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Purpose: Theories of the policy process recognize that policy proposals are typically generated, debated, redrafted, and accepted for consideration through the gradual accumulation of knowledge within communities of specialists. Thus, to inform long-term care (LTC) reform efforts, we conducted a Web-based survey of 1,147 LTC specialists nationwide., Design and Methods: Survey respondents included consumer advocates, provider representatives, public officials, policy experts, and others with experience in LTC. Administration took place between September 2007 and March 2008 and addressed prevailing challenges and options for reform., Results: Although differences could be discerned, constituency group views converged in several areas. There was general agreement that LTC financing needed to be socialized more and that impediments to organizational change needed to be overcome. Respondents also felt that LTC needed to be rebalanced toward home- and community-based settings, though few supported doing so by limiting nursing home (NH) bed supply. Although virtually all felt that the federal government was doing a poor job regulating LTC providers, most believed that the approaches used to oversee NHs should also be applied to assisted living. Payment incentives were highlighted as the most effective strategy for improving quality even though it suffers from the same informational deficits compromising consumer reporting., Implications: By giving voice to those who know LTC very well, and identifying areas of agreement and disagreement, this study should prove useful in promoting LTC reform where it might otherwise remain politically intransigent.

This study proposes that exogenous shocks emanating from national governments can significantly change health policy processes among subnational units. The relevance of this insight for comparative health policy research is examined in the context of Medicaid nursing facility reimbursement policymaking in the American states. Event history techniques are used to model state adoption of case-mix methods for reimbursing nursing homes under Medicaid from 1980 to 2004. Case-mix adjusts Medicaid nursing home payments for patient acuity, thereby enabling states to pay more for residents with higher care needs and to pay less for residents with lower care needs. The goal is to improve access for more resource intensive Medicaid beneficiaries and to distribute payments more equitably across the providers who serve them. The most noteworthy national policy changes affecting case-mix implementation by state governments were adoption of nursing home quality reform with the Omnibus Budget Reconciliation Act (OBRA) of 1987 and case-mix by Medicare with the Balanced Budget Act (BBA) of 1997. In light of the 1990 and 1999 implementation of OBRA 1987 and the BBA, respectively, five models were estimated, which in addition to covering the entire time period studied (1980-2004) include pre-/post-BBA comparisons (1980-1998, 1999-2004) and pre-/post-OBRA 1987 comparisons (1980-1989, 1990-1998). Results suggest that in contrast to early adoption, which tended to be grounded in the capabilities of innovative states, later adoption tended to take place among less capable states influenced more by the changing federal policy environment. They also highlight the salience of programmatic and fiscal conditions but during the middle of the adoption cycle only. Future research should clarify the ways in which national policy changes influence health policy adoption at the subnational level, both in other nations and across different levels of government.

Aims: This study reports findings from the first national survey of long-term care opinion leaders in New Zealand., Methods: Potential respondents were chosen purposively based on their knowledge and experience in long-term care policy and planning. Questions focused on assessing views regarding long-term care quality, financing, services, workforce, organisation, and regulation. The survey was administered via Web-based format during May-June 2007. Seventy-three individuals responded for an overall response rate of 47.7%., Results: Experts support cost-sharing, insurance, and individual savings/preparation as supplements to predominately government-based financing. They view increased compensation and improved work environments as the key to recruiting/retaining paraprofessionals and educational assistance and curriculum reform as the key to attracting professionals. Most would expand access to home-based support through adoption of comprehensive service packages and various navigational aides (e.g. care coordination, counselling). Consumer-direction and public payment of family members were also deemed desirable. There was a lack of knowledge regarding emerging models of culture change/client-centred care in long-term care. Promoting quality by advising providers about how to improve quality and increasing public availability of comparative provider information was highlighted., Conclusions: There are varying degrees of consensus regarding the kinds of solutions to long-term care problems that are viable from a policy perspective. Results should help determine how best to improve the current system to meet the needs of the growing elderly population.

Despite the great promise that telehealth holds for improving cost, quality and access, there is currently a disjunction between what we know about telehealth and system growth and performance. To better understand the relationship between these two facets of telehealth development, this paper examines trends in telehealth, both as an intellectual endeavor and as a practical means of providing health services. Although there are promising avenues for government intervention in the way of coordination, funding, and regulatory practice, lack of knowledge regarding what works and what does not work has served as a major impediment to further progress in this area. In the absence of solid empirical evidence, key decision makers entertain doubts about telehealth's effectiveness, which, in turn, limits public leadership, private investment, and the long-term integration of telehealth into the health and technological mainstream. Solving the disjuncture between research and practice will require additional clinical trials and evaluation studies that examine the efficacy of various technologies, both relative to each other and to conventional in person medical encounters. At the same time, it will require more even distribution of research across applications, service locations, regions, and nations. But the generation of additional high-quality empirical data on process, benefits, costs, and effects is only the beginning. That data must in turn be used to effectuate change. This will require researchers to take a more proactive stance in promoting use of their findings, both instrumentally, to adjust, modify or improve particular programs or policies, and conceptually, to influence how key stakeholders think about telehealth more generally.

This paper suggests modifications to the Roter Interaction Analysis System (RIAS)--the most widely used measure for assessing provider-patient communication during conventional face-to-face consultations--for use in telemedicine. The RIAS, which describes and categorizes communication behaviors, is used to quantify communication events, which may then be correlated with patient, provider, and system attributes and health outcomes. Most of the changes suggested here add new coding subcategories to characterize technology-related utterances and to provide opportunities for global assessments of the overall technology environment within which provider-patient interactions took place. There are also general issues raised that interaction analysis researchers should consider when studying provider-patient communication in a telemedicine context. These relate to nonverbal behavior, multiple participants, missing information, and validity and reliability. In addition to comparing telemedicine to in person consultations, a modified RIAS could be used to compare televideo consultations to each other, across different specialties and technical specifications. A modified RIAS would accommodate not only differences in the current technology environment, but also changes in the way providers and patients communicate over time. The more we know about what interaction patterns lead to best outcomes, the more emphasis can be placed on developing training programs and other interventions to enhance patient-provider interactions in telemedicine.