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PubMed1982

The metamorphosis of the country psychiatric service.

From their beginnings, county or municipal psychiatric services have reflected the political and social attitudes of the times. Traditionally they were public facilities that delivered acute inpatient care and a variable range of outpatient services, and, within their mandate, they functioned well. During the past two decades institutional psychiatry has evolved in such a way that there is little difference in the range of services delivered by county, state, and voluntary facilities. The logical role of the county hospital continues to be the provision of acute care for the poor. But for county systems to survive and flourish, they must be prepared to regionalize some services, and to differentiate their role in relation to voluntary and state facilities, yet integrate services with them where needed. They must strengthen ties with academic institutions and effectively address problems of third-party payment and other financial issues.

Delivery of Health Care↗
PubMed2006

Koreans' use of medical services in Seoul, Korea and California.

This study assessed the types of health care services used by Korean immigrants, and differences in use between different countries, genders, health insurance status, acculturation status, and cardiovascular risk. Participant selection used probability sampling to represent the adult populations of California, United States, and Seoul, Republic of Korea. A telephone survey was administered to 2,830 adult Korean-Californians and 500 adult Koreans living in Seoul. Female gender was significantly associated with higher use of outpatient services, ER usage, and hospitalization. Californian residence was significantly associated with higher outpatient usage and lower hospitalization rates. Health insurance was associated with higher allopathic health care utilization, and lower traditional health care usage, and acculturation with lower traditional health care usage. Higher self-reported cardiac risk factors were associated with lower allopathic and higher traditional health care. This suggests barriers to allopathic health care, but not traditional health care, for Koreans living in California without health insurance.

Acculturation↗
PubMed1995

Multisite experimental cost study of intensive psychiatric community care.

A 2-year experimental cost study of 10 Intensive Psychiatric Community Care (IPCC) programs was conducted at Department of Veterans Affairs (VA) medical centers in the Northeast. High hospital users were randomly assigned to either IPCC (n = 454) or standard VA care (n = 419) at four neuropsychiatric (NP) and six general medical and surgical (GMS) hospitals. National computerized data were used to track all VA health care service usage and costs for 2 years following program entry. At 9 of the 10 sites, IPCC treatment resulted in reduced inpatient service usage. Overall, for IPCC patients compared with control patients, average inpatient usage was 89 days (33%) less while average cost per patient (for IPCC inpatient, and outpatient services) was $15,556 (20%) less. Additionally, costs for IPCC patients compared with control patients were $33,295 (29%) less at NP sites but were $6,273 (15%) greater at GMS sites. At both NP and GMS sites, costs were lower for IPCC patients in two subgroups: veterans over age 45 and veterans with high levels of inpatient service use before program entry. No interaction was noted between the impact of IPCC on costs and other clinical or sociodemographic characteristics. Similarly, no linear relationship was observed between the intensity of IPCC services and the impact of IPCC on VA costs, although the two sites that did not fully implement the IPCC program had the poorest results. With these sites excluded, the total cost of care for IPCC patients at GMS sites was $579 (3%) more per year than that for the control patients.

Activities of Daily Living↗
PubMed2006

Process of care for battle casualties at Walter Reed Army Medical Center: Part IV. Occupational therapy service.

Occupational therapy addresses deficits in activities of daily living, upper-extremity motor performance deficits secondary to injury or disease, and occupational or role performance deficits attributable to mental and behavioral health conditions. We describe the inpatient and outpatient services provided, the problems and solutions encountered, and the lessons learned.

Amputation, Surgical↗
PubMedDate not supplied

Perceived need and receipt of outpatient mental health services. Factors affecting access in Israeli HMOs.

The finance and provision of care have been suggested as variables that affect the utilization of mental health services. This study compared perceived need and receipt of outpatient mental health services in a staff-model health maintenance organization (HMO) and in three HMOs with preferred provider organization (PPO) arrangements. A national random phone survey (n = 1,394) of perceived need for and receipt of mental health assistance was conducted in Israel in 1995. Health care is provided by four HMOs that differ in mental health benefits, utilization management (i.e., prior authorization and referral requirements), and availability of mental health services (i.e., pool of providers and geographic dispersal). About one-quarter of the respondents had perceived a need for help at some time in their life. Significantly fewer respondents from the HMO with a small pool of providers got help (20%) than respondents from the other HMOs, which had almost identical rates of obtaining care (40.3%, 37.3% and 40.3%). Providing generous outpatient mental health care benefits does not appear to increase the proportion of persons in need who get help. However, severely limiting the availability of services does reduce the proportion of persons getting care. Implications for regulating insurers are discussed.

Adult↗
PubMed1996

Measuring public hospital costs: empirical evidence from the Dominican Republic.

Effective analysis of hospital performance requires the existence of accurate cost and output data. However, these are missing ingredients in most developing countries due to lack of information systems or other sources of data. Typically, expenditures are substituted for actual costs in analyzing hospital finance. This paper presents a methodology and analysis of the actual costs of inpatient, emergency, and outpatient services in a Dominican hospital. Through applying a set of survey instruments to a large sample of patients, the study measures and costs all hospital staff time, in-kind goods (drugs, medical supplies, reagents, etc.), overhead, and the depreciated value of plant and equipment related to the treatment of each patient. The results are striking. The budget is over 50% higher than the actual costs of services, reflecting the high cost of waste, down time, and low productivity. For example, high fixed costs translate into immunizations that on the average cost over 20% more than outpatient surgical interventions. The most disturbing finding is that although physicians represent the bulk of personnel spending, the surveys could account for only 12% of the contracted time of staff physicians, including time dedicated to treatment, supervision, administration, and teaching. As a proportion of the hospital total budget, personnel spending represents a high 84%. Yet staff costs for patient treatment never exceed 12%. These results suggest gross inefficiency, chaotic medical care organization, and poor hospital management.

Ambulatory Care↗
PubMed1975

Factors determining effective psychiatric outpatient treatment for Mexican-Americans.

A mental health center offering outpatient services to Mexican-Americans should be centrally located in the Mexican-American community, should have a bicultural and bilingual staff, and should have an informal atmosphere with a minimum number of bureaucratic procedures. The center's services must be publicized in a way that minimizes the stigmatization of mental illness, promotes preventive care, and indicates that staff understand Mexican-Americans' problems. La Frontera, a mental health outpatient clinic serving the Tucson area, operates under those guidelines. Clinic records in March 1973 showed that Mexican-Americans accounted for 61 per cent of the active cases.

Adult↗
PubMed1993

The effects of immune status and race on health service use among people with HIV disease.

OBJECTIVES: The purpose of this study was to examine the relationship between CD4 lymphocyte count and health service use, and to determine whether differences in the rates of service use between Whites and people of color could be identified. METHODS: Medical records for 571 HIV-infected individuals were analyzed. Incidence rates and relative rates across CD4 strata (defined by cell counts) were calculated for inpatient and outpatient events. Rate ratios comparing people of color with Whites were estimated within strata, adjusting for confounding factors using a Mantel-Haenszel pooling procedure. RESULTS: Both inpatient and outpatient service use increased over progressively lower levels of CD4 counts. Within each CD4 stratum and controlling for other factors, White participants had more HIV clinic visits and fewer admissions than people of color. Among participants with fewer than 51 CD4 cells per cubic millimeter, people of color were admitted 20% more often, had 35% more inpatient days per person-year, and had only 74% as many HIV clinic visits as their White counterparts. CONCLUSIONS: These results indicate that CD4 lymphocyte count is strongly associated with increased usage of health services. People of color with HIV disease are more likely than similar Whites to be admitted to the hospital and less likely to use outpatient care.

Ambulatory Care↗
PubMedDate not supplied

Management considerations in the development of a chemical dependency program.

In summary, using an outside firm may be a profitable method to enter a new market quickly with low financial risk. However, there are certain pitfalls in the contracting process. The process should be undertaken with particular attention to the right to re-employ staff. The increasing costs of a per diem fee arrangement as volume grows, and the outside firm's reluctance to move to outpatient services in this type of financial arrangement.

Contract Services↗
PubMed1993

State policies and programs that address the needs of mentally ill mothers in the public sector.

OBJECTIVE: The authors sought to determine whether state departments of mental health have specific policies and programs addressing the needs of mentally ill women served in the public sector who have preschool-age children. METHODS: A questionnaire was sent to the commissioner of mental health for each state and the District of Columbia. Questions addressed whether information was routinely collected on the parenting status of women who receive public-sector psychiatric services, whether services targeting mentally ill women with young children were available, and whether the state had policies concerning hospitalized women who are pregnant or who have young children. RESULTS: Sixteen states routinely collect data on whether women who receive public-sector services have young children. Four states have residential programs for mentally ill women and their children. About half of the states have programs for assessing parenting skills and outpatient services focused on improving those skills. No state has a policy about visitation between a hospitalized mentally ill mother and her children. Twenty states have policies for the care of hospitalized pregnant patients, primarily for their medical management. CONCLUSIONS: Further efforts are needed to identify mentally ill women in the public sector who have young children, to enhance the parenting skills of mentally ill patients, and to promote positive outcomes for their children.

Child↗
PubMed1984

Severe alcoholism in the mental health sector: II. Effects of service utilization on readmission.

A follow-up study of a cohort of suburban alcoholics who are comprehensively served by the public mental health sector used a Cox survival time analyses to examine the relationship of patient characteristics, receipt of outpatient services and readmission to inpatient care. Patients were followed up until their first readmission to inpatient care or for 2 yr subsequent to an inpatient episode. As expected, established chronicity was associated with short "survival" in the community, as were youth and living alone. For first admissions, the receipt of aftercare was associated with a decreased likelihood of readmission, especially in conjunction with inpatient stays of treatment that included rehabilitation services. Patients who had established a pattern of chronicity, however, appeared resistant to the effect of these services. The transition from inpatient to aftercare services was identified as a crucial point in treatment. Aftercare patients who did not receive services beyond 6 months in the community were likely to be readmitted, suggesting that this period is also an important focus for treatment planning.

Adult↗
PubMed2006

[Asthma related knowledge among parents of asthmatic children at the moment of admission to a specialized service].

OBJECTIVE: To assess asthma related knowledge among parents of asthmatic children at the moment of admission to a specialized service. METHODS: This was a descriptive study. Parents of 93 asthmatic children (aged from 29-18 yr) were interviewed, at the moment of admission to the Pediatric Pulmonary Outpatient Service of a university hospital, using a questionnaire to assess their asthma related knowledge. The assessment focused on understanding of the nature, prognosis and treatment of asthma. Only the data from parents of 87 children aged from 29 days to 10 years were analyzed. RESULTS: Upon self-assessment, 93.1% of the parents considered their asthma related knowledge insufficient and 88.5% showed interest in obtaining more information. With regard to understanding of the nature, prognosis and treatment of asthma, 96.6% of the parents did not know the role of airway inflammation on synthesis of symptoms and 51.7% believed in a cure for the disease. Among the parents whose children use a home nebulizer, 80.6% used it incorrectly; all of the parents whose children use spray without a spacer were not familiar with the correct inhalation technique; 65.5% of the parents were unaware of the importance of environmental control. Presence of allergic sources and of smokers was found in 77.0% and 68.9% of families respectively. CONCLUSIONS: This study shows an insufficient asthma related knowledge among parents of asthmatic children at the moment of admission to a specialized service, characterized by ignorance about the nature and prognosis of the disease, inadequate technique to use inhaled drugs and unawareness of home environmental control.

Asthma↗
PubMed1990

Online access to MEDLINE in clinical settings. A study of use and usefulness.

STUDY OBJECTIVE: We introduced self-service access to the medical literature database, MEDLINE, into clinical settings to assess the frequency, patterns, purposes, and success of use. DESIGN: Longitudinal descriptive study. SETTING: Inpatient and outpatient services of a university medical center. PARTICIPANTS: All trainees and attending staff working at the service sites were invited to participate; 158 (84%) did so. INTERVENTIONS: Free online access was provided to MEDLINE through GRATEFUL MED software. Participants were offered a 2-hour introduction to online searching and 2 hours of free search time. MEASUREMENTS AND MAIN RESULTS: For each search, a computer program requested identification of the user and the question to be addressed. Search transactions were recorded automatically. Interviews were conducted after a random sample of searches, and search questions were given to more expert searchers to run for comparison with the original. Eighty-one percent of participants did searches on study computers, at a mean rate of 2.7 searches per month. On comparison searches, participants retrieved 55% of the number of relevant articles retrieved by reference librarians (P = 0.024) and 50% more irrelevant articles (P less than 0.001). Forty-seven percent of searches on patient problems affected clinical decisions, but often on scanty information. CONCLUSIONS: MEDLINE searching from clinical settings is feasible with brief training and affects clinical decisions. However, inexperienced searchers miss many relevant citations and search inefficiently. Further studies are needed to assess the impact of searching on physician performance and patient care.

Academic Medical Centers↗
PubMed1995

Adoption of HIV-related services among urban US hospitals: 1988 and 1991.

Recent reports document that US hospitals vary considerably, notably by ownership, in the number of acquired immunodeficiency syndrome (AIDS) patients they treat. Still, little is known about other types of hospital response to human immunodeficiency virus (HIV) and AIDS and the relative strength of ownership as a determining factor. With annual survey data from the American Hospital Association the authors examine the formal adoption of HIV-related services among urban US hospitals at the turn of the decade. Descriptive analyses of 2 years of data (1988 and 1991) are presented. A multivariate logistic regression analysis, conducted on the 1991 data, tests for unique ownership effects on the likelihood that hospitals are heavy investors in HIV-related care. Patterns of service adoption for 1991 strongly resemble those for 1988. Nearly three fourths of urban US hospitals offer general inpatient AIDS care, and over half provide HIV testing. Few urban hospitals offer outpatient services; even fewer operate AIDS units. A substantial minority report no formal adoption of HIV-related services. For-profit hospitals stand out as least likely to formally adopt these HIV-related services. Those adopting a comprehensive set of HIV-related services typically are public or secular, not-for-profit in ownership, large, affiliated with a medical school, and high volume users of Medicaid funding. The logistic regression analysis suggests that public ownership is a key determinant of greater service investment, even after controlling for other explanatory factors. This study appears to mirror a familiar pattern of hospital response to undercompensated care in the United States.

AIDS Serodiagnosis↗
PubMed1991

Assessing the needs for care of non-psychotic patients. A trial with a new standardized procedure.

Recent psychiatric epidemiological studies using standardized interviews in the community have yielded high rates of non-psychotic disorders. The implications for service provision in terms of treatment and planning remain unclear. No methodology exists to link the individual needs for care and services to problems associated with disorders. The Needs for Care Assessment Schedule (NFCAS) is a relatively new procedure for assessing the needs of long-term mentally ill patients, mostly psychotic and attending psychiatric services. We report here a trial application of a modified version of the NFCAS on a sample of 39 non-psychotic patients, most of whom were attending psychiatric outpatient services. The results show that the modified procedure requires further refinement to achieve acceptability and reliability. Some improvements are suggested for refining items and for the collation of others. The difficulties encountered underline the key issues in developing such technology: specifying the threshold for recognizing the problems, detailing the interventions considered appropriate, defining the model of care and specifying the composition of the research team.

Activities of Daily Living↗
PubMed2001

Impact of VA bed closures on use of state psychiatric services.

This study examined whether inpatient bed reductions at a Department of Veterans Affairs (VA) medical center increased VA patients' use of state mental health agency services. Veterans residing in two Connecticut cities who used VA psychiatric services during fiscal years 1993 through 1998 (n = 2,943) were identified from computerized files. Then their records were merged with state files. Coinciding with the time of VA bed closures, the proportion of VA patients who used any state services increased from 2.6%, 2.8%, and 2.7% from 1993 through 1995 to 3.6%, 3.5%, and 3.6% from 1996 through 1998 (p < .03). These changes reflect increased likelihood of state outpatient service use, but not inpatient services. No statistically significant changes occurred in the cost of state services used by VA patients. Bed closure impact may be reflected in increased cross-system service use, which may be a useful indicator of unmet needs resulting from system changes.

Adult↗
PubMedDate not supplied

Co-occurring disorders: policy and practice in Germany.

The occurrence of substance use disorders (SUD) with other mental disorders-what is often referred to as co-occurring disorders (COD)-is a common phenomenon, but for a long time, little attention has been paid to this problem in Germany. During the last 25 years, however, COD awareness has increased due to a shift toward community-based services. Scientific research has also demonstrated the significance and clinical relevance of COD. High prevalence rates and evidence of poor clinical outcomes were found in German studies. Many practitioners as well as policymakers acknowledge that changes in systems of care are necessary to meet the requirements of COD patients. The traditional German system is currently divided into addiction services and mental health services (predominantly in inpatient settings), often resulting in ineffective sequential treatment for COD patients. Research demonstrates that integrative treatment models are more appropriate, and the division of services should be reorganized to help COD patients appropriately. Efforts have already been made to restructure healthcare systems toward a more flexible approach with improved networking between in- and outpatient services. A further issue is the general attitude toward SUD patients. Many practitioners continue to hold negative opinions (eg, "SUD patients are only weak-minded") or feel insecure when confronted with SUD. This results in SUD problems being frequently ignored or depreciated. Educational programs have been intensive over recent years to address this problem (eg, Fachkunde Sucht, an advanced training program on SUD). In general, treatment conditions for COD patients are improving, but further efforts are necessary. Guidelines and treatment strategies for COD patients have been recently published in Germany.

Alcoholism↗
PubMedDate not supplied

The 'quiet' crisis in mental health services.

The failure of insurers and managed care organizations to reimburse providers of mental health services for the costs of care has led to a crisis in access to these services. Using the situation in Massachusetts as a case example, this paper explores the impact of this defunding. Unable to sustain continued losses, hospitals are closing psychiatric units, and outpatient services are contracting or closing altogether. The situation has been compounded by the withdrawal of many practitioners from managed care networks and cuts in public-sector mental health services. Unless purchasers demand effective coverage of mental health treatment, mental health services will likely continue to wither away.

Adult↗