The Internet in managed health care

Blue Shield of California recognized it could realize business gains by implementing solutions that would streamline health care administration. It began looking for opportunities to apply the Internet to the core business and defining which of those services would benefit quickly from implementation. It selected Internet technology from Healtheon Corp., a Silicon Valley startup in Palo Alto, California.     

The challenges of mental health care reform for contemporary mental health nursing practice: delivery of nursing care

This ethnographic account of mental health nursing in a 22-bed acute inpatient facility in New South Wales, Australia, uncovered cultural meaning and cultural realities associated with the delivery of nursing care within the context of current challenges, demands, and influences brought about by service reforms. The findings demonstrate that mental health nurses have been responsive to changes brought about by the reforms. The ability of nurses to readily identify service gaps in their everyday practice provides them with the opportunity to develop strategies to respond to workplace challenges. As such, findings of the study contribute to current discussions concerning acute inpatient mental health nursing practice.     

The recovery alliance theory of mental health nursing

The recovery alliance theory (RAT) is a mid-range theory of mental health nursing based on humanistic philosophy. The conception of the RAT was the outcome of collaboration among service users, practising mental health nurses, educationalists and managers and was developed in the context of a number of political and social changes as well as changes in the mental health field. The theory is composed of six constructs: humanistic philosophy, recovery, partnership relation, strengths focus, empowerment and common humanity. The derivation of three concepts from these constructs, namely coping, self-responsibility/control and working alliance, forms the basis for the translation of the constructs into a system of mental health nursing practice [Partnership in Coping system (PinC)]. The constructs underpinning the RAT were clearly demonstrated in a preliminary trial of the PinC system.     

Minority youth in foster care: managed care and access to mental health treatment

BACKGROUND: Public sector mental health treatment has been transformed in recent years by the advent of managed care, but investigators of managed care policy have not yet focused on ethnic minority children, especially those involved with the child welfare system. Because of an overrepresentation of high-need minority children, foster care in particular is important to consider. OBJECTIVES: The present study examined children placed in foster care and documented differences between minority children and youth (black persons, Hispanic persons, and white persons) in use of mental health services. The primary concern of the study was to consider whether there were differences in access to services or service use among the groups in the transition to capitated managed care. MATERIALS AND METHODS: Medicaid claims and encounter data for two experimental managed care sites and one comparison fee-for-service site are used in a "difference-in-difference" analysis to estimate a changes in inpatient, outpatient, and residential treatment center (RTC) utilization, controlling for patient characteristics. RESULTS: The study finds persistent declines in inpatient and outpatient use for all ethnic groups, persistent under-representation of Hispanic persons and black persons in treatment regardless of managed care, and greater use of RTCs by black persons and Hispanic persons that is attributable in part to managed care. CONCLUSIONS: Black and Hispanic children received more rather than less mental health care under capitated managed care. The significance of this shift, largely increased in use of RTCs, however, cannot be determined at present, as the effectiveness of treatment delivered in RTCs is not known.     

Reflective practice and team teaching in mental health care

AIM: To develop and test new approaches to professional education that would address issues of team capacity and readiness to learn, thereby strengthening the ability to practise reflectively. METHOD: The time out and the debrief approaches to team training in core competencies were piloted with ten care teams in the north west of England. Pre- and post-training measures of competency were obtained to assess the effectiveness of the training. RESULTS: The results show that competence measures taken after attending the programme were significantly higher than those taken before training. Self-assessments and manager assessments supported this, indicating that the training had a positive effect on the overall capability of practitioners. CONCLUSION: The findings suggest that the innovative educational process created in this study could be used to support the structures of reflexivity and thoughtful practice. This educational process could be used to support practitioners to fully embrace work challenges.     

Building a therapeutic alliance in brief therapy: the experience of community mental health nurses

Current mental health trends in brief therapy require a new understanding of the nurse--client relationship. This qualitative focused ethnography explored the perceptions and actions of community mental health nurses in building a therapeutic alliance in the context of brief therapy and the factors that facilitate or impede its development. Informants were 11 nurses with at least 3 years of experience in community mental health nursing primarily providing brief therapy or consulting practice. Participants described therapeutic alliance as the point at which the clients recognize that the nurse is fully attuned to "being in the moment" as they connect to their own issues in a positive way. Building an alliance consisted of three nonlinear overlapping phases: "establishing mutuality," "finding the fit in reciprocal exchange," and "activating the power of the client." Implications include recommendations to enhance intentional alliance building and directions for further research to explore differing world views among nurses on alliance formation within the context of brief therapy and consultations.     

New Zealand general practice nurses' roles in mental health care

MCKINLAY E., GARRETT S., MCBAIN L., DOWELL T., COLLINGS S., & STANLEY J. (2011) New Zealand general practice nurses' roles in mental health care. International Nursing Review 58 , 225–233 Aim: To examine the roles of nurses in general practice interdisciplinary teams caring for people with mild to moderate mental health conditions. Background: Supporting mental health and well‐being is an important aspect of primary care. Until now nurses in general practice settings have had variable roles in providing mental health care. The New Zealand Primary Mental Health Initiatives are 26 government‐funded, time‐limited projects using different service delivery models. Methods: An analysis was undertaken of a qualitative data set of interviews, which included commentary about nurses mental health work collected from the different project stakeholders throughout a 29‐month external evaluation. Findings: Two main groups of roles for nurses within the general practice interdisciplinary team were identified: specialist mental health nurses working in newly created roles and practice nurses working in existing roles. Barriers exist to the development of the latter roles. Conclusions: Mental health care is a key role in general practice as this is where people frequently present. Internationally, nurses represent a large workforce with the potential to provide effective mental health care. This study found that attitudinal, structural and professional barriers are restricting New Zealand practice nurse role development in the care of those with mild to moderate mental health conditions. There is potential to develop their role within a structured pathway by workforce development and recognition of the value of interdisciplinary care. Given the shortage of mental health professionals this will be an important aspect of the improvement of primary mental health care.     

Integrated health care in California's managed care capital

Sacramento, California's capital, represents the nation's most competitive managed care marketplace. The Sutter Health organization represents a significant force in this marketplace and surrounding regions of Northern California. Sutter has created an integrated regional health care network capable of delivering a full continuum of care through appropriate community-based facilities, a variety of physician relationships, and both owned and aligned managed care structures. The overall Sutter Health strategy that incorporates facilities, physician partnerships, and patient care financing is described. The article identifies six key lessons learned during this period of growth.     

The family-focused mental health practice questionnaire

It is estimated that 1 in 5 children have a parent with a mental illness, and studies have shown that such children are more likely to develop mental health problems when compared with their peers. Research has demonstrated the benefits of mental health clinician family-sensitive practice to both parents and their children; however, a measure of clinician practice is not available. The psychometric properties of a questionnaire measuring family-focused practice in the psychiatric setting are reported here. There were 307 public adult mental health worker participants, predominantly from the nursing profession and working full time. Principal component analysis highlighted 14 subscales that summarize 49 items reflecting organizational and worker factors, such as skill/knowledge about the impact of parental mental illness on children and worker confidence. Subscales are discussed in relation to the literature and psychiatric policy. The measure appears a useful tool for evaluation, benchmarking for training and organizational improvement, and ultimately, for increasing quality services to parents, families, and particularly children associated with psychiatric services.     

The challenges of mental health care reform for contemporary mental health nursing practice: relationships,power and control

This ethnographic investigation was concerned with the way mental health nurses' construct their practice in an acute inpatient psychiatric unit in light of the current challenges, demands and influences brought about by service reforms of the 1990s. The setting for this study was a 22-bed acute inpatient mental health facility. Over a 5-month period, data were collected through fieldwork observations, focused interviews and discussion groups. In this article, common cultural practices in relation to the imperatives of relationships, power, restrictions and safety are discussed. The findings demonstrate how the client stabilization role of the unit locates these imperatives as central to the delivery of nursing care. The discussion reveals nurses negotiating relationships that are contradictory and challenging in ordinary and everyday ways within the exigencies of daily practice.     

Quality measurement and accountability for substance abuse and mental health services in managed care organizations

OBJECTIVES: To analyze managed care organizations' (MCOs') use of behavioral health quality management activities using nationally representative survey data. MATERIALS AND METHODS: The primary data source is the Brandeis Survey on Alcohol, Drug Abuse, and Mental Health Services in MCOs. Using a sampling strategy designed for national estimates, we surveyed 434 MCOs in 60 market areas (response rate = 92%) regarding their commercial products' behavioral health services in 1999. Of these, 417 MCOs reported clinically oriented information for 752 products. We investigated the use of four behavioral health quality management activities: patient satisfaction surveys, clinical outcomes assessment, performance indicators, and practice guidelines. chi tests and logistic regression were used to determine effects of product type (HMO, PPO, point-of-service) and behavioral health contracting arrangement (specialty contract, comprehensive contract including general medical and behavioral health, internal provision). RESULTS: Three-quarters of products used patient satisfaction surveys (70.1%), performance indicators (72.7%), and practice guidelines (73.8%) for behavioral health. Under half (48.9%) assessed clinical outcomes. HMO products were most likely, and PPOs least likely, to conduct activities. Quality activities were significantly more common among specialty-contract products. Logistic regression showed significant negative effects on quality activity use for PPO and POS products compared with HMOs. For clinical outcomes, specialty- and comprehensive-contract arrangements had significant positive effects. There were interactions between product type and contract arrangement. CONCLUSIONS: Most commercial managed care products use patient satisfaction surveys, performance indicators, and practice guidelines for behavioral health, whereas clinical outcomes assessment is less common. Product type and contracting arrangements significantly affect use of these activities.     

A lack of therapeutic engagement and consumer input in acute inpatient care planning limits fully accountable mental health nursing practice

It is mental health consumer's human right to lead a fulfilling life as they are empowered to actively manage their recovery. This can be facilitated through care planning, yet research suggests that the care plan is not routinely created, discussed, or updated in acute mental health settings. Research on care planning and the role of the mental health nurse highlights the importance of therapeutic communication in care plan development. This paper argues that the lack of meaningful care plan discussions between consumers and mental health nurses in an acute setting is a limitation to the practice of fully accountable mental health nursing care. We explore this limitation in quality care provision by examining literature on accountability and conclude that in mental health nursing, accountability is frequently enacted through an overarching focus on the organizational need to manage risks, rather than on therapeutic engagement.     

Enhancing patient adherence: outcomes of medication alliance training on therapeutic alliance, insight, adherence, and psychopathology with mental health patients

The results of interventions to enhance patient adherence to medication have been inconsistent. This research investigated the utility of an enhanced adherence training programme to ascertain its effectiveness and the possible mechanisms of that effect. Forty-six clinicians were trained in 'medication alliance', and data were collected from 51 patients matched to the clinician. Data on clinician changes in skills, knowledge, and attitudes, in relation to enhancing patient adherence and patient changes in adherence, insight, and psychopathology were collected at baseline and at 6 and 12 months. The quality of the therapeutic relationship between the clinician and the patient was also assessed. The results indicated significant improvements in both clinician and patient measures, the majority of which were maintained over time. The quality of the therapeutic relationship was also enhanced. A hypothesized explanatory model accounting for the data was supported. It was concluded that clinician training to support improved patient adherence should include strategies that also enhance the therapeutic alliance.