Managed care and the rationalization of mental health services

Managed care represents a response to the wider institutional demand for technical rationality and efficiency, and it may be in conflict with professionally generated logics of mental health care which emphasize the delivery of quality care, as well as providing services to all who need care. The organizational and policy conundrum is to balance conflicting institutional demands for efficiency (cost savings) and effectiveness (access and quality). This paper examines managed care in one public sector mental health care system that has attempted to incorporate the principles of managed care into a community based system of care and to overcome the potential contradictions between demands for efficiency and professional logics of care. Both qualitative and quantitative data are used to examine changes in organizational structure and service offerings; providers' experience of managed care, and the effect of managed care on working conditions and work experiences, and changes in the goals of the organization as measured by the specification of client outcomes. I find that, while increased performance accountability and outcome assessment (in keeping with demands for efficiency) have the potential to improve mental health care services, in fact, providers report that the primary effect of managed care has been an emphasis on cost containment, and there has been a corresponding de-emphasis on the provision of community based services for clients with long term care needs. However, there is potential for professional logics to be maintained by larger institutional forces demanding quality care.     

Organizational structure,leadership and readiness for change and the implementation of organizational cultural competence in addiction health services

Increasing representation of racial and ethnic minorities in the health care system and on-going concerns about existing health disparities have pressured addiction health services programs to enhance their cultural competence. This study examines the extent to which organizational factors, such as structure, leadership and readiness for change contribute to the implementation of community, policy and staffing domains representing organizational cultural competence. Analysis of a randomly selected sample of 122 organizations located in primarily Latino and African American communities showed that programs with public funding and Medicaid reimbursement were positively associated with implementing policies and procedures, while leadership was associated with staff having greater knowledge of minority communities and developing a diverse workforce. Moreover, program climate was positively associated with staff knowledge of communities and having supportive policies and procedures, while programs with graduate staff and parent organizations were negatively associated with knowledge of and involvement in these communities. By investing in funding, leadership skills and a strategic climate, addiction health services programs may develop greater understanding and responsiveness of the service needs of minority communities. Implications for future research and program planning in an era of health care reform in the United States are discussed.     

Health promotion and disease prevention: a look at demand management programs

This Issue Brief describes employers' efforts to contain health expenditures through demand management programs. These programs are designed to reduce utilization by focusing on disease prevention and health promotion. Demand management includes work site health promotion, wellness programs, and access management. Work site health promotion is a comprehensive approach to improving health and includes awareness, health education, behavioral change, and organizational health initiatives. Wellness programs usually include stress management, smoking cessation, weight management, back care, health screenings, nutrition education, work place safety, prenatal and well baby care, CPR and first aid classes, and employee assistance programs (EAPs). These programs are often viewed positively by workers and can have long-term benefits for employers above and beyond health care cost containment. Demand management can benefit employers by increasing productivity, employee retention, and employee morale and by reducing turnover, absenteeism, future medical claims, and ultimately expenditures on health care. Even though a growing number of employers are offering wellness programs, only 37 percent of full-time workers employed in medium and large private establishments were eligible for wellness programs by 1993. However, a recent survey found that 88 percent of major employers have introduced some form of health promotion, disease prevention, or early intervention initiative to encourage healthy lifestyles among their salaried employees. Distinctions must be drawn between short- and long-term strategies. Demand management can be thought of as a short-term strategy when the focus of the program is on creating more appropriate and efficient health care utilization. Disease prevention is characterized by longer-term health improvement objectives. Whether the purpose is to reduce utilization in the short term or in the long term, the ultimate goal remains the same: to reduce health care expenditures while improving overall health. This goal can be achieved through the use of health risk appraisals, organizational health risk appraisals, high risk programs, awareness programs, medical call centers, return to work programs, EAPs, and smoking cessation programs. Studies of a health program's cost effectiveness must disentangle the effects of many competing factors on cost effectiveness. For example, a health risk appraisal program may identify health problems of which the patient and the health care provider were unaware, resulting in the treatment of these health problems. At the same time, the employer may have switched from a nonmanaged pharmaceutical program to a managed program with incentives for participants to utilize generic and/or mail order drugs. As a result, when evaluating a health promotion program, the long-run impact on the program's cost effectiveness is most important.     

Gendered,Invisible Work in Non‐profit Social Service Organizations: Implications for Worker Health and Safety

Nonprofit organizations (NPOs) play an important role in the provision of health and social services. In Canada the nonprofit sector includes 7.5 million volunteers and employs over 1.6 million paid workers. The sector is overwhelmingly female‐dominated — women make up over 80 per cent of workers in these nonprofit services. Work performed by women has traditionally been undervalued and invisible. It has often been considered safe by researchers, employers, policymakers and sometimes even workers themselves. Although there is some indication that jobs in the restructuring social services sector can be characterized by constant demand, high stress and violence, research into the working conditions and health hazards of these types of jobs has not been a priority. Using data from a qualitative study examining work in NPOs, we trace the ways that work performed in these workplaces is both gendered and invisible. We identify three types of invisible labour. ‘Background work’ facilitates and supports more visible and recognized organizational activities. Certain organizational language obscures the full spectrum of work that takes place in the organizations and the risks it may involve. ‘Empathy work’ includes the relationship building, counselling and crisis intervention that comprise key components of social service delivery. ‘Emotional labour’ involves the management of client emotions and workers' own emotions in the process of working with clients and delivering care under conditions of scarcity and contraction. The invisibility of these activities means that much of the day‐to‐day work done in the organizations, while particularly important in the context of social service restructuring, is taken‐for‐granted and undervalued by organizational outsiders. As a result, many of the hazards present in the jobs are hidden from view and workers' health may be compromised. We argue that the invisibility and taken‐for‐grantedness of certain types of work in NPOs is reflected in, and constitutive of, particular exclusions and shortcomings of current occupational health and safety systems designed to protect the health of workers.     

Effects of government policies on the work of home care personnel and their occupational health and safety

The health sector in Québec (Canada) is dealing with profound macro-economic and macro-organizational changes. This article is interested in the impact of these changes on the work of home health aides (HHAs) and home care nurses and their occupational health and safety (OHS). The study was carried out in the home care services (HCS) of four local community service centres (CLSC) with different organizational characteristics. It is based on an analysis by triangulation of 66 individual and group interviews, 22 observed workdays and 35 observed multidisciplinary or professional meetings, as well as on administrative documents. HHAs are experiencing an erosion of their job because the relational and affective aspects of their work are disappearing. This may be due to an increase in their physical workload, leading to an increase in musculoskeletal problems and, to a lesser extent, in psychological health problems. Nurses are seeing an increase in the volume of invisible work that they have to do, which also has the effect of decreasing the relational aspects of their activity. The increasingly numerous psychological health problems are the consequence of this change in their profession. This study also shows that managers' decisions at the local level can reduce or increase the work constraints of HHAs and nurses. Examples of good practices for HHAs are the stabilization of clienteles and the possibility of organizing their itinerary, while for nurses, it is in how clientele follow-up tools are implemented. This article discusses the effects of government policies and decisions on the work and OHS of home care personnel. To address this subject, we use a specific analysis of the workload of home health aides (HHAs) and nurses. We will show the relationships between managers' organizational choices to respond to governmental constraints and the resulting work changes. We will also look at their consequences on occupational health and safety (OHS) and on the work of different personnel.     

Ärztliche Resilienz durch Achtsamkeit

This article in the journal Gruppe. Interaktion. Organisation (GIO) examines the reforms in the German public health care system, which lead to increased pressure on physicians due to the new economic incentive structures. Therefore burnout and depression was explored as a serious problem among this profession. In research mindfulness is seen as an important factor to enhance the medical resilience and thus increase the quality of care. The available empirical evidence suggests that individual mindfulness training should be combined with organizational interventions in order to achieve the greatest impact. The integration of the spiritual, social, juridical and ethical dimensions within an interdisciplinary research area “Medical Spirituality” may take into account transpersonal experiences which have a healing transforming influence on the physicians as well as the whole health care system.     

How physician-employees experience their work lives in a changing HMO

The present study advances our understanding of both physician adaptation and the physician-organization relationship in a managed care environment defined by structural diversity and constant change. It does so through a longitudinal examination of a single group of physician-employees experiencing their work lives within a nonprofit health maintenance organization (HMO) in the midst of major strategic developments. Using interview, observation, and archival data collected over a five-year period, the analysis reveals that the form and substance of individual physician adaptation to organizational life is dependent upon social exchanges over time with the HMO, making it an emergent, evolutionary process rather than a pre-determined, static phenomenon. However, the results also demonstrate that physician adaptive response to rapid, unpredictable organizational change is slow and delayed, in particular when this change makes physicians more dependent on their employing organization. This confers an advantage onto the organization vis-à-vis professionals in interpreting and responding to environmental change. These insights should encourage sociologists to employ research designs and contingency models of physician attitudes and behavior that capture the dynamic and particularistic nature of everyday physician work life in contemporary health care.     

AZT kill or cure? The social essences of scientific authority

This paper examines differing institutional responses to and interpretation of the same scientific and medical data, and looks at the way in which policies, ostensibly based upon these interpretations, are presented to public audiences. The case study concerns the use of AZT as a prophylactic for injured health care workers. Data was collected from personal in depth interviews in two health authorities and telephone interviews with a further 35 health authorities. Observations include the fact that widely different interpretations of scientific data by scientific and medical experts is likely to be presented to the lay audience in terms of scientific certainty, based on an institutional need for certainty and consensus. Contrary to conventional perspectives which would suggest that scientific knowledge was completed in its expert arena, then applied in different settings, this analysis suggests that the scientific knowledge is socially ‘completed’ or ‘closed’ in each of the different situations in which it is interpreted into practice. Ideal models of both the science and of organisational working practice, appear to have been used as the basis of these different constructions.     

AN ALTERNATIVE TO MANAGED CARE: A "GUILD" MODEL FOR THE INDEPENDENT PRACTICE OF PSYCHOTHERAPY

As health care is reconfigured by HMOs and managed care organizations, family therapists often have to decide whether or not to cooperate with the new power structures and their ways of doing things. The chief concern of many therapists is the ehtical bind created when the managed care orgranization demands breaches of confidentiality or makes decisions about the course of treatment that may not, in the therapist's opinion, be in the best interest of the family. Associations of independent, nonmanaged care psychotherapists are springing up in response to these dilemmas. This paper describes the philosophical evolution and organizational development of one such association.     

Health technology assessment between our health care system and our health

In this contribution, I wish to explore the potential of health technology assessment and ethics for increasing our capacity to pre-empt the shortcomings and undesired consequences of modern health care while maintaining its benefits. Central is the presumption that in case of some health problems this cannot be done unless we explicitly reconsider some features of the modern health care system, especially those related to its strong reliance on scientific rationality and the strong role played by medical professionals. So as to both maintain the benefits of advanced health care and ensure that it produces less reason for concern, we need to reconsider our approach to rationality—and maybe even the way in which we build our health care system around that rationality. That is, we need to introduce an element of reflexivity. Two types of circumstances are being explored in which such reflexivity may prove worthwhile: controversies on side effects, and persistent problems encountered in optimising health care. Drawing on brief discussions of typical cases, we explore the potential of reflexive HTA and its methodical prerequisites. We conclude that ethicists may contribute to reflexive HTA, if they combine a hermeneutic—and often also participative—methodology with a solid understanding of the relation between the health problem under scrutiny and more general critique of the health care system. Insights from the areas of science and technology studies, as well as from social philosophy may be critical items in their tool kit.     

Is that all there is? The concept of care and the dialectic of critique

Recognition of the usefulness of critical social analysis for gerontology has been increasing just as a range of new problems, ranging from globalization to the anti-aging movement, are posing fresh questions about ideology, legitimation and inequality for the study of aging. Such problems and questions represent the negative moment of critique in the theory–practice dialectic. As is generally true of critical theory, in critical gerontology it is rare to find research that reflects a positive movement toward emancipatory change. Yet gerontology is one of the fields that offers special opportunities for critiquing the status quo of aging and elders in society, envisioning new possibilities for aging and developing practices that produce positive change. This paper describes the movement of our own thinking and work, away from a primary focus on analysis and critique and toward an embrace of the possibilities of generating and sustaining change in organizational care settings. We argue that principles of critical developmental and social theory can be used to reframe the concept of care, and we describe briefly how the methodology of action research can be applied in efforts to create new opportunities and possibilities in the everyday experience of elders in long-term care. In our work, we are learning how a constructive theory–practice dialectic can be initiated when critical principles are applied to a practical and urgent domain — the domain of interpersonal care within long-term care institutions for elders.     

Citizen participation in neighborhood health centers for the poor: the politics of reform organizational change, 1965-77

Through a longitudinal study of neighborhood health centers for the poor in the United States, this paper presents an analysis of the political economy of change within reform organizations. In the final accounting, we seek to explain the shift in the role of poor people participating in health care decision making from that of program developer and change agent to the role of program restrictor. We conceptualize the neighborhood health center (NHC) as a reform organization whose initial objective was to use health care as a tool for achieving political and economic development within low-income rural and urban communities. The analysis, based on a prospective study of NHCs between 1965 and 1977, using interviews with citizen board members, NHC project administrators, NHC physicians, HEW decision elites, and oral history interviews with former Office of Economic Opportunity (OEO) administrators and directors, exemplifies the generic social organizational problem of how social, political, economic, and ideological forces shape the emergence and performance of a new reform organization.     

Tobacco Control and Smoking Cessation Efforts in an Inner-City African American Community

This paper describes the conceptual framework that guided the development and implementation of a large-scale, community-based health initiative to lower the prevalence of smoking in an urban African American community. This project developed culturally-sensitive approaches to reducing smoking in the community and to promoting tobacco control efforts developed and implemented by community members. A randomized clinical-trial methodology was used to test the efficacy of the culturally-sensitivey community-developed smoking cessation interventions in lowering smoking rates as compared with a self-help approach. Two theoretical models guided the intervention strategies: a macro-level model applicable to the community as a whole, and a psychological process model applicable to individuals. The community model was based on community systems theory and incorporated the Readiness for Change Model which was applied in both the individual and organizational models. In addition, culturally-sensitive data collection methods were developed to improve the reliability and validity of project data, especially in determining the smoking prevalence rates and smoking behaviors of hard-to-reach, inner-city African Americans. Since the health of individuals is related to the health of their communities, smoking cessation and tobacco control activities that are integrated into the framework of the community (Le., churches, city-council, housing developments, community organizations), and incorporate culturally-relevant and specific interventions can be effective methods for achieving behavioral and societal change.     

Tobacco control and smoking cessation efforts in an inner-city African American community

This paper describes the conceptual framework that guided the development and implementation of a large-scale, community-based health initiative to lower the prevalence of smoking in an urban African American community. This project developed culturally-sensitive approaches to reducing smoking in the community and to promoting tobacco control efforts developed and implemented by community members. A randomized clinical-trial methodology was used to test the efficacy of the culturally-sensitive, community-developed smoking cessation interventions in lowering smoking rates as compared with a self-help approach. Two theoretical models guided the intervention strategies: a macro-level model applicable to the community as a whole, and a psychological process model applicable to individuals. The community model was based on community systems theory and incorporated the Readiness for Change Model, which was applied in both the individual and organizational models. In addition, culturally-sensitive data collection methods were developed to improve the reliability and validity of project data, especially in determining the smoking prevalence rates and smoking behaviors of hard-to-reach, inner-city African Americans. Since the health of individuals is related to the health of their communities, smoking cessation and tobacco control activities that are integrated into the framework of the community (i.e., churches, city-council, housing developments, community organizations), and incorporate culturally-relevant and specific interventions can be effective methods for achieving behavioral and societal change.     

Coordinating health, extended care, and community support services: reforming aged care in Australia

Under pressure to maximize the cost-effectiveness of programs, efforts to improve coordination have become increasingly central to the development of the broader health and welfare service delivery system in Australia in the past few years. This article reviews recent experience in two related fields: (1) the coordination of different community care services for older people and people with disabilities, funded by the Home and Community Care program; and (2) the attempt to enhance links between community and residential care services, hospitals, and other health care providers. Why coordination has emerged as such an important issue in the field of community care and, increasingly, across the entire system of what the Australian government now terms health and family services is discussed. A number of measures that have been introduced or are proposed to improve a coordination of services are briefly reviewed. These range from individualistic approaches based on information and referral, through schemes involving gatekeeping, case management and brokerage of services, to models involving the reconfiguration of organizational structures, linkages, and finances. These measures are not mutually exclusive and are increasingly likely to be applied in more complex mixed models of service coordination. It is argued that coordination at the level of direct-service provision is difficult if government policies that direct services lack coordination.     

The Formative Context of Organizational Hierarchies and Discourse: Implications for Organizational Change and Gender Relations

Society as artifact, meaning society as a thing that is made and imagined, is a central aspect of Roberto Unger's constructive social theory. This article develops Unger's social theory, specifically his notions of organizational hierarchy, discourse, and organizational change, and applies it to an understanding of gender relations at work. Constructive social theory is defined with a focus on the instrumental concept of formative context. A critical perspective of Unger's constructive social theory is also presented to illustrate its strengths, challenges and limitations. Drawing on literature from a variety of sources and perspectives, organizational hierarchy, organizational discourse, organizational change and gender relations are viewed through a formative context lens. The concept is then applied as a framework for organizational change through change in organizational discourse, specifically language. Change in organizational discourse through language is utilized as a means of improving gender relations: in particular, the advancement of women in organizations.     

From Philanthropy to Social Welfare,Philip Klein. San Francisco,Jossey-Bass Inc., 1968. 307 Pages. $8.50 Hardbound

Interdisciplinary collaboration of health care professionals is necessary if quality health care is to be assured. Social work's concern for the social functioning of human beings should be reflected in its organization of health-care services. To achieve this end, social work education should be structured to prepare students for collaborative activities. This paper describes the process and difficulties of planned change undertaken at the Wayne State University School of Social Work with other health-related schools, in the conception, design, and implementation of an interdisciplinary course and practicum for graduate social work and nursing students.     

The use of antidepressant medications in substance abuse treatment: the public-private distinction, organizational compatibility, and the environment

Many studies of innovation adoption in health care organizations focus either on organizational characteristics or the institutional environment, but not both. Furthermore, these perspectives are rarely employed simultaneously in both public and private health care organizations. This research considers the public-private distinction, organizational compatibility, and interorganizational referral relationships in the use of selective serotonin reuptake inhibitors (SSRIs) by substance abuse treatment organizations. Using data from nationally representative samples of 363 publicly funded and 403 privately funded substance abuse treatment centers, a four-category typology of public and private organizations initially predicted variation in SSRI use. However some differences were no longer significant once organizational and environmental characteristics were added to the statistical model. These data support hypotheses about the associations between organizational characteristics and SSRI use as well as hypotheses regarding the external environment. Future research should continue to integrate both internal and external factors in theoretical explanations of innovation adoption.     

Strengthening Social Protection in East Asia,Mukul G. Asher and Fukunari Kimura (Eds.)

Few studies have analyzed for-profit and nonprofit differences in the home health care sector. Using data from the National Home and Hospice Care Survey, we found that patients in nonprofit agencies were more likely to be discharged within 30 days under Medicare cost-based payment compared to patients in for-profit agencies. However, this difference in length of enrollment did not translate into meaningful differences in discharge outcomes between nonprofit and for-profit patients, suggesting that—under a cost-based payment system—nonprofits may behave more efficiently relative to for-profits. These results highlight the importance of organizational and payment factors in the delivery of home health care services.     

Not <Emphasis Type="Italic">Merely</Emphasis> TLC: Nurses’ Caring Revisited

The profession and practice of nursing has been studied from quite diverse scholarly perspectives in the United States and abroad. Feminist critiques focus on the gendering of caring and its knowledge/skill features, while professionalization advocates view emotive caring as secondary to other critical activities necessary for the occupational advancement of nursing. Based on ethnographic observations 30 in-depth, semi-structured interviews with nurses across different units working at a large urban hospital, this paper examines how nurses define caring as knowledge-based, skilled work. Specifically, nurses described four types of skills—observational, analytical, interactional, and comforting—that they deploy in the accomplishment of caring work at the bedside. My findings go beyond previous literature in this area by showing how nurses think of caring work in line with occupational strategies that emphasize their biomedical knowledge and diagnostic skills and uphold an advocacy or intermediary role in health care. I argue that while this ideological work may reassure nurses of their professional identity and critical role in health care, it may also reinforce the dilemma of nurse professionalization by obscuring the organizational nature of caring, as it remains an unsupported dimension of their work.