Patient Capacity in Mental Health Care: Legal Overview

The discriminatory effects of categorizing psychiatric patients into competent and incompetent, have urged lawyers, philosophers and health care professionals to seek a functional approach to capacity assessment. Dutch and English law have produced some guidelines concerning this issue. So far, most legal systems under investigation have concentrated on alternatives for informed consent by the patient in case of mental incapacity, notably substitute decision-making, intervention of a judge and advance directives. It is hard to judge the way in which the law may further adapt to a more functional assessment of capacity, because the nature of law shows that legal reforms usually take place only when new methods have been accepted by the field. This is not yet the case today.     

寻找失去的奶酪

医院该不该提高医疗服务收费标准？“以药养医”的源头在哪里？     

The Mental Capacity Act 2005: implications for dietetic practice

The Mental Capacity Act (MCA) 2005 will be implemented in England and Wales in 2007 and have consequences for dietitians who work with people who may lack capacity to make specific decisions. This paper will explore issues arising from the introduction of the Act and considers the implications for dietitians involved in the delivery of clinical care, using enteral feeding as an illustrative example. If patients lack capacity to make specific decisions, dietitians will be required to record if, how and why they reached a decision, how they are involved in the decision making process and need to be able to justify their actions in relation to those decisions. This paper discusses the importance of dietitians' involvement in best interests decision making and considers the implications of decision making where people have drawn up a Lasting Power of Attorney. The role of such advance decisions is discussed and consideration is given to the potential compatibility of perspectives between the patient and family that may give rise to disputes. Dietitians may be well placed within multidisciplinary team working to ensure patients and their carers are part of the decision making process through effective communication and support for patients. Dietitians in England and Wales must consider the implications of the MCA upon their clinical practice and others outside these jurisdictions may like to reflect on the relevance of such developments in their own contexts.     

In Search of the MCH Professional

One of the goals of the Maternal and Child Health Journal is to encourage professional development. This letter was written to the Editor in light-hearted spirit to convey the true challenge such a goal poses for the journal and the profession.     

Consumer and Case Manager Perspectives of Service Empowerment: Relationship to Mental Health Recovery

This study examines the relationship between service empowerment and recovery. Service empowerment is defined as the extent to which consumers participate in service decisions and the level of reciprocity and respect within the relationship with their case managers. Assessments were made from two perspectives: consumers and their case managers. Structural equation models were developed to examine the direct and indirect effects of service empowerment on four recovery outcomes: Quality of Life, Level of Functioning, Consumer-Reported Symptomatology, and Case Manager-Reported Symptomatology. Consumers' perceptions of service empowerment were the most powerful predictor of recovery outcomes across the four models. Consumers' and case managers' perceptions were related but the magnitude of the relationship was small, indicating that considerable differences exist between their perceptions of service empowerment.Wilma J. Lutz, PhD, RN, Office of Program Evaluation & Research, Ohio Department of Mental Health, Columbus, OH, USA.Dee Roth, MA, Office of Program Evaluation & Research, Ohio Department of Mental Health, Coloumbus, OH, USA.     

Hidden Children: Perspectives of Professionals on Young Carers of People with Mental Health Problems

Young carers of people with mental health problems are highly hidden, ostracised and vulnerable. To make matters worse, many professionals from the social, health and education sectors are not fully aware of the difficulties and central issues facing young carers of people with mental health problems. In order to make young carers of people with mental health problems more visible and to explore gaps in need and good practice from the perspectives of professionals, 65 participants were interviewed. The sample included professionals from the social, healthcare and voluntary sectors. Respondents were asked to discuss their understanding of young carers and appropriate interventions and methods to address young carers’ needs. Findings highlight: young carers’ isolation, stigma and restricted opportunities; fears involving family separation and child protection; and examples of good professional practice. New findings and examples of good professional practice that provide holistic, sensitive and effective support include: young carer groups and forums; young carer days; raising awareness of young carers in schools, especially via technology such as DVDs and the Internet; and having key workers to befriend young carers so as to advocate for better care, to provide emotional and psychological support and to facilitate young carer involvement.     

In Search of Financial Savings from Disease Management

Background

In a previous article using population-level data, an a priori number-needed-to-decrease (NND) analysis was conducted to determine if there is potential opportunity in a given population for a disease management program to achieve financial effectiveness. Critics of that study have suggested that analysis at the entire population level does not account for differential enrollment trends. They also contend that reviewing disease-only hospitalization data disregards changes in acute utilization for comorbidities of the primary condition. This article responds to these two criticisms by critically examining the hypothesis that evaluating a specific diseased cohort elicits more reasonable projections of the financial effectiveness of a disease management program than when the analysis is conducted at the population level. To do this, this article reports the results of an a priori NND analysis of hospitalizations conducted on a diabetes mellitus cohort.

Methods

An NND analysis was conducted on a diabetes cohort that was identified in a health plan population using Health Plan Employer Data and Information Set (HEDIS®) criteria. Hospitalizations were categorized in three groups: diabetes-only; diabetes plus comorbid conditions; and diabetes plus comorbid conditions and diagnoses possibly associated with diabetes.

Results

To cover fees alone, it is estimated that a disease management program would have to reduce diabetes-only hospitalizations by 74%; hospitalizations for diabetes and comorbid conditions by 39%; or hospitalizations for diabetes, comorbid conditions, and diagnoses possibly associated with diabetes by 26%.

Conclusions

The findings of the present study indicate that when performing the NND analysis at the cohort level as opposed to at the population level, even more stringent levels of performance are required to break even. Given that program fees is the only variable that can truly be manipulated a priori by the disease management program under the current model to improve the likelihood of achieving economic effectiveness, alternative approaches to this dilemma are discussed.