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Strategies for improving services for the chronic mentally ill.

A central goal of policies aimed at improving care of the chronic mentally ill is better service coordination and integration. The author examines four current policy strategies--continuous care teams, local mental health authorities, integrated entitlement programs, and capitation payment systems--and discusses their incorporation in four model programs of integrated services. The programs differ in the degree to which they attempt to direct service coordination at the patient level, but all four programs have created local mental health authorities to oversee services. The success of any of the policy strategies depends on a system's capacity not only to regulate services but to ensure that presumed incentives to deliver cost-effective services filter down to well-trained and motivated front-line staff.

Chronic Disease↗

[Status of day care treatment of elderly psychiatric patients in West Germany and West Berlin].

The possibilities as well as the limits of day-hospital treatment for elderly mentally ill patients are described, using as a basis a general survey on the situation of psychiatric day-hospitals in the Federal Republic of Germany and West Berlin. As of July 1, 1982, there were at least seven day-hospitals specializing in psychogeriatric patients, whereas a further eight institutions admitted elderly mentally ill patients as well as the usual patients. For all these day-hospitals a review of the current status is given regarding funds, size of program, integration into the existing network of psychiatric services, referral sources, the individual programs perceived mission, clientele, exclusionary criteria, duration of stay, therapeutic activities and staffing. Finally problems such as indication, clientele and delimitation of other ways of treatment are discussed. Questions are asked with regard to the purpose and the necessity of specialized psycho-geriatric partial hospitalization programs.

Aged↗

Supported employment outcomes of a randomized controlled trial of ACT and clubhouse models.

OBJECTIVE: In a randomized controlled trial, a vocationally integrated program of assertive community treatment (ACT) was compared with a certified clubhouse in the delivery of supported employment services. METHODS: Employment rates, total work hours, and earnings for 121 adults with serious mental illness interested in work were compared with published benchmark figures for exemplary supported employment programs. The two programs were then compared on service engagement, retention, and employment outcomes in regression analyses that controlled for background characteristics, program preference, and vocational service receipt. RESULTS: Outcomes for 63 ACT and 58 clubhouse participants met or exceeded most published outcomes for specialized supported employment teams. Compared with the clubhouse program, the ACT program had significantly (p<.05) better service engagement (ACT, 98 percent; clubhouse, 74 percent) and retention (ACT, 79 percent; clubhouse, 58 percent) over 24 months, but there was no significant difference in employment rates (ACT, 64 percent; clubhouse, 47 percent). Compared with ACT participants, clubhouse participants worked significantly longer (median of 199 days versus 98 days) for more total hours (median of 494 hours versus 234 hours) and earned more (median of $3,456 versus $1,252 total earnings). Better work performance by clubhouse participants was partially attributable to higher pay. CONCLUSIONS: Vocationally integrated ACT and certified clubhouses can achieve employment outcomes similar to those of exemplary supported employment teams. Certified clubhouses can effectively provide supported employment along with other rehabilitative services, and the ACT program can ensure continuous integration of supported employment with clinical care.

Adult↗

[Evaluation of costs and effectiveness of an integrated outpatient training program for hypertensive patients].

BACKGROUND: Clinical management of hypertension needs a comprehensive therapeutic approach including both somatic and psychological aspects to ensure long-term treatment success. We have developed and evaluated an integrated outpatient training program for hypertensive patients. METHODS: The impact of the integrated training program was evaluated in an open label prospective single-center study of 120 consecutive patients. The outpatient training program consisted of moderate physical exercise, patient education (relaxation techniques and stress management) and individual psychotherapy as indicated. Training sessions were held twice weekly during the initial six-month period. Anti-hypertensive medications were managed by the program director in close cooperation with the primary care physician. Hypertension control, medication and program costs were monitored prospectively. Evaluated parameters were measured at study enrolment (T1), upon completion of the six-month program (T2) and at follow-up at 18 +/- 5 months (T3). RESULTS: Maximum exercise capacity increased from 85.1 +/- 1.3% at enrolment (T1) to 95.8 +/- 1.5% of the expected value at 6 months (T2) (p < 0.005). There was no change in body mass index, though a reduction in anti-hypertensive medication was observed (betablockers, -30.1%; thiazides, -20.9%; ACEI/ARB, -19.8%; calcium channel antagonist, -13.4%; alpha-blockers, -41.5%; p < 0.05; p < 0.01). Blood pressure fell from 144.6 +/- 1.8/ 88.1 +/- 0.9 at enrolment (T1) to 136.8 +/- 1.4/83.5 +/- 0.8 mm Hg at 6 month (T2) (p < 0.01). A similar decrease in systolic blood pressure at submaximal workload of 8.5 +/- 1.4 (6.6-11.2) mm Hg was observed. The daily costs for anti-hypertensive medications decreased 20.7% from EUR 0.92 to 0.73 (p < 0.01). The overall costs for the program were EUR 970 per patient. At follow-up at 18 +/- 5 months (T3), there was persistence in the reduction in medication use as well as an increase in exercise capacity. Blood pressure control had deteriorated but the values were lower than at enrolment (T1) (p = 0.1, p < 0.05). CONCLUSION: The integrated training program represents a comprehensive and effective approach to the treatment of hypertension. The costs of the program are likely to be offset by reduced expenses for anti-hypertensive medications over time at least in part.

Ambulatory Care↗

The role of core stability in athletic function.

The importance of function of the central core of the body for stabilisation and force generation in all sports activities is being increasingly recognised. 'Core stability' is seen as being pivotal for efficient biomechanical function to maximise force generation and minimise joint loads in all types of activities ranging from running to throwing. However, there is less clarity about what exactly constitutes 'the core', either anatomically or physiologically, and physical evaluation of core function is also variable. 'Core stability' is defined as the ability to control the position and motion of the trunk over the pelvis to allow optimum production, transfer and control of force and motion to the terminal segment in integrated athletic activities. Core muscle activity is best understood as the pre-programmed integration of local, single-joint muscles and multi-joint muscles to provide stability and produce motion. This results in proximal stability for distal mobility, a proximal to distal patterning of generation of force, and the creation of interactive moments that move and protect distal joints. Evaluation of the core should be dynamic, and include evaluation of the specific functions (trunk control over the planted leg) and directions of motions (three-planar activity). Rehabilitation should include the restoring of the core itself, but also include the core as the base for extremity function.

Humans↗

Development and implementation of nonpharmacologic protocols for the management of patients with Alzheimer's disease and their families in a multiracial primary care setting.

PURPOSE: Most patients and families with dementia are cared for in primary care clinics. These clinics are seldom designed to provide the necessary comprehensive care. The purpose of this article is to describe nonpharmacologic protocols for the management of patients with Alzheimer's disease and their families that are administered as part of a multifaceted care-management intervention program in a multiracial primary care clinic. DESIGN & METHODS: The nonpharmacologic component for the integrated program of collaborative care was developed based on a literature review and previous clinical experience. The care is coordinated by a geriatric nurse practitioner who meets with patients, families, and the primary care physicians. The nonpharmacologic protocols included general educational guidelines about Alzheimer's disease. Specific protocols to treat the common behavioral disturbances associated with Alzheimer's disease also were developed. A major component of the intervention is a monthly psychoeducational support group for caregivers. RESULTS: The intervention has been well accepted by patients, families, and physicians. Approximately one-half of the treatment group has participated in the support group regularly. IMPLICATIONS: The integration of behavioral interventions and team care within the primary care environment has been successful.

Aged↗

[Behavior therapy and communication theory as treatment for inpatients with anorexia nervosa (author's transl)].

A staged program for inpatient treatment of anorexia nervosa is presented. This program integrates behaviour-therapeutic and interactional models. Results show that five of seven patients completed the program successfully and maintained their stable condition after an average catamnestic period of 16 months. The necessity of integrating both models and the practical difficulties in a clinical setting are discussed.

Adolescent↗

A curriculum based on systems theory.

This paper describes an entry-level curriculum based on systems theory that was designed to promote integrated thinking and a shared image of practice among all of the members of an educational community that included students, faculty, and clinicians. Initiated in 1983, the program integrates occupational therapy theory, critical thinking, and knowledge about person-environmental transactions with traditional medical, biological, psychological, and sociological course work to create a unique educational experience. The curriculum model is based on a spiral learning process that encourages integrated thinking. Furthermore, all concepts are systematically tied to the occupation core, the central theme of the program. Fieldwork is used to reinforce ideas presented in the classroom and features discrete learning experiences where students demonstrate their integration of knowledge and skills. In an evaluation of the program, responses from 78 clinician, 51 alumni, and 132 student questionnaires; feedback from 132 fieldwork supervisors; and longitudinal data from 33 alumni confirmed that graduates are critical thinkers who appreciate the diverse needs of clients while demonstrating an appreciation for the curative effect of meaningful, goal-directed activities.

Curriculum↗

Comparison of conventional and integrated pest management programs in public schools.

This study compared an integrated pest management (IPM) program with conventional, calendar-based pest control in nine North Carolina elementary schools. Both programs primarily targeted the German cockroach, Blattella germanica (L.). The IPM program relied heavily on monitoring and baiting, whereas the conventional approach used baseboard and crack-and-crevice sprays of insecticides. Within the constraints of an existing pest management contract, we quantified service duration, materials used, cost, levels of cockroach infestation, and the pesticide residues generated by the two service types. IPM services were significantly more time-consuming than conventional services, resulting in a significantly higher cost associated with labor. Nevertheless, the two types of treatments incurred similar total costs, and the efficacy of both treatments was also similar. Most importantly, pest monitoring, a central element of the IPM program, revealed few cockroaches and indicated that most of the conventional treatments were unnecessary. Environmental residues of the organophosphate pesticides acephate, chlorpyrifos, and propetamphos were significantly higher in swab samples taken in the conventionally treated schools. This study demonstrates that an IPM program is an appropriate and preferable alternative to conventional methods of pest control in the school environment.

Animals↗

Trends in acute mental health care: comparing psychiatric and substance abuse treatment programs.

This study compared psychiatric and substance abuse acute care programs, within both inpatient and residential modalities of care, on organization and staffing, clinical management practices and policies, and services and activities. A total of 412 (95% of those eligible) Department of Veterans Affairs' programs were surveyed nationwide. Some 40% to 50% of patients in psychiatric and substance abuse programs, in both inpatient and residential venues of care, had dual diagnoses. Even though psychiatric programs had a sicker patient population, they provided fewer services, including basic components of integrated programs, than substance abuse programs did. Findings also showed that there is a strong emphasis on the use of clinical practice guidelines, performance monitoring, and obtaining client satisfaction and outcome data in mental health programs. The author's suggest how psychiatric programs might better meet the needs of acutely ill and dually diagnosed patients (e.g., by incorporating former patients as role models and mutual help groups, as substance abuse programs do; and by having policies that balance patient choice with program demand).

Acute Disease↗

Strategies for the physiome project.

The physiome is the quantitative description of the functioning organism in normal and pathophysiological states. The human physiome can be regarded as the virtual human. It is built upon the morphome, the quantitative description of anatomical structure, chemical and biochemical composition, and material properties of an intact organism, including its genome, proteome, cell, tissue, and organ structures up to those of the whole intact being. The Physiome Project is a multicentric integrated program to design, develop, implement, test and document, archive and disseminate quantitative information, and integrative models of the functional behavior of molecules, organelles, cells, tissues, organs, and intact organisms from bacteria to man. A fundamental and major feature of the project is the databasing of experimental observations for retrieval and evaluation. Technologies allowing many groups to work together are being rapidly developed. Internet II will facilitate this immensely. When problems are huge and complex, a particular working group can be expert in only a small part of the overall project. The strategies to be worked out must therefore include how to pull models composed of many submodules together even when the expertise in each is scattered amongst diverse institutions. The technologies of bioinformatics will contribute greatly to this effort. Developing and implementing code for large-scale systems has many problems. Most of the submodules are complex, requiring consideration of spatial and temporal events and processes. Submodules have to be linked to one another in a way that preserves mass balance and gives an accurate representation of variables in nonlinear complex biochemical networks with many signaling and controlling pathways. Microcompartmentalization vitiates the use of simplified model structures. The stiffness of the systems of equations is computationally costly. Faster computation is needed when using models as thinking tools and for iterative data analysis. Perhaps the most serious problem is the current lack of definitive information on kinetics and dynamics of systems, due in part to the almost total lack of databased observations, but also because, though we are nearly drowning in new information being published each day, either the information required for the modeling cannot be found or has never been obtained. "Simple" things like tissue composition, material properties, and mechanical behavior of cells and tissues are not generally available. The development of comprehensive models of biological systems is a key to pharmaceutics and drug design, for the models will become gradually better predictors of the results of interventions, both genomic and pharmaceutic. Good models will be useful in predicting the side effects and long term effects of drugs and toxins, and when the models are really good, to predict where genomic intervention will be effective and where the multiple redundancies in our biological systems will render a proposed intervention useless. The Physiome Project will provide the integrating scientific basis for the Genes to Health initiative, and make physiological genomics a reality applicable to whole organisms, from bacteria to man.

Computer Simulation↗

Enhancing outcomes in an indicated drug prevention program for high-risk youth.

This study examined the net effects of refining a high school-based indicated drug prevention program. The Personal Growth Class (PGC), tailored to meet the needs of high-risk youth, was designed to increase control of drug use, school performance, and emotional well-being. The program integrates social support and life-skills training. Process evaluation revealed the need for program enhancements to address underestimated levels of depression, anger, and suicidal behaviors prevalent among high-risk youth and to ensure that core content was being emphasized consistently. Youth participating in Late cohorts received the refined PGC with enhanced skills training. Study participants (N = 280) were youth, primarily ages fifteen to-seventeen, at high-risk for school failure or dropout. Indicators of emotional well-being (e.g., depression, stress, anger, self-esteem, personal control), drug involvement, and school performance were compared for Late versus Early cohorts. Regression analyses revealed the Late versus Early cohorts showed significantly greater decreases in hard drug use, depression, perceived stress, and anger, and greater increases in self-esteem. The results support arguments that effective indicated prevention programs should target specific high-risk youth employing strategies to counteract the multifaceted risk factors they experience and enhance needed protective factors.

Adolescent↗

Fine particles and oxidant pollution: developing an agenda for cooperative research.

This paper describes a background for the North American Research Strategy for Tropospheric Ozone (NARSTO) cooperative program integrating studies of O3 and PM2.5. It discusses several important aspects for rationalizing NARSTO's trinational investigative approach, including (1) an outlook on the state of knowledge about fine particles in the troposphere and their origins in Canada, Mexico, and the United States; (2) the need for enhancement and strengthening of key field measurements in relation to tropospheric chemistry and a health effects component; and (3) the use of a central theme for advancing air quality modeling using evolving techniques to integrate and guide key process-oriented field campaigns. The importance of organizing a scientific program to acquire "policy-relevant" information is stressed, noting cooperative research directions that address combined PM2.5 and O3 issues, illustrated through exploration of hypothetical pathways of PM2.5 response to choices of O3 and PM precursor emission reductions. The information needed for PM2.5 research is noted to intersect in many cases with those of O3, but diverge in other cases. Accounting for these distinctions is important for developing NARSTO's strategy over the next decade.

Air Pollution↗

An innovative strategy for conducting clinical research: the academic associate program.

Performance of high-quality clinical research usually requires procurement of substantial funding to support and sustain the research infrastructure. The authors have developed a program to support a research infrastructure that minimizes financial start-up costs and maximizes productivity of clinical-educator faculty with limited protected time. The program integrates clinical research with undergraduate education. The authors report the experience with the academic associate program at two academic institutions. They describe the program, provide measures of program success, and discuss potential methods for other institutions to initiate similar programs. Similar programs can be developed in a variety of outpatient and inpatient settings allowing the performance of high-quality clinical research in a time-efficient and cost-effective manner.

Academic Medical Centers↗

[The integration of teaching and care: a conceptual approach].

The author describes the origin of community medicine, its diffusion and the source of Teaching-Caring Integration Programs. Besides this, she points out the fundamental concepts that identify the Teaching-Caring Integration as an of teaching-service integration.

Brazil↗

The role of the EAP in the identification and treatment of substance abuse.

Employee Assistance Programs (EAPs) are cost-effective strategies for employers to contain the substantial direct and indirect costs of substance abuse in the workplace. EAPs offer prevention, early detection, assessment of referral, and after-care programs to help stem the enormous costs of substance abuse in the workplace. Most effective employer substance abuse programs integrate drug-testing and EAP services to ensure a well coordinated, cost-effective program.

Humans↗

[Program of community integration: search for new strategies and new life styles].

The Program of Community Integration of the Municipal Bureau of Health of the city of Ribeirão Preto aims at promoting health, directing its actions for the change of life styles. The purpose of this study is to look, in the light of the framework of Health Promotion and through declarations of users of the program, how it has been formed as an important strategy to increase the autonomy and emancipation of the population. The analysis reveals that the program has improved the autonomy and emancipation of the population, as an important instrument for life defence.

Brazil↗

[The prevention of acute disorders of cerebral circulation: the theory and the reality].

It would be valid to conduct prophylaxis of acute cerebrovascular disturbances (ACVD) in the context of state integral program of prophylaxis of the main noninfectious diseases. Its basic principles are: control of risk factors, integral approach and priority of populational strategy. The main medical directions of ACVD prophylaxis are: control of arterial hypertension and prevention of cardioembolic insult in patients with heart rhythm disorders. It is also possible to prevent repeated ACVD in patients with transitory ischemic attacks and minor insults. The best result is prognosed in combination of the state policy of providing the healthy mode of life of population and medical prophylaxis of ACVD in high risk groups.

Acute Disease↗