Health Care for Older Persons in Singapore

Abstract

Health care policy in Singapore is similar to that in the United States and the United Kingdom, where a residualist strategy is used to pass health care costs to individuals and their families, the rationale being that this enables the state to concentrate on devolution of care to the community and ensure efficient and affordable service to all Singaporeans. The services include public restructured hospitals and outpatient poly-clinics as well as community services such as community hospitals and hospitals for the chronically ill, nursing homes, day care centers, and home help services. Availability does not translate into optimum usage because current and potential users and their families are not able to match their financial and social resources with the services. Instead, the state acts as the case manager and places parameters on what individuals can access.     

Social Work and Disadvantage: Addressing the Roots of Stigma through Association

Abstract

This paper reports on a small-scale research study that explores the impact of climate change on rural women. Qualitative data were collected through interviews with 7 women, who came from a regional centre and were either employed by women's services or who had activist roles within the community pertaining to women's services. Outcomes of the study identified a range of areas of impact, including increased hardship for rural women, implications of household roles, and subsequent organisational responsibilities. A high level of concern, particularly for the vulnerability of women in crisis, was identified among participants. We contend that the effects of climate change are becoming increasingly relevant to the social work profession and that specific groups such as women are at risk of further disadvantage unless collective action is taken to circumvent the impact of climate change. Strategies for social work practice and policy initiatives are considered.     

Coordinating Health,Extended Care,and Community Support Services

Abstract

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

Mothering,equality and the individual: Feminist debates and welfare policies in the USA and Sweden

This paper addresses issues raised by ‘welfare reform’ in the USA by using the example of Sweden's women activists in constructing a ‘woman friendly’ welfare state. In the USA, feminist advocates see a tension between the argument that motherhood should be valued by the provision of care allowances, and the view that work should be reformed to meet the needs of parents. This reflects debates about gender difference/equality, the possibility of commonality, and the individual.

The Swedish ‘woman friendly’ welfare state was built on the recognition, through social policy, of the interrelationship among care, material resources, and public voice. The interrelationship was embodied in what I call the ‘social individual’, and articulated in public child care and other policies and collective services. The adequacy of those universal policies and services was frequently judged by the situation of lone mothers, who ceased being ‘deviant’, and often became a model for understanding the interrelationship. Cross-class solidarity among women was a prerequisite for, and was built on, the social individual. This solidarity is now threatened by neoliberal economic and social policies that fragment care, resources, and voice, and therefore the social individual.

It is possible to challenge the downsizing of welfare states by moving the terms of discussion away from the poor as deviant other, acknowledging that all women have much in common with the targets of current policy making. This involves the creation of concrete social policies that embody the relationship among care, resources, and voice, and recognize the inseparability of community, work and family.     

Culturally-Protective Health Practices

ABSTRACT

Everyday pregnancy care may play an important role in explaining why Mexican immigrant women have positive birth outcomes despite relatively low incomes, low formal education levels, and lack of access to medical care. The paper is based on findings from a qualitative study utilizing in-depth ethnographically-in-formed interviews with 41 Mexican immigrant women in Chicago who had recently given birth. Results indicate that everyday pregnancy care guides maternal behaviors in pregnancy and has important effects on birth weight. Implications for the design of prenatal health care and social services for immigrant women are discussed.     

Creating a Family Centered Wellness Team: Lessons learned in creating an integrated continuum of care for families facing homelessness,addiction, and trauma recovery.

Abstract

Homelessness is often experienced by women and children, and recent evidence suggests that women and children are the fastest growing segments of the homeless population. Homelessness is often accompanied by mental illness, substance abuse, and histories of violence, for both women and their children. While trauma informed care has been incorporated into women's treatment systems there has not been widespread application of this knowledge to family centered work with homeless families. This paper explores the need for family strengthening approaches and identifies one model currently being evaluated that seeks to decrease service fragmentation, increase positive family interaction, and deepen the family's connections with each other and with the community.     

BPD and the Need for Community

SUMMARY

This chapter emphasizes the importance of a community/systems approach in managing the treatment of individuals with borderline personality disorder. The natural systems existing around patient, clinician and family are recognized, and we examine how working teams are built from these systems. The Borderline Center at McLean Hospital is used as an illustration of an organizational model that utilizes the concept of the “holding environment” (Winnicott, 1965) to provide comprehensive services to borderline patients and their families. As patients move through various levels of care and exhibit typical borderline symptomatology, the importance of communication and coordination on the part of the treatment team is highlighted. This chapter also will illustrate the essential ways in which patients, clinicians and families are able to join together in the treatment of this disorder, with special emphasis on the necessity of family involvement. We also will examine how the treatment teams provide the foundation for larger communities, which are critical to sustaining the ongoing work of its members.     

Managing Risk in Community Care of Older People: Perspectives from the Frontline

Abstract

Since the mid-1980s, Australian governments have focused on expanding community and home-based services for older people. This has led to increased levels of dependency, vulnerability, and complexity to be managed in the community. Consequently, aged care services have had to develop mechanisms for regulating and managing these increased risks, and risk management has become more central to the practices of professional workers in this field. This paper reports on some findings from a large-scale study that explores the way risk management policies have been translated into practice by community-based services in Victoria, Australia. Drawing on interviews with 18 frontline and management professionals employed in community aged care, we found that these workers were wrestling with a diverse and new range of institutional risks beyond those encountered in the actual delivery of frontline care. We found that these workers experienced “risk” in four different contexts, which often created demands for contradictory or conflicting responses. Here we examine these “contexts of risk practice”: professional workers' relationships with their clients, relationships with other service providers, the unregulated nature of the home as a work environment, and community expectations about the management of risk. Despite tensions that frequently arose, workers expressed strong professional commitments to their clients and were motivated to find positive resolutions amid competing interests. We conclude that tensions experienced by workers were embedded in the structural dimensions of institutional relationships and the systematic absence of shared understandings of “acceptable” risks in the community care of older people, rather than in the failure of professional agency.     

Issues Related to HIV Stigma in Nepal

ABSTRACT

We conducted a qualitative study to understand and describe experiences of people living with HIV and AIDS with regard to HIV-associated stigma in Nepal. The study has revealed four key themes associated with HIV stigma: a hierarchy of stigma (sexual transmission and women stigmatized more than injecting-drug transmission and men); exclusion and rejection (denial of care services, rejection from family); death as a form of punishment (untimely death is seen as a punishment for something done wrong in the past); and Mumbaiya disease (caught from working in “other places”). Cultural contexts are the best ways to understand HIV stigma in Nepal along with socially and culturally established gender roles. This study has confirmed that stigma manifests at different levels: individual, social, and structural, with denial and rejection being a key mechanism of stigma.     

TigerPlace,A State-Academic-Private Project to Revolutionize Traditional Long-Term Care

ABSTRACT

The Aging in Place Project at the University of Missouri (MU) required legislation in 1999 and 2001 to be fully realized. An innovative home health agency was initiated by the Sinclair School of Nursing specifically to help older adults age in place in the environment of their choice. In 2004, an innovative independent living environment was built and is operated by a private long term care company, as a special facility where residents can truly age in place and never fear being moved to a traditional nursing home unless they choose to do so. With care provided by the home care agency with registered nurse care coordination services, residents receive preventative and early illness recognition assistance that have markedly improved their lives. Evaluation of aging in place reveal registered nurse care coordination improves outcomes of cognition, depression, activities of daily living, incontinence, pain, and shortness of breath as well as delaying or preventing nursing home placement. Links with MU students, faculty, and nearly every school or college on campus enrich the lives of the students and residents of the housing environment. Research projects are encouraged and residents who choose to participate are enjoying helping with developing cutting technology to help other seniors age in place.     

A comprehensive health service evaluation and monitoring framework

ObjectiveTo develop a framework for evaluating and monitoring a primary health care service, integrating hospital and community services.MethodA targeted literature review of primary health service evaluation frameworks was performed to inform the development of the framework specifically for remote communities. Key principles underlying primary health care evaluation were determined and sentinel indicators developed to operationalise the evaluation framework. This framework was then validated with key stakeholders.ResultsThe framework includes Donabedian's three seminal domains of structure, process and outcomes to determine health service performance. These in turn are dependent on sustainability, quality of patient care and the determinants of health to provide a comprehensive health service evaluation framework. The principles underpinning primary health service evaluation were pertinent to health services in remote contexts. Sentinel indicators were developed to fit the demographic characteristics and health needs of the population. Consultation with key stakeholders confirmed that the evaluation framework was applicable.ConclusionData collected routinely by health services can be used to operationalise the proposed health service evaluation framework. Use of an evaluation framework which links policy and health service performance to health outcomes will assist health services to improve performance as part of a continuous quality improvement cycle.     

Finding Our Way

Abstract

In the fall of 1992, a community needs assessment on the problem of family violence was completed in the Aboriginal community of Conne River, Newfoundland, Canada. This article reports both the process and findings of the study which was guided by two important principles. First, community participation was a critical component of all aspects of the assessment and, second, the assessment was based on multiple sources of data.

The data were collected from face-to-face interviews with key informants (community experts) and consumers/potential consumers of services, focus groups with youth and women, and informal contact and discussion with interested members of the community, some of them professionals.

The findings indicate that the people of Conne River are knowledgeable about the types of family violence that occur in the community and the various sources of support and help. There was also a high level of interest in the topic and a genuine concern that some positive action would result from this assessment.

The assessment identified the need for more supports for women with families in crisis, not just crisis intervention during incidents of violence but a more holistic network of supports. These supports need to be community-based, operating within existing agencies. The study identified the need for a community-based committee to undertake the planning of emergency services for women and families in crisis and long-term planning for a support network and/or community centre for women.     

Recent Developments in Aged Care Policy in Australia

Summary

A series of major reforms implemented through the mid 1980s sought to contain residential care and expand community care in Australia's long-term care system. While this goal has been maintained, a number of new policy initiatives followed the change of federal government in 1996. This article presents a systematic account of current policy objectives, implementation measures, and outcomes in three major policy areas: changing the balance between residential and community care, targeting in community care, and support for family caregivers. This analysis shows that while there have been shifts in emphasis from time to time, concerted policy efforts over the last 20 years have contained the growth of expenditure on long-term care and realized significant change in the service system.     

Depression and Mental-Health Service Utilization Among Women in WIC

Abstract

This exploratory 2003 study of 261 women in WIC addresses depression and mental-health service utilization in six race/ethnic-immigrant/migrant groups and factors amenable to change. Using the PrimeMD-PHQ, island-born Puerto Rican women had the highest prevalence of subthreshold depressive syndrome (27.8%); African American women had the highest prevalence of major depressive syndrome (21.3%); proportionately more White women used mental-health services (41.9%). The odds for major depressive syndrome among those with no one to help with childcare were almost four times greater than those with help. The odds of mental-health service use among those with indirect exposure to mental-health care were four times greater than those without such exposure. Implications for intervention and further research are discussed.     

Social and Health Factors Affecting Community Service Use by Vulnerable Older People

Abstract

This article reports on Outcomes for older people with complex or chronic care needs, a study undertaken by the Brotherhood of St Laurence and La Trobe University, examining older Victorians’ use of community services following Aged Care Assessment Service (ACAS) recommendations that they remain living at home. The paper reports on interviews with older people and carers undertaken at three-monthly intervals, over 12 months. This paper contributes to understanding the factors that impede or facilitate uptake of community aged care services that are critical to meeting the needs of older people and their carers. The study found that among other factors social isolation, high carer burden, and the older person reporting low mood were important barriers to service uptake. Cost, waiting lists, and service satisfaction were also identified in qualitative data as influencing factors. The study concludes there is a need for better means of identifying and supporting older people and carers at risk to improve community service uptake.     

Importance of Macro Social Structures and Personality Hardiness to the Stress-Illness Relationship in Low-Income Women

Abstract

Individuals confronted with poverty are at increased risk for disease and death due, in part, to the influence of macro social structures on differential exposure and heightened responsiveness to stress (Williams, 1990). For this reason, the influence of personality hardiness in moderating the stress-illness relationship in a biracial sample (African-American and European-American) of low-income women was examined. The effect of differential perceptions of the community on illness also was studied. Participants (100) completed rating scales, including Social Readjustment, Dispositional Resilience, Community Stress, and Seriousness of Illness. Hierarchical regression indicated that hardiness moderated the stress-illness relationship (p < .01), with high stress, low hardy women having higher levels of illness. In addition, race moderated the effect of stress, with high stress, Caucasian women having higher levels of illness. Group mean differences on community stress scores for low and high hardy women were obtained (p < .0001), but community stress was not associated with illness. Stress is linked to illness in low-income women; furthermore, both personality hardiness and being African-American buffer the effect of stress.     

Building on Mutual Goals

ABSTRACT

In this era of diminishing federal and state funds for social services, greater attention has been directed toward how social work and the religious sector can cooperate in providing services. This article suggests that social workers should move beyond this focus and begin to identify and join in collective action with local congregations or faith-based organizations, which take an activist approach toward community needs. The author uses a case study of an activist central city church to illustrate how churches can be involved in community change. Social workers are encouraged to consider all methods of collaboration with the religious sector that would lead to the mutual goal of community betterment.