Facilitators and Barriers to Implementing Transitional Care Managers Within a Public Health Care System

Transitional care is crucial to ensure quality of care and safety for elderly patients. In the context of health care reforms promoting a shift from a hospital-centered approach to a home care approach, transitional care becomes a vital component and social workers can play an important role in easing transitions. Most recent studies have focused on the development or improvement of transitional care intervention models or tools, but few have addressed implementation issues. In this study, the implementation process of an innovative intervention aiming to integrate transitional care managers (TCMs) from Health and Social Services Centres (HSSC) within two Canadian hospitals was evaluated. Data collection comprised focus groups (n = 8), direct observations, meeting minutes, activity grids and logbooks. To facilitate the implementation of TCMs, decisions were made to clearly indicate their involvement in patients’ files and concentrated their efforts on a restricted number of units. Barriers included confusion about target clientele, inequitable information exchange between partners, limited powers regarding coordination of care, and organizational constraints limiting additional measures to improve transitional care. Evaluating implementation processes is crucial to efficiently identify obstacles and apply additional implementation strategies to promote the integration of new practices within the health care system.     

The health care system of the People's Republic of China: Between privatization and public health care

Chinese health care policy has undergone numerous reforms in recent years that have often led to new challenges, inciting the need for further reform. The most recent reforms attempt to find a middle path between public health care provision and commercial private insurance. In this way, China is following in the footsteps of countries that initially increased the role of privatization in the 1990s and at the beginning of the 21st century, but are now gearing towards public health care. However, this process of constant reform has led to a lack of transparency in the functioning of the health care system, provoking a loss in public trust. There remains an important degree of uncertainty about the future direction of developments in China. Nonetheless, a dual financing approach to health care using tax finance and social insurance might yet crystallize, offering a potential model to inform developments in other countries.     

Caregiver‐endorsed strategies to improving sexual health outcomes among foster youth

Foster youth are at an increased risk of unintended pregnancies and sexually transmitted infections (STIs) compared with peers. We conducted 11 semistructured focus groups with 86 foster and kinship caregivers in three child welfare jurisdictions to understand their strategies for monitoring and communicating with youth in foster care around sexual health topics, with the overall goal of developing a training for caregivers to reduce STI and unintended pregnancies among youth in foster care. We used thematic analysis to analyse the data. Three main themes emerged: (1) strategies to communicate with youth about sexual health (trust‐building, open/direct communication, tailoring information to each individual youth, creative conversation‐starters, and self‐education), (2) strategies for monitoring youth (e.g., tailoring monitoring to youth development/characteristics, clearly communicating rules, co‐development of rules, spending time with youth/friends/friends' parents, using technology, using a social support system), and (3) other strategies to promote positive youth development (advocating for youth, engaging youth in goal‐setting). Trainings that provide caregivers with (1) information on sexual health and normal adolescent development and (2) strategies and skills to help caregivers engage in open, evidence‐informed communication, and monitor youth in a tailored, developmentally‐informed manner are likely to improve reproductive health and other outcomes among youth in foster care.     

Long-term Care Policies in Italy, Austria and France: Variations in Cash-for-Care Schemes

Cash benefit provisions have been at the core of many recent reforms in the long-term care sector in Europe. The respective schemes, however, vary widely in terms of the definition of entitlements, the level of benefits, and the ways in which benefits can be used by recipients. This article investigates cash-for-care schemes in three European social insurance countries. It asks whether the diversity of these schemes indicates different paths or just differences in the pace with which the respective policies address the risk of dependency. A characterization of the three schemes and a discussion of the implications for care work arrangements lead to the conclusion that the context and timing of long-term care reform processes are in fact quite variegated. All three countries have histories of cash schemes and of applying the cash approach to support – and to some extent relieve – traditionally strong family obligations. Differences predominate in terms of linking cash to employment, although some convergence is apparent in the effects on qualifications, working conditions and wages in care work.     

‘Creating NHS Local’: The Relationship between English Local Government and the National Health Service

Following recent reforms of both local government and the National Health Service, there is significant emphasis in both services on improving inter‐agency collaboration, user involvement and strategic commissioning. In response, this article reviews historical debates about the relationship between local government and health care, before arguing that these two ‘partners’ need each other now more than ever. If local government is to be a ‘place‐shaper’, then it needs significant influence over local health services, while the NHS needs to learn from the best of local government if it is to gain sufficient local legitimacy to take the difficult decisions it needs to take. Against this background, the article reviews different options for future joint working, exploring various options for enacting a new relationship between local government and the NHS.     

Health insurance system financing reforms in the Netherlands,Germany and France: Repercussions for coverage and redistribution?

For a number of years, the Dutch, German and French health insurance systems have been attempting to contain costs and diversify their sources of finance, which traditionally have come mainly from social contributions. Diversification may involve broader‐based public finance, as well as greater recourse to private resources and operators. In the case of the Netherlands and Germany, the reforms go hand in hand with efforts to introduce competition between health insurance bodies. In France, private complementary insurance has become indispensable for adequate access to health care. However, these measures have repercussions for redistribution, which social assistance programmes have difficulty in addressing.     

The Organization of Health Policy Functions in the German Federal Government

This article gives an account of the organizational history of the German federal ministry of health (and its predecessors) since the beginnings of public policy intervention in health care. In doing so it analyses the role of ministerial organization and examines the functional and political rationale underlying acts of reorganizing the tasks and resources of federal ministries. This analysis has two sides: the first concerns the expressive function of organizational form, as revealing something about the scope and perceived importance of the policy field, while the second interrogates the policy‐shaping role of organization and the political influence of the federal health ministry in health policy‐making. The article thus considers the organizational location of health issues in the central executive from the perspective of what it reveals about government goals and priorities. Then it examines possible policy implications. It looks at resources and the size of the ministry as a first attempt to learn something about the ministry's political weight. The question of policy implications draws our attention away from organization and resource allocation and back to a focus on policy‐making and policy outcomes. The final section therefore examines substantive policy implications that might have emanated from the organizational consolidation of the federal health ministry. It concludes that one such policy implication might be the erosion of the social insurance model as a regulatory idea in health‐care services and financing.     

英国医疗卫生体系问题与医疗卫生政策改革研究

健康是人们福利的重要组成部分,因此医疗卫生政策和体系是社会政策的重要领域。该项研究从贫穷、低收入和健康之间的关联中评估人们对医疗保健的需要;指出英国存在全科医生、医院医生及公共卫生医生是医疗卫生服务提供的主体;英国在医疗卫生政策改革方面的内容包括:(1)对英国全民医疗体系(NHS)多渠道的财政支持,(2)提高服务质量的机构管理改革,(3)实施提高服务质量的安全、有效、病人中心、及时、效率、和平的原则;英国存在的强大政治集团及其利益影响着改革;政府需要在减少医疗服务中不平等和提供及时有效的服务方面努力。     

Public health care in the balance: exploring popular support for health care systems in the European Union

Which factors explain intra‐ and inter‐country variations in levels of public support for national health care systems within the European Union, and why? We propose that public opinion towards public health care is dependent on (1) the type of welfare state regime to which the various European welfare states belong, (2) typical features of the national care system and (3) individual social and demographic characteristics, which are related to self‐interest or morality oriented motives. To assess the explanatory power of these factors, data from the Eurobarometer survey series are analysed. Support for public health care appears to be particularly positively related to social‐democratic attributes of welfare states, whereas support drops with increasing degrees of liberalism and conservatism. Further, support for public health care proves to be associated with wider coverage and public funding of national care services. We also find higher levels of support in countries with scarce social services for children and the elderly, and larger proportions of female (part‐time) employment. Lastly, with respect to individual characteristics, we find remarkably little evidence for self‐interest oriented motives affecting the preference for solidary health care arrangements.     

Putting the child at the centre of inter‐professional cooperation in out‐of‐home care

A large part of most children's childhood is about taking part in educational and leisure‐time activities together with other children across various contexts. However, children in out‐of‐home care do not always have easy access to these possibilities for participation. In general, parents coordinate their children's everyday lives, but in the case of children in out‐of‐home care, the responsibility of care is distributed between several professionals and institutions. Research often recommends that inter‐professional cooperation should put the child at the centre and be more child focused. But what does that mean? The paper investigates theoretical understandings of ‘child centredness’ in inter‐professional cooperation. It also includes an empirical example taken from a research project that followed four children in their everyday lives in two residential homes in Denmark. The research explored how professionals work together across contexts in order to support children to take part in school and leisure‐time activities. The overall reasoning leads to the point that for children in out‐of‐home care, the possibility of exercising personal agency in their everyday life constitutes a difficult but vital issue. How children in out‐of‐home care learn how to conduct their everyday lives, is closely related to the ways professionals cooperate across contexts. It points to the need for close inter‐professional cooperation in order to encourage and support children's initiatives and engagements in activities in communities with other children.     

‘Best of Both Worlds’? A Comparison of Third Sector Providers in Health Care and Welfare‐to‐Work Markets in Britain

This article compares the welfare markets in primary health care and ‘welfare‐to‐work’ in the UK since the late 1990s. A longitudinal comparison of two different policy areas enables us to study the context in which marketization and the resulting shift of welfare provision takes place. We outline the general background of the market‐based reforms and highlight in what way policymakers have ascribed third sector organizations (TSOs) a number of positive characteristics, particularly the ability to address concerns about well‐known market failures. While consecutive governments promoted these organizations as welfare providers, case studies of two illustrative provider organizations in each policy area reveal a number of problems regarding their distinctiveness in increasingly competitive welfare markets. We conclude that the crisp distinction made by policymakers between the third and other sectors as well as the alleged advantages of the former present a rather naïve picture of a complex reality and argue for a more critical view of third sector characteristics and performance. The third sector is not only characterized by a high degree of fuzziness at the boundaries to other sectors, but even within single organizations, which often undergo significant transformations over time. As a result, policy intentions and practical outcomes are contradictory with TSOs losing their alleged distinctiveness as players in increasingly competitive markets. Furthermore, we contend that detailed longitudinal studies of organizations are essential in the advancement of the discussion of the third sector concept as they provide conceptual insights into organizational change and behaviour.     

The vicious layering of multilevel governance in Southern Europe: The case of elderly care in Italy and Spain

Aging and changes in family arrangements and female employment have brought about important policy developments in long‐term care (LTC). Southern European countries have relied for a long time on family care and residual social care for the dependent elderly. Two paradigmatic cases, Italy and Spain, have shown two apparently different trends during the last 15 years: while in Italy, reforms seem to have been persistently blocked, in Spain, an ambitious reform has fallen short of expectations. Based on data on services and institutional arrangements, the article shows that a complex and inconsistent allocation of responsibilities across government levels, a sort of “vicious layering” of multilevel governance, may be playing a key role in this situation. The article discusses the dysfunctional effects of such arrangements, namely territorial inequalities, cost‐shifting between government levels and towards users, and misallocation of resources. We suggest that the development and reform of LTC in Southern European countries must address these problems if they want to avoid getting marooned by a complex network of vetoes and resource allocation problems.     

Organization and Supply of Long‐term Care Services for the Elderly: A Bird's‐eye View of Old and New EU Member States

This article provides an overview of the organization of formal long‐term care (LTC) systems for the elderly in ten old and 11 new EU member states (MS). Generally, we find that the main responsibility for regulating LTC services is centralized in half of these countries, whereas in the remaining countries, this responsibility is typically shared between authorities at the central level and those at the regional or local levels in both institutional and home‐based care. Responsibilities for planning LTC capacities are jointly met by central and non‐central authorities in most countries. Access to publicly financed services is rarely means tested, and most countries have implemented legal entitlements conditional on needs. In virtually all countries, access to institutional care is subject to cost sharing, which also applies to home‐based care in most countries. The relative importance of institutional LTC relative to home‐based LTC services differs significantly across Europe. Although old MS appear to be experiencing some degree of convergence, institutional capacity levels still span a wide range. Considerable diversity may also be observed in the national public–private mix in the provision of LTC services. Lastly, free choice between public and private providers exists in the vast majority of these countries. This overview provides vital insights into the differences and similarities in the organization of LTC systems across Europe, especially between old and new MS, while also contributing valuable insight into previously neglected topics, thus broadening the knowledge base of international experience for mutual learning.     

Third Sector In Transition – A Question of Sustainability for Community Service Organizations and the Sector?

Third sector organizations are transitioning towards entrepreneurial and managerial models as a result of quasi‐market strategies. This paper reports on the research findings of a survey of nonprofit disability organizations in Queensland and Victoria impacted upon by quasi‐market reform. Enterprising organizations were found to have made substantial change to organizational structures and systems, whilst more traditional organizations made few changes. All organizations demonstrated commitment to a social justice ethos. However across the organizational archetypes there were reports of an organizational ‘fragility’. It is argued that the problems of sustainability of community service organizations that existed prior to quasi‐market reforms remain. This implies community service organizations will experience ongoing difficulties in the post‐market era without further rationalization and change. A conceptual framework for sustainability of the community service sector is presented at the policy and organizational level.     

Big Business in a Thin Market: Understanding the Privatization of Residential Care for Children and Youth in Sweden

This article analyzes the transformation of Swedish residential care for children from a regionally coordinated, public social service system into a thin, but highly profitable, national spot market in which large corporations have a growing presence. Marketization and privatization are theorized as complex processes, through which the institutional structure and logics of this small, but significant, social policy field changed profoundly. Using official documents, register data, media reports and existing research, three consecutive phases in the development of the children's home market are identified since the early 1980s. Change was driven on one hand by policies inspired by New Public Management, which shifted public authority horizontally to the private sector, and vertically to local authorities (funding) and to the state (regulation). On the other hand were the responses of local authorities and private actors to the changing incentives that policy shifts entailed. During the first two phases, both the proportion and size of for‐profit providers increased, and the model of family‐like care was replaced by a professional model. Cutting across the trend of privatization in the third phase was establishment of a parallel system of homes for unaccompanied refugee children – mostly in public ownership. Similarities with privatization in the English system of children's care homes are noted. By showing how the Swedish market for residential care has been created by policy and by actors’ responses to those reforms, the article provides a foundation for thinking through how the predictable, significant and well‐documented problems of such care markets might be addressed.     

Looking Inwards,Looking Outwards: Dismantling the “Berlin Wall” Between Health and Social Services?

This paper argues that at a time when policy guidance urged closer collaboration and joint working between health and social services, the long-established cultural and professional gaps were widening and deteriorating. Drawing on data from four research sites, the paper argues that the deterioration was rooted principally in practitioners' preoccupations with changes within their own organizations and daily work, resulting from a major period of change in both health and social services, which, ironically, was at the expense of the joint working which the "Caring for People" reforms required. As the policy environment changes again, under the Labour government, it is likely that health and social care practitioners will be working within further organizational turbulence and change. It will be crucial that those changes are managed in such a way that they avoid the very real danger of compounding the problems which our respondents identified.     

The proof of the pudding: What difference does multi‐agency working make to families with disabled children with complex health care needs?

More than 20 years of research with disabled children, young people and their families has highlighted the need for the different professionals and services that support them to work more closely together. The British policy and legal framework for ‘joined up working’ has never been stronger. However, there has been an assumption that multi‐ or inter‐agency working will inevitably be a ‘good thing’ for families. This paper discusses findings from a 3‐year research project which looked at both the process and impact of multi‐agency working on families with a disabled child with complex health care needs. Interviews with 25 parents and 18 children and young people who used six developed, multi‐agency services were carried out. Findings suggested that the services had made a big difference to the health care needs of disabled children but were less able to meet the wider needs of the child and the family – particularly in relation to social and emotional needs. Multi‐agency working appeared to make some positive, but not significant, differences to the lives of families.     

Gaps in social protection for health care and long‐term care in Europe: Are the elderly faced with financial ruin?

While public expenditure on health care and long‐term care (LTC) has been monitored for many years in European countries, far less attention has been paid to the financial consequences for older people of private out‐of‐pocket (OOP) expenditure necessary to access such care. Employing representative cross‐sectional data on the elderly populations of 11 European countries in 2004 from the Survey of Health, Ageing and Retirement in Europe (SHARE), we find that OOP payments for health care and LTC are very common among the elderly across European countries and such expenditures impact significantly on disposable income: up to 95 per cent of the elderly make OOP payments for health care and 5 per cent for LTC, resulting in income reductions of between 5 and 10 per cent, respectively. Failure to prevent financial ruin, as a consequence of excessive OOP payments, is evident in 0.7 per cent of elderly households utilizing health care and 0.5 per cent of elderly households utilizing LTC. Those particularly concerned are the poor, women and the very old.     

Governing the coordination of care for older people: Comparing care agreements in Denmark and Norway

Increasing specialisation and demands to decrease the length of hospital stays have important consequences for the integration of specialised health and local care services. Based on case studies of care agreements in Denmark and Norway, this article compares subnational governance strategies for coordinating care services for older people discharged from hospitals. The question is how, and to what degree, national government regulations have an impact on local service coordination strategies. The analysis reveals that the numerous subnational procedures for coordination are somewhat more itemised in Denmark, and that regional variation in care agreements is greater in Norway. The identified differences can partly be accounted for by national differences in regulation, which is tighter in Denmark than in Norway. The study suggests that despite decentralisation of responsibility, subnational procedures to facilitate coordination are heavily influenced by national government policy.     

“Just Like I'm Saving Money in the Bank”: Client Perspectives on Care Coordination Services

Older adults face many challenges to community living. The literature has not sufficiently explored the roles of care coordination in the maintenance of housing and access to health care among older adults, particularly from their own perspectives. This qualitative study analyzes the findings from 25 interviews and 6 focus group discussions (48 participants) with a multiethnic sample of older adults in the New York City area. Care coordination services appear to assist older adults access health care, and to a lesser extent, maintain affordable housing. Disparities in access to care coordination appear to remain for immigrant, minority and suburban populations.