The Family Team at Boston Healthcare for the Homeless Program: an integrated approach to care in outreach settings

Since 1986, the Family Team at Boston Health Care for the Homeless Program has implemented an integrated, inter-professional, team-based model of care to serve families experiencing homelessness. The Family Team employs key strategies delineated by the well-established Health Care for the Homeless model, which emphasizes the importance of outreach medicine and a case management “one-stop shop approach”. We include an account of a specific case where the Family Team’s unique model helped a refugee family in Massachusetts access medical and social services otherwise more difficult to obtain. The Family Team’s onsite presence in the hotel-shelter and the team-based approach facilitated diagnosis of and successful treatment for cervical cancer in a mother of eight children. This case report suggests that the Health Care for the Homeless model of care should be more widely adopted in order to best serve homeless families.

Abbreviations: Boston Health Care for the Homeless Program (BHCHP); Emergency Assistance (EA); Health Care for the Homeless (HCH); Massachusetts General Hospital (MGH)     

From pipeline to practice: Utilizing tracking mechanisms for longitudinal evaluation of physician recruitment across the health workforce continuum

PurposeArea Health Education Centers work with community partners to prepare a diverse, primary care workforce particularly among rural and underserved communities. We set out to assess our impact on the physician workforce across a multitude of short-term, intermediate, and long-term benchmarksMethodWe used a comprehensive evaluation scaffolding to assess benchmarks of success across the workforce pipeline including short-term (i.e. pre-medical intent to pursue a health career or medical students’ intent to practice in primary care), intermediate (college matriculation and primary care residency match rates) and longterm measures (licensure and medical practice location of program participants).ResultsWe identified significant findings in each part of the AHEC program continuum. Among our alumni, we found a significant increase in the pre-medical learner’s intent to pursue a health care career. Among medical students, we found a significant increase in intent to practice in primary care, rural areas, and medically underserved communities and a high rate of primary care residency match (compared to peers). Approximately one-third of licensed physicians are now practicing medicine serve in an underserved communityConclusionsOur findings confirm the value of longitudinal evaluation on confirming that participation in an AHEC supported program strengthen the physician workforce development.     

The making of the "women's physician" in American obstetrics and gynecology: re-forging an occupational identity and a division of labor

After struggling as a surgical specialty, obstetrics and gynecology initiated its "women physician" program in the 1970s. This program officially defined the mostly male obstetricians and gynecologists at that time as women's primary care physicians. Using archival data, this article explains this development as a response to the specialty's dishonored position within the medical division of labor. Whatever else it was intended to be, the women's physician program, in its most developed form, aimed to galvanize the various interests within obstetrics and gynecology behind a strategy to restructure the medical division of labor serving women so that obstetricians and gynecologists controlled both the upstream positions responsible for their own case referrals and the downstream positions to which they referred their difficult cases. The article illustrates the importance of integrating insights from both macro-institutional and intra-occupational explanatory frameworks in accounting for significant developments in medicine.     

FAMILY SYSTEMS THERAPY IN A PRIMARY CARE MEDICAL SETTING: THE ROCHESTER EXPERIENCE

Collaboration between family therapists and physicians has attracted increasing attention in the field of family therapy. Family therapists practicing in medical settings encounter many stimulating oppoutunities and challenges. This paper focuses on the experience of the authors providing family therapy in a primary care medical setting which is also a family medicine residency program. The authors discuss the role of physician and patient expectations in treatment as well as the influence of the medical context on the development of family therpists.     

Documenting effective coordination of medical education programs in response to medical underservice.

The Federal government has in the past initiated a variety of programs in an effort to address the issue of medical underservice throughout the United States. The results of two such programs sponsored by the University of Colorado Health Sciences Center are examined. Their federal and state support have been decreased at a time when encouraging progress was being made in reducing rural Coloradoans' inaccessibility to medical care, although much of the state remains designated a primary care health manpower shortage area. This paper challenges the Federal Government's policy of temporarily "seed" funding programs whose interventions require several years to complete, under the assumption that state legislatures will eagerly pick up financial support for all that document continuing need and effectiveness. It also describes the difficulties this policy and prevailing state legislative attitude pose for program evaluators in performing their professional function.     

Access to Interprofessional Continuing Education in Integrated Care Through Digital Instructional Technology

ABSTRACT

In preparing the workforce for integrated care, continuing professional education serves a critical role. Within a rapidly changing health care landscape, matriculated students now benefit from pedagogical innovations supporting integrated care, particularly interprofessional education, and working professionals must not be excluded from this transformation. University-based digital instructional programs can support the learning needs of working professionals, providing an alternative and complement to brick-and-mortar classrooms and ad hoc onsite trainings. This paper describes the structure, content, digital approach, and outcomes of a continuing education program in integrated behavioral health and primary care, housed in a school of social work at a major university. The challenges of interprofessional digital education are described and future directions are suggested.     

Launching Medical Foster Home Programs: Key Components to Growing This Alternative to Nursing Home Placement

Objective: The objective of this research was to examine and explain elements that enhanced or thwarted program growth of the United States Veterans Health Administration Medical Foster Home program. Methods: This qualitative study was conducted nationally through individual interviews over the phone and in-person (n = 22) with coordinators (n = 15 at slow-growth programs; n = 6 at fast-growth programs), program support assistants (PSAs) (n = 1 at slow-growth program), and home-based primary care team members (n = 3), as well as three in-person focus groups (n = 28 total participants) with home-based primary care team members. All participants (N = 53) were involved with programs in existence for at least two years. Results: Facilitators and barriers that enhanced or thwarted program growth emerged around four themes: A full-time coordinator; Unmitigated home-based primary care team engagement; Pursuit and receipt of appropriate referrals; and Match between caregiver, home, and Veteran. Conclusions: To facilitate program growth, program leaders should consider themes identified and how to foster situations and shape policies that put themes into practice.     

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

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

Ways of Seeing: An Early Childhood Integrated Therapeutic Approach for Parents and Babies

This paper describes the use of a multisensory psychotherapeutic treatment approach that supports the primary attachment relationship. This program, called Ways of Seeing, is based on dance/movement therapy principles that incorporate dance, movement, music, creative expression, and Laban nonverbal movement analysis to facilitate healing and change. This method is discussed within the context of attachment system theory and research, trauma, and painful early childhood experiences. Implicit knowledge, intersubjective motivations, early infancy memory, embodied attunement, and dyadic nonverbal therapeutic video-analysis support the psychotherapeutic approach. The Ways of Seeing method is exemplified through the presentation of a videotaped mother–infant dyad involving a preverbal and newly verbal child who has experienced a series of innate environmental stressors. These stressors include medical intervention in the NICU at birth, a mother who suffered from post partum depression, and complex extended family dynamics.     

Education and the professionals. Some aspects of innovation in medical education adopted by Ahfad University for Women

This article describes the establishment in 1990 of a School of Medicine at Ahfad University for Women in Sudan. The school was premised on the view that women doctors would have a better opportunity to affect and improve women's health than men doctors. The curriculum is innovative and relies on a community orientation and a problem-solving approach. Medicine and health are taught in a holistic way. The new approach is rooted in the Alma Ata Declaration in 1978 of Health for All by the year 2000. The new method of delivery of medical care in the School of Medicine is based on the promotion of health through health education, prevention of disease, proper nutrition, provision of a safe water supply, attention to maternal/child health and family planning, and attention to the treatment of endemic diseases. In order to teach primary health care, medical schools must change their practices. Delivery of health care will have to be changed. New curriculum approaches emphasize learning objectives in each of the teaching modules and small group teaching. Integrated learning means the separate disciplines of medicine are taught as a whole multidisciplinary unit. Case management learning has the potential for increasing motivation and the ability to discover the knowledge needed to solve the problem. McMaster University relies on a problem-oriented approach to medical education that prepares the student for coping with changes in medical knowledge in the future. The challenge for educators is to create an efficient and comprehensive curriculum that will prepare a doctor for lifelong learning. Health settings have also changed to deemphasize sophisticated hospital settings in favor of community-based health centers. Ahfad University is the only one of its kind in Sudan. Medical education includes 6 years of schooling divided into 3 phases.     

Maternal and child health and family planning services in the Sudan

Given the high rates of infant and maternal mortalty, the prevalence of infectious diseases, poor nutritional status among women and children, and numerous endemic diseases such as malaria and bilharzia, maternal-child health serivces have been given a high priority in the Sudan. In reality, however, this area has not received adequate attention within the primary health care system in terms of management, service provision, and training. Major obstacles to effective maternal-child health services include: 1) the lack of involvement of community health workers, the main providers of other primary health care services in the Sudan, in the area; 2) the clinical orientation of physicians, which mitigates against attention to the promotive and preventive components of health care; 3) a lack of standardization of medical records or data collection routines, which hinders program monitoring; and 4) the failure to integrate related national programs such as immunization into a comprehensive maternal-child health program. In addition, there are administrative and organizational obstacles, such as the lack of institutionalization of maternal-child health services within the Ministry of Health, inadequate managerial capabilities, an absence of guidelines for service delivery at the regional and provincial levels, delays in the procurement of equipment and supplies, a widely dispersed population, and transportation difficulties. Family planning, too, is supposed to be the responsibility of all primary health care workers in the Sudan. However, current training programs for physicians, nurses, village midwives, and community health workers do not prepare them to fulfill this role. Development of an official population policy in the Sudan is recommended to ameliorate some of these problems.     

Factors contributing to eviction from permanent supportive housing: Lessons from HUD-VASH

IntroductionEviction from housing is associated with several negative outcomes, further exacerbated among high-need populations requiring financial and supportive services to maintain housing stability. This study investigated risk and protective factors—both characteristics and precipitating events of tenant eviction—informing permanent supportive housing (PSH) programs’ efforts to identify tenants at risk and intervene.MethodsUsing administrative data for a cohort of 20,146 Veterans participating in PSH, this study assessed differences in Veterans who exited the program due to eviction and Veterans who exited because they accomplished their goals. A series of logistic regressions identified patterns of health services use that may signal imminent eviction.ResultsVeterans with a drug use disorder and those who received inpatient, emergency, or outpatient care related to mental/behavioral health and substance use conditions proximal to program exit had greater risk for eviction. Receipt of outpatient primary medical care and supportive services was generally protective against eviction. The likelihood of eviction was greatest for Veterans with acute care use within 30 days of exit.DiscussionPSH providers may use these correlates of eviction to identify Veterans in need of an intervention to prevent eviction. Future work should focus on operationalizing these findings and identifying appropriate interventions.     

Implementation of a high-performance cardiopulmonary resuscitation protocol at a collegiate emergency medical services program

ABSTRACT

Out-of-hospital cardiac arrest (OHCA) is a significant public health issue. Although OHCA occurs relatively infrequently in the collegiate environment, educational institutions with on-campus emergency medical services (EMS) agencies are uniquely positioned to provide high-quality resuscitation care in an expedient fashion. Georgetown University's on-campus EMS program recently updated its medical protocols to reflect the latest literature in resuscitation science. In a high-performance CPR (HPCPR) resuscitation, minimally interrupted chest compressions are emphasized, along with a coordinated team-based approach.     

Chapter 3: Health and Productivity Management

SUMMARY

This article focuses on the emergence of Health and Productivity Management (HPM) as a context for understanding the integration of health and wellness into employee assistance and work-life programs. Major factors influencing the growth of HPM are raising medical costs as well as the rising incidence of obesity. The Wake-up Call to Corporate America underscores the need to manage these costs and improve health through the proactive alignment of health-related benefits and programs. HPM is described as an integrated approach to capture direct medical costs as well as the indirect costs associated with poor health and lost productivity. Critical design and implementation features that are likely to contribute to a successful integrated approach are described and highlighted. An HPM case example of a large pharmaceutical company examines a unique cross referral program including considerations for continuous improvement. Finally, the article concludes with key challenges related to marketplace competition, pricing pressures, concerns regarding the sub-optimization of programs and the influence of current health care system changes.     

Medical Utilization and Health Expenditure of the Elderly in Taiwan

The present analysis, based upon data from the 1989 Taiwan Labor Force Survey, includes two parts. First, the determinants of physician visits and hospitalization by the elderly are analyzed according to the behavioral systems approach, and, second, variation in health expenditures among the elderly are examined using the Tobit model with sample selection. Findings show that elderly with good or poor health conditions are less likely to use medical services than the frail elderly and that married elders are less likely than the non-married to use medical care. The higher the educational level, the lower the probability of using formal medical services, and elderly who have health insurance are more likely to use formal health care than those who have no health insurance. The elderly who live with their children are less likely to use formal medical services than those who do not live with their children. Finally, among the elderly who have used formal health care, individual health expenditures are influenced primarily by three factors: health condition, health insurance, and residential location. Implications for Taiwan's relatively newly established national health insurance program (effective April 1, 1995) are discussed based upon the findings of this research.