Operations management applied to home care services: Analysis of the districting problem
Introduction
Recent developments in technological, social and economical environment have dramatically increased the need for improved service systems. Well designed service systems allow reducing costs and increasing customer satisfaction. This paper deals with a well-known type of service system, namely the home health care service. Home health care (HHC) which represents an alternative to the traditional hospitalization has been developed in France fifty years ago in order to solve the problem of hospitals' capacity saturation by providing to patients, at their home, complex and coordinated medical and paramedical care for a limited period which can be extended depending on patients' needs. This care is comparable, in terms of nature and intensity, to the one which would be delivered to the patient within a traditional hospitalization framework where the patient stays in the hospital to receive his/her treatment. HHC can be prescribed either by the family doctor or the doctor in charge of the patient in the hospital. Once admitted to a HHC structure, patients who suffer from pathologies such as cancer, nervous system diseases, circulatory system diseases, etc., receive medical and paramedical care based on one or several protocols/standards of care. The French HHC structures use twenty four protocols of care listed in the circular of May 30th, 2000 such as: the chemotherapy, radiotherapy, breathing assistance, palliative care, post-operation treatment, etc. [14]. Based on these protocols as well as on patients' social conditions, their age and their autonomy measured by the Karnofsky Performance Scale Index, a therapeutic project is then designed for each patient so that the number and average duration of visits required during the treatment of the patient within the HHC as well as the type and number of human and material resources required for the care delivered can be determined. The diversity of human resources that can be involved in the care (e.g. physicians, nurses, physiotherapists, social workers, home support workers, pharmacists, etc.) explains, as it will be described in detail later in the paper, the necessity of assigning to each patient a reference caregiver who is in charge of coordinating the execution of the therapeutic project. At this level, it is important to mention that most of HHC structures classify patients' therapeutic projects into categories named “profiles”. Indeed, patients whose therapeutic projects have similarities in terms of the expected duration of care, type, number and average duration of visits are grouped into the same profile.
During the last decade, HHC services have known an important growth. Indeed, the total number of HHC structures in France rose steadily from 68 structures in 1999 to 123 in 2005 and finally reached 271 structures in 2007. Despite the importance of the development of HHC services in practice, the amount of investigations dealing with operations management problems within the HHC context still remains modest, in comparison with earlier models developed for hospitals (e.g. [15], [21], [26], etc.). Most of the investigations considering HHC services mainly focus on either the problem of assigning caregivers to patients (or to visits) or the routing problem. Among the existing works developed so far, some models have been able to capture some of the specificities of HHC operations, i.e. what makes this care service different from the one delivered by hospitals, with respect to the way operations are managed. Hence, a first characteristic we can identify is the issue of the continuity of care in the HHC context defined by Shortell [29] as being the extent to which the medical and paramedical care are delivered by means of a sequence of coordinated and uninterrupted activities consistent with patients' needs, if possible by the same human resources. In practice, in order to guarantee the continuity of care in HHC, a patient is often assigned to only one caregiver, the reference caregiver, who follows the treatment of the patient during the time spent in the HHC structure. Most of time, the reference caregiver is the nurse who gives the paramedical care and coordinates the overall care with other caregivers such as the physician, social worker, etc. This is an important quality requirement of the HHC service due to the fact that it enables to preserve the service quality perceived by the patient since he/she receives the care from the same caregiver and thus does not have to continuously change his/her relationships with a new caregiver. A second characteristic of HHC operations is the necessity to integrate the patients' home within the care supply chain and hence to move the different flows of human and material resources needed for the care towards the patients' home. However, the diversity of human resources delivering the care and the variety of clinical and organizational decisions involved in the care delivery process need a tight coordination between different types of caregivers and material resources. Note that this coordination is especially difficult within this context since these resources are not grouped in the same health unit [12]. Another interesting problem which seems to us specific to HHC services concerns the consideration of human aspects while choosing the best organization for caregivers' teams. More specifically, if we consider one type of HHC caregivers, let's say the nurses, one may be interested in investigating the difference between two organizations: in the first organization, we assume that all nurses are grouped in a single team so that all the patients are treated by the same nurses' team independently of the basic unit where they live, while in the second organization, the area where the HHC structure operates is partitioned into several clusters (subareas), each of them being managed by a dedicated nurses' team. In our terminology, each cluster will be called a district. This second organization may enable not only to answer to a patient demand more quickly but also to increase the quality of service provided to him/her due to the diminution of the average time spent to reach him/her. Therefore, caregivers can spend more time in delivering care to patients. Furthermore, working in smaller areas, i.e. districts, within a smaller team may enhance caregivers' motivation since they can find a reinforced collaboration inside the team they belong to as well as a closer proximity with the HHC manager in charge of their team. Hence, the aim of a HHC structure in considering a districting approach may be to better manage its employees and, as a consequence, to satisfy patients more efficiently.
In this paper, we focus our attention on the districting problem due to the importance of such a decision in the achievement of HHC objectives in terms of improvement of the care delivery efficiency. Indeed, as explained above, the districting of a territory is a strategic HHC decision which aims at grouping basic units (a set of patients) into larger clusters, i.e. districts, so that these districts are “good” according to relevant criteria. These criteria can be related to the activity, demography or geographic characteristics of the basic units. Even if the districting approach can be viewed as time and resource consuming, it can have important impacts on caregivers' team structure and patients' satisfaction level.
This paper is organized as follows. In Section 2, we survey the literature related to our work: the first part of investigations reviewed concerns models that are developed in the operations management literature applied to HHC services while the second part is more related to the districting approach. In Section 3, we propose two mathematical formulations for the HHC districting problem. Results of computational experiments carried out on randomly generated instances to validate these two models are presented in Section 4. Finally, Section 5 presents some conclusions and perspectives that can be considered for future research.
Section snippets
Literature review
This part surveys two types of literature: operations management based models which have been proposed in the HHC literature and districting models developed in the operations research literature.
The three main issues treated in the existing HHC operations management literature are the problems of strategic resource dimensioning, districting and scheduling of human resources' activities. The first issue has been considered by Busby and Carter [9], who created a decision tool for the Simcoe
Modeling the home health care districting problem
Remember that the districting of a territory aims at grouping basic units into larger clusters, i.e. districts, so that these districts are “good” according to relevant criteria. Note that the basic units represent an aggregation of patients living in the same location. Typically, basic units can be zip code areas, postal areas, streets, geo-code addresses, etc.
As explained before, adopting the districting approach in the HHC context would allow the improvement of the service quality towards
Computational results
The purpose of this section is to analyze the behavior of the models proposed for the HHC districting problem by testing each model on 4 scenarios. Table 1 presents the objective function and hard constraints that have to be respected for each of the eight scenarios considered.
For each scenario, we begin by setting the values of the number of basic units N, number of districts to design M, number of profiles H, maximum distance between two basic units that can be assigned to the same district d
Conclusion and perspectives
In this paper, we developed two models for the districting problem applied to HHC structures. We also presented a numerical analysis based on different instances generated randomly. This enabled us to evaluate the impact of the key parameters on the workload balance and compactness criteria. Indeed, their analysis indicates that for a given M, pmax and dmax (Model 1) or τ (Model 2), by increasing N, the feasibility percentage and the mean distance are weakened while the mean gap_max is
Emna Benzarti is currently a PhD student in the area of supply and services operations management at Ecole Centrale Paris (ECP), France. She holds her Master's degree in supply chain management from Ecole Centrale Paris. Her research interests include services operations management, home health care, districting and redistricting problem.
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Emna Benzarti is currently a PhD student in the area of supply and services operations management at Ecole Centrale Paris (ECP), France. She holds her Master's degree in supply chain management from Ecole Centrale Paris. Her research interests include services operations management, home health care, districting and redistricting problem.
Evren Sahin is an Associate Professor at Ecole Centrale Paris (ECP). She holds a PhD in Industrial Engineering from ECP. Her area of interest is operations management, specifically, the production and distribution of goods and services. She is interested in optimizing service processes, with a particular focus on health care services, by using both qualitative and quantitative modeling approaches. She has been involved in several projects with hospitals and home health care service providers in France and in Italy. She regularly publishes in prestigious journals such as EJOR, IJPE, IJPR, OR Spectrum, etc.
Yves Dallery is a Professor of supply chain management at Ecole Centrale Paris (ECP). He holds a PhD from the Institut National Polytechnique de Grenoble (INPG). He is currently the head of the supply chain management executive education program and the executive director of the Enterprise Chair in Supply Chain sponsored by six international companies (Carrefour, Danone, DHL, Gefco, PSA, and Vallourec). In the past, he has held positions at Harvard University, MIT, Boston University, and HEC. He is also a partner in a consulting company that specializes in supply chain management. His main areas of expertise are in supply chain strategy, supply chain planning and flow management, and service operations management.