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A fully capitated, integrated healthcare delivery system endeavored to improve the care of its sickest members. A computer algorithm severity index that encompassed a 1-year history of hospitalization and adjusted for inclusion of a variety of chronic conditions was calculated on the basis of clinical and administrative claims databases for the entire membership of the healthcare system. Monthly updated lists were produced to find patients with acute and chronic illnesses. These patients accounted for one-fourth of hospital admissions and almost half of inpatient days, but they numbered less than 1% of system membership. Each listed person, regardless of age or diagnosis, had a custom care plan formulated by nurses in consultation with the primary care physician and involved specialists. Plan development featured in-home assessments in most instances and incorporated a variety of ancillary services, telephone and home-care follow-up, and strategies to increase continuity and access to care. Patient-reported functional status was obtained at establishment of the care plan and periodically thereafter in expectation of raising the cross-sectional mean values of the population. Three months after initiation of the program, the expected winter hospitalization peak did not occur, and utilization tended to be lower in subsequent months. Inpatient admissions among members with acute and chronic illnesses decreased 20%, and inpatient days decreased 28% from baseline levels. Among the subset of seniors in the population, inpatient days decreased 37%. Net financial impact was a medical expenditure decrease of more than 5% from 1995 levels. On a population basis, functional status was raised, and the acuity of patients' conditions and need for inpatient hospital care were reduced.

Post-traumatic stress disorder (PTSD) can be a serious aftermath of catastrophic events such as war. The incidence of PTSD appears to be high among Vietnam veterans. PTSD can be extremely disruptive to a person's physical and mental well-being, family life, social relationships, and employment status. Yet, for a variety of reasons, many Vietnam veterans suffering from PTSD have remained undiagnosed or insufficiently treated. The Massachusetts Department of Public Health, in cooperation with the Massachusetts Department of Veterans Services, initiated a hospital-based treatment and rehabilitation program for Vietnam veterans who have PTSD. As of November 1989, 150 Vietnam veterans had been admitted to this program.