Cost Effective Assessment Models in Providing Patient-Matched Psychotherapy

Examined are various models of assessing cost-effectiveness in the use of psychological measures employed for screening patient pathology through psychological testing as a precursor to providing psychotherapy. Actual and simulated quality assurance studies are provided. The authors caution that cost-containment limited to financial incentives may have negative consequences for patient care. Systems analysis and program restructuring designed to better balance the service system through levels of care may be more clinically sound, and less costly. Clinical algorithms and critical pathways are discussed, as are recommendations that incorporate psychological testing services as an ingredient in providing contemporary psychotherapy.     

The Future of Psychology in Family Medicine

Psychology has been integral to the field of family medicine since its inception as a medical specialty in the 1960s. Psychologists and other behavioral scientists contribute to family medicine in teaching clinical skills, in defining research questions, in developing research methodology, and in creating integrated physical/mental health care delivery systems. Future developments in the field of psychology in family medicine are likely to emphasize development and evaluation of screening measures which identify mental health problems in primary care, development of early intervention for those mental health problems, and more precise measurement of process and quality of care and health outcomes. Psychologists have an important role to fulfill in educating physicians on alternatives to pharmacologic and medical interventions for common presenting problems in primary care. However, current economic forces shaping the practice of medicine may work against further enhancing the efficacy of the physician in dealing with psychosocial issues. The future role of psychology in family medicine is not yet delineated, and while the move toward parity of reimbursement for mental and physical health care delivery may enhance this collaboration, there is a need to continue to evaluate how the psychological well-being of patients is influenced in the evolution of new models of care delivery.     

The Future of Psychology in Medicaid's Health Delivery System for People with Disabilities

State Medicaid programs are rapidly converting fee-for-service health delivery systems to managed care for people with disabilities. In theory, managed care models of health delivery will substantially improve the quality of care for people with disabilities, but in reality, few successful models exist. This period of transition holds both opportunities and challenges for psychologists in medical settings. Because Medicaid reforms for people with disabilities may herald similar reforms for both the public and the private sectors, psychology's response will determine its role in the future of health care delivery for this population. Changes in training and increased attention to outcomes research, innovations in practice, and advocacy will be the keys to success.     

Psychology and Medical Rehabilitation: Moving Toward a Consumer-Driven Health Care System

Changes in health care will provide both opportunities and threats for rehabilitation psychologists. We must demonstrate the relevance of our clinical services to important outcomes or risk being excluded as treatment providers. With shifts to nonhospital settings, we can provide increasing clinical and administrative leadership. However, we must redefine models of treatment to include home care and telepsychology, practice guidelines and critical paths, involvement of paraprofessionals, case management, injury prevention, and health promotion. We should be involved when datasets are established to define disability-related health policies and reimbursement and be proactive in Medicare, Medicaid, and managed care reform to develop treatment packages to decrease long-term handicap. Collaboration with consumers is critical. We must frame research questions to address current policy issues. Our skills can help improve the effectiveness of human behavior, whether it be patients with illness, consumers with disability, health care providers, health systems managers, or legislators.     

Pediatric Psychology: Child Psychological Health in the Next Century

The future of pediatric psychology is reviewed and placed in brief historical context in relation to children's psychological health care. Contemporary trends affecting the delivery of psychological services, research, and clinical training are highlighted, with suggestions for future development. Pediatric psychology is a child-based, developmentally-focused multidisciplinary practice directed toward psychosocial and neuropsychological issues of health and illness in children and youth. Pediatric psychologists need to develop strong professional identities as health care psychologists combined with a collegial and collaborative arrangement with physicians to ensure the future growth and development of pediatric psychology in the next century as a major vehicle to promote children's health care.     

The Call of the Wild Woman

Abstract

Women have a longstanding and unique connection to healing and health care. The feminine perspective, however, has been discounted and decimated through the last 600 years. Now general social and political changes, as well as increasing numbers of women practitioners in health and mental health, are leading to a re-emergence of the feminine perspective in addressing women's needs and in providing health care. This paper traces some of the elements in the history of women and their influences on present day models of health care. It emphasizes women's roles as healers, as patients and as crafters of a new synthesis of health care delivery in the 21st century.     

Ethics and Changing Mental Health Care: Concerns and Recommendations for Practice

Recent developments in health care delivery in the United States have left many professionals baffled by the continuing changes in practice sparked by the relatively new managed care environment. Psychologists who practice in medical settings are struggling to balance the seemingly competing needs to deliver quality care to clients and patients, while meeting the demands of third-party payers and trying to remain true to their ethical responsibilities. Critical elements of managed care, which many suggest compromise the ethical provision of quality care, include utilization review, financial incentives, and threats to confidentiality. Recommendations are proposed so that mental health professionals may be proactive in protecting their ethical responsibilities in this changing environment.     

Task-shifting to improve the reach of mental health interventions for trauma patients: findings from a pilot study of trauma nurse training in patient-centered activity scheduling for PTSD and depression

ABSTRACT

Despite high rates of posttraumatic stress disorder (PTSD) and depression among traumatically injured patients, engagement in session-based psychotherapy early after trauma is limited due to various service utilization and readiness barriers. Task-shifting brief mental health interventions to routine trauma center providers is an understudied but potentially critical part of the continuum of care. This pilot study assessed the feasibility of training trauma nurses to engage patients in patient-centered activity scheduling based on a Behavioral Activation paradigm, which is designed to counteract dysfunctional avoidance/withdrawal behavior common among patients after injury. Nurses (N = 4) and patients (N = 40) were recruited from two level II trauma centers. A portion of a one day in-person workshop included didactics, demonstrations, and experiential activities to teach brief intervention delivery. Nurses completed pre- and posttraining standardized patient role-plays prior to and two months after training, which were coded for adherence to the intervention. Nurses also completed exit interviews to assess their perspectives on the training and addressing patient mental health concerns. Findings support the feasibility of training trauma nurses in a brief mental health intervention. Task-shifting brief interventions holds promise for reaching more of the population in need of posttrauma mental health care.     

Health Care Behaviours and Beliefs in Hasidic Jewish Populations: A Systematic Review of the Literature

Cultural issues impact on health care, including individuals’ health care behaviours and beliefs. Hasidic Jews, with their strict religious observance, emphasis on kabbalah, cultural insularity and spiritual leader, their Rebbe, comprise a distinct cultural group. The reviewed studies reveal that Hasidic Jews may seek spiritual healing and incorporate religion in their explanatory models of illness; illness attracts stigma; psychiatric patients’ symptomatology may have religious content; social and cultural factors may challenge health care delivery. The extant research has implications for clinical practice. However, many studies exhibited methodological shortcomings with authors providing incomplete analyses of the extent to which findings are authentically Hasidic. High-quality research is required to better inform the provision of culturally competent care to Hasidic patients.     

Psychoeducation and managed care: Clinical issues for the 1990s

Managed care has challenged mental health professionals to develop more efficient ways of addressing patient care needs. Psychoeducational programs, for patients and their families, have emerged as a medium by which relevant education and mutual support can be provided to participants. A review of the literature, a comprehensive model of psychoeducation, and the advantages of such models within the managed care program are offered. Also addressed are issues and import, treatment and research considerations.     

“What if There's Something Wrong with Her?”-How Biomedical Technologies Contribute to Epistemic Injustice in Healthcare

While there is a steadily growing literature on epistemic injustice in healthcare, there are few discussions of the role that biomedical technologies play in harming patients in their capacity as knowers. Through an analysis of newborn and pediatric genetic and genomic sequencing technologies (GSTs), I argue that biomedical technologies can lead to epistemic injustice through two primary pathways: epistemic capture and value partitioning. I close by discussing the larger ethical and political context of critical analyses of GSTs and their broader implications for just and equitable healthcare delivery.     

Implications of Healthcare Payment Reform for Clinical Psychologists in Medical Settings

Health reform, post the passing of the Patient Protection and Affordable Care Act, has highlighted the need to better address critical issues such as primary care, behavioral health, and payment reform. Much of this need is subsequent to robust data showing the seemingly uncontrollable growth of healthcare costs, and the exacerbation of these costs for patients with comorbid behavioral health and medical conditions. There is increasing recognition that incorporating behavioral health in primary care leads to improved outcomes and better care. To address these problems, primary care will play critical roles across the healthcare system, especially in the delivery of behavioral health services. Psychologists are uniquely positioned to take advantage of this propitious moment and can help facilitate the integration of behavioral and primary care by developing competencies in integrated care, training a capable workforce, and advocating for integrated care as the status quo.     

Schools as Health Service Delivery Sites: Current Status and Future Directions

Summary

The health of our nation is inextricably linked with the health of our children. While families and professionals alike have recognized this truth for decades, current social reform movements in education and health services have provided an unprecedented opportunity for schools to become equal partners in addressing the needs of children, families, and communities in a wholistic, boundary-free, and collaborative manner. Since schools are the one social institution with which every child has contact, they offer a natural environment for assessment, services, and follow-up to promote the convergent education and health agendas articulated in Goals 2000 and Healthy People 2000. This article examines the components of education and health care reform with particular attention to a recon-ceptualization of health care services in schools. Within this framework, special services professionals are highlighted as leaders in service coordination and delivery for students, staff, and the community at large.     

Measuring health status and quality of life in HIV and AIDS

Abstract

HIV can diminish quality of life profoundly, and it is important to understand and measure such effects of HIV and its treatments Although the term quality of life is commonly used, “health status” more accurately describes dimensions that are directly health related and that may be affected by traditional interventions. There is a substantial literature on general health status measurement, and several of the most established measures have been applied or adapted for use in HIV infected populations These measures include the Medical Outcomes Study health ratings, the Quality of Well-Being scale, and the Sickness Impact Profile. Cancer-specific measures such as the EORTC Quality of Life Core Questionnaire and the CARES have also been adapted. In the last three years, health status measures for HIV have been completed by several thousand patients, and have generally proved to be reliable and valid indicators of relevant clinical differences such as disease stage, numbers of symptoms, and other psychometic measures of disability and distress. Health status measures were included in a few completed clinical trials, and are being incorporated in a growing number of antiretroviral and antimicrobial studies. Health status measures provide the best way to evaluate psychosocial interventions directly aimed at improving patients' quality of life. Although challenges remain in further developing health status measures for HIV disease and in applying them, measurement of these concepts has proved to be both technically and operationally feasible. Measures of health status and quality of life can play an important role in the evaluation of clinical treatments in research studies, directing clinical treatment, assessing changes in health care delivery, and planning health care services.     

The Effect of Racial and Ethnic Diversity on the Delivery of Mental Health Services in Pediatric Primary Care

The effects of racial and ethnic diversity on the detection and management of behavioral and emotional problems in pediatric primary care are addressed. Service access and utilization as a function of race and culture are initially examined. Important barriers within pediatric training including minimal emphases on behavioral training and the limited supply of minority physicians are underscored. The impact of ethnicity on the development and maintenance of the clinical relationship that is critical to accurately and sensitively identifying and managing behavioral and developmental problems is briefly addressed. Recommendations for further integration of racial/ethnic issues into mental health service provision within the pediatric primary care arena are presented.     

Education and Training of Children's Mental Health Professionals: The Existing and Potential Role of Schools of Public Health

Since the early 1980s, increasing attention has been devoted in the literature to the conceptualization, development, and implementation of integrated and comprehensive mental health systems of care for children and adolescents. In establishing this new children's mental health paradigm of community-based systems of care, there are presently very few well-trained professionals and leaders focused on collaborative (including interagency) initiatives in the delivery of children's mental health services. Nevertheless, the field of public health offers an interdisciplinary setting for the education and training of individuals in children's mental health services. This national survey of all 27 accredited schools of public health in the United States and Puerto Rico examined the existing capacity for and potential to expand educational and training opportunities in the organization, financing, and delivery of children's mental health services.     

The Future of Psychology in Medical Specialities: Introduction to the Special Issue

The continuing evolution of the health care delivery system in the United States presents threats and opportunities to psychologists in medical settings. This special issue explores the future of psychology in psychiatry, family medicine, rehabilitation, geriatric medicine, and pediatric medicine. The challenges facing neuropsychology and pain management are explored also. Finally, the professional issues of ethics in managed care, psychology in the public sector, and training future psychologists are addressed. Each paper summarizes concerns and provides recommendations for clinical practice, research, and training.     

General practitioners' perceptions of psychologists: A response to the Medicare changes in Australia

General practitioners (GPs) have historically been at the centre of primary health‐care delivery in Australia, including delivery of mental health‐care services. Recent changes, however, by the Australian Federal government have led to the creation of a number of mental health‐care items provided by psychologists that are now available on the Medicare Benefits Schedule. The aim of the present study was to examine GPs' perceptions of psychologists and the ways in which GPs have responded to these policy changes in making referrals for mental health patients. Nine GPs were interviewed regarding the provision of mental health‐care services. Analysis of the interviews indicated a number of themes including the benefits of the new Medicare policy in increasing accessibility of psychologists, GPs' frustrations with the bureaucracy surrounding the use of this policy, GPs' knowledge about the specific skills and training of psychologists, and the importance of GPs' matching patients and clinicians. Recommendations are made to facilitate the professional and clinical relationship between GPs and psychologists.     

Implementing Trauma-Informed Care in Primary Medical Settings: Evidence-Based Rationale and Approaches

ABSTRACT

Chronic stress stemming from trauma exposure and posttraumatic stress disorder (PTSD) leads to many health problems that are typically seen by primary care providers. Unfortunately, providers rarely identify trauma as the root cause of patient difficulties. The present paper provides an evidence-based rationale for implementing trauma-informed care principles and processes into medical primary care systems. Beginning with a review of prevalence of trauma exposure and PTSD in primary care clinics, this article elucidates relationships between trauma exposure and behavioral and medical health problems, as well as clinical and physiological pathways that lead from trauma exposure to illness. The article concludes with exposition of trauma-informed interventions that can be implemented in primary care clinics, and discussion of future directions.