A case study in defining developmental costs for quality assurance in mental health center programs

Issues related to the state-of-the-art of ambulatory mental health care review as well as to the resources necessary for planning and operating a quality assurance program may be hampering development of such programs in community mental health centers nationwide. Faced with the problem of responsible and prudent program management, it has become increasingly difficult for CMHC directors to implement innovative, but unproven, and often unpriced programs which have the potential to draw scarce professional resources away from direct service delivery. Pressure to implement CMHC program requirements that are not ordinarily considered revenue-producing in nature, for example, consultation and education services and quality assurance activities, may further create anxiety for mental health program directors, especially during periods when they are ostensibly confronted with the need to maximize CMHC revenues. Before mental health professionals and administrators of mental health programs can be expected to introduce quality assurance programs, they need to have some idea how much the system costs. The figures reported from three North Carolina mental health centers may offer some indication of what other mental health centers might expect to spend in developing a quality assurance program. Salary expenses for multidisciplinary staff participation in quality assurance activities are presented.     

Re-visioning nurses' punitive attitudes within forensic psychiatric and correctional nursing: the significance of ethical sophistication

1. Development is an essential lifelong process if we are to compassionately care for patients in forensic and correctional nursing. 2. Many of us are blocked in our ability to understand and to care; we will need to grow to meet the challenges and to bear the shocks of forensic and correctional nursing. 3. Concepts that correspond to Kegan's levels of consciousness imply a progression from punitive attitudes toward more positive attitudes.     

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.     

The Atascadero State Hospital experience. Engaging patients in violence prevention.

When it comes to caring for the forensic psychiatric inpatient, there is no "how to" book. In the forensic hospital environment, the commingling of severe and persistent mental illness with criminality poses vexing clinical challenges and complex moral dilemmas not faced in either general psychiatric or correctional environments. While providing evaluation and treatment in our maximum security forensic environment, we continually strive to create and maintain a therapeutic milieu as we fulfill our social mandate to protect the public from the dangerous "criminally insane." Few studies guide us. We do know that within the forensic population there is a spectrum of psychopathology to manage, some of which responds to traditional psychotherapeutic techniques and some of which does not. For example, patients with psychopathic traits may not respond well to traditional treatment methods (Rice, 1997). As forensic psychiatric staff, we sometimes feel as if we are making it up as we go, adapting and blending psychiatric theory with knowledge from penology and criminal justice science to provide a safe environment conducive to growth for patients, the majority of whom may be considered "violence-prone" persons (Toch, 1969). Change is a characteristic of public-sector settings (Smoyak, 1991). Forensic hospitals must continually strive to monitor, refine, and improve their organizational systems as they respond and adapt to constant change. Despite the inherent challenges posed when collaborating with forensic patients, the VAC has achieved some notable successes. Staff and patients have been encouraged to work together to create and maintain a milieu where violence is neither assumed nor condoned. An active collaboration and partnership with our forensic patients has been one component of the hospital's successful violence reduction program. We trust that ASH's successful effort to collaborate with patients on the issue of violence reduction may be of use to other forensic hospitals faced with similar challenges.     

Professional education for correctional nurses. A community-based partnership model.

Advanced, professional education is the key to shift the correctional health nursing role from isolated practice behind bars to a seamless community-based, managed-care approach. From a public health perspective, the state of health or illness of the correctional population reflects the state of health or illness of the community of which they are a part. The aim of correctional health is to close the health-trauma cycle and to restore the inmate's health to a state and a process of being, and the inmate to an integrated and whole person within the community.     

Pediatricians and foster children

The poor state of health and health care of foster children is well documented. The cure lies in the hands of the agencies that administer the foster care system and pay for medical services, and in those of the physicians who provide that care. This study suggests that much of the problem may be solvable. Adequate numbers of pediatricians in Connecticut seem to be committed to caring for foster children, but major impediments remain, including inadequate reimbursement for both primary and specialty health services. The institution of a medical passport can make needed information available and help to establish and promote standards of care. Pediatricians appear willing to take a leadership role in assisting other agencies in developing programs to improve the care of these children; despite the problems in providing medical care to foster children, most pediatricians view it as part of their responsibility to the community and to all children.     

Addressing intimate partner violence in primary care: lessons from chronic illness management

Though many studies have documented the high prevalence, morbidity, mortality and costs attributable to intimate partner violence (IPV), it is still unclear how our health care system should address this major public health problem. Many have advocated for routine screening, yet there is still insufficient evidence that routine IPV screening can lead to improved outcomes. Though recognition of IPV is very important, a screening paradigm may not be the optimal way to approach IPV within the health care system. For many patients, exposure to violence is a chronic condition, characterized by long-term abusive relationships, histories of childhood and community violence, multiple associated chronic symptoms, and extra barriers to addressing their other chronic illnesses. Thus, there may be important lessons to be learned from work being done in the area of chronic care. We explore how Wagner's Chronic Care model may guide efforts to improve health care for IPV survivors and may serve as a framework for future research studies.     

Improving Primary Care for Persons with Disabilities: the nature of expertise

It has been well documented that persons with disabilities (PWDs) have a more vulnerable health status than persons without disabilities; yet, they often receive inadequate primary care within the US health care system. This study explores how PWDs think about the health care they receive, particularly how primary care providers facilitate or hinder quality care for PWDs. The findings from this study expand the concept of expertise in health care, suggesting it goes well beyond technical competence of health care providers. For PWDs, expertise is multi-dimensional, not solely the domain of providers and includes having knowledge and using that knowledge within the context of the provider-patient relationship. PWDs identified three distinct areas of expertise: medical/technical, medical/biographical, and systems. Expertise can be brought to health care encounters by both PWDs and providers, and it can be developed through collaboration during interactions between providers and PWDs.     

Grass-roots reflections on substance abuse. A community dialogue approach

The Greater Cleveland Dialogue brings together people from all walks of life to express their sufferings and opinions. Professional ethicists have a role to play in this process, but chiefly as listeners and interpreters rather than as theoreticians. The ethics that arises from this process is at least as useful as the conclusions that descend deductively from the many rival "first principles" of a more theory-driven approach. If community dialogues provide a partial answer to questions of ethics and health care, they do so because they include the public. Policies related to health care affect the public and must be in tune with public sentiment if they are to be effective. Moreover, a different style of health care ethics emerges from the dialogue process. My view is that a truly public bioethics is ultimately necessary, since the policies our society develops in the area of health care can be meaningful only if they are grounded in the general will. We need to work harder at widening the umbrella of bioethics to include the public, for the sake of the community and for our own education as professionals. Certainly major questions for the future surround the nature of consensus and the process of achieving it.     

The process and results of an evaluation of a nurse-managed, family-oriented health care center

This paper discusses an example of action research, the evaluation of a nurse-managed, family-oriented health care center serving a low-income, black population in an isolated section of a highly industrialized suburban community. The evaluation was the result of many necessary compromises, yet other than lack of cost effectiveness, it brought substantial evidence of the success of the agency. Patients had positive health attitudes, were knowledgeable, and practiced health-inducing behaviors. As compared to other community health centers, the quality of care was found to range from average to excellent. Notable gains in quality of care occurred from pre- to posttest, partially as a result of formative evaluation procedures. Despite the positive nature of the product evaluation, the Center was closed, raising questions as to the utility of evaluation in the decision-making process.     

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.     

Psychiatric nursing in the 1990s & beyond.

In the decade of the '90s, psychiatric mental health nursing will need to take stock of itself--its practice, its education, and its research--if it is to successfully prepare for the changes in care of the mentally ill. Like psychiatrists, we will need to rethink our agendas in light of new science and technology and rationalize the mental health delivery system and our role in it through systematic research and advocate for a system that provides quality care for the chronically ill and the poor. In the next century, we will need to rethink the basics of nursing care and the leadership roles of nurses as hospitals and the doctor's role within them changes. Psychiatric mental health nurses will need to be at the forefront in advocating for a delivery system that listens to patients and families, that humanizes the dehumanizing experience of hospitalization. The challenges before us are formidable.     

Health maintenance behaviors of individuals with severe and persistent mental illness in a state prison

The purpose of this grounded theory study is to define health and health-seeking behaviors of incarcerated individuals experiencing severe and persistent mental illness (SPMI) in a state prison. The strategies used to prevent loss of control and maintain health in the prison environment were examined. Nineteen incarcerated individuals with SPMI were interviewed in a state prison. Constant comparative analysis of the data revealed that while establishing a "fit" with the core variable "loss of control" and its identified properties, differences were found in the enactment of health maintenance behaviors related to properties in the prison environment. Several of these behaviors are inconsistent with behaviors expected of individuals in a community day treatment center and reflect a need for bridging programs to facilitate entry into the "free" world. Correctional nurses and mental health providers in this system can advocate for incarcerated individuals with SPMI by developing programs that provide cost-effective intermediate care and collaborating with community health systems for continuity of care. The findings related to alcohol and drug abuse among incarcerated individuals with SPMI challenges mental health providers in both correctional facilities and community-based programs to generate appropriate and effective substance abuse treatment programs for these individuals.     

The evaluation of healthy city projects in developing countries

In international public health and other disciplines there is a debate about the use of process versus impact (sometimes referred to as outcome) indicators in project evaluations. With growing international and national support for Healthy City Projects in developing countries it is timely to address the issue of how to evaluate such projects. This paper briefly describes process and impact indicators, considers the importance of process indicators given the role of institutional strengthening and capacity building in Healthy City Projects and discusses the balance between locally and internationally generated indicators. A case study of the first Healthy City Project in a developing country in Asia (Chittagong, Bangladesh) illustrates how the project is linked with urban management and can enhance co-operation, co-ordination, motivation, internal organisation, decentralisation and community participation. Finally, some institutional indicators for evaluation are suggested.     

Psychiatric nursing for the 21st century. The PACED model.

Health care reform has had a profound effect on the way psychiatric treatment occurs in this country. Decreasing length of stay, increasing acuity, and reducing staff levels are making traditional approaches to mental health care infeasible. Resources already in place may still be focusing on long-term treatment issues and do not facilitate rapid stabilization and discharge planning that includes continued care within an integrated system. Research supports the feasibility of quality mental health care, which can be accomplished in shortened lengths of stay, as long as clinical managers plan inpatient programs focused on short-term goals followed by appropriate aftercare. In addition to recommendations for clinical managers, this article provides a proposal for executives redesigning a mental health care delivery system, which includes the goals of rapid assessment and stabilization, as well as discharge planning and appropriate follow up within an integrated system.     

How and why are Theory of Change and Realist Evaluation used in food security contexts? A scoping review

The complex ways in which food security actions lead to nutrition and other health outcomes make it important to clarify what programs work and how, with theory-driven evaluation emerging as a promising approach to evaluate complex programs. However, it is unclear how and why theory-driven evaluation is applied in food security contexts. Our objective is to examine the development and use of Theory of Change and Realist Evaluation to support food security programs globally. Using a systematic search and screening process, we included studies that described a food security program, used a Theory of Change or Realist Evaluation, and presented original research or evaluations. We found a total of 59 relevant Theory of Change studies and eight Realist Evaluation studies. Based on our analysis, Theories of Change arose in response to three main problems: 1) the need to evaluate under complexity; 2) challenges with evaluation; and, 3) information gaps surrounding a program. In contrast, Realist Evaluation was reported to be developed primarily to understand a program’s outcomes. Reflecting on the problem to be addressed in the evaluation would help improve understandings of the evaluation context, which would then inform the choice and design of an evaluation approach.     

Piloting different approaches to personalised offender management in the English criminal justice system

Various approaches to personalisation are well-established in the UK social care sector and are now starting to ‘travel’ to other sectors. In this paper we report findings from an evaluation of a pilot to test elements of personalisation in the management of offenders in probation services within the English criminal justice system. Following a review of evidence from social care, three different approaches to personalised-practice were developed and tested on a small-scale in three separate sites. The evaluation finds that all three approaches were implemented reasonably successfully, but challenges were identified including that personalised approaches are more time-consuming, that staff need support to exercise professional discretion and that balancing greater choice with managing criminogenic risk requires new ways of conceptualising the relationship between case manager and service user. Overall, ‘deeper’ approaches to personalisation, such as co-production, will take time to emerge. This paper makes two important contributions to the debate on personalisation in public services. First, it addresses the question of how transferable the concept of personalisation is from the social care sector to other sectors in the UK, in this case the criminal justice system. Secondly, it outlines a methodology for developing and evaluating personalisation pilots, prior to a wider roll-out.     

Teaching Note—Asserting Social Work’s Role in Developing an Interprofessional Education Project

ABSTRACT

Interprofessional (IP) education is an essential component of today’s health care education. IP education has been recognized and supported for its potential to educate workforce-ready health care clinicians with the knowledge and skills, necessary to collaboratively deliver high-quality, client-centered care. While social work’s reflective, patient-centered, and holistic approach to care is invaluable in addressing healthcare challenges at all levels, social work’s lack of involvement in IP health care team practice is evident in the development of IP education curriculum with other health care disciplines. This article describes how one School of Social Work at a regional public university became part of a longitudinal IP education project in collaboration with a large R-1 research university, creating an IP opportunity for Master’s in Social Work (MSW) students. It also discusses the process taken for social work inclusion in the IP project, an experiential elective course designed to supplement the project, as well as Transformative Learning Theory, the conceptual framework used.