Briefly Noted

At last week's annual conference of the National Association for Behavioral Healthcare (NABH), the increase in managed care figured prominently as causing a significant barrier to access to treatment. “The issue that is front and center is access to care, the problems that people are having getting necessary care, and not being able to access the right care at the right time,” NABH President and CEO Mark Covall told ADAW. In addition, the continuum of care has been severely impacted by managed care, he said. “Managed care companies are restricting care to crisis care only,” he said. This means that the longer‐term care needed for recovery when patients emerge from a crisis is not being covered. There are no clear legislative or regulatory fixes yet, said Covall, speaking by phone from the busy meeting. As an organization, NABH “will continue to be proactive and reach out to managed care companies,” he said. “We hope the collaboration that is desperately needed will be a two‐way street.” NABH members have reported that “it has been exceedingly difficult to get patients the care they need, and our members are saying that it's hurting patients, and this is not acceptable.” Last week, NABH launched Access to Care, an initiative “that will send our message to policymakers, regulators, payers and patient advocates that only true access to care can lead to recovery.”     

Scotland's children and the new parliament

The establishment of the Scottish Parliament in 1999 has raised the profile of children's issues and allowed more time for debate and legislation. This has led to some key developments, including a decision to establish a Children's Commissioner, more legislative provisions enabling children's views to be taken into account, and a more explicit commitment to ‘child and family centred’ working. A Ministerial Task Force has been established to ‘drive forward progress on integrated children's services’. Some pre‐school and school age child care services have seen significant growth but the structure of services remains fragmented. A National Education Debate has strengthened the Scottish Executive's resolve to maintain its distinctive education policies and reaffirm its commitment to comprehensive schooling and an ‘equality of outcomes’ approach. New Community Schools put education in the driving seat of change, offering a vehicle for establishing new kinds of services and relationships between services, sectors and age groups. Copyright © 2003 John Wiley & Sons, Ltd.     

Medicaid Managed Care Programs for High-Risk Older People in Massachusetts

The Commonwealth of Massachusetts has undertaken a major initiative in the development of comprehensive managed health care programs for two sets of high-risk older people: those who are frail and homebound and those who reside in nursing homes. This effort has been coordinated by the state's Department of Public Welfare (DPW; Medical Assistance [Medicaid] Program) and Executive Office of Elder Affairs, and expedited ba a set of Health Care Financy Administration (HCFA) waivers and by the state's revised Nurse Practice Act (MGS Chapter 56). Than act allows nurse-practioners and physician assistants expanded roles as primary providers in home care and nursing home settings. The managed care initiatives have supplemented other efforts (1) to coordinate health and social services for older people, (2) to provide as broad a range as possible of community-based services for older people, and (3) to enroll as many older adults as possible in Health Maintenance Organization (HMO) "Senior Plans" and other similar "Competive Medical Plans."

Though there is still no evidence of the managed care programs' effects, this article summarizes some of the possible risks and benefits of managed care programs for those kinds of populations and presents an agenda of questions that evaluations of managed care programs must address.     

The potential educational benefits of extending foster care to young adults: Findings from a natural experiment

Research has demonstrated the employment and earnings benefits accompanying educational attainment, and the relatively poor educational attainment and economic well-being of young people who transition to adulthood from foster care. Policymakers' concern over these poor outcomes has long been reflected in U.S. child welfare policy, most recently in the provisions of the 2008 Fostering Connections to Success Act allowing states to claim federal reimbursement for extending foster care from age 18 to age 21. While the policy of allowing youth to remain in foster care past age 18 has promise as a strategy for helping them continue their education, empirical evidence of its impact is lacking. Using data from a longitudinal study of youth (n = 732) who transitioned to adulthood from foster care, this study takes advantage of between-state policy variation in the age at which youth are required to leave care to assess the relationship between extended foster care and educational attainment at age 26. Distinguishing between not having obtained a high school diploma or GED, having only a high school diploma or GED, and having obtained at least one year of college, each additional year in care is associated with a 46% increase in the estimated odds that former foster youth will progress to the next level of educational attainment, controlling for a range of youth characteristics measured at ages 17–18. Background characteristics including youth's gender, race, employment, parenting, educational performance and aspirations, and indicators of behavioral health problems are also associated with educational attainment in early adulthood.     

Relational aspects of decisions to sell

Mental accounting has been identified as an important source of non-fungibility in household and individual decision making. Ostensibly uniform assets, including cash, are perceived differently according to their originating source. In this study we examine assumptions of fungibility by using scenarios within a factorial survey to compare the effects of four specific factors on individuals’ willingness to trade a specified possession that varies according to its relational source, dollar value, uniqueness and the potential buyer's identity. Two measures of willingness to trade are used; a composite distress measure and the minimum price that the participant is willing to accept in exchange for the possession. In addition, data are analyzed to explore relationships between willingness to sell, the four defined characteristics of the possession and participant's characteristics including age, gender, education and income. The possession's source and the buyer's identity dominate effects over the possession's value and uniqueness. The strength of the effects varies significantly depending on how distress is measured and between identifiable population groups.     

The Program of All-Inclusive Care for the Elderly (PACE)

Summary

This article examines the long-term care service system in the United States, its problems, and an improved long-term care model. Problematic quality of care in institutional settings and fragmentation of service coordination in community-based settings are two major issues in the traditional long-term care system. The Program of All-Inclusive Care for the Elderly (PACE) has been emerging since the 1970s to address these issues, particularly because most frail elders prefer community-based to institutional care. The Balanced Budget Act of 1997 made PACE a permanent provider type under Medicare and granted states the option of paying a capitation rate for PACE services under Medicaid. The PACE model is a managed long-term care system that provides frail elders alternatives to nursing home life. The PACE program's primary goals are to maximize each frail elderly participant's autonomy and continued community residence, and to provide quality care at a lower cost than Medicare, Medicaid, and private-pay participants, who pay in the traditional fee-for-service system. In exchange for Medicare and Medicaid fixed monthly payments for each participating frail elder, PACE service systems provide a continuum of long-term care services, including hospital and nursing home care, and bear full financial risk. Integration of acute and long-term care services in the PACE model allows care of frail elders with multiple problems by a single service organization that can provide a full range of services. PACE's range of services and organizational features are discussed.     

Population Ageing in Japan: A Brief Survey

During the next fifty years, the absolute number of elderly in Japan will increase while the absolute number of children and persons in the working age groups will decline. The main cause of this demographic trend is low fertility, which can in turn be traced mostly to delayed and foregone marriages. Absent policy measures and sociocultural change to reduce young women's opportunity costs of marriage and childbearing, it is difficult to imagine this demographic situation changing. Policy makers have stressed the importance of keeping elderly workers in the labour force. However, the problem is not elderly labour force participation per se (which is already very high for a country with Japan's per capita income) but rather the relatively low productivity of elderly workers, who are often employed part-time, work informally in private unincorporated enterprises, etc. Reforms to Japan's public pension system, which is essentially financed on a pay as you go basis with benefits linked to wages, have not been very effective to date. Official projections call for steep increases in the payroll contribution rate. In contrast to the pension system, the Japanese health system has managed to deliver high-quality care at a relatively low cost as measured by health spending as a proportion of GDP. More must be done, however, to expand the availability of long-term disabled elderly. The article concludes with a few observations elicited for European policy makers.     

Sinic conundrum: A history of HIV/AIDS in the people's republic of china

China's HIV/AIDS case rate continues to grow despite national and World Health Organization efforts. Reports in Western journals are nearly nonexistent, and what is in print does not provide evidence of the infection's historical progress. I traced progress of the infection since my last report (1991) and based current findings on unobtrusive data [HIV blood screening (assays)] provided by State epidemiology‐prevention stations and on ethnographic interviews conducted with public health officials from the Center for AIDS Surveillance, Chinese Academy of Preventive Medicine, and epidemiology personnel in Beijing, Chengdu, Chongqing, and Shanghai during fieldwork in China in 1992 and 1993. Cultural, social, economic, and political factors involved in China's historical attempts to manage a growing HIV case rate are discussed. Together, data reveal a widening geographic and social distribution of the virus over time, which, in conclusion, should now qualify China's HIV status as epidemic.     

Employment-Based Training on Alcohol and Other Drugs in England: Bridging the Gap

The first of its kind in England, this study explored the extent and nature of employer-based training on alcohol and other drugs for social workers working in children's and adults' services. A national survey of workforce development departments was undertaken to find out how social workers are being prepared by their employers for engaging with people who use alcohol and other drugs. Based on a response rate of 46%, the findings show that a majority of departments (82%) provided training on these issues in the year 2011–2012. However, most of this training was not mandatory. These courses are targeted most often at those working in children's services rather than those in adults' services. Most courses are offered at basic or intermediary level, and content of training is covered inconsistently. These findings suggest a need to increase the priority of alcohol and other drugs' training across adults' services in particular and to make this training mandatory, as well as ensuring that staff have adequate time and incentive to attend. Effectiveness of social care practice for all social care practitioners around alcohol and other drugs use could be improved with more focus on training practitioners how to talk to service users about their substance use.     

Child Care Preferences of Foreign-Born Immigrant Groups in California

This study using California Health Interview Survey 2005 Child Survey data presents disparities among three major immigrant groups' child care preferences. Asian immigrant families used a grandparent or a relative care and a preschool more than Latino and European immigrant families. Latino immigrant families used child care from a nonfamily member in the provider's home and Head Start more than Asian and European immigrant families. To understand the predictors of time spent in child care by California's immigrant children, a multiple regression analysis was run. Being a child from an Asian immigrant family, child's age, being a girl, and being a child from a single mother-headed immigrant family emerged as predictors explaining 17.2% of the variance in the amount of time spent in child care. Variations in child care usage among immigrant groups warrant concern and suggest a need for culturally sensitive child care programs for immigrants.     

Domestic Abuse Against Elder Women and Perceived Barriers to Help-Seeking

The study's (n = 447) purposes were to (1) describe relationships of abuser behavior to elder women's perception of barriers to help-seeking; (2) compare fit of model to participants' levels of abuse, race-ethnicity, age, and gender and relationship of identified close other; and (3) determine extent to which the model differentiated relationship of abuser to participant and level of abuse. Analyses identified six factors contributing to the overall barrier score, accounting for 84% of total variance (χ²/df = 1.527, CFI = .989, RMSEA = .034), including three internal and two external factors and a single abuser behavior factor that were invariant across participant characteristic; however, covariances did differ.     

We've Looked at Care from Both Sides Now: The Effects of Alternative Evaluation Strategies on Study Conclusions

This study uses two studies about the role of managed-care programs in serving Medicaid long-term care clients in Florida to illustrate how different research designs can reach divergent conclusions. Two reports from different groups using essentially the same database to assess the impact of managed care on a group of older Medicaid clients served by a Nursing Home Diversion Program reached different conclusions. The report from Florida's Office of Program Policy Analysis and Government Accountability concluded that the Diversion program saved money, whereas the report from the Florida Policy Exchange Center on Aging at the University of South Florida reached basically the opposite conclusion. Both agreed that the capitation rate was too high. How the policy questions are framed and analyzed can affect the conclusions reached. A variety of factors can influence the apparent effects of programmatic interventions. Evaluations must take relevant confounding variables into account.     

NEW TRENDS IN THE DOCTOR-PATIENT RELATIONSHIP: IMPACTS OF MANAGED CARE ON THE GROWTH OF A CONSUMER PROTECTIONS MODEL

Managed care is prompting a large revision not only in the ways doctors are employed and paid but also in the essence of the relationship between doctors and patients. In medical sociology, a discipline with a long-standing focus on scrutinizing the role of both the physician and the patient, there has already been discussion of a shift from the doctor as more all knowing to a less dominant position vis-a-vis both the patient and delivery of care. Patients are aware of shifts that place physicians in an environment characterized by new roles and responsibilities, such as acting as a gatekeeper. Limitations on health care coverage and the rethinking of roles have led to a depiction of the patient as the consumer of care and the managed care plan's becoming the commercial enterprise from which a service is obtained. The model of the patient as consumer of medically related goods and services appears to be growing, as does a model of the physician as one who contracts for a specified range of services for specific patients. In this article, trends in and problems with contemporary managed care are raised. Calls for patients' rights legislation may be among the health trends of the new millennium.     

Gendering the Eye of the Norm: Exploring Gendered Concertive Control Processes in Two Self‐Managing Teams

This article is the result of an ethnographic research project exploring the workplace interactions of two self‐managed teams of recruitment consultants. I use data from participant observation and recorded interviews to show the gendered nature of what Barker terms concertive control: the social processes by which team members regulate each others' conduct in line with negotiated team values. My analysis examines how team members negotiate core team values, translate these into specific actions and regulate these actions through concertive control interactions. I then set out three ways in which gender acts as a resource for these concertive control processes. These are: team members' assumptions about men's and women's relative skills and capacities, the ‘tough’ masculinity of the haulage industry in which one of the teams operates and the regulation of performances of heterosexuality during customer interactions. Building on research by others, I show gender to be not only embedded in the values and managerial style associated with teamwork but also integrated into the collaborative process of team‐working itself. I emphasize that social categories like gender become resources in the regulation of conduct at work and can reify hierarchies even in so‐called participative practices like self‐managed teamwork.     

Community College Health Service Programs: A Progress Report

Abstract

What progress has been made in improving the health service programs available to the millions of students attending the nation's public community colleges? This question was investigated by sending a follow-up survey to deans of students in 1977; the original study was done five years earlier and resulted in a national profile of health service programs at public two-year institutions.

Some of the significant findings were: the percent of colleges offering health service programs has increased from 41.5% to 51.3%; the campus nurse continues to be the most common health professionals available to students; facilities are considered to be adequate and accessible; and a broad range of student health needs are met. New elements in the survey covered health education and mental health services, and these were positively evaluated.

On the basis of survey results it was concluded that community colleges have made considerable progress in improving student health services, but there is still much to be done.     

Residential care for children with intellectual disabilities in the social protection system in Serbia

This paper presents and discusses the characteristics of the social protection of children with intellectual disabilities who are placed in children's homes in Serbia. It draws on a survey that covered the entire population—586 users in all five institutions for children with intellectual disabilities who resided there in 2009. The analysis shows the heterogeneity of users in relation to age and degree of intellectual disability, their long-term stay in homes, the inadequate structural and functional standards, and insufficient health care. Residential care becomes the most common form of permanent rather than temporary care. These findings suggest the need for a number of strategies to be adopted, and the paper concludes by outlining potential ways forward.     

Managing the process of change in residential child care: A consultancy approach

This article explores the impact of a consultancy undertaken with groups of residential child care staff within a large local authority who were experiencing considerable changes in their working environment as a result of a review of residential care structures. The authors were invited to engage directly with staff on an individual and group basis to help them work through the barriers they perceived to changing their approach to practice. The theoretical underpinning for the work was Charles Handy's [1993, Understanding Organisations (Harmondsworth, Penguin)] belief that change is more likely to have a positive outcome when staff have an investment in and contribution to the change processes. The model of change utilised within the sessions with staff was Kurt Lewin's three stages of 'unfreezing', 'change' and 'refreezing'. The consultancy raised a number of issues about the process of change and how this can be achieved within the residential child care context. In particular, it highlighted the problems of assuming that change is a linear process which can be directly controlled and managed in the flux and uncertainty which characterises this sector.     

Health care,social care or both? A qualitative explorative study of different focuses in long-term care of older people in France,Portugal and Sweden

Challenges with an ageing population are increasingly becoming a reality in the Western world. Since cognitive impairment increases with age, we can expect an increasing number of older people in need of care. The aim of this article is to describe, analyse and compare different focuses on care of older people with dementia, using examples from France, Portugal and Sweden. The questions are principally focused on the participants’ view about their tasks, the organisation of work, the professional role and cooperation with other professions. Everyday care was studied through observations and participant observations and the staff's opinion was explored by means of interviews. Twenty-two care settings for older people were included. The findings showed that France provided mainly ‘health care’, Sweden ‘social care’ and Portugal an integrated ‘health care and social care’. In a comparative perspective the Portuguese general care of older people, which focuses on integration of health care, social care and social work, also seems to provide care for older people suffering from dementia which best corresponds to the previously developed group living model.     

Telephone communication with children as part of the self‐care arrangement: A research note

Children in self‐care (latchkey) arrangements have been portrayed as a population at risk, and this has recently led to research investigations, social policy discussions, and legislative proposals. This study examines selected characteristics of mother, child, and family, and the amount of time children spend in self‐care, for their influences on the use of the telephone to communicate with children in self‐care. The analysis builds on earlier studies that indicate the importance of time, child's age, and mother's employment for understanding the growing phenomenon of self‐care. The results of multiple regression analyses are presented and discussed. As expected, the age of the child is the most important variable in predicting the length of time spent in self‐care. The age of the child and the length of time spent in self‐care are the strongest predictors of telephone communication with children in self‐care arrangements.     

Observational Stance as a Predictor of Subjective and Genital Sexual Arousal in Men and Women

Observational stance refers to the perspective a person takes while viewing a sexual stimulus, either as a passive observer (observer stance) or an active participant (participant stance). The objective of the current study was to examine the relationship between observational stance and sexual arousal (subjective and genital) across a range of sexual stimuli that do or do not correspond with a participant's sexual attraction (preferred or nonpreferred stimuli, respectively). Regression analyses revealed that, for men (n = 44), participant stance significantly predicted subjective and genital arousal. Women's (n = 47) observer and participant stance predicted subjective arousal but not genital arousal. Analysis of variance showed that participant stance was greatest under preferred sexual stimuli conditions for all groups of participants, while observer stance scores revealed a less consistent pattern of response. This was particularly true for opposite-sex-attracted women, whose ratings of observer stance were lowest for preferred stimuli. Observational stance does not appear to account for gender differences in specificity of sexual arousal; for men, however, participant stance uniquely predicted genital response after controlling for sexual attractions. Similarities in the relationships between men's and women's observational stance and sexual responses challenge previous claims of gender differences in how men and women view erotica.