Small Caseload Research Articles

Letter to the Editor

The authors are indeed fortunate that they have (1) a small case load, (2) serum specimens and not dried blood on filter paper, and (3) the opportunity to measure both thyroxine (T4) and thyroid-stimulating hormone (TSH) in all samples. Unfortunately, in the current economic climate most mass screening programs must limit their laboratory approach to T4 supplemented by TSH measurements or forego the T4 procedure and rely on TSH as the sole marker. In the latter instance, infants with hypothyroidism secondary to hypothalamic or pituitary disease will be missed and even those with mild primary thyroid insufficiency could be overlooked because of the large coefficient of variation in the assay at TSH concentrations between 20-25 µU/ml in dried blood on filter paper.

Differences Between Public and Private Rehabilitation Services & the Professionals Who Staff Them

Historically master's level programs in rehabilitation counseling produced trained graduates, many of whom became employed in state Divisions of Vocational Rehabilitation. In recent years an increased number of these experienced public sector counselors have switched from public to private sector employment which offers better salary incentives, training opportunities, smaller caseloads and a new sense of professional esteem. Some difficulty in job adjustment was reported by the seven counselors interviewed because of the differing philosophies and practices found in private rehabilitation companies. Despite these detriments, the trend away from the public sector is expected to continue as government budgetary cutbacks progress. Public agencies may need to develop and re-emphasize employment incentives to stall the exodus of trained counselors from the public to private sector of rehabilitation.

Freestanding Abortion Clinics: Services, Structure, Fees

In 1981, The Alan Guttmacher Institute (AGI), in collaboration with the National Abortion Federation (NAF), conducted a survey of 240 abortion clinics to update information about clinic structure and the relationship of structural characteristics to services, policies and fees. The clinics surveyed were a stratified random sample of all non-hospital abortion facilities that provided 400 or more abortions in the United States in 1980. Among the findings are the following: Thirty-one percent of the clinics reported that they are nonprofit or tax-exempt corporations. The nonprofit clinics are not significantly different from for-profit clinics in either the number of patients they serve or the region of the country in which they are located. Twenty percent of facilities, although regarded as clinics by the AGI for research purposes, define themselves as physicians' offices. These offices are more often located in the West and have smaller caseloads than other clinics. They are also disproportionately located in states with high abortion rates, which suggests that private physicians in these states are more willing than doctors in other states to provide relatively large numbers of abortions in their offices. Two-thirds of the clinics are licensed, most of them by states, but some by cities and counties. Licensed clinics have larger caseloads than nonlicensed facilities, but they are no different in terms of the other characteristics measured in the study, including services offered and fee structure. Fifty-four percent of clinics provide abortions after 12 weeks since the last menstrual period (LMP), and 24 percent, past 14 weeks.(ABSTRACT TRUNCATED AT 250 WORDS)

Rehabilitation Placement Services: Unlicensed Employment Agencies or Something Else?

Research into the roles and functions of rehabilitation, counselors has revealed job placement services to be among the most important duties reported. Yet, counselors have indicated they have insufficient time to perform placement services because of increased case load size. Thus, clients who are approaching job readiness generally have been referred to private not-for-profit rehabilitation facilities for placement services. More recently, private for-profit rehabilitation practitioners have discovered that placement efforts are enhanced by having smaller case loads which allows for attention to be focused toward job placement in a timely manner. However, both private not-for-profit rehabilitation facilities and for-profit practitioners generally charge a fee for client placement services. The dilemma confronting rehabilitation professionals and facilities who collect fees for placement is that they may be in violation of state statutes requiring such activities to be licensed as employment agencies, agents, or both. State statutes regulating employment agency functions are examined relative to fee-generating placement activities performed by rehabilitation personnel.

California's Community Treatment Program For Delinquent Adolescents

Since 1961, the Community Treatment Project (CTP) has handled seriously delinquent male and female offenders who have been committed from juvenile courts to the state correctional system from four California communities. Rather than being institution alized for several months, these youths, ages 13 to 19 at intake, are placed directly into a small caseload, intensive, community- located parole program: CTP. There, after being "matched" with a parole agent, they receive "differential" or relatively individual ized, as well as long-term, treatment. An "interpersonal maturity level" system is used to classify youths and as one important basis for establishing treatment objectives and techniques. Comparative effectiveness of the experimental (CTP) and control (traditional) programs was evaluated in terms of six separable out come measures: suspensions, recidivism, discharge, psychological tests, etc. E-C comparisons indicate that the E program has been able to handle a large majority of eligible youths (89 percent) at least as effectively as has the traditional program, while ten percent do better within the traditional program. Close to 25 percent do rather poorly within both types of program. A major objective of CTP—Phase Three (1969-1974) is that of developing more effective techniques and settings for working with this latter, rather sizable, "unsuccessful" group. Another objective is that of determining whether the CTP approach can be applied successfully to a wider range of offenders than have been handled to date — e.g., those committed from adult courts and/or for seriously assaultive offenses. Five main factors are mentioned as having made a sub stantial contribution to the comparative effectiveness of CTP during 1961-1969.

PATIENTS' VIEWS OF MEDICAL PRACTICE

This book examines patients' assessments of three kinds of medical practice in the Bronx: entrepreneurial or practice, group practice in HIP, and that in the Montefiore Group Family Health Maintenance Demonstration. Families chosen for participation in the demonstration were drawn at random from the Montefiore medical group and were cared for by teams composed of a physician, a public health nurse, and a social worker. The small caseload of professionals working in the demonstration encouraged patients to make maximum use of medical care facilities, and gave the professionals involved sufficient time so that they could provide more thorough care to the families assigned to them than is usual. Freidson finds that patients view physicians practicing in solo fashion as being much more interested in their welfare and concerned about their interpretations of illness, therapy, and the like. On the other hand, physicians practicing in groups, while showing less interest in the patient, are viewed by the patient as being more competent, in part, because they have more equipment for diagnosis and therapy easily available to them. As might be expected, the patients in this study reacted more favorably to the demonstration than to the other two forms of practice studied. The demonstration approach, although impossible to apply on any but a small scale, seemed to combine the best features of both group and solo practice. In the concluding chapter, the author suggests that group practice is increasing in one form or another throughout the country. He is somewhat alarmed at this, because of the lack of interest in patients that is shown by physicians in group practice. Freidson feels that the physician in group practice is more likely to make his patients wait in the waiting room, to use the impersonal appointment system, and to give patients short shrift in rotating examining rooms, he is less likely to make night calls, he discourages home visits, and he has so much practice and is so controlled by his peers that he caters little to patients' expectations. Freidson finds that among the highly competitive conditions facing solo practitioners in the Bronx, these characteristics of practice are present in much smaller degree than in group practice. It would not surprise me, however, if many a reader of this book might recognize the above characteristics attributed to group practice as traits exhibited by many solo practitioners of his own acquaintance. It is possible that solo practice in the Bronx is just as aberrant from that in the rest of the country as is HIP practice and the Family Health Maintenance Demonstration. SAXON GRAHAM

Relationship between Violation Rate and Initially Small Caseload

Relationship between Violation Rate and Initially Small Caseload