Meeting U.S. Health Care Needs: A Challenge to Psychology.

Is there really a growing need for primary care psychologists? U.S. population health statistics reveal a great deal of variability in the care Americans receive and in their associated health outcomes. Members of minority groups, the inner-city poor, and rural Americans bear a disproportionate burden of ill health. The decreasing pool of primary care physicians is documented as well as is the growing pool of nonphysician primary care providers. The need to expand the nature of psychological interventions in primary care is examined, and change in the training of professional psychologists is recommended. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The Polish experience of quality improvement in primary care

THE POLISH HEALTH CARE SYSTEM: The health care system in Poland is based on a model typical of east-central European countries, with features such as state-owned health care organizations, centralized management and administration, and primacy of access to care over quality. Poorly planned and uncoordinated reforms have been undertaken to transfer some of the authority for health service management to local governments. PRIMARY HEALTH CARE IN POLAND: The reform of the health care system entails substitution of family physician-based for medical specialist-based primary care. Newly trained family physicians, as the first to start private surgery clinics financed from public sources, are the forerunners of the comprehensive reform and property structure transformation. MAKING THE TRANSITION FROM QUALITY ASSURANCE TO QUALITY IMPROVEMENT: Since the early 1990s, more and more organizations, individuals, and professional groups have begun to perceive health care regulations and other external control mechanisms as ineffective. Attempts have been made to replace periodic, restrictive activities with systematic continuous quality improvement efforts. Systems of voluntary accreditation are being developed and fostered. Groups have started meeting to develop medical practice guidelines and conduct peer review. Concern about quality of health care services is now reflected in the Polish legislation for the first time, as well as in numerous local and nationwide projects and publications. CONCLUSION: Despite some successes, the pioneers of quality improvement (QI) still have a long way to go. Continuation of educational activities and creation of a system of motivation for the development, of QI in primary care should be prioritized and encouraged.     

Considerations for ethical practice in managed care.

How does one maintain an ethical practice while facing the requirements and limits of a health care system that is dominated by managed care? Psychologists are increasingly raising such questions about ethical issues when working in or contracting with managed care organizations. The authors review the process involved in ethical decision making and problem solving and focus on 4 areas in which ethical dilemmas most commonly arise in a managed care context: informed consent, confidentiality, abandonment, and utilization management-utilization review. The need for sustained and organized advocacy efforts to ensure patient access to quality health care is discussed, as is the impact of managed care's competitive marketplace on professional relationships. Hypothetical examples of typical dilemmas psychologists face in the current practice environment are provided to illustrate systematic ethical decision making. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Editorial: What will the 21st century bring? An emphasis on quality care.

Day-to-day concerns frequently take precedence over abstract concepts for psychologists practicing in the United States. However, traditional mental health services are a subset of the more generic health care environment, and changes in this environment will eventually affect the daily practice of mental health practitioners. For a profession to continue to mature and thrive, leadership must be aware of and capitalize on relevant national and international changes. In the 21st century, advances in technology and communication will affect the quality of services and will likely result in increased stress for practitioners and patients. This article reviews developments within the American Psychological Association and explores both current and potential roles that will shape the future of professional mental health practice. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Finding value in nursing care: a framework for quality improvement and clinical evaluation

Fiscal constraints have heightened attention to health care costs and patient outcomes as measures of health care system effectiveness. Determining which patient and costs outcomes nurses may be held accountable for requires differentiating the impact of dependent, independent and interdependent nursing activities. A nursing role effectiveness model that includes a number of structural variables is offered to help track quality improvement and research activities. Some of the nurse-sensitive patient outcomes that have been identified include: freedom from complications, clinical outcomes, functional health outcomes, knowledge outcomes, perceived health benefit (or satisfaction), and costs outcomes. This model can be used to evaluate the effectiveness of current as well as evolving nurse roles, processes, and structural changes.     

Organizational stages and processes of change for continuous quality improvement in health care.

This article provides an overview of the transtheoretical model of change (TTM, or stage model) and how it can guide the development of stage-matched interventions to increase physicians' readiness for continuous quality improvement (CQI) in health care. In addition, this article describes the development and initial validation of two TTM measures—stages and processes of change—designed to assess the extent to which hospitals are engaging in activities that can facilitate individual providers' movement through the stages of change for CQI. 299 Ss participated in the study. A majority (57%) of informants reported that their organizations were in the maintenance stage for CQI. Organizational-level processes of change differed significantly across the stages: Hospitals in the precontemplation stage tended to use the processes least, and hospitals in the maintenance stage tended to use them most. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The Colorado Medicare study: Perspective of the peer review committee.

In 1977, the Social Security Administration sponsored a study to determine whether including psychologists as independent providers and increasing the dollar limit of Medicare's mental health benefits would have an impact on the availability of mental health care to Medicare recipients, the quality of care provided, and the cost and utilization of the program. The present study discusses peer review issues that emerged from the study: (1) the peer review criteria for quality of care provided, (2) the range of covered services and covered diagnoses under Medicare, (3) the unique patient population aspects, (4) patient participation in the treatment plans and outcome forms used for peer review, (5) the issue of confidentiality of the peer review forms, (6) and findings regarding medical consultation on cases treated by psychologists. The review committee concluded that within the limits of the study, the review system was successful and the quality of services delivered was high. (1 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Professional associations' strategies for revitalizing professional psychology.

The professional associations of psychologists are working to revitalize professional psychology. In response to recent challenges, these associations have attempted to (a) remove barriers to quality services within the mental care health delivery system; (b) help psychologists become better integrated within the overall health care system, as opposed to being narrowly defined as mental health professionals; and (c) help more psychologists move into services outside of the health care delivery system. These 3 strategies are motivated by a vision of psychology as a broad problem-solving discipline that can contribute to human welfare in a varied range of domains. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Pay for performance in primary and specialty behavioral health care: Two "concept" proposals.

Incipient pay-for-performance (P4P) plans offer to improve the quality of general medical care, but they have not yet begun to influence clinical outcomes in the behavioral health care arena. Following a brief review of the quality chasm in behavioral health care and some initial applications of P4P programs, this article presents 2 bird's-eye view proposals with which the primary and behavioral specialty care sectors of the American health care system can begin to design and implement P4P incentives. Discussion of the value of behavioral health care, the Provider Quality Index, P4P implementation issues, implications for practicing psychologists, and some cautionary notes conclude the article. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Changes in medical problems and use of medical services following psychological intervention.

Important life changes and significant psychological stress occur before, during, and after episodes of physical illness in the lives of many individuals. Significant life-adjustment or developmental difficulties have been shown to be associated with high use of medical services. This article discusses the reduction in medical problems and use of medical facilities with referral for psychological services. On the assumption that psychologists can contribute significantly to reduction in patients' psychological stress levels and associated physical complaints, a new self-image for many psychologists could be that of health care professional. Furthermore, this self-image and role could be implemented by having psychologists contribute to the treatment of patients in a continuous manner, starting with the initial patient visit to a health care facility. (44 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Implementing the Health Care Quality Improvement Program in the Medicare ESRD Program: a new era of quality improvement in ESRD

Improving the quality of health care is a central challenge for America's health care system. The mission of the End-Stage Renal Disease (ESRD) program is to promote the quality, effectiveness, and efficiency of ESRD patient care and program administration. The program provides an ideal opportunity to demonstrate the use of information to help clinicians analyze and improve the care they deliver to patients in an ambulatory setting. This is possible because the program has established regional surveillance systems, called ESRD Networks, that gather information on the occurrence and outcomes of treatment of Medicare beneficiaries with ESRD. The Health Care Financing Administration, which is responsible for the administration of the program, and the renal community have worked together since 1990 to identify ways of incorporating new methods of quality improvement into the program. These methods include statistical evaluation of the processes and outcomes of care in dialysis populations; communicating recommended practices with clinical guidelines and algorithms; regional peer review and feedback (ie, technical assistance and/or collaborations for quality improvement); interventions that focus on the provision of assistance for quality improvement efforts; continuing collection and active feedback of data to providers; and a commitment to continue to evaluate and revise quality improvement activities to reflect lessons learned and newly identified needs. These ideas have been included in the 1994-1997 scope of work for the ESRD Networks and is called the ESRD Health Care Quality Improvement Program (HCQIP). This article describes the background for the ESRD HCQIP and the program's elements.     

Cost control through quality improvement: The new challenge for psychology.

Argues that if national health care reform attempts to control mental health costs by reducing the quality of services, short-term expenditure reduction may be followed by a long-term increase in overall spending. A more effective strategy would be the pursuit of maximum value: the level of quality yielding the greatest possible degree of long-term cost containment. Maximizing value involves assuring appropriate access to mental health care, achieving an optimal mix of mental health services, and increasing the efficiency and effectiveness of service delivery. W. E. Deming's (e.g., 1993) approach to industrial quality improvement constitutes a useful framework for improving efficiency and effectiveness. This strategy involves identifying and meeting the needs of all mental health "customers" through a continuous linkage of process improvement and outcome measurement. Particularly important is clinical process standardization, which is best pursued through ongoing research and the collaboration of all interested groups. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

A framework for integrated quality improvement

The importance of maintaining and improving quality is well understood in most health care organizations. This work becomes more challenging as internal and external conditions rapidly change. A quality improvement framework was developed to help clinicians and administrators organize intergrated, multifaceted quality programs that have the flexibility necessary for success in today's fast-paced health care environment.     

Information technology applications in quality assurance and quality improvement, Part II

Many information technologies have been or could be applied to efforts to measure and improve health care quality. This article reviews the recent literature in medical informatics, quality assurance, and quality improvement to identify these and current, emerging, and potential technologies.     

Barriers to implementing a quality improvement program

Critical barriers can prevent the implementation of an effective quality improvement (QI) program in the health care setting, including organizational culture, restructuring, quality assurance/quality control functions, QI teams and costs. Common pitfalls encountered that cause QI programs to falter--or worse, to fail--are discussed.     

Medicaid policy: Psychology's overlooked agenda.

Although psychologists are recognized as autonomous providers under almost every major federal health care initiative, they are not federally recognized as such under Medicaid because of Medicaid's unique federal–state partnership. State-by-state information on the access to psychologists under state Medicaid regulations are presented. As the move toward national health care reform becomes increasingly evident in the 1990s, psychologists have the responsibility and the opportunity to design innovative, behaviorally oriented health care delivery models in response to the national concerns of adequate coverage, access, and quality care. To do this, psychology as a profession must gain formal recognition under the various state Medicaid plans, either on a state-by-state basis or by way of federal mandates (as it was achieved by professional nursing). (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Patient-oriented quality assurance. Information and cooperation of the health services as a condition for integrated care

The increasing care needs of the elderly and chronically ill have a growing impact on health care services. With complex needs to meet, the patient's quality of life depends on multiple factors, of which the continuity of care plays an important role. Information on the past and present health state and on self care resources are prerequisites for adequate rehabilitation efforts that are patient-oriented and of high quality. Institutionally induced "cascade episodes of incompetence" (Ulmer & Saller, 1994) have to be avoided. To make sure that interventions promote or stabilize the quality of life, the participation of the client is crucial in all stages of the process of care planning and coordination. Integrated care requires the exchange of information and close coordination on the concept of care between all participants in the care process. Yet, collaborative care is often seriously jeopardized by lack of knowledge about the concepts, scope of action and requests of the involved health professionals and services. At the Agnes Karll Institute of Nursing Research an action research project aiming at cooperative quality assurance was carried out. It became obvious that there is a large amount of intersectoral knowledge necessarily needed by all professionals and services to ensure seamless professional care. But often they have no access to the information needed. Therefore a client's accompanying booklet was developed to pass on basic information. It is kept by the client and shall be used and filled out by them, their relatives and the different health professionals and health care services involved.     

The role of psychology in health care delivery.

There is a wealth of professional opportunities for practicing psychologists, particularly given the recent recognition of psychology as a health care profession. A number of dimensions are discussed that can be used as a heuristic to outline the participation of psychologists in the general health care arena. Dimensions include the breadth of disease categories in which psychology has been involved, the involvement of psychologists at different stages of the progression of illnesses, and the diverse roles that psychologists may play in health care. Examples are provided to exemplify the contributions psychologists have made to health care. Recommendations are made to strengthen psychology's role in the health care system. Recent challenges are also reviewed regarding the association of health care and the delivery of services that demand the participation of psychologists. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Psychologists in medical schools: Medical staff status and clinical privileges.

It is argued that professional autonomy for psychologists in medical settings requires that psychologists exercise self-governance responsibilities. Inclusion of psychologists on the hospital medical staff is critical because of the self-governance responsibilities afforded to the hospital medical staff by the governing body of the hospital. Central among these responsibilities are the delineation of clinical privileges and the monitoring of quality of patient care. The challenges to psychology inherent in these issues are discussed in terms of the continuing need for political activism and professional "maturity." (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

Professional burnout in clinical military psychologists: Recommendations before, during, and after deployment.

Clinical military psychologists (CMPs) hold one of the most difficult positions within professional psychology. Given their exposure to a variety of environmental, physical, psychosocial, and emotional stressors, professional burnout (PB) can be a serious issue for CMPs. In order to (a) protect job satisfaction, (b) increase professional confidence, (c) facilitate a long and rewarding military career, and (d) ensure competent care is provided to our clients, a two-pronged approach of CMPs taking care of themselves on the one hand, and the military providing effective assessment, prevention, and intervention, on the other hand, is needed. Such an approach to protecting the military's limited mental health resources could ultimately ensure that service members receive proper care. In this article, the authors discuss the challenges experienced by CMPs as potential contributors to PB during all three phases of the deployment cycle. Several recommendations are offered for addressing such challenges. (PsycINFO Database Record (c) 2011 APA, all rights reserved)