Report of the Working Group on Clinical Services

Prepared by the Working Group on Clinical Services from the November 1995 Georgetown conference sponsored by the Association of Medical School Psychologists, this paper focuses upon issues related to the effects of health care reform and changes to the health care system on psychologists practicing within academic health care settings. Discussion of the changes in the health care economic system and the call for cost-effectiveness produced five specific suggestions for psychology to establish accountable, data-based models of behavioral health care.     

近五十年美国医疗保健制度演进对我国医疗制度改革的启示

通过对美国自1945年以来50余年医疗保健制度演进的研究。涵概了四个发展时期;民办医疗保险体制;公办免费医疗保健制度和健康维持组织;医疗费用控制政策的实施;医疗保健制度的全面改革,以求对我国从计划经济向市场经济转轨后,医疗保健制度的改革提供借鉴。     

Psychosocial Predictors of Health Status and Health Care Costs among People with Fibromyalgia

The purpose of the present study was to examine the effects of psychosocial characteristics on health status and the relationship between health status and health care use and costs in a group of people with fibromyalgia (FMS) over a 1-year period. The participants were 600 members of a large health maintenance organization. Demographic characteristics (age, education, employment status, ethnicity and income), need variables (comorbid conditions and baseline health status), and psychosocial variables (self-efficacy, helplessness, coping, and depression) were examined. Better health status at baseline, use of emotion-focused coping, and higher self-efficacy predicted better health status the following year. Higher health care use at baseline, being Caucasian, being older, and having more co-morbid conditions predicted higher health care use at 1 year. Only health care costs at baseline predicted health care costs the following year. Our results indicate that health care use and cost tend to be stable. Intense interventions focused on changing patterns of health care use and methods for coping with the change need to be developed and tested.     

Quality Improvement in Health Care: The Role of Psychologists and Psychology

Quality Improvement (QI) is a health care interprofessional team activity wherein psychology as a field and individual psychologists in health care settings can and should adopt a more robust presence. The current article makes the argument for why psychology’s participation in QI is good for health care, is good for our profession, and is the right thing to do for the patients and families we serve. It reviews the varied ways individual psychologists and our profession can integrate quality processes and improve health care through: (1) our approach to our daily work; (2) our roles on health care teams and involvement in organizational initiatives; (3) opportunities for teaching and scholarship; and (4) system redesign and advocacy within our health care organizations and health care environment.     

RECENT TRENDS IN RESPONSE TO CHILD VICTIMIZATION

Abstract

This chapter serves as an introduction to the many roles of health care professionalsin the assessment, care, and treatment of child victimization. It concentrates on those professionals caring for the physical health of victims of child abuse and neglect, although there are many similarities between child maltreatment and other family violence victims. In reviewing the health impact of maltreatment and the historical contributions of health care professionals, it discusses the roles that health care disciplines play in clinical care, training, research, and advocacy and their interaction with the community's child welfare, legal, and criminal justice systems.     

Predictors of Health Care Use Among Individuals Seeking Therapy for Marital and Family Problems: An Exploratory Study

A number of studies have examined variables associated with health care use. However, no study is known to have considered health care use among people seeking services for marital and family problems. In this study, health care use of persons (N = 110) seeking these services was investigated to determine the strongest psychosocial correlates of health care use. The goal was to identify potential “targets” of clinical intervention that may be driving excessive health care use. “Informational support” and “somatization” were the strongest correlates for the complete sample, with the model explaining 24% of the variance in health care use. For “high users” of health care, “hostility” was the strongest correlate, accounting for more than 36% of the variance in health care use.     

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.     

不同语境下的初级卫生保健

初级卫生保健一词在国内文献中涵义不同,研究发现《阿拉木图宣言》中的初级卫生保健更多的具有卫生体系变革的涵义,强调公平性、多部门合作、社区参与、适宜技术和适宜人力的原则;选择性初级卫生保健则以推广具有成本效益的卫生干预措施为重点;国内政策语境下的初级卫生保健则更多的是具体的卫生服务内容。     

Integrating Mental Health and Primary Care Services in the Department of Veterans Affairs Health Care System

Integrating mental health care in the primary care setting has been identified in the literature as a model for increasing access to mental health services and has been associated with enhanced clinical and functional patient outcomes and higher patient satisfaction. The Department of Veterans Affairs (VA), which operates the nation’s largest integrated health care system, has taken a leadership role in creating a health care system in which mental health care is provided in the primary care setting. This article examines VA’s efforts and progress to date in implementing evidence-based models of integrated mental health services nationally in community based outpatient clinics, home based primary care, and outpatient primary clinics at medical facilities. Psychology plays an important role in this progress, as part of an overall interdisciplinary effort, in which all professions are crucially important and work together to promote the overall well-being of patients. This article is based in part on a presentation by the first author at the 3rd National Conference of the Association of Psychologists in Academic Health Centers (APAHC) in May of 2007 in Minneapolis, Minnesota.     

Succeeding in Rural Mental Health Practice: Being Sensitive to Culture by Fitting in and Collaborating

Sustainable solutions to the access to mental health care problems are complex and must address both the availability of mental health care resources and the acceptability of those resources to consumers. The purpose of this study was to determine how to address the acceptability problem by learning from medical and mental health care providers what mental health therapists need to know to be successful in providing care in rural communities. Using a qualitative design, focus groups were conducted in three rural communities (<2,500) with medical and mental health care providers practicing in these communities. Data were analyzed using inductive qualitative methods. Results indicate that in addition to sound clinical skill, mental health therapists should (A) be sensitive to the culture of the rural community in which they are working and (B) practice in a way that accommodates to the care culture of the community. The latter includes spending time with patients commensurate with what is expected by other providers, engaging in generalist practice, and collaborating with local providers in patient care. An important implication of these results is that mental health care must be acceptable to both the residents of the community and the gatekeepers to health care.     

Health Risk Behaviors and Their Relationships to Health Care Utilization Among Veterans Receiving Primary Medical Care

This paper reports the findings of a behavioral health risk screening form and examines the interrelationships among behavioral risk factors and health care utilization. Participants were 1,000 veterans who completed a brief self-report questionnaire assessing affective distress and behavioral health risk factors while they waited to see their primary care provider. Participants reported a mean level of affective distress in the mild range on a scale of 0 to 20 (M = 6.4, SD = 4.95), and 22.4% reported moderate or high levels of affective distress. Fifty percent of the sample denied alcohol use; 5% of the men and none of the women reported a pattern of use that met established criteria for at-risk drinking. Twenty-six percent of the sample reported current tobacco use, 45% acknowledged concerns about diet and/or weight, and 54% reported concern about pain. These factors were largely significantly intercorrelated and several were related to indices of health care utilization. It was concluded that veterans receiving health care in primary care settings report significant levels of affective distress and other health risk behaviors and that the presence of these factors is associated with increased use of the health care system. These data encourage increased efforts to identify these factors and to develop behavior change interventions.     

Caregivers’ Level of Trust in Their Children's Health Care Providers

Trust in healthcare providers is associated with clinical outcomes among adult patients. Children with disabilities have complex health needs that place stress on caregivers. Consequently, they are increasingly likely to rely on their children's health care providers to ensure children's health care needs are met. However, no studies have explored factors affecting caregivers’ trust in their children's providers. We assessed caregivers’ trust in their children's providers and identified predictive factors of trust. The results indicate that children's disability condition, functional status, age, the providers’ specialty, and the type of health care plan are significant predicators of caregiver's trust. Specifically, caregivers of children with emotional/behavioral disabilities and children with poor physical or emotional/behavioral functioning reported less trust in their children's providers compared to caregivers of children without physical disabilities or no disability and those having higher levels of physical or emotional/behavioral functioning. In addition, caregivers of younger children had more trust compared to caregivers of older children. Caregivers of children enrolled in a managed care plan for physical health care reported less trust compared to caregivers of children in other organizational arrangements. Finally, caregivers reported more trust in physical health providers compared to mental health providers.     

A cascade of disparities: health and health care access for people with intellectual disabilities

People with ID represent approximately 2% of the population and, as a group, experience poorer health than the general population. This article presents recent conceptualizations that begin to disentangle health from disability, summarizes the literature from 1999 to 2005 in terms of the cascade of disparities, reviews intervention issues and promising practices, and provides recommendations for future action and research. The reconceptualization of health and disability examines health disparity in terms of the determinants of health (genetic, social circumstances, environment, individual behaviors, health care access) and types of health conditions (associated, comorbid, secondary). The literature is summarized in terms of a cascade of disparities experienced by people with ID, including a higher prevalence of adverse conditions, inadequate attention to care needs, inadequate focus on health promotion, and inadequate access to quality health care services. Promising practices are reviewed from the perspective of persons with ID, providers of care and services, and policies that influence systems of care. Recommendations across multiple countries and organizations are synthesized as guidelines to direct future action. They call for promoting principles of early identification, inclusion, and self-determination of people with ID; reducing the occurrence and impact of associated, comorbid, and secondary conditions; empowering caregivers and family members; promoting healthy behaviors in people with ID; and ensuring equitable access to quality health care by people with ID. Their broadscale implementations would begin to reduce the health disparity experienced by people with ID.     

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.     

Health care reform: Can a communitarian perspective be salvaged?

The United States is culturally oriented more toward individual rights and values than to communitarian values. That proclivity has made it hard to develop a common good, or solidarity-based, perspective on health care. Too many people believe they have no obligation to support the health care of others and resist a strong role for government, higher taxation, or reduced health benefits. I argue that we need to build a communitarian perspective on the concept of solidarity, which has been the concept underlying European health care systems, by focusing not on individual needs, but rather, on those of different age groups—that is, what people need at different stages of life.     

United States and Canadian approaches to justice in health care: A comparative analysis of health care systems and values

The purpose of this study is to compare and contrast the basic ethical values underpinning national health care policies in the United States and Canada. We use the framework of ethical theory to name and elaborate ethical values and to facilitate moral reflection about health care reform. Section one describes historical and contemporary social contract theories and clarifies the ethical values associated with them. Sections two and three show that health care debates and health care systems in both countries reflect the values of this tradition; however, each nation interprets the tradition differently. In the U.S., standards of justice for health care are conceived as a voluntary agreement reached by self-interested parties. Canadians, by contrast, interpret the same justice tradition as placing greater emphasis on concern for others and for the community. The final section draws out the implications of these differences for future U.S. and Canadian health care reforms.