Tewa children who have epilepsy: a health care dilemma

This paper explores the part ethnicity may play in utilization of available western health care methods by Tewa families who have a child with epilepsy. Suggestions are made for appropriate responses by non-Indian health care providers to Tewa patients with epilepsy and their families. Findings indicate that, on the surface, Tewa families behave much like other Americans generally in utilization of western health care services. However, the Tewa are extremely reluctant to discuss with non-Indian health care providers traditional healing practices that may be used simultaneously. Such reluctance is well-documented in literature on the Tewa Pueblos and is substantiated in the present research. Suggestions are made for health care providers who wish to be "culturally aware" about the appropriateness of routinely asking a patient about his or her perception of the traditional etiology of the disease. The roles of the family and the western health care system are challenged. The response of Tewa extended families to children who have epilepsy is complex and not necessarily supportive. Often considered the primary health care provider for Native Americans, the Indian Health Service is based on an acute care model and lacks the ability to serve chronically disabled American Indian children. Finally, the paper argues that epilepsy is varied enough to complicate the development of a single model of chronic illness that is appropriate for those who suffer from the disability.     

Exploratory evidence on the market for effective depression care in Pittsburgh

OBJECTIVE: Despite the existence of effective and relatively cost-effective depression treatments, many depressed patients do not receive appropriate care. The authors assessed opportunities for increasing the rate of effective depression treatment by investigating the market for such treatment in the Pittsburgh area. METHODS: A conceptual framework was developed to evaluate the market for effective depression care. On the basis of the conceptual framework, interviews were conducted with representatives from seven large employers, two medical health insurance carriers, two behavioral health insurance carriers, four primary care providers, and four behavioral health care providers. Respondents were asked to assess the barriers to and opportunities for increasing the rates of depression treatment from their perspectives. RESULTS: The findings suggest that there is currently little demand among purchasers for improving depression care and little interest among insurers and providers for improving care in the absence of purchaser demand. Even stakeholders who identified depression as an important problem could not come to a consensus about who should be responsible for addressing the problem. Employers reported that they look primarily to their vendors to initiate quality improvement efforts, whereas insurers reported that such improvement efforts were more likely to occur if they were initiated by employers who purchase their health plans; providers, in turn, reported feeling powerless to initiate change. CONCLUSIONS: The absence of a clear locus of responsibility for improving depression care lends considerable inertia to the status quo. Because the currently low treatment rates are likely to be socially inefficient, researchers and policy makers should consider strategies to help overcome this inertia.     

Contact with mental health and primary care providers before suicide: a review of the evidence

OBJECTIVE: This study examined rates of contact with primary care and mental health care professionals by individuals before they died by suicide. METHOD: The authors reviewed 40 studies for which there was information available on rates of health care contact and examined age and gender differences among the subjects. RESULTS: Contact with primary care providers in the time leading up to suicide is common. While three of four suicide victims had contact with primary care providers within the year of suicide, approximately one-third of the suicide victims had contact with mental health services. About one in five suicide victims had contact with mental health services within a month before their suicide. On average, 45% of suicide victims had contact with primary care providers within 1 month of suicide. Older adults had higher rates of contact with primary care providers within 1 month of suicide than younger adults. CONCLUSIONS: While it is not known to what degree contact with mental health care and primary care providers can prevent suicide, the majority of individuals who die by suicide do make contact with primary care providers, particularly older adults. Given that this pattern is consistent with overall health-service-seeking, alternate approaches to suicide-prevention efforts may be needed for those less likely to be seen in primary care or mental health specialty care, specifically young men.     

Economic grand rounds: A pay-for-performance program for behavioral health care practitioners

This column describes a pay-for-performance program for behavioral health care practitioners. Implemented in 1996 by a large national health insurer, the program's goals are to improve the quality of care, recognize the practitioners who provide higher-quality care, demonstrate the value of behavioral health services to purchasers, and help providers align their practices with national standards. A future goal is to provide patients with data on provider quality to improve their treatment decisions. Important considerations in measure development include application of the measure to all disciplines, feasible data collection processes for providers, creation of clinically meaningful and fair measures, and selection of measures with large baseline variability.     

Rebuilding Family Relationship Competencies as a Primary Health Intervention

The authors present Relationship Competence Training (RCT), which is an organized conceptual framework developed by them for assessing a family's ability to mobilize their relational support in times of distress. RTC is a process of studying family relationship patterns and how these patterns influence family health. The RTC model is described as a method of promoting mental health as a part of everyday family health, which is suitable for health care providers working in a wide variety of environments who have in common the desire to offer continuity and value in promoting the health of the families under their care. RCT provides an empathic way of dealing with the "compassion fatigue" that health care providers often experience when managing complex family health issues in constantly changing and quality-strained primary health care environments.     

Patient case study: in the case of Miss Christine

Young stroke survivors often return to the community for ongoing recovery and reintegration. Their needs are somewhat different than their older counterparts, and they can be easily lost in the complex health care system of specialty and primary care services. This young woman and her outpatient rehabilitation providers exemplify some problems encountered and the persistent, caring, and successful work that teams can accomplish to maximize ongoing recovery.     

"Holistic" care for stroke in the context of the current health care bureaucracy and economic reality

The target paper by Sharon Kaufman argues that modern Western health care delivery is characterized by "the coexistence of two conflicting conceptual frameworks," namely a "holistic" approach that attempts to take into account the cultural and personal needs of the individual stroke patient and "medicalization" that attempts to reduce people and their illnesses to biological processes which can then be treated through "evidence-based" biomedical approaches. Although it is true that these 2 approaches often coexist and are sometimes in conflict, it would be misleading to see these as totally dichotomous. Patients want holistic approaches less than we give them credit for, and physicians are less mechanical than such a dichotomy would suggest. In fact, more often than not, patients and their health care providers combine to engender unrealistic expectations about what modern medicine is actually able to accomplish. When the system breaks down, as it often does in stroke (with a patient who is still left with a significant impairment an disability as well as unresolved concerns and issues related to his or her often catastrophic loss of function), there is a certain inevitable backlash. However, this tension between holistic expectations and the medical response is overshadowed by institutional constraints on clinical decision making that are designed to manage or balance expectations of both patients and health care professionals with economic realities and, in doing so, often run rough-shod over the "holistic" needs of patients and their families as well as health care providers' attempts to manage disease and disability within a medical framework.     

Mental health experiences and needs among primary care providers treating OEF/OIF veterans: preliminary findings from the Geisinger Veterans Initiative

This study describes the results of the Reaching Rural Veterans Initiative (RRVI) funded by the Commonwealth of Pennsylvania and the Federal Government. The purpose of this project was to address the needs of veterans and their family members in rural communities who were seen by non-VA primary care providers. As part of this project, an assessment of healthcare providers' knowledge and awareness of mental health-related issues and experiences with veterans' healthcare services was conducted. Following this assessment, an education program was developed and implemented at primary care sites within the Geisinger Health System and also made available to other area providers. The survey indicated that Geisinger's primary care providers are currently involved with providing mental health care to area service members and their families. It was estimated that these providers saw about 1,200 Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) patients and 3,600 of their family members in clinics over a 6 month period. A significant number of these persons had mental health problems. About two-thirds (65.4%) of providers reported having a mental health professional onsite and nearly 23% reported that over one-third of their patients have mental health problems. Significant mental health gaps discovered indicated that providers lacked knowledge of PTSD and other combat-related stress disorders, as well as knowledge of VA resources. In addition only 20% of the providers rated their mental health treatment skills as high and only about 8% reported that they had adequate knowledge of current mental health treatment strategies. Based on this needs assessment and the results of the provider intervention, further service improvements are planned.     

A Common Factors Approach to Improving the Mental Health Capacity of Pediatric Primary Care

To expand the mental health service capacity of pediatric primary care, we ask whether there are evidence-based skills to allow providers to 1) immediately begin treatment for children with emotional and behavioral problems while diagnostic procedures are being pursued, and 2) offer evidence-based care to children who do not meet criteria for a specific diagnosis. We discuss why the epidemiology of child mental health problems poses difficulties for disorder-specific mental health interventions, and review evidence that "common factors" contributing to the outcome of mental health treatments define a core set of skills that primary care providers might use to complement disorder-specific interventions.     

Serving Veterans in their Communities: Evaluation of an Online Resource for Behavioral Health Care Providers

Many veterans receive behavioral health care services from providers in their communities. The Community Provider Toolkit (the Toolkit) is a website developed by the National Center for PTSD and the Department of Veterans Affairs intended to provide community mental health care providers with key veteran-focused educational resources. This mixed-methods study examined the potential impact of the Toolkit on provider knowledge and behaviors. Sixty-four clinicians in the community who currently or plan to provide services to veterans were surveyed. The majority of providers found the website useful and easy to navigate. After visiting the site, many providers found additional online and educational resources that they would add to a hypothetical treatment plan. Forty-five providers completed a 1-month follow-up survey focused on use of the Toolkit. Results indicate that the Toolkit may be a valuable tool for increasing provider knowledge about veteran-specific resources.

     

Barriers to metabolic care for adults with serious mental illness: provider perspectives

This study assessed barriers to metabolic care for persons with serious mental illness (SMI) by surveying experienced healthcare providers. Sixty-eight medical, mental health, and other stakeholders who care for patients with SMI attended a CME conference focused on medical management of SMI patients in 2007. They completed a 27-item survey assessing barriers to and systemic responsibility for metabolic care. The top three ranked barriers were: "separate mental health and primary care systems," "patient's lack of resources," and "[mental health] providers are not trained to do basic primary care." Results indicated that ratings of CMHC responsibility for SMI metabolic care (M = 5.2, SD = 1.5) were significantly lower than ratings of public health (M = 5.7, SD = 1.4), t(66) = 2.3, p = 0.027, and primary care providers (M = 6.3, SD = 1.1), t(67) = 4.7,p <0.001. Experienced providers identified a lack of integrated care and patient characteristics as important barriers to metabolic care and concluded that the primary care and public health systems are primarily responsible for metabolic treatment.     

Individualized music for dementia:Evolution and application of evidence-based protocol

The theory-based intervention of individualized music has been evaluated clinically and empirically leading to advancement and refinement of an evidence-based protocol, currently in its 5th edition. An expanded version of the protocol was written for professional health care providers with a consumer version tailored for family caregivers. The underlying mid-range theory is presented along with a seminal study that was followed by further research in the United States, Canada, Great Britain, France, Sweden, Norway, Japan and Taiwan. Key studies are summarized. Given its efficacy when implemented by research staff, studies have advanced to testing the intervention under real-life conditions when implemented and evaluated by trained nursing assistants in long-term care facilities and visiting family members. In addition, one study evaluated the implementation of music by family members in the home setting. Initial research focused on agitation as the dependent variable with subsequent research indicating a more holistic response such as positive affect, expressed satisfaction, and meaningful interaction with others. The article advances by describing on-line programs designed to train health care professionals in the assessment, implementation and evaluation of individualized music. In addition, Gerdner has written a story for apicture book intended for children and their families(in press). The story models principles of individualized music to elicit positive memories, reduce anxiety and agitation, and promote communication. The article concludes with implications for future research.     

Late-life alcoholism: issues relevant to the geriatric psychiatrist.

Alcohol use and abuse are often overlooked as an important clinical issue in older adults. However, with a rapidly growing population of older adults who grew up during an era of increased illicit drug and alcohol use, there are reasons to believe that there will be a greater impact of alcohol abuse or dependence on the next generation of older adults. Because older adults seek the majority of behavioral health care either in primary care settings or from mental health providers, it is necessary for primary care providers and geriatric mental health providers to become proficient at assessing and providing interventions. This article discusses the state of research in this area and reviews clinically-relevant concepts related to identifying, assessing, and treating older adults with alcohol-related disability.     

Facilitating treatment of anxiety disorders in patients with comorbid medical illness

Anxiety is a universal human response that usually is adaptive, allowing one to prepare for a perceived threat. This can be a normal coping mechanism when dealing with a medical illness that may require hospitalization, surgery, or painful procedures. It becomes maladaptive when it is persistent and leads to panic attacks, severe physical symptoms, and impairment in functioning. Most of these patients are treated by primary care providers who frequently fail to adequately recognize and treat anxiety disorders in their patients. This leads to increased health care costs and chronic disability. To reach this under-served group of patients, mental health practitioners need to collaborate with their primary care colleagues to provide screening tools and education on diagnosis and effective treatment of these disorders.     

Sexual attraction and experiences in the primary care setting: Examining disparities in satisfaction with provider and health self-efficacy

IntroductionTo test whether sexual minority males and females report lower satisfaction with primary care providers and lower health self-efficacy relative to heterosexual males and females.MethodsData from 535 adolescents who participated in one of two randomized clinical trials conducted in a primary care setting were analyzed. Multiple linear regressions controlling for demographic characteristics and treatment condition were used to examine sexual attraction differences in indicators of satisfaction with provider and health self-efficacy.ResultsSexual minority and heterosexual youth both endorsed high satisfaction with providers. Relative to heterosexual males, sexual minority males reported lower self-efficacy in reaching their health goals. Relative to heterosexual females, sexual minority females reported lower confidence in positively impacting their own health, and lower self-efficacy in setting goals and working actively to improve their health.ConclusionsSexual minority youth may benefit from additional support from health care providers to enhance their health self-efficacy and reach their health goals.     

Health behaviors, service utilization, and access to care among older mothers of color who have children with developmental disabilities

This study examined health behaviors, utilization, and access to care among older Latina and Black American mothers who co-reside with a child with developmental disabilities. Using data from the National Health Interview Survey National Center for Health Statistics (2005a), we compared Latina and Black American caregivers to similar women who did not have caregiving responsibilities. Findings showed that Latina caregivers were more likely to smoke and have insurance; Black American caregivers were less likely to be able to afford medication and mental health care; and both groups were less likely to have seen a doctor in the past year than their noncaregiving counterparts. Findings suggest that service providers should consider developing programs that focus on health for caregivers of color. Furthermore, results suggest that providers should take into account differing trends across ethnicities when designing programs.     

Community Mental Health Care Providers’ Understanding of Recovery Principles and Accounts of Directiveness with Consumers

The present qualitative study examined community mental health providers’ accounts of their therapeutic interactions with adults with serious mental illness in a recovery-oriented model of care. Ten long-time mental health care providers discussed their understanding of recovery principles, their use of directive practices, and factors that shape their work with consumers. Content analysis of mental health providers’ accounts suggest that providers had no difficulty articulating basic principles of recovery-oriented care. Providers reported engaging in directive practices with consumers and described using traditional clinical factors such as level of functioning, degree of psychiatric symptoms, safety concerns, and legal status to assess consumers’ ability for autonomous decision making. Providers generally did not express tension between their views of mental health recovery and their beliefs about utilizing directive approaches with consumers. Implications of present findings for research and practice are discussed.     

Understanding and treating panic disorder in the primary care setting

According to studies, the median prevalence of panic disorder in the primary care setting is 4%. Rates are higher among certain patient populations, such as those with cardiac (20% to 50%) or gastrointestinal presentations (28% to 40%). Consequently, patients with panic disorder are high utilizers of medical services and are heavily represented among patients classified as high health care utilizers, compared with other psychiatric or non-psychiatric groups. Despite its frequency in the primary care setting, panic disorder is significantly under-recognized by medical providers. Corresponding with inadequate recognition is the substantial proportion of these patients who fail to receive appropriate treatment (pharmacotherapy and psychotherapy). Most experts have concluded that panic disorder is poorly managed in the primary care setting because of the process of care and patient engagement. In terms of process of care, primary care practice still operates on an acute disease model (leaving no time for initial patient education or follow-up), which is a poor fit for the management of chronic diseases. Insufficient patient engagement in treatment (i.e., being involved in the treatment process, "buying into" rationale for treatment, and being willing to collaborate with clinician and adhere to recommendations) is the second important contributor to inadequate treatment. Use of a chronic disease self-management approach would enhance treatment of panic disorder. This model requires that patients, in collaboration with the health care provider/system, take day-to-day responsibility for managing their illness by doing 3 things: adhering to recommended medical management, adopting improved health habits/coping skills, and assisting in ongoing monitoring of illness status/change. Future approaches to treating panic disorder in primary care would be enhanced by including assessments of patient beliefs and preferences, spending more time in preparing the patient for treatment, utilizing a simple pharmacotherapy algorithm, utilizing simple rating scales to monitor outcomes, and training providers in brief CBT interventions.     

Mental health assessment of young children in a managed care environment

Managed behavioral health care is widely perceived as a threat to traditional practice in mental health at the expense of quality care. Although such assertions by mental health providers may prove to be justified in certain circumstances, they should not serve to obscure the quite reasonable public health motives behind managed care and the favorable effect managed care organizations may ultimately have on clinical decision-making and practice. By compelling practitioners to more clearly articulate the basis for their clinical judgments and by increasingly requiring evidence to support such judgments, they discourage the application of ill-considered, sometimes inappropriate, and occasionally iatrogenic evaluation and treatment interventions. In the future, there is significant danger that developmental assessment and treatment procedures for young children will be inappropriately constrained and diminished. This is especially true if those who work with young children fail to use the tools available to them to make the case for the best of current practice, whether a clearly stated clinical rationale, a formal appeal, the advocacy of our health professions, or applied clinical services research. The practices of our health plans need to be understood by providers in the context of managed care values. Primitive systems should not be confused with corrupt systems. Although undoubtedly the latter exist, they do not necessarily predominate. Within a managed care context and with due respect to managed care assumptions, it is possible to bring utilization management and contemporary practices in developmental assessment into closer alignment, ultimately to the benefit of children who need them.     

The role of monitoring outcomes in initiating implementation of evidence-based treatments at the state level

This article describes a six-year statewide initiative to help mental health service providers in continuously monitoring the outcomes of youths with serious emotional disturbances who are treated in the public-sector managed behavioral health care system. Participating providers submit outcome data to a state-sponsored evaluator, using the Child and Adolescent Functional Assessment Scale (CAFAS), and receive monthly feedback that identifies youths who are making poor progress in treatment. Additional reports are used to ensure record compliance, monitor at-risk youths, and assist in reviewing the adequacy of treatment plans. In addition, outcome data for closed cases are generated for various types of clients. The consistently poor outcomes for some types of clients have generated a genuine interest among clinical staff in learning and implementing evidence-based treatments. The data for all participating providers were pooled to generate state averages for various indicators so that each provider can compare their site to these benchmarks. State administrators consider the data in generating policy and identifying systemwide needs. The processes that shaped this initiative and that created the providers' investment in continuous quality improvement activities are described.