Health care for older persons in Singapore: integrating state and community provisions with individual support

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.     

Wraparound Services: An Effective Intervention for Families Impacted by Severe Mental Illness

ABSTRACT

Children and families impacted by severe mental illness (SMI) have multiple strains that effect family functioning, child safety, and parental rights. Traditional services for children and families struggling with severe mental illness have not achieved success in improving family functioning and keeping families intact. Wraparound is a philosophy and a system of care with a promising evidence base that could enhance collaboration of child welfare, mental health, and community services to work more effectively with families impacted by SMI.     

Shared Family Care: Fostering the Whole Family to Promote Safety and Stability

ABSTRACT

Shared Family Care is an innovative child welfare service that temporarily places whole families in the homes of community mentors who, along with a team of professionals, help the families to obtain the skills and resources they need to move toward self-sufficiency and adequately care for their children. This article provides an overview of this model, identifies existing programs in the United States, discusses key elements of the model, summarizes outcomes and comparative cost information, identifies implementation challenges, and provides tips for starting a Shared Family Care program in any 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.     

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.     

Home Is Where the Help Is

Abstract

Policy regarding long-term care has been an issue of rising national concern. In this paper we examine the transition of Danish long-term care policy with special attention to Skævinge, the first community in Denmark to integrate institutional and community-based services for the elderly. Recent studies on the variation between costs and services in Danish communities and the results of U.S. studies on community-based care suggest that successful implementation of integrated institutional and community-based long-term care is feasible in the United States. Lessons from Denmark highlight conditions that will facilitate success in this endeavor.     

Meeting the Needs of the Growing Very Old Population: Policy Implications for a Global Challenge

ABSTRACT

Very old adults are one of the fastest-growing age groups worldwide. Yet they rarely constitute a targeted group for public policies. Drawing on the results of the centenarian studies presented in this special issue, we highlight major challenges that arise from the increase of this population. We outline several promising approaches for policy makers and professionals to develop evidence-based policies and programs that are tailored to the needs of very old adults and their families. We focus our discussion on three key topics essential to life care: the importance of integrated care to meet the complex care needs of the very old; the balance between formal and informal care; and the development of suitable places for living. Besides more specific measures, we propose that policies promoting the social integration of very old adults in their communities would be particularly helpful, as these may benefit not only the very old and their families but also individuals of all ages. We conclude that the development of suitable policies addressing the needs of the very old will benefit from future investigation of cross-cultural similarities and differences in centenarians’ characteristics, available services, as well as life conditions they encounter in communities and institutional contexts.     

Thirty Years of CURE

SUMMARY

The authors describe how, for the past thirty years, they have worked to organize CURE (Citizens United for Rehabilitation of Errants), a prison reform constituency of prisoners and their families. Better rehabilitative opportunities as well as less reliance on incarceration have been the goals of their organization. Beginning in Texas, they have, by trial and error, brought about a community of prison reformers at the local, state, national and international levels. Their organizing principles for this achievement are presented and the reasons for them explained. They conclude that every jail and prison should have an organized monitoring entity of the families of prisoners, and that CURE could be a model.     

Family support in late life: A review of the literature on aging,disability, and family caregiving

ABSTRACT

For older adults and people with disabilities in the United States, family caregiving is an important part of remaining at home and in the community. As care recipients and caregivers age, family dynamics change, and the health, social, and financial impacts of this (largely unremunerated) work have implications for individuals, families, and social policy. In this review, the authors map the literature across multiple fields related to disability and aging to understand caregiving in late life, what it means to be an older caregiver and/or to care for older people. The authors summarize the findings of 97 articles to address the care, services, and supports family caregivers provide for older adults; negative and positive impacts for caregivers serving in this role; supports that family members use or need; and societal impact of family caregiving. Much of the literature describes the work family caregivers provide and negative impacts of caregiving. Less attention is devoted to caregiving benefits, supports used by family caregivers, and societal impacts. The authors conclude with an agenda for future research that attends to the need for research that includes: more diverse samples, new types of caregivers, longitudinal data, qualitative data and analysis, and comparative research.     

An exploratory study examining needs,access, and competent social services for the transgender community in Phoenix,Arizona

ABSTRACT

Phoenix is the sixth largest city in the United States, with a vibrant yet underserved lesbian, gay, bisexual, transgender, and queer (LGBTQ) population. Despite an extensive community presence, social service delivery bias persists among members of the LGBTQ community, but more often among transgender individuals. Existing research has examined social services from the perspective of either the client or the practitioner. This exploratory study specifically examines social services in the Phoenix metropolitan area for the transgender community. Data collected from interviews with participants and providers contributed to an assessment of the current level of social services for the transgender community, with a specific emphasis on identifying service gaps and recommendations for culturally competent and comprehensive services.     

Facing Time Limits

Abstract

With reauthorization of the 1996 Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA) on the horizon, policy makers need to have a sound understanding of the act's consequences for children and families. In contrast to earlier studies, the present study quantifies the impact of a 24-month state imposed welfare time limit on foster care placements. It also examines the impact of a “hardship” provision that temporarily excuses select families from meeting a two-year time limit on foster care placements in Nevada. In order to determine how these factors, in conjunction with other relevant welfare experiences and personal factors, affect parent-child separation, a multivariate logit model was tested. Key findings reveal that families who have more months counted toward their time limits also are more likely to have at least one child removed and placed in foster care. On the other hand, hardship families are not more likely to have their children placed in foster care than non-hardship families. The findings lend support to the notion of providing family-centered casework services to those identified to be at risk of approaching their welfare time limits. The findings also lend support to inter-agency collaboration between TANF and child welfare systems.     

Challenging implicit bias: preparing students to practice with African American families

ABSTRACT

The disparity of African American families in the foster care system is a concern in the field of child welfare services and the social work profession. African American families experience unique challenges related to discriminatory practices and implicit biases in the child welfare system and by mandated reporters. To address these inequalities, state and local agencies have implemented prevention and intervention services to support minority families. Additionally, child welfare agencies have invested in professional development training for their workers to alleviate possible intolerant practices. This article describes implicit biases and considers how they could contribute to the disparity of African American families involved in the child welfare system. Furthermore, the article presents approaches to help social work students to identify and challenge their implicit biases to support culturally sensitive practices while working with African American families. It concludes with implications for social work education.     

The impact of para-professional social workers and community health care workers in Côte d'Ivoire: Contributions to the protection and social support of vulnerable children in a resource poor country

BackgroundResearch indicates a disproportionate impact of HIV and AIDS in sub-Saharan African countries, leading to many vulnerable families and children. Many of these communities have limited resources to support these vulnerable families, especially orphans and vulnerable children (OVC).Study aims and objectiveThis study set out to investigate how para-professional social workers and community health workers (PSWCHW) impact the provision of services and the psychosocial wellbeing and protection of vulnerable children in the community.MethodsThis quasi-experimental research study used data from an independent Save the Children program evaluation study in Côte d'Ivoire. We compared the health and psychosocial wellbeing of identified vulnerable children supported by para-professionals (n = 334) and children not receiving para-professional support (n = 213).FindingsSupport services and activities provided by PSWCHW included encouraging the children to be part of psychosocial support groups. Many of the children reported legal issues that ranged from getting a birth certificate issued to fighting or quarrelling with adults, disputes, public insults, beatings, and refusing to go to school. We found that the engagement of PSWCHW helped three out of four children go to school (compared to only one in four of the children without PSWCHW). PSWCHW also helped the children improve access to health care services.ConclusionsCommunities in sub-Saharan Africa should continue to consider the integrated utilization of para-professional social workers and community health care workers to support and improve psychosocial wellbeing of orphaned and vulnerable children which, in turn, enhances child protection services and access to healthcare.     

Individualization and Prevention

SUMMARY

In 1905, Massachusetts General Hospital initiated the first medical social work program in the United States. Based on the writings of its leaders, this paper presents the early history of medical social work in the United States. Inspired by developments in European health care that emphasized the community context of disease, medical social work pioneers saw a need to individualize the patient while also promoting public health measures in the community, improving the patient's environment to eliminate the causes of disease. In addition, since they served patients because of their diseases rather than their poverty, medical social workers were among the first to provide social work services to the non-poor. In spite of their emphasis on environmental change, many of early medical social work leaders had an anti-institutional bias; they were suspicious of large-scale solutions for what they saw as fundamentally individual problems. Consequently, methods for promoting individual adaptation developed more rapidly than methods for promoting environmental change. Ironically, the medicalization of social problems in contemporary times has resulted in a focus on individual pathology rather than social and lifestyle causation in health, even as the rising cost and complexity of the system challenges health care consumers in the United States. Reaffirming the environmental emphasis of medical social work pioneers provides a way for today's health care social workers to incorporate environmental modification into their practice and promote the health of all citizens.     

Challenges of Interdisciplinary Collaboration

Abstract

The realities of the 1990s, which include reduced funding and resources, the public's impatience with bureaucratic rigidity, and the empowerment of families who want timely and appropriate services, have created a favorable climate for collaborative, interdisciplinary practice. Collaborative, family-centered practice models are being promoted by family/child advocates and professionals. Yet child and family services, for the most part, continue to be provided in traditional ways using individual treatment and categorical services. However, federal child mental health funding is supporting community-wide, collaborative practice in twenty-one sites scattered across the United States. One site, in rural northeastern North Carolina, is unique as it includes a graduate-level, interdisciplinary academic component [East Carolina University's (ECU) Social Sciences Training Consortium (SSTC)] to train and support service providers and families, and to prepare master's level graduates to work in such innovative programs. Called PEN-PAL [an acronym for Pitt-Edgecombe-Nash (three NC counties) Public Academic Liaison] this university/interagency collaborative effort works in partnership with families to coordinate public and community services into a seamless system of care for children with severe emotional disturbances. This article is based upon a qualitative study of SSTC faculty members, and it chronicles the successes and difficulties encountered by faculty in the first year of a five-year collaborative process.     

Personal and Professional Knowledge of and Experience With Suicide and Suicide Prevention Among Stakeholders in Clinical and Community Practice

Community-dwelling veterans at risk for suicide may be in contact with a variety of providers in agency-based settings that offer health and human services. The study aim is to describe the perspective of agency-based clinical and community providers who may come into contact with veterans in need of suicide prevention services and to examine the nature of their personal and professional relationships to individuals at risk for suicide among this sample.

This study reports on qualitative data from a sample of Veterans’ Affairs (VA) and community providers serving veterans and military families in one Midwestern state (N = 70). Providers completed a survey assessing exposure to suicide, including contact with and relationship to someone suicidal, and organizational characteristics of the providers’ employing agencies. Semi-structured interview questions probed for the nature of how they would react with suicidal individuals. Most providers (94%) had some prior contact with someone who was suicidal, and nearly three quarters (77%) knew someone who had died by suicide. Providers reported powerful emotional responses of sadness and remorse to suicidal experiences. While these providers interact with veterans and military families as part of their jobs, they may have their own history of being exposed to suicide, both professionally and personally.     

Families' Values and Attitudes Regarding Responsibility for the Frail Elderly

Abstract

This study examines the norms and values associated with care to disabled and frail aging parents, in particular those with regard to the sharing of responsibilities for care between families and formal services, and this within three age cohorts in Quebec, Canada. It is based on a telephone interview of 1,315 people. Factor analysis yielded four factors: (1) family responsibility; (2) uncompromising family obligations; (3) acceptance of services; (4) distrust of services. Analyses of the data indicate that all three age cohorts consider that families have responsibilities for their aging family members, at the same time that they score very high on the acceptance of service scale. This article discusses these seemingly paradoxical results and their implications for aging policy.     

Family Experiences of Caring for Relatives Who Have Received Electroconvulsive Therapy (ECT)

The research literature on family members’ experiences of the use of electroconvulsive therapy (ECT) is limited. This article explores the perspectives of family members whose relatives had received ECT. Drawing on a social constructionist perspective, this qualitative study collected data using in-depth interviews with nine families in South Australia, to examine how family members constructed the supports and challenges they experienced. The research found that families experienced a range of social and service system barriers, including social stigma and isolation, and limited support from health professionals. They had to negotiate caring expectations within a social context that stigmatised both mental illness and ECT. A need for ECT-specific mental health support groups was identified.

IMPLICATIONS

• Social workers’ roles in Australian hospitals could be further expanded to accommodate supporting families whose relatives have received ECT, referring families to community support, and advocating for specialist support post-ECT treatment.

• Social workers can further articulate their unique contribution to community care post-ECT treatment and advocate for supporting families.

• Increased focus on ongoing and preventative care for supporting families is a potential growth area for social workers in mental health.