Resource allocation problems and health services for the elderly.

The provision of appropriate health support services for the elderly has increased in importance because of the trend towards aging populations in Europe and other developed regions. Health service resource allocation models and their roles in health service systems, which are also changing to reflect changing needs for the elderly, are discussed in this article. Different types of economic and health care delivery systems are examined, particularly those leading towards decentralization, consumer participation and "deinstitutionalization". A promising resource allocation approach--the "balance-of-care" approach--is described in some detail. This and other potential approaches make it possible to identify areas which hold promise for crossnational research.     

部队离退休干部居家养老服务管理模式及医疗保健工作探索

目的评价部队离退休干部居家养老服务管理模式并探索适于高龄老人（≥80岁）的新模式。方法回顾总结部队居家养老服务管理模式并评价干休所工作质量,调查44个驻京部队3473人离退休干部的健康和功能状况及高龄老人养老服务需求。结果部队干休所围绕“生活服务、医疗保健、文化活动”三个中心为离退休干部提供全方位居家养老服务保障,2012年干休所工作质量考评“达标”及“先进”的干休所分别为486所及111所。30．8％离退休干部为高龄老人,其日常生活能力依赖率较60～79岁者增高2—6倍,多系统疾病共患率亦均明显增高（P〈0．001）。高龄老人对基本日常生活及个性化服务等需枣增多。结论应探索适于“高龄、多病、失能”离退休干部需求的养老服务分级管理新模武。     

Enhancing social networks: a qualitative study of health and social care practice in UK mental health services

People with severe mental health problems such as psychosis have access to less social capital, defined as resources within social networks, than members of the general population. However, a lack of theoretically and empirically informed models hampers the development of social interventions which seek to enhance an individual's social networks. This paper reports the findings of a qualitative study, which used ethnographic field methods in six sites in England to investigate how workers helped people recovering from psychosis to enhance their social networks. This study drew upon practice wisdom and lived experience to provide data for intervention modelling. Data were collected from 73 practitioners and 51 people who used their services in two phases. Data were selected and coded using a grounded theory approach to depict the key themes that appeared to underpin the generation of social capital within networks. Findings are presented in four over‐arching themes – worker skills, attitudes and roles; connecting people processes; role of the agency; and barriers to network development. The sub‐themes which were identified included worker attitudes; person‐centred approach; equality of worker–individual relationship; goal setting; creating new networks and relationships; engagement through activities; practical support; existing relationships; the individual taking responsibility; identifying and overcoming barriers; and moving on. Themes were consistent with recovery models used within mental health services and will provide the basis for the development of an intervention model to enhance individuals’ access to social capital within networks.     

A partnership approach to health promotion: a case study from Northern Ireland

In recent years there has been a renewal of interest in community development and partnership approaches in the delivery of health and social services in Northern Ireland. The general thrust of these approaches is that local communities can be organized to address health and social needs and to work with government agencies, voluntary bodies and local authorities in delivering services and local solutions to problems. Since the Ottawa Charter was launched in 1986, government in Northern Ireland has stressed that community development should no longer simply be added on to key aspects of Health and Social Services, but should instead be at the core of their work. There is increasing consensus that traditional approaches to improving health and well-being, which have focused on the individual, are paternalistic and have failed to tackle inequalities effectively. Partnerships within a community development setting have been heralded as a means to facilitate participation and empowerment. This paper outlines the policy background to community development approaches in health promotion and delivery in Northern Ireland. Drawing on evidence from a case study of a community health project it highlights the benefits and difficulties with this approach. The findings suggest that partnerships can positively influence a community's health status, but in order to be effective they require effective planning and long-term commitment from both the state and the local community.     

Mental health and social security: the case of the Incapacity Benefit in Northern Ireland

Although mental illness affects people from all income levels, a significant proportion of discharged psychiatric patients rely heavily on the benefit system. Therefore, changes in benefit entitlement are of great concern to these people who already find this system difficult to use. In the summer of 1995, using both focus groups and individual interviews, the views of 35 individuals with mental health problems and of five organizations involved in advocacy work were sought on the introduction of the Incapacity Benefit. These views raised serious questions about the extent to which the benefit system meets the needs of claimants with mental health problems, on the relevance of the models of disability used in sickness benefits, and on the impact of the Incapacity Benefit and the Job Seeker's Allowance on people with mental health problems and confirmed the need for further research.     

Continuous and integrated health care services in rural areas. A literature study

This article presents the result of a literature review examining possible ways to improve healthcare services in rural areas. While there is abundant literature on making healthcare programs integrated, interdisciplinary and managed in order to reduce fragmentation and improve continuity and coordination of care, only some part of this relates to rural issues. An added challenge is the lack of a generally accepted international definition of rurality, which makes it difficult to generalise from one region to another, and to develop an evidence-based understanding of rural health care. In evaluating the literature it was found that the development of new forms of interaction is particularly relevant in rural regions - such as interdisciplinary and team-based work with flexibility of roles and responsibilities, delegation of tasks and cultural adjustments. In addition, programs such as integrated and managed care pathways, outreach programs , shared care and telemedicine were relevant initiatives. These may be associated with greater equity in access to care, and more coherent services with greater continuity, but they are not necessarily linked to reduced costs; they may, in some cases, entail additional expenses. Such endeavours are, to a large degree, dependent on a well-functioning primary healthcare system as a base.     

Integrating health and social services for older adults: a case study of interagency collaboration

As public housing residents age in place, they require health and social services outside of those traditionally offered by housing authorities. A promising response to these emerging needs is for housing authorities to collaborate with local public health departments to deliver coordinated services to older adult residents. Aging residents' health needs include health promotion activities, preventive health services, health education, and mental health services, among others. From 2001-2004 the New York City Department of Health and Mental Hygiene (DOHMH) and the New York City Housing Authority (NYCHA) collaborated to implement the Senior Wellness Project. This outreach program integrated health and social services provided by DOHMH and NYCHA, and delivered these services to older adult residents on site in 21 New York City public housing developments. Services were rendered at senior centers located in the housing developments and in residents' apartments. The program also referred residents to community healthcare providers to address special needs such as addiction. This article retroactively applies a formal model for interagency collaboration, the Stages of Collaboration, to describe and analyze the process of collaboration between DOHMH and NYCHA. It identifies the successes and shortcomings of the collaborative process, and explores the theory that successful collaboration leads to inherent challenges for implementation. Recommendations are then made for other public housing and public health agencies that have considered collaborating to address the needs of public housing residents who are aging in place.     

Removing barriers and improving choices: a case study in reproductive health services and managed care.

Managed care contains inherent structural features that can create obstacles to time-sensitive, confidential reproductive health services. Such structural impediments often exacerbate the sociocultural barriers that have historically affected low-income women--the population that has been targeted for mandatory enrollment in Medicaid managed care plans in many states. This article recommends public policy strategies to overcome and prevent multiple barriers that were identified in a New York-based study in 1995, which focused on access to reproductive health services in managed care settings. This article also includes updated evidence supporting the study's findings and its relevance to other states.     

Delivering preventive oral health services in pediatric primary care: a case study

Dental disease, the most prevalent chronic disease of childhood, affects children's overall health and ability to succeed. Integrating oral health into routine well-child checkups is an innovative and practical way to prevent dental disease. The Washington Dental Service Foundation is partnering with Group Health Cooperative, a large integrated delivery system, and other providers in Washington State to change the standard of care by incorporating preventive oral health services into primary care for very young children. This paper describes systemic and policy changes for engaging primary care providers in oral health, including provider training, expanding access to dental care, and reimbursement.     

Staking a claim for claims: a case study of resource allocation in Australian Aboriginal health care

There have been numerous ways in which the notion of equity has been put forward in the literature. This reflects the fact that equity is essentially driven by values and is therefore subject to individual interpretation and preferences. Deciding between these various value judgements is however outside the scope of economic analysis, as conventionally defined. This poses a problem for the examination of issues of resource allocation in Aboriginal health services in Australia, where equity, very clearly, has a role to play. One possibility for moving forward on this issue is the adoption of a 'claims' approach where the emphasis is on the explicit recognition of the values to be employed in the 'equitable' allocation of resources. This involves teasing out the principles by which, under various approaches, resources are allocated differentially across groups (e.g. under resource allocation formulae, the criterion of 'need' as measured by SMRs can be viewed to be a basis for a 'claim' over resources). The commonly cited 'basic needs approach' is then used in the paper as a case in point to illustrate how such underlying principles may be identified and then assessed. In relation to the issue of equity in Aboriginal health services, there are a number of possible standards for equity which seem to have a significant degree of community acceptance. The paper discusses ways in which they can be applied to the problem of deciding how to allocate resources in Aboriginal health.     

Population predictors of community health and social service use in Northern Ireland.

STUDY OBJECTIVE: To investigate the characteristics of elderly populations associated with variations in their use of community health and personal social services and to test the hypotheses that the variations are related to: (a) the age structure of an elderly population; (b) the population's socioeconomic composition, including the level of deprivation; and (c) household or living arrangements. DESIGN: A common file of 1991 population census and 1994 NHS community trust operational variables was constructed for 67 postcode sectors, with the independent variables describing the age-sex groups to be studied. Clear criteria for the exclusion of "empty" sectors were developed. Relationships using bivariate and multivariate correlation and stepwise multiple regression were explored. SETTING: Eastern Health and Social Services Board area, Northern Ireland (Belfast and hinterland). PARTICIPANTS: Population of statutory pensionable age; in aggregate, younger and older age bands. MAIN RESULTS: The age structure or mean age of the elderly population had only a weak association with the community health and social service client rate, but there were strong associations with socio-economic variables, particularly the percentage of those living alone who were without a car and the percentage of pensioner households that included an adult of below pensionable age. Parsimonious multiple regression models accounted for between 46% and 80% of the variation in the NHS community trust client rate. Greater explanations were achieved for the young elderly population than for those aged 75+ years and, when the population was divided between young and old age bands, for men than for women. CONCLUSIONS: Community health and social services for elderly people in eastern Northern Ireland were focused on those with a low income and those who were not co-resident with adults of working age. When local elderly populations are compared, per capita morbidity and dependency are often higher where the mean age is low, and vice versa, because of the inverse relationship between socioeconomic status and survival in old age. Capitation scales for resource allocation with positive age weighting will be of little use if no account is taken of the relative prevalence of need in the youngest or base age group.     

Homeless women's access to health services: a study of social networks and managed care in the US.

Homeless women experience more severe physical and mental health problems than women in the general population. Under-utilization of health services complicates these health conditions. The study reported here explored how homeless women access health services within the context of shelter living and emerging managed care systems. Informed by grounded theory and dimensional analysis, the investigator conducted in-depth interviews with 19 homeless women, 6 staff from agencies serving homeless women, and 2 community health nurses. Findings revealed that homeless women usually had circuitous rather than direct routes to health services. First, they typically found a social network opportunity structure where brokers could assist them into the health care system. The first tiers of access included a domestic violence shelter, a shelter for single homeless women, and a cafe offering low-cost meals to an inner city homeless population. Even after locating this opportunity structure, the conditions of managed care, with its mechanisms of referral and unfamiliarity with the needs of impoverished women, complicated access. Thus, access requires policies that address not only the availability of health professionals, but also tiers of access that include a social network opportunity structure where women can interact with advocates who broker their entry into the health care system.     

Stress, cortisol and well-being of caregivers and children in home-based child care: a case for differential susceptibility

Background We examined whether children cared for by stressed caregivers show lower socio‐emotional well‐being and more stress, compared with children cared for by less stressed caregivers. Methods Perceived stress and cortisol levels of professional caregivers (n= 44), and associations with children's (n= 44) well‐being and cortisol levels in home‐based child care were examined. Results Caregiver perceived stress and cortisol levels were related to children's well‐being but not to children's cortisol levels. Children's social fearfulness acted as a moderator between caregivers' mean ratio of diurnal change in cortisol and children's well‐being. When caregiver cortisol levels decreased, more fearful children were reported higher on well‐being than less fearful peers. In contrast, when caregiver cortisol levels increased, more fearful children were reported lower on well‐being. Conclusions The findings point to differential susceptibility. Child care organizations and parents need to notice that a non‐stressful child care environment is in particular important for children with a difficult temperament.     

Public health services in Shenzhen: a case study

As one of the fastest growing cities in Pearl River Delta of southern China, Shenzhen accommodates a higher percentage and increasing number of internal migrants, mainly coming from the inland areas. The public health issues that challenge its local government include the special population structure, high incidence of infectious diseases, high prevalence of mental problems, rising chronic disease burdens, and maternal and children's health issues, although progress has been made in the past years. The health authority of?Shenzhen has realized that provision of high quality equitable public health services to its residents, including migrants is of high priority, and should be supported by innovations in the health insurance system and establishment of community-based primary care networks. Making changes within the national-level health reform framework and learning from international experiences are necessary and important.     

An exploratory study of services marketing in global markets: major areas of inquiry for the health care services industry

It has been stated that one of the major challenges for the international marketer is the design of an efficient strategy for marketing services to international markets. This paper reviews some of the issues associated with services marketing in global markets along with the basic variables of service industries. An exploratory assessment of the health care services industry results in a list composed of several inquiry areas which should be examined by multinational companies. It is hoped that the review of the issues raised in this paper provides a basis for decision making and further research.     

Improving the geographical accessibility of health care in rural areas: a Nigerian case study

The paper addresses problems of geographical accessibility of health care in rural areas of Nigeria. It provides analyses of the location, distribution and accessibility of government-provided health care facilities to people and presents a framework for measuring improvements in accessibility and for assessing the efficiency of decisions about location of new facilities. It shows that while accessibility in the study area improved between 1979 and 1982 through the establishment of more dispensaries and maternity and child-welfare centres, the relative efficiency of locations has remained low. It identifies alternate locations for the new facilities introduced in the 1979-1982 period that could have increased the utilization of maternal and child health centres by an estimated 12% and the utilization of dispensaries by 16%.