The Supportive Community

Abstract

This study examines supportive community programs in Israel, which aim to improve the quality of life of the elderly. These innovative programs pool existing resources to provide a benefits package that includes medical services, an emergency call switchboard, a “neighborhood facilitator,” and social activities. Data were collected in 2000-2001 using qualitative and quantitative methods. The program provides specific services to meet needs that otherwise are not adequately addressed. The major contributions of the program reported by the members was increasing their personal security (two-thirds), easing the burden on their children (one-third), and enabling them to remain at home (one-quarter). The supportive community program enriches the variety of services available, thus providing the elderly with the choice of staying within their familiar surroundings of their homes and neighborhoods. This model appears to be both a cost-effective way to facilitate aging in place and a way to meet many of the elderly's essential needs, thereby maintaining their quality of life.     

Socioeconomic Resource Environments in Biological and Alternative Family Care and Children's Cognitive Performance*

We examined social and economic resources in the environments of children involved with child protective services and their associations with children's cognitive performance. We used a national dataset of child protection investigations (children aged 6–16 at Wave 1). Using latent class analysis, we constructed profiles of the financial resources, parental education and employment, and family structure and size. We then examined within‐ and across‐time associations between resource environment profiles and children's math and reading scores and tested whether associations differed by family care type. Our latent class analysis identified four distinct family resource environments: educated middle class, single earner, large working class, and severely disadvantaged. Family resource environment profiles predicted current cognitive performance and changes in performance over time, but associations were more consistent for children in biological family care. Children who remain in home following maltreatment allegations may benefit from services that target social as well as economic resources.     

The supportive community: a new concept for enhancing the quality of life of elderly living in the community

This study examines supportive community programs in Israel, which aim to improve the quality of life of the elderly. These innovative programs pool existing resources to provide a benefits package that includes medical services, an emergency call switchboard, a "neighborhood facilitator," and social activities. Data were collected in 2000-2001 using qualitative and quantitative methods. The program provides specific services to meet needs that otherwise are not adequately addressed. The major contributions of the program reported by the members was increasing their personal security (two-thirds), easing the burden on their children (one-third), and enabling them to remain at home (one-quarter). The supportive community program enriches the variety of services available, thus providing the elderly with the choice of staying within their familiar surroundings of their homes and neighborhoods. This model appears to be both a cost-effective way to facilitate aging in place and a way to meet many of the elderly's essential needs, thereby maintaining their quality of life.     

SOS—Satisfied or Stuck,Why Older Rural Residents Stay Put: Aging in Place or Stuck in Place in Rural Utah*

As rural communities undergo substantial demographic and economic changes, understanding the migration intentions and their antecedents of rural elderly persons becomes increasingly important. Using data drawn from a survey of adults from 24 rural Utah communities conducted in 2008, we examine whether rural residents 60 years of age or older plan to remain in their present communities (N= 621). We use structural equation models (SEM) to estimate the relationships between a variety of individual and community-level background measures, including perceptions of local service quality, leaving one's community for health care, Internet use, attachment to and satisfaction with community, and plans to age in place. Results suggest that even as the rural context of economic decline, population loss, and distance to medical services may reduce the viability of staying in a community, a desire to remain in the community is primarily a function of perceptions of the quality of local services and community satisfaction. This research highlights the need to better understand the interplay between the availability of medical services and perceptions of distance as well as to understand the complex relationship between individual and community level characteristics for migration intentions.     

The Program of All-Inclusive Care for the Elderly (PACE)

Summary

This article examines the long-term care service system in the United States, its problems, and an improved long-term care model. Problematic quality of care in institutional settings and fragmentation of service coordination in community-based settings are two major issues in the traditional long-term care system. The Program of All-Inclusive Care for the Elderly (PACE) has been emerging since the 1970s to address these issues, particularly because most frail elders prefer community-based to institutional care. The Balanced Budget Act of 1997 made PACE a permanent provider type under Medicare and granted states the option of paying a capitation rate for PACE services under Medicaid. The PACE model is a managed long-term care system that provides frail elders alternatives to nursing home life. The PACE program's primary goals are to maximize each frail elderly participant's autonomy and continued community residence, and to provide quality care at a lower cost than Medicare, Medicaid, and private-pay participants, who pay in the traditional fee-for-service system. In exchange for Medicare and Medicaid fixed monthly payments for each participating frail elder, PACE service systems provide a continuum of long-term care services, including hospital and nursing home care, and bear full financial risk. Integration of acute and long-term care services in the PACE model allows care of frail elders with multiple problems by a single service organization that can provide a full range of services. PACE's range of services and organizational features are discussed.     

Safe Motherhood in the Context of Nepal

ABSTRACT

Nepal ranks low on the Human Development Index and has a high maternal mortality rate. Various factors contribute to the high rate of maternal mortality and include a shortage of health care professionals, limited access to basic maternal health care, poverty, illiteracy, women's low social status, a poorly developed transportation system, a limited communication system, political conflict, and a diverse population. Interviews with pregnant women, observational data, and national statistics provide the basis for suggestions provided by the author. These include upgrading and opening new maternal care facilities, integrating midwives into local health services, providing education on women's health needs during pregnancy, and improving public awareness of the availability of maternal care services.     

A review of private residential care in Hong Kong: implications for policy and practice

Hong Kong government policy encourages and facilitates families to care for their older members as long as possible by providing families and their older relatives with community support services. Residential care for the elderly is viewed as a last resort. Due to the inadequate supply of community support services, the long period of care required, and the gradual breakdown of values of filial support, families may increasingly give up their caring roles and seek residential care for their dependent elderly relatives. A shortfall in subsidized residential care may lead to needy elderly persons' being cared for in private residential facilities. The demand for private residential care is projected to increase, despite criticism about the standard of care provided. Although an Ordinance, a Regulation, and a Code of Practice for residential care homes are in place to control, monitor, and upgrade private residential care in Hong Kong, problems remain that put the elderly at risk of receiving substandard services. These include the existence of substandard private aged care homes operating either with or without a license; the provision of substandard "places" to the elderly under the government's "bought place" scheme and "enhanced bought place" scheme; ineffective inspection; a lack of grading to indicate the quality of private aged care homes; and a general neglect of the quality of care. We provide recommendations to address these concerns. This requires paying attention to both the quality of care, as well as to the physical environment of homes.     

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.     

Neighborhood Experiences and Community Integration

Abstract

This exploratory study examines the social interactional aspect of community integration among persons with psychiatric disabilities. Six focus groups were conducted with 18 mental health consumers in three publicly sponsored community residential programs and 11 staff members providing services to these consumers. Mental health consumers reported both positive and negative experiences in their interactions with community residents. Despite perceived differences between persons with psychiatric disabilities and their neighbors, consumers considered reciprocity and mutual accommodation to be critical for building social relationships in their communities. Mental health providers suggested that social integration can be facilitated by developing independent living and social skills, by overcoming self-stigma and institutional and homeless mindsets, and by having a supportive community of consumers.     

“The Politics of the HealthCare Reform Debate: Public Support of Including Undocumented Immigrants and Their Children in Reform Efforts in the U.S.”

Although U.S. immigration and health care policies appear to be highly correlated, scholarship has yet to gauge the public's views toward providing undocumented immigrants with health coverage at the state level. We analyze support for including undocumented immigrants in health care reform in New Mexico. Utilizing an original public opinion survey of New Mexico adults, we find that individuals are more supportive of the state providing health care to the children of undocumented immigrant than to their parents. Multivariate logistic regression analyses suggest that factors such as liberal ideology and perceptions of commonalities with Latinos increase support levels. Despite a lack of support among a majority of respondents, the influence of perceived commonalities with immigrants suggests that reform advocates and political elites who mobilize along ethnic or human solidarity may be successful in creating conditions for the inclusion of undocumented immigrants in the public provision of health care at the state level.     

Social Adaptation and Welfare Planning in the Post-Nomadic Urban Environment: The Case of the Israeli Negev Bedouin

Abstract

State planning to settle and to provide services for nomadic populations is a complex enterprise. In Israel, the government's efforts to plan, direct, and contain the Negev Bedouins' social development upon settlement has fostered both positive and negative changes in the new communal setting. Women, children, and the elderly have proven to be particularly at risk during the settlement transition period. Proactive efforts on the part of indigenous and Jewish community planners and social workers provide a crucial component encouraging communal adaptation to new environments and lifestyles. Experiences in the Negev may also provide lessons for community practitioners in other previously mobile communities.     

Managed care and the rationalization of mental health services

Managed care represents a response to the wider institutional demand for technical rationality and efficiency, and it may be in conflict with professionally generated logics of mental health care which emphasize the delivery of quality care, as well as providing services to all who need care. The organizational and policy conundrum is to balance conflicting institutional demands for efficiency (cost savings) and effectiveness (access and quality). This paper examines managed care in one public sector mental health care system that has attempted to incorporate the principles of managed care into a community based system of care and to overcome the potential contradictions between demands for efficiency and professional logics of care. Both qualitative and quantitative data are used to examine changes in organizational structure and service offerings; providers' experience of managed care, and the effect of managed care on working conditions and work experiences, and changes in the goals of the organization as measured by the specification of client outcomes. I find that, while increased performance accountability and outcome assessment (in keeping with demands for efficiency) have the potential to improve mental health care services, in fact, providers report that the primary effect of managed care has been an emphasis on cost containment, and there has been a corresponding de-emphasis on the provision of community based services for clients with long term care needs. However, there is potential for professional logics to be maintained by larger institutional forces demanding quality care.     

Community Context,Women's Natal Kin Ties,and Demand for Children: Macro-Micro Linkages in Social Demography1

Abstract Recent research in many areas of social demography has begun to address the implications of cultural, social, and economic context for individual–level preferences and behavior. We expand on this theme by arguing that multiple levels of context may simultaneously direct individual–level strategies. We focus on the relationship between women's natal kin ties and their demand for children, a substantive area in which context is thought to be particularly important. We use a combination of ethnographic and survey data to measure contextual characteristics, women's ties to their natal families, and couples' fertility preferences and behavior. Our results demonstrate that particularly supportive relationships with natal kin have more influence on fertility preferences and behavior than contact with natal kin, although both dimensions are important. The results also show that even within the same cultural context, radically different community environments can produce opposite consequences of ties to natal kin.     

Long-Term Care Alternatives:

Definition of Life Care Community. A continuing care requirement community (CCRC), or life care community, is a long-term care alternative providing a package of services, including housing, health care and social services, to the elderly. More specifically, a CCRCL (1) provides independent living units, either apartments, rooms or cottages; (2) guarantees a range of health care and social services, which may include intermediate or skilled nursing care, usually available on the premises; (3) requires some type of prepayment, generally an entrance fee and/or monthly fees; and (4) offers a contract that lasts for more than one year or for life and that describes the service obligations of the community and the financial obligations of the resident.     

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.     

Policy networks and the implementation of community care policy for people with mental handicaps

Although community care has been the professed policy of successive governments over three decades, according to the Prime Minister's own adviser, Sir Roy Griffiths, 'in few areas can the gap between political rhetoric and policy on the one hand or between policy and reality in the field on the other hand have been so great'. This paper examines the extent and causes of this 'implementation gap' in respect of services for people with mental handicaps--a consistent priority group for national policymakers. We examine centre-periphery relations in the health and personal social services in the light of Rhodes' power-dependence framework and his concepts of policy networks and policy communities. The NHS has been described as the archetypal professionalised policy network but we conclude that it is possible to account for implementation failures in community care only partly in terms of the dominance of the medical professions' values and interests and the deficiencies of accountability and control due to clinical autonomy. Such failures are due also to the inherently limited power of the centre. Sub-central units are not merely its meek agents. Moreover, the centre must explicitly structure local environments by itself providing a coherent framework of service and resource policies compatible with the national objectives it is seeking to achieve.     

Whither practice-near research in the modernization programme? Policy blunders in children's services

In this article, we lament the effects of practice-distant research and associated policy initiatives on contemporary children's services in England. In the last decade, as a result of high profile inquiries into non-accidental child deaths, statutory children's social care services in the UK have been subject to a wide-reaching ‘modernization’ programme. We studied decision-making in the high blame environment of local authority children's services. Our research sought to examine the relationship between performance management and the impact of anticipated blame within the decision-making practices of those providing, supervising and managing these services. We show that systems and technologies can be developed which both assist the users in their daily work and achieve desired organizational goals, but without an ethnographically informed, practice-near approach, unsafe work regimes and practices can ensue.     

How to house a child: providing homes for Jewish children in interwar Poland

After World War I Jewish community leaders in Poland addressed the increasing number of orphans due to the war and continued violence by placing children in foster care and building orphanages run by local non-governmental organisations. The care of children in private homes was seen as the most practical solution to the crisis and a real alternative to the establishment of institutions. The records of these non-governmental organisations and the writings of Jewish community leaders reveal that the discussion regarding institutions and private care reflected a desire to provide effective and efficient services but was also a sign of the institutional immaturity of the organisations that had emerged to address the needs of children. Proponents of both institutions and private care advocated greater supervision of these services and, if not institutionalisation, more organisation of those working in child welfare and of children's lives. Believing that such supervision would make the children under their care into more productive, responsible adults, the leaders of Jewish children's aid associations in Poland viewed positively the increasing involvement of non-governmental organisations and the state in the intimate lives of families.     

Educational Attainment and Stability in Long-Term Foster Care

SUMMARY. This paper explores the relationship between the reading attainment of a group of 8–14 year olds in long-term foster care and factors in their histories and current home environments. The findings suggest that children's early histories before entry to care may have an effect on their educational attainment in middle childhood. Some amelioration of early childhood experience may be found in a stable foster home placement which has an expectation of permanence. The type of permanent placement seems less important than the expectation of stability. There was no difference in progress between children where the eventual outcome might be adoption or custodianship and those who would remain foster children. Of especial interest was the fact that the foster children's educational attainment was not related either positively or negatively to contact with their birth parents.