Assessing Health Care Needs Among Street Homeless and Transitionally Housed Adults

ABSTRACT

This study examined the health services received and needed among homeless persons in Hillsborough County, FL (N = 823). Lifetime and current need and receipt of health services were assessed with a cross-sectional survey. Participants reported extensive lifetime and current needs for physical and behavioral health care services. Nearly a third of participants reported current unaddressed health problem(s); an inability to obtain needed health care; and feelings of unaddressed mental health issue(s) as well as substance abuse problem(s) in the past year. Future research on homelessness and health should focus on identifying different pathways to health and mental health services for this vulnerable population and the outcomes of these interventions.     

Forecasting the cost of U.S. Health Care in 2040

One of the most important debates among health economists in rich nations is whether advances in biotechnology will spare their health care systems from a financial crisis. We must consider that prevalence rates of chronic diseases declined during the twentieth century and that this rate of decline has accelerated. However, health care costs may continue to increase even as the age of onset of chronic diseases is delayed, because the proportion of a cohort living to late ages will increase. The accelerating decline in the prevalence of chronic diseases during the course of the twentieth century supports the proposition that increases in life expectancy during the twenty-first century will be fairly large, but the effect on health care in the U.S. will be modest. The income elasticity for health services is calculated at 1.6, meaning that income expenditures on health care in the U.S. are likely to rise from a current level of about 15 percent to about 29 percent of GDP in 2040.     

Increasing the use of alcohol screening and brief intervention in New Zealand

New Zealand has high rates of acute alcohol-related harm relative to chronic harm, and when compared with other countries. Acute harm is typically caused by binge drinking. New Zealand alcohol use surveys consistently find that about 20–25% of adult drinkers binge drink. There is substantial overseas evidence that alcohol screening and brief intervention (SBI) in primary health care is effective and cost-effective for reducing alcohol harm among binge drinkers. However, while there is also growing evidence that alcohol SBI can successfully be implemented in New Zealand, the approach has been significantly under-utilised. This article provides a brief overview of New Zealand research that supports a case for increasing the use of alcohol SBI in primary health care. It also highlights that when looking to successfully implement alcohol SBI in other settings, it is important to ensure that the intervention is simple and purpose-built for both the setting and recipient.     

Integrating Mental Health Parity for Homebound Older Adults Under the Medicare Home Health Care Benefit

Despite high rates of mental illness, very few homebound older adults receive treatment. Comorbid mental illness exacerbates physical health conditions, reduces treatment adherence, and increases dependency and medical costs. Although effective treatments exist, many home health agencies lack capacity to effectively detect and treat mental illness. This article critically analyzes barriers within the Medicare home health benefit that impede access to mental health treatment. Policy, practice, and research recommendations are made to integrate mental health parity in home health care. In particular, creative use of medical social work can improve detection and treatment of mental illness for homebound older adults.     

Working U.S. Adults without Paid Sick Leave Report more Worries about Finances

Using the National Health Interview Survey 2015 data release, an analytic sample of 17,897 working U.S. adults in current paid employment were examined to determine if there was a relationship between not having paid sick leave and worry about finances. A series of nine indicators of financial worry were regressed on paid sick leave status with ten control variables. U.S. workers who lack paid sick leave are more likely to report worry about: medical bills from a potential future sickness or accident, retirement, current medical costs from an illness or accident, maintenance of standard of living, medical costs for normal health care, normal monthly bills, rent, mortgage, or other housing costs, and credit card payments. Based on this set of nine multinomial multivariable regressions equations, findings indicate a positive association between not having paid sick leave and reporting financial worry after controlling for gender, age, marital status, education level, race and ethnicity, personal health status, full time work status, insurance coverage, family size, and annual family income. Implications for policy, practice, and future research are set forth.     

社会医疗保险对老年人健康水平的影响：基于浙江省的实证研究

本研究根据2010年浙江省城乡老年人口生活状况调查的数据认为,对于老年人的社会医疗保险问题,不仅要关注保险覆盖面的扩大,更应关注不同保险项目参保老人之间的健康平等。在揭示医疗服务使用与健康水平负向关系这一主效应的基础上,研究发现,职工医保作为moderator可以改善使用较多医疗服务老人的健康水平,新农合的作用则相反。研究希望对医疗保险的改革思路进行反思,全民医保的改革思路不仅是医疗服务可及性的提高,更应该是不同社群享有平等的医疗福利,并最终促进健康结果的平等。     

Expanding social health protection in Cambodia: An assessment of the current coverage potential and gaps,and social equity considerations

The Royal Government of Cambodia recently launched its National Social Protection Policy framework to strengthen and expand social security and assistance. To inform social health protection policy, we examine socio-economic survey data and administrative coverage data to assess the coverage potential of existing coverage mechanisms and current gaps; and compare equitable contribution rates. Over 53 per cent of the population currently has no social health protection coverage mechanism, and about 16 per cent of the population who do have access to a mechanism are not yet enrolled. Current expansion efforts focus on the formal employee scheme, primarily benefiting individuals from higher income households. In addition, recent coverage expansion to some informal workers leaves significant gaps, particularly among the informal sector. We find out-of-pocket health care expenditure to be an excessive share of income among lower wealth quintile individuals and conclude they are financially vulnerable. Finally, we illustrate that an equitable approach to individual, monthly health care contributions among the lower three quintiles has a severely limited potential for revenue generation, and collection costs could exceed the amount collected. Therefore, we recommend that vulnerable groups should be exempted from contribution payments as social health protection is expanded.     

Mental health and wellbeing of care leavers: Making sense of their perspectives

Despite considerable quantifiable data about the circumstances of care leavers in the United Kingdom, there is less qualitative data about how these circumstances are experienced. This article is underpinned by positioning theory, with a particular focus on the unfolding personal narratives of young care leavers in relation to their mental health and wellbeing and the role of a life‐skills programme in supporting them in this respect. The research illustrates that leaving care projects, such as the one in the current study, are more focused on employment and housing issues than on addressing the mental health and wellbeing needs of young people. Our analysis of interviews with young people illustrates the ambiguity of understandings of concepts such as “mental health” and “wellbeing,” and the complexity of responses to questioning around this area. This illustrates one of the major problems in evaluating the outputs and outcomes of such projects in terms of simplistic targets, where mental health and wellbeing are not clearly defined or understood by young people themselves. The current research provides a more complex picture. More research is needed that involves in‐depth and longitudinal assessment of specific mental health needs of care leavers and how they can be addressed successfully.     

Transitions of Youth in Mental Health Residential Care to Less Restrictive Settings: The Role of Strengths and Gender

ABSTRACT

Changes in youth's behavioral/psychosocial functioning has been found to play an important role in the transitions from mental health residential care to less restrictive settings, and this functioning differs significantly by gender. However, there has been little attention paid to the roles played by psychosocial strength and gender in transitions out of residential care. The current study examined gender differences in the role of strengths in transitions to less restrictive settings using data on 675 youth's admission and discharge records collected from Illinois Residential Treatment Outcome System during 2005–2007 (Mean age = 15 years, SD = 2.0; 57.5% = boys). The results of multivariate logistic regression model indicated that positive recreational activities and lack of chronic illness were related to a higher likelihood of transitions to less restrictive settings among girls, while appropriate sexual development, psychological strengths, and strong spiritual/religious strengths were related to the transitions among boys. This study demonstrates the potential importance of youth strengths in the provision of mental health services and suggests a need to develop models of outcomes that take gender into account. Additional research based on multiple informants including youth self-report is needed to understand the role of gender in transitions out of residential care.     

The impact of parental incarceration on children's care: identifying good practice principles from the perspective of imprisoned primary carer parents

Parental incarceration has wide‐ranging impacts on families. One key effect may be disruption to the care and legal custody of children, yet few studies have examined processes and outcomes relating to care planning for children of prisoners. This paper presents findings of interviews with 151 primary carer prisoners in two Australian states which aimed to address this research gap. The study examined care planning for children upon parental arrest, sentencing and imprisonment, stability of care arrangements and primary carer prisoners' involvement and satisfaction with care planning. Around one third of prisoners had discussions regarding children's care arrangements at arrest and imprisonment, although the issue was more commonly raised at sentencing. While there was much variation in the stability of care arrangements, children placed in out‐of‐home care experienced the most instability. A minority of prisoners reported being involved in care planning and decision‐making for children upon imprisonment, and around one third rated care planning process poorly. Prisoners were more satisfied with care planning when there were fewer movements of children, where prisoners felt involved with decision‐making, and when police officers, lawyers and corrections staff inquired about the welfare of their children. Implications for policy and future research are discussed.     

Tackling and Mitigating Health Inequalities – Policymakers and Practitioners ‘Talk and Draw’ their Theories

In the context of a long‐standing academic acceptance of the socially structured nature of health inequalities, there has been a growing literature that critically examines policies that aim to reduce them. This has demonstrated inadequate policy assessment of the nature of the problem of health inequalities and correspondingly partial solutions that privilege interventions that focus on individual lifestyle solutions over more structural approaches. Much of the research that has been undertaken in this field to explore competing theories of inequalities has analyzed national policy documents or the views of senior policy advisers rather than practitioners. This study uses Raphael’s ‘seven discourses of the social determinants of health’ to understand the implicit theories of health inequalities of both practitioners and policymakers working within a single health care system as they talk about different policy typologies. To help penetrate potentially well‐rehearsed discourses about health inequalities, it tests a visual method of stimulating discussion about how different types of policy might operate to narrow/widen existing gaps in outcomes. Building on Raphael, it finds that individuals’ theories of health inequalities contain co‐existing although not synthesized material and behavioural explanations and that, although the social patterning of material disadvantage was recognized, the role of power and politics is underplayed. Variations between participants did not align with role (policy/practice) and using visual methods to represent the impact of different policy types on health inequalities, though challenging for participants, stimulated reflection about a subject matter that has otherwise become rather stagnant.     

Health Care in Asia and the Pacific: Increasing the focus on social health insurance

This paper focuses on health insurance reform within the broader frameworks of both social security and health services system development. In most countries in Asia and the Pacific, it is indeed the reform of the health services system, through policy changes in health care financing, that has led to an increased focus on health insurance. The underlying issue in this reform is the shift in responsibility that has taken place in most countries in the region over recent years. In the past, governments were responsible for financing health care for their populations. This shifted to defining, legislating and implementing an appropriate health care financing mechanism, presenting several challenges: to reach universal health insurance coverage through new initiatives for new populations, mainly the informal sector accounting for the majority of the population in almost all these countries; to apply provider payment systems that enable control over costs and the volume of utilization; and to strengthen primary health care as a foundation for rational utilization and more resources for prevention, including prevention of chronic diseases among the ageing population. This approach will require an active partnership between health insurance schemes and government that should reflect the new division of responsibilities to guarantee access to high-quality health care for all.     

The relationship between adverse childhood experiences,health and life satisfaction in adults with care experience: The mediating role of attachment

Adverse childhood experiences (ACEs) are associated with a plethora of negative outcomes. Research has also found that adults who were separated from parental care and lived in alternative care settings during childhood have high levels of ACEs and are more likely to have poor outcomes. A growing body of research has supported the importance of attachment as a mechanism underlying the relationship between ACEs and adult wellbeing. However, little work has examined the role that attachment may play in the outcomes of adults who resided in residential and foster care during childhood. The current study examined the role of attachment avoidance and anxiety in the associations between ACEs and mental health, physical health, and life satisfaction in a sample of 529 adults with alternative care experience from 11 nations. Attachment avoidance partially mediated the relationship between ACEs and life satisfaction, mental health, and physical health. Attachment anxiety partially mediated the relationship between ACEs and life satisfaction and mental health, but not physical health. Taken together, the present study suggests that both attachment anxiety and avoidance play important, but unique, roles in understanding the relationship between ACEs and health and wellbeing for adults with care experience. Implications and limitations are discussed.     

Health informatics for older people: a review of ICT facilitated integrated care for older people

Growing demands on welfare services, arising from expanding populations of older people in many countries, has led policy makers to consider the use of information and communications technologies (ICTs) as a means to transform the cost-effective delivery of health and social care. The evidence for these claims is examined by reporting the main findings of a review of worldwide published literature documenting the adoption of health informatics applications to improve health and social care for older people. It focuses around two dimensions of the UK government's programme for 'modernising' public services, which emphasise the use of ICTs to facilitate the sharing of health and social services information and its potential to foster person-centred approaches to independent living. Findings suggest that there is little evidence that these dimensions have been realised in practice and the perceived incompatibility between them is more likely to produce expensive and ineffective health informatics outcomes.     

“A game of two halves?” Understanding the process and outcomes of English care home closures: Qualitative and quantitative perspectives

With care services increasingly delivered via a market there is always a risk that care homes could fail financially or struggle in terms of quality, ultimately having to close. When this happens, the received wisdom is that subsequent relocation can be detrimental to the health and well‐being of older residents (possibly even culminating in increased mortality). However, there is very little formal evidence in the United Kingdom (UK) or beyond to guide policymakers and local leaders when undertaking such sensitive work. Against this background, this article reports findings from an independent evaluation of what is believed to be the largest care home closure program in the UK (and possibly beyond). This consisted of qualitative interviews with older people, families, care staff, and social work assessors during the closure process in one case study care home and one linked day center, as well as self‐reported health and quality of life data for older people from 13 homes/linked day centers at initial assessment, 28 days after moving and at 12‐month follow up. The study is significant in presenting public data about such a contested topic from such a large‐scale closure process, in its focus on both process and outcomes, in its mixed‐methods approach, and in its engagement with older people, families, and care staff alongside the use of more formal outcome measures. Despite significant distress part‐way through the process, the article suggests that outcomes either stayed the same or improved for most of our sample up to a year after moving to new services. Care homes closures may thus be a “tale of two halves”, with inevitable distress during the closure but, if done well, with scope for improved outcomes for some people in the longer term. These findings are crucial for current policy and practice given that the risk of major closures seems to be growing and given that there is virtually no prior research on which to base local or national closure processes. While some of this research is specific to England, the underlying issue of care home closures and lessons learned around good practice will also apply to other countries.     

Relative foster care: An emerging trend in foster care placement policy and practice

Abstract

Increases in the foster child population, at a time when terminations in foster care placement have decreased along with a decline in the number of non‐related foster parents, has resulted in an increasing use of relative foster care placement. Relative care as an emerging trend in foster care placement, is not without controversy. Its merits, however, should be assessed in terms of its benefits to the children in care, the fiscal and organizational costs, and the problems it creates for the child welfare system. This paper reviews what is known about the characteristics of relative caregivers and the children in their care. Federal and state policies that affect the use of relatives as an alternative placement resource for children are described. The available data regarding the length of time in placement, number of placements, physical, mental health and educational and permanency outcomes for children placed with relatives are discussed. Implications for practice are drawn and areas for further research are suggested.     

Early Relational Health: Infants’ Experiences Living with Their Incarcerated Mothers

ABSTRACT

Little is known about the experiences and inner worlds of infants who live with their parents in prison-based residential programs. Infant observation and qualitative methods were used to study the experiences of seventeen infants living with their incarcerated mothers in a women’s correctional facility. Glimpses into their inner worlds provide insights into factors that hearten and hinder early relational health. Practitioners and parents can use a relational health approach to recognize and cultivate budding capacities in infant-parent relationships. The researcher discusses the usefulness and relevance of infants’ accounts for communities of practice and research.     

Participation and health – a research review of child participation in planning and decision‐making

Effective child participation in child protection proceedings has proved difficult to achieve in Norway. Although participation is in principle accepted as a human right and something of benefit to children, when children's health is at stake there is a tendency to view participation in decision‐making processes by children as potentially disruptive to their well‐being. The purpose of this study is to review the research evidence for effects, positive or negative, of participation on health outcomes for children in care. A scoping review of major health and social work research databases was undertaken. Searches in five databases yielded 1830 studies of which 21 were finally included in this review. Studies were included if a relationship between health and participation was evident from the data presented, even if this was not the main objective in the study at hand. We conclude that when participation is successful, it may have beneficial side effects. Chief among these are that participation may improve children's safety, increase the success of care arrangements and increase feelings of well‐being for children involved. Evidence for long‐term effects of successful or failed participation attempts on subsequent health outcomes is however largely absent.     

Managed care: Challenges to survival and opportunities for change

Many agree that the health care delivery system is in serious trouble. Managed care emerged in response to growing concern over spiraling health care costs without commensurate increases in population health outcomes. However, managed care needs to be evaluated within the historical context of using rationing strategies to distribute health care resources. This paper will explore the impact of managed care on social work practice, including the many challenges faced by practitioners. It will conclude with a discussion of potential opportunities for change in this volatile, health care environment.     

Contradictions and Confounds in Coverage of Obesity: Psychology Journals, Textbooks, and the Media

Although obesity is not listed as a psychiatric condition in the Diagnostic and Statistical Manual of Mental Disorders, psychologists focus on obesity in their research, clinical practice, and teaching. This article reviews the methods and outcomes of the weight loss research in psychology journal articles, and discusses some of the confounds. These studies focus on comparisons among treatment conditions rather than on the low amounts of weight lost, and do not use clinical criteria for evaluating outcome. Although improvement in physical health is viewed as the reason for weight loss programs, few studies assess physical health. There has been little concern about how weight loss participants feel when they regain weight. Furthermore, the journal peer review process does not encourage paradigm shifts. The article also discusses how the results of the weight loss research studies are covered in undergraduate psychology textbooks and how they are (mis)interpreted by the media. Recommendations for a paradigm shift in the peer review process, coverage in textbooks and the media, are offered.