Psychiatric health service areas in the southeast.

Analysis of small areas in psychiatric health services research is sensitive to the choice of geographic units. To partially overcome the arbitrary aspects of political boundaries, service areas can be synthesized from empirical data on consumer migration patterns. Using patient flow data from 1991 Medicare discharges, we completed an agglomerative cluster analysis to generate psychiatric health service areas (PHSAs) and found that the optimal solution contained 75 PHSAs. Solutions greater than 75 clusters had high rates of area fragmentation and small single-county clusters. Psychiatric resource supply and health status indicators should be analyzed using expanded geographic units.

Malpractice: provider risk or consumer protection?

The National Practitioner Data Bank (NPDB) began operation in September 1990 as a clearinghouse for adverse action, licensure, and malpractice information in an effort to protect consumers and promote quality in health care. This study analyzed 66,107 and 1291 records of payments made for 50,396 physicians and 1218 nurses, respectively, from 1994 through 1998, to describe characteristics, trends, and risk factors of malpractice payment for physicians and nurses. The median payments, more often settlements paid by insurance companies than judgments in courts of law, were higher for physicians than for nurses. Mean payments were higher for residents than for non-resident physicians; median payments for residents were slightly lower than other physicians when adjusted for number of providers included in the payment. On the state level, correlation analyses suggested a significant positive association between the nurse rate of malpractice payments that were made and median per capita income, number of physicians per 1000 residents, and number of attorneys per 1000 residents; analysis revealed a significant negative association between this rate and the percentage of residents residing in rural areas and the number of nurses per 1000 residents. Although findings suggested that payment trends remained stable, there was great regional variation in the risk of malpractice payment for both physicians and nurses. The physician risk ranged from a low of 0.73% per physician per year in Alabama to a high of 3.7% in Wyoming, and the nurse risk ranged from a low of 0% per nurse per year in Vermont to a high of 0.075% in the District of Columbia. If the quality of health care provided by physicians and nurses does not vary geographically in the United States, then such a great discrepancy seems to challenge the notion that the risk of malpractice litigation consistently promotes the quality of health care.

Trends in psychiatric mental health nursing education.

Eighty-five program coordinators responded to a survey concerning Psychiatric Mental Health (PMH) graduate-nursing education. Twelve of these 85 program coordinators reported their programs had closed. Data from the remaining 73 indicated that the number of students entering PMH graduate programs is small. In the past 2 years, most programs have undergone some redesign. A significant curricular trend is the inclusion of pharmacology, physical assessment, and pathophysiology. Another trend is the shift to a Nurse Practitioner (NP)-type curriculum. PMH curricula seem increasingly modeled on a primary mental health care model and training in a broad base of skills.

Advanced practice psychiatric nursing: a national profile.

The results of a national survey of Advanced Practice Psychiatric Nurses (APPN) are presented. Results are based on the Society for Education and Research in Psychiatric/Mental Health Nursing's (SERPN) Primary Mental Health and Advanced Practice Psychiatric Nursing monograph. Characteristics of the nurses, the clients they serve, and their practice patterns are described. Documenting the cost-effectiveness of these practitioners and increasing the number of younger APPNs is recommended.

Patient outcomes used by advanced practice psychiatric nurses to evaluate effectiveness of practice.

Health care in the 1990s requires Advanced Practice Psychiatric Nurses (APPNs), like other health care providers, to identify and evaluate the outcomes of their practices. Many APPNs report that they are not currently engaging in outcome evaluation, and many report that they would like more resources on outcome measurement. This study identifies outcome evaluations currently in use, through an analysis of the responses of 364 Certified Clinical Nurse Specialists in a survey conducted by the Society for Education and Research in Psychiatric Nursing in 1994-1995. Specific tools that APPNs report using to assess outcomes are also identified and referenced.

An organizational and economic framework for restructuring psychiatric nurse labor use.

A conceptual framework of psychiatric nurse labor use is developed based on organizational and economic theories. The relationship between staffing decisions and quality of care is presented. Implications for restructuring the workforce within the context of managed care and increased cost containment pressures are discussed. The importance of using a conceptual framework to guide staffing evaluations, research, and management decisions is emphasized.

Implementation and outcomes of a community-based self-help smoking cessation program.

In a time of budget constraints, health professionals are turning to minimal-contact smoking cessation programs as the most financially feasible alternative for smoking cessation. The purpose of this study was to evaluate a program by the American Lung Association using the manual Freedom From Smoking for You and Your Family (Strecher & Rimer, 1988) in a community-based smoking cessation self-help intervention. Results showed a quit rate of 15%, and study findings were consistent with other similar studies. Those most likely to succeed were over 40 years old, better educated, and among the most confident of quitting at the onset.

Human resource issues in rural mental health services.

Human resource issues related to the provision of mental health care in rural areas under the proposed health care reform are addressed. Rural areas continue to utilize more non-specialty providers in the provision of mental health care. First, issues surrounding the training, recruitment, and retention of specialty mental health providers differ between urban and rural areas. Next, innovative strategies currently being used to attract and retain specialty providers to rural practice are presented. Finally, implications for expanding the knowledge base related to rural providers are explored.

Psychiatric nursing outcome research: the state of the science.

A review of the nursing literature from 1989 to 1994 indicates that few psychiatric nursing studies are published in the major nursing research journals. The psychiatric specialization literature includes a large number of studies that are classified as either outcome studies or could serve as building blocks for future outcome studies. Few studies build on prior research, resulting in a weak scientific basis for evaluating the outcomes of psychiatric nursing care. Strategies for increasing the quantity and quality of psychiatric nursing outcome research are presented.

Building interdisciplinary mental health services research teams: a case example.

The experience of developing an interdisciplinary research team to study outcomes of psychiatric nurse labor use in free-standing psychiatric hospitals is presented. The creation of roles for research team members, the development of working relationships, and the evolution of additional research projects are discussed. Useful suggestions of strategies for developing research teams are presented within the context of proposal development, successful funding, and implementation of a research study.

Relationship of clinical case management to hospitalization and service delivery for seriously mentally ill clients.

This article describes the use of a clinical case management team approach in the care of severely mentally ill individuals and the organization of the service. Patient characteristics and use of community services are evaluated as predictors of the use of inpatient care. Findings suggest that hospitalized clients use more community services than nonhospitalized clients and that the use of certain community services--such as medical, legal, and housing services--affects hospital use. Clients who had assistance in obtaining medical services were less likely to be hospitalized, and those needing legal and housing assistance were more likely to be hospitalized.

De facto mental health services in the rural south.

Health care reform efforts highlighted the continuing scarcity of mental health services for the rural poor. Most mental health services are provided in the general medical sector, a concept first described by Regier and colleagues in 1978 as the de facto mental health service system, rather than through formal mental health specialist services. The de facto system combines specialty mental health services with general medical services such as primary care and nursing home care, ministers and counselors, self-help groups, families, and friends. The nature of the de facto system in rural areas with large minority populations remains largely unknown due to minimal available data. This article examines the availability, accessibility, and use of mental health services in the rural South and the applicability of the de facto model to rural areas. The critical need for data necessary to inform changes in health care relative to rural mental health service delivery is emphasized.

A community-based smoking-cessation program: self-care behaviors and success.

Given the serious health consequences of smoking, nurses need to be well-informed on how to help various client populations with smoking cessation. Much recent research is focused upon effectiveness of various programs to enhance self-efficacy and self-management skills necessary to succeed in permanent smoking cessation. This study used a model based on Orem's Self-Care Deficit Theory to examine specific variables of importance in smoking cessation using descriptors relevant to understanding self-care actions. The model is used to examine the outcomes of a community-based smoking-cessation program. Results indicate that 15% of the final sample quit smoking and 42% reduced smoking while participating in the program. Additional findings are helpful in describing actions taken by subjects who were and were not successful in quitting. Remedies suggested by the American Lung Association booklet "Freedom from Smoking for You and Your Family" were reported by subjects to be helpful in dealing with the most common problems experienced during smoking cessation. Results are applied to public health nursing, emphasizing that smoking cessation is "a process" in which individuals learn strategies that work for them.

The role of the principal clinical coordinator in the Health Care Financing Administration's Health Care Quality Improvement Initiative.

The Health Care Quality Improvement Initiative (HCQII) is the Health Care Financing Administration's latest approach to quality management by peer review organizations (PROs) of the health care delivered to Medicare beneficiaries. The principal clinical coordinator (PCC) of each PRO, a physician with both clinical and methodological expertise, has the overall responsibility for all HCQII-related activities. The PCC works with a clinical coordinating team to analyze patterns of care and provide feedback about these patterns to the medical community for the purpose of improving the quality of care. Each PRO provides its PCC with the necessary infrastructure and expertise to conduct pattern analyses and implement the dissemination process. However, the effectiveness of the HCQII will depend largely on the PCC's ability to maintain the full support and cooperation of the local medical community. The success of the PCC role under the HCQII may enable it to serve as a useful model of physician leadership in the quality oversight organizations that will accompany national health care reform.

Creation of state-level Medicare database for healthcare evaluation applications.

The Health Care Quality Improvement Initiative (HCQII) of the Health Care Financing Administration (HCFA) calls for Professional Review Organizations (PROs) to undertake pattern analysis of large administrative datasets for the purposes of quality of care assessment. The limitations of such administrative databases (primarily the MEDPAR file and derivatives thereof) include impoverished information regarding clinical attributes of Medicare enrollees and the process and outcome of their healthcare. This paper describes preliminary efforts to address this problem by the creation of a database, the PRO Concatenated Database (PCD), from the pooled implicit judgment review data of four Peer Review Organizations (PROs). The data elements comprising the PCD were carefully selected to provide important information regarding quality and appropriateness of care. Preliminary inter-state comparative studies employing the PCD are discussed. A method is also described by which the analytical power of state-level databases may be enhanced by linkage to state-level Modeled MEDPAR data which are issued by HCFA and contain patient-level risk-adjusted mortality data. This approach to the acquisition of data whose clinical content is enriched may prove to be particularly useful to the PRO community during the pattern analysis phase of the HCQII. Such analyses will evolve into more detailed studies involving primary data collection followed by dissemination of the results to local healthcare providers. In this manner, the PCD may facilitate rapid feedback regarding the effectiveness of healthcare delivery to the local community.

Cost-effective integration of mental health professions.

This article describes the need for cost-effectiveness evaluation of the use of labor within mental health systems. It calls for building on the unique knowledge base of each mental health discipline in the development of new models of care that incorporate clients' social and physical needs and rely less on psychotherapy. The utilization and integration of the core mental health disciplines is described. Recommendations for developing more cost-effectiveness utilization of labor are made.