Health Service Delivery Models Research Articles

Aboriginal Health Workers – Primary health care at the margins

Aboriginal Health Workers: Primary health care at the margins Bill Genat with Sharon Bushby, May McGuire, Eileen Taylor, Yvette Walley and Thelma Weston 2006 University of Western Australia Press, Claremont 6010, vii +226pp, ISBN 1 92069 476 5 Wanted--Aboriginal person who can efficiently and competently deal with: difficult clients, inflexible structures, minimal resources, demands of other health professionals, destructive gossip, and complex family and health issues. Welcome to the life of an Aboriginal health worker described aptly and in detail in this most interesting book. Aboriginal health workers in Australia have a long history and are quickly building their professional profile. This book focuses upon experiences of Aboriginal health workers employed in a Family Care Program at an Aboriginal Health Service in Western Australia. It aims to describe the Aboriginal health workers' experiences and compare these to literature on Aboriginal health worker practice. The book begins by providing background about the origins and development of this unique profession. Literature in this area is generally limited and the author largely relies on material from Commonwealth, Northern Territory and Western Australian perspectives. The history of Aboriginal health workers in each state and territory differ slightly as health service delivery models, funding programs and available training have influenced roles and practices. Sourcing an accurate history of Aboriginal health workers is often difficult; rarely are their accounts of their practice voiced and detailed in a systematic or consistent way. This fact is exactly what makes this book significant as it provides a detailed record of the scope of practice and issues faced by this particular group of Aboriginal health workers. The experiences of the Family Care Program Aboriginal Health Workers are recorded through interviews. The author identifies emerging themes from these interviews including diverse demands and multiple dilemmas, dispirited response, breakdown in family caring, the community context, and the outcomes of exclusion and oppression. The Aboriginal health workers' voices as excerpts of interviews are dispersed throughout the discussion of these themes and provide humorous and complex emotional insights into the realities of their working lives. The Aboriginal health workers particularly highlight their struggle with developing client independence and providing services with limited resources. …

Impact of graduate mental health workers upon primary care mental health: a qualitative study

The role of the primary care graduate mental health worker (GMHW) was developed to improve the availability of mental health services within primary care. However, little is known concerning the impact of the role upon primary care mental health. Semistructured interviews were undertaken with 27 key stakeholders (12 clients, 10 managers/supervisors, 5 general practitioners) who had experience of the GMHW role and activities provided. Thematic analysis of interview transcripts highlighted four main themes: Access to primary care mental health, Inappropriate referrals, GMHW characteristics, and Role developments. All participant groups highlighted a range of ways in which the GMHW role was making significant contributions to primary care mental health. Many of these were associated with increasing access to mental health services afforded by the range of interventions provided. Benefits, however, may exclude working clients who expressed concerns about a lack of flexibility in the appointment times offered. Concerns arise as a consequence of inappropriate referrals made by some general practitioners. Such referrals were, in part, motivated by a belief that developments in primary care mental health should have been directed towards clients with more severe difficulties. In conclusion, this study suggests that the GMHW role is having a significant impact upon primary care mental health. Attempts to improve primary care mental health through the incorporation of the GMHW role within stepped care models of mental health service delivery should be encouraged.

Future public health delivery models for Native American tribes

More and more Native American tribes are assuming control of their own public health care delivery systems by contracting the functions of the Indian Health Service (IHS) through the provisions of P.L. (public law) 93-638, the Indian Self-Determination and Education Assistance Act. In doing this, some Native American tribes are making decisions to create or plan their own departments of public health. In Arizona, the Gila River Indian Community has already established its own department of public health and the Navajo Nation is in the planning stages of establishing its own department of public health. This paper proposes three public health organizational delivery models to meet the public health needs of small, medium, and large Native American tribes. Information for these models was derived from interviews with officials associated with the Arizona Department of Health Services and leaders of Native American tribes. These models progress in size and complexity as we move from small to medium to large tribes. (a) service delivery should focus on both preventative and curative services; (b) services should be developed with input from the underserved population; (c) members of underserved populations should be trained to provide service to their communities; (d) one model of health service delivery will not be appropriate for all underserved populations; and (e) different models are required to respond to differing cultures, populations, and geographic locations.

Skill shortages in health: innovative solutions using vocational education and training

This article reports findings of a project funded by the Australian National Council for Vocational Education Research. The project explores solutions to current and projected skills shortages within the health and community services sector, from a vocational education and training perspective. Its purpose is to locate, analyse and disseminate information about innovative models of health training and service delivery that have been developed in response to skill shortages. The article begins with a brief overview of Australian statistics and literature on the structure of the national health workforce and perceived skill shortages. The impact of location (state and rurality), demographics of the workforce, and other relevant factors, on health skill shortages is examined. Drawing on a synthesis of the Australian and international literature on innovative and effective models for addressing health skill shortages and nominations by key stakeholders within the health sector, over 70 models were identified. The models represent a mixture of innovative service delivery models and training solutions from Australia, as well as international examples that could be transposed to the Australian context. They include the skill ecosystem approach facilitated by the Australian National Training Authority Skill Ecosystem Project. Models were selected to represent diversity in terms of the nature of skill shortage addressed, barriers overcome in development of the model, healthcare specialisations, and different customer groups. Key barriers to the development of innovative solutions to skills shortages identified were: policy that is not sufficiently flexible to accommodate changing workplace needs; unwillingness to risk take in order to develop new models; delays in gaining endorsement/accreditation; current vocational education and training (VET) monitoring and reporting systems; issues related to working in partnership, including different cultures, ways of operating, priorities and timelines; workplace culture that is resistant to change; and organisational boundaries. For training-only models, additional barriers were: technology; low educational levels of trainees; lack of health professionals to provide training and/or supervision; and cost of training. Key enhancers for the development of models were identified as: commitment by all partners and co-location of partners; or effective communication channels. Key enhancers for model effectiveness were: first considering work tasks, competencies and job (re)design; high profile of the model within the community; community-based models; cultural fit; and evidence of direct link between skills development and employment, for example VET trained aged care workers upskilling for other health jobs. For training only models, additional enhancers were flexibility of partners in accommodating needs of trainees; low training costs; experienced clinical supervisors; and the provision of professional development to trainers. There needs to be a balance between short-term solutions to current skill shortages (training only), and medium to longer term solutions (job redesign, holistic approaches) that also address projected skills shortages. Models that focus on addressing skills shortages in aged care can provide a broad pathway to careers in health. Characteristics of models likely to be effective in addressing skill shortages are: responsibility for addressing skills shortage is shared between the health sector, education and training organisations and government, with employers taking a proactive role; the training component is complemented by a focus on retention of workers; models are either targeted at existing employees or identify a target group(s) who may not otherwise have considered a career in health.

Predictors of general medical and psychological treatment use among a national sample of peacekeeping veterans with health problems

We investigated general medical and psychological treatment use predictors among peacekeeping veterans with health problems, aiming to find those characteristics most associated with treatment use intensity (i.e., visit counts). One thousand one hundred and thirty-two male Canadian Forces peacekeeping veterans registered with Veterans Affairs for health problems were randomly recruited for a prospective national survey. Regression analyses for treatment use intensity controlled for age, total time deployed and health problems (covariates), and examined the incremental contribution of depression and post-traumatic stress disorder (PTSD) severity on health service use intensity. Results revealed that after controlling for covariates, the depression and PTSD model was associated with increased medical and psychological treatment use intensity. Medical use intensity was significantly predicted by married status, greater depression and health problems; psychological treatment use intensity was predicted by younger age, greater PTSD severity and health problems. This study highlights the importance of an integrated primary care-mental health service delivery model for veterans.

Aboriginal mental health workers and the improving Indigenous mental health service delivery model in the 'Top End'

This article reviews the changing Aboriginal mental health service delivery model of Top End Mental Health Services, and highlights the importance of Aboriginal mental health workers in improving communication with Aboriginal patients. The Australian Integrated Mental Health Initiative Northern Territory Indigenous stream (AIMHI NT) is introduced.Baseline measures of AIMHI NT in 2003, and findings from two clinical file audits (1996 and 2001) at Royal Darwin Hospital inpatient unit are presented. The files were audited for a range of assessment and treatment interventions.The audits reveal significant improvements in Aboriginal inpatient care between 1995 and 2001.Aboriginal mental health workers provide essential services as cross-cultural brokers in the setting of Aboriginal mental illness. The improvements in care found in this file audit coincide with the commencement of employment of Aboriginal mental health workers in the inpatient unit. The AIMHI consultation reveals broad support for employment of more Aboriginal mental health workers in the Top End.

Aboriginal Mental Health Workers and the Improving Indigenous Mental Health Service Delivery Model in the ‘Top End’

This article reviews the changing Aboriginal mental health service delivery model of Top End Mental Health Services, and highlights the importance of Aboriginal mental health workers in improving communication with Aboriginal patients. The Australian Integrated Mental Health Initiative Northern Territory Indigenous stream (AIMHI NT) is introduced. Baseline measures of AIMHI NT in 2003, and findings from two clinical file audits (1996 and 2001) at Royal Darwin Hospital inpatient unit are presented. The files were audited for a range of assessment and treatment interventions. The audits reveal significant improvements in Aboriginal inpatient care between 1995 and 2001. Aboriginal mental health workers provide essential services as cross-cultural brokers in the setting of Aboriginal mental illness. The improvements in care found in this file audit coincide with the commencement of employment of Aboriginal mental health workers in the inpatient unit. The AIMHI consultation reveals broad support for employment of more Aboriginal mental health workers in the Top End.

Users’ perceptions of health care reforms: Quality of care and patient rights in four regions in the Russian Federation

In the early 1990s, the government of the Russian Federation (RF) decided to depart from the centralised and integrated model of health service delivery and financing in favour of mandatory social health insurance (MHI). The rationale for introducing social health insurance in Russia in the early 1990s was primarily to secure a reliable source of funding but also to improve the quality of care and introduce user entitlements known as patient rights. This paper discusses findings of a survey carried out in 1999–2000 to explore users’ perceptions of reforms, changes in quality of care and their satisfaction with patient rights in Murmansk, Yaroslavl, Moscow Region and Moscow City, using a structured questionnaire and metric scales. Nearly half of the respondents thought that the quality of services had not changed significantly since the introduction of the MHI, although the majority accepted the necessity for reforms. Many reported having little or no information about health insurance or patient rights. While there were many similarities among the regions studied, a number of considerable differences existed which could be linked to different ways of implementing the insurance scheme and different levels of funding health care.

Nursing in Tele-Mental Health

This article discusses a cooperative project involving an academic health sciences center, a state university, a women's shelter, and a community mental health center in East Texas, a medically underserved, rural region of Texas. The U.S. Department of Commerce provided grant funding to develop a telehealth network to provide an evaluation, referral, and treatment program for victims of domestic violence. Nurses were involved in all phases of the project, from initial conception through development, implementation, and evaluation. The authors concluded that all of the women involved in the study had significant mental health issues and other health concerns that were not being addressed by the existing health care delivery system. Without the use of telehealth, these women would have had limited access to primary health care and virtually no access to mental health services. The East Texas Tele-Mental Health Network demonstrates the value of the clinical and organizational skills that nurses bring to innovative models of mental health service delivery.

An Introduction to Prostate Cancer and Geographic Information Systems

An Introduction to Prostate Cancer and Geographic Information Systems

Hot Topics in Geriatrics Draw Funding

Hot Topics in Geriatrics Draw Funding

Sedentarization and children's health: Changing discourses in the northeast Badia of Jordan

The significance of the socioeconomic and cultural contexts of individuals’ accounts of health and illness is recognized in studies of lay discourses of health and illness. However, many studies of health care utilization argue that social and cultural contexts in non-industrialized countries reinforce the use of traditional medicines and constitute barriers to the effective use of biomedical services, reflecting the rooting of such studies in discourses of modernization and development. Based on interviews with 181 parents, this article illustrates the influence of development on changing discourses of children's health and illness among sedentarizing Bedu communities of the northeast Badia of Jordan. The accounts of sedentarized and semi-nomadic families are contrasted. It is suggested that Bedu social values have precipitated rather than inhibited changes. The article highlights the importance of understanding historical, socioeconomic and cultural contexts in formulating appropriate models of health service delivery.

Primary Health Care: A Preferred Health Service Delivery Option for Women

It is well known that gender is a determinant of health, but less understood is whether differences in health status attributable to gender can be mitigated through the implementation of primary health care. Primary health care, notably distinct from primary care, refers to a wide-ranging approach to the delivery of a comprehensive variety of health services. This article traces the similarities between primary health care and women-centred care from their overlapping philosophical foundations to the similar health, social, and economic benefits of both approaches. It is argued that investments in primary health care positively impact women's health, and, as such, should be a preferred option for the delivery of women's community health services. Several models of health service delivery that operate in accordance with principles of primary health care and also address the key tenets of women's-centred care are examined and their merits are compared. The article also identifies the major impediments to the adoption of both primary health care and women's-centred care approaches.

Assertive Community Treatment: Re-thinking a Tried and Tested Service Model

Assertive Community Treatment (ACT) is a team-based, mobile, high contact model of mental health service delivery for people with disability and high risk of relapse. Typical interventions by ACT teams include delivery of medications, monitoring mental state, intensive work on everyday living skills, response to crises, assistance with stable accommodations, and facilitation of access to other community supports and clinical services. Case managers in standard care perform broadly similar roles but at much lower levels of intensity and with higher caseloads. Standard case management relies more on the initiative and active

Synergies between veterinarians and para-professionals in the public and private sectors: organisational and institutional relationships that facilitate the process of privatising animal health services in developing countries.

The delivery of veterinary services in most developing countries was, until recently, considered to be the responsibility of the public sector. However, over the past four decades, economic constraints and the imposition of structural adjustment policies (SAPs) have led to a gradual decline in public sector investment in real terms and thus a reduction in the quality and quantity of services available to livestock keepers. Many governments acknowledged that they were no longer able to provide services that were essentially of a 'private good' nature and introduced radical policy changes which sought to introduce the concepts of a market orientated approach towards agriculture and livestock production in particular. The role of government, in the future, would be to provide a reduced range of essential 'public good' services and to create a favourable environment in which the private sector could become established as a provider of 'private good' services and at the same time act as a partner in carrying out certain public functions under contract or 'sanitary mandates'. In almost all developing countries, however, these policy changes were not accompanied by appropriate development strategies. The reasons for this are complex. Firstly, SAPs may be considered to have been foisted upon governments by donors and are thus perceived by many policy-makers as the cause of financial problems, rather than a solution to them. Secondly, most animal health senior policy-makers in the public sector have been trained as veterinarians and lack the required management skills to plan change effectively. Furthermore, as regards clinical veterinary service delivery, especially in rural or more remote areas, the solution fostered by donor investment, which involves deregulation and the deployment of privately operating para-professionals, is often perceived as a threat to the veterinary profession and might result in limiting access to international markets for the trade of livestock and livestock products. An informal delivery system has gained a foothold in many developing countries in the absence of a well-planned strategy for the privatisation of animal health services. Most governments would now acknowledge that this presents a greater risk than the deployment of well-regulated and effectively supervised para-professionals. This paper explores some of the principal challenges facing policy-makers in their efforts to bridge the transition from full state provision of animal health services to the formation of a partnership with the private sector. Governments and donors need to take active steps to facilitate the process of privatisation of animal health services, especially those targeting the poorer rural subsistence and pastoralist farming systems. This would entail an initial investment in developing the necessary management skills at all levels in the delivery system. Thereafter, further investment would be required to allow the changes to be managed using tools such as the strategic planning cycle. Should sufficient resources be made available to allow the full participation of all stakeholders in the delivery of animal health services, appropriate institutions and effective organisational relationships addressing all the more important issues will have to be identified. The paper then proceeds to describe how different livestock production systems determine the level of demand for animal health services. If these services are to be provided on a financially sustainable basis, they must be tailored to meet actual rather than perceived demand. Identifying an appropriate model for animal health service delivery thus requires careful analysis of the production system to be targeted. Governments and donors can play a useful role in providing resources for this type of study as well as for appropriate market studies, business planning, training and access to soft loans. Finally, as regards regulation, as the law stands today, many activities currently practised by para-professionals are classified as 'acts of veterinary medicine or surgery' and may only legally be performed by qualified and registered veterinarians. The concept of 'principal' and 'subsidiary' legislation provides the necessary flexibility in the regulation of the delivery of animal health services to accommodate the rapid changes taking place in this environment today. Deregulation involves the delegation of responsibility for the performance of a defined range of veterinary interventions to para-professionals under the 'supervision' or 'direction' of a registered veterinarian. The author illustrates how the experiences of a number of projects in Tanzania were used to propose a definition of 'supervision' in law. The definition offers an opportunity to overcome the fear of compromising standards of delivery of animal health services through the deployment of para-professionals. In addition, such functioning provides employment opportunities for private veterinarians in rural areas where access to formal primary animal health services would otherwise be denied and may contribute to the process of quality assurance of national veterinary services in developing countries.

School Social Work: Meeting the Mental Health Needs of Students through Collaboration with Teachers

School-based mental health services hold promise for reaching youths in need. This article draws on an ecological-mediational model for school-based mental health services that links factors in the school environment to children's mental health and academic achievement. School influences are mediated by the teachers' role in promoting mental wellness among students. Collaboration with teachers is the centerpiece for change at the school, classroom, and individual teacher levels. A mental health services delivery model that incorporates school social workers as resources to teachers, families, and children is discussed as an approach to promote and expand prevention, identification, and treatment of child emotional and behavioral difficulties in school settings.

Breast reconstruction following mastectomy: current status in Australia.

Although breast reconstruction provides some advantages for women following mastectomy, few Australian breast cancer patients currently receive reconstruction. In Australia, the routine provision of breast reconstruction will require the development of specific health service delivery models. The present paper reports an analysis of the provision of breast reconstruction in eight sites in Australia. A semi-structured telephone interview was conducted with 10 surgeons offering breast reconstruction as part of their practice, including nine breast or general surgeons and one plastic surgeon. Surgeons reported offering breast reconstruction to all women facing mastectomy; the proportion of women deciding to have breast reconstruction varied between sites with up to 50% of women having a reconstruction at some sites. Most sites offered three types of reconstruction. Two pathways emerged: either the breast surgeon performed the breast surgery in a team with the plastic surgeon who undertook the breast reconstruction or the breast surgeon provided both the breast surgery and the reconstruction. Considerable waiting times for breast reconstruction were reported in the public sector particularly for delayed reconstruction. Surgeons reported receiving training in breast reconstruction from plastic surgeons or from a breast surgery team that performed reconstructions; a number had been trained overseas. No audits of breast reconstruction were being undertaken. Breast reconstruction can be offered on a routine basis in Australia in both the private and public sectors. Women may be more readily able to access breast reconstruction when it is provided by a breast surgeon alone, but the range of reconstruction options may be more limited. If access to breast reconstruction is to be increased, there will be a need to: (i) develop effective models for the rural sector taking account of the lack of plastic surgeons; (ii) address waiting times for reconstruction surgery in the public sector; (iii) review costs to women in the private sector; (iv) develop a better understanding of women's views and how best to communicate about breast reconstruction; and (v) improve training in breast reconstruction.

‘Victoria on the Move’: Mental Health Services in a Decade of Transition 1992-2002

Objective: Australia adopted a national mental health strategy in the early 1990s and each State has had to go through its own implementation process in the intervening years. The present paper describes the process of reform in services in Victoria, and ventures explanations as to why the process may have been more comprehensive and successful than in other States. Conclusions: Victoria adopted a Statewide ‘framework’, defining structural elements of area-based services, with rational resource distribution. A transitional process involving a population health approach and relatively rigid implementation of a tightly specified service framework, within a political environment that favoured strong health services management, was successful in achieving desired structural reforms in this State. This was undoubtedly at the cost of promoting a model of public mental health service delivery that is generally rationed so as to accept only a restricted range of types of referral. New initiatives from the current State government are explicitly targeted to correcting this situation.

Models of mental health services in nursing homes: a review of the literature.

The authors review the research literature on models and outcomes of extrinsic mental health services in nursing homes and summarize the data on current practices in this area. Extrinsic mental health services are those delivered in the nursing home by specialists who are not full-time staff of the nursing home. English-language articles providing descriptive and research reports on models and outcomes of extrinsic mental health services in nursing homes were identified through a comprehensive search of peer-reviewed journals, using MEDLINE and psychological literature databases. The research methods of the reports were also noted. Three primary models of mental health service delivery were identified: psychiatrist-centered, nurse-centered, and multidisciplinary team models. Uncontrolled observational studies suggested that mental health services may result in improved clinical outcomes and less use of acute services. However, few well-designed controlled intervention studies have been conducted. Education and training appeared to improve staff members' knowledge and performance and to decrease turnover. The least effective model involved traditional consultation-liaison service in which a lone clinician provided a one-time, written consultation on an as-needed basis. Multidisciplinary team approaches were favored as preferred service models. Few studies using an experimental design have examined the outcomes of mental health services in nursing homes. Program descriptions and uncontrolled outcome studies suggest that preferred practice includes the routine presence of qualified mental health clinicians in the nursing home, that optimal services are interdisciplinary and multidimensional, and that the most effective interventions blend innovative approaches to training and education with consultation and feedback on clinical practices.

Clinical psychology in rural general practice: A pilot of a collaborative model of mental health service delivery*

*A project funded by the Partnerships in Service Reform Section, Mental Health and Special Programs Branch of the Commonwealth Department of Health and Age Care.