Mental Health Services for Nursing Home Residents: What Will It Cost?

The Nursing Home Reform Act of 1987 requires nursing homes to provide basic mental health services for all residents and to give active mental health treatment, a set of specialized mental health services, to those residents who are admitted with a serious mental illness. This article examines the potential size of the nursing home population who will require mental health services, its demographic composition, and the facilities in which these individuals reside using the Institutional Population Component of the National Medical Expenditure Survey. Estimates of the potential costs of providing monthly psychotherapy and pharmacological management to this population in nursing homes indicate that the mandate will have significant financial effects on nursing facilities. Conclusions about how the requirements for maintaining the mental and psychosocial well-being of nursing home residents may affect the future of nursing home care and mental health care are considered.

A New Symbiosis: Municipalities, Private Contractors and Non-Governmental Organisations for the Provision of Local Public Services"

This project considered the second stage of transforming local administration and public service management to reflect democratic forms of government. In Hungary in the second half of the 1990s more and more public functions delegated to local governments have been handed over to the private or civil sectors. This has led to a relative decrease of municipal functions but not of local governments' responsibilities, requiring them to change their orientation and approach to their work so as to be effective in their new roles of managing these processes rather than traditional bureaucratic administration. Horvath analysed the Anglo-Saxon, French and German models of self-government, identifying the differing aspects emphasised in increasing the private sector's role in the provision of public services, and the influence that this process has on the system of public administration. He then highlighted linkages between actors and local governments in Hungary, concluding that the next necessary step is to develop institutional mechanisms, financial incentives and managerial practices to utilise the full potential of this process. Equally important is the need for conscious avoidance of restrictive barriers and unintended consequences, and for local governments to confront the social conflicts that have emerged in parallel with privatisation. A further aspect considered was a widening of the role of functional governance at local level in the field of human services. A number of different special purpose bodies have been set up in Hungary, but the results of their work are unclear and Horvath feels that this institutionalisation of symbiosis is not the right path in Hungary today. He believes that the change from local government to local governance will require the formulation of specific public policy, the relevance of which can be proven by processes supported with actions.

AccessMod 3.0: computing geographic coverage and accessibility to health care services using anisotropic movement of patients

Background Access to health care can be described along four dimensions: geographic accessibility, availability, financial accessibility and acceptability. Geographic accessibility measures how physically accessible resources are for the population, while availability reflects what resources are available and in what amount. Combining these two types of measure into a single index provides a measure of geographic (or spatial) coverage, which is an important measure for assessing the degree of accessibility of a health care network. Results This paper describes the latest version of AccessMod, an extension to the Geographical Information System ArcView 3.×, and provides an example of application of this tool. AccessMod 3 allows one to compute geographic coverage to health care using terrain information and population distribution. Four major types of analysis are available in AccessMod: (1) modeling the coverage of catchment areas linked to an existing health facility network based on travel time, to provide a measure of physical accessibility to health care; (2) modeling geographic coverage according to the availability of services; (3) projecting the coverage of a scaling-up of an existing network; (4) providing information for cost effectiveness analysis when little information about the existing network is available. In addition to integrating travelling time, population distribution and the population coverage capacity specific to each health facility in the network, AccessMod can incorporate the influence of landscape components (e.g. topography, river and road networks, vegetation) that impact travelling time to and from facilities. Topographical constraints can be taken into account through an anisotropic analysis that considers the direction of movement. We provide an example of the application of AccessMod in the southern part of Malawi that shows the influences of the landscape constraints and of the modes of transportation on geographic coverage. Conclusion By incorporating the demand (population) and the supply (capacities of heath care centers), AccessMod provides a unifying tool to efficiently assess the geographic coverage of a network of health care facilities. This tool should be of particular interest to developing countries that have a relatively good geographic information on population distribution, terrain, and health facility locations.

Community participation in health services

This study critically analyzes and synthesizes community participation (CP) theory across disciplines, defining and beginning to map out the elements of CP according to a preliminary framework of structure, process, intermediate outcomes, and ultimate outcomes. The first study component sought to determine the impact of Sight N' Soul, a CP project utilizing neighborhood health workers (NHWs), on appointment missing in an indigent urban African-American population. It found that persons entering the vision care system through contact with an NEW were about a third less likely to miss an appointment than those persons entering the system through some other avenue. While theory in this area remains too poorly developed to hypothesize causal relationships between structure, process, and outcomes, a summary of the elements of Sight N' Soul's structure and process both developed the preliminary framework and serves as a first step to mapping these relationships. The second component of the study uncovered the elements of structure and process that may contribute to a sustained egalitarian partnership between community people and professionals, a CP program called Project HEAL. Elements of Project HEAL's structure and process included a shared belief in the program; spirituality; contribution, ownership, and reciprocation; a feeling of family; making it together; honesty, trust, and openness about conflict; the inevitability of uncertainty and change; and the guiding interactional principles of respect; love, care, and compassion; and personal responsibility. The third component analyzed the existing literature, identifying and addressing gaps and inconsistencies and highlighting areas needing more highly developed ethical analysis. Focal issues include the political, economic, and historical context of CP; the power of naming; the issue of purpose; the nature of community; the power to muster and allocate resources; and the need to move to a systems view of health and well-being, expanding our understanding of the universe of potential outcomes of CP, including iatrogenic outcomes. Intermediate outcomes might include change in community, program, and individual capacity, as well as improved health care delivery. Ultimate outcomes include increased positive interdependencies and opportunities for contribution; improved mental, physical, and spiritual health; increased social justice; and decreased exploitation. ^

Unique and shared techniques in cognitive-behavioural and short-term psychodynamic psychotherapy: a content analysis of randomised trials on depression

Randomised controlled trials (RCTs) of psychotherapeutic interventions assume that specific techniques are used in treatments, which are responsible for changes in the client's symptoms. This assumption also holds true for meta-analyses, where evidence for specific interventions and techniques is compiled. However, it has also been argued that different treatments share important techniques and that an upcoming consensus about useful treatment strategies is leading to a greater integration of treatments. This makes assumptions about the effectiveness of specific interventions ingredients questionable if the shared (common) techniques are more often used in interventions than are the unique techniques. This study investigated the unique or shared techniques in RCTs of cognitive-behavioural therapy (CBT) and short-term psychodynamic psychotherapy (STPP). Psychotherapeutic techniques were coded from 42 masked treatment descriptions of RCTs in the field of depression (1979-2010). CBT techniques were often used in studies identified as either CBT or STPP. However, STPP techniques were only used in STPP-identified studies. Empirical clustering of treatment descriptions did not confirm the original distinction of CBT versus STPP, but instead showed substantial heterogeneity within both approaches. Extraction of psychotherapeutic techniques from the treatment descriptions is feasible and could be used as a content-based approach to classify treatments in systematic reviews and meta-analyses.

A follow-up on Acute Pain Services in Germany compared to international survey data.

BACKGROUND After the introduction of instruments for benchmarking, certification and a national guideline for acute pain management, the aim of this study was to describe the current structure, processes and quality of German acute pain services (APS). METHODS All directors of German departments of anaesthesiology were invited to complete a postal questionnaire on structures und processes of acute pain management. The survey asked for staff, techniques and quality criteria, which enabled a comparison to previous data from 1999 and surveys from other countries. RESULTS Four hundred and eight (46%) questionnaires were returned. APS have increased considerably and are now available in 81% of the hospitals, mainly anaesthesia based. However, only 45% fulfilled the minimum quality criteria, such as the assignment of personnel, the organization of patient care during nights and weekends, written protocols for postoperative pain management, regular assessments and documenting pain scores. Staff resources varied considerably, but increased compared to 1999. Two daily rounds were performed in 71%, either by physicians and nurses (42%), by physicians only (25%) or by supervised nurses (31%). Most personnel assigned to the APS shared this work along with other duties. Only 53% of the hospitals had an integrated rotation for training their specialty trainees. CONCLUSIONS The availability of APS in Germany and other countries has increased over the last decade; however, the quality of nearly half of the APS is questionable. Against the disillusioning background of recently reported unfavourable pain-related patient outcomes, the structures, organization and quality of APS should be revisited.

Quality of care for uninsured type 2 diabetic patients in a financial assistance medical home model

The medically uninsured population in the United States is 16% or 42 million people and consists of a significant number of Type 2 diabetic patients which is the predominant form of diabetes with 798,000 new cases diagnosed each year. There is limited health services research on uninsured populations concerning health system measures or specific disease conditions. ^ The purpose of this investigation was to determine the impact a newly implemented health care program had on the quality of care provided to patients with Type 2 diabetes. The primary study objective was to compare the quality of care while controlling for utilization, and health status of patients in the new program to their status during the previous financial assistance program. The research design was a retrospective matched-pairs design. The study population consisted of 225 patients who received medical care during 1996 and 1997 at the University Health System in San Antonio, Texas. ^ Six quality of care measures individually failed to demonstrate a statistically significant difference when compared between the two periods. However, an index measure reflecting the number of patients who received all six of the quality of care measures demonstrated a statistically significant increase in 1997 (p-value < 0.05). In 1996, 8 patients (2.6%) received all six medical management components. In 1997, 38 patients (16.8%) received all six medical management components. Four regression models were analyzed; two out of the four models demonstrated inconsistent results based on the program membership variable. ^ It is concluded that there has been a small effect of the Carelink program demonstrated by an increase from 8 to 38 patients receiving all quality of care components for Type 2 diabetics at the UHS. It is recommended that additional research be conducted in order to evaluate the quality of care provided to Type 2 diabetic patients. ^

Social support, health status and health services utilization among the noninstitutionalized elderly: An analysis of the Supplement on Aging to the 1984 national health interview survey

The association between Social Support, Health Status, and Health Services Utilization of the elderly, was explored based on the analysis of data from the Supplement on Aging to the National Health Interview Survey, 1984 (N = 11,497) using a modified framework of Aday and Andersen's Expanded Behavioral Model. The results suggested that Social Support as operationalized in this study was an independent determinant of the use of health services. The quantity of social activities and the use of community services were the two most consistent determinants across different types of health services use.^ The effects of social support on the use of health services were broken down into three components to facilitate explanations of the mechanisms through which social support operated. The Predisposing and Enabling component of Social Support had independent, although not uniform, effects on the use of health services. Only slight substitute effects of social support were detected. These included the substitution of the use of senior centers for longer stay in the hospital and the substitution of help with IADL problems for the use of formal home care services.^ The effect of financial support on the use of health services was found to be different for middle and low income populations. This differential effect was also found for the presence of intimate networks, the frequencies of interaction with children and the perceived availability of support among urban/rural, male/female and white/non-white subgroups.^ The study also suggested that the selection of appropriate Health Status measures should be based on the type of Health Services Utilization in which a researcher is interested. The level of physical function limitation and role activity limitation were the two most consistent predictors of the volume of physician visits, number of hospital days, and average length of stay in the hospital during the past year.^ Some alternative hypotheses were also raised and evaluated, when possible. The impacts of the complex sample design, the reliability and validity of the measures and other limitations of this analysis were also discussed. Finally, a revised framework was proposed and discussed based on the analysis. Some policy implications and suggestions for future study were also presented. ^

THE EFFECTS OF COST-SHARING ON USE OF SERVICES AND CONSUMER CHARACTERISTICS IN A STATE'S CRIPPLED CHILDREN'S DIVISION

The present study analyzed some of the effects of imposing a cost-sharing requirement on users of a state's health service program. The study population consisted of people who were in diagnosed medical need and included, but was not limited to, people in financial need.^ The purpose of the study was to determine if the cost-sharing requirement had any detrimental effects on the service population. Changes in the characteristics of service consumers and in utilization patterns were analyzed using time-series techniques and pre-post policy comparisons.^ The study hypotheses stated that the distribution of service provided, diagnoses serviced, and consumer income levels would change following the cost-sharing policy.^ Analysis of data revealed that neither the characteristics of service users (income, race, sex, etc.) nor services provided by the program changed significantly following the policy. The results were explainable in part by the fact that all of the program participants were in diagnosed medical need. Therefore, their use of "discretionary" or "less necessary" services was limited.^ The study's findings supported the work of Joseph Newhouse, Charles Phelps, and others who have contended that necessary service use would not be detrimentally affected by reasonable cost-sharing provisions. These contentions raise the prospect of incorporating cost-sharing into programs such as Medicaid, which, at this writing, do not demand any consumer payment for services.^ The study concluded with a discussion of the cost-containment problem in health services. The efficacy of cost-sharing was considered relative to other financing and reimbursement strategies such as HMO's, self-funding, and reimbursement for less costly services and places of service. ^

Interpretation services for immigrants in federally qualified health centers: Barriers, best practices, and suggestions for the future

This paper examines the provision of interpretation services to immigrants with limited English proficiency in Federally Qualified Health Centers, through examination of barriers and best practices. The United States is a nation of immigrants; currently, more than 38 million, or 12.5 percent of the total population, is foreign-born. A substantial portion of this population does not have health insurance or speak English fluently: barriers that reduce the likelihood that they will access traditional health care organizations. This service void is filled by FQHCs, which are non-profit, community-directed providers that remove common barriers to care by serving communities who otherwise confront financial, geographic, language, and cultural barriers. By examining the importance and the implementation of medical interpretation services in FQHCs, suggestions for the future are presented.^

Democratization and Financial Reform in Taiwan: The Political Economy of Bad-Loan Creation

This study shows that many bad loans now burdening Taiwan's financial institutions are interrelated with the society's democratization which started in the late 1980s. Democratization made the local factions and business groups more independent from the Kuomintang government. They acquired more political influence than under the authoritarian regime. These changes induced them to manage their owned financial institutions more arbitrarily and to intervene more frequently in the state-affiliated financial institutions. Moreover they interfered in financial reform and compelled the government to allow many more new banks than it had originally planned. As a result the financial system became more competitive and the qualities of loans deteriorated. Some local factions and business groups exacerbated the situation by establishing banks in order to funnel funds to themselves, sometimes illegally. Thus many bad loans were created as the side effect of democratization.

Financial Aspects of Transactions with FDI: Trade Credit Provision by SMEs in China

This paper will document financial aspects of transactions, and trade credit supply behavior with FDI among small and medium-sized enterprises(SMEs) based on two original surveys, conducted in four cities in China in 2003. The survey was designed to capture the nature of inter-firm transactions, trade credit and other financial conditions. Literature on FDI mainly refers to technology transfer, employment or investment. This paper focuses on the role and significance of FDI in the supply of trade credit due to its trade credit enforcement technology. Yanagawa, Ito and Watanabe [2006] developed a model which indicates that when a seller has higher enforcement technology or a buyer has richer liquidity, both trade credit and transaction volume will be increased. In this paper, we confirmed that FDI and G contributed to the provision of trade credit and had a positive external effect on trade credit enforcement towards China’s economy. (1) Sales towards FDI customers have the power to increase the trade credit ratio,even when controlling other factors such as choice of payment instrument, competitiveness, and expost default management. This implies that FDI does provide trade credit, not only because it has superior liquidity, but because it is also superior in terms of enforcement of trade credit repayment.(2) Cash constraints of the buyer influence the decisions concerning trade credit provided by the seller, as a model in Yanagawa, et al. [2006] predicted, and this implies that strategic default is a serious concern among SMEs in China. (3) Spillover effect exists in payment enforcement technology in transactions with FDI customers.

Harmonization of trade in services by APEC members

This study maps out the degree of services trade liberalization by the APEC members toward achieving a Free Trade Area of the Asia-Pacific (FTAAP) and makes some comparative analyses. The study finds that the commitment level differs greatly between sensitive and less sensitive sectors, and that the commitment level under the ASEAN Framework Agreement (AFAS) package 8 is the highest among the four FTAs studied. It also finds that there are cross-country and sector-wide similarities in the pattern of service sector commitment under and across each of the FTAs; this implies that the shared domestic sensitivities can be overcome by an APEC-wide economic cooperation scheme for enhancing competitiveness (through, e.g., the Trans-Pacific Strategic Economic Partnership Agreement or TPP).

A policy-driven architecture for supporting joint degrees through e-learning services

En un mercado de educación superior cada vez más competitivo, la colaboración entre universidades es una efectiva estrategia para acceder al mercado global. El desarrollo de titulaciones conjuntas es un importante mecanismo para fortalecer las colaboraciones académicas y diversificar los conocimientos. Las titulaciones conjuntas están siendo cada vez más implementadas en las universidades de todo el mundo. En Europa, el proceso de Bolonia y el programa Erasmus, están fomentado el reconocimiento de titulaciones conjuntas y dobles y promoviendo la colaboración entre las instituciones académicas. En el imparable proceso de la globalización y convergencia educativa, el uso de sistemas de e-learning para soportar cursos tanto semipresencial como online es una tendencia en crecimiento. Dado que los sistemas de e-learning soportan una amplia variedad de cursos, es necesario encontrar una solución adecuada que permita a las universidades soportar y gestionar las titulaciones conjuntas a través de sus sistemas de e-learning en conformidad con los acuerdos de colaboración establecidos por las universidades participantes. Esta tesis doctoral abordará las siguientes preguntas de investigación: 1. ¿Qué factores deben tenerse en cuenta en la implementación y gestión de titulaciones conjuntas? 2. ¿Cómo pueden los sistemas actuales de e-learning soportar el desarrollo de titulaciones conjuntas? 3. ¿Qué otros servicios y sistemas necesitan ser adaptados por las universidades interesadas en participar en una titulación conjunta a través de sus sistemas de e-learning? La implementación de titulaciones conjuntas a través de sistemas de e-learning es compleja e implica retos técnicos, administrativos, culturales, financieros, jurídicos y de seguridad. Esta tesis doctoral propone una serie de contribuciones que pueden ayudar a resolver algunos de los retos identificados. En primer lugar se ha elaborado un modelo conceptual que incluye la información del contexto de las titulaciones conjuntas que es relevante para la implementación de estas titulaciones en los sistemas de e-learning. Después de definir el modelo conceptual, se ha propuesto una arquitectura basada en políticas para la implementación de titulaciones interinstitucionales a través de sistemas de e-learning de acuerdo a los términos estipulados en los acuerdos de colaboración que son firmados por las universidades participantes. El autor se ha centrado en el componente de gestión de flujos de trabajo de esta arquitectura. Por último y con el fin de permitir la interoperabilidad de repositorios de objetos educativos, los componentes básicos a implementar han sido identificados y validados. El uso de servicios multimedia en educación es una tendencia creciente, proporcionando servicios de e-learning que permiten mejorar la comunicación y la interacción entre profesores y alumnos. Dentro de estos servicios, nos hemos centrado en el uso de la videoconferencia y la grabación de clases como servicios adecuados para el desarrollo de cursos impartidos en escenarios de educación colaborativos. Las contribuciones han sido validadas en proyectos de investigación de ámbito nacional y europeo en los que el autor ha participado. Abstract In an increasingly competitive higher education market, collaboration between universities is an effective strategy for gaining access to the global market. The development of joint degrees is an important mechanism for strengthening academic research collaborations and diversifying knowledge. Joint degrees are becoming increasingly implemented in universities around the world. In Europe, the Bologna process and the Erasmus programme have encouraged both the global recognition of joint and double degrees and promoted close collaboration between academic institutions. In the unstoppable process of globalization and educational convergence, the use of e-learning systems for supporting both blended and online courses is becoming a growing trend. Since e-learning systems covers a wide range of courses, it becomes necessary to find a suitable solution that enables universities to support and manage joint degrees through their e-learning systems in accordance with the collaboration agreements established by the universities involved. This dissertation will address the following research questions: 1. What factors need to be considered in the implementation and management of joint degrees? 2. How can the current e-learning systems support the development of joint degrees? 3. What other services and systems need to be adapted by universities interested in participating in a joint degree through their e-learning systems? The implementation of joint degrees using e-learning systems is complex and involves technical, administrative, security, cultural, financial and legal challenges. This dissertation proposes a series of contributions to help solve some of the identified challenges. One of the cornerstones of this proposal is a conceptual model of all the relevant issues related to the support of joint degrees by means of e-learning systems. After defining the conceptual model, this dissertation proposes a policy-driven architecture for implementing inter-institutional degree collaborations through e-learning systems as stipulated by a collaboration agreement signed by two universities. The author has focused on the workflow management component of this architecture. Finally, the building blocks for achieving interoperability of learning object repositories have been identified and validated. The use of multimedia services in education is a growing trend, providing rich e-learning services that improve the communication and interaction between teachers and students. Within these e-learning services, we have focused on the use of videoconferencing and lecture recording as the best-suited services to support collaborative learning scenarios. The contributions have been validated within national and European research projects that the author has been involved in.

Integrating periurban agrarian ecosystem services into spatial planning to cope with urban pressure

According to Corine Land Cover databases, in Europe between 1990 and 2000,77% of new artificial surfaces were built on previous agrarian areas. Urban sprawl ¡s far from being under control, between 2000 and 2006 new artificial land has grown in larger proportion than the decade before. In Spain, like in most countries, the impact of urban sprawl during the last decades has been especially significant in periurban agrarian spaces: between 2000 and 2006, 73% of new artificial surfaces were built on previous agrarian areas. The indirect impact of this trend has been even more relevant, as the expectations of appreciation in the value of land after new urban developments reinforce the ongoing trend of abandonment of agricultural land. In Madrid between 1980 and 2000 the loss of agricultural land due to abandonment of exploitation was 2-fold that due to transformation into urban areas. By comparing four case studies: Valladolild, Montpellier.Florence and Den Haag, this paper explores if urban and territorial planning may contribute to reduce urban pressure on the hinterland. In spite of their diversity, these regions have in common a relative prosperity arising from their territorial endowments, though their landscapes are still under pressure. The three last ones have been working for years on mainstream concepts like multifunctional agriculture. The systematic comparison and the analysis of successful approaches provide some clues on how to reconsider urban planning in order to preserve agricultural land. The final remarks highlight the context in which public commitment, legal protection instruments and financial strategies may contribute to the goals of urban, peri-urban or regional planning about fostering agrarian ecosystem services