Community-based Care System Research Articles

Medical Mondays: ED Utilization for Medicaid Recipients Depends on the Day of the Week, Season, and Holidays

The purpose of this study is to describe and explain the temporal and seasonal trends in ED utilization for a low-income population. A retrospective analysis of 66,487 ED Medicaid-insured health care claims in 2009 was conducted for 2 Western New York Counties using time-series analysis with autoregressive moving average (ARMA) models. The final ARMA (2,0) model indicated an autoregressive structure with up to a 2-day lag. ED volume is lower on weekends than on weekdays, and the highest volumes are on Mondays. Summer and fall seasons demonstrated higher volumes, whereas lower volume outliers were associated with holidays. Day of the week was an influential predictor of ED utilization in low-income persons. Season and holidays are also predictors of ED utilization. These calendar-based patterns support the need for ongoing and future emergency leaders' collaborations in community-based care system redesign to meet the health care access needs of low-income persons.

At the intersection of lay and professional social networks: how community ties shape perceptions of mental health treatment providers.

The therapeutic alliance is a critical determinant of individuals' persistence and outcomes in mental health treatment. Simultaneously, individuals' community networks shape decisions about whether, when, and what kind of treatment are used. Despite the similar focus on social relationship influence for individuals with serious mental illness, each line of research has maintained an almost exclusive focus on either 'inside' (i.e. treatment) networks or 'outside' (i.e. community) networks, respectively. For this study, we integrate these important insights by employing a network-embedded approach to understand the therapeutic alliance. Using data from the Indianapolis Network Mental Health Study (INMHS, n=169, obs=2206), we target patients experiencing their first major contact with the mental health treatment system. We compare patients' perceptions of support resources available through treatment providers and lay people, and ask whether evaluations of interpersonal dimensions of the therapeutic alliance are contingent on characteristics of community networks. Analyses reveal that providers make up only 9% of the whole social network, but are generally perceived positively. However, when community networks are characterized by close relationships and frequent contact, patients are significantly more likely to report that treatment providers offer useful advice and information. Conversely, when community networks are in conflict, perceptions of treatment providers are more negative. Community-based social networks are critical for understanding facilitators of and barriers to effective networks inside treatment, including the therapeutic alliance. Implications for community-based systems of care are discussed in the context of the USA and global patterns of deinstitutionalization and community reintegration.

Work organization and elderly care: plan evaluation findings from the Flemish Care Living Labs (Belgium)

Introduction: An extensive, three-year, _living labs_ based program has been initatied in Flanders (Belgium) to stimulate innovation in the domain of elderly care. The program kicked off in September 2013, and comprises 23 projects, grouped in 6 regional platforms. A scientific consortium is entrusted with the scientific support of the program. One of the disciplinary aspects is the organization of work, which is studied in three steps: 1) evaluation of the platform and project plans; 2) survey on quality of labor (karasek) and relational coordination (Gittell) among care professionals, at the start and at the end of each project; 3) qualitative study on the cooperation between professionals and informal caregivers. This abstract treats the first step. Theory/methods: The research combines concepts from sociotechnical systems (de Sitter) and relational coordination theory. The projects are very diverse, with topics including technology, housing, informal care networks, mobility, care management, care and cure integration and career platforms for care professionals. A quick scan of the platform and project plans revealed that direct references to aspects of work organization could usually not be found. The plan evaluation is therefore based on whether following three goals were present, which each imply challenges with regard to the organization of work: 1) integrating care; 2) realizing community based care; 3) improving care quality. Information was gathered by qualitative document analysis and semistructured interviews with platform coordinators. Results: Out of the 6 platform plans, 3 explicitly mentioned integrating care as a goal, referring to cooperation between organisations. While the other 3 platform plans did not stated integrated care as an explicit goal, they all stressed the importance of cross-organisational cooperation. Four plans explicitly aimed at the realization of community based care systems, while one plan did this in a rather implicit way. The last platform plan did not contain any reference to community based care. All six platform plans explicitly aimed at improving care quality. At the project level, 22 out of 23 project plans explicitly (17) or implicitly (5) aimed at integrating care. Ten project plans explicitly (9) or implicitly (1) referred to the realization of community based care, while all 23 project plans explicitly aimed at improving care quality. International Journal of Integrated Care – Volume 15, 27 May – URN:NBN:NL:UI:10-1-116968 – http://www.ijic.org/ 15th International Conference on Integrated Care, Edinburgh, UK, March 25-27, 2015 2 Discussion: The results suggest that aspects of work organization could be crucially important for the projects within the six platforms. An example is that various project plans strive to apply technological tools to increase cross-organisational coordination, encompassing a possible risk for increased bureaucratization. Another example is that the introduction of care managers could draw attention away from the underlying problem, being the underlying fragmentation of the work organization. A third example is that various projects are focused on care integration at the micro-level of care professionals and informal caregivers, which could affect tasks and roles of both groups. Conclusion: The various platform and project plans offer good leads for studying aspects of work organization in the next research steps.

Patient Preferences versus Family Physicians' Perceptions Regarding the Place of End-of-Life Care and Death: A Nationwide Study in Taiwan.

Enabling people to die in their preferred place is important for providing high-quality end-of-life care. The study objective was to explore patients' preferences regarding the place of end-of-life care and death and to compare these preferences with the perceptions of their family physicians. This cross-sectional study used stratified random sampling, surveying 400 registered patients and 200 of their family physicians nationwide, with a five-part, structured, self-report questionnaire. Of the selected population, 310 patients (response rate 77.5%) and 169 physicians (response rate 84.5%) responded. Regarding the preferred place for end-of-life care, most of the patients would choose to receive care at home (60.6%) if home care services were available. Additionally, home was the most frequently preferred (66.5%) place of death. The family physicians' survey showed that a higher proportion of physicians selected home as the preferred place for end-of-life care and death (71.6% and 87.2%, respectively). The results of logistic regression analysis showed that patients younger than 50 years of age who believed in Chinese folk religion and who resided in a rural area were more likely to prefer to die at home. The most commonly preferred place for end-of-life care and death is the patient's home. Establishing a community-based palliative care system should be encouraged to allow more individuals to die in their preferred locations. There were discrepancies in the preferred place of end-of-life care and death between the patients' preferences and their family physicians' perceptions. More effective physician-patient communication regarding end-of-life care is needed.

The present and future of community/home-based palliative care in Taiwan

In Taiwan, the Department of Health (DOH) has implemented regulations and policies related to hospice and palliative care since 1995. Taiwan is the first country in Asia to have a Natural Death Act, promulgated in 2000. Although recognition of the need for palliative care in non-cancer terminally ill patients is increasing, at present, the needs of these patients are often not met. Moreover, while a majority of the population prefers to die at home, the percentage of patients who die in the home setting remains small. The palliative care system should be adjusted to improve the accessibility and continuity of care based on the needs of patients. Therefore, the Jin-Shan Branch of the National Taiwan University Hospital has run a pilot community palliative care service model since 2012. National Health Insurance reimbursement was introduced in 2014 for community-based palliative care services. Establishing a formal system of community-based palliative care should be encouraged in order to improve the quality of care at the end of life and to allow more patients to receive end-of-life care and die in their own communities. This system will require that skilled nurses provide discharge planning, symptoms control, end-of-life communications, social-resources integration, and social-support networks in order to achieve a high quality of end-of-life care.

Meaning in work and emerging work identities of housing support workers: A quest for a comprehensible plot

Work and employees are often marginalized in studies on community-based psychiatric care and support systems. This paper highlights the role of the worker at congregated supported housing for people with severe mental illness (SMI). Housing support workers (HSW) are a fairly new professional role and have developed as a result of major changes in Swedish mental health care and services. The development of new roles is not unproblematic and raises intriguing questions. The purpose of this article is to describe housing support workers' experiences of meaning in their work, and in addition illuminate how the work identity of HSWs can be negotiated and constructed. Four focus group interviews were conducted with a total of 25 participants. Additionally, three follow up sessions were conducted with the same participants. The material consists of employees from four different sites. The intepretation of the material was inspired by a constructionist approach. The analysis generated three themes: to do a good job, everyday needs and the formal role. The work identity for HSWs is complex and not easily interpreted. The experience of an unclear assignment affects the description of what is meaningful and important-the work identity and significant affiliations for HSWs. In the long run, this fragmented world can have negative implications for the HSW.

The Therapeutic Farm Community: An Innovative Intervention for Mental Illness

Romania is currently making efforts to deinstitutionalize residents of its mental health hospitals and initiate a system of community-based mental health care. To be successful, the system of community-based mental health care must include a network of caring and responsible people who are committed to helping those who are mentally ill meet their needs while reintegrating into and remaining a part of the community. Therapeutic farm communities (TFC), or care farms (CF) as they are known in Europe, can serve as a critical component in efforts to assist mentally ill individuals regain their stability and independence. TFCs, which often focus on individuals diagnosed with schizophrenia, bipolar disorder, and major depression, promote self-sufficiency through their therapeutic use of farming-related activities, including organic farming and animal care. In addition to farm maintenance activities, programming may include mood management, dialectical behavior therapy, creative expression, equine assisted learning, meditation, education, money management training, and independent living skills activities (planning, shopping, cooking, healthy living), and medication management. This paper first reviews the use of TFCs in Europe and the US, focusing on Hopewell as a model for the US TFCs, and examines the suitability and sustainability of the TFC/CF model for mentally ill persons in Romania in the context of Romania's current political and economic climate.

An Advocate’s Observations on Research Concerning Assisted Outpatient Treatment

“Assisted outpatient treatment” (AOT) is a practice designed to improve treatment outcomes for people with severe mental illness whose difficulties adhering to voluntary outpatient care have left them trapped in the revolving door of the mental health and criminal justice systems. Under AOT, an individual found to meet strict eligibility criteria is placed under court order to comply with an approved treatment plan as a condition of remaining in the community and receives intensive case management and monitoring. A patient’s substantial violation of the court order typically leads to short-term evaluative detention to determine whether hospital commitment has become necessary. In my work for the Treatment Advocacy Center promoting AOT across the United States, I am often puzzled by the wide gulf between the perceptions of AOT among intelligent and dedicated mental health professionals and the findings of researchers on the effectiveness of AOT in improving treatment outcomes for the most challenging subset of psychiatric patients. The research is good enough to lead one to expect a near-universal embrace of AOTwithin the mental health field, and yet this is hardly the case. While 45 states and the District of Columbia have laws authorizing local mental health systems to practice AOT, implementation of these laws remains spotty in all but a few. Many professionals I encounter seem to have absorbed anti-AOT messages emanating from various mental-health consumer organizations who reflexively oppose any infringement on patient autonomy. Among these messages are patently false claims that the research on AOT is “mixed or inconclusive,” or that the research only suggests AOT might be worthwhile in an exceedingly well-funded system of community-based care. In this article, I hope to set straight the record on the AOT research by summarizing the mountain of positive data, placing the purportedly inconclusive or negative findings in a more intellectually honest context, and putting to rest the pervasive myth that impressive results achieved in New York are rooted in anomalies of that state.

Cancer mortality among psychiatric patients treated in a community-based system of care: a 25-year case register study

Cancer mortality data allow assessing, at the same time, the risk of developing the disease and the quality of care provided to patients after the oncologic diagnosis. This study explores the risk of death caused by a single tumor site in a psychiatric population treated in a community-based psychiatric service. All patients with an ICD-10 psychiatric diagnosis, seeking care in 1982-2006 (25 years), were included. Data were drawn from the South Verona Psychiatric Case Register (PCR). Mortality and cause of death were ascertained using different procedures and sources. Standardized mortality ratios (SMRs) were used to compare the observed number of deaths with the expected number using as reference a population in the Veneto region. Having been admitted to the hospital (SMR = 1.32), having a short interval from registration (1.52), having a diagnosis of alcoholism (2.03), and being a middle-aged male (1.83) were factors showing an increased risk of death from cancer. Increased SMRs were found for cancer of the oral cavity (22.93), lymphoma, leukemias, Hodgkin's lymphoma (8.01), and central nervous system (CNS) and cranial nerve tumors (4.75). The SMR decreased for stomach tumors (0.49). Patients with alcoholism (5.90 for larynx), affective disorders (20.00 for lymphomas), and personality disorders (28.00 for SNC) were found to be exposed to a high risk of cancer death in specific sites. Psychiatric patients showed different patterns of site-specific cancer mortality when compared with the general population. The 20-fold higher risk of dying from hematological neoplasms needs further investigation. Chronic use of phenothiazines could be involved in the relative protection from stomach and prostate cancer found in psychiatric patients.

Obtaining Stakeholder Consensus on the Core Components of a Parent Support and Training Model for Parents of Children with Serious Emotional Disturbances

Parent-to-parent peer interventions are nationally recognized as an important service within children's community-based mental health systems of care. Despite rapid growth, clearly defined models of professional parent services for statewide application do not exist. In this study, concept mapping was used to achieve stakeholder consensus on the core components of the Parent Support and Training (PST) peer intervention model developed within the Kansas community mental health system. Participants rated the importance and observed frequency of 49 distinct statements related to the service and sorted them into conceptual groups. Analyses reflected a high level of agreement across stakeholders on statements identified as most important and most frequently demonstrated in PST services statewide.

Factors Associated with Prognosis of Eating and Swallowing Disability after Stroke: A Study from a Community-based Stroke Care System

The long-term prognosis of eating and swallowing disability has not been fully clarified. As community-based stroke care systems have developed in Japan, these data have become available. We examined changes in nutritional intake using data acquired from a community-based stroke care system. There were 334 stroke patients who were discharged from our acute care hospital and transferred to rehabilitation hospitals with tube feeding. We examined the relationship between the initial bedside swallowing assessment and the method of nutrition delivery at discharge from a rehabilitation hospital. We also calculated the functional independent measure (FIM) to examine the relationship between activities of daily living and nutritional intake. There were 291 patients on oral intake and 43 on enteral feeding at discharge from a rehabilitation hospital. Patients with enteral feeding were older than patients with oral intake (69.4 ± 11.4 v 75.2 ± 9.9 years; P = .0016). The enteral feeding group also had lower FIM gain (27.5 ± 28.3 v 16.5 ± 23.5; P = .0161) and FIM efficiency (1.10 ± 1.24 v 0.65 ± 1.26; P = .0270) at the acute care hospital. Age, FIM gain, and FIM efficacy in the acute care hospital reliably predicted the long-term prognosis of eating and swallowing disability.

An approach to family-centered coordinated co-management for individuals with conditions identified through newborn screening

The care of individuals with rare heritable conditions, such as those detectable through newborn screening, is an important target for quality improvement. Not only is there great opportunity to improve long-term outcomes, but there are lessons that can be generalized to the care of all children with special health-care needs. To identify an approach to quality improvement for individuals with conditions identified through newborn screening, the National Coordinating Center for the Regional Genetic and Newborn Screening Service Collaboratives convened an expert workgroup to develop strategies based on a family-centered, community-based system of care. These recommendations centered on involving families, the primary care medical home, and specialty care providers as equal partners. Key activities to improve care include explicit care coordination, identification of the location of management, and planned co-management. To implement this model of care, the Regional Collaboratives will develop a clearinghouse of tools, engage in activities to evaluate the effectiveness of interventions to improve co-management, and identify strategies to align incentives for health-care providers and families to work together.

A systematic approach towards the development of a set of quality indicators for public reporting in community-based maternity care

Objectiveto demonstrate the process and outcome of a systematic approach towards the development of a set of quality indicators for public reporting on quality of community-based maternity care. Design and settinga four-stepped approach was adopted. Firstly, we defined key elements of community-based maternity care, by performing a systematic search on care guidelines/ standards. Secondly, the literature was searched for existing indicators for maternity care, which were subsequently categorised according to the key elements and systematically selected on suitability of public presentation. The emerging set of indicators suitable for public reporting was presented to five health-care professionals using a Delphi technique (step 3). Based on the comments of the professionals, the set was adjusted and subsequently presented to the health-care consumers (a sample of pregnant women) in step four to test its validity, after which the final set was composed. Participantshealth-care professionals in the field of maternity care and pregnant women. Findingskey elements of community-based maternity care were extracted from eight guidelines and care standards. We then extracted 10 documents with 223 indicators in total, from which 19 indicators covering the key elements were included in the first set and presented to experts. Based on their comments three indicators were deleted and four indicators were added to the set or slightly rephrased. These were subsequently judged by 13 pregnant women. Seventy-five per cent of the indicators were judged positively by them; no indicator was judged negatively. The set of indicators was thus left unchanged after this final step. Key conclusions and implications for clinical practicethe systematic approach adopted in this study resulted in an indicator set that was considered valid by both maternity care professionals and pregnant women, and is likely to satisfy the essential requirements on clinimetric properties. The next step will be to pilot test the indicator set on feasibility in daily clinical practice and to refine the set when necessary. In the future, maternity care professionals may use the set to present the quality of care they provide and to define issues of improvement. Pregnant women may use the information to make a founded choice between maternity care professionals, which ultimately should result in improved safety and quality of maternity care as well as patient satisfaction. Although we focused on the Dutch, community-based maternity care system, the approach used may be extrapolated to other care processes and health-care systems. Extrapolation of the results itself (i.e. the indicator set) may need to be limited to systems with an emphasis on community-based maternity care.

Psychiatric-Related Emergency Department Visits Among Children With an Autism Spectrum Disorder

This study aimed to examine the prevalence and characteristics of psychiatry-related emergency department (ED) visits among children with an autism spectrum disorder (ASD), including the specific reason for visit, as well as the influence of insurance type. Data used for this cross-sectional, observational study were obtained from the 2008 National Emergency Department Sample, the largest all-payer ED database in the United States. Psychiatry-related visits to the ED among children with ASD were identified using International Classification of Diseases, Ninth Revision, billing codes. A total of 3,974,332 visits (unweighted) were present for youth 3-17 years, of which 13,191 involved a child with ASD. Thirteen percent of visits among children with ASD were due to a psychiatric problem, as compared with 2% of all visits by youths without ASD. Results from the multivariate analyses revealed that the likelihood for a psychiatric ED visit was increased 9-fold (odds ratio [OR], 9.13; 95% confidence interval [CI], 8.61-9.70) among pediatric ASD visits, compared with non-ASD visits. Children with ASD who were covered by private insurance, compared with those with medical assistance, were at even greater risk for a psychiatric ED visit (OR, 1.58; 95% CI, 1.53-1.63). Visits among children with ASD were more likely to be due to externalizing (OR, 1.62; 95% CI, 1.44-1.83) and psychotic (OR, 1.93; 95% CI, 1.58-2.35) disorders compared with visits among non-ASD children. This study highlights the need for improving community-based psychiatric systems of care for youths with ASD to divert psychiatry-related ED visits, particularly for those children with private insurance.

“If We're Going to Change Things, It Has to Be Systemic:” Systems Change in Children's Mental Health

Communities that undertake systems change in accordance with the system of care philosophy commit to creating new systems entities for children and adolescents with serious emotional disturbance. These new entities are values-based, voluntary, and cross-agency alliances that include formal child-serving entities, youth, and families. Describing the scope and intent of one such implementation of systems of care, a mental health administrator commented, "If we're going to change things, it has to be systemic" (B. Baxter, personal communication, December 2, 2005). This paper explores the concept of "systemic" in the context of systems of care. Systems theory is used to understand strategies of purposeful systems change undertaken by stakeholders in established system of care communities. The paper presents a conceptual model of systems change for systems of care that is grounded in data from a national study of system of care implementation (Research and Training Center for Children's Mental Health in Case Studies of system implementation: Holistic approaches to studying community-based systems of care: Study 2, University of South Florida, Louis de la Parte Florida Mental Health Institute, Research and Training Center for Children's Mental Health, Tampa, FL, 2004). The model is based on Soft Systems Methodology, an application of systems theory developed to facilitate practical action around systems change in human systems (Checkland in Systems thinking, systems practice, Wiley, Chichester, 1999). The implications of these findings to real world actions associated with systems change in systems of care are discussed.

Cuban public health: Living the Marxist dream.

Cuban Public Health: living the Marxist Dream William Reay OMNI Behavioral Health Northcentral University How one actually carry out a work of social welfare? How one unite individ­ual endeavor with the needs of society? (Ernesto Che Guevara) 1 A ny serious discussion of com­munity-based global health care must include Cuba's public health care system. The system is a curiosity in terms of political ideol­ogy, social history, economics, design, delivery, and outcomes. Cuba is note­worthy for its (a) low infant mortal­ity, {b) low rates of birth defects, and (c) life expectancy at a level found in high-income countries. All of this has been accomplished in spite of the U.S. embargo that has been in place for 50 years and the loss of trading partners since the fall of the Soviet Union about 20 years ago. When the American Public Health Association sponsored an academic and profes­sional exchange between the United States and Cuba in November 2010, I was anxious to participate so that I could explore the public health care system, which has been a hallmark of Cuban life since the 1959 revolu­tion. I wanted to look behind the outcomes to the methods employed and examine how Cuba conceptual­izes and implements health care, especially in relation to prevention. As a psychologist and administra­tor whtl has been advocating for a public health approach to behavioral health care, I have studied integrated community-based care systems for years. Educated in both psychology and law, I am especially interested in public health systems' balance among the competing interests of personal sovereignty, personal well-being, and community needs. These interests vary substantially within and among cultures in close relation to social con­ditions, including economic factors. As a result of my trip to Cuba, my conclusions about its health care sys­tem are mixed. Their revolutionary medical system remains militarized. The methods responsible for the outstanding rates of child health indi­cators, including high rates of immu­nizations, have high costs in personal autonomy and privacy. Moreover, problems in evaluation persist at all levels of this unique, highly aligned system of government and social management. Politics and Values of the Cuban Public Health System Our delegation was joined by Cuban midlevel political and admin-10n Revolutionary Medicine (speech to the Cuban militia; Aug. 19, 1960). istrative medical personnel responsi­ble health care management, including the minister of public health. From exchanges with these individuals, it became very clear that the theoretical framework of Cuban health care remains strongly aligned with Marxist-Leninist ideology, a relationship evident at every level of the system. In other words, the choice of outcomes of interest and the methods used to achieve those outcomes are driven by the values associated with the prevailing political ideology. Moreover, these choices in health policy are sustained by the social and political structures that are pervasive in Cuban life. The Cuban health care system consists of multiple nested primary relationships, all originating at the family level. Hence, maintenance of a healthy lifestyle-behavior consis­tent with the public health care sys­tem's goals-is a duty of citizens, who are strongly influenced by the health care system at every level of personal and institutional interac­tion. The relationships among par­ents and family members, medical clinics (called polyclinics), and med­ical and political personnel are so tightly nested that citizen perspec-article is based on a presentation.at the Third Greenville Family Symposium (cosponsored by the American Orthopsychiatric Association, the Clemson University Institute on Family & Neighborhood Life, the International Family Therapy Association, and the International Society for Child Indicators) at University Center in- Greenville, SC, in April 2011. Correspondence concerning this article should be addressed to William Reay, OMNI Behavioral Health, 5115 F St., Omaha, NE 68117. Electronic mail may be sent to breay@omnibehavioralhealth.com. American Journal of Orthopsychiatry 2012, Vol. 82, No.2, 181-185 © 2012 American Orthopsychiatric Association DOl: IO.llll/j.l939-0025.2012.01152.x

Parent-Provider-Community Partnerships: Optimizing Outcomes for Children With Disabilities

Children with disabilities and their families have multifaceted medical, developmental, educational, and habilitative needs that are best addressed through strong partnerships among parents, providers, and communities. However, traditional health care systems are designed to address acute rather than chronic conditions. Children with disabilities require high-quality medical homes that provide care coordination and transitional care, and their families require social and financial supports. Integrated community systems of care that promote participation of all children are needed. The purpose of this clinical report is to explore the challenges of developing effective community-based systems of care and to offer suggestions to pediatricians and policy-makers regarding the development of partnerships among children with disabilities, their families, and health care and other providers to maximize health and well-being of these children and their families.

Transition from Pediatric to Adult Healthcare Services for Young Adults with Chronic Illnesses: The Special Case of Human Immunodeficiency Virus Infection

The term ‘‘healthcare transition’’ refers to the purposeful, planned movement of adolescents and young adults with chronic medical conditions from childcentered to adult-oriented healthcare systems. 1 Implicitly embedded in this term is the belief that transition should be uninterrupted, comprehensive, integrated, and developmentally appropriate. 2 All young adults eventually must make this move, sometimes after receiving interim care in an adolescent program or a pediatric practice that provides expert care to teenagers and college students, but for those with serious physical and emotional disabilities, the process is complex and often delayed. In particular, youth who were infected with human immunodeficiency virus (HIV) perinatally are beset with some of the most complicated life challenges, and for them the process of transition from pediatric and adolescent to adult medicine practices is daunting, one that requires a response by their healthcare providers (HCPs) that is skillful but time-consuming. In 1989, the US Surgeon General, C. Everett Koop, convened a national conference with the Maternal and Child Health Bureau (MCHB) to address the issues of transition for youth with special healthcare needs (YSHCN). The conferees, including HCPs caring for youth with chronic conditions, were asked to examine approaches for providing smooth passage and better communication between HCPs as these youth moved from child-centered to adultcentered care. A number of legislative initiatives emerged from this conference, including Omnibus Budget Reconciliation Act 1989, which emphasized that YSHCN must receive support from maternal and child health agencies tasked with implementing family-centered, community-based, comprehensive, coordinated care focused on the total continuum of needs of mothers and children, including adolescents. 3 In the late 1990s, it was estimated that >4 million children in the United States had chronic conditions that affected them daily. 4 Thus, the MCHB has made the implementation of transition services a core performance outcome for community-based systems of care for YSHCN. The Individuals with Disabilities Education Act also requires that students with disabilities, by age 14 years, must be the recipients of case-managed school transitional services that are integral to their individualized educational plans. 5 However, in a 2005 national survey of YSHCN and their guardians, only approximately half had talked with their HCPs about their healthcare needs and the adult providers who might accept their transfer, and only 15% of YSHCN met the MCHB outcome measures for medical transition. 6 When discussions with providers do occur, questions are raised about health insurance and the need for the patients’ self-sufficiency. These discussions are less likely to take place with poor African-American and Latino families and with those not speaking English. 7,8 Discussions with providers were associated with older age and connection with a medical home. Ignorance and uneasiness with the mechanics of transition are impediments equally shared by the pediatricians, internists, and family physicians who form the points of contact in the transition process. HCPs feel ill-equipped to initiate discussions about issues for which they have no ‘‘scripts’’ and that they cannot resolve realistically without considerable ‘‘outside help.’’ Internists vocalize a need for better education on congenital and childhood conditions that afflict YSHCN and more comprehensive programs for a different ‘‘breed’’ of highly skilled subspecialists in the care of older adolescents and young adults (including neurologists, pulmonologists, developmentalists, etc). 9 Internists also express a need to move toward an untraditional but necessary involvement in care of adult family members and designated friends.

Multiple perspectives on mental health outcome: needs for care and service satisfaction assessed by staff, patients and family members

Community-based mental health care requires the involvement of staff, patients, and their family members when both planning intervention programmes and evaluating mental health outcomes. The present study aimed to compare the perceptions of these three groups on two important subjective mental health outcome measures--needs for care and service satisfaction--to identify potential areas of discrepancy. The sample consisted of patients with a DSM diagnosis of psychosis and attending either outpatient or day centres operating in a community-based care system. Staff, patients and family members were assessed by using the CAN and the VSSS to evaluate, respectively, needs for care and service satisfaction. Kappa statistics were computed to assess agreement in the three groups. Patients identified significantly fewer basic (e.g. daytime activities, food, accommodation) and functioning needs (e.g. self-care, looking after home, etc.) than staff or family members. Only fair levels of agreement were found in the three groups (average kappa was 0.48 for staff and patients, 0.54 for staff and family members, and 0.45 for patients and relatives), with patients and family members showing more areas of discrepancies in both needs and service satisfaction. These findings provide further support for the idea that mental health services should routinely involve patients and their relatives when planning and evaluating psychiatric intervention and that this policy is a premise for developing a partnership care model.

Mortality among psychiatric patients treated in a community-based system of care: a 25-year follow-up

Mortality among psychiatric patients treated in a community-based system of care: a 25-year follow-up