El terapeuta ocupacional como acompañante terapéutico en el ámbito de la salud mental comunitaria / No disponible

Lo que se explica en este artículo, corresponde a una visión concreta de lo que significa el acompañamiento a personas con una enfermedad mental severa. Esta visión y orientación está basada en la teoría psicodinámica. Se ha teorizado una manera de trabajar específica del terapeuta ocupacional dentro de la atención comunitaria en el ámbito de la salud mental. La intervención domiciliaria que se hace desde la Terapia Ocupacional como acompañante terapéutico está basada en el uso terapéutico del vínculo entre terapeuta y persona, y entre la persona y su comunidad. Dándole a la persona un lugar de protagonismo en la intervención, fomentando la autonomía, la responsabilidad y la creación de un proyecto de vida saludable. Respecto al terapeuta como profesional, se analiza las dificultades con las que se puede encontrar a nivel emocional con la persona a la cual atiende desde una perspectiva transferencial y contratransferencial. Así como la utilidad del uso terapéutico del encuadre que proporciona a la persona coherencia, seguridad y límites

What is explained in this article corresponds to a precise vision of what it means to accompany people with severe mental illness. This view is base on psychodynamic theory. A specific Occupational Therapy way of working in a mental health community setting has been theorized. Home interventions carried out from Occupational Therapy as a therapeutic companion are based on the therapeutic use of the bond between the professional and the person, and between the professional and the community. Offering the client a leading role in the intervention, promoting autonomy, responsibility and the possibility to create a healthy life project. Regarding the therapist as a professional, the emotional issues that may appear, both at a transferential and countertransference level are analysed. As well as the benefits of using a therapeutic setting which offers the client coherence, security and limits

[Chronicle of a century of public health in Mexico: from public health to social protection in health.] / Crónica de un siglo de salud pública en México: de la salubridad pública a la protección social en salud.

This paper describes the creation of the legal framework and the origin, growth and consolidation of the institutions and interventions (initiatives, programs and policies) that nourished public health in Mexico in the past century. It also discusses the recent efforts to guarantee universal social protection in health. This quest, which lasted a century, developed through three generations of reform that gave birth to a health system that offers protection against sanitary risks, protection of health care quality and financial protection to all the population in the country.

En este artículo se describen la creación de los marcos legales y el origen, crecimiento y consolidación de las instituciones e intervenciones (iniciativas, programas, políticas) que han conformado la salud pública moderna en México. También se discuten los esfuerzos recientes por hacer universal la protección social en salud. Esta gesta, que duró un siglo, se fue abriendo paso a través de tres generaciones de reformas que dieron lugar a un sistema de salud que hoy ofrece protección contra riesgos sanitarios, protección de la calidad de la atención y protección financiera a los habitantes de todo el país.

Crónica de un siglo de salud pública en México: de la salubridad pública a la protección social en salud / Chronicle of a century of public health in Mexico: from public health to social protection in health

Resumen: En este artículo se describen la creación de los marcos legales y el origen, crecimiento y consolidación de las instituciones e intervenciones (iniciativas, programas, políticas) que han conformado la salud pública moderna en México. También se discuten los esfuerzos recientes por hacer universal la protección social en salud. Esta gesta, que duró un siglo, se fue abriendo paso a través de tres generaciones de reformas que dieron lugar a un sistema de salud que hoy ofrece protección contra riesgos sanitarios, protección de la calidad de la atención y protección financiera a los habitantes de todo el país.

Abstract: This paper describes the creation of the legal framework and the origin, growth and consolidation of the institutions and interventions (initiatives, programs and policies) that nourished public health in Mexico in the past century. It also discusses the recent efforts to guarantee universal social protection in health. This quest, which lasted a century, developed through three generations of reform that gave birth to a health system that offers protection against sanitary risks, protection of health care quality and financial protection to all the population in the country.

Health care in a homophobic climate: the SPEND model for providing sexual health services to men who have sex with men where their health and human rights are compromised.

We present a model for developing health services for men who have sex with men (MSM) in sub-Saharan Africa and other places where MSM are heavily stigmatized and marginalized. The processes of the SPEND model include Safe treatment for sexually transmissible infections (STIs) and HIV; Pharmacy sites for treatment of STIs in countries where pharmacies and drug stores are the source of medical advice and treatment; Education in sexual health issues for health professionals to reduce discrimination against MSM patients; Navigation for patients who have HIV and are rejected or discriminated against for treatment; and Discrimination reduction through educating potential leaders in tertiary education in issues of human sexuality. Supporting empirical evidence from qualitative and quantitative studies is summarized, and barriers to implementation are discussed. Health care for MSM is one of the casualties of anti-homosexual social and legal climates. There is no amnesty for MSM in health care settings, where the stigma and discrimination that they face in the rest of society is replicated. Such conditions, however, make it necessary to consider ways of providing access to health care for MSM, especially where rates of HIV and STIs in MSM populations are high, and stigma and discrimination encourages high proportions of MSM to marry. This in itself enhances the status of MSM as an important bridge population for STIs including HIV. Where anti-homosexual laws encourage, or are believed to encourage, the reporting of MSM to authorities, health care may be seen as an agent of authority rather than an agency for care.

A novel personal health system with integrated decision support and guidance for the management of chronic liver disease.

A personal health system platform for the management of patients with chronic liver disease that incorporates a novel approach to integrate decision support and guidance through care pathways for patients and their doctors is presented in this paper. The personal health system incorporates an integrated decision support engine that guides patients and doctors through the management of the disease by issuing tasks and providing recommendations to both the care team and the patient and by controlling the execution of a Care Flow Plan based on the results of tasks and the monitored health status of the patient. This Care Flow Plan represents a formal, business process based model of disease management designed off-line by domain experts on the basis of clinical guidelines, knowledge of care pathways and an organisational model for integrated, patient-centred care. In this way, remote monitoring and treatment are dynamically adapted to the patient's actual condition and clinical symptoms and allow flexible delivery of care with close integration of specialists, therapists and care-givers.

Designing a patient-centered personal health record to promote preventive care.

BACKGROUND: Evidence-based preventive services offer profound health benefits, yet Americans receive only half of indicated care. A variety of government and specialty society policy initiatives are promoting the adoption of information technologies to engage patients in their care, such as personal health records, but current systems may not utilize the technology's full potential. METHODS: Using a previously described model to make information technology more patient-centered, we developed an interactive preventive health record (IPHR) designed to more deeply engage patients in preventive care and health promotion. We recruited 14 primary care practices to promote the IPHR to all adult patients and sought practice and patient input in designing the IPHR to ensure its usability, salience, and generalizability. The input involved patient usability tests, practice workflow observations, learning collaboratives, and patient feedback. Use of the IPHR was measured using practice appointment and IPHR databases. RESULTS: The IPHR that emerged from this process generates tailored patient recommendations based on guidelines from the U.S. Preventive Services Task Force and other organizations. It extracts clinical data from the practices' electronic medical record and obtains health risk assessment information from patients. Clinical content is translated and explained in lay language. Recommendations review the benefits and uncertainties of services and possible actions for patients and clinicians. Embedded in recommendations are self management tools, risk calculators, decision aids, and community resources--selected to match patient's clinical circumstances. Within six months, practices had encouraged 14.4% of patients to use the IPHR (ranging from 1.5% to 28.3% across the 14 practices). Practices successfully incorporated the IPHR into workflow, using it to prepare patients for visits, augment health behavior counseling, explain test results, automatically issue patient reminders for overdue services, prompt clinicians about needed services, and formulate personalized prevention plans. CONCLUSIONS: The IPHR demonstrates that a patient-centered personal health record that interfaces with the electronic medical record can give patients a high level of individualized guidance and be successfully adopted by busy primary care practices. Further study and refinement are necessary to make information systems even more patient-centered and to demonstrate their impact on care. TRIAL REGISTRATION: Clinicaltrials.gov identifier: NCT00589173.

Medicaid Personal Care Services and caregivers' reports of children's health: the dynamics of a relationship.

OBJECTIVE: To investigate the relationship between Medicaid Personal Care Services (PCS) and caregivers' reports of activity (activities of daily living [ADL]) limitations for children with chronic health problems. DATA SOURCES/STUDY SETTING: Primary data collected in 2008 and 2009. A state Medicaid program was the setting. The focus was children receiving Medicaid PCS. DATA COLLECTION: Medicaid case managers assessed children to determine their need for PCS, using information provided by the child or informal caregivers. Two thousand seven hundred assessments were provided to researchers directly from case managers. PRINCIPAL FINDINGS: Medical conditions and impairments explained 58 percent of the variance in the child's activity limitations. Activity limitations and problem behaviors explained 28 percent of the variance in PCS hours authorized. Which case manager completed the assessment also played a substantial role in determining hours of care. CONCLUSIONS: Caregivers' reports of the severity of a child's activity limitations effectively summarize the effects of conditions and impairments on the child's ADL performance and have a significant impact on the level of services provided. Assessors often respond differently to children's characteristics and circumstances as they move from assessment to decisions concerning care provision. Our results imply that the provision of appropriate services may be enhanced when both case managers and caregivers play an active role in decisions concerning care provision.

Creating a place for caregivers in personal health: the iHealthSpace copilot program and diabetes care.

BACKGROUND: As America's baby boom generation reaches retirement, the number of elders, and, in turn, the number of lay individuals who support them, will continue to increase. With the important services caregivers provide, it is critical that we recognize and provide assistance to the informal caregivers who play this important role in our society. The network of support provisioned by relatives, partners, friends, and neighbors suggests that the dyadic, unidirectional caregiver-care recipient relationship assumed by caregiver research so far and by resources deployed to assist caregivers may be insufficient to ascertain and meet the needs of the care community. METHODS: In this article, we describe the extension of a Web-based personal health record system, iHealthSpace, for explicitly and openly incorporating caregivers into the care community. RESULTS: Using this portal, a set of business rules was implemented to support the creation of custodial accounts. These business rules will be used to create modules that support diabetes care in an adult population. CONCLUSIONS: We successfully extended an existing patient portal to accommodate the creation of custodial accounts. We will use this portal to assess the impact of custodial access in the care of older patients with diabetes.

Are satisfaction with and self-management of personal assistance services associated with the life satisfaction of persons with physical disabilities?

PURPOSE: To examine the relationships between satisfaction with and self-management of personal assistance services (PAS) and the quality of life (QoL) of persons with disabilities. To test the postulate that consumer-directed PAS can fulfil the human need for control and contribute to a satisfactory life. METHOD: A survey compared the perspectives of persons using consumer-directed PAS versus those using agency-directed. A Personal Data Form obtained demographics and PAS characteristics. The Quality of Life Inventory measured life satisfaction. A PAS questionnaire measured perceptions about the management of, desire for control of, and satisfaction with PAS. Data were analysed using SPSS®- 14. RESULTS: Significant relationships were found between QoL and satisfaction with PAS (p < 0.001) and between perceived control of PAS and satisfaction with PAS (p < 0.001). Significant group differences were also found. Consumer-directed participants reported higher satisfaction with their PAS (p < 0.01), greater control over services (p < 0.001) and greater QoL than agency-directed participants, (p = 0.001). CONCLUSIONS: The relationships found between self-management, PAS satisfaction, and QoL support the value of consumer-directed programmes. Rehabilitation professionals can use this knowledge to develop, implement and research practises that enable self-management.

[Satisfaction of needs of disabled people 60 and over according to care provider. Spain, 2008]. / La satisfacción de las necesidades de las personas dependientes de 60 años y más según proveedor de cuidado. España, 2008.

BACKGROUND: In spite of its importance for policy making, there have been few studies examining the satisfaction of care needs by the different care providers. The aims of this paper are: (1) to estimate the prevalence of dissatisfaction of care needs among people older than 59 years receiving care; and (2) to identify what care provider (family care, private care -paid care- or public care) has a higher probability of satisfying the needs of this population. METHODS: This study is based on a sample of 3718 non-institutionalized people older than 59 years from the Survey on Disability, Personal Autonomy and Dependency Situations 2008. The distribution of unmet care needs among different groups of elderly people was cross-tabulated, and a regression logistic model was used to identify factors related to dissatisfaction of care needs. RESULTS: 1,039 (29%) people older than 59 years had dissatisfied care needs. Compared to those receiving only family care, people receiving only public care were more likely to have dissatisfied needs (OR=1.932 sig.=0,001), and people receiving only paid care were less likely to have dissatisfied needs (OR=0.673 sig.=0.015). CONCLUSIONS: People receiving only paid care had a higher probability of having their needs satisfied than any other care combination. Those receiving only public care had a lower probability of having their needs satisfied than people receiving family care or paid care.

The Healthy Ageing Model: health behaviour change for older adults.

Proposed is a model of primary care for older adults with chronic health conditions that focuses on active engagement in health care. The Healthy Ageing Model is anchored in established theory on motivation and health behaviour change. The model draws on empirical and applied clinical underpinnings in such diverse areas as health promotion and education, treatment of addictions or obesity, management of chronic diseases, goal-setting, and coaching techniques. The conceptual foundation for the Healthy Ageing Model is described first, followed by a brief description of the key characteristics of the model. In conclusion, suggestions are offered for the clinical application and for further developing the model.

International development in self-directed care.

Self-directed care is an alternative way of delivering services that seeks to empower participants by expanding their degree of choice and control in selecting services. Over the last decade, it has been widely adopted internationally in home and community-based long-term care for people with physical and cognitive disabilities and for seniors. It has been shown to improve satisfaction with services, improve quality of life, and reduce costs compared with services from an agency. A small number of pilot programs are now experimenting with self-directed care in other areas; for example in the management of serious mental illness and other chronic conditions. If positive findings from long-term care can be replicated, self-directed care can make an important contribution to improving health care quality and effectiveness. This issue brief examines a range of innovative self-directed care programs in England, Germany, the Netherlands, and the United States.

Tailor-made finance versus tailor-made care. Can the state strengthen consumer choice in healthcare by reforming the financial structure of long-term care?

BACKGROUND: Policy instruments based on the working of markets have been introduced to empower consumers of healthcare. However, it is still not easy to become a critical consumer of healthcare. OBJECTIVES: The aim of this study is to analyse the possibilities of the state to strengthen the position of patients with the aid of a new financial regime, such as personal health budgets. METHODS: Data were collected through in-depth interviews with executives, managers, professionals and client representatives of six long-term care institutions. RESULTS: With the introduction of individual budgets the responsibility for budgetary control has shifted from the organisational level to the individual level in the caregiver-client relationship. Having more luxurious care on offer necessitates a stronger demarcation of regular care because organisations cannot simultaneously offer extra care as part of the standard care package. New financial instruments have an impact on the culture of receiving and giving care. Distributive justice takes on new meaning with the introduction of financial market mechanisms in healthcare; the distributing principle of 'need' is transformed into the principle of 'economic demand'. CONCLUSION: Financial instruments not only act as a countervailing power against providers insufficiently client-oriented, but are also used by providers to reinforce their own positions vis-à-vis demanding clients. Tailor-made finance is not the same as tailor-made care.

A comparison of Personal Dental Service (PDS) and General Dental Service (GDS) patients in terms of reported interventions, oral health and dentists' perceptions.

AIMS: The aim of the study was to investigate the reported working patterns, dentist perceptions and patient oral health for dentists in a Personal Dental Services (PDS) pilot and compare this with that of matched dentists working in the General Dental Services (GDS) arrangements in the same part of England. METHOD: Ten dentists were recruited, five each from PDS and GDS practices in Warwickshire, UK. The number of interventions carried out for adult patients in the year to April 2003 was obtained from the Dental Practice Board (DPB) for the two groups and compared. An Oral Health Index (OHX) (Burke and Wilson, 1995) was used to determine the oral health of a selection of patients from the two groups of dentists in the study. The final stage of the study involved semi-structured interviews with the dentists. RESULTS: The average age of dentists was similar, in the early to mid 40's (p>0.05). Both groups were, on average, around 20 years post qualification. The GDS dentists made an average of 3,507 activity reports to the Dental Practice Board in the year examined, compared with 3,441 from the PDS dentists. PDS dentists provided fewer simple periodontal treatments than GDS dentists, but otherwise the pattern of reported activity was similar. Both PDS and GDS dentists suggested that GDS dentists carried out more fillings because of a perverse incentive to provide fillings compared with PDS arrangements. PDS dentists believed that their treatment profiles had not changed significantly since changing to PDS, and suggested that their prescribing was based on clinical need only and was not influenced by the remuneration system. A total of 225 OHX scores were obtained for patients attending PDS dentists and a further 214 from patients attending GDS dentists. Overall, the mean OHX score was lower in the GDS patients than for PDS patients. CONCLUSIONS: PDS dentists provided fewer simple periodontal treatments than their GDS counterparts. There was no difference in the oral health of patients treated under either system. Although there was some evidence of a difference in attitude between GDS and PDS dentists towards charging and claiming for simple periodontal treatment, there was no uniformity of opinion within either group. There would appear to be a number of complex factors impacting upon decisions to treat or monitor dental conditions.

Job satisfaction of dental practitioners before and after a change in incentives and governance: a longitudinal study.

OBJECTIVES: to measure changes in dental practitioners' job satisfaction following a contractual change, and compare differences between those transferring from a fee-per-item system (general dental service, GDS) and those previously working under a block contract with the primary care trust (personal dental service, PDS). DESIGN: Analysis of postal questionnaires conducted in 2006 and 2007. PARTICIPANTS: Four hundred and forty dental practitioners responding to the 2006 baseline questionnaire. RESULTS: Although perceived workload was unchanged, global job satisfaction had decreased for 24.7% (31) of GDS dentists and 49.0% (95) of PDS dentists comparing their scores given before and after the contractual change. PDS dentists showed a significant change in attitudes towards feeling restricted in providing quality care (change in factor mean [SD] = -2.88 [0.82]; p < 0.001). They also showed less positive attitudes towards 'respect' (change in factor mean [SD] = -3.70 [0.48]; p < 0.001). CONCLUSIONS: The 2006 contractual change appears to have had a negative impact on dentists' job satisfaction and has not addressed concerns which have led dentists to move into the private sector. The study indicates that the fall in job satisfaction is more a result of a perceived erosion of professional autonomy than a reaction to the change in the system of remuneration.

Focus group study of ethnically diverse low-income users of paid personal assistance services.

This study examined the experiences of ethnically diverse, low-income consumers of paid personal assistance services (PAS) to understand the successes and problems they faced setting up and maintaining their assistance. A thematic analysis was conducted with transcripts from eight focus groups of ethnically homogeneous consumers (n = 67): African American, Latino, Chinese, Native American, and non-Hispanic white. These experienced consumers were generally satisfied with their current PAS but noted significant difficulties: Getting access to appropriate care, obtaining enough paid care to avoid unmet need, and dealing with confusing bureaucracies and cultural differences between them and agency staff/attendants. They desired more control over their care, including the use of paid family attendants when possible. Respondents recommended improved screening and training of attendants, more attendant time, higher wages for attendants, improved cultural sensitivity of attendants and agency staff, and greater consumer control over PAS. Although these low-income PAS consumers are ethnically and geographically diverse, the similarity of findings points to their ongoing struggle to access adequate high quality assistance. The burden they have in obtaining and maintaining services is substantial.