Knowledge and Social Work in Health Care—The Case of Finland

Abstract

Studies carried out in different countries have shown that there is a lack of a common and up-dated knowledge base in social work, and that social workers make use of research in their everyday practice only to a very limited extent. On the other hand it has been shown that social workers feel they need knowledge but not necessarily in the form it is produced by the researchers.

This paper explores issues of knowledge and competence in health social work based on the results of a survey and a focus group interview conducted among social workers in Finland. According to the results, social workers in health care do feel they need new knowledge. Some significant differences were found in the way health social workers view the acquisition and maintenance of professional competence and in the way they seek knowledge, when compared to social workers working in the municipal social services.     

Is Health Insurance Enough? A Usual Source of Care may be More Important to Ensure a Child Receives Preventive Health Counseling

Despite the promise of expanded health insurance coverage for children in the United States, a usual source of care (USC) may have a bigger impact on a child’s receipt of preventive health counseling. We examined the effects of insurance versus USC on receipt of education and counseling regarding prevention of childhood injuries and disease. We conducted secondary analyses of 2002–2006 data from a nationally-representative sample of child participants (≤17 years) in the Medical Expenditure Panel Survey (n = 49,947). Children with both insurance and a USC had the lowest rates of missed counseling, and children with neither one had the highest rates. Children with only insurance were more likely than those with only a USC to have never received preventive health counseling from a health care provider regarding healthy eating (aRR 1.21, 95% CI 1.12–1.31); regular exercise (aRR 1.06, 95% CI 1.01–1.12), use of car safety devices (aRR 1.10, 95% CI 1.03–1.17), use of bicycle helmets (aRR 1.11, 95% CI 1.05–1.18), and risks of second hand smoke exposure (aRR 1.12, 95% CI 1.04–1.20). A USC may play an equally or more important role than insurance in improving access to health education and counseling for children. To better meet preventive counseling needs of children, a robust primary care workforce and improved delivery of care in medical homes must accompany expansions in insurance coverage.     

Co-Responsibility: a New Horizon for Today’s Health Care?

In this article, we focus at a key concept of today’s healthcare, namely responsibility. Personal responsibility is so important today because it is obvious that the way society is organized, many people are facing a lot of difficulties to live their lives in a responsible way. We explicitly obtain an analysis of responsibility from a view which avoids the binary thinking which is so remarkably present in today’s health care discourse. The aim of this pilot study is therefore to open up the horizon of the use of responsibility in today’s healthcare. We develop the notion of ‘co-responsibility’ to understand how individuals, despite the fact they are responsible for their own agency, are always also affected by an ought which contaminates their efforts to fulfill their duties and obligations. We discuss co-responsibility not as conclusion or a magic formula to all problems, but as a new starting point of which we have to explore the opportunities for current and future health care dilemmas.     

Towards Cost-Value Analysis in Health Care?

By describing societal value judgements in health care in numerical terms one may in theory increase the precision of guidelines for priority setting and allow decision makers to judge more accurately the degree to which different health care programs provide societal value for money. However, valuing health programs in terms of QALYs disregards salient societal concerns for fairness in resource allocation. A different kind of numerical valuation of medical interventions, that incorporates concerns for fairness, is described. The usefulness to decision makers of such numerical information remains to be tested. This revised version was published online in August 2006 with corrections to the Cover Date.     

How is Primary Health Care conceptualised in nursing in Australia? A review of the literature

Australia, in common with many other countries, is expanding the role of Primary Health Care (PHC) to manage the growing burden of chronic disease and prevent hospitalisation. Australia's First National Primary Health Care Strategy released in 2010 places general practice at the centre of care delivery, reflecting a constitutional division of labour in which the Commonwealth government's primary means of affecting care delivery in this sector is through rebates for services delivered from the universal healthcare system Medicare. A review of Australian nursing literature was undertaken for 2006–2011. This review explores three issues in relation to these changes: How PHC is conceptualised within Australian nursing literature; who is viewed as providing PHC; and barriers and enablers to the provision of comprehensive PHC. A review of the literature suggests that the terms ‘PHC’ and ‘primary care’ are used interchangeably and that PHC is now commonly associated with services provided by practice nurses. Four structural factors are identified for a shift away from comprehensive PHC, namely fiscal barriers, educational preparation for primary care practice, poor role definition and interprofessional relationships. The paper concludes that while moves towards increasing capacity in general practice have enhanced nursing roles, current policy and the nature of private business funding alongside some medical opposition limit opportunities for Australian nurses working in general practice.     

Disparities in Adolescent Health and Health Care: Does Socioeconomic Status Matter?

DATA COLLECTION/EXTRACTION METHODS: National household survey. DATA SOURCES/STUDY SETTING: We analyzed data on 12,434 adolescents (10 through 18 years old) included in the 1999 and 2000 editions of the National Health Interview Survey. STUDY DESIGN: We assessed the presence of income gradients using four income groups. Outcome variables included health status, health insurance coverage, access to and satisfaction with care, utilization, and unmet health needs. PRINCIPAL FINDINGS: After adjustment for confounding variables using multivariate analysis, statistically significant disparities were found between poor adolescents and their counterparts in middle- and higher-income families for three of four health status measures, six of eight measures of access to and satisfaction with care, and for six of nine indicators of access to and use of medical care, dental care, and mental health care. CONCLUSION: Our analyses indicate adolescents in low-income families remain at a disadvantage despite expansions of the Medicaid program and the comparatively new State Children's Health Insurance Program (SCHIP). Additional efforts are needed to ensure eligible adolescents are enrolled in these programs. Nonfinancial barriers to care must also be addressed to reduce inequities.     

Managing Care? Medicare Managed Care and Patient Use of Cardiologists

Objective. To examine the impact of Medicare managed care (MMC) versus Medicare fee for service (MFFS) on stent patients' use of physicians with lower resource use and better outcomes. Data Sources/Study Setting. Retrospective secondary data from 2003 through 2006 for 67,476 patients without acute myocardial infarction, staying 2 or more days in hospital, and treated by 486 physicians in Florida performing 10 or more cases per quarter. Study Design. Analysis was at the patient level. Multivariate logistic models estimated the probability of an MMC patient using a physician with a particular risk‐adjusted profile rank with respect to hospital peers. Principal Findings. No differences were found in usage of physicians with shorter admissions. Compared with MFFS, MMC patients were significantly less likely to use physicians whose average mortality was the lowest/lowest quartiles/below median among facility peers, and more likely to use a physician ranked below median on live discharges directly home (not needing home health care, skilled nursing care, or a subacute hospital convalescence). Similar results were found with emergency admissions, and where physicians both attended and treated. Conclusions. Florida percutaneous coronary interventions patients insured by MMC used physicians with worse outcome profiles than those of MFFS patients. Results were not consistent with hospital care differences, physician–patient, or payor–physician selection, but they were consistent with selection of unobservably sicker members into MMC and concentration of MMC among physicians.     

Health Care Students’ Differing Conceptions of Expertise: A Challenge for Inter-Professional Care

The aim of the study was to examine do health care students, who study at different programs, value similar expert qualities. To investigate this issue, a questionnaire was administered among health care students in a Finnish polytechnic (two cohorts, total n = 466), consisting of a scale for rating the importance of different expert qualities. The questionnaire resulted in the following dimensions of the conceptions of expertise: (1) social skills, (2) scientific skills, (3) innovativeness, (4) continuing self-development, and (5) problem-solving skills. Also the Inventory of General Study Orientations (IGSO) was applied to analyse possible motivational explanations for different conceptions of expertise. In addition to the scales, an open-ended writing task was used to explore in depth students’ conceptions of expertise. It appeared that study orientations were a minor factor in the study, while study environment (study programs) clearly differentiated students’ conceptions of expertise. Thus, the study argues that health care students’ conceptions of expertise are constituted mainly on domain-specific bases and that students who graduate from different programs may possess very diverse ideas about their profession. Consequently, different conceptions captured during the education form a major challenge for inter-professional care later in work-life. This phenomenon should be taken into account when organising health care education.     

Does Convenience Matter in Health Care Delivery? A Systematic Review of Convenience-Based Aspects of Process Utility

ObjectivesTo systematically review the existing literature on the value associated with convenience in health care delivery, independent of health outcomes, and to try to estimate the likely magnitude of any value found.MethodsA systematic search was conducted for previously published studies that reported preferences for convenience-related aspects of health care delivery in a manner that was consistent with either cost-utility analysis or cost-benefit analysis. Data were analyzed in terms of the methodologies used, the aspects of convenience considered, and the values reported.ResultsLiterature searches generated 4715 records. Following a review of abstracts or full-text articles, 27 were selected for inclusion. Twenty-six studies reported some evidence of convenience-related process utility, in the form of either a positive utility or a positive willingness to pay. The aspects of convenience valued most often were mode of administration (n = 11) and location of treatment (n = 6). The most common valuation methodology was a discrete-choice experiment containing a cost component (n = 15).ConclusionsA preference for convenience-related process utility exists, independent of health outcomes. Given the diverse methodologies used to calculate it, and the range of aspects being valued, however, it is difficult to assess how large such a preference might be, or how it may be effectively incorporated into an economic evaluation. Increased consistency in reporting these preferences is required to assess these issues more accurately.     

Play Therapy in Health Care Settings: Promises Never Kept?

This article examines the variety of claims made about the effectiveness of play therapy in health care settings. The claims are organized into four categories of "promises": (a) mastery, autonomy, and control; (b) cooperation and communication; (c) coping with anxiety and fear; and (d) learning and information giving. The empirical questions within each promise are identified and relevant experimental research is discussed. The conclusion is that play therapy has not yet delivered on its promises in health care settings.     

Transformation of the Health Care Industry: Curb Your Enthusiasm?

Policy Points:

• Policymakers seek to transform the US health care system along two dimensions simultaneously: alternative payment models and new models of provider organization.
• This transformation is supposed to transfer risk to providers and make them more accountable for health care costs and quality.
• The transformation in payment and provider organization is neither happening quickly nor shifting risk to providers. The impact on health care cost and quality is also weak or nonexistent.
• In the longer run, decision makers should be prepared to accept the limits on transformation and carefully consider whether to advocate solutions not yet supported by evidence.

Context

There is a widespread belief that the US health care system needs to move “from volume to value.” This transformation to value (eg, quality divided by cost) is conceptualized as a two‐fold movement: (1) from fee‐for‐service to alternative payment models; and (2) from solo practice and freestanding hospitals to medical homes, accountable care organizations, large hospital systems, and organized clinics like Kaiser Permanente.

Methods

We evaluate whether this transformation is happening quickly, shifting risk to providers, lowering costs, and improving quality. We draw on recent evidence on provider payment and organization and their effects on cost and quality.

Findings

Data suggest a low prevalence of provider risk payment models and slow movement toward new payment and organizational models. Evidence suggests the impact of both on cost and quality is weak.

Conclusions

We need to be patient in expecting system improvements from ongoing changes in provider payment and organization. We also may need to look for improvements in other areas of the economy or to accept and accommodate prospects of modest improvements over time.     

Should Health Care Providers Uphold the DNR of a Terminally Ill Patient Who Attempts Suicide?

An individual’s right to refuse life-sustaining treatment is a fundamental expression of patient autonomy; however, supporting this right poses ethical dilemmas for healthcare providers when the patient has attempted suicide. Emergency physicians encounter patients who have attempted suicide and are likely among the first medical providers to face the dilemma of honoring the patient’s DNR or intervening to reverse the effects of potentially fatal actions. We illustrate this issue by introducing a case example in which the DNR of a terminally ill woman was not honored because the cause of her cardiac arrest was suicide. We argue that although a terminal diagnosis should change the way health care providers respond to a suicide attempt, many of the theoretical underpinnings for how one should treat suicide attempts—especially the criterion of external reasonability, that is the action to withhold or withdraw life-sustaining measures is reasonable independent of the precipitating event—are common to all situations (Brown et al. in Am J Bioeth 13(3):3–12, 2013). The presumption that patients who attempt suicide lack capacity due to acute mental illness is flawed because it fails to account for a competent individual’s reasonable preference to not be forced to live in an unbearable, terminal condition. In states without legislation allowing physician aid in dying, patients and providers must grapple with these limitations on a case-by-case basis. In cases where the patient has a limited life expectancy and there is not concern for psychiatric illness as the primary cause of the suicidal action, we argue that the negative right to refuse life-sustaining treatment should prevail.