Procedure for the identification of population characteristics for targeting intervention services on the basis of outcome-goal priorities: Case management services for the chronic mentally ill

Although the processes involved in rational patient targeting may be obvious for certain services, for others, both the appropriate sub-populations to receive services and the procedures to be used for their identification may be unclear. This project was designed to address several research questions which arise in the attempt to deliver appropriate services to specific populations. The related difficulties are particularly evident for those interventions about which findings regarding effectiveness are conflicting. When an intervention clearly is not beneficial (or is dangerous) to a large, diverse population, consensus regarding withholding the intervention from dissemination can easily be reached. When findings are ambiguous, however, conclusions may be impossible.^ When characteristics of patients likely to benefit from an intervention are not obvious, and when the intervention is not significantly invasive or dangerous, the strategy proposed herein may be used to identify specific characteristics of sub-populations which may benefit from the intervention. The identification of these populations may be used both in further informing decisions regarding distribution of the intervention and for purposes of planning implementation of the intervention by identifying specific target populations for service delivery.^ This project explores a method for identifying such sub-populations through the use of related datasets generated from clinical trials conducted to test the effectiveness of an intervention. The method is specified in detail and tested using the example intervention of case management for outpatient treatment of populations with chronic mental illness. These analyses were applied in order to identify any characteristics which distinguish specific sub-populations who are more likely to benefit from case management service, despite conflicting findings regarding its effectiveness for the aggregate population, as reported in the body of related research. However, in addition to a limited set of characteristics associated with benefit, the findings generated, a larger set of characteristics of patients likely to experience greater improvement without intervention. ^

PREPAID MENTAL HEALTH SERVICES: A NATIONAL PERSPECTIVE

The purpose of this 1982 national survey of all operational prepaid health plans, or PHPs (including health maintenance organizations), was to provide information on the current coverage of PHP mental health and substance abuse services, benefits and service provision, general and mental health organization characteristics, mental health service costs, and physical and mental health service utilization.^ Two survey instruments were designed, pretested and distributed to all operational PHPs throughout the United States. A total of 237 PHPs were surveyed, of which 205 (86.50 percent) completed and returned both questionnaires.^ One result of the rapid growth in the PHP field over the past ten years has been the expansion in both the number of PHPs as well as the organizational characteristics of these PHPs. However, little attention in the research literature has been given to the application of empirical results to the PHP arrangements. This project has attempted to contribute to current knowledge regarding prepaid mental health services from a national perspective, and explore, on a preliminary descriptive basis, the variety of potential service delivery arrangements for physical and mental health services (total services) and for mental health services.^ The study emphasized that PHPs must continue to monitor the costs and utilization of mental health services, particularly in light of the apparent elimination of data collection and statistical summary responsibilities within the federal government regarding PHP activities as well as the proposed legislation to eliminate mandated mental health and substance abuse services from basic health plan benefits for federally qualified PHPs. ^

Learning What Works: Demonstrating Practice Effectiveness with Children and Families Through Retrospective Investigation

Intensive family preservation services (IFPS), designed to stabilize at-risk families and avert out-of-home care, have been the focus of many randomized, experimental studies. Employing a retrospective “clinical data-mining” (CDM) methodology (Epstein, 2001), this study makes use of available information extracted from client records in one IFPS agency over the course of two years. The primary goal of this descriptive and associational study was to gain a clearer understanding of IFPS service delivery and effectiveness. Interventions provided to families are delineated and assessed for their impact on improved family functioning, their impact on the reduction of family violence, as well as placement prevention. Findings confirm the use of a wide range of services consistent with IFPS program theory. Because the study employs a quasi-experimental, retrospective use of available information, clinical outcomes described cannot be causally attributed to interventions employed as with randomized controlled trials. With regard to service outcomes, findings suggest that family education, empowerment services and advocacy are most influential in placement prevention and in ameliorating unmanageable behaviors in children as well as the incidence of family violence.

Editorial: Broadening Our Vision, Refining the View

This issue of the Family Preservation Journal combines two emerging interests in the fields of family preservation and family support. First, contemporary forces are making the world a smaller and smaller orb, and we see the plight of families and children around the globe on a daily basis. Our vision of families' needs is broadening, bringing with it questions about how services and systems support families in different cultures and under different governmental structures. Accompanying this global awareness is a greater emphasis on making service delivery and the evaluation of services more transparent to families. True to the original vision of family-based services, more and more agencies are incorporating consumers' perspectives into the design of services and are seeking their perspectives on what works and why.

Exploring the Benefits of a Parent Partner Mentoring Program in Child Welfare

Parent partner mentoring programs are an innovative strategy for child welfare agencies to engage families in case planning and service delivery. These programs recruit and train parents who have been involved in the system and have successfully resolved identified child abuse or neglect issues to work with families with current open cases in the child welfare system. Parent partner mentors can provide social and emotional support, advocacy, and practical advice for navigating this challenging system. Insofar as parent partners share similar experiences, and cultural and socioeconomic characteristics of families, they may be more successful in engaging families and building trusting supportive relationships. The current study presents qualitative data from interviews and case studies of families who were matched with a parent partner in a large county in a Midwestern state. Interviews with families, parent partner mentors, child welfare agency staff, and community partners and providers suggest that parent partner programs may be just as beneficial for parent partner mentors as they are for families being mentored. These programs can build professional skills, help improve self-esteem, provide an avenue for social support, and may potentially prevent recidivism. Parent Partner programs also provide a mechanism for amplifying family voice at all levels of the agency.

Supporting Families through Short-Term Foster Care: An Essay Review

Aldgate, J. and Bradley, M. (1999). Supporting families through short-term fostering. London: The Stationery Office. This essay reviews a British qualitative study of short-term foster care from the perspectives of birth parents, children, foster parents, and social workers. Respondents highlighted the value of short-term foster care as a family support service and also offered many recommendations for improving service delivery. The study provides useful implications for restructuring child welfare services in the United States and for promoting cross-national collaboration in future research activities in the area of child and family services.

Failed Child Welfare Policy: An Essay Review

Hutchinson, J.R. (with C.E. Sudia) (2002). Failed Child Welfare Policy—Family Preservation and the Orphaning of Child Welfare. Lanham, MD: University Press of America. This essay reviews Failed Child Welfare Policy (Hutchinson, 2002), in which the author argues that the public child welfare system has failed to meet the needs of children and families coming to its attention. She recommends using the available—and limited—resources to reorganize and reconstruct the service delivery system with emphasis on familycentered services.

Saving Young Lives: Pathfinder International’s Youth-Friendly Postabortion Care Project

As many as 2.5 million adolescent women seek abortion each year, and nearly 70,000 women die from complications related to unsafe abortion, of which almost half are women under the age of 25. A further 5 million women suffer disability due to unsafe abortion yearly. In most developing countries, abortion is legally restricted or highly inaccessible, which leads young women to seek services from unskilled practitioners often leading to incomplete, septic abortions and massive bleeding, which can result in permanent injury, infertility, and death. Based on our deeply held belief that all people, including adolescents, have a right to sexual and reproductive health services and the importance of addressing adolescent needs within Postabortion Care (PAC) services, Pathfinder used private funds to initiate a Youth-Friendly Postabortion Care (YFPAC) program in eight sub-Saharan African countries. Implemented between June 2007 and May 2008, the YFPAC program offered an opportunity to apply the PAC Consortium’s Technical Guidance on Youth-Friendly PAC, generating promising approaches and lessons learned. The goal of the YFPAC initiative was to increase access to PAC services that are responsive to adolescent needs in sub-Saharan Africa. While outcomes varied according to the country, the overall outcomes included: Increased community support for services and activities that prevent unwanted pregnancy, decreased stigma around abortion, and awareness of the issue of unsafe abortion among adolescent women: 311 peer educators reached almost 17,487 youth and other community members; 171 stakeholders (e.g., religious and traditional leaders, health officials, and local government officials) were sensitized on YFPAC, resulting in a positive shift in communities’ attitudes toward youth in need of PAC services. 125 service providers were trained to deliver YFPAC services and three doctors in Ghana were provided with a technical update on YFPAC. YFPAC services are available in Angola, Ghana, Nigeria, Mozambique, Tanzania, Uganda, Ethiopia, and Kenya. Pathfinder introduced YFPAC services into 25 facilities (in 27 service delivery points), and provided more than 3,800 clients with YFPAC services throughout the eight countries. The number of adolescent PAC clients seen at the project facilities increased— 710 clients were seen in the first quarter, 1,144 were seen in the fourth. The number of adolescent PAC clients who adopt a contraceptive method to prevent future unintended pregnancies has increased. Statistics show an average postabortion contraceptive acceptance of 69%, with the highest acceptance being 83% and the lowest being 44%. Evidence-based approaches, tools, and lessons learned are being disseminated and used for scale-up or replication of YFPAC interventions.

Effectiveness of medical abortion with mifepristone and buccal misoprostol through 59 gestational days

BACKGROUND: From 2001 to March 2006, Planned Parenthood Federation of America (Planned Parenthood) health centers throughout the United States provided medical abortions principally by a regimen of oral mifepristone, followed 24-48 h later by vaginal misoprostol. In late March 2006, analyses of serious uterine infections following medical abortions led Planned Parenthood to change the route of misoprostol administration and to employ additional measures to minimize subsequent serious uterine infections. In August 2006, we conducted an extensive audit of medical abortions with the new buccal misoprostol regimen so that patients could be given accurate information about the success rate of the new regimen. OBJECTIVES: We sought to evaluate the effectiveness of the buccal medical abortion regimen and to examine correlates of its success during routine service delivery. METHODS: In 2006, audits were conducted in 10 large urban service points to estimate the success rates of the buccal regimen. Success was defined as medical abortion without vacuum aspiration. These audits also permitted estimates of success rates with oral misoprostol following mifepristone in a subset in which 98% of the subjects stemmed from two sites. RESULTS: The effectiveness of the buccal misoprostol-mifepristone regimen was 98.3% for women with gestational ages below 60 days. The oral misoprostol-mifepristone regimen, used by 278 women with a gestational age below 50 days, had a success rate of 96.8%. CONCLUSION: In conjunction with 200 mg of mifepristone, use of 800 mcg of buccal misoprostol up to 59 days of gestation is as effective as the use of 800 mcg of vaginal misoprostol up to 63 days of gestation.

Vietnamese Local State-owned Enterprises (SOEs) at the Crossroads: Implications of SOE Restructuring at the Local Level

This paper aims to capture the changing features of local SOEs under the national SOE restructuring program in the 2000s. The national policy on SOE reform in this phase had an effect of considerably clarifying and narrowing down the raison d'être of SOEs, which has been put into practice at the local level through provincial master plans. Consequently, some signs of an important change are observed: the structure of the local SOE sector is being standardized to a certain extent, and the remaining local SOEs are becoming more geared to the needs of a market economy. This trend would have far-reaching implications for the policy implementation and public service delivery by localities, which in turn would affect the long-term development of non-state sectors.

Fertility and rural electrification in Bangladesh

We use a panel dataset from Bangladesh to examine the relationship between fertility and the adoption of electricity with the latter instrumented by infrastructure development and the quality of service delivery. We find that the adoption of electricity reduces fertility, and this impact is more pronounced when the household already has two or more children. This observation can be explained by a simple household model of time use, in which adoption of electricity affects only the optimal number of children but not necessarily current fertility behavior if the optimal number has not yet been reached.

Mejora de la competitividad del sistema portuario español mediante la optimización del servicio de manipulación de mercancías

Los servicios portuarios son responsables de la mayor parte del coste que se produce en el paso de la mercancía por un puerto, particularmente el servicio de manipulación de mercancías. La prestación de éstos de forma fiable y eficiente resulta clave en un sector en el que existe una gran opacidad. Con el estudio realizado se dota a la Administración responsable, la Autoridad Portuaria, de una herramienta que le ayude a objetivar la toma de decisiones tanto a la hora de otorgar las preceptivas licencias como durante el periodo de prestación del servicio. Además se proponen una serie de medidas cuya aplicación mejoraría las condiciones de prestación del servicio así como una reducción de costes al paso de la mercancía por el puerto. Port services are responsible for most of the cost for the passing of goods through the port, especially the cargo handling service. Reliability and efficiency in the provision of them are key in a sector where there is a high opacity. With this study, we provide the responsible Administration, the Port Authority, with a tool that will help to objectify the decision making process, both at the time of granting the required licenses and during the period of the service provision. Also, proposes a number of measures whose implementation would improve the conditions of the service delivery and will reduce the total cost of transporting goods through the port.

VISIONS Vehicular communication Improvement : solution based on IMS Operational Nodes and Services

Digital services and communications in vehicular scenarios provide the essential assets to improve road transport in several ways like reducing accidents, improving traffic efficiency and optimizing the transport of goods and people. Vehicular communications typically rely on VANET (Vehicular Ad hoc Networks). In these networks vehicles communicate with each other without the need of infrastructure. VANET are mainly oriented to disseminate information to the vehicles in certain geographic area for time critical services like safety warnings but present very challenging requirements that have not been successfully fulfilled nowadays. Some of these challenges are; channel saturation due to simultaneous radio access of many vehicles, routing protocols in topologies that vary rapidly, minimum quality of service assurance and security mechanisms to efficiently detect and neutralize malicious attacks. Vehicular services can be classified in four important groups: Safety, Efficiency, Sustainability and Infotainment. The benefits of these services for the transport sector are clear but many technological and business challenges need to be faced before a real mass market deployment. Service delivery platforms are not prepared for fulfilling the needs of this complex environment with restrictive requirements due to the criticism of some services To overcome this situation, we propose a solution called VISIONS “Vehicular communication Improvement: Solution based on IMS Operational Nodes and Services”. VISIONS leverages on IMS subsystem and NGN enablers, and follows the CALM reference Architecture standardized by ISO. It also avoids the use of Road Side Units (RSUs), reducing complexity and high costs in terms of deployment and maintenance. We demonstrate the benefits in the following areas: 1. VANET networks efficiency. VISIONS provide a mechanism for the vehicles to access valuable information from IMS and its capabilities through a cellular channel. This efficiency improvement will occur in two relevant areas: a. Routing mechanisms. These protocols are responsible of carrying information from a vehicle to another (or a group of vehicles) using multihop mechanisms. We do not propose a new algorithm but the use of VANET topology information provided through our solution to enrich the performance of these protocols. b. Security. Many aspects of security (privacy, key, authentication, access control, revocation mechanisms, etc) are not resolved in vehicular communications. Our solution efficiently disseminates revocation information to neutralize malicious nodes in the VANET. 2. Service delivery platform. It is based on extended enablers, reference architectures, standard protocols and open APIs. By following this approach, we reduce costs and resources for service development, deployment and maintenance. To quantify these benefits in VANET networks, we provide an analytical model of the system and simulate our solution in realistic scenarios. The simulations results demonstrate how VISIONS improves the performance of relevant routing protocols and is more efficient neutralizing security attacks than the widely proposed solutions based on RSUs. Finally, we design an innovative Social Network service based in our platform, explaining how VISIONS facilitate the deployment and usage of complex capabilities. RESUMEN Los servicios digitales y comunicaciones en entornos vehiculares proporcionan herramientas esenciales para mejorar el transporte por carretera; reduciendo el número de accidentes, mejorando la eficiencia del tráfico y optimizando el transporte de mercancías y personas. Las comunicaciones vehiculares generalmente están basadas en redes VANET (Vehicular Ad hoc Networks). En dichas redes, los vehículos se comunican entre sí sin necesidad de infraestructura. Las redes VANET están principalmente orientadas a difundir información (por ejemplo advertencias de seguridad) a los vehículos en determinadas zonas geográficas, pero presentan unos requisitos muy exigentes que no se han resuelto con éxito hasta la fecha. Algunos de estos retos son; saturación del canal de acceso de radio debido al acceso simultáneo de múltiples vehículos, la eficiencia de protocolos de encaminamiento en topologías que varían rápidamente, la calidad de servicio (QoS) y los mecanismos de seguridad para detectar y neutralizar los ataques maliciosos de manera eficiente. Los servicios vehiculares pueden clasificarse en cuatro grupos: Seguridad, Eficiencia del tráfico, Sostenibilidad, e Infotainment (información y entretenimiento). Los beneficios de estos servicios para el sector son claros, pero es necesario resolver muchos desafíos tecnológicos y de negocio antes de una implementación real. Las actuales plataformas de despliegue de servicios no están preparadas para satisfacer las necesidades de este complejo entorno con requisitos muy restrictivos debido a la criticidad de algunas aplicaciones. Con el objetivo de mejorar esta situación, proponemos una solución llamada VISIONS “Vehicular communication Improvement: Solution based on IMS Operational Nodes and Services”. VISIONS se basa en el subsistema IMS, las capacidades NGN y es compatible con la arquitectura de referencia CALM estandarizado por ISO para sistemas de transporte. También evita el uso de elementos en las carreteras, conocidos como Road Side Units (RSU), reduciendo la complejidad y los altos costes de despliegue y mantenimiento. A lo largo de la tesis, demostramos los beneficios en las siguientes áreas: 1. Eficiencia en redes VANET. VISIONS proporciona un mecanismo para que los vehículos accedan a información valiosa proporcionada por IMS y sus capacidades a través de un canal de celular. Dicho mecanismo contribuye a la mejora de dos áreas importantes: a. Mecanismos de encaminamiento. Estos protocolos son responsables de llevar información de un vehículo a otro (o a un grupo de vehículos) utilizando múltiples saltos. No proponemos un nuevo algoritmo de encaminamiento, sino el uso de información topológica de la red VANET a través de nuestra solución para enriquecer el funcionamiento de los protocolos más relevantes. b. Seguridad. Muchos aspectos de la seguridad (privacidad, gestión de claves, autenticación, control de acceso, mecanismos de revocación, etc) no están resueltos en las comunicaciones vehiculares. Nuestra solución difunde de manera eficiente la información de revocación para neutralizar los nodos maliciosos en la red. 2. Plataforma de despliegue de servicios. Está basada en capacidades NGN, arquitecturas de referencia, protocolos estándar y APIs abiertos. Siguiendo este enfoque, reducimos costes y optimizamos procesos para el desarrollo, despliegue y mantenimiento de servicios vehiculares. Para cuantificar estos beneficios en las redes VANET, ofrecemos un modelo de analítico del sistema y simulamos nuestra solución en escenarios realistas. Los resultados de las simulaciones muestran cómo VISIONS mejora el rendimiento de los protocolos de encaminamiento relevantes y neutraliza los ataques a la seguridad de forma más eficientes que las soluciones basadas en RSU. Por último, diseñamos un innovador servicio de red social basado en nuestra plataforma, explicando cómo VISIONS facilita el despliegue y el uso de las capacidades NGN.

Práticas administrativas para a sustentabilidade financeira de operadoras de planos de saúde médico-hospitalares: um estudo de múltiplos casos

No Brasil, o sistema de saúde é composto por duas estruturas: pública, representada pelo Sistema Único de Saúde (SUS) e privada suplementar, composta por 1.268 operadoras de planos de saúde, supervisionadas pela Agência Nacional de Saúde (ANS). No entanto, as operadoras têm sido consideradas ineficientes tanto na geração de resultados financeiros quanto na prestação de serviços aos beneficiários, destacando-se a necessidade e relevância para a saúde pública ao se buscar avaliar o seu desempenho sob essas perspectivas. O objetivo do trabalho foi, para um mesmo nível de eficiência na prestação de serviços, identificar as práticas administrativas que diferenciam as operadoras de planos de saúde (OPS) financeiramente sustentáveis. Para tanto, inicialmente foi aplicada a técnica da Análise Envoltória de Dados (DEA) no intuito de identificar operadoras eficientes em transformar inputs em outputs e, a partir dos escores obtidos, selecionar duas OPS de nível de serviços semelhantes e desempenho financeiro opostos para que fossem comparadas por meio de um estudo de múltiplos casos. A análise quantitativa indicou que as OPS de medicina de grupo apresentaram maior eficiência do que as demais modalidades. Já o estudo de múltiplos casos identificou que a gestão de políticas de crédito, de captação e aplicação de recursos, o planejamento tributário, a adoção de políticas de promoção e prevenção à saúde, as formas de remuneração dos médicos e a estratégia de composição de receitas diferenciaram a OPS de melhor desempenho.

How do primary health care teams learn to integrate intimate partner violence (IPV) management? A realist evaluation protocol

Background: Despite the existence of ample literature dealing, on the one hand, with the integration of innovations within health systems and team learning, and, on the other hand, with different aspects of the detection and management of intimate partner violence (IPV) within healthcare facilities, research that explores how health innovations that go beyond biomedical issues—such as IPV management—get integrated into health systems, and that focuses on healthcare teams’ learning processes is, to the best of our knowledge, very scarce if not absent. This realist evaluation protocol aims to ascertain: why, how, and under what circumstances primary healthcare teams engage (if at all) in a learning process to integrate IPV management in their practices; and why, how, and under what circumstances team learning processes lead to the development of organizational culture and values regarding IPV management, and the delivery of IPV management services. Methods: This study will be conducted in Spain using a multiple-case study design. Data will be collected from selected cases (primary healthcare teams) through different methods: individual and group interviews, routinely collected statistical data, documentary review, and observation. Cases will be purposively selected in order to enable testing the initial middle-range theory (MRT). After in-depth exploration of a limited number of cases, additional cases will be chosen for their ability to contribute to refining the emerging MRT to explain how primary healthcare learn to integrate intimate partner violence management. Discussion: Evaluations of health sector responses to IPV are scarce, and even fewer focus on why, how, and when the healthcare services integrate IPV management. There is a consensus that healthcare professionals and healthcare teams play a key role in this integration, and that training is important in order to realize changes. However, little is known about team learning of IPV management, both in terms of how to trigger such learning and how team learning is connected with changes in organizational culture and values, and in service delivery. This realist evaluation protocol aims to contribute to this knowledge by conducting this project in a country, Spain, where great endeavours have been made towards the integration of IPV management within the health system.