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Biomedical subjects

M A Hoge

Publications and source records attributed to M A Hoge.

At least 19 recordsLinked to original sources
PubMed2001

Reengineering clinical psychiatry in academic medical centers: processes and models of change.

Managed care poses a major threat to the future of clinical psychiatry in academic settings. High costs and an aversion to the business aspects of service delivery have left academic departments at a disadvantage in the marketplace. However, numerous departments have attempted to adapt to the current health care environment. On the basis of a review of these efforts, the authors identify the processes of change and seven models of change being employed to reengineer psychiatry within academic medical centers. The models are labeled transform, build, manage, buy, partner or affiliate, sell or lease, and consult. The authors discuss the strengths and weaknesses of these efforts and suggest three approaches to establishing the unique value of academic clinical services for purchasers and for the public. The first is to enhance productivity and clinical effectiveness through greater integration of clinical care, research, and training. The second is to take a leadership role in managing care, and the third is to advance the integration of behavioral health care with primary medical care and other specialties in the medical center.

Academic Medical Centers↗
PubMed2000

Understanding managed behavioral health care.

Managed care can be understood from an historical perspective as a reaction to perceived abuses by providers or an extension of earlier efforts to manage care in the public sector. It can be viewed as a young and emerging force--a fourth party to the health care transaction--that is rapidly progressing through a series of generations that redefine the approach to organizing and delivering services. And finally, because managed care emerges with so many faces, consumers and providers can perhaps best understand its implementation in a specific state or community by examining the multiple dimensions, such as those outlined herein, on which these initiatives vary. Until the forms and functions are more uniform, no simple definition of managed care will exist.

Behavior Therapy↗
PubMed2000

Psychiatric residency training, managed care, and contemporary clinical practice.

Managed care has transformed the health care environment that residents encounter on completion of their training. Unfortunately, residency education has not kept pace with changes in the field, leaving graduates inadequately prepared. The authors identify necessary changes in the residency training tasks of instilling values, imparting required knowledge, building core skills, selecting appropriate training sites, and offering a diversity of instructors and supervisors. They also discuss the obstacles that have impeded the evolution of academic clinical services and clinical training. They suggest strategies of change that may lead to more relevant educational programs that provide residents with a balanced perspective on the strengths and weaknesses of both traditional and contemporary approaches to delivering care.

Humans↗
PubMed2000

The case against outpatient commitment.

Among individuals with severe mental illness, a small proportion commit violent acts. Since these individuals are often not engaged in ambulatory treatment, there has been a move in the states to legislate and implement outpatient commitment programs. The American Psychiatric Association Council on Psychiatry and Law has issued a Resource Document that supports the use of mandatory outpatient treatment. The purpose of this article is to challenge the logic and legitimacy of using the courts to force treatment compliance of individuals who are neither incompetent by legal standards nor at imminent risk of harming themselves or others.

Adult↗
PubMed1999

Ten dimensions of public-sector managed care.

Managed care in the public sector remains a poorly defined concept. It is currently understood largely through case examples, an approach of limited usefulness because each managed care initiative is shaped by local forces and is constantly changing. The authors describe ten key dimensions on which such initiatives vary and suggest that they can be used to examine essential characteristics of the initiatives and core differences between them. The dimensions are objectives, scope, organizational structures and authority, enrollment, benefit package, strategies for managing utilization, best practices, financing, quality management and outcomes measurement, and the impact of the initiative on the public mental health system. Using these dimensions to assess existing initiatives, the authors conclude that most focus on one principal dimension to the exclusion of other critical dimensions. The authors argue for a comprehensive approach to planning and implementing managed care projects that should ultimately lead to better care for public-sector populations.

Health Plan Implementation↗
PubMed1998

Services for mentally ill homeless persons: street-level integration.

The key elements of a systems integration approach to delivery of human services are reviewed in terms of their application to services for mentally ill homeless persons. The example of a mental health outreach project illustrates the service- and systems-integrating influences of clinical case management with this population, and the ability of a "bottom-up" street-level approach to improve coordination and service accessibility for clients in general is discussed.

Community Health Workers↗
PubMed1997

Organizational development strategies for integrating mental health services.

The recent debates about health care reform have focused attention on the need to develop organized systems of care capable of delivering comprehensive services which are coordinated or integrated. Achieving service integration has emerged as a central and pressing objective in most mental health systems in response to existing difficulties with fragmentation of care. However, attempts at service integration often fail at the implementation stage as provider agencies zealously guard their organizational boundaries and struggle with each other for power and control. In this article, the authors formulate an organizational development approach to service integration that focuses on reducing the rigid maintenance of agency boundaries by developing informal networks among staff of local provider agencies. Eight strategies, drawn from the research literature on services integration and recently implemented by a local mental health authority, are described as potential tools for use by systems managers in accomplishing these goals.

Community Health Planning↗
PubMed1994

Defining managed care in public-sector psychiatry.

Although managed care is an established force in the private sector, there is growing interest and experimentation with this concept in the public sector. This interest has been generated by the increased demand for services, the shrinking resource base due to cutbacks in state budgets, and the fragmentation of care that has accompanied the shift from a centralized, hospital-based model to a decentralized, community-based model for treating individuals with serious mental illness. But despite this interest, no consensus exists about the form or functions of managed care in the public arena. Simply importing private-sector versions of managed care is inadequate given the substantial differences in the patient population and service delivery mechanisms. The authors present a functional analysis of managed care in the public sector. Drawing on their conceptualization of managed care, they outline a functional approach to evaluating the strengths and weaknesses of treatment systems, innovations such as privatization and capitation, and recent health care reform proposals.

Community Mental Health Services↗
PubMed1993

The evolution of mental health services: partial hospitalization as a case example.

Controversy exists regarding the current status, merits, and future of partial hospitalization. Originally conceptualized as one of the least restrictive modalities for treating acutely ill or highly impaired individuals in the community, these functions increasingly are being addressed by rehabilitation programs and assertive or intensive outpatient treatments. At the same time, third-party payers, such as managed-care firms, are extending coverage for the partial-hospital modality. We use the current debates about the merits of this modality to identify potential forces that impede and promote the evolution of mental health services. Specifically, we use this case example to illustrate four prevailing myths about the manner in which services evolve.

Day Care, Medical↗
PubMed1992

The promise of partial hospitalization: a reassessment.

In this review of trends in partial hospitalization since 1987, the authors provide a brief overview of the field, summarize recent research findings, examine the data on the growth of partial hospitals, and outline recent changes in public- and private-sector use of this treatment modality. Support for intermediate and long-term partial hospitalization is diminishing rapidly, while support for short-term partial hospitalization as an alternative to inpatient care is increasing in the private sector and diminishing in the public sector. The future for partial hospitals seems uncertain, as the treatment functions of these programs are being assumed by psychosocial and vocational rehabilitation programs and assertive community treatment teams. In light of these trends, the authors recommend new directions for partial hospital research involving comparisons between short-term day hospitalization and intensive outpatient interventions.

Cost Control↗
PubMed1991

Group psychotherapy in acute treatment settings: theory and technique.

Group psychotherapy has long been a part of most inpatient and partial hospital programs, but conducting groups in these settings has become more difficult as the average patient stay has shortened. The authors integrate findings from previous research in which patients ranked the importance of several therapeutic processes in acute care groups, and they suggest a theory of group psychotherapy that incorporates realistic clinical objectives for these short-term settings. Seven therapeutic factors--self-responsibility, self-understanding, instillation of hope, group cohesiveness, catharsis, altruism, and universality--are identified as important in promoting patient change. Specific techniques to enhance these factors in short-term settings are recommended.

Acute Disease↗
PubMed1991

Overnight hospitalization of acutely ill day hospital patients.

As the trend toward community-based treatment of the seriously mentally ill has continued, partial hospital programs have admitted an increasing number of highly symptomatic individuals. As a result, patient crises occur more often in these programs, and staff have had to develop novel crisis intervention strategies that do not rely on standard hospital care. One such strategy involves the use of "overnight hospitalization" or a "backup bed" to provide temporary safety and clinical management with the goal of returning the patient to the partial hospital within 24 hr. Given the lack of data on this intervention the present study was designed to provide further information about the implementation and effectiveness of this clinical strategy. The authors outline the rationale and procedures for a backup bed system and provide data on outcome that is drawn from an examination of backup bed utilization in a public-sector mental-health setting over a 1-year period. Clinical implications of the findings for future use of overnight hospitalization with partial hospital patients are reviewed.

Bed Conversion↗
PubMed1991

A group psychotherapy model for acute treatment settings.

Traditional models of group psychotherapy have become less applicable in inpatient and partial hospital programs as the lengths of stay in these programs have decreased. Shorter lengths of stay are associated with rapid changes in group membership and high levels of symptoms among group members. The clinical objectives and clinical techniques suggested by traditional group models are simply less relevant under these conditions. In this paper the authors outline a model of group psychotherapy designed to meet the needs of acutely ill patients and accommodate to the demands of the short-term acute-care setting. Drawing on previous research that has identified the therapeutic factors that operate in these groups, the authors offer specific recommendations regarding group structure, therapist role, and clinical technique.

Acute Disease↗
PubMed1988

Therapeutic factors in partial hospitalization.

In recent years, partial hospitalization programs have become an accepted major component of community-based care for psychiatric patients. Studies have shown that partial hospitalization is at least as effective as inpatient hospitalization in treating a spectrum of psychiatric disorders and is substantially more cost effective than standard inpatient care (Guillette et al. 1978; Herz et al. 1971; Washburn et al. 1976; Wilder et al. 1966). Despite these positive findings, the therapeutic factors that contribute to the effectiveness of partial hospitalization continue to be a subject of speculation (e.g., Goldberg 1982; Vannicelli et al. 1978; Washburn 1983). In a recent review of the literature on the efficacy of partial hospitalization, Mason et al. (1982) emphasize that the "active ingredient" in this treatment modality remains unclear. In an outcome study by Dunn et al. (1982, p. 297), hope was expressed that "future studies might best explore which nonspecific factors are most powerful therapeutically." The current study is part of a larger effort to develop from an empirical base a comprehensive model of partial hospitalization. The comprehensive model provides a framework for understanding partial hospitalization by examining: 1) the functions of a partial hospital admission, 2) the types of patient changes that occur in these programs, 3) the processes of change, and 4) the therapeutic factors that appear to facilitate change. Findings regarding the first three elements of the model are described in a companion paper. This report focuses on the findings regarding the fourth element of the model, the therapeutic factors that appear to facilitate change in a short-term partial hospitalization program. It also examines how specific program components contribute to these therapeutic factors.

Adult↗
PubMed1987

Functions of short-term partial hospitalization in a comprehensive system of care.

An increasing number of short-term partial-hospital programs are being created as alternatives to standard inpatient care in the treatment of acutely ill patients. Despite this increase, both referring clinicians and partial-hospital staff are often unclear about the capabilities and limitations of such programs. The purpose of this study was to clarify the clinical functions of a short-term partial hospital within a comprehensive system of care. The findings include a description of the five functions identified for the program under study and a review of the process by which these clinical functions were accomplished over the partial-hospital stay. Implications of the findings for program planning, patient selection, and clinical training are discussed.

Comprehensive Health Care↗