Health Promotion for Older Adults: What Is the Potential? 11th Annual Herbert Lourie Memorial Lecture on Health Policy

As a greater number of people reach old age, medicine is challenged to develop new approaches to this population. Health promotion, not just treatment of disease but improving the quality of life for older persons, must play a role. What happens to individuals in terms of health status as they get older, and what are the implications for health care needs? Where should we focus to get the biggest benefits in terms of health promotion? Overall, we have learned a tremendous amount over the last 25 years about the components of health as people get older, and what modifies their health. We know, for example, that the health status of older adults is a composite of the chronic diseases that they may have, of how many chronic diseases are present, and of underlying physiological changes of aging, such as a decline in muscle strength, that appear to be an intrinsic part of the aging process. Disability can result from chronic disease. In addition, people are more susceptible to acute illnesses and injuries as they get older.

Neutrality Agreements: Innovative, Controversial, and Labor’s Hope for the Future

[Excerpt] In spite of the criticisms, there can be little doubt that labor’s campaigns to achieve and enforce neutrality agreements offer hope that the long-term decline in union density actually can be reversed. A high-profile example of a strategic blend of bargaining and organizing demonstrates the potential of this approach

Addressing ethnicity in social care research

This article surveys recent developments in relation to the dimensions of ethnicity and ethnicdisadvantage in social policy research and practice, with a focus on social care. While therehas been limited increase in attention to ethnicity within general policy discussion andincreasing sophistication within specialist debates, advances in theory and methodology havelargely failed to penetrate the research mainstream, let alone policy or practice. This is along-standing problem. We advocate more focussed consideration of ethnicity and ethnicdisadvantage at all levels. Failure to do so creates the risk of social policy research being leftbehind in understanding rapid changes in ethnic minority demographics and patterns of migration, with increasing disadvantage to minorities

Balancing Margin and Mission: Nonprofit Competition in Charitable versus Fee-Based Programs

Competition in the nonprofit world has intensified in recent years, and nonprofit managers are challenged to devise strategies that will serve both organizational needs and public interest. We propose a framework for thinking about nonprofit competition based on the intersection of two dimensions: the domain of competition, which can be either fee-based or donative activities; and the competitive strategy, which can be either price- or differentiation-based. The experience of the American Red Cross, a prominent nonprofit organization facing competition in both fee-based and donative domains, provides data for the elaboration of the framework, and for tentative conclusions about the implications of nonprofit competition for both margin and mission.This publication is Hauser Center Working Paper No. 11. The Hauser Center Working Paper Series was launched during the summer of 2000. The Series enables the Hauser Center to share with a broad audience important works-in-progress written by Hauser Center scholars and researchers

The impacts of corporatisation of healthcare on medical practice and professionals in Maharashtra, India

A heterogeneous private sector dominates healthcare provision in many middle-income countries. In India the contemporary period has seen this sector undergo corporatisation processes characterised by emergence of large private hospitals and the takeover of medium-sized and charitable hospitals by corporate entities. Little is known about the operations of these private providers and the effects on healthcare professions as employment shifts from practitioner-owned small and medium hospitals to larger corporate settings. This article uses data from a mixed-methods study in two large cities in Maharashtra, India, to consider the implications of these contemporary changes for the medical profession. Data were collected from semi-structured interviews with 43 respondents who have detailed knowledge of healthcare in Maharashtra, and from a witness seminar on the topic of transformation in Maharashtra’s healthcare system. Transcripts from the interviews and witness seminar were analysed thematically through a combination of deductive and inductive approaches. Our findings point to a restructuring of medical practice in Maharashtra as training shifts towards private education and employment to those corporate hospitals. The latter is fuelled by substantial personal indebtedness, dwindling appeal of government employment, reduced opportunities to work in smaller private facilities, and the perceived benefits of work in larger providers. We describe a ‘re-professionalisation’ of medicine encompassing changes in employment relations, performance targets and constraints placed on professional autonomy within the private healthcare sector, that is accompanied by trends in cost inflation, medical malpractice, and distrust in doctor-patient relationships. The accompanying ‘re-stratification’ within this part of the profession affords prestige and influence to ‘star doctors’ while eroding the status and opportunity for young and early career doctors. The research raises important questions about the role that government and medical professionals’ bodies can, and should, play in contemporary transformation of private healthcare, and the implications of these trends for health systems more broadly

Crossing Organizational Boundaries in Palliative Care: The Promise and Reality of Community Partnerships

This report presents the first of a series of findings from the Community-Oriented Palliative Care Initiative (COPCI), an innovative program testing new approaches to caring for individuals with progressive, life threatening illness. Developed and supported by the United Hospital Fund, the project was designed to initiate collaborations among health care and social service organizations, with the goal of reaching seriously ill individuals and their caregivers earlier in the course of illness and providing a broad range of coordinated services. Six such networks of diverse partners received a total of $2.1 million in grants over the two-year period from mid-2000 into 2002.The urgency to provide alternatives to current standard practice is underscored by the number of individuals affected: in New York City alone, in the year 2000, some 46,000 people died of diseases typically marked by a lengthy course from diagnosis to death. While many could have benefited from appropriate and timely palliative care services, most did not receive them.The Fund reasoned that networks including not only hospitals and hospices but also social services agencies and other community resources could collectively respond, earlier and more fully, to the complex combination of medical, social, psychological, and spiritual needs that typify the months and years leading to death. Local expertise and resources should determine the structure of each network, the partners involved, and the specific model for service delivery. Drawing on the experiences of the six pioneering projects, this report focuses on the challenges of creating such new networks

Complex Care Management Program Overview

This report includes brief updates on various forms of complex care management including: Aetna - Medicare Advantage Embedded Case Management ProgramBrigham and Women's Hospital - Care Management ProgramIndependent Health - Care PartnersIntermountain Healthcare and Oregon Health and Science University - Care Management PlusJohns Hopkins University - Hospital at HomeMount Sinai Medical Center -- New York - Mount Sinai Visiting Doctors Program/ Chelsea-Village House Calls ProgramsPartners in Care Foundation - HomeMeds ProgramPrinceton HealthCare System - Partnerships for PIECEQuality Improvement for Complex Chronic Conditions - CarePartner ProgramSenior Services - Project Enhance/EnhanceWellnessSenior Whole Health - Complex Care Management ProgramSumma Health/Ohio Department of Aging - PASSPORT Medicaid Waiver ProgramSutter Health - Sutter Care Coordination ProgramUniversity of Washington School of Medicine - TEAMcar

Transitions along the Continuum of Care: Elderly and Disabled Persons in New York

This site visit examined transitions along the continuum of care for elderly and disabled persons in New York. The state offers its residents an extensive array of services, including nursing homes, home health care, personal care, and community-based services. New York spends more than any other state on its Medicaid program, which is reflected in a comprehensive benefit package, full-cost reimbursement of hospitals, high nursing home rates, and extensive coverage of personal care services. Site visitors were briefed on the history and development of long-term care in the state as well as the various care settings available. Panels discussed transitions in and out of acute, subacute, and long-term care settings and variations in managed long-term care. Discussions included strategies to improve the quality of care provided to nursing home residents, individuals living at home, and those nearing the end of life. Site visitors traveled to the Visiting Nurse Service of New York, the largest nonprofit home health care agency in the country. They also toured a long-term care facility with a large Chinese population and discussed multicultural competency, staffing, and reimbursement

The robot in the kitchen: The cultural politics of care-work and the development of in-home assistive technology

This paper considers two trends at opposite ends of the new economy: low-paid in-home care work, and the development of high-tech “social” robots. At present, the work of caring for the elderly, disabled, and convalescents is done primarily by women (disproportionately women of color) in the space of the home (Pratt, 1999). Meanwhile, in robotics labs at elite research universities and industry think-tanks in the U.S., Europe, and Japan, prototypes are being developed to take over some of this labor. Considered together, these two phenomena raise a number of questions, including: how might ideas about gender and race shape the development of assistive technologies; what does development in this field mean for understandings about technology’s “place” in our lives; and, potentially, even for those who rely on carework for their livelihood? The space of the home carries great cultural and symbolic significance (England, 2000). Allowing robots into this space to help us with our most private tasks would mark an unprecedented level of intimacy in our relationship with technology. While a “nursebot” may be able to measure vital signs, how would the replacement of a human care-giver with an assistive technology alter the relationship between the person being cared-for and the world outside? Drawing on disciplinary frames of Cultural Geography and Science and Technology Studies, this paper explores the social politics, and possible futures, of in-home assistive technology