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PubMedDate not supplied

Developing a strategy for managing behavioral health care within the context of primary care.

Although most patients with psychological disorders are diagnosed and treated within the primary care setting, there are few guidelines to help primary care physicians and managed care plan administrators construct programs of behavioral health care that are compatible with the primary care environment. We report the findings from a review of the literature from 1970 to 1996 on factors that predict the use of mental health and substance abuse services with specific reference to primary care. We use a heuristic framework of service use that includes the characteristics of patients, primary care physicians, practice settings, and managed care plans. Recognizing that the factors associated with the use of services center on the primary care practice, we argue that programs of behavioral health care will work best when they are decentralized to account for variations among primary care patients, physicians, and practices; when they are integrated clinically, financially, and administratively within the primary care setting; and when primary care physicians are active leaders in the design and implementation of these services, for clinical and financial reasons.

Behavior↗

PubMed2001

The impact of practice setting on physician perceptions of the quality of practice and patient care in the managed care era.

BACKGROUND: Managed care is practiced in both traditional institutional health maintenance organization (HMO) settings and in a variety of complex and decentralized office-based arrangements. This study examines how practice setting affects physician perceptions of the quality of professional practice and patient care in a managed care environment. PARTICIPANTS AND METHODS: A survey was conducted in 1998 of 1081 physicians in San Mateo County, California, who practice in either a traditional staff group model HMO (SGM-HMO) (n = 113) or office-based independent practice (OBIP) (n = 250). Respondents were surveyed about current and past practice characteristics, income changes, current satisfaction with professional and patient care matters, utility of treatment guidelines and formularies, and general perceptions of managed care. Responses were compared between practice settings using bivariate comparisons and logistic regression analyses. RESULTS: Physicians in the SGM-HMO and those in OBIP reported similar hours worked per week, time spent with patients during office visits, and total patient encounters per week. Declining income was more frequent in OBIP (61% vs 47%) and relatively more substantial (27% with income declines >25% vs 4% in SGM-HMO). Adjusting for income changes, practice setting, years in practice, and sex, SGM-HMO physicians were significantly more satisfied with a variety of professional and quality of care issues (P<.001), viewed more favorably the utility of treatment guidelines and drug formularies (P<.001), and held more positive general perceptions of managed care (P<.001) than OBIP physicians. CONCLUSIONS: In a managed care environment, SGM-HMO physicians are significantly more satisfied with the quality of practice and patient care than physicians in OBIP. This study suggests that the myriad managed care contracts, formularies, and guidelines received by physicians in OBIPs may lead to more negative perceptions of the quality of professional practice and patient care.

Attitude of Health Personnel↗

PubMed1991

An experimental study comparing various anterior capsulectomy techniques.

Radial tears at the margin of an anterior capsulectomy may be associated with the exit of at least one loop of an intraocular lens out of the capsular bag ("pea pod" effect) and subsequent decentration. Many ophthalmologists have gained a clinical impression that the anterior capsule is more likely to remain intact if the continuous circular capsulorhexis (CCC) technique is used. However, controlled comparison of the incidence of radial tears with the use of different capsulectomies under standardized conditions has not been performed, to date. In this study, we analyzed the incidence of radial tear formation in 40 human eyes that were obtained post mortem. These eyes were randomized to four technique groups: (1) "can opener," (2) linear capsulotomy, (3) capsulopuncture, and (4) CCC. We demonstrated that the CCC technique is much less likely to cause or be associated with anterior capsular radial tears as opposed to the other three techniques. With the technique of nuclear expression used in this study, radial tears occurred in 100% of cases treated with the can opener, linear capsulotomy, and capsulopuncture techniques, whereas no tears occurred with the CCC technique. This study provides convincing evidence that the CCC is the best available anterior capsulectomy procedure to minimize the incidence of radial tears.

Aged↗

PubMed1995

One-year results of the intrastromal corneal ring in nonfunctional human eyes. Intrastromal Corneal Ring Study Group.

OBJECTIVE: The intrastromal corneal ring (ICR), a new keratorefractive device designed to correct myopia, was evaluated for safety and efficacy as part of a phase I Food and Drug Administration clinical trial. PATIENTS AND METHODS: Ten patients, each with one nonfunctional eye, underwent surgical implantation of the ICR, which is a split ring composed of polymethyl methacrylate. The eyes were followed up during a 1-year period and were evaluated for wound healing, implant-related inflammation, intraocular pressure, corneal thickness, endothelial cell count, and refractive effects. RESULTS: Wound healing was uncomplicated in all of the patients. No patient experienced implant-associated inflammation or extrusion. Intraocular pressure, corneal thickness, and endothelial cell counts were unaffected by the ICR. Non-sight-threatening intraoperative events included ring decentration and inadequate attachment of a vacuum-centering guide. The ICR reduced keratometrically determined spherical equivalence by an average of -2.5 +/- 1.1 diopters (mean +/- SD). Spherical equivalence, as determined by retinoscopy, was reduced by an average of -2.4 +/- 1.0 D. Results of corneoscopy and computerized videokeratography further confirmed this reduction of myopia. CONCLUSIONS: The ICR may be a safe and efficacious device that offers predictable results with few side effects, and it may be a feasible alternative to current keratore-fractive procedures.

Adult↗

PubMed1996

Visual performance after photorefractive keratectomy. A prospective study.

OBJECTIVE: To prospectively examine the effect of excimer laser photorefractive keratectomy (PRK) on best-corrected visual performance using psychophysical tests that were likely to be more sensitive to image degradation than high-contrast Snellen visual acuity. DESIGN: Prospective cases series. PATIENTS: A cohort of 18 subjects with an average of -5.08 diopters (D) of myopia (SD = +/- 1.63 D) was tested before PRK and at 3, 6, and 12 months after PRK. INTERVENTION: Photorefractive keratectomy was performed using a laser (Excimed UV200, Summit Technology, Waltham, Mass) and a polymethylmethacrylate mask; a 5-mm ablation zone was used. MAIN OUTCOME MEASURES: Best-corrected high-contrast visual acuity, best-corrected low-contrast visual acuity (18% Weber contrast), and best-corrected letter-contrast sensitivity. Measurements were repeated with dilated pupils and in the presence of a glare source. RESULTS: One year after PRK, the mean best-corrected high-contrast visual acuity was reduced by half a line (P = .01), and the mean best-corrected low-contrast visual acuity was reduced by 1 1/2 lines (P = .002). The losses were somewhat greater when the subject's pupils were dilated and a glare source was used. The reduction in dilated low-contrast visual acuity was positively correlated with the decentration of the ablation zone (r = 0.47), providing evidence of an association between corneal topography and the functional outcome of PRK. CONCLUSION: Low-contrast visual acuity losses after PRK are notably greater than high-contrast visual acuity losses for best-corrected vision. Low-contrast visual acuity is a sensitive measure for gauging the outcome success and safety of refractive surgery.

Adult↗

PubMed1997

Managed care and the future of psychiatry.

In 1987, one of us (T.D.) issued 3 predictions about the future of psychiatry, all of which have come true: (1) The promiscuous use of psychiatry to address a world of problems that are not biomedical and are unrelated to individual patients or their families has diluted the specialty's focus and made it what it should not be-a proposed solution to social ills. (2) The routinization of complex clinical tasks has inevitably resulted in downward decentralization, enabling lower-level professionals to take over responsibilities that were once the purview of physicians. (3) New knowledge about the brain and the mind have made it mandatory for psychiatry and neurology to mate for life to assure the future of both.

Career Choice↗

PubMed2001

Documenting and comparing medical students' clinical experiences.

CONTEXT: The decentralization of clinical teaching networks over the past decade calls for a systematic way to record the case-mix of patients, the severity of diseases, and the diagnostic procedures that medical students encounter in clinical clerkships. OBJECTIVE: To demonstrate a system that documents medical students' clinical experiences across clerkships. DESIGN AND SETTINGS: Evaluation of a method for recording student-patient clinical encounters using a pocket-sized computer-read patient encounter card at a US university hospital and its 16 teaching affiliates during academic years 1997-1998 through 1999-2000. PARTICIPANTS: A total of 647 third-year medical students who completed patient encounter cards in 3 clerkships: family medicine, pediatrics, and internal medicine. MAIN OUTCOME MEASURES: Number of patient encounters, principal and secondary diagnoses, severity of diseases, and diagnostic procedures as recorded on patient encounter cards; concordance of patient encounter card data with medical records. RESULTS: Students completed 86 011 patient encounter cards: 48 367 cards by 582 students in family medicine, 22 604 cards by 469 students in pediatrics, and 15 040 cards by 531 students in internal medicine. Significant differences were found in students' case-mix of patients, the level of disease severity, and the number of diagnostic procedures performed across the 3 clerkships. Stability of the findings within each clerkship across 3 academic years and the 77% concordance of students' reports of principal diagnosis with faculty's confirmation of diagnosis support the reliability and validity of the findings. CONCLUSIONS: An instrument that facilitates students' documentation of clinical experiences can provide data on important differences among students' clerkship experiences. Data from this instrument can be used to assess the nature of students' clinical education.

Diagnosis-Related Groups↗

PubMed2002

The burden of out-of-pocket payments for health care in Tbilisi, Republic of Georgia.

CONTEXT: In the 1990s, the Republic of Georgia instituted health care reforms to convert the centralized, state-operated health care system inherited from the Soviet Union to a decentralized, market-driven system of health care delivery. Under the new system, 87% of health care expenditures are financed through out-of-pocket payments at the point of service. OBJECTIVE: To describe the effects of health care reforms on access to care and health care financing among ill residents of Tbilisi, Georgia. DESIGN, SETTING, AND PARTICIPANTS: A probability-proportionate-to-size cluster survey conducted in 1999 of 248 households containing 306 household members who had been ill in the past 6 months in Tbilisi, Georgia. MAIN OUTCOME MEASURES: Reported health care utilization, out-of-pocket expenditures, and financing practices. RESULTS: Of sick household members, 51% used official health care services at hospitals and clinics; 49% did not use official services and sought advice from relatives or friends, used traditional medicines, or did nothing. Those with serious illness were more likely to seek care through official services (82%) than those with nonserious illness (27%). Ninety-three percent of respondents said costs were the major deterrent to obtaining health care. Ten percent of ill household members reported that they were unable to obtain health care because of high costs; 16% reported being unable to afford all the medications necessary to treat their illness. Sixty-one percent of ill household members used savings to pay for health care expenditures and 19% of those able to obtain care had to use strategies such as borrowing money or selling personal items to pay for health care. Total out-of-pocket health care expenditures (53%) were paid for by borrowing money or selling personal items. A significant portion of households with ill members (87%) reported an interest in purchasing health care insurance. CONCLUSIONS: Economic disruption and health care reforms have led to access problems and out-of-pocket financing strategies that include reliance on personal savings, selling personal items, and borrowing money. Future reforms should consider an appropriate system for health care insurance risk pooling for the population of Tbilisi, Georgia.

Cluster Analysis↗

PubMed1998

Overall survival of the medical oncologist: a new outcome measurement in cancer medicine.

BACKGROUND: Changing patterns of patient referral, decreasing payments for service provision, confusing network participation and reimbursement, as well as challenges to autonomous clinical decision-making jeopardize the traditional role of the oncologist in delivering cancer care. The cancer patient also may be at risk with unproven cancer delivery systems that displace the oncologist as decision-maker and care provider. The authors have constructed a model that preserves the oncologist's clinical and financial autonomy while meeting marketplace demands for improved access, decreasing costs and preserved quality of care. METHODS: During a 4-year period, a group of private practice medical oncologists initiated a formal business plan to evaluate marketplace needs, then designed and implemented a novel cancer care delivery model. The model required reconfiguring the practice into an integrated Joint Commission on Accreditation of Healthcare Organizations-certified cancer service corporation, providing medical, radiation, and gynecologic oncology. Palliative care, pain management, psychologic, and nutritional services were instituted as well as the vertical integration of home health and hospice care. Clinical pathways and treatment protocols were designed to enhance patient care and facilitate cost-of-care projections in designated populations using a cancer incidence forecasting model. Outcomes analysis are performed as part of ongoing continuous quality improvement, which continues to change this health care delivery system. RESULTS: In the 3 years since implementation of the model, the practice has increased from 16 to 24 physicians, and the number of offices has increased from 12 to 17. Patient encounters, both new and established, have doubled. Cost of services, specifically hospitalization, have been reduced by 50%. Clinical research referrals have increased 300%. Physician compensation has improved >20%. CONCLUSIONS: The model created a low cost, high value provider not burdened by allocated overhead. Decentralized care enhanced community access, which improved patient compliance, enhanced patient satisfaction, decreased hospitalization, and thereby decreased cost. The horizontal structure permited the flexibility for varied purchaser products and politically sensitive physician and hospital provider panels. Consensus-based protocol and pathway determination achieved maximum physician participation, which preserved clinical and financial autonomy, decreased variance, and facilitated clinical research.

Age Distribution↗

PubMed1999

Role of N- and L-type calcium channels in depolarization-induced activation of tyrosine hydroxylase and release of norepinephrine by sympathetic cell bodies and nerve terminals.

Multiple types of voltage-activated calcium (Ca(2+)) channels are present in all nerve cells examined so far; however, the underlying functional consequences of their presence is often unclear. We have examined the contribution of Ca(2+) influx through N- and L- type voltage-activated Ca(2+) channels in sympathetic neurons to the depolarization-induced activation of tyrosine hydroxylase (TH), the rate-limiting enzyme in norepinephrine (NE) synthesis, and the depolarization-induced release of NE. Superior cervical ganglia (SCG) were decentralized 4 days prior to their use to eliminate the possibility of indirect effects of depolarization via preganglionic nerve terminals. The presence of both omega-conotoxin GVIA (1 microM), a specific blocker of N-type channels, and nimodipine (1 microM), a specific blocker of L-type Ca(2+) channels, was necessary to inhibit completely the stimulation of TH activity by 55 mM K(+), indicating that Ca(2+) influx through both types of channels contributes to enzyme activation. In contrast, K(+) stimulation of TH activity in nerve fibers and terminals in the iris could be inhibited completely by omega-conotoxin GVIA alone and was unaffected by nimodipine as previously shown. K(+) stimulation of NE release from both ganglia and irises was also blocked completely when omega-conotoxin GVIA was included in the medium, while nimodipine had no significant effect in either tissue. These results indicate that particular cellular processes in specific areas of a neuron are differentially dependent on Ca(2+) influx through N- and L-type Ca(2+) channels.

Action Potentials↗

PubMed1999

The relationship of authority to decision-making behavior: implications for redesign.

Redesigning health care environments has occurred in response to cost and quality pressures. Efforts to redesign the nursing practice environment have focused on the structure and process of nursing care delivery. When redesign efforts address the structure of nursing practice systems to facilitate one important process, nurses' participation in decision making, better patient and organizational outcomes are expected. The purpose of this study was to determine if two dimensions of structure: administrative (decentralization) and professional authority (expertise) influence the process of participation in decision making for two kinds of decisions (caregiving and condition-of-work) that nurses make. The stratified sample consisted of 300 registered nurses working on medical-surgical units. Administrative and professional authority accounted for a small but significant amount of variation in participation in decision making. Because the extent of explained variation was small, the findings may challenge the prevailing assumption that greater authority for decision making results in the exercise of that authority. Redesign of the practice environment therefore must incorporate multiple factors in achieving greater participation in decision making.

Adult↗

PubMed1999

Inferring capitation rates from aggregate health plans' costs.

Setting risk-adjusted capitation rates in health systems with centralized financing and decentralized delivery is one of the most intriguing policy issues. The common practice to set capitation group rates is based on individual data collected from either population surveys or medical records, using a single-and in most cases arbitrary-set of relative unit costs of services. This paper presents a method for estimating group-specific mean costs and capitation rates using a panel of aggregate cost data of the competing health plans and the composition of their populations. This method is used to estimate mean costs and capitation rates for the Israeli health care system. The limited data available severely constrains the range of estimable models, however, the results evoke some questions with regards to reimbursement and rates presently used, as well as to the methodology used to estimate them.

Adolescent↗

PubMedDate not supplied

Merging managed care with the German model.

Since public officials in the United States may lack the courage and political will to significantly raise payroll taxes or the contain Social Security, Medicare and Medicaid benefits, Americans can anticipate that; (a) future generations increasingly will pay for these entitlements; (b) additional cutbacks to providers in Medicare, Medicaid and health maintenance organization reimbursement will hasten the current thrust of hospitals, physicians and insurers in forming huge health networks with their powerful managed care plans; and, (c) many of these new alliances will function as virtual monopolies--eventually resulting in the public proposing that state health services commissions be established. This article then suggests that future modifications in how the United States health delivery system be organized and financed preferably should be along the lines of the German multi-player, multi-tier, self-governing, decentralized, quasi-private, quasi-public model; and, also patterned after experiences of the State of Arizona's Medicaid program. It concludes that what America needs most is a hybrid of the European global budgetary targets to constrain total health expenditures, and the competitive managed care concept to curtail use patterns and to enhance quality.

Delivery of Health Care, Integrated↗

PubMedDate not supplied

The Philippines' National Health Insurance Act: a German perspective.

Through the recent National Health Insurance Act (NHIA), the Philippines have committed themselves to introducing a social health insurance with universal coverage within 15 years. Germany was the first country to introduce a social health insurance system more than 100 years ago. Its system is based on the principles of corporatism, federalism and a mandate for equity. Based on a long-term German experience with equity, quality, cost and efficiency issues, the Philippines' NHIA is analysed concerning the entitlement to benefits and the benefit package, the organization of the health insurance programme, health insurance financing, and provider payment mechanisms. It is suggested that the Philippines could profit from including preventive and promotive services as well as pharmaceuticals in the benefits package. The organization of the health insurance system could be decentralized using the 13 regions as its principal units. To achieve financial equity between regions and health funds, a contribution compensation scheme is proposed. To prevent over-utilization in over-served areas and to promote utilization in under-served areas, a relative value scale for fee-for-service payments seem advisable.

Fee-for-Service Plans↗

PubMedDate not supplied

Demarketing dysfunctional demand in the UK National Health Service.

This article considers demarketing as a strategy to manage dysfunctional demand in the UK NHS. Demarketing seeks to persuade customers not to use a service which is provided. It appears in all four modes in the NHS as general, selective, ostensible and unintentional demarketing with an emphasis on supply-side applications. It is proposed that, as a demand-side strategy, it would allow purchasers of health care on behalf of communities, to discern values, attitudes and beliefs which predicate current behaviour through the use of the Theory of Planned Behaviour; and, subsequently, to develop appropriate demarketing alternatives to change these behaviours where they are dysfunctional for both consumer and provider. This approach is proposed for the significant behavioural changes required to manage the increases in the use of emergency services: in particular, general practitioner night calls, which are already developing evidence-based demand management strategies. Such alternative strategies need to demonstrate their acceptability to consumers rather than just the professionals. Such demand management strategies would be made more acceptable as they are drawn from both consumer and normative attitudes, values and beliefs. In this way demarketing could demonstrably provide a framework for intervention, collaboration, decentralization, explicitness and an ethical foundation to the key problem of demand management in health care.

Attitude to Health↗

PubMedDate not supplied

Swedish models of health care reform: a review and assessment.

Resource constraints and the necessity to improve efficiency and effectiveness have provided challenges for the Swedish health care system during the 1990s. Whereas there are no comprehensive reforms of funding and organization, measures have been taken at both national and regional level to meet these challenges. Decentralization has been a core issue in long-term reforms and current changes can be seen as continuing this pattern. As a consequence different solutions are sought in the various county councils (locally elected self-government bodies financing and procuring health services). In about one third of these county councils some sort of purchaser-provider models have been introduced. Emerging evaluation reports claim that the models have succeeded in improving efficiency; making the system more patient-oriented; and enhancing cost-consciousness. The roles of politicians, managers and professionals are also more clear, according to the proponents. However, there are also problems with more difficulties in controlling costs, and with inadequate remuneration systems. Over time the purchaser-provider schemes have matured, developing from emphasizing short-term tendering, negotiations and detailed contracts to more comprehensive agreements based on mutual commitments to improve health services. Rhetoric has changed; competition has been replaced by co-operation. The lure of the market concept has diminished. Similarities can be seen between county councils with and without purchaser-provider models.

Ambulatory Care↗

PubMedDate not supplied

From cooperation to competition in national health systems--and back?: impact on professional ethics and quality of care.

Ethical behaviour in health workers is the jewel in the crown of health services. Health system policies need to nurture a professional service ethic. The primary health care policy envisioned a national health system led by the public sector and based on a philosophy of cooperation. A common theme of 'health sector reform' in OECD countries, introduced in the context of neoliberalism, has been the use of 'managed competition' to increase efficiency. Some countries that flirted with health system competition have returned to cooperation. Market relationships tend to be oppositional and to stimulate self-seeking behaviour. Health system relationships should encourage patient and community centred behaviour. The World Bank and bilateral donors have exported health sector reform theories from the north to the south, involving privatization and marketization policies. This is despite the lack of evidence on their desirability or feasibility of implementing them. Private health care has increased in many developing countries, more as a result of economic crisis and liberalization than specific health sector reforms. Much of this private practice is unlicensed and unregulated, and informal privatization has had a damaging effect on health worker ethics. The lead policy should be reconstruction of the public health system, involving decentralization, democratization and improved management. Commonsense contracting of an existing private sector is different from a policy of proactive privatization and marketization. Underlying the two approaches is whether health care should be viewed as a human right best served by socialized provision or a private good requiring governments only to correct market failures and ensure basic care for the poor. It is a matter of politics, not economics.

Cooperative Behavior↗

PubMed1999

The mental health care delivery system in greece: regional variation and socioeconomic correlates.

BACKGROUND: In Greece, the functional capacity of the mental health care system until 1980, was totally inadequate to meet the increasing mental health needs of the population and to provide efficient and community-based services. This situation was brought to the attention of the Commission of European Communities and a special EEC Regulation No 815/84 provided the financial technical support for an extended psychiatric reform programme. The psychiatric reform programme initiated in 1984 and ended in 1995. AIMS OF THE STUDY: This study compared the geographical distribution of neuropsychiatrists and the mental health care delivery system structural components (psychiatric beds, extramural mental health units and places in rehabilitation services), according to the regional socioeconomic development for the years 1984, 1990 and 1996. Additionally the possible effects of the operation of community-based mental health services on the psychiatric hospitalizations were examined. METHODS: Data on the geographical distribution of neuropsychiatrists in the previously mentioned years were drawn from local Medical Association from each of 54 prefectures of the country. The corresponding distribution of the mental health care delivery system components was made available from the database of the Monitoring and Evaluation of Mental Health Services Unit. Pearson product moment correlations of the regional distribution of neuropsychiatrists and the various components of the mental health care system, as population-based ratios, with the corresponding socioeconomic development in the form of the general index of development were performed. Mental hospital age standardized rates were collected from the Hospital Central Register for the periods 1984-1987 and 1990-1993. Discharge rates were elaborated according to the existence of mental health services in specific regions. RESULTS: A wide regional variation in neuropsychiatrists per 100000 population was found in all three years, with the majority of them working in the greater Athens and Thessaloniki areas. In the geographical distribution of health regions, there is an uneven significant decrease in psychiatric beds between 1984 and 1996. However in almost all regions an increase in extramural services between the two critical periods was noticed, as part of the implementation of the psychiatric reform programme. A parallel and more dramatic increase in the places of rehabilitation in 12 out of 13 regions has been observed during the implementation of the reform programme. At the level of prefectures, the changes across time, in the mean ratios of beds, extramural services and rehabilitation places were not found to be significant. A significant decrease of discharges in prefectures covered by newly established extramural services for the period 1990-1993, compared to discharge rates during the period 1984-1987, when none of these services were in operation in these prefectures, was noticed. The intercorrelation matrix between the various mean values (1990-1996) of the mental health care system components in the 54 prefectures and the local general index of development scores produced statistically significant correlation coefficients. It seems that the greater the level of local socioeconomic development the higher the degree of mental health care delivery system growth. DISCUSSION: Our results have shown uneven regional distribution of neuropsychiatrists, as well as extramural mental health units and rehabilitation places, despite the current reorganization of the whole mental health care delivery system. The positive correlation between the various structural components of the system in the 54 prefectures and the local socioeconomic conditions could be interpreted as follows. Urban areas of higher socioeconomic growth had a long history of development of inpatient services in mental hospitals. In these several community-based alternatives have been established for their transformation into modern ones. Urban areas exhibit also higher psychiatric morbidity and therefore increasing mental health needs. Additionally in several cities local University Psychiatric Departments have developed a variety of mental health and rehabilitation services. Many new services highly specialized and complementary to existing mental hospitals were established in urban areas. Rural areas are mostly uncovered by mental health care facilities. However it seems that the establishment of community-based services could have an effect on mental hospital utilization. CONCLUSION: It becomes evident that after the implementation of the psychiatric reform programme in Greece significant progress in the areas of decentralization of mental health and rehabilitation services has been observed. However there are still areas in many prefectures, mainly rural or semirural, lacking the appropriate delivery of mental health care. IMPLICATIONS FOR HEALTH CARE AND POLICY FORMULATION: Our results suggest that flexible models of services should be introduced for the benefit of population living in areas lacking the necessary socioeconomic resourses. IMPLICATIONS FOR FUTURE RESEARCH: Mental health services research in Greece should focus on quasi-experimental studies on the effectiveness of various models of mental health care in areas of different socioeconomic growth.

Journal Article↗