Health systems and physician behavior

We have the ability to deliver outstanding health care in the United States, but fall far short of this goal. Between the health care system we have and the system we could have, lies not just a gap, but a chasm. Change is needed in physician behavior and in the health care system. We need to consider the value (ie, = quality/cost) of the medical care delivered in this country. There are limited resources, but there is much room for improvement.Before long-term solutions can be found to maximize the quality of medical care, we must understand the need for change and what changes need to be made, how decisions are made, how changes in physician behavior occur, and the role of health care systems in making changes occur. This article reviews these topics and introduces a broader paradigm for clinical decision-making. It is an overview for those new to the field and provides a platform for those interested in further study.     

Analysis of a care planning intervention for reducing depression in older people in residential care

Approximately 40% of older people in residential care have significant symptoms of depression. A training and care-planning approach to reducing depression was implemented for 114 depressed residents living in 14 residential care homes in North Yorkshire, UK. Care staff were offered brief mental health training by community mental health teams for older people. They were then assigned to work individually with residents in implementing the care-planning intervention, which was aimed at alleviating depression and any health, social or emotional factors that might contribute to the resident's depression. Clinically significant improvements in depression scores were associated with implementation of the care-planning intervention as evidenced by changes in scores on the Geriatric Mental State Schedule-Depression Scale. There was evidence of an interaction between the power of the intervention and degree of dementia. These improvements were not accounted for by any changes in psychotropic medication. The training was highly valued by care staff and heads of homes, and they considered that the care-planning intervention represented an improvement in quality of care for all residents, irrespective of levels of dementia. Staff also reported improvements in morale and increased confidence in the caring role as a result of their participation. The limitations of this study are discussed. On the basis of a growing body of evidence, it is argued that there is an urgent need for a suitably powered randomised controlled trial and economic evaluation, to test the cost-effectiveness of personalised care planning interventions aimed at reducing depression in older people in residential care.     

Graduate education and training for contemporary behavioral health practice

Over the past decade, a new paradigm in behavioral health care has emerged. It places emphasis on cost control, evidence-based practice, patient safety, access to care, treatment relevance for diverse populations, consumerism, and quality of care. Unfortunately, graduate education and training programs have had difficulty keeping pace with the dramatic changes in the field. As a consequence, there is concern that the graduates of many of these programs are not being adequately prepared to practice in current health care systems. This article reviews the nature of recent changes in behavioral health care, the current status of graduate education programs with respect to these changes, and offers 15 recommendations for increasing the relevance of graduate education to contemporary clinical practice.     

Psychiatric residency training, managed care, and contemporary clinical practice

Managed care has transformed the health care environment that residents encounter on completion of their training. Unfortunately, residency education has not kept pace with changes in the field, leaving graduates inadequately prepared. The authors identify necessary changes in the residency training tasks of instilling values, imparting required knowledge, building core skills, selecting appropriate training sites, and offering a diversity of instructors and supervisors. They also discuss the obstacles that have impeded the evolution of academic clinical services and clinical training. They suggest strategies of change that may lead to more relevant educational programs that provide residents with a balanced perspective on the strengths and weaknesses of both traditional and contemporary approaches to delivering care.     

Enhancing primary health care services for adults with intellectual disabilities

Background Primary health care teams have an important part to play in addressing the health inequalities and high levels of unmet health needs experienced by people with intellectual disabilities (ID). Practice nurses have an expanding role within primary health care teams. However, no previous studies have measured their attitudes, knowledge, training needs, and self-efficacy in their work with people with ID. Methods All practice nurses working in a defined area were identified. A purpose-designed questionnaire to measure nurse attitudes, knowledge, training needs and self-efficacy was developed and piloted. All practice nurses were then invited to participate. Data from completed questionnaires were entered onto PC and analysed. Results Of a total of 292 practice nurses 201 (69%) participated. Whilst 89% (n = 179) of participants reported having infrequent contact, 25% (n = 50) reported a growing workload with people with ID. Only 8% (n = 16) had ever received any training in communicating with people with ID. A knowledge gap regarding the health needs of people with ID was identified. Eighty-six per cent reported having experienced specific difficulties during previous appointments, and only 23% thought they had sufficient case note information at appointments, but 68% did not modify the duration of their appointments with people with ID. Conversely, responses demonstrated that practice nurses have a high level of experience and qualification in general nursing, have positive attitudes to working with people with ID, and high self-efficacy scores were identified for work with people with ID. The practice nurses viewed ID to be a high priority area for future training. Conclusions Primary health care teams have a key role in tackling the unmet health needs of people with ID. Whilst this project has identified factors that may impact on the accessibility of services, it has also identified practice nurses as having positive attitudes and high self-efficacy scores in their work with people with ID. This indicates that they should be targeted for specific training in this area, which may make an important contribution in enhancing future accessibility of primary health care services for people with ID.     

Mental health care in Fiji

Fiji is one of the largest island nations in the South Pacific. It is multicultural and has an economy based on tourism and sugar production. Like many developing countries Fiji faces the double burden of communicable and non‐communicable diseases as well as a third emerging burden of accidents and injuries. Fiji lacks data on the national prevalence and burden of disease of mental disorders. Using World Health Organization estimates there is over a 90% treatment gap for mental disorders. Contributing to this treatment gap are the misconceptions and stigma surrounding mental illness leading people to seek alternative treatments. Fiji's mental health services were established in 1884, comprising a single ward to care for mentally ill expatriates. Services have since expanded to include a 136‐bed inpatient facility (St. Giles Hospital), which provides outpatient, psychosocial rehabilitative and community psychiatric services. Mental health services remain centralized at St. Giles, with follow‐up in the community supported by a well‐established public health hierarchy and by medical personnel at the divisional hospitals. St. Giles is also responsible for conducting mental health awareness and training for health workers and the public and provides input at a national level for mental health policy, plans and legislation. Psychiatric training is available at the undergraduate nursing and medical levels. The Fiji School of Medicine is in the process of developing a postgraduate psychiatric program. With its limited resources Fiji needs to integrate mental health services into the general and public health systems to achieve a comprehensive and integrated mental health system.     

Epilepsy control program in India: a district model

Based on data originating from neuroepidemiologic studies in India, epilepsy has been identified as a public health problem. The treatment gap varies from 50 to 70% among persons with epilepsy and is compounded further by limited availability of neurologists, often working in urban metropolises, thus restricting the availability of services in a predominantly rural agrarian country. Cost-effective, sustainable epilepsy care programs are urgently required in India. To bridge this wide gap, a district model was developed with the central focus on training the district medical officers in providing epilepsy care with sensitization of state health administrators and nodal neurologists to support and sustain the program. Workshops were conducted for all three groups during the period 1999-2001, with the involvement of 21 state health administrators, 148 district medical officers, and 28 neurologists. Preliminary evaluation indicates a growing interest, enthusiastic commitment, and willingness among health professionals to expand epilepsy care to the periphery. The program revealed that it is possible to reach people with epilepsy on the premise of early diagnosis and management, need-based referral network, and a rational planning for uninterrupted availability of antiepileptic drugs along with education of families. Policy-level initiatives are required further to transform this on a wider scale and to evaluate the efficacy and effectiveness of this approach.     

Primary care in psychiatry residency training

The author summarizes patient perspectives and government initiatives that have fostered closer medicine-psychiatry cooperation and more comprehensive treatment of patients. Despite the growing numbers of people requiring more formal mental health care, most patients are being treated by primary health care providers. This trend will continue as long as there is a decline in the number of medical students entering psychiatry. The author summarizes several general principles that psychiatry residency program directors should consider in designing primary care experiences for their residents and for medical students rotating on their services: longitudinal primary care experiences in organized medical care settings, training in basic medical principles and techniques, and instruction in the biopsychosocial model of disease. The author also recommends three specific training experiences for psychiatry residents that would enhance their ability to provide more effective mental health services to primary care physicians and their patients: consultation psychiatry, primary mental health care, and general psychiatry. The author concludes that medical students, throught their contact with primary care-oriented psuchiatry residency programs, would be more attracted to psychiatry as a specialty choice and that residents, upon completion of training, would be more inclined to practice in primary care settings.     

The impact of managed care on community mental health outpatient services in new york state

This article explores the impact of managed care on community mental health outpatient services in New York State. A survey was sent to directors of all the licensed mental health organizations to obtain information about staff composition, services provided, training, funding, managed care affiliations, and advertising. The survey focus was on changes that had taken place in the past 4 years and those anticipated in the future due to managed care. Results indicate that managed care has led to changes in the aforementioned areas and that these changes varied by agency size, region, and type.Adrienne Cypres, Ph.D., is a consultant and has a private practice in Washington, DC.This article is based on the First author's doctoral dissertation submitted June 1996 to the New York University School of Social Work.