re looking for…” [P06].

The development of the care plan also included a consultation phase, involving conversations with the person-supported, their family members, and potentially external care providers: “We would use the application information, we’d use the supports intensity scale, but we’d also spend time with the person and their connections, their family and friends, in their home to figure out what are the kinds of things that this person needs assistance with.” [P10]. Participants described the person-supported’s view as taking precedence in these meetings: “We definitely include the family or [alternate] decision-maker in that plan, but the person-supported ultimately has the final stamp of approval.” [P08]. Many participants also acknowledged the difficulty of identifying and incorporating the person-supported’s view in cases where opinions clash and the person-supported has difficulty communicating and/or is non-verbal: “Some of the people we support are very good at expressing what they want. Some people are not. Some of our staff are really strong in expressing what they support. …And some of the family members are very strong. So you have to be very careful that the [person-supported] is not being lost in the middle of it.” [P06].

Participants also noted that some persons-supported preferred not to have a care plan:

“Some of the people say ‘I hate [the plans] I don’t want to do them’…. we look at it in a different way then. We’ll use graphic art, we’ll use video, we’ll think outside the box to get them to somehow—because at the end of the day when we’re audited by MCCSS every [person-supported] either has to have [a plan]… or there has to be [an approval of] why it wasn’t completed.” [P02].

Plan development may also include a prioritization process, particularly in cases where resources are limited. A person-supported’s goals could be prioritized using different schemas. One participant noted that “the support coordinator takes the cue from the person-supported - … what they’ve identified as ‘have to have’ and ‘nice to have’. … because the ‘have to haves’ are prioritized.” [P09]. Likewise, the person-supported’s preference could also be identified through “[an] exercise, called ‘what’s important for and what’s important to .’” [P06]. This model, based on a Helen Sanderson approach [ 18 ], was described as being helpful in highlighting what is important to the person-supported, as opposed to what others (i.e., friends, family, staff, etc.) feel is important for them.

Several organizations updated care plans throughout the year, to document progress towards goals, adapt to changing needs and plan for future goals: “We revisit the plan periodically through the year. And if they say the goal is done, we may set another goal.” [P06]. Organizations may also change plans to adapt to the person-supported’s changing health status or personal capacity.

Implementing a person-centred care plan

The implementation of care plans differed based on the nature of services provided by the organization. The delivery of health-based or personal support services often involved matching the length and intensity of care with the individual’s needs and capacity:

“Sometimes that is a long time, sometimes it’s a short time, sometimes it’s an intervention that’s needed for a bit, and then the person is able to function.” [P05].

In contrast, the delivery of community-based services involved matching activities and staff by interests: “[if] a person-supported wants to go out and be involved in the music community, then we pull the staff pool in and match them up according to interest.” [P06].

Broad personal goals were broken down into smaller, specific activities. For example, one participant described their organization’s plan in helping a person-supported achieve his professional goal of securing employment:

“[The person-supported] said ‘Okay, I want a job.’ So for three weeks he was matched up with a facilitator. They came up with an action plan in terms of how to get a job, what kind of job he’s looking for, where he wants to go, where he wants to apply, how to conduct an interview. And after three weeks he got a job.” [P09].

Organizations that provided residential services focused on developing independent-living skills. One participant described their organization’s plan to empowering persons-supported by allowing them to make their own financial decisions:

“If one month they’re looking after their own finances, and they’ve overspent. Well, maybe we help them out with a grocery card or something and say ‘okay, next month how are you going to do this?’ [The person-supported may say], ‘well, maybe I’ll put so much money aside each week rather than doing a big grocery shop the first week and not having enough money left at the end of the month.’” [P03].

The participant noted that “a tremendous amount of learning [happens] when a person is allowed to [take] risks and make their own decisions.” [P03].

Likewise, participants representing organizations that provided residential services described tailoring care to the persons-supported’s sleeping schedule and daily routine:

“We develop a plan and tweak it as we go. With [the person-supported] coming to the home, what worked well was, we found that he wanted to sleep in, so we adjusted the [staff] time. We took a look at his [medication] times in the morning… and [changed] his [medication] times. We found that he wanted to sleep [until] later in the day, so he would get up at 10 o’clock, so then instead of having breakfast, lunch, and supper he would just have a bigger brunch. Just really tailoring the plan around the person-supported, and it’s worked out well.” [P08].

These examples highlight how organizational context and culture influence how organizations operationalize person-centred care plans; the same individual may experience different approaches to care and engage in different activities depending on the organization they receive services from.

In this paper, we described key elements of the person-centred planning process across different community-care organizations in Southwestern Ontario. We also identified that the context and culture of an organization play a central role in informing the process by which services are personalized to an individual’s needs. These findings shed light on the diversity of factors that influence the implementation of person-centred care plans and the degree to which organizations are able to address medical and social needs in an integrated fashion. They also inform future evaluations of person and system-related outcomes of person-centred planning.

There are regulations around individualizing services delivered by community-care organizations, whereby care providers must allow persons-supported to participate in the development and evaluation of their care plans. HCCSS or MOH-funded services are largely focused on in-home rehabilitation or medical care. In contrast, MCCSS-funded organizations often focus on developing independent living skills or promoting community participation, thus highlighting the role of the funding agency in determining organizational context as well as the nature of services and personalization of care plans.

We also identified organizational culture as a key influence in the person-centred planning process. In previous reports, organizational culture, and specifically the way in which staff perceive and view persons-supported and their decision-making capabilities can impact the effective delivery of person-centred care [ 19 ]. Staff support, including their commitment to persons-supported and the person-centred process, has been regarded as one of the most powerful predictors of positive outcomes and goal attainment in the developmental services sector [ 20 , 21 ]. Moreover, in order to be successful, commitment to this process should extend across all levels of the organization, be fully integrated into organizational service delivery, and be reflected in organizational philosophy, values and views of persons-supported [ 22 , 23 , 24 ].

MCCSS mandates that agencies serving individuals with IDDs develop an individual service plan (ISP) for each person-supported, one “that address[es] the person’s goals, preferences and needs.” [ 7 ]. We reference ISPs as person-centred care plans, as is in line with the view of participants in interviews. There are a series of checklists designed to measure compliance with these policies, and the process is iterative, with mandated annual reviews of care plans and active participation by the person-supported [ 25 ]. In our study, the agencies funded by MCCSS adhered to the general framework outlined by these regulations and informed service delivery accordingly. However, participants also described areas for improvement with respect to the implementation of these policies in practice. These policies, while well-intentioned, may imply a one-size-fits-all approach and appear more as an administrative exercise as opposed to a meaningful endeavor designed to optimize care. Participants spoke about individuals who preferred not to have an ISP, and how that in and of itself is a person-centred approach, respecting the person’s wishes. Additionally, we heard about how the goal-setting process may not be realistic as it can be perceived as unnatural to have goals at each point in one’s life. Moreover, participants noted challenges in implementing person-centred care in shared residential settings (e.g., group homes) or in cases where persons-supported had difficulty communicating.

Prior research indicates that individuals living in semi-independent settings fare better across several quality-of-life measures relative to individuals living in group homes, including decreased social dissatisfaction, increased community participation, increased participation in activities of daily living, and increased empowerment [ 26 ]. Furthermore, a recent study by İsvan et al. (2023) found that individuals living in the community (e.g., own home, family home, or foster home) exhibit greater autonomy in making everyday and life decisions, and greater satisfaction with their inclusion in the community [ 27 ]. These findings may be indicative of a reduced focus on person-centred care plan development and implementation in congregate care settings, where limited staff capacity can make it difficult to tend to the needs of everyone in the home. However, poor outcomes may also be explained by potentially more complex health challenges or more severe disability in persons-supported living in congregate care settings. The challenges described in our study are consistent with calls to improve the quality of care provided in residential group home settings [ 28 , 29 ].

In line with our findings, previous literature also describes challenges in implementing person-centred planning for individuals who have difficulty communicating or are non-verbal [ 19 , 30 , 31 , 32 ]. Communication has also been identified as a barrier to patient-centred care for adults with IDDs in healthcare settings [ 33 , 34 ]. Other reports have identified a need for increased training and awareness of diverse communication styles (including careful observation of non-verbal cues) to aid staff in including persons-supported in the development of care plans [ 35 , 36 , 37 ]. Importantly, these methods take substantial time which is often limited, and compounded by staffing shortages that are widespread across the sector [ 38 ]. Similar barriers were identified in interviews with staff and persons-supported at a partner community-care agency within our larger project [ 39 ]; other papers from the project examine strategies used by the organization to overcome these barriers.

Limitations

The findings from this study should be interpreted in the context of the following limitations. There is a risk for social desirability bias, whereby participants may feel pressure to present their care plan process in a more positive light due to societal norms and expectations [ 40 ]. Additionally, the experiences and views of community-care organizations may vary by region and organization type (i.e., for-profit vs. not-for-profit). In this study, we limited participation to agencies providing services in Southwestern Ontario and we were only able to interview one for-profit agency, despite concerted recruitment efforts. Consequently, we may not have fully captured how financial pressures, or different contextual and cultural components of an organization impact their implementation of care plans.

The person-centred planning process in community-care organizations is largely informed by the characteristics of the population served and the nature of services offered (i.e., organizational context). This process usually involves initial and continued consultations with persons-supported to tailor plans to their specific needs and desired outcomes. There are ongoing challenges in the implementation of person-centred planning, including a need for increased adaptability and clarity in current regulations. In some areas, there may be benefit to incorporating nuance in the application of policies (e.g., in cases where a person-supported does not want to have a formal plan in place). In other areas, it may be helpful to have increased guidance on how to optimize care delivery to improve outcomes (e.g., in cases where a person-supported has difficulty communicating, or is residing in a group home). Policymakers, administrators, and service providers can leverage these insights to refine policies, advocating for inclusive, flexible approaches that better align with diverse community needs.

Data availability

The datasets generated and analyzed in the current study are not publicly available to maintain participant confidentiality, however access may be granted by the corresponding author upon reasonable request.

Abbreviations

Acquired Brain Injury

Disability Services Ontario

Home and Community Care Support Services

Intellectual and Developmental Disabilities

Individual Service Plan

Ministry of Children, Community and Social Services

Ministry of Health

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Acknowledgements

The authors thank Ruth Armstrong, from PHSS - Medical & Complex Care in Community, for her valuable feedback and support throughout the research process.

This research was funded by the Canadian Institutes of Health Research. The funding agency had no role in the conceptualization, design, data collection, analysis, decision to publish, or preparation of the manuscript.

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S.I. conducted the interviews, developed the coding template, coded the data, thematically analyzed the data, and prepared the manuscript. G.Y. helped develop the coding template, and reviewed and approved the final manuscript. B.D. and D.A. helped conceptualize the study, aided in the interpretation and analysis of study findings, and reviewed and approved the final manuscript. L.M. coordinated research activities, aided in the interpretation and analysis of study findings, and reviewed and approved the final manuscript. M.M. conceptualized the study, supervised its implementation, and was a major contributor in reviewing and editing the manuscript. All authors have read and approved the final manuscript.

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Idrees, S., Young, G., Dunne, B. et al. The implementation of person-centred plans in the community-care sector: a qualitative study of organizations in Ontario, Canada. BMC Health Serv Res 24 , 680 (2024). https://doi.org/10.1186/s12913-024-11089-7

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Correctional health encompasses all aspects of health and well-being for adults and juveniles who are justice system*-involved. This starts at the point of arrest, continues at detention or incarceration, and carries through after they return to their community (called "reentry"). Correctional health also includes the health of families and communities of persons who are justice system-involved, as well as the health administrators and staff who work in facilities.

Justice System-Involved‎

Persons who are justice system-involved are more likely to experience risk factors for HIV, viral hepatitis, sexually transmitted infections (STIs), tuberculosis (TB), latent TB infection (LTBI), and traumatic brain injuries (TBI) and concussions . The prevalence of these infections, diseases, and injuries is higher than in the general population. Additionally, a high proportion of people with justice system involvement have a history of unstable housing and mental health and substance use disorders, which increases vulnerability and risk for HIV, viral hepatitis, STIs, tuberculosis/latent tuberculosis infection, and injuries like TBI. This puts many in need of linkage to substance use and mental health treatment, employment, and permanent housing upon release. Justice-involvement also leads to family and community instability and adverse childhood events , with 1 in 28 children having a caregiver who is incarcerated.

Taken together, these multiple health conditions and social determinates of health contribute to the health disparities found in this population and their communities.

CDC has worked to provide people who are justice system-involved, correctional facility staff, public health professionals, community organizations, and anyone else with an interest in correctional health with data, testing and treatment guidelines, educational materials, and other correctional health resources.

How CDC supports correctional health

Community support.

Funds partners working with health departments to improve health in the communites of justice-involved persons, particularly related to priority pathogens such as HIV, hepatitis, STIs, and TB.
Develops programs and guidance that address community health disparities and social determinants of health (SDOH).

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Develops intake screening and treatment guidance for use by clinicians/administrators of correctional health services and health departments.

During incarceration

Works with state, tribal, local, and territorial health departments to investigate disease outbreaks.
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Identifies/monitors cases and potential exposures to HIV, viral hepatitis, STIs, TB, and other pathogens among persons who are justice-involved or work in correctional facilities.

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According to the U.S. Bureau of Justice Statistics , over 5 million people are estimated to be under the supervision of U.S. adult correctional systems (in prison or jail, or on probation or parole). Many persons who are justice-involved experience multiple risk factors for HIV, viral hepatitis, sexually transmitted infections (STIs), tuberculosis (TB) and latent TB infection (LTBI), and traumatic brain injuries (TBI) and concussions . The prevalence of these infections, diseases, and injuries among people who are incarcerated is higher than in the general population.

In 2021, about 1.1% of persons incarcerated in state and federal prisons were known to be persons with HIV; this rate was three times higher than the prevalence in the general U.S. population.
In 2021, 16 U.S. states conducted mandatory HIV testing of all persons under state law enforcement custody, and 23 states and the U.S. Federal Bureau of Prisons offered opt-out HIV testing, accounting for 84% of all persons admitted and sentenced to more than 1 year in the custody of state and federal correctional authorities.
In a 2013 survey of women across 20 metropolitan areas with high HIV prevalence, women who were recently incarcerated were significantly more likely to have factors that increase their risk for HIV infection than those who were never incarcerated, including receiving money or drugs in exchange for sex with a partner, multiple casual partners, multiple casual condomless partners, and sexually transmitted infection (STI) diagnosis.

More information on HIV Surveillance in the United States .

Viral hepatitis

In 2009, a systematic review of 23 studies from incarcerated populations in the U.S. reported a wide chronic hepatitis B virus (HBV) prevalence range of 0.9%–11.4%.
HBV prevalence has been estimated to be 3 to 38 times higher in correctional settings than in the general population in 2009.
From 2013–2016, people who were incarcerated were estimated to have a rate of current hepatitis C virus (HCV) infection 10 times higher (10.7% vs 1%) than persons in the general population.
Approximately 30% of all persons infected with HCV in the United States spend at least part of the year in correctional facilities.

More information on viral hepatitis surveillance in the United States.

Males and females 35 years of age and younger in juvenile and adult detention facilities have been reported to have higher rates of chlamydia and gonorrhea than nonincarcerated persons in the community.
Jail-based chlamydia screen-and-treat programs can potentially decrease chlamydia prevalence in communities with higher incarceration rates —as much as 13% in large communities and 54% in small communities.

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In 2021, 2.4% of persons 15 years of age or older diagnosed with tuberculosis were current residents of correctional facilities at the time of diagnosis.
From 2003–2013, annual median tuberculosis incidence was about 6 times higher for persons in jails and federal prisons compared with the general population.
An analysis during 2011–2019 demonstrated that large tuberculosis outbreaks still occur in state prisons and account for a large proportion of total tuberculosis cases in some states.

For more information on Tuberculosis cases by residence in and type of correctional facility .

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Research in the United States and from other countries suggests almost half (46%) of people in correctional or detention facilities such as prisons and jails have a history of TBI, but the exact number is not known.
Studies show an association between people in correctional or detention facilities with a history of TBI and mental health problems, such as severe depression and anxiety, substance use disorders, difficulty controlling anger, and suicidal thoughts and/or attempts.
People in correctional or detention facilities with TBI-related problems may not be screened for a TBI or may face challenges with getting TBI-related care. These challenges may continue after a person is released from the facility.

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HIV, viral hepatitis, STIs, and tuberculosis

At-A-Glance: CDC Recommendations for Correctional and Detention Settings for Testing, Vaccination, and Treatment for HIV, Viral Hepatitis, TB, and STIs – Summary of current CDC guidelines and recommendations for testing, vaccination, and treatment of HIV, viral hepatitis, TB, and STIs for persons who are detained or incarcerated. Links to full guidance documents are included.
Guidance on Management of COVID-19 in Homeless Service Sites and in Correctional and Detention Facilities – Guidance that can be used to inform COVID-19 prevention actions in homeless service sites and correctional and detention facilities.

Worker safety

Safe and Proper Use of Disinfectants to Reduce Viral Surface Contamination in Correctional Facilities – Steps to reduce viral surface contamination through safe and proper use of disinfectants for persons who work in correctional facilities, including a companion printable poster to be displayed throughout the facility. The poster is available in English and Spanish.
Reducing Work-Related Needlestick and Other Sharps Injuries Among Law Enforcement Officers (PDF) – Provides recommendations for reducing needlesticks and other sharps injuries to law enforcement officers, which specifically includes guidance for correctional employees.

Overdose prevention

Partnerships Between Public Health and Public Safety – Overview of CDC partnerships built through multiple public health and public safety collaborations to strengthen and improve efforts to reduce drug overdoses.
Public Health and Public Safety Resources – Resources for jails and prisons that support public health and public safety related to overdose prevention and medication-assisted treatment (MAT) for opioid use disorder.
What Health Departments Need to Know When Responding to Mumps Outbreaks in Correctional and Detention Facilities – Job-aid with guidance for health departments and facilities during mumps outbreaks.
LM Maruschak. HIV in Prisons, 2021—Statistical Tables. U.S. Department of Justice, Bureau of Justice Statistics, Washington, DC (Published May 2022). https://bjs.ojp.gov/document/hivp21st.pdf , Accessed 16 Mar 2023
Wise A, Finlayson T, Nerlander L, Sionean C, Paz-Bailey G; NHBS Study Group. Incarceration, Sexual Risk-related Behaviors, and HIV Infection Among Women at Increased Risk of HIV Infection, 20 United States cities. J Acquir Immune Defic Syndr. 2017 Jul 1;75 Suppl 3:S261-S267. Incarceration, Sexual Risk-Related Behaviors, and HIV Infection Among Women at Increased Risk of HIV Infection, 20 United States Cities – PubMed (nih.gov)
Harzke AJ, Goodman KJ, Mullen PD, Baillargeon J. Heterogeneity in Hepatitis B Virus (HBV) Seroprevalence Estimates from U.S. Adult Incarcerated Populations. Ann Epidemiol. 2009;19(9):647-650. doi:10.1016/j.annepidem.2009.04.001. Heterogeneity in Hepatitis B Virus (HBV) Seroprevalence Estimates from U.S. Adult Incarcerated Populations | Elsevier Enhanced Reader
Roberts H, Kruszon-Moran D, Ly KN, Hughes E, Iqbal K, Jiles RB, Holmberg SD. Prevalence of Chronic Hepatitis B Virus (HBV) Infection in U.S. Households: National Health and Nutrition Examination Survey (NHANES), 1988-2012. Hepatology. 2016 Feb;63(2):388-97. doi: 10.1002/hep.28109. Epub 2015 Oct 27. PMID: 26251317. Prevalence of chronic hepatitis B virus (HBV) infection in U... : Hepatology (lww.com)
Hofmeister MG, Rosenthal EM, Barker LK, et al. Estimating Prevalence of Hepatitis C Virus Infection in the United States, 2013-2016. Hepatology. 2019;69(3):1020-1031. doi:10.1002/hep.30297. Estimating Prevalence of Hepatitis C Virus Infection in the United States, 2013-2016 – PubMed (nih.gov)
CDC 2021 Sexually Transmitted Infections (STI) Treatment Guidelines: Persons in Correctional Facilities
Bernstein KT, Chow JM, Pathela P, Gift TL. Bacterial Sexually Transmitted Disease Screening Outside the Clinic–Implications for the Modern Sexually Transmitted Disease Program. Sex Transm Dis. 2016;43(2 Suppl 1):S42-S52. Bacterial Sexually Transmitted Disease Screening Outside the Clinic–Implications for the Modern Sexually Transmitted Disease Program – PubMed (nih.gov)
Owusu-Edusei K Jr, Gift TL, Chesson HW, Kent CK. Investigating the potential public health benefit of jail-based screening and treatment programs for chlamydia. Am J Epidemiol. 2013 Mar 1;177(5):463-73. doi: 10.1093/aje/kws240. Epub 2013 Feb 12. PMID: 23403986. Investigating the potential public health benefit of jail-based screening and treatment programs for chlamydia – PubMed (nih.gov)
CDC Tuberculosis Data & Statistics: Reported Tuberculosis in the United States, 2021 in Residents of Correctional Facilities https://www.cdc.gov/tb/statistics/reports/2020/risk_factors.htm Lambert LA, Armstrong LR, Lobato MN, Ho C, France AM, Haddad MB. Tuberculosis in Jails and Prisons: United States, 2002-2013. Am J Public Health. 2016 Dec;106(12):2231-2237. doi: 10.2105/AJPH.2016.303423. Epub 2016 Sep 15. PMID: 27631758; PMCID: PMC5104991. Tuberculosis in Jails and Prisons: United States, 2002-2013 – PubMed (nih.gov)
Stewart RJ, Raz KM, Burns SP, Kammerer JS, Haddad MB, Silk BJ, Wortham JM. Tuberculosis Outbreaks in State Prisons, United States, 2011 – 2019. Am J Public Health. 2022, 112(8), 1170-1179. PMID: 35830666; PMCID: PMC934802. Doi: 10.2105/AJPH.2022.306864
Hunter S, Kois L, Peck A, Elbogen E, LaDuke C. (2023). The prevalence of traumatic brain injury (TBI) among people impacted by the criminal legal system: An updated meta-analysis and subgroup analyses. Law and Human Behavior , 47(5), 539–565.
Moore E, Indig D, Haysom L. Traumatic brain injury, mental health, substance use, and offending among incarcerated young people. Journal of Head Trauma Rehabilitation. 2014;29(3):239-247.
Ray B, Sapp D, Kincaid A. Traumatic brain injury among Indiana state prisoners. Journal of Forensic Sciences. 2014;59(5):1248-1253.
Walker R, Hiller M, Staton M, Leukefeld C. Head injury among drug abusers: An indicator of co-occurring problems. Journal of Psychoactive Drugs. 2003;35(3):343-353.
Slaughter B, Fann J, Ehde D. Traumatic brain injury in a county jail population: Prevalence, neuropsychological functioning and psychiatric disorders. Brain Injury. 2003;17(9):731-741.
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“Criminal legal system” may also be used as an alternative to “justice system” to reflect historic and current challenges to achieving justice in the U.S. criminal legal system.

CDC provides health resources to protect the health of people in correctional settings who are at higher risk for HIV, Viral Hepatitis, STIs, and Tuberculosis.

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What is depression?

Everyone feels sad or low sometimes, but these feelings usually pass. Depression (also called major depression, major depressive disorder, or clinical depression) is different. It can cause severe symptoms that affect how a person feels, thinks, and handles daily activities, such as sleeping, eating, or working.

Depression can affect anyone regardless of age, gender, race or ethnicity, income, culture, or education. Research suggests that genetic, biological, environmental, and psychological factors play a role in the disorder.

Women are diagnosed with depression more often than men, but men can also be depressed. Because men may be less likely to recognize, talk about, and seek help for their negative feelings, they are at greater risk of their depression symptoms being undiagnosed and undertreated. Studies also show higher rates of depression and an increased risk for the disorder among members of the LGBTQI+ community.

In addition, depression can co-occur with other mental disorders or chronic illnesses, such as diabetes, cancer, heart disease, and chronic pain. Depression can make these conditions worse and vice versa. Sometimes, medications taken for an illness cause side effects that contribute to depression symptoms as well.

What are the different types of depression?

There are two common types of depression.

Major depression includes symptoms of depressed mood or loss of interest, most of the time for at least 2 weeks, that interfere with daily activities.
Persistent depressive disorder (also called dysthymia or dysthymic disorder) consists of less severe depression symptoms that last much longer, usually for at least 2 years.

Other types of depression include the following.

Seasonal affective disorder comes and goes with the seasons, with symptoms typically starting in the late fall and early winter and going away during the spring and summer.
Depression with symptoms of psychosis is a severe form of depression in which a person experiences psychosis symptoms, such as delusions or hallucinations.
Bipolar disorder involves depressive episodes, as well as manic episodes (or less severe hypomanic episodes) with unusually elevated mood, greater irritability, or increased activity level.

Additional types of depression can occur at specific points in a woman’s life. Pregnancy, the postpartum period, the menstrual cycle, and menopause are associated with physical and hormonal changes that can bring on a depressive episode in some people.

Premenstrual dysphoric disorder is a more severe form of premenstrual syndrome, or PMS, that occurs in the weeks before menstruation.
Perinatal depression occurs during pregnancy or after childbirth. It is more than the “baby blues” many new moms experience after giving birth.
Perimenopausal depression affects some women during the transition to menopause. Women may experience feelings of intense irritability, anxiety, sadness, or loss of enjoyment.

What are the signs and symptoms of depression?

Common signs and symptoms of depression include:

Persistent sad, anxious, or “empty” mood
Feelings of hopelessness or pessimism
Feelings of irritability, frustration‚ or restlessness
Feelings of guilt, worthlessness, or helplessness
Loss of interest or pleasure in hobbies and activities
Fatigue, lack of energy, or feeling slowed down
Difficulty concentrating, remembering, or making decisions
Difficulty sleeping, waking too early in the morning, or oversleeping
Changes in appetite or unplanned weight changes
Physical aches or pains, headaches, cramps, or digestive problems without a clear physical cause that do not go away with treatment
Thoughts of death or suicide or suicide attempts

Depression can also involve other changes in mood or behavior that include:

Increased anger or irritability
Feeling restless or on edge
Becoming withdrawn, negative, or detached
Increased engagement in high-risk activities
Greater impulsivity
Increased use of alcohol or drugs
Isolating from family and friends
Inability to meet responsibilities or ignoring other important roles
Problems with sexual desire and performance

Not everyone who is depressed shows all these symptoms. Some people experience only a few symptoms, while others experience many. Depression symptoms interfere with day-to-day functioning and cause significant distress for the person experiencing them.

If you show signs or symptoms of depression and they persist or do not go away, talk to a health care provider. If you see signs of depression in someone you know, encourage them to seek help from a mental health professional.

If you or someone you know is struggling or having thoughts of suicide, call or text the 988 Suicide and Crisis Lifeline at 988 or chat at 988lifeline.org . In life-threatening situations, call 911 .

How is depression diagnosed?

To be diagnosed with depression, a person must have symptoms most of the day, nearly every day, for at least 2 weeks. One of the symptoms must be a depressed mood or a loss of interest or pleasure in most activities. Children and adolescents may be irritable rather than sad.

Although several persistent symptoms, in addition to low mood, are required for a depression diagnosis, people with only a few symptoms may benefit from treatment. The severity and frequency of symptoms and how long they last vary depending on the person.

If you think you may have depression, talk to a health care provider, such as a primary care doctor, psychologist, or psychiatrist. During the visit, the provider may ask when your symptoms began, how long they have lasted, how often they occur, and if they keep you from going out or doing your usual activities. It may help to take some notes about your symptoms before the visit.

Certain medications and medical conditions, such as viruses or thyroid disorders, can cause the same symptoms as depression. A provider can rule out these possibilities by doing a physical exam, interview, and lab tests.

Does depression look the same in everyone?

Depression can affect people differently depending on their age.

Children may be anxious or cranky, pretend to be sick, refuse to go to school, cling to a parent, or worry that a parent may die.
Older children and teens may get into trouble at school, sulk, be easily frustrated‚ feel restless, or have low self-esteem. They may have other disorders, such as anxiety, an eating disorder, attention-deficit/hyperactivity disorder, or substance use disorder. Older children and teens are also more likely to experience excessive sleepiness (called hypersomnia) and increased appetite (called hyperphagia).
Young adults are more likely to be irritable, complain of weight gain and hypersomnia, and have a negative view of life and the future. They often have other disorders, such as generalized anxiety disorder, social phobia, panic disorder, or substance use disorder.
Middle-aged adults may have more depressive episodes, decreased libido, middle-of-the-night insomnia, or early morning waking. They often report stomach problems, such as diarrhea or constipation.
Older adults often feel sadness, grief, or other less obvious symptoms. They may report a lack of emotions rather than a depressed mood. Older adults are also more likely to have other medical conditions or pain that can cause or contribute to depression. Memory and thinking problems (called pseudodementia) may be prominent in severe cases.

Depression can also look different in men versus women, such as the symptoms they show and the behaviors they use to cope with them. For instance, men (as well as women) may show symptoms other than sadness, instead seeming angry or irritable.

For some people, symptoms manifest as physical problems (for example, a racing heart, tightened chest, chronic headaches, or digestive issues). Many men are more likely to see a health care provider about these physical symptoms than their emotional ones. While increased use of alcohol or drugs can be a sign of depression in any person, men are also more likely to use these substances as a coping strategy.

How is depression treated?

Depression treatment typically involves psychotherapy (in person or virtual), medication, or both. If these treatments do not reduce symptoms sufficiently, brain stimulation therapy may be another option.

Choosing the right treatment plan is based on a person’s needs, preferences, and medical situation and in consultation with a mental health professional or a health care provider. Finding the best treatment may take trial and error.

For milder forms of depression, psychotherapy is often tried first, with medication added later if the therapy alone does not produce a good response. People with moderate or severe depression usually are prescribed medication as part of the initial treatment plan.

Psychotherapy

Psychotherapy (also called talk therapy or counseling) can help people with depression by teaching them new ways of thinking and behaving and helping them change habits that contribute to depression. Psychotherapy occurs under the care of a licensed, trained mental health professional in one-on-one sessions or with others in a group setting.

Psychotherapy can be effective when delivered in person or virtually via telehealth. A provider may support or supplement therapy using digital or mobile technology, like apps or other tools.

Evidence-based therapies to treat depression include cognitive behavioral therapy and interpersonal therapy. Using other forms of psychotherapy, such as psychodynamic therapy, for a limited time also may help some people with depression.

Cognitive behavioral therapy (CBT) : With CBT, people learn to challenge and change unhelpful thoughts and behaviors to improve their depressive and anxious feelings. Recent advances in CBT include adding mindfulness principles and specializing the therapy to target specific symptoms like insomnia.
Interpersonal therapy (IPT) : IPT focuses on interpersonal and life events that impact mood and vice versa. IPT aims to help people improve their communication skills within relationships, form social support networks, and develop realistic expectations to better deal with crises or other issues that may be contributing to or worsening their depression.

Learn more about psychotherapy .

Antidepressants are medications commonly used to treat depression. They work by changing how the brain produces or uses certain chemicals involved in mood or stress.

Antidepressants take time—usually 4−8 weeks—to work, and problems with sleep, appetite, and concentration often improve before mood lifts. Giving a medication a chance to work is important before deciding whether it is right for you.

Treatment-resistant depression occurs when a person doesn’t get better after trying at least two antidepressants. Esketamine is a medication approved by the U.S. Food and Drug Administration (FDA) for treatment-resistant depression. Delivered as a nasal spray in a doctor’s office, clinic, or hospital, the medication acts rapidly, typically within a couple of hours, to relieve depression symptoms. People will usually continue to take an antidepressant pill to maintain the improvement in their symptoms.

Another option for treatment-resistant depression is to combine an antidepressant with a different type of medication that may make it more effective, such as an antipsychotic or anticonvulsant medication.

All medications can have side effects. Talk to a health care provider before starting or stopping any medication. Learn more about antidepressants .

Note : In some cases, children, teenagers, and young adults under 25 years may experience an increase in suicidal thoughts or behavior when taking antidepressants, especially in the first few weeks after starting or when the dose is changed. The FDA advises that patients of all ages taking antidepressants be watched closely, especially during the first few weeks of treatment.

Information about medication changes frequently. Learn more about specific medications like esketamine, including the latest approvals, side effects, warnings, and patient information, on the FDA website .

Brain stimulation therapy

Brain stimulation therapy is an option when other depression treatments have not worked. The therapy involves activating or inhibiting the brain with electricity or magnetic waves.

Although brain stimulation therapy is less frequently used than psychotherapy and medication, it can play an important role in treating depression in people who have not responded to other treatments. The therapy generally is used only after a person has tried psychotherapy and medication, and those treatments usually continue. Brain stimulation therapy is sometimes used as an earlier treatment option when severe depression has become life-threatening, such as when a person has stopped eating or drinking or is at a high risk of suicide.

The FDA has approved several types of brain stimulation therapy. The most used are electroconvulsive therapy (ECT) and repetitive transcranial magnetic stimulation (rTMS). Other brain stimulation therapies are newer and, in some cases, still considered experimental. Learn more about brain stimulation therapies .

Natural products

The FDA has not approved any natural products for treating depression. Although research is ongoing and findings are inconsistent, some people report that natural products, including vitamin D and the herbal dietary supplement St. John’s wort, helped their depression symptoms. However, these products can come with risks, including, in some cases, interactions with prescription medications.

Do not use vitamin D, St. John’s wort, or other dietary supplements or natural products without first talking to a health care provider. Rigorous studies must test whether these and other natural products are safe and effective.

How can I take care of myself?

Most people with depression benefit from mental health treatment. Once you begin treatment, you should gradually start to feel better. Go easy on yourself during this time. Try to do things you used to enjoy. Even if you don’t feel like doing them, they can improve your mood.

Other things that may help:

Try to get physical activity. Just 30 minutes a day of walking can boost your mood.
Try to maintain a regular bedtime and wake-up time.
Eat regular, healthy meals.
Do what you can as you can. Decide what must get done and what can wait.
Connect with people. Talk to people you trust about how you are feeling.
Delay making important life decisions until you feel better. Discuss decisions with people who know you well.
Avoid using alcohol, nicotine, or drugs, including medications not prescribed for you.

How can I find help for depression?

You can learn about ways to get help and find tips for talking with a health care provider on the NIMH website.

The Substance Abuse and Mental Health Services Administration (SAMHSA) also has an online tool to help you find mental health services in your area.

How can I help a loved one who is depressed?

If someone you know is depressed, help them see a health care provider or mental health professional. You also can:

Offer support, understanding, patience, and encouragement.
Invite them out for walks, outings, and other activities.
Help them stick to their treatment plan, such as setting reminders to take prescribed medications.
Make sure they have transportation or access to therapy appointments.
Remind them that, with time and treatment, their depression can lift.

What are clinical trials and why are they important?

Clinical trials are research studies that look at ways to prevent, detect, or treat diseases and conditions. These studies help show whether a treatment is safe and effective in people. Some people join clinical trials to help doctors and researchers learn more about a disease and improve health care. Other people, such as those with health conditions, join to try treatments that aren’t widely available.

NIMH supports clinical trials across the United States. Talk to a health care provider about clinical trials and whether one is right for you. Learn more about participating in clinical trials .

For more information

Learn more about mental health disorders and topics . For information about various health topics, visit the National Library of Medicine’s MedlinePlus .

The information in this publication is in the public domain and may be reused or copied without permission. However, you may not reuse or copy images. Please cite the National Institute of Mental Health as the source. Read our copyright policy to learn more about our guidelines for reusing NIMH content.

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES National Institutes of Health NIH Publication No. 24-MH-8079 Revised 2024

Health Services Research

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Thomas Schäfer ,
Christian A. Gericke &
Reinhard Busse

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After a brief introduction into the general field of health services research, a large section deals with the specific issues arising when epidemiological or statistical methods are used to study health services. This is followed by sections describing the main fields of investigation which are usually thought of as pertaining to the wider realm of health services research. These are studies of demand, need, utilization, and access to health services which have the interface between the patient and health services in common. The next section describes the importance of financial resources, structure, and organization for the delivery of effective and efficient health care. This is followed by a description of the processes and outcomes of health care, including concepts such as effectiveness and appropriateness of care and their use, for example, in physician profiling or in hospital rankings. In the section on outcomes, special emphasis is put on health status measurement and the evaluation of health systems in international comparisons. Important health economic concepts, such as cost-effectiveness and efficiency, are covered in various sections. This chapter concludes with describing common pitfalls and caveats in interpreting health services research.

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Schäfer, T., Gericke, C.A., Busse, R. (2014). Health Services Research. In: Ahrens, W., Pigeot, I. (eds) Handbook of Epidemiology. Springer, New York, NY. https://doi.org/10.1007/978-0-387-09834-0_38

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Types of Primary Medical Research
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Health Services Research: Scope and Significance
In 1968, the National Center for Health Services Research and Development was established as part of the U.S. Public Health Services to address concerns with access to health services, quality of care, and costs. The Center funded demonstration projects to measure quality and investigator-initiated research grants.
Health services research
Health services research (HSR) became a burgeoning field in North America in the 1960s, when scientific information and policy deliberation began to coalesce. Sometimes also referred to as health systems research or health policy and systems research (HPSR), HSR is a multidisciplinary scientific field that examines how people get access to health care practitioners and health care services ...
Health Services Research
After a brief introduction into the general field of health services research, a large section deals with the specific issues arising when epidemiological or statistical methods are used to study health services. ... When comparing the developed countries with respect to financing from the first perspective we can find two marked types of ...
Introduction
Health Services Research: A Definition. Health services research is a "multidisciplinary field of scientific investigation that studies how social factors, financing systems, organizational structures and processes, health technologies, and personal behaviors affect access to health care, the quality and cost of health care, and ultimately ...
Description of Health Services Research
Abstract. Health services research (HSR) aims to contribute to the improvement of healthcare by addressing challenges in real-world healthcare settings. It is centred around the values, needs and interests of people who are (potential) users of healthcare (i.e. individuals and populations). HSR complements life sciences and clinical research as ...
An Introduction to Health Services Research
AcademyHealth defines health services research as the multidisciplinary field of scientific investigation that studies how social factors, financing systems, organizational structures and processes, health technologies, and personal behaviors affect access to health care, the quality and cost of health care, and ultimately our health and well-being.
Health Services Research
Health services research (HSR) provides the information needed to understand the effectiveness and efficiency of our health care delivery system and its impact on the health and well-being of individuals and populations. 1 Health services research documents deficiencies in patient and population health and in the provision of health services and seeks to identify contributing factors.
Health Systems Research
Health Services Research and Primary Care Research. AHRQ convened an interactive roundtable meeting of leaders in health systems, public health preparedness, and resiliency, facilitated by the Department of Health and Human Services Office of Climate Change and Health Equity interim director. The roundtable discussion laid the groundwork for advancing work on health system resilience, along ...
Health Services Research: Translating Discovery and Research Into
Health services research examines individual, family, organizational, institutional, community, and population level factors that affect health behaviors and outcomes. Grounded in theory, the goal of health services research is to generate knowledge to inform and guide decision-makers and those responsible for delivering health care.
PDF HEALTH RESEARCH METHODOLOGY
Health services research - methods. 2. Research design. I. World Health Organization. Regional Office for the Western Pacific ... types of research, with the more affluent and technologically advanced societies able to support a greater proportion of basic research than
Research
Health research entails systematic collection or analysis of data with the intent to develop generalizable knowledge to understand health challenges and mount an improved response to them. The full spectrum of health research spans five generic areas of activity: measuring the health problem; understanding its cause(s); elaborating solutions; translating the solutions or evidence into policy ...
Types of Health Research
This type of research can be one or a combination of the types of research mentioned above. Public health research tries to improve the health and well-being of people from a population-level perspective. More Information about Clinical Trials. Clinical trials are often done in a "randomized" way. These are sometimes called RCTs for "randomized ...
Understanding Clinical Research
There are many different types of clinical research. Epidemiology studies improve the understanding of a disease by studying patterns, causes, and effects of health and disease in specific groups of people.; Behavioral studies improve the understanding of human behavior and how it relates to health and disease.; Health services studies examine how people access health care providers and health ...
Health Services Research Methods: A Guide to Best Practice
Foreword. 1.Researching health services. Part one: measurement of benefits and costs. 2.Patient-assessed outcome measures. 3.The use of health-related quality of life measures in economic evaluation. 4.Collecting resource use data in clinical studies. 5.Designing and using patient and staff questionnaires. Part two: Methods of evaluating health ...
Types of Research
Types of Research. In the Health Sciences, we generally categorize evidence into two main types: Filtered and Unfiltered resources. When you look at the traditional evidence pyramid, we are looking at the research cycle: starting with unfiltered information (the original research), once a body of work is established, we can start analyzing and ...
National Institute of Nursing Research
The mission of the National Institute of Nursing Research (NINR) is to promote and improve the health of individuals, families, and communities. To achieve this mission, NINR supports and conducts clinical and basic research and research training on health and illness, research that spans and integrates the behavioral and biological sciences, and that develops the scientific basis for clinical ...
The implementation of person-centred plans in the community-care sector
The context of care and the types of services offered by the organization were directly informed by the needs and characteristics of the population served. The culture of the organization (e.g., their values, attitudes and beliefs surrounding persons-supported) was a key influence in the development and implementation of person-centred care plans.
Psychiatry and Psychology Services at Mayo Clinic
Expect the best. Psychiatry and psychology services draws upon the strength of a multidisciplinary team combined with leading research to ensure that you get the best care available. Comprehensive mental health assessments and treatments are coordinated by psychiatrists and psychologists, working with experienced nurses, social workers and others.
Department of Human Services (DHS)
Department Of Human Services, Blair County Enter into Settlement Agreement to Improve the County's Office of Children, Youth, And Families Shapiro Administration Highlights Mental Health and Substance Use Disorder Resources for Older Pennsylvanians, Governor's Proposed Investments in Behavioral Health Funding
Public Health Considerations for Correctional Health
Correctional health is community health. CDC provides treatment guidelines and other correctional health resources. Correctional health encompasses all aspects of health and well-being for adults and juveniles who are justice system*-involved. This starts at the point of arrest, continues at detention or incarceration, and carries through after ...
Depression
Depression (also called major depression, major depressive disorder, or clinical depression) is different. It can cause severe symptoms that affect how a person feels, thinks, and handles daily activities, such as sleeping, eating, or working. Depression can affect anyone regardless of age, gender, race or ethnicity, income, culture, or education.
Health Services Research
1.1 Health Services Research Defined. Health services research (HSR) attempts to answer questions about the best medical treatment or preventive course of action, the quality of care provided by a hospital or a physician, the efficient delivery of services to all populations, and their costs.
MHS Home
The Health.mil is the official website of the Military Health System. The Military Health System is one of America's largest and most complex health care institutions, and the world's preeminent military health care delivery operation. Our MHS saves lives on the battlefield, combats infectious disease around the world, and is responsible for providing health services to approximately 9.6 ...

Patient Safety and Quality: An Evidence-Based Handbook for Nurses.

Affiliations

Structure of Health Care

Process of Care

Outcomes of Care

Public Health Perspective on Health Services

Efficacy and Effectiveness

Methods for Effectiveness Research

RCT and Policy Research

Health insurance experiment

Medicare preventive services experiment

Comparative Clinical Effectiveness and RCTs

Comparing Effectiveness and Costs Across Nonequivalent Groups

Data Sources for Effectiveness Research

Medical records

Administrative and billing data

Survey questionnaires

Using HSR Methods To Improve Clinical Practice

Evidence-based treatment

Outcomes management system

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FEDERAL SUPPORT OF HEALTH SERVICES RESEARCH

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Understanding Clinical Research

Types of Clinical Research

What Is a Clinical Trial?

A Clinical Trial Is a Scientific Test

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The implementation of person-centred plans in the community-care sector: a qualitative study of organizations in Ontario, Canada

Conclusions

Positionality

Organizational context

Populations served

Services offered

Nature of care: social vs. medical

Duration of care: short-term vs. long-term

In-home vs. community-based care

Full-time vs. part-time support

Organizational Culture

Perceptions, attitudes, and beliefs regarding persons-supported

Model of care provision

Evolving service orientation

Person-centred care plans

Developing a person-centred care plan

Implementing a person-centred care plan

Limitations

Data availability

Abbreviations