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PubMed2000

A hybrid supported employment program for persons with schizophrenia in Japan.

INTRODUCTION BY THE COLUMN EDITORS: Because the mental health system in Japan has emphasized hospital-based treatment (1), patients with schizophrenia often remain institutionalized for long periods, even after their symptoms have stabilized. In addition, the introduction of modern community-based methods of treatment and rehabilitation was delayed by an antipsychiatry movement in the 1970s and the ascendance of a reductionistic biological approach to services (2). Lack of adequate outpatient services and community residential care in Japan has been a serious obstacle to destigmatization of mental disorders and has contributed to the heavy burden and stress experienced by families of mentally ill persons (3). More than 80 percent of patients discharged from mental hospitals return to live with their families, who are ill prepared to provide the supportive services required for community tenure. Involvement in work activities can facilitate community reentry for people with serious and persistent mental illness because employment displaces symptoms, provides structure and meaning in daily life, offers socialization with peers, and permits workers to earn income for shelter and food. In this issue's Rehab Rounds column, the authors describe an innovative vocational rehabilitation program for patients with schizophrenia that was designed to overcome obstacles to discharge and community adjustment. The program at Yabuki Prefecture Psychiatric Hospital, in the northern prefecture of Fukushima, Japan, has been successful in training patients for competitive work while capitalizing on the importance of work in Japanese culture and its traditionally supportive employer-employee relationships. The program is termed "hybrid" because it combines elements of transitional employment with supported employment (4).

Adult↗

PubMed1999

[Biological ad social characteristics of infants who died from pneumonia in the Metropolitan Region of Chile, 1995].

In order to determine the biological, sociocultural, and health-care characteristics associated with deaths from pneumonia among infants, this study used cases and controls to obtain quantitative information from a semistructured questionnaire given to those infants' mothers and to 28 doctors (15 who headed inpatient services and 13 who directed outpatient services). The cases were defined as children under 1 year of age who had died from pneumonia in 1995 in the Metropolitan Region of Chile (Greater Santiago). The controls were 118 children who survived after being hospitalized with pneumonia during the same period in the same area. The two groups were paired by age, month of hospitalization, and community of residence. A qualitative study was also done. It consisted of in-depth interviews with the mothers of 20 cases and of 5 controls and with 12 key informants from primary health care staffs. Of the 149 cases identified, 113 (75.8%) were studied, divided into two major groups: those who had died in the hospital (69%) and those who had died at home (31%). Of the deaths, 63.7% occurred during the first three months after birth. Both the cases and the controls had more biological and social risk than the Chilean population in general, although there were significant differences in risk between the cases and controls. The incidence of both low birthweight (< 2,500 g) and of very low birthweight (< 1,500 g) was higher in the two groups than in the general population and was significantly greater in the cases (40.7% and 13.3%, respectively) than in the controls (18.8% and 1.7%). Prematurity (gestational age < 37 weeks) was especially high among the children who had died in the hospital (40.3%), in contrast to 25.7% for those who had died at home and 17.1% among the controls. Those who had died in the hospital also had 10 times as many congenital disorders as did those who had died at home, and seven times as many as did the controls. According to their mothers, more than half (18/35) of the children who had died at home had not shown signs of pneumonia, which suggests sudden infant death syndrome or death from aspiration of food into the lungs. In terms of socioeconomics, the standard of living of the controls was lower than that of the cases. During 1995 or the second half of 1994, 60.3% of the fathers of the controls had been unemployed, as had 58.6% of the fathers of the cases. There were no differences between the cases and the controls with respect to the mothers' having noticed signs of illness or the mothers' knowledge of how to prevent pneumonia. The surveyed physicians generally believed that the primary cause of the deaths had been the high level of biological problems among those children. Since the group of children who died at home differed in both size and other characteristics from those who died in the hospital, there should be different strategies aimed at reducing deaths in the two groups. It is important to do autopsies in all deaths in order to determine if the cause of death is pneumonia, sudden infant death syndrome, or aspiration of food.

Chile↗

PubMedDate not supplied

Reform of the Quebec healthcare system.

This article briefly describes issues surrounding the reform process in Quebec and discusses its major thrusts--regionalization, definition of healthcare objectives, strengthening frontline services and greater use of outpatient services--and their effect on institutions which must above all come to terms with the reduction of the provincial deficit. Fewer human resources, longer waiting periods, institutional autonomy and the creation of integrated networks are some of the issues of current concern to the Quebec healthcare community.

Delivery of Health Care, Integrated↗

PubMed1995

[Effects of 2 reimbursement models on house calls by general practitioners].

This study compares the effects of the salary payment in the former GDR with the fee for service remuneration in Germany for outpatient service. The investigation focused on home visits 3 by family doctors in Magdeburg in the first two quarters of the years 1985 and 1992. The retrospective study based on existing documentations. Main questions were the modification of frequency resp. nature and matter of home visits. The frequency of home visits increased by about 134%. Distributed by age-groups, the home visits at patients up to the age of 55 showed only a small increase. However, the increase with patients between 60 and 79 years of age was 350%. In particular, diseases of the ICD Group VII (diseases of the vascular system) were affected by the increase. In contrast to this home visits of nurses were influenced to a lesser degree by the system changes. These are indications that the increase in the home visits is not due to an increased demand for them.

Adolescent↗

PubMed2000

Children in foster care: factors influencing outpatient mental health service use.

OBJECTIVE: To determine factors influencing outpatient mental health service use by children in foster care. METHOD: Detailed survey and administrative data were collected on 480 children who entered long-term foster care in San Diego County from May 1990 through October 1991. These data were linked with claims data from Medicaid and San Diego County Mental Health Services information systems. A Poisson regression model was used to determine whether the following factors influenced outpatient mental health service use: age, race/ethnicity, gender, maltreatment history, placement pattern, and behavioral problems as measured by the Achenbach Child Behavior Checklist (CBCL). RESULTS: Except for maltreatment history, all independent variables included in the multivariate regression model were statistically significant. The total number of outpatient mental health visits increased with age, male gender, and non-relative foster placements. Relative to Caucasians, visits were lower for Latinos, and Asian/Others, but comparable for African-Americans. Concerning maltreatment history, differences were only found in one category; children experiencing caretaker absence received fewer visits compared to children who did not experience caretaker absence. Children with CBCL Total Problem Scale T-scores of 60 or greater had significantly more visits than those with a score less than 60. CONCLUSIONS: Both clinical and non-clinical factors influence outpatient mental health service use by foster children. Limitations imposed by gender, race/ethnicity, and placement setting need to be addressed by child welfare policies. These finding suggest that guidelines are needed to systematically link children in foster care with behavioral problems to appropriate services.

Adolescent↗

PubMed1999

Effect of race on insurance coverage and health service use for HIV-infected gay men.

OBJECTIVE: To determine whether race is associated with health insurance coverage and health service use among gay and bisexual men in the Baltimore center of the Multicenter AIDS Cohort Study. METHODS: Data from eight semiannual study visits between 1991 and 1996 were used. Descriptive, stratified, and logistic regression analyses were conducted to determine whether race is associated with insurance coverage, medical, or dental service use, after controlling for socioeconomic variables. RESULTS: No difference was found between blacks' and whites' likelihood of having health insurance, private insurance, using inpatient, emergency department services, or antiretroviral medications. Whites were more likely to use outpatient services, particularly if CD4 cell counts were high, and were more likely to use dental services, although blacks were more likely to have dental insurance. CONCLUSIONS: Further research must be conducted to examine cultural, social, and psychological factors that help explain why white gay men use more outpatient and dental services, when other service use is unrelated to race. Investigators should be precise when using race as a variable in health services and epidemiologic research, emphasizing when racial differences truly exist versus when the variable race is a surrogate for another factor.

Adult↗

PubMedDate not supplied

Outpatient mental health service use by older adults after acute psychiatric hospitalization.

This study described outpatient mental health service used by elderly patients discharged from acute inpatient psychiatric treatment for depression, assessed services barriers, and identified factors related to the use of outpatient mental health services. The sample consisted of 199 elderly patients discharged home from a geropsychiatric unit of an urban midwestern hospital. Multivariate logistic regression was used to identify factors associated with use of various mental health services. Almost three quarters of the elderly patients saw a psychiatrist within 6 weeks postdischarge, but few used other outpatient mental health services. The most frequently reported barriers to use included (1) cost of services, (2) personal belief that depression would improve on its own, and (3) lack of awareness of available services. The use of various outpatient services was differentially related to predisposing, need, and enabling factors. Female patients, those residing in rural areas, and those who wanted to solve their problems on their own were less likely to use outpatient mental health services. Patients who reported greater levels of functional impairment, resided in rural areas, and perceived that getting services required too much time were less likely to see a psychiatrist in the postacute period. African American patients were more likely than whites to use day treatment programs. This may be related to the fact that most day treatment centers were located in areas where the majority of residents were African Americans.

Aged↗

PubMed1984

How to establish a pharmacokinetics consulting service for ambulatory patients.

Guidelines on establishing a pharmacokinetics consultation service are presented with emphasis on outpatient services. Need for the service must first be demonstrated, using the literature and local data on frequency of serum drug concentration monitoring for particular drugs and patient subgroups. Physician interest in the program must be determined. The pharmacist intervention may be restricted to technical interpretation of serum drug concentration data, or it can include advice based on the patient's disease process, drug effects, and the interaction between the two. In the service described, a patient interview, a chart review, drug analysis, and a written consultation were provided. A flow chart showing movement of the patient through the service was used, and the pharmacist documented the consultation in the patient's medical record, including recommendations for dosage change and follow-up. Cost items to consider in establishing the service include equipment and supplies, space, and personnel. Staff members who are responsible for serum drug analyses must meet state-specific requirements. In estimating revenues, the current number of requests for serum drug concentrations should be doubled and the institution's estimated rate of collection should be used. After the service is established, the cost of a computerized system for pharmacokinetic predictions may be justified by the increased efficiency of such a system.

Cost-Benefit Analysis↗

PubMed1997

Service utilization and expenditures for the treatment of panic disorder.

The outpatient service utilization and estimated expenditures for the treatment of panic disorder for patients prior to their enrollment in a large clinical trial were examined. Data were drawn from the Cross-National Collaborative Panic Study. The sample consists of 391 patients who met DSM-III criteria for panic disorder and were enrolled at one of the US sites of the trial. The rate and frequency of outpatient mental health visits to primary care and specially mental health providers for the current episode of panic disorder are examined. Estimates of direct expenditures for these services are presented (in 1993 US dollars). Over 70% of the patients used primary care for mental health services whereas about 47% of the patients used specialty mental health services. Nearly half of the patients (46.8%) saw a nonpsychiatrist medical specialist, most often a cardiologist (20.6%). Among all patients, those with more frequent panic attacks were more likely to use some form of outpatient mental health services for panic disorder. Among users of any services, those with more severe impairment were more likely to use specialized mental health services. The mean estimated expenditure for the panic episode was $3339, about half of which was accounted for by specialty mental health expenditures. Among users, the median estimated expenditures was $518 for primary care physicians and $2122 for specialty mental health services. In conclusion, the service utilization in this sample of patients with panic disorder is highly varied. Both the primary care and specialty mental health sectors play prominent roles in the community treatment of panic disorder.

Adult↗

PubMed1980

A multi-tiered screening system for the least restrictive setting.

The authors evaluated the placement process in a large psychiatric facility with both inpatient and outpatient services. They examined 71 inpatient and 90 outpatient new admissions using standardized tests of psychopathology and sociodemographic status. After correcting for response bias, the authors found, in contrast to other studies, that the level of morbidity in the inpatient service was significantly different from that in the outpatient unit. The measures of sociodemographic data indicate that inpatients were more dependent on social support systems and that this finding was not influenced by response bias.

Commitment of Persons with Psychiatric Disorders↗

PubMed2000

Is more better than less? An analysis of children's mental health services.

OBJECTIVE: To assess the dose-response relationship for outpatient therapy received by children and adolescents-that is, to determine the impact of added outpatient visits on key mental health outcomes (functioning and symptomatology). DATA SOURCES/STUDY SETTING: The results presented involve analyses of data from the Fort Bragg Demonstration and are based on a sample of 301 individuals using outpatient services. STUDY DESIGN: This article provides estimates of the impact of outpatient therapy based on comparisons of individuals receiving differing treatment doses. Those comparisons involve standard multiple regression analyses as well as instrumental variables estimation. The latter provides a means of adjusting comparisons for unobserved or unmeasured differences among individuals receiving differing doses, differences that would otherwise be confounded with the impact of treatment dose. DATA COLLECTION/EXTRACTION METHODS: Using structured diagnostic interviews and behavior checklists completed by the child and his or her caretaker, detailed data on psychopathology, symptomatology, and psychosocial functioning were collected on individuals included in these analyses. Information on the use of mental health services was taken from insurance claims and a management information system. Services data were used to describe the use of outpatient therapy within the year following entry into the study. PRINCIPAL FINDINGS/CONCLUSIONS: Instrumental variables estimation indicates that added outpatient therapy improves functioning among children and adolescents. The effect is statistically significant and of moderate practical magnitude. These results imply that conventional analyses of the dose-response relationship may understate the impact of additional treatment on functioning. This finding is robust to choice of functional form, length of time over which outcomes are measured, and model specification. Dose does not appear to influence symptomatology.

Adolescent↗

PubMed2002

Medicare's fee schedule for hospital outpatient care.

Medicare's hospital outpatient prospective payment system (OPPS) went live on August 1, 2000, after a decade of developmental work. The new system introduced a fee schedule that replaced the cost-related methods that Medicare previously used to reimburse various hospital outpatient services. Hospitals are now paid predetermined rates or fees based on the Ambulatory Patient Classification (APC) groups assigned to the services that Medicare patients receive during outpatient encounters. The new system aims to simplify Medicare's intricate cost-based reimbursement policies, improve hospital efficiency, ensure that payments are sufficient to compensate hospitals for reasonable Medicare costs, and reduce Medicare coinsurance amounts for beneficiaries. Implementation of OPPS-related administrative and operational changes has been a major challenge for hospitals.

Accounting↗

PubMed1980

Follow-up study of the impact of a rural preventive care outreach program on children's health and use of medical services.

The present study is a follow-up of a previous evaluation of a rural pediatric preventive care outreach program in Appalachia, which showed that although program participants did not differ substantially from their matched controls on health outcomes, they did have significantly lower utilization rates for outpatient services. The purpose of this second study was to determine whether replication of the original study would yield similar results on a fresh sample of children and whether differences observed between study and control groups would hold firm once families had terminated contact with the program. In general, the findings of the present study provided additional evidence to suggest that program children had lower utilization of outpatient medical services with no appreciable difference from the control children in health outcomes. Lower outpatient utilization rates were also found after termination of contact with the program, but the differences were not statistically significant.

Child↗

PubMed1990

Funding children's mental health services in an underfunded climate: collaborative efforts.

In New York State and elsewhere, the lack of outpatient services results in inappropriate psychiatric hospitalization of children. Funding for specialized mental health services for children is not federally or state-mandated and county-levied dollars often are required to generate a state match. In New York State, counties relying exclusively on traditional sources of mental hygiene funding are unlikely to develop a variety of quality programs for children. This article discusses in detail how interagency collaboration developed in Dutchess County, New York resulted in procurement of funds that financed an array of children's outpatient mental health services to county residents.

Child↗

PubMed2000

Fees for outpatient operations in Germany: development, evaluation and European comparison.

In Germany, discussions on the fees for statutory sickness insurance for ambulatory surgery has, in the last few years, become almost a symbol of dispute for the German health services. Outpatient surgeons complain about the fact that the fees do not cover their services. They see innovation severely threatened by bureaucracy, profitability by planned economy, rights by reasons of State, aggravated by the 'reform' attempts of the Greens and Socialist coalition Federal Government. On the other hand their opponents complain about the money mindedness of the doctors. Intentional panic or real disaster? The fundamental consideration to clarify this question is based on a comparison of the German statutory medical insurance fees and private fees with our neighbours. In Europe an economic area with similar prices for goods, services and wages, even 'outpatient operations' services with comparable cost rates should be paid for at a corresponding level. Any discrepancies would give cause to look for an explanation by analysing the historic development of fees and the question of a fair comparison between operations and the non-operative services.

Journal Article↗

PubMed1994

Differences in the use of hospital-based outpatient mental health services by the elderly.

Visits to hospital outpatient clinics and emergency rooms by patients age 65 and over were studied. Differences were found in the use of mental health services between the oldest old and youngest old. A significant portion of psychiatric and substance abuse disorders was found among the youngest old, while the oldest old made a greater number of visits to emergency rooms.

Age Factors↗

PubMed1999

A limited-service rural hospital model: the freestanding emergency department.

A rural hospital that has been downsized to a freestanding emergency department is an important model in that it offers a possible solution to a community's need to have emergency-care services locally available. This model could include other important local services, such as skilled-nursing and outpatient services. This study looks at the financial feasibility of a rural hospital shutting down acute-care services and maintaining emergency services. Expenses were determined, and changes to revenue and expenses were estimated. Reimbursement was assumed static. Medicare cost reports and hospital financial disclosure reports were used in investigating three model categories: an urgent-care clinic with emergency services; a hospital-based emergency department with an outpatient clinic; a hospital-based emergency department with an outpatient clinic and a hospital-based skilled-nursing facility. Even with best-case assumptions regarding continued reimbursement, results show only a small increase in net income and, in two cases, large losses compared with the size of the hospital operations. A subsidy would be required from the community or an affiliated hospital or network for the model to remain financially stable. The regulatory barriers to implementation are noted, as well as the potential problems with the human aspects of implementation--staffing, recruitment and retention, professional education and quality. If the model rural hospital is an affiliate or partner with one or more health care facility, which could assist with financial and staffing needs, it may be feasible.

Ambulatory Care Facilities↗

PubMedDate not supplied

Quality of preventive care for diabetes: effects of visit frequency and competing demands.

PURPOSE: We sought to determine the association between timely receipt of diabetes-related preventive services and the longitudinal pattern of outpatient service use as characterized by a novel taxonomy that prioritized visits based on the Oregon State Prioritized Health Services List. METHODS: We performed a cross-sectional analysis of mail survey and automated health care data for a population-based sample of patients with diabetes enrolled in a health maintenance organization in Washington State (N = 4,463). Outcomes included American Diabetes Association-recommended preventive services, including regular hemoglobin A1C (HbA1C) monitoring, retinal examination, and microalbuminuria screening. Patients with fewer than 8 visits during the 2-year study period were considered infrequent users, while patients with 8 or more visits were classified as lower-priority users if most visits were for conditions of relatively low rank on the Oregon list and as higher-priority users otherwise. RESULTS: After adjustment for social, demographic, and clinical factors, and depression, infrequent users had significantly reduced odds of receiving at least 1 HbA1C test (odds ratio [OR] = 0.35, 95% confidence interval [CI], 0.24-0.51), retinal examination (OR = 0.74, 95% CI, 0.63-0.86), and microalbuminuria screening (OR = 0.75, 95% CI, 0.58-0.96) relative to higher-priority users during the previous year. Lower-priority users also had relatively reduced odds of receiving at least 1 HbA(1C) test (OR = 0.59, 95% CI, 0.35-1.01), retinal examination (OR = 0.68, 95% CI, 0.56-0.84), and microalbuminuria screening (OR = 0.79, 95% CI, 0.57-1.09) despite attending a similar mean number of total visits as higher-priority users. CONCLUSIONS: Patients who attend relatively few outpatient visits or who attend more frequent visits for predominantly lower-priority conditions are more likely to receive substandard preventive care for diabetes.

Aged↗