Mental health care: Access, stigma, and effectiveness.

Discusses the lack of commitment by the US as a nation to ensure that high-quality mental health care will be provided to all who are in need. The mental health benefits under Medicare and Medicaid programs are meager at best. Psychologists and other nonphysician health care providers are not considered bona fide professionals. Prevention, program evaluation efforts, and the use of alternatives to traditional inpatient care, such as halfway houses and crisis intervention programs, are not treated under the current reimbursement system. An "efficacy proposal" created by US Senators D. K. Inouye and S. M. Matsunaga is described. The essence of the proposal was modeled after the current Food and Drug Administration requirements for safety and efficacy for all new drugs and medical devices. In addition to these 2 requirements, the notion of "appropriateness" or "cost-effectiveness" was added. This proposal, which was deleted in 1980, would have established an interdisciplinary commission comprised of representatives of both the scientific and clinical communities. The commission would have been charged with the responsibility for making recommendations as to what types of mental health services, and under what conditions, should be reimbursed under the Social Security Act. It is concluded that the establishment of an independent entity with the charge of seriously reviewing the "probably public benefit" of providing psychotherapy would be in the national interest of the US. (5 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Providing mental health care to older adults: Unraveling the maze of Medicare and managed care.

This article reviews fundamental information about mental health benefits for older adults. Major systems, including Medicare, Medicaid, and managed care, are described. Regulations and policies that influence mental health care for older adults are distinct from those for the general population. In addition, Medicare has adopted managed-care options more recently than the private insurance industry. This relationship between Medicare and managed care is chronicled and future directions are postulated. Finally, we examine several empirical questions that have been raised due to the recent changes in the delivery of mental health care to older adults. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Access to health care services among people with rehabilitation needs receiving Medicaid.

Objective: To investigate access to care for individuals with rehabilitation-related conditions receiving fee-for-service Medicaid. Study Design: Telephone survey. Participants: One hundred thirty-eight individuals with spinal cord injury (SCI), brain injury (BI), or stroke. Main Outcome Measures: Frequency of difficulty or failure to access medical services, perceived effect on health, services most difficult to access, and reasons for difficulty. Results: People with SCI reported the most frequent difficulty accessing services (87%), followed by persons with BI (79%) and stroke (65%). In a subgroup of respondents, 60% reported failure to receive at least 1 service; 81% reported that access difficulties affected health or daily routine. Conclusions: People with rehabilitation-related disabilities may experience greater barriers to needed services than the larger population of persons with disabilities. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Improving health care, Part 5: Applying the Dartmouth clinical improvement model to community health

BACKGROUND: Traditional approaches to community health initiatives provide guidance on community mobilization, health assessment, planning, and intervention. Yet direction in how to frame the action steps to implement and measure results is often missing. Many community health initiatives find implementation overwhelming and ineffectual. FRAMEWORK FOR COMMUNITY HEALTH-THE CLINICAL IMPROVEMENT MODEL: The process--outcome methodology of continuous quality improvement (CQI) can translate large community aims into manageable projects. The sequential application of the clinical improvement model and the Community Health Value Compass for measuring outcomes-in state of health, quality of life, satisfaction, and costs-provides a link between data and action, thereby producing accountability for the community health initiative. USING THE CLINICAL IMPROVEMENT MODEL IN TWIN FALLS: Healthy Magic Valley (Twin Falls, Idaho) is the vision for long-term improvement in health status and reduction of health risks for the Southcentral Idaho Health Network. Since 1996 the Twin Falls Community Health Collaborative and SAFE KIDS Coalition have used the Value Compass model and CQI methods to decrease the rate of motor vehicle collisions, serious injuries, and deaths involving teens, while reducing the health, educational, legal, and financial consequences associated with teen-involved motor vehicle collisions. In 1993 the Twin Falls collaborative convened to apply CQI methods to the health of the community. The team has since met periodically to address the issues of community health, using the Dartmouth value compass model since 1996. Each sequential application of the process-outcome CQI framework exposes a blueprint for action and the unfolding of a health improvement strategy. The interventions should affect one or more dimensions of the value compass for teenage driving and motor vehicle collisions. CASE STUDY OF THE CLINICAL IMPROVEMENT MODEL: The motor vehicle death in October 1997 of a high school football player, who was not wearing a seat belt, led to a call to action for injury prevention. Implementation of a local community health initiative on seat belt use started in 1998. A strategy was developed to address implementation of the project among high school teens (for immediate impact) and elementary school children (for long-term impact) and to promote collaboration between the school and the rest of the community. RESULTS: Observed use of seat belts increased from January to September 1998. Data on fatality rates; injury rates; percentages of teens in crashes, of teens injured, and of teen collisions involving use of alcohol; and comprehensive costs are also monitored. DISCUSSION: Once coalitions are built and priorities set, the Dartmouth clinical improvement model presents a method that emphasizes measuring the benefits to the individual members of the community. A portfolio composed of a value compass for each health improvement initiative provides ongoing feedback for guiding subsequent strategic planning by the governing community health network.     

Restraint-free care. Part 1: Legal and regulatory mandates. Part 2: Creating a restraint-free environment

In response to the revised 1996 Joint Commission of Accreditation of Healthcare Organization's restraint standards, many facilities are assessing and revising their current practice. Part 1 discusses the regulatory, legal and ethical dimensions of patient restraints. Part 2 describes one hospital's approach to promoting a restraint-free environment. As a result of this hospital's assessment, restraint use decreased 25% in intubated patients; 50% in nonintubated patients.     

Access to health care for destitute persons at Public Assistance Hospitals in Paris

All legal French residents are entitled to health care. The 1992 regulatory measures, which create a contractual agreement between the government and public medical institutions, aim at facilitating access to health care by resolving the financial obstacles to accessing health care. The Assistance Publique-H?pitaux de Paris (AP-HP) has set up a medical reception center in several hospitals since 1993. This system is integrated in the general structure of each hospital: in some cases, there is a single and centralized unit; in other cases, all departments of the hospital, including the emergency room, are involved in caring for destitute patients. Whatever the type of the structure may be, social workers are a key element to helping the patients recover their social rights. Thirty to seventy-percent of patients visiting these centers regain access to social and health care coverage. The epidemiological survey of the active file of patients revealed that 70% are male, more than 50% are non-French nationals, half of which do not have legal immigration status in France. Homeless people represent 40 to 80% of the population. The average age is around 35. The number of medical visits varies greatly from one hospital to another and range from 20 to 60 per month. The reasons for visiting the center and the identified medical disorders are strongly related to the patients' life conditions and vary significantly with the risk factors related to the social and economic situation. The frequency of some diseases (psychiatric disorders, tuberculosis, infections by the HIV and HCV) is higher in this population than in general population. Delayed visits to the medical center represents a severity factor. The hospitals' mission statement is not only to ensure that patients facing a precarious social and professional situation have equal access to health care, but also to help such patients recover their social rights, facilitate their integration in the society and fight against social exclusion.     

Drug-resistant tuberculosis in adults: implications for the health care worker

In recent years, several outbreaks of drug-resistant tuberculosis have occurred in U.S. hospitals. In response to this recognized risk of tuberculosis exposure in health care facilities, the Centers for Disease Control and the Occupational Safety and Health Administration have issued guidelines or policy procedures for minimizing risks of tuberculosis transmission within these facilities. Some of the recommendations outlined in these governmental documents have been controversial. In this review the guidelines/policies and the debate surrounding them are discussed as they affect the health care worker who cares for adult patients with tuberculosis.     

Health care systems in transition: People's Republic of China. Part I: An overview of China's health care system

The People's Republic of China for the first 30 years of its existence had a centrally directed health care system which achieved impressive health gains for its population. By emphasizing prevention; organizing innovative, low-cost, locally controlled health services; and promoting accessible primary health care in rural areas, China increased life expectancy for most of its people, dramatically reduced levels of infant mortality, and eradicated or controlled a range of infectious and parasitic diseases. Since 1978, however, China's leadership has come to depend more upon market forces than central direction and planning to achieve economic growth. These new orientation has had major effects upon the organization and financing of health services. After more than a decade of economic and agricultural reform, China still has problems providing good-quality, affordable, and equitable health services for the majority of the rural population and both urban and rural poor. The need to pay for health care considerably exacerbates poverty in China. This paper describes the structure of government and the health care system, the nature of change during 1978-90, the impact of the reforms upon health status and health care delivery, and future challenges.     

Preparing Canadian physicians for health care of older adults

Two experiments were performed in order to study the effects of lesions of the rostral thalamic reticular nucleus (Rt) on two-way active avoidance. Male Wistar rats were subjected to either a bilateral electrolytical lesion of the rostral Rt or to control procedures. After recovery, all rats were trained in either a distributed (five training sessions, ten trials each; experiment I) or a massed (a single 30-trials session; experiment II) two-way, active-avoidance task. The level of long-term retention of the task was assessed 10 days later. Lesioned rats showed an overall higher performance than control rats both in experiment I (with lesions affecting the rostral Rt and small portions of some adjacent nuclei) and in experiment II (with lesions almost restricted to the rostral Rt). In contrast, detrimental effects on other tasks have been reported in the literature. Although it cannot be ruled out that those differences might be due to methodological factors, they also might be indicative of an action of rostral Rt lesions on certain mechanisms (either indirectly or directly related to information processing) that could be differentially required depending on the kind of learning task. The latter possibility is discussed in terms of the role played by this nucleus as a modulator of thalamocortical transmission, attentional mechanisms and cortical arousal.     

Visions and revisions: viewpoints on nuclear medicine & health care reform. Part 1: Outcomes research

Although health care reform movements and the strategies that medical societies use to meet the challenges existed long before President Bill Clinton's September 1993 presentation of his reform bill, these strategies have since come into the foreground of medical reform discussions. Medical groups are carefully eying outcomes research as a method to both pinpoint their most effective procedures and to point up the effectiveness of their practice in overall patient care. Practice guidelines promise a way to sift out the optimal procedures and suggest them to all nuclear medicine physicians--to both unify the specialty and perhaps help protect practitioners in malpractice cases. Discussions of the specialty physician workforce question the need and practicality of any policy that substitutes generalists for specialists. And vigilance over the several pieces of legislation currently sifting through Congress alert members of specialty societies about political developments and how to influence congressmen. The question remains, are these strategies being employed in such a way as to best pull a specialty like nuclear medicine through the gantlet and optimize health care provision in the US? This four-part series will explore this question.     

Access to hypertensive care. Effects of income, insurance, and source of care

BACKGROUND: This study examines the relationship between income, health insurance, and usual source of care characteristics and screening and management of hypertension. METHODS: This is a secondary analysis of data from the 1987 National Medical Expenditure Survey. Adult survey respondents constitute a sample representative of the total adult noninstitutionalized US population. Screening, follow-up care, and pharmacologic treatment for hypertension were examined among low income individuals, the uninsured, those without a usual source of care place, and those without a particular usual source of care physician. RESULTS: The uninsured, individuals without a usual source of care place, and those without a particular usual source of care physician received less screening, follow-up care, and pharmacologic treatment for hypertension. Income did not affect receipt of hypertensive care. CONCLUSIONS: Lack of health insurance and lack of a usual source of care are barriers to hypertensive care. Policies that increase access to health insurance or to usual source of care physicians may enable more individuals to attain control of hypertension.     

Providing mental health care services to Americans.

Summarizes legislation introduced or cosponsored by the author, a US Senator from Minnesota, to respond to Americans' need for mental health services. This legislation included the Medicare Ambulatory Mental Health Services Access Amendments of 1987; S.123, a bill that would amend Part B of the Medicare program to recognize and reimburse psychologists as independent mental health providers; S.763, the Services for Homeless Mentally Ill Individuals Act of 1987; S.809, the Urgent Relief for the Homeless Act; and S.1663, the Child Abuse Prevention Act of 1987. The author encourages mental health professionals to promote public policies that expand Americans' access to public health services through research, effective communication of this research, and preventive mental health efforts (such as programs aimed at preventing teen suicide). (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

CEO summit. Building the new health care delivery alliance, Part III. Roundtable discussion

In cooperation with McManis Associates, Hospitals & Health Networks recently convened a CEO summit on physician/hospital integration activities. In the third report of a three-part series on the summit, leading health care executives discuss investor capital needs, strategic information management needs, and the management competencies required for capitated managed care success.