Family Organizations in Children’s Mental Health Systems of Care: the Challenge of Maintaining Financial Sustainability

The Journal of Behavioral Health Services & Research - Family-run organizations are an important source of support for families of children with serious emotional disturbance, yet little work...     

The Sustainability of Systems of Care for Children’s Mental Health: Lessons Learned

The federal Comprehensive Community Mental Health Services for Children and Their Families Program was initiated in 1992 to provide grants to states, communities, territories, and Indian tribes to develop systems of care to serve children and adolescents with or at risk for emotional disorders and their families. As part of the national evaluation of this program, a study was undertaken to assess the ability of funded sites to sustain their systems of care beyond the federal grant period. The study involved a web survey and telephone interviews with local and state respondents to examine the extent to which key components of systems of care were maintained during the period in which federal funds were phasing out and during the postgrant period. Study results demonstrate positive and negative changes that occurred in the communities which are included in the sample, with respect to maintaining the availability of each service included in the broad service array, the implementation of system of care principles, the system of care infrastructure, and the achievement of system of care goals. In addition, results identify factors that contribute to or impede the ability to sustain systems of care, and the effectiveness of various strategies for sustainability. Study findings offer guidance not only to federally funded system of care communities but also to nonfunded communities engaged in system of care development to enhance their ability to sustain systems of care for this population over time. Findings will also assist federal, state, and local policymakers, technical assistance providers, family members, advocates, and other key stakeholders to more effectively support the development of viable, sustainable systems of care.     

Assessment of University Students’ Suboptimal Health and Social Media Use: Implications for Health Regulatory Authorities

Journal of Community Health - This study aimed to assess the patterns of social media usage amongst university students at Ajman University (AU) and to explore health issues in relation to social...     

Community Health Development: A Strategy for Reinventing America’s Health Care System One Community at a Time

The purpose of this article is to propose a set of ideas for reinventing America’s health care system, one community at a time. Community health development is proposed as a strategy and approach to population health improvement, the ultimate goal of health care reform. The practice of community health development, particularly the partnership approach, provides guidance about how this approach might be employed as a national health care reform strategy. Examples of two communities successfully using the partnership approach illustrate the methods described. Six specific recommendations for policy makers and public administrators in the new administration resulting from our experience with community health development are presented. First, adopt and apply community health development (CHD) as the American approach for facilitating population health improvement and building community capacity. Second, the partnership approach should be promoted as a model for communities to use in implementing CHD. Third, make the community-level the focus for planning, implementing, evaluating, and sustaining a full continuum of health and human services. Fourth, formally recognize the social determinants of health as a key component of a new population/community health status model and as a public policy driver for health care reform, marketplace issues, and population health status improvement at all levels of society. Fifth is a call for a national strategy for the recruitment, training, education, and support of individuals to facilitate this community movement. Sixth, Congress and the Obama Administration adopt and apply CHD as a national strategy and utilize American community-based experiences to bring about a national plan.     

Health Care Students’ Attitudes Towards Working with Sexual Health in Their Professional Roles: Survey of Students at Nursing,Physiotherapy and Occupational Therapy Programmes

The aim of this study was to explore differences and similarities in health care students’ attitudes towards working with and communicating with patients about sexual health issues in their future professions. The aim was also to explore whether the students’ gender, age and future professions were influencing factors and whether there was a change in attitude depending on educational levels, gender, age and future professions. The study also aimed to explore the potential development of those differences and similarities in attitudes between health care students having achieved different levels of education and training in their future professions. A cross-sectional quantitative study was performed with an online survey distributed to nursing, occupational therapy and physiotherapy students. The students believed that they needed increased sexual health education and increased communication skills about sexual health. Gender and future profession are factors that significantly affect the attitudes of the students towards working with sexual health. Nursing and occupational therapy students have a more positive attitude towards addressing sexual health in their future professions than do physiotherapy students. Further research is needed in this field to improve competence in sexual health for all student groups, particularly physiotherapy students. Further research is also needed to explore the significance of gender regarding education in sexual health and attitudes towards working with sexual health.     

“Chaplains for Wellbeing” in Primary Care: A Qualitative Investigation of Their Perceived Impact for Patients’ Health and Wellbeing

The growing importance of professional chaplains in patient-centered care has raised questions about education for professional chaplaincy. One recommendation is that the curricula of Clinical Pastoral Education (CPE) residency programs make use of the chaplaincy certification competencies. To determine the adoption of this recommendation, we surveyed CPE supervisors from 26 recently re-accredited, stipended CPE residency programs. We found the curricula of 38% of these programs had substantive engagement with the certification competencies, 38% only introduced students to the competences, and 23% of the programs made no mention of them. The majority of the supervisors (59%) felt engagement with the competencies should be required while 15% were opposed to such a requirement. Greater engagement with chaplaincy certification competencies is one of several approaches to improvements in chaplaincy education that should be considered to ensure that chaplains have the training needed to function effectively in a complex and changing healthcare environment.     

Health Promotion and Managed Care:: Surveys of California’s Health Plans and Population

Introduction:The purpose was to examine whether health-promotion programs offered by California health plans are a serious attempt to improve health status or a marketing device used in an increasingly competetive marketplace. The research examined differences in the coverage, availability, utilization, and evaluation of health-promotion programs in California health plans.Methods:A mail survey was done of the 35 HMOs (86% response) and 18 health insurance carriers (83% response) licensed to sell comprehensive health insurance in California in 1996 (some plans sell both HMO and PPO/indemnity products). The final sample included 30 commercial HMOs and 20 PPO and indemnity plans. The 1996 California Behavioral Risk Factor Survey (BRFS) of 4,000 adults was used to estimate population participation rates in health-promotion programs.Results:California’s HMOs in 1996 offered more comprehensive preventive benefits and health-promotion programs compared to PPO and indemnity plans. HMOs relied on a more comprehensive set of health-education methods to communicate health information to members and were more likely to open their programs to the public. HMOs are also more likely to have developed relationships with community-based and public health providers. Participation in health-promotion programs is low (2%–3%), regardless of plan type, and most health plans limit evaluations to assessment of member satisfaction and utilization. Only 35%–45% of HMOs, and no PPO/indemnity plans, assess the impact of health-promotion programs on health risks and behaviors, health status, or health care costs.Conclusion:For the majority of California’s PPO and indemnity plans, health promotion is not an integral part of their business. For the majority of HMOs, health-promotion programs are offered primarily as a marketing vehicle. However, a substantial minority of HMOs offer health-promotion programs to achieve other organizational goals of health improvement and cost control.     

Rethinking Preconception Care: A Critical,Women’s Health Perspective

Objectives Preconception care aims to provide care to reproductive aged individuals in order to improve pregnancy and birth outcomes. Given that preconception care is a public health priority, it is important to evaluate the evolution of this health paradigm and the promotion of preconception messages that are obtained by the public. We identified online preconception health messages, which were critically assessed through a women’s health perspective. Methods We searched for “preconception care” on three major search engines. Websites were included if they were U.S.-based, provided content in English, and mentioned preconception care. Blogs and journal articles were excluded. The final sample included 52 websites. Using a content analysis approach, we assessed the presence of gender bias and identified other emergent themes. Results The majority of websites focused on preconception care for women only (67%). The recommendations centered on: (1) health behaviors for women (e.g., folic acid, drinking, smoking); (2) visiting healthcare providers; and (3) evaluating medical risks. Moreover, most content implied that women desired, or should desire, pregnancy. Overall, the messages used biomedical language and rarely mentioned other important health topics, such as social support and violence. Conclusions The primary messages presented on preconception care websites emphasized biomedical aspects of women’s health. The current context of preconception care medicalizes this pre-pregnancy period by defining it as a biomedical condition requiring lifestyle changes and interventions. Additionally, the biases presented in these messages assumed women want and are capable of pregnancies and excluded an integral factor for heteronormative reproduction—men.

     

Advancing a Shared Conversation to Enhance Health Care Enrollment in the United States—A Timely Opportunity and Challenge for Health Literacy

Few published studies describe processes in the development of mobile health interventions. This study reports data from a formative evaluation of a text messaging intervention being developed to increase adherence to smoking cessation medication (varenicline) among tobacco-dependent persons with HIV/AIDS. Four focus groups were conducted (N = 29) using a mixed-methods approach to assess: (a) beliefs and preferences regarding the use of varenicline, (b) preferences for receiving tobacco-related texts, and (c) the acceptability of draft text messages. Themes that emerged from the focus groups were that (a) participants were cautious and wanted to discuss varenicline carefully with health care providers, (b) participants preferred simple messages that were positive and encouraging, (c) messages should emphasize tobacco cessation and not varenicline adherence, and (d) texts would serve as a reminder about goals and foster support and connectedness with the health care team. Overall, 47 out of the 100 messages received a grade of C or less (rated on a 5-point grade scale: A, B, C, D, or F), the majority of which focused on medication adherence. All participants reported that they were likely to read the messages. The majority (64%) indicated that they preferred receiving 2 or more messages per day. Gathering systematic participant feedback provides critical input in intervention planning.     

Group Well-Child Care and Health Services Utilization: A Bilingual Qualitative Analysis of Parents’ Perspectives

Maternal and Child Health Journal - Objective Alternative primary care structures such as group well-child care (GWCC) may enhance care for families, particularly those subject to structural...     

Defining “Rural” for Veterans’ Health Care Planning

Purpose: The Veterans Health Administration (VHA) devised an algorithm to classify veterans as Urban, Rural, or Highly Rural residents. To understand the policy implications of the VHA scheme, we compared its categories to 3 Office of Management and Budget (OMB) and 4 Rural-Urban Commuting Area (RUCA) geographical categories. Method: Using residence information for VHA health care enrollees, we compared urban-rural classifications under the VHA, OMB, and RUCA schemes; the distributions of rural enrollees across VHA health care networks (Veterans Integrated Service Networks [VISNs]); and how each scheme indicates whether VHA standards for travel time to care are met for the most rural veterans. Results: VHA's Highly Rural and Urban categories are much smaller than the most rural or most urban categories in the other schemes, while its Rural category is much larger than their intermediate categories. Most Highly Rural veterans live in VISNs serving the Rocky Mountains and Alaska. Veterans defined as the most rural by RUCA or OMB are distributed more evenly across most VISNs. Nearly all urban enrollees live within VHA standards for travel time to access VHA care; so do most enrollees defined by RUCA or OMB as the most rural. Only half of Highly Rural enrollees, however, live within an hour of primary care, and 70% must travel more than 2 hours to acute care or 4 hours to tertiary care. Conclusions: VHA's Rural category is very large and broadly dispersed; policy makers should supplement analyses of Rural veterans’ health care needs with more detailed breakdowns. Most of VHA's Highly Rural enrollees live in the western United States where distances to care are great and alternative delivery systems may be needed.     

Integration of Oral Health Care and Mental Health Services: Dental Hygienists’ Readiness and Capacity for Secondary Prevention of Eating Disorders

Often the first to observe overt health effects of eating disorders, dentists and dental hygienists play a fundamental role in the secondary prevention of eating disorders. The purpose of this study was to explore readiness and capacity for integration of oral health and mental health services. Employing a randomized cross-sectional study based upon the Transtheoretical and Health Belief Models, data were collected from 378 dental hygienists. Results reveal that the majority do not currently engage in secondary prevention practices. Only 18% of respondents indicated referring patients exhibiting oral manifestations of eating disorders to treatment. Significantly increasing the likelihood of assessment, referral, and case management included modifying factors regarding greater perceived self-efficacy, and knowledge of oral cues of disordered eating, as well as the individual’s perception pertaining to severity of eating disorders. Implications for bridging dental care to mental health services include increasing behavioral capacity among dental hygienists via consciousness raising and improved self-efficacy. Stacey B. Plichta ScD, is an associate professor of School of Community and Environmental Health, Old Dominion University, 140c Spong Hall, Norfolk, VA 23529, USA. Lisa A. Tedesco PhD, is a vice president and secretary of The University of Michigan, 2014 Fleming Administration Building, 503 Thompson Street, Ann Arbor, MI 48109-1340, USA. Wendy E. Kerschbaum, RDH, MPH, is an associate professor and director of Dental Hygiene in the Department of Periodontics, Prevention, & Geriatrics, University of Michigan, School of Dentistry, 1011 N. University, Ann Arbor, MI 48109-1078, USA.     

Impact of Medical Home on Health Care of Children With and Without Special Health Care Needs: Update from the 2016 National Survey of Children’s Health

Objective The medical home has been promoted as an optimal model of health care delivery for children. The purpose of this study was to examine the association between having access to a medical home and the health care experiences of children with and without special health care needs (SHCN) in the United States. Methods We analyzed data from the 2016 National Survey of Children’s Health. We modeled logistic regressions to assess associations of having access to a medical home with health care experiences for 11,392 CSHCN and 38,820 non-CSHCN. Results We found that not having access to a medical home was negatively associated with preventive medical and dental care visits, greater unmet medical and dental needs, and hospital emergency room visits. Additionally, not having access to a medical home was negatively associated with the physical and oral health among CSHCN and oral health among non-CSHCN. However, we found no significant association between improved physical health status and having access to a medical home among non-CSHCN. Conclusions Results from our analysis suggest that having access to a medical home remains key determinant of improved health care experiences by CSHCN and non-CSHCN in the United States. Our findings underscore the need to develop policies and implement a more concerted program to increase access to health care delivered under the medical home model for CSHCN and non-CSHCN. Policymakers, health care administrators and physician groups can use these findings to inform future policy decisions and service delivery reforms.

     

Patterns of Health Insurance Discontinuity and Children’s Access to Health Care

Objectives This study classified patterns of discontinuous health insurance coverage, including change in coverage type and gaps in coverage, and described their associations with children’s access to health care. Methods Using the 2011–2013 National Health Interview Survey data, we determined children’s insurance coverage over the past year, and whether children had a usual source of care, had to delay getting care, or had unmet health care needs. Using multivariable logistic regression, we compared measures of access to care across insurance coverage patterns, classified as continuous private coverage; continuous public coverage; continuous lack of coverage; change in coverage type (public versus private) without gaps in coverage; and any gap in coverage. A subgroup analysis repeated this comparison for children with a caregiver-reported chronic physical illness. Results The analysis included 34,105 children, of whom 7% had a gap in coverage and 1% had a change in coverage type. On multivariable analysis, gaps in coverage were associated with increased likelihood of unmet health care needs, compared to continuous private (OR 6.9; 95% CI 5.9, 8.0) or continuous public coverage (OR 5.1; 95% CI 4.4, 6.0). Seamless changes in coverage were also associated with greater likelihood of unmet health care needs [OR vs. private: 3.8 (95% CI 2.3, 6.1); OR vs. public: 2.8 (95% CI 1.8, 4.6); all p < 0.001]. Results were similar for other study outcomes, and among children with chronic physical illness. Conclusions for Practice Both gaps in coverage and seamless changes between coverage types were associated with limited health care access for children.

     

The effect of commissioning on Portuguese Primary Health Care units’ performance: A four-year national analysis

BackgroundPortugal underwent a paradigmatic Primary Health Care (PHC) reform in 2005. The reform implemented better health information systems, goal-oriented management, pay-for-performance schemes, functional autonomy for the front-line units, and the general adoption of commissioning processes.Since the implementation of the reform, the same set of indicators have been monitored nationally every year. However, from 2014–2016, the five Regional Health Administrations could individually select part of set of indicators to be commissioned.As the same some indicators were used commissioned in some regions, but not in others, a natural experimental setting to observe the impact of commissioning on the results by comparing the performance of commissioned versus non-commissioned indicators emerged and the effects of commissioning on PHC performance could be evaluated.AimOur article aims to clarify the effect of commissioning on the results achieved by PHC units in Portugal following the implementation of the reform.ResultsIn general, the indicator values improved with time in the three types of units that existed after the reform. However, Model B Family Health Units (‘Unidades de Saúde Familiar’ or USFs that use pay-for-performance and are more mature) obtained the highest absolute indicator values, followed by Model A USFs (newer units with a fixed salary) and Personalised Health Care Units (‘Unidades de Cuidados de Saúde Personalizados’ that were created under the model before the reform and offer a fixed salary), respectively.ConclusionThe results show a general increase in indicators in all PHC units. However, the indicators used in the commissioning processes exhibited a greater increase. There was no evidence that the better results exhibited by the commissioned indicators were achieved at the expense of a detrimental effect on non-commissioned indicators.     

Children’s Receipt of Health Care Services and Family Health Insurance Patterns

PURPOSE Insured children in the United States have better access to health care services; less is known about how parental coverage affects children’s access to care. We examined the association between parent-child health insurance coverage patterns and children’s access to health care and preventive counseling services.METHODS We conducted secondary analyses of nationally representative, cross-sectional, pooled 2002–2006 data from children (n = 43,509), aged 2 to 17 years, in households responding to the Medical Expenditure Panel Survey (MEPS). We assessed 9 outcome measures pertaining to children’s unmet health care and preventive counseling needs.RESULTS Cross-sectionally, among US children (aged 2 to 17 years) living with at least 1 parent, 73.6% were insured with insured parents, 8.0% were uninsured with uninsured parents, and the remaining 18.4% had discordant family insurance coverage patterns. In multivariable analyses, insured children with uninsured parents had higher odds of an insurance coverage gap (odds ratio [OR] = 2.45; 95% confidence interval [CI], 2.02–2.97), no usual source of care (OR = 1.31; 95% CI, 1.10–1.56), unmet health care needs (OR = 1.11; 95% CI, 1.01–1.22), and having never received at least 1 preventive counseling service (OR = 1.20; 95% CI, 1.04–1.39) when compared with insured children with insured parents. Insured children with mixed parental insurance coverage had similar vulnerabilities.CONCLUSIONS Uninsured children had the highest rates of unmet needs overall, with fewer differences based on parental insurance status. For insured children, having uninsured parents was associated with higher odds of going without necessary services when compared with having insured parents.     

Accountable Care for the Poor and Underserved: Minnesota’s Hennepin Health Model

Hennepin Health provides integrated medical and social services to low-income Medicaid patients in a large county located in Minneapolis, Minnesota. Data sharing is critical to program operations along with care coordination provided by community health workers. Early evidence indicates fewer emergency department visits and increased use of outpatient primary care. By focusing on prevention, coordination, and team-based care, the county hopes to improve individuals’ quality of life while reducing costs through better care management and reductions in emergency department use.Hennepin Health represents a new model of integrated care targeted to low-income individuals with complex health and social needs—needs very similar to the Affordable Care Act Medicaid expansion population. The program is supported by enhanced data integration to better coordinate medical care with other needed social services in a capitated Accountable Care Organization (ACO) framework. The positive outcomes achieved and the ability to reinvest in the model have helped to garner political support and have motivated providers and care teams who see the opportunities to make a difference in the lives of a largely disenfranchised patient population. Hennepin Health provides an integrated care management model that other care plans can use to improve care and lower costs for the Medicaid expansion population under the Affordable Care Act.     

Patterns of Older Americans’ Health Care Utilization Over Time

Objectives. We analyzed correlates of older Americans’ continuous and transitional health care utilization over 4 years.Methods. We analyzed data for civilian, noninstitutionalized US individuals older than 50 years from the 2006 and 2008 waves of the Health and Retirement Study. We estimated multinomial logistic models of persistent and intermittent use of physician, inpatient hospital, home health, and outpatient surgery over the 2004–2008 survey periods.Results. Individuals with worse or worsening health were more likely to persistently use medical care and transition into care and not transition out of care over time. Financial variables were less often significant and, when significant, were often in an unexpected direction.Conclusions. Older individuals’ health and changes in health are more strongly correlated with persistence of and changes in care-seeking behavior over time than are financial status and changes in financial status. The more pronounced sensitivity to health status and changes in health are important considerations in insurance and retirement policy reforms.In choosing to seek medical care, individuals weigh the financial cost of treatment against its perceived benefit to their health. Clearly physician input, in combination with the presence and generosity of health insurance coverage, weighs heavily in this decision. As individuals age they begin to experience the onset of new health conditions at the same time that their households often begin to deplete their savings to finance retirement.1–4 Because of these new experiences and potentially limited financial resources, older individuals may become more selective in which types of care they receive, perhaps focusing first on their most pressing medical needs or delaying or skipping procedures prescribed by their physician that they deem relatively costly or not immediately necessary.Studies have investigated the differences in health care expenses for the elderly by health status and changes in health status,5 the changes in health related to persistence or changes in health insurance coverage for the near elderly,6 correlation between health and health insurance coverage,7,8 and the relationship between functional change and hospital use and cost.9 None of these studies, however, has focused on the relative importance of financial versus health factors in determining an elderly population’s persistent or intermittent health care use over time.The motivation for our study comes from a related recent analysis we conducted showing that dental use was surprisingly resistant to changes in household net wealth and household income.1 We found that only when household net wealth falls by 50% or more were older adults less likely to seek dental care.1 This finding inspired our interest in pursuing related findings for medical care.In this study, we determined correlates of continuous and intermittent health care use for a population of civilian, noninstitutionalized Americans older than 50 years. This population is of particular concern because they consume an increasingly disproportionate share of health care as the baby boomer generation advances to the top of the national age distribution. We investigated the relative strengths of financial factors and health factors at 1 point in time and over time as correlates of this older population’s altering or continuing medical care use.Our analysis is particularly relevant at a time when the financial status of many US households has been affected adversely by economic conditions.10 We used longitudinal data from the 2006 and 2008 waves of the Health and Retirement Study (HRS) to explore health and financial factors associated with older adults’ changes in and persistence of health care use between these periods, including (1) physician visits, (2) overnight hospital stays, (3) outpatient surgery, and (4) home health care. We hypothesized for this population that health factors would outweigh financial factors in explaining continuous and intermittent health care use over this period.