VALUASI TOTAL EKONOMI HUTAN MANGROVE DI KAWASAN DELTA MAHAKAM KABUPATEN KUTAI KARTANEGARA KALIMANTAN TIMUR

Abstract

Most older adults are admitted to home health care with some functional impairment related to chronic illness and/or hospitalization. This article describes: (1) the impact of a quality improvement initiative (QI) on functional outcomes of older, chronically ill patients served by a large homecare organization; and (2) key implementation challenges affecting intervention outcomes. Over 6,000 patients were included in two dissemination phases. Phase 1 randomly assigned service delivery teams to intervention (QI) or usual care (UC). Phase 2 spread the intervention to UC teams. Phase 1 yielded statistically significant, albeit modest, functional improvements among intervention team patients relative to UC. Phase 2 improvements in the original intervention group were smaller, suggesting some regression to the mean. UC teams did not "catch up" when exposed to the intervention in Phase 2. Analysis of the implementation process suggested that modification of improvement strategies and "dilution" of peer-to-peer communication hindered additional Phase 2 improvements. The findings highlight the challenges of relying on peer-to-peer spread, and of distinguishing the core elements of an effective improvement strategy that must be spread consistently from those that can be adapted to variations within and across organizations. Copyright (C) 2011 John Wiley & Sons, Inc.; References: Baker, D. I., Gottschalk, M., Eng, C., Weber, S., & Tinetti, M. E. (2001). The design and implementation of a restorative care model for home care. Gerontologist, 41, 257-263. Berwick, D. M. (2003). Improvement, trust, and the healthcare workforce. Quality and Safety in Health Care, 12, 448-452. Beswick, A. D., Rees, K., Dieppe, P., Ayis, S., Gooberman-Hill, R., Horwood, J., et al. (2008). 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