Home Care

The utility of examining the effectiveness of home care is illustrated by selected examples and applications. The growth rate of home care over the past decade, regarding the possibly substantial differenccs between the quality of home care in rural and urban America, and empirical evidence that suggests inferior quality of home care for health maintenance organization patients support the need for measuring and monitoring outcomes of home care. The conclusions of a research program targeted at developing a system of outcome measures for home care, and the resulting national demonstration program to implement and refine that system, are summarized.     

Home care: moving forward with continuous quality improvement

The utility of examining the effectiveness of home care is illustrated by selected examples and applications. The growth rate of home care over the past decade, questions regarding the possibly substantial differences between the quality of home care in rural and urban America, and empirical evidence that suggests inferior quality of home care for health maintenance organization patients support the need for measuring and monitoring outcomes of home care. The conclusions of a research program targeted at developing a system of outcome measures for home care, and the resulting national demonstration program to implement and refine that system, are summarized.     

Urban cultivation in Accra: an examination of the nature, practices, problems, potentials and urban planning implications

The literature on urban farming in Sub-Saharan African cities reveals that most studies have been conducted in Eastern, Southern and Central African cities. A few have focused on West Africa, including Sierra Leone, Guinea Bissau, and Cameroon. In Ghana there is a paucity of information on urban farming. The purpose of this paper is to examine the status of urban cultivation in Accra, Ghana's capital, reviewing existing research, and to present new empirical findings on urban cultivation emphasizing on its history, nature, practices, problems, potentials and urban planning implications.     

Alternative prenatal care interventions to alleviate Black–White maternal/infant health disparities

This paper attempts to forward the maternal health literature that critiques standard prenatal care in the United States by drawing on intersectionality, medicalization, and fundamental causation theories. We argue that these theories deepen our understanding of the maternal health experiences of Black women and can help explain why alternative prenatal care interventions have value for Black pregnant women. Alternative models of prenatal care, which include the use of midwives, doulas, and group prenatal care, are associated with equal or better health outcomes for infants and mothers compared to the standard prenatal model in the United States. We begin by drawing on these sociological perspectives to identify gaps in the maternal health literature that is critical of standard biomedical maternal health approaches. We then go on to describe select alternative methods of prenatal care and then provide a summary of the epidemiological literature as it relates to sociodemographic trends in usage and the relative effectiveness of alternative models compared to standard care. We conclude by arguing that a joint, critical application of these three theories can help scholars explain the utility of alternative interventions for African American maternal/infant health and can inform policies that aim to alleviate Black–White maternal/infant health disparities.     

Treatment of late-life mental disorders in primary care: we can do a better job

Health care services provided to older adults today are not as effective as they should be. The quality of care for late-life mental disorders often falls short of desired standards. The growth of the elderly population makes it imperative for the health care system to address late-life mental disorders more effectively. Intervention strategies based in primary care settings show the most promise, but effectiveness will depend on solving the geriatric psychiatry workforce crisis. Collaborative care is one promising model for improving geriatric mental health care delivery in primary care. Diffusion of collaborative care into the health care system and integrating geriatric psychiatry into other models such as geriatric medical homes will require redesign of the organization and financing of primary care and psychiatry to overcome current barriers. Public policy should reflect the essential role of psychiatry in geriatrics and promote the integration of geriatric psychiatry with primary care.     

The effectiveness of health care cost management strategies: a review of the evidence

This Issue Brief discusses the evolution of the health care delivery and financing systems and its effects on health care cost management and describes the changes in the health care delivery system as they pertain to managed care. It presents empirical evidence on the effectiveness of managed care and concludes with an analysis of the potential of future health care reform to influence the evolution of the health care delivery system and affect health care costs. Between 1987 and 1993, total enrollment in health maintenance organizations (HMOs) increased from 28.6 million to 39.8 million, representing an additional 11.2 million individuals, or 4 percent of the U.S. population. At the same time, new forms of managed care organizations emerged. Enrollment in preferred provider organizations increased from 12.2 million individuals in 1987 to 58 million in 1992, and enrollment in point-of-service plans increased from virtually none in 1987 to 2.3 million individuals in 1992. In addition, the percentage of traditional fee-for-service plans with some form of utilization review increased to 95 percent in 1990 from 41 percent in 1987. Measuring the effects of the changing delivery system on the costs and quality of health care services has been a difficult task, resulting in considerable disagreement as to whether or not costs have been affected. In a recent report, the Congressional Budget Office recognizes two new major findings. First, managed care can provide cost-effective health care at a level of quality comparable with the care typically provided by a fee-for-service plan. Second, independent practice associations can be as effective as group- or staff-model HMOs under certain conditions. In the future, we are likely to see a continued movement of Americans into managed care arrangements, an increase in the number of physicians forming networks, a reduction in the number of insurers, an increase in the number of employers joining coalitions to purchase health care services for their employees, and a health care system that is generally more concentrated and vertically integrated.     

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.     

Increased Public Financing and Health Care Outcomes in Russia

The paper proposes to estimate effectiveness in the rise of public health care expenditure within the 2006 Russian health care project by using the following indicators: mortality of working age population (from all causes except for external), life expectancy at birth, number of illness days for working population, and infant mortality under 1. Regional time-trend eliminated panel data regression analysis demonstrates significance of the dummy for the year 2006 in explaining the first three of the above health outcomes. Price-level adjusted medical staff salary turns out to be a significant predictor, too. Yet, since increased financing was almost unrelated to efficiency issues, it may be seen only as a first step in perfecting the post-Soviet Russian health system.     

Independent living programs for young people leaving the care system: The state of the evidence

A substantial body of evidence suggests that young people leaving public care systems are at increased risk for low educational attainment, unemployment, homelessness, physical and mental health difficulties, dependency on public assistance, and involvement with the criminal justice system. Independent living programs (ILPs), which incorporate life skills and personal development, are one strategy frequently used to improve outcomes for young people leaving care. However, the effectiveness of ILPs remains unknown. This paper systematically reviews the current evidence for ILPs, summarizing all controlled comparisons designed to evaluate their effectiveness. Reviewers were unable to find any randomized controlled trial evaluating ILPs, but the results of eight non-randomized controlled studies suggest that some ILPs may have protective effects for youth leaving the public care system. These trends were observed for outcomes related to educational attainment, employment, housing, health, and other life skills; nevertheless, the weak methodological quality of the evidence tempers the validity and generalizability of these conclusions. Further research utilizing random assignment of participants is imperative in order to draw reliable conclusions for policy and practice.     

Measuring the quality of health care

This Issue Brief examines some of the issues involved in defining and measuring the quality of health care and in implementing quality measures. It discusses the importance of measures of health care quality in the evolving health care delivery system, examines some of the conceptual issues involved in defining quality of care, and discusses some of the measures of health care quality and how these measures have been implemented in the health care delivery system. The major impetus for quality assurance programs is cost management: it is an attempt to allocate scarce health care resources efficiently. This requires making choices among alternatives, which may mean that maximizing quality of care for whole populations may not maximize the quality of care for individuals. Quality, in terms of any single good or service, has a number of dimensions. Health care is a complex bundle of services, and each component service within an episode of care affects the other components and the patients differently. Moreover, patients differ in numerous ways, which means that similar symptoms may require different services if care is to be effective. Measuring quality of health care services requires accounting for all of these factors. In attempting to manage health care costs, employers and other private health plans have begun to employ process measures of quality, i.e., evaluating caregivers' activities, the decisions made at each step in an episode of illness, and the appropriateness of the care provided. Process is an important component of quality measures because it focuses directly on the uncertainty in the efficacy of treatment. Given this uncertainty, the logic of medical decision making is an important determinant of quality and cost effectiveness. Examining the process of care involves assembling a panel of physicians who review medical records to determine the appropriateness of the care received. Providers have increasingly found that their medical decision making and practice styles are being monitored by purchasers as new health care delivery systems are being formed. The American Medical Association found that 39 percent of surveyed physicians were subject to clinical profiling.     

Contingent constellations: African urban complexity seen through the workings of a Ghanaian bus station

In this article, I explore the intricate relationship between regulation and contingency in processes of urban economic organisation by focusing on the workings of a central bus station in Accra, Ghana. After introducing the position of the station in Ghana’s urban economy and transport infrastructure, I set out its internal regulative arrangements in relation to larger socio-economic and political constellations the practices of the station workers are contingent upon. Next, I turn the analysis around and describe the ways in which people accommodate themselves within, exploit and thereby co-produce emergent contingencies. The focus on the station, I suggest, offers a window into the complex constituents of niche economic practices that prevail in many spheres of African cities and allows a nuanced reflection on the incongruous and undetermined dynamics of everyday urban ‘becomings.’     

Parents' searches for child care and the design of information services

This article reports selected findings from a study of the process by which urban parents search for child care. Analyses of interview data indicate that (a) parents used informal sources of information to a considerably greater extent than formal sources, (b) the general pattern was to begin the search with relatives and close friends and gradually move out to more peripheral ties, (c) there does not appear to be an effective informal system of neighbors or community persons who matched parents with child care providers, and (d) there was no single or several sources that were outstanding in effectiveness for a large proportion of parents. The article sets forth implications of these data for the design of child care information and referral services in urban settings.     

Urban college student self-report of hookah use with health care providers

Objective: This study's purpose was to describe urban college students’ communication about hookah with health care providers. Participants: Participants included a random sample of undergraduate urban college students and health care providers. Methods: Students surveyed determined the epidemiology of hookah use in this population, how many health care providers asked about hookah, and how many students admitted hookah use to a physician. Results: Of 375 students surveyed, 78 (20.8%) had never tried it, 284 (75.7%) had smoked hookah at least once, and 64 students (22.6%) were classified as frequent hookah smokers. Only 15 (4.7%) reported a health care provider asking about hookah during visits, whereas 36 (12.7%) admitted their hookah use to a health care provider. Conclusion: Hookah use was found to be highly prevalent among students in one urban university. This study supports the hypothesis that few health care providers broach the topic with patients. Additional research on health consequences of hookah use, education, and improved screening is warranted.     

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.     

“Give us respect,support and understanding”: Women veterans of Iraq and Afghanistan recommend strategies for improving their mental health care

Although women veterans of Iraq and Afghanistan have experienced war-related mental health challenges, they underutilize Veterans Affairs (VA) health care relative to men. Quantitative studies have identified barriers that limit women veterans’ use of health care, but there is a dearth of research asking recent women veterans to volunteer their own recommendations for improving their mental health care. The current qualitative study sought to increase representation of the client voice by asking 29 women veterans of the recent wars to recommend strategies for improving VA and community-based mental health services. 16 strategies were identified in three thematic areas, including the therapeutic relationship, clinical care environment, and health care system. Implications of the findings for enhancing access, use, and quality of mental health services for this cohort of women veterans are discussed.     

Access to Mental Health Services: The Struggle of Poverty Affected Urban Children of Color

It is estimated that, in the United States, one in ten children and adolescents suffer from illness severe enough to cause some level of psychosocial dysfunction. Urban children, and in particular low-income children of color, are at greater risk of developing mental health problems, and are less likely to receive effective child mental health services. Prompt and effective access to mental health services by urban children of color is a critical direct practice and social policy concern. This article provides an overview of significant barriers to mental health care experienced by poverty affected urban children of color and their families. It also addresses a broad range of practice and policy issues that need to be raised in order to ensure competent delivery of mental health services for children living in urban environments. The role of social work in assisting poor urban children of color to access and benefit from mental health services is stressed. Manny John González, D.S.W., is an Assistant Professor of Social Work at Fordham University Graduate School of Social Service.     

Integrating Services for Older People in Aging Communities in The Netherlands: A Comparison of Urban and Rural Approaches

ABSTRACT

The aim of this article is to discuss approaches to services integration for older people in urban and rural aging environments in The Netherlands, and the preliminary effects of these approaches on local aging conditions. In urban areas, services integration revolves around the creation of functional spatial hierarchy. In rural areas, the emphasis is on forging links between service providers. Outcomes for health and use of professional care services are similar. Out-comes for housing, informal care, and accessibility of services differ between urban and rural areas in ways that can be traced back to local aging conditions and elements of the specific approach to services integration used. In both urban and rural areas, much more could be done to connect formal programs to the lifeworlds of older dwellers.     

Controlling health care costs: An evaluation of strategies

There has been much discussion about the factors underlying inflation in the health care sector and the means to moderate increases in health expenditures. This paper identifies various costcontainment strategies and synthesizes research findings that may be helpful in evaluating their effectiveness. The review demonstrates the complexity of the issues and relationships that must be confronted and understood in cost containment. The delivery system is shown to be not well-suited to improving efficiency and restraining health care expenditure. Any single strategy, whether it involves restructuring the market or more direct regulation, cannot in itself accomplish the combination of expenditure control and adequacy of services that is socially desirable. A number of mutually reinforcing strategies are required. Finally, more empirical and analytical information on incentives, provider and regulatory decisionmaking, costs of regulation, and the dynamics of negotiation, is essential for the design of an effective costcontainment program.     

Improving healthcare for children entering foster care

Despite the fact that children in foster care are, perhaps, the most vulnerable children, healthcare for them has been lacking woefully for many years. A growing body of research has documented the need for such care as well as the failure of child welfare agencies to make major improvements in providing healthcare to foster children. Nonetheless, current efforts are being made to change this situation. This article reports on one effort to improve the provision and timeliness of health exams for children entering care. One rural and one urban county served as project treatment sites, with two additional rural and urban counties serving as control sites. The treatment sites achieved a statistically significant improvement in their rate of exam completion as compared to the control sites. The study finds that despite an existing policy for healthcare for children entering foster care, legislation mandating additional efforts, shortened time frames, and provision for judicial oversight are needed for improvement.