Care for Canada's frail elderly population: fragmentation or integration?

Budget constraints, technological advances and a growing elderly population have resulted in major reforms in health care systems across Canada. This has led to fewer and smaller acute care hospitals and increasing pressure on the primary care and continuing care networks. The present system of care for the frail elderly, who are particularly vulnerable, is characterized by fragmentation of services, negative incentives and the absence of accountability. This is turn leads to the inappropriate and costly use of health and social services, particularly in acute care hospitals and long-term care institutions. Canada needs to develop a publicly managed community-based system of primary care to provide integrated care for the frail elderly. The authors describe such a model, which would have clinical and financial responsibility for the full range of health and social services required by this population. This model would represent a major challenge and change for the existing system. Demonstration projects are needed to evaluate its cost-effectiveness and address issues raised by its introduction.     

In vitro metabolism of cyanohydroxybutene: formation of a glutathione-S-transferase catalyzed product

This paper examines the financing of elderly health care in Japan for medical institutions, nursing homes, and at home. The analysis demonstrates that the conventional figures for elderly health expenditures in Japan systematically underestimate the real costs by excluding the costs of uninsured services, nursing homes, and home health care. The paper estimates these costs and shows that they add about 10% to the conventional figure for elderly health care costs in Japan. This inquiry also shows how government policy for health care financing shaped distinctive Japanese patterns of elderly care provision. The financing system provided a hidden subsidy--through national health insurance coverage of long-term hospitalization--that encouraged high institutionalization rates of elderly in medical facilities. Public financing for long-term elderly hospitalization, however, has not been matched by government attention to quality of care, resulting in serious quality problems and reflecting a social trade-off between cost and quality. Also, until recently the financing system rarely reimbursed home health care, thereby creating strong disincentives to the development of formal home health care services. This analysis has important implications for reforms now being considered by the Japanese government in the financing and provision of health care for the elderly, especially the limitations of relying on reimbursement price policy. The reforms could have unintended negative consequences for equity, efficiency, and quality of care.     

Public policy and public service: Our professional duty.

Psychology is a steadily maturing profession, and we psychologists are finally beginning to accept our societal responsibility to be involved in the public policy and political process. Although psychologists have shown increased involvement in the recent past, there are still many areas in which psychologists could become markedly more involved—especially in the area of programs that affect the quality of life of our nation's elderly, disabled, and poor citizens. As our profession seeks to become more active in the overall health care arena, we will, of necessity, begin to define the parameters of "quality of care" for other professions. In doing so, we must closely explore the "outer limits" of our own practice. We must ensure that all state and federal legislative (and administrative) policies do not impose arbitrary limitations on the scope of practice. To accomplish this objective, we must seek to influence our subset of our nation's health policy priorities and policies that we have traditionally shunned—the subset that affects "the public good." (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Restructuring long-term care and the geography of ageing: a view from rural New Zealand

This paper examines the major points of contact between the restructuring of long-term care and the evolving geography of the elderly in the Waikato, one of New Zealand's agricultural heartlands. The time frame of the study is 1981-91, a decade in which new Zealand embarked on a sweeping program of service restructuring and privatization. Comparative analysis of data on the evolving distribution of the elderly and on the shifting supply of long-term care beds reveals that restructuring has sharpened contrasts between urban and rural contexts for ageing. Almost all the urban centres in the Waikato benefited from an expansion of long-term care driven by private-sector initiatives, while rural communities suffered a broad-based depletion of services. However, the data indicate that, contrary to the trend in long-term care, more older elderly people (defined as those aged 80 or older) are "staying on' in rural communities. The paper concludes with a consideration of emergent policy issues; we speculate that it through the aggregate outcomes of decisions to "stay on' that the personal troubles of the elderly residents of service-depleted communities may yet become an important policy issue in rural New Zealand.     

Biophysical characterization of the interaction of the beta-lactamase TEM-1 with its protein inhibitor BLIP

Health care expenditures on the elderly tend to grow about 4 percent per year more rapidly than the gross domestic product (GDP). This could plunge the nation into a severe economic and social crisis within two decades. This paper describes recent growth in age/sex-specific health care utilization by the elderly and discusses the important role of technology in that growth. It also explores the potential for the elderly to pay for additional care through increases in work and savings. Efforts to "save Medicare" will prove to be "too little, too late" unless they are embedded in broader policy initiatives that slow the rate of growth of health care spending and/or increase the income of the elderly.     

Introduction to the special issue on long-term care.

There are over 1.3 million American residents in long-term care (LTC) facilities of one type or another. We have a considerably greater number of patients in LTC facilities than in general hospitals. Because of the projections that in the next several decades millions more will become residents of LTC institutions, it is remarkable that so little attention has been directed to the psychological issues that involve elderly residents in these settings. In recognition of the variety of recent changes in the relationship between acute care settings and LTC institutions, because of an emerging body of research being developed about the nursing home, and in view of the large number and projected growth of the LTC institutional population, our focus in this special issue is largely upon the institutional setting. Individual articles in this issue focus upon aspects of a range of subjects. These include broad issues of health policy in the United States as they relate to LTC; the future of nursing homes; staff-patient relationships in LTC institutions; and the clinical and social-psychological issues that must be addressed by rehabilitation psychology in LTC settings. The hope is that this issue of Rehabilitation Psychology will stimulate greater interest among psychologists and allied professionals in the field of LTC and in addressing the needs of the millions of persons who could profit from help. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Does the "Thunderbirds syndrome" still exist

Rationing of resources within both the private and public health care systems is a fact of life. The Thunderbirds TV series encapsulated an idealistic philosophy that life should be saved independent of the pecuniary cost. Doctors, in particular, are trapped between their role as advocates for the patient within the "Thunderbirds" philosophy and as citizens with a responsibility to use resources wisely. This dichotomy is challenged by point of care rationing, which can conflict with clinical responsibilities, undermines the patient-doctor relationship and is often undertaken in a clandestine manner. This form of controlling health costs is difficult to justify from an ethical perspective, particularly when other forms of health care rationing and expenditure are frequently modulated by political expediency and inadequate economic modelling. Indeed, focusing on improving quality and disease prevention, rather than reducing marginal costs can often control the long-term growth in health expenditure. Doctors have a responsibility to ensure that rationing decisions are made but these should be made as part of a transparent, evidence-based and democratic process away from the point of care. While the resources to implement the "Thunderbirds Syndrome" have never been available, the philosophy must remain at the heart of patient-doctor relationship.     

Moving toward a broader model of health care.

This article looks at how we can move toward a broader model of health care. It discusses advances in U.S. health care, the issue of health care coverage for all Americans, the need for a biopsychosocial model of health care, and the impact that psychologists can make in improving health. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Introduction to the special issue: Psychology and AIDS.

From its beginnings in 1981, psychologists have been involved in worldwide efforts to meet the many challenges of the AIDS health crisis. As researchers and practitioners, as consultants and policy advisors, as educators and evaluators, and as activists and concerned members of the community--we psychologists have responded in many ways. We have attempted a broad perspective in approaching this special issue. We wanted coverage of the science, the practice, and the social issues that AIDS has brought into focus for psychology. Any attempt to cover all the issues is doomed to failure, however. The science changes too quickly, and the disease is spreading too rapidly, for any group of journal articles to ever claim currency and comprehensiveness. The issue has been divided into six major sections, each with an introduction. We begin with articles that overview the roles of psychology in the AIDS health crisis as seen in our own profession, and from various levels of science, health care, and legislative and government action. Then we present articles reviewing some of the primary issues AIDS commands us to examine: public health, antibody testing, AIDS and the communities of Black and Hispanic men, IV drug abuse, sexual behavior change, stigma, and psychoneuroimmunology. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Good psychologists must also be good citizens.

In the United States, the wealthiest nation in history, our nation, 43 million of our fellow citizens, including more than 6 million children, have no health insurance. Of those who do have insurance, the vast majority do not have mental health benefits. Among those who have insurance, increasing numbers are insured by for-profit HMO and managed care plans that limit provider selection, dictate patient care, and seem far more interested in the profits of shareholders and the compensation of CEOs than the well-being of patients. The average citizen, and, for that matter, the average professional acting individually, probably feels he or she has little direct ability to affect these and other issues facing our country. I want to dispel that notion and insist that individual psychologists, and psychology as a profession, are, in fact, influencing policy every day in Congress and in state legislatures. But there is much more to be done. The message of this article is that good psychologists, for their own benefit and for the benefit of their patients and their nation also must be good citizens. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Foreword: Psychotherapy in later life.

This special topic issue (psychotherapy in later life) is an outcome of our increasing interest and involvement in recent years with gerontology, particularly with psychotherapy for the elderly. It reflects the new and current social, economic and political significance of this population in our society and within the helping professions. This issue encompasses a broad sampling of the present state of the art represented by contributions from recognized authorities and dedicated workers in gerontology at academic, clinical, private and government centers serving the elderly throughout the United States. The currently broad spectrum of psychotherapeutic theory, research, and practice focusing on the elderly is demonstrated in our contributors' articles. Included are works concerned with historical, psychosocial aspects, individual and group therapy, sexism and sex differences, possibilities and limitations of applying various psychotherapeutic approaches such as behavioral, environmental, psychoanalytic and cognitive. Attention is paid to special needs of the frail and dependent elderly as well as to the more vigorous and autonomous older person coping, with varying degrees of independence, in non-institutional settings. No single publication can deal effectively with the enormity of issues confronting the elderly and the range of gerotherapies. If we have opened new doors for continued progress, and stimulated more reflection and action on behalf of this population, we shall feel rewarded by having laid the seeds for a new special topic issue in the approaching decade by future investigators. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The perils of knowing

As we await the government White Paper on social services, the authors examine; in the first of two articles, the current two-tier service which means that elderly people are often moved unnecessarily between residential and nursing homes when their health needs change. The Royal College of Nursing's proposals for single registration care homes is explained on pages 32 and 33 in this issue. The second article will appear next week.     

Implications for health services

Health services for older people in the NHS have developed pragmatically, and reflect the nature of disease in later life and the need to agree objectives of care with patients. Although services are likely to be able to cope with the immediate future, the growth of the elderly population anticipated from 2030 calls for long-term planning and research. The issue of funding requires immediate political thought and action. Scientifically the focus needs to be on maximizing the efficiency of services by health services research and reducing the incidence of disability in later life through research on its biological and social determinants. Senescence is a progressive loss of adaptability due to an interaction between intrinsic (genetic) processes with extrinsic factors in environment and lifestyle. There are grounds for postulating that a policy of postponement of the onset of disability, by modifications of lifestyle and environment, could reduce the average duration of disability before death. The new political structures of Europe offer under exploited-unexploited opportunities for the necessary research.     

Sexual predators and the structure of the mental health system: Expanding the normative focus of therapeutic jurisprudence.

This article clarifies the normative focus of therapeutic jurisprudence and the sense in which that research program is appropriately considered normatively neutral. It then examines the principles of political morality underlying mental health law as health care and as social control. It advances a proposed structure of mental health law and of the mental health system that reflects these principles. Finally, it applies this analysis to recent cases involving sexual predators, concluding that these cases and the statutes on which they are based undermine the moral force of mental health law and of the more comprehensive institution of social control including the criminal law. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Diagnosis and management of lead-poisoned children: the pediatric nurse practitioner in a specialty program

Lead poisoning, the leading environmental illness in this country, is a challenge to our health care and social systems. Because they provide routine health care in a variety of settings, including care to children from poor inner city families, who are most at risk for plumbism, nurse practitioners should be knowledgeable about this illness and prepared to care for children who have it. This article describes the role of a pediatric nurse practitioner in a specialty program who cares for children with lead poisoning and informs the general practitioner about prevention, education, treatment, coordination of care, and long-term follow-up for these children and their families.     

The media vs managed health care: are we seeing a full court press?

BACKGROUND: Despite the fact that medical coverage for many Americans is shifting rapidly from traditional insurance to managed care, studies suggest that most citizens have limited knowledge or understanding of the implication of this change. OBJECTIVE: To evaluate the predominant message being portrayed by the lay press on managed care. METHODS: We conducted a review of newspaper articles dealing with managed care from several leading national newspapers. Surveys, editorials, letters to the editor, or nonclinical articles were excluded. The articles were examined to evaluate their likely effect on the reader's willingness to join a managed care organization, and were scored using a standardized survey instrument. The final analysis included data from 85 articles from an original pool of 277. RESULTS: In only 8% of cases, the articles were considered likely to have had a positive influence on the reader and, thus, encourage them to join or remain with a managed care organization. More important, in fully two thirds of cases, we believed the articles portrayed so unfavorable a message that the reader was less likely to join, or might even decide to leave, a managed care organization. The articles dealt most frequently (67%) with patient concerns with managed care, focused mainly on cost and quality issues, and managed care representatives were the people whose opinions were most commonly (53%) solicited. CONCLUSIONS: It seems highly likely that public perception of managed health care will be influenced by the strongly negative representation being portrayed by the newspapers. While debate over the good vs bad features of managed care continues, available evidence suggests this form of health care coverage continues to grow. The press is likely to remain an important source by which information about managed care is transmitted to the public and will certainly influence public decision making on the issue. If the current negative representation continues, we may soon begin to see a widespread backlash of public opinion opposing this form of health care.     

The family's role in long-term care

Long-term care provided by family members is the central care of our current health care system. The purpose of this article is to review the family's role in long-term care. Issues such as cost containment and inequities in our current social policy are reviewed. Suggestions for future directions in social policy are presented.     

Epilogue: Psychological interventions in the changing health care systems.

Psychotherapy has utility for a wide variety of circumstances that have significant economic, personal, and social consequences. This special issue is a small attempt to address some of these problems. There are important omissions, such as the frequent use of psychotropic medications in psychotherapy, psychological rehabilitation of patients and families with chronic health problems, and hospice care. The need for establishment of a national policy on how psychotherapy can be used to create more effective and humane solutions to societal problems has been identified. The challenge is how to fund the study of health and other social problems responsive to psychotherapy. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The user fee debate

The issue of user fees for health care generates a highly charged and emotional response from most Canadians. Access to health care services based on need rather than income is a feature of our system, of which we are extremely proud. Yet, there is increasing pressure on provinces to consider user fees. Are user fees the best method to cope with these financial pressures? Nurses can play a decisive role in ensuring that governments and the public are continuously well informed on this issue.     

Should hepatitis C positive donors be accepted for renal transplantation?

Recent advances in medical technology, such as an assisted ventilation, have made a big impact on pediatrics. With such a progress, many children with intractable diseases have survived intact. On the other hand, chronically ill children with handicaps have also been increasing. Some of them have been artificially supported by a respirator to maintain life in a hospital or at home. Under these social conditions, we should establish a system for total care of these children, to promote their quality of lives, in collaboration with medicine, health & welfare, and education.