Rural and metropolitan South Australian mental health workers’ views about nurse prescribing: A thematic analysis

Almost one third of the South Australian population reside in regional locations, which are serviced by just 8% of the State's total psychiatrist workforce. Consequently, access to psychotropic medications in regional South Australia (SA) can be challenging. Granting prescribing rights to mental health nurses (MHNs) located in regional settings presents an opportunity to increase consumer access to psychotropic medications. The aim of the study was to understand the perspectives of mental health workers (MHWs) practising in regional and metropolitan settings towards MHN prescribing. The study adopted a qualitative approach. Seventeen MHWs participated in three focus groups, including two in regional SA and one in a metropolitan site within the State of SA. Participants reported difficulties in accessing medicines in regional areas. The regional focus groups indicated that MHN prescribing may help to release psychiatrists’ time and provide quicker assessment and diagnosis. By contrast, the metropolitan focus group expressed reservations about MHN prescribing. Participants indicated that suitable governance structures supported by appropriate education programmes were a necessary prerequisite for MHN prescribing of psychotropic medications. MHN prescribing may help to mitigate the impact of psychiatrist shortages in regional South Australia and possibly in other areas of the world where recruitment is a challenge. The provision of adequate education and the establishment of a suitable governance and support framework are considered necessary steps to progress MHN prescribing.     

医学心理学教学和团体咨询对蒙古族医学生心理健康的干预研究

目的 探讨医学心理学教学和团体咨询对蒙古族医学生心理健康的影响,为少数民族大学生心理健康教育提供参考依据。方法 以某高校87名蒙古族医学生为研究对象,开设医学心理学课程,同时对存在心理问题的学生进行团体咨询,干预前后采用症状自评量表(SCL-90)和大学生人格问卷(UPI)测试研究对象的心理健康状况。结果 干预前,87名蒙古族医学生心理健康水平低于全国青年组常模,有23人存在心理问题,各种心理问题检出率为26.44 %;干预后,SCL-90中的各项因子评分均明显低于干预前,差异有统计学意义(P<0.05),有12人存在心理问题,心理问题检出率为13.79 %,明显低于干预前(P<0.05)。结论 医学心理学教学和团体咨询有助于改善医学生心理健康水平。     

Effects of a mental health carve-out on use, costs, and payers: A four-year study

This study examines the effects of a mental health carve-out on a sample of continuously enrolled employees (N = 1,943) over a four-year time frame (1990–1994). The article presents a health care services utilization model of the effect of the carve-out on outpatient mental health use, cost, and source of payment in the three years post implementation relative to the year prior to the carve-out model. In the first three years of the carve-out, the likelihood of employees seeking mental health care increased in significant part because of the carve-out. For the outpatient mental health services user, the carve-out was not associated with the level of mental health services received. The carve-out was significantly associated over time with a reduction in the patient's and employer's mental health costs. This effect was more pronounced in the second and third years of the carve-out. The article explores the policy implications of these and other findings.     

Containing mental health treatment costs through program design: a Massachusetts study.

A single site pre-post study of seriously mentally ill patients treated in a public mental health system shows that annual treatment costs can be substantially reduced with the use of day hospital treatment. Two cohorts of psychiatric patients--282 consecutive admissions to a traditional public inpatient unit in 1980, and 340 consecutive admissions to a combination of inpatient and day hospital care in 1984--were followed 12 months after admission. The substitution of the day hospital is made possible because the facility provided a dormitory residence for those who could not go home at night. Cost savings per hospital episode are about 31 per cent when the additional costs of day hospital and residence are considered. Cost shifting from inpatient to residential sites is noted, but overall mean annual costs, when all other treatment (including additional admissions), residential and family costs were included, are reduced. Readmission rates did not rise. The generalizability of the findings is limited to public mental health centers and state hospitals.     

Achievement levels and mental health in medical students: a Monash University study

An extensive battery of multi-choice psychology tests was administered to Monash University medical students in 1975. Respondents were classified by sex, year and achievement level. Significant differences in parameters of psychological adaptation were detected when students in the three different achievement groups were compared. In general, the low achievers were more depressed and anxious, and less extroverted and empathic than their colleagues. In addition, their own assessment of their mental health was lower than that of their colleagues. They also tended to study less actively, were more prone to avoid the study of core material and derived less gratification overall from the medical course. It is suggested that underachieve-ment in medical students is a danger signal connoting psychological difficulties and that under-achievers constitute a potentially under-counselled group. Counselling facilities should be sufficiently comprehensive to deal with the problems outlined as it is unlikely that this particular set of observations is unique to the group studied who happened to be medical students. The lesson is there for all faculties.     

Substitution in a Medicaid mental health carve-out: services and costs

The objective is to empirically test the incentives associated with a Medicaid capitated mental health carve-out contract, whether outpatient services (less expensive, inside the contract) and residential treatment center care (costly care, outside of the contract) were substituted for inpatient psychiatric hospitalization used by children and adolescents. Data sources include Medicaid fee-for-service (FFS) claims for the non-capitated comparison sites and for residential treatment center use, and "shadow billing" encounter data for the experimental capitated managed care sites that provided public mental health services for children and adolescents with Medicaid insurance statewide in Colorado from September 1994 to June 1997. Two part least squares regression models are used to decompose services. Managed care sites are compared to sites that remained under FFS financing, before and in two post-periods after the carve-out. Principal findings show that children and adolescents who received mental health services from a capitated managed care provider were significantly less likely to receive inpatient care, and significantly more likely to receive residential treatment center care. In addition, insurance contract design contains financial incentives that affect the amount and mix of clinical care provided to clients by risk-bearing provider agencies. Findings provide evidence of cost substitution from inpatient care both inside the specialty system and outside the carve-out to other child-serving systems.     

大额医疗费用与补充医疗保险

作对1997年、1998年云南省某三级甲等医院一次住院费用超过1万元的公费医疗患的情况进行调查分析。对医改后的费用筹集与实际支付的差额问题，从患承受能力、供方管理、建立补充医疗保险的必要性、建立补充医疗保险的医疗消费自我约束机制和商业医疗保险发展方向等几方面问题进行论述，建议应建立符合我国国情的多层次医疗保障体系。     

The mental health residential care study: the "hidden costs" of provision

Reforms to the organization and funding of health and social care in the UK have placed new responsibilities on social and health care purchasers to undertake assessment of the accommodation and care needs of people with mental health problems who are living in the community. This responsibility is hampered by a lack of reliable or complete data on the range of services and costs associated with residential care, in particular the non-accommodation or costs which are hidden in the sense that they are often unaccounted for by individual agencies, such as the use of hospital, community and peripatetic services falling outside residential facilities core functions or budgets. Employing service use and cost data from a wider study of residential care, non-accommodation costs were calculated for a number of residential settings (both in and outside London). As a proportion of total costs of care, these ranged from below 10% in hospital settings to between 13% and 39% in community-based staffed hostels. These figures represent estimates of the cost “add-ons” required for this element of care where only accommodation costs are known. Multiple regression analyses were also undertaken to examine the possible influence of resident, facility and area characteristics on hidden costs. Resident characteristics alone explained only a small amount of the inter-resident variation in hidden costs. The inclusion of care environment, sector and locality enhanced the predictive power of the models. The relevance and interpretation of these findings are discussed.     

高校不同心理健康教育教学方法有效性的对比分析

了解高校心理健康课程对大学生心理健康的影响,为开展有效的心理健康教育提供科学依据.方法 以湖北省某高校学习心理健康必修课的408名大学生为被试,其中216名作为体验组接受体验式教学方法,理论组192人接受传统讲授教学;同时设置未上心理健康课程的120人为对照组,采用自我接纳问卷(SAQ)和一般自我效能感问卷(GSES)进行调查.结果 在开始心理健康课程学习之前,体验组、理论组、对照组三组学生自我接纳、自我效能感各指标得分差异均无统计学意义(P值均>0.05).在1个学期的心理健康课程结束后,对照组各指标得分前后测差异均无统计学意义(P值均>0.05);理论组在SAQ总分和自我接纳维度上后测得分(分别为42.26±5.65,23.03±3.65)均显著高于前测(分别为36.38±4.21,17.66±3.97)(P值均<0.05);体验组在所有测量指标上后测得分均显著高于前测(t值分别为6.781,15.389,16.850,4.864,P值均<0.05).结论 开设心理健康教育课程能有效促进大学生心理健康;相对于知识讲授的传统教学,体验式教学对大学生心理品质提高的效果更显著.     

A comparison of users and nonusers of a school-based health and mental health clinic

This study compares student health and mental health knowledge, behavior, and access to services for adolescents who used and did not use a school-based health and mental health clinic. Data were collected as part of an anonymous, self-administered survey completed by all students in a school housing a clinic that had been in operation for a school year. Comparisons of clinic users and nonusers revealed differences in health- and mental health-related knowledge and behavior and access to needed care. The clinic was found to be serving adolescents at high risk for a variety of psychosocial problems (e.g., drug use, depression, dropout).     

子宫肌瘤手术医疗临床路径与非临床路径对医疗费用控制的对照研究

目的探讨手术医疗临床路径管理对子宫肌瘤医疗费用控制的效能和可行性,为医疗付费方式改进提供循证医学证据。方法以子宫肌瘤手术医疗临床路径为基础,识手术类型为基点设计相应临床路径,对不同临床路径控制下的同类手术治疗医疗费用情况和相同临床路径控制下的不同类手术治疗医疗费用情况进行对照研究,通过医院HIS系统提取相关数据并建立数据库,并对各组数据进行相关的统计学分析。结果不同临床路径控制下的同类手术治疗产生的医疗费用不同、各种医疗费用构成不同、变异也不同,相同临床路径控制下的不同类手术治疗产生的医疗费用不同、各种医疗费用构成不同、变异也不同。结论子宫肌瘤手术医疗临床路径对医疗费用控制效果良好,为其他病种医疗费用控制提供了新思路,也为建立一种全新的付费机制和临床路径的设计提供了新的思路。     

The medical and financial costs associated with termination of a nutrition support nurse

BACKGROUND: Cost-containment pressures have adversely affected hospital nutrition support team staffing. We determined the effect of termination of a nutrition support nurse responsible for patients receiving total parenteral nutrition (TPN) on quality assurance and financial indicators. METHODS: A retrospective review of all 1,093 patients receiving TPN from fiscal year (FY) 1992 through FY 1998 in a tertiary care community hospital. We documented the changes in care during years when the nutrition support nurse position was staffed, terminated, and restored. Indicators studied included inappropriate TPN, central venous line sepsis, TPN wastage, and estimates of preventable costs. RESULTS: When the nurse was present, 8.6% of TPN patients had a functional gastrointestinal (GI) tract and inappropriately received TPN compared with 12.1% when the nurse was absent, a risk difference of 3.5% points (95% confidence interval [CI], -.06 to 8.3; p = .069). Risk of TPN-associated line sepsis increased from 8.8% of patients when the nurse was present to 13.2% when the nurse was absent, a difference of 4.4% points (95% CI, 0.06 to 9.2; p = .028). In the absence of the nurse, 26.3% of TPN patients had preventable charges vs 17.5% when the nurse was present (p < .0001). Total preventable charges were higher in the years without a nurse (p < .003). Total preventable costs increased by $38,148 to $194,285 (depending on the estimate for sepsis) in the year after termination. Reinstatement of the nurse resulted in a decrease in costs between $34,485 and $156,654. CONCLUSIONS: Adequate staffing of a nutrition support team reduced inappropriate TPN and complications of TPN. Financial savings of the same order of magnitude as the nurse's compensation accompany substantial decreases in patient morbidity.     

Providing incentives to control health care costs and remain competitive in the marketplace: a pilot study

Few marketplaces in the United States have been subject to as much scrutiny, and undergone as much transformation in the 1990s, as has health care. Even based on the slowest growth rates experienced in the 1980s and 1990s, the United States is projected to be spending $3,140,221 per minute on health care by the year 2000. The purpose of this study was to examine how coordination between providers of medical care, and working with their customers (i.e., payors) might reduce costs without compromising quality. Providing incentives to these groups of businesses that form the health systems can be a means for achieving both individual health system objectives. Because of the importance of pharmacists in health care delivery systems, they were considered an excellent group for testing and measuring the impact of incentive programs. The study involved a before and after six month period involving dispensing patterns through a pharmacy benefit manager. Incentives were provided to pharmacies based on percent improvement in generic substitution rates and formulary compliance. A network of 342 independent pharmacies, with their dispensing patterns monitored through a pharmacy benefit manager under its contract program. The results of the study were that generic substitution rates rose from the pre-trial period of 68.5% to 73.7% in the first three months of the trial period, and to 75.6% in the second three months of the trial period. The overall increase in substitution was from 68.5% in the base period to 74.7% over six months. These differences were statistically significant at the 0.05 level. Estimated savings to health plans on an annualized basis would be approximately $3.4 million, and the payout per conversion to pharmacies was $3.23. While not measured directly, no adverse clinical effects were reported due to substitutions. Thus, an incentive system to reward those health care providers can effectively control expenses to achieve mutually desirable goals of all parties. If properly structured, the providers, health systems of which they are a part, and payors can benefit. Using an incentive program like the one designed for this study, health systems may be able to be more competitive in marketing their services to payors.     

Smoking behaviour and health care costs coverage: a European cross-country comparison

The empirical evidence about the effect of smoking on health care cost coverage is not consistent with the expectations based on the notion of adverse selection. This evidence is mostly based on correlational studies which cannot isolate the adverse selection effect from the moral hazard effect. Exploiting data from the Survey of Health, Aging, and Retirement in Europe, this study uses an instrumental variable strategy to identify the causal effect of daily smoking on perceived health care cost coverage of those at age 50 or above in 12 European countries. Daily smoking is instrumented by a variable indicating whether or not there is any other daily smoker in the household. A self-assessment of health care cost coverage is used as the outcome measure. Among those who live with a partner (72% of the sample), the result is not statistically significant which means we find no effect of smoking on perceived health care cost coverage. However, among those who live without a partner, the results show that daily smokers have lower self-assessed perceived health care cost coverage. This finding replicates the same counter-intuitive relationship between smoking and health insurance presented in previous studies, but in a language of causality. In addition to this, we contribute to previous studies by a cross-country comparison which brings in different institutional arrangements, and by using the self-assessed perceived health care cost coverage which is broader than health insurance coverage.     

Doomed to fail: the persistent search for a modernist mental health nurse identity

The perennial issue of the distinctiveness of the mental health nurse (MHN) is once again to the fore. Previous attempts to resolve this apparent identity crisis in the discipline have included proposals for new models, new research and new educational preparation as well as new alliances, and new ways of practising. Now the politically driven concept of the generic nurse is gaining enough momentum to potentially end the discussion once and for all. This paper takes a postmodernist approach to MHN identity that questions the requirement for MHNs to articulate their distinctiveness, and offers alternative constructions of this identity to those promulgated by policy makers and by other health disciplines.     

Surfacing the life phases of a mental health support group

Support groups have increased rapidly in number and become a viable alternative to formal treatment in the United States. However, little is known regarding how mental health advocacy or support groups start and develop, or about challenges that can threaten their survival. In this 2 1/2-year ethnography, the author studied the culture of a developing family support program associated with a system of care. Several phases emerged, reflecting an organizational dynamic. The group dynamics and response to challenges have implications for organizers and parent organizations about the need for technical assistance necessary for survival of the group. Participant observation and immersion in the culture of such groups can provide a deeper understanding of the ideologies and values around which they organize and the kinds of tensions that members can experience during the group's cycle.     

七年制与五年制学生临床阶段心理健康状况比较

目的 探讨临床阶段七年制与五年制学生的心理健康状况及其差异，以便有效进行心理健康教育。方法采用症状自评量表（SCL-90）对临床阶段236名七年制学生、334名五年制学生进行测试和比较研究。结果 临床阶段七年制与五年制学生心理健康状况比全国正常人群常模差；七年制与五年制学生除强迫症状外，差异无显著意义；临床阶段七年制学生13．5％有明显的心理问题，主要表现为强迫症状。结论 针对临床阶段七年制学生的心理问题特点开展心理健康教育。