Showing papers in "Families, Systems, & Health in 2013"

Cancer-related traumatic stress reactions in siblings of children with cancer.

Abstract: The purpose of this study was to explore cancer-related posttraumatic stress (PTS) reactions in siblings of children with cancer including prevalence, common symptoms, comorbidity with anxiety and depression, and gender- and age-related patterns. A total of 125 children (63 girls) between the ages of 8 and 17 (M = 12.4; SD = 2.9 years) with a brother or sister with cancer, diagnosed 4 to 38 months prior to the study (M = 1.3 years; SD = 6.7 months), completed the Child PTSD Symptom Scale (CPSS), Revised Children's Manifest Anxiety Scale, and Child Depression Inventory-Short Form. Over half of the sample (60%) scored in the moderate to severe range for PTS and 22% fulfilled full criteria for PTSD based upon CPSS responses. Nearly 75% reported "Feeling upset when you think about or hear about the cancer," and "Trying not to think about, talk about, or have feelings about the cancer." Over 60% reported arousal symptoms. PTS symptoms reportedly interfered with functioning for 75% of the sample and co-occurred with anxiety and depressive symptoms. Gender and age-related patterns were not found. Siblings of children with cancer experience cancer-related PTS reactions and greater attention should be paid to ameliorating their cancer-related distress with empirically based treatments.

Resilience in families of children with developmental disabilities.

Abstract: This study aimed to identify strengths and resources associated with the adaptation of families from previously disadvantaged backgrounds in South Africa following the diagnosis of a child with a developmental disability. Data was collected from parents (N = 40), as family representatives, using 7 self-report questionnaires and an open-ended question. The results showed positive correlations between an acceptance of the situation, positive patterns of family communication, commitment to the family unit, a positive attitude toward new experiences and challenges, and family adaptation, whereas incendiary communication and the age of the child were found to be inversely correlated with family adaptation. The quality of family patterns of communication was found to be the most significant predictor of family adaptation. The findings can be used to enrich existing family interventions to promote family resilience and affirm the reparative potential of families.

Parent-reported outcomes of comprehensive care for children with medical complexity.

Abstract: The Medical Home Clinic for Special Needs Children (MHCL) at Arkansas Children’s Hospital provides comprehensive care oversight for children with medical complexity (CMC). The objective of this study is to evaluate parent perceptions of health care delivery outcomes after 12 months of enrollment in the MHCL. This is a prospective cohort study of parents of MHCL patients, who completed surveys at initial and 12 months visits. Surveys assessed parent health, child health and function, family stress, and overall satisfaction, using previously validated measures and scales. Paired analyses examined differences in measures between baseline and 12 months. 120 of 174 eligible parents completed the follow-up survey at 12 months. Respondents were 63% white/Caucasian, 90% biological parent, and 48% with family income <$20K. From baseline to 12 months, a greater number of respondents reported having a care plan (53% vs 85%, p<.001); fewer respondents needed help with care coordination (78% vs 31%, p<.001). No changes were seen in reports of having emotional needs met. Parents reported a decline in the physical subscale of the SF-12 Health-Related Quality of Life measure (49.1 vs 46.4, p<.01), with those parents with ≥1 additional child with special needs reporting a marked decline (49.2 vs 42.5, p<.001). No other changes in family impact were found. We conclude that comprehensive care oversight may improve care coordination for parents of CMC, but no association with improved parent health was found. Future studies should identify the factors that influence parental burden and tailor clinical interventions to address such factors.

Factors related to caregiver state anxiety and coping with a child's chronic illness.

Abstract: The resiliency of families, based on family functioning and family hardiness, may influence caregivers' anxiety while their child is in the hospital undergoing treatment for his or her chronic illness. The current study assessed the relationship among these factors for caregivers of children with various chronic illnesses who were residing at a local Ronald McDonald House (RMH). Caregivers completed paper-based questionnaires to assess family hardiness, functioning, and parent state anxiety and interviews to identify positive and negative strategies and behaviors affecting how they were coping with their child's illness. Findings indicated that family functioning mediated the relationship between family hardiness and caregiver anxiety as a resilience factor that further reduced caregiver anxiety. During interviews, caregivers suggested that support from family members strengthened their coping abilities. Negative interactions with their child's medical team and not knowing how or being equipped to help their child live with his or her illness heightened caregiver stress. Future research should focus on developing, implementing, and measuring the effectiveness of interventions to improve caregiver support, such as by holding caregiver support groups at local RMHs, especially during a child's hospitalization.

Current and potential support for chronic disease management in the United States: the perspective of family and friends of chronically ill adults.

Abstract: Family members and friends can be an important source of self-management support for older adults with chronic diseases. We characterized the U.S. population of potential and current "disease management supporters" for people with chronic illness who are independent in activities of daily living, the help that supporters could provide, and barriers to increasing support. We used a nationally representative survey of U.S. adults (N = 1,722). Forty-four percent of respondents (representing 100 million US adults) help a family member or friend with chronic disease management; another 9% (representing 21 million U.S. adults) are willing to start. Most are willing to assist with key tasks such as medication use and communicating with providers, although they feel constrained by privacy concerns and a lack of patient health information. The majority of U.S. adults already helps, or would be willing to help, one of their family members or friends with chronic illness care. Supporters' specific concerns could be addressed through innovative programs.

Effectiveness of groups for adolescents with type 1 diabetes mellitus and their parents.

Abstract: Peer- and family-based group therapies have been used as separate interventions to improve adjustment and self-management among youth with Type 1 diabetes mellitus. This study replicates a treatment protocol that combined these two types of diabetes management groups, while also using a wait-list control design methodology within an outpatient mental health clinic setting. General psychosocial and diabetes-related variables were assessed at baseline, immediately posttreatment, and 4 months posttreatment. Youths' medical information, including metabolic control values, was extracted from medical charts for the 6 months prior to baseline and 6 months after treatment ended. At 4 months posttreatment, parents and youth reported increased parent responsibility, and parents reported improved youth diabetes-specific quality of life. Although there were no statistically significant changes in hemoglobin A1c values and health care utilization frequency from 6 months prior to and 6 months posttreatment, other psychosocial changes (i.e., increases in parent responsibility and diabetes-specific quality of life) were documented. Therefore, this treatment was found to be a promising intervention for use in an outpatient clinical setting to aid in improving the psychosocial functioning of youth with Type 1 diabetes mellitus.

Hispanic children and the obesity epidemic: Exploring the role of abuelas.

Abstract: This study evaluated the rate of Hispanic children who have grandparents involved in caretaking and whether grandparents' involvement had a negative impact on feeding practices, children's physical activity, and body mass index (BMI). One-hundred and 99 children and their parents were recruited at an elementary school. Parents completed a questionnaire regarding their children's grandparents' involvement as caretakers and the feeding and physical activity practices of that grandparent when with the child. Children's height and weight were measured and zBMI scores were calculated. Forty-three percent of parents reported that there was a grandparent involved in their child's caretaking. Grandparents served a protective role on zBMI for youth of Hispanic descent, except for the Cuban subgroup. There was no relationship between grandparent involvement and feeding and physical activity behaviors. In some cases grandparents may serve a protective function for childhood obesity. These results highlight the need for future research on grandparents and children's health, especially among Hispanic subgroups.

Navigating the legal and ethical foundations of informed consent and confidentiality in integrated primary care.

Abstract: This article describes findings from ongoing research and analysis of current literature in addition to discussions with leaders in the field, communications with lawyers and administrators of advocacy and government agencies pertaining to integrated primary care (IPC). Standards of care are established based on a myriad of factors, including professional codes of ethics, case law, state and federal laws, professional standards, existing best practices, current professional guidelines, administrative rules and regulations, and licensing board regulations. Regulations may differ for behavioral health and medical providers, posing challenges in IPC settings. This article provides a review of these regulations, particularly 42CFR Part 2, a federal law governing confidentiality for substance abuse programs, Health Insurance Portability and Accountability Act (HIPAA), and state laws relevant to patient care in IPC settings. On the basis of findings from the study, the authors make recommendations related to patient care practices concerning informed consent and release of information procedures, treatment and warm hand-off protocols, documentation and electronic record keeping, agreements with other providers, and billing.

Provider practices in the primary care behavioral health (PCBH) model: an initial examination in the Veterans Health Administration and United States Air Force.

Abstract: The goals of this study were to identify characteristics of both behavioral health providers (BHPs) and the patients seen in a primary care behavioral health (PCBH) model of service delivery using prospective data obtained from BHPs. A secondary objective was to explore similarities and differences between these variables within the Veterans Health Administration (VHA) and United States Air Force (USAF) primary care clinics. A total of 159 VHA and 23 USAF BHPs, representing almost every state in the United States, completed the study, yielding data from 403 patient appointments. BHPs completed a web-based questionnaire that assessed BHP and setting characteristics, and a separate questionnaire after each patient seen on one day of clinical service. Data demonstrated that there are many similarities between the VHA and USAF BHPs and practices. Both systems tend to use well-trained psychologists as BHPs, had systems that support the BHP being in close proximity to the primary care providers, and have seamless operational elements (i.e., shared record, one waiting room, same-day appointments, and administrative support for BHPs). Comorbid anxiety and depression was the most common presenting problem in both systems, but overall rates were higher in VHA clinics, and patients were significantly more likely to meet diagnostic criteria for mental health conditions. This study provides the first systematic, prospective examination of BHPs and practices within a PCBH model of service delivery in two large health systems with well over 5 years of experience with behavioral health integration. Many elements of the PCBH model were implemented in a manner consistent with the model, although some variability exists within both settings. These data can help guide future implementation and training efforts.

E-Health innovations, collaboration, and healthcare disparities: developing criteria for culturally competent evaluation.

Abstract: E-Health alters how health care clinicians, institutions, patients, caregivers, families, advocates, and researchers collaborate. Few guidelines exist to evaluate the impact of social technologies on furthering family health and even less on their capacity to ameliorate health disparities. Health social media tools that help develop, sustain, and strengthen the collaborative health agenda may prove useful to ameliorate health care inequities; the linkage should not, however, be taken for granted. In this article we propose a classification of emerging social technologies in health care with the purpose of developing evaluative criteria that assess their ability to foster collaboration and positively impact health care equity. The findings are based on systematic Internet ethnographic observations, a qualitative analysis of e-health tool exemplars, and a review of the literature. To triangulate data collection and analysis, the research team consulted with social media health care experts in making recommendations for evaluation criteria. Selected cases illustrate the analytical conclusions. Lines of research that are needed to accurately rate and reliably measure the ability of social media e-health offerings to address health disparities are proposed.

Perspectives of parents on making decisions about the care and treatment of a child with cancer: a review of literature.

Abstract: This review focuses on parental decision making regarding the care and treatment of children with cancer Articles were abstracted from the following sources: Ovid Databases (Cochrane Database of Systematic Reviews, Database of Abstracts of Review of Effects, Medline, and Social Work Abstracts) and EBSCOhost (Academic Search Premier and Academic Search Complete) using smart text The criteria for the search were publications between 2005 and 2012 and publication in peer-review journals The descriptors used were parents of children with cancer, decision making, decisions about childhood cancer, and parents The search yielded 59 references, but after duplicates, as well as dated and irrelevant articles were removed, 17 articles were identified that focused specifically on the decisions parents make regarding the care and treatment of children with cancer Coders agreed that the child's quality of life/well-being, parental hope/expectations, support/supportive care, communication, and information were important themes in considering the decisions parents made regarding the care and treatment of children with cancer These themes provide insight into the needs of parents in making decisions about the care and treatment of children with cancer

Growth and the cancer caregiving experience: psychometric properties of the Portuguese Posttraumatic Growth Inventory.

Abstract: The purpose of the present study was to investigate the psychometric properties of the Portuguese version of the Posttraumatic Growth Inventory (PTGI) and relate posttraumatic growth with psychological morbidity. This is a cross-sectional study with a sample of 214 adult children of cancer patients. Additionally, a comparison group was recruited with 78 participants without a chronically ill parent. Measures of distress, posttraumatic stress disorder (PTSD) symptoms, and posttraumatic growth were collected. The original five-factor structure of the PTGI was maintained, with satisfactory internal consistency. The reorganization of the items in five factors was similar to the solution found in the original PTGI study, except for four items. Positive correlations between posttraumatic growth and PTSD symptoms/distress were significant. Women showed significantly higher posttraumatic growth. Adult children with parental cancer, and with probable PTSD, showed higher scores on the PTGI. Regression analysis revealed that PTSD symptoms were associated with higher posttraumatic growth, after controlling for demographic and clinical variables. Analysis with the comparison group showed that differences in posttraumatic growth were observed as a function of a shattered experience. This study confirmed the multidimensionality of the posttraumatic growth construct, underscoring the importance of considering the subjective nature of the shattered event, and the experience of emotional distress with parental cancer.

Social control and smoking: examining the moderating effects of different dimensions of relationship quality

Abstract: A common form of social regulation of an individual's health behavior is social control. The contextual model of social control assumes that higher relationship quality goes along with more beneficial effects of social control on health behavior. This study examined potential differential moderating effects of different dimensions of relationship quality on the associations between positive and negative social control and smoking behavior and hiding smoking. The sample consisted of 144 smokers (n = 72 women; mean age = 31.78, SD = 10.04) with a nonsmoking partner. Positive and negative social control, dimensions of relationship quality consensus, cohesion and satisfaction, numbers of cigarettes smoked (NCS), hiding smoking (HS), and control variables were assessed at baseline. Four weeks later NCS and HS were assessed again. Only for smokers with high consensus, but not cohesion and satisfaction, a negative association between positive control and NCS emerged. Moreover, smokers with high consensus tended to report more HS when being positively and negatively socially controlled. This also emerged for cohesion and positive control. Satisfaction with the relationship did not display any interaction effects. This study's results emphasize the importance of differentiating not only between positive and negative social control but also between different dimensions of relationship quality in order to gain a comprehensive understanding of the dynamics in romantic dyads with regard to social regulation of behavioral change.

Patient and provider relationships: consent, confidentiality, and managing mistakes in integrated primary care settings.

Abstract: Health care in the United States is advancing toward increasingly integrated primary care systems. With this evolution comes a responsibility for providers to carefully consider a variety of issues related to ethical conduct. While working within the same teams on behalf of the same patients and families, professionals representing different disciplines are guided by different sets of baseline ethics guidelines and codes-and the overlap and differences between these principles can easily translate into ethical breaches. Using a clinical vignette as the basis for our discussion, we address issues of informed consent, confidentiality, and grievance procedures specifically. We review extant literature and formal ethics codes upheld by nine leading professional organizations across these foci, offer recommendations about how to manage this clinical scenario, and highlight what is needed to advance our understanding of integration ethics.

The home environment and family asthma management among ethnically diverse urban youth with asthma.

Abstract: While the pediatric psychology literature underscores the importance of illness related aspects of the home environment for optimal family asthma management, little is known about the contribution of more global aspects of the home environment (e.g., family routines/schedule, quality of stimulation provided to child) to asthma management in ethnic minority and urban families. The goals of this study were to: 1) explore ethnic/racial group differences in global and specific dimensions of home environment quality among Latino, non-Latino white (NLW), and African American urban children with asthma; and 2) examine associations between the quality and quantity of support and stimulation within the home environment, as measured by the HOME Inventory, and family asthma management in this sample. Urban, low-income children (N=131) between the ages of 6 and 13 with asthma and a primary caregiver participated in a multi-modal assessment including an in home observation and semi structured interviews to assess aspects of home environment quality and family asthma management practices. While controlling for poverty, no ethnic group differences were found in the global home environment; however, there were significant differences in specific dimensions (e.g. Family Participation in Developmentally Stimulating Experiences, and Aspects of the Physical Environment) of home environment quality. Across the whole sample, home environment quality predicted family asthma management. When examining this association for specific ethnic groups, this finding did not hold for the Latino subsample. The results highlight the need to consider ethnic group differences in non-illness specific aspects of the home environment when addressing families’ asthma management strategies.

Effects of different models of integrated collaborative care in a family medicine residency program.

Abstract: Integrated collaborative care (ICC) combines medical and behavioral health services in the primary care setting. Our family medicine residency program implemented care across three different models of integration over five years, allowing retrospective, cohort evaluation of the changes in behavioral health services and patient outcomes for depression. We identified three time periods representing increasing levels of services: Colocation of behavioral health services in 2004-05 (CL), primary care behavioral health model (behavioral health providers embedded in primary care) in 2009 (PCBH), and a blended model of PCBH and care management for depression in early 2010 (BM). All adult patient charts (n = 552) with PHQ9 scores ≥10 were analyzed for number of provider contacts (physician and behavioral health) and changes in scores during the 12-week follow-up. The percent of patients receiving adequate care (≥3 provider contacts in 12 weeks) improved from 43.5% (CL) to 55.1% (PCBH) to 60.6% (BM; Pearson chi-square, p = .02). Forty-two percent of patients in BM achieved remission (PHQ9 ≤ 4), 25.2% in PCBH and 12% in CL (Pearson chi-square, p = .02). The Blended Model resulted in better access to behavioral health care and outcomes for patients with depression symptoms.

"There is still so much ahead of us"-family functioning in families of palliative cancer patients.

Abstract: Adopting a systems approach, parental cancer has its impact on patients, spouses, and dependent children. The purpose of the current study was to examine family functioning dependent on parental disease stage and on family member perspective in families of cancer patients with adolescent children. The cross-sectional study was conducted within a German multisite research project of families before their first child-centered counseling encounter. The sample comprised individuals nested within N = 169 families. Analyses performed included analysis of covariance (ANCOVA) and intraclass correlation. Open answers were analyzed following quantitative content analysis procedures. Between 15% and 36% of family members reported dysfunctional general functioning scores. Parents indicated more dysfunctional scores on the Family Assessment Device scale Roles, and adolescents more dysfunctional Communication scores. Regarding assessment of family functioning, there was higher agreement in families with parents in a palliative situation. For adolescents with parents in palliation, incidents because of the disease tend to become more dominant, and spending time with the family tends to become even more important. As our study pointed out, parental cancer, and especially parental palliative disease, is associated with both perceived critical and positive aspects in family functioning. Supporting families in these concerns as well as encouraging perceptions of positive aspects are important components of psycho-oncological interventions for families with dependent children.

Accommodating families during a child's hospital stay: implications for family experience and perceptions of outcomes.

Abstract: Family accommodation programs, such as Ronald McDonald House® (RMH), aim to facilitate family proximity and family-centered care during a child's hospitalization, yet little is known about how the programs influence family experience. The aim of this study was to investigate the perspectives of families regarding the impact of the RMH stay on the family and their hospital experience and to explore the influence of demographic and clinical factors on family member views about their experience and outcome of their child's hospitalization. Family members who spent one or more nights at an RMH in Southern California completed a cross-sectional, self-report survey that included descriptive information about the family and the hospital experience. The 2,081 respondents (53% mothers, 24% fathers, 7% other family members, and 15% multiple family members) generally reported positive experiences at RMH. Although effect sizes were small, families who stayed together for at least a portion of their stay believed more strongly that their ability to stay nearby improved their child's recovery and that RMH helped their family to stay together. Cultural differences were also evident, with Hispanic families believing more strongly that RMH shortened their child's hospital stay. A family's ability to stay together and in close proximity during a pediatric hospital stay is facilitated by accommodations such as RMH and provides important benefits in terms of family experience, psychosocial well-being, and perceptions of child recovery. These services also contribute meaningfully to the priority of providing family-centered care.

The Ethics of Complex Relationships in Primary Care Behavioral Health

Abstract: Primary care settings are particularly prone to complex relationships that can be ethically challenging. This is due in part to three of the distinctive attributes of primary care: a whole family orientation; team-based care; and a longitudinal care delivery model. In addition, the high patient volume of primary care means that the likelihood of encountering ethically challenging relationships is probably greater than in a specialty setting. This article argues that one ethical standard of the American Psychological Association (APA, 2010, Ethical principles of psychologists and code of conduct, www.apa.org/ethics/code) (10.02, Therapy Involving Couples or Families) should be revised to better accommodate the work of psychologists in primary care. The corresponding Principles of Medical Ethics from the American Medical Association (AMA, 2012, Code of medical ethics: Current opinions with annotations, 2012-2013, Washington, DC: Author), most notably the principle regarding a physician's duty to "respect the rights of patients, colleagues, and other health professionals as well as safeguard privacy" are also noted. In addition, the article details how the three attributes of primary care often result in complex relationships, and provides suggestions for handling such relationships ethically.

Multiple role relationships in healthcare education.

Abstract: Healthcare training environments, particularly in multidisciplinary training settings, present unique ethical dilemmas as a result of the multiple relationships faculty must balance while working with trainees. The historical and current perspectives on multiple roles in training environments will first be summarized. Evidence of a gap between the extant discipline specific guidelines and the realities of situations that occur in healthcare training will then be revealed, as illustrated in a case example. Primary care medicine training environments are highly nuanced, potentially leading to an infinite number of ambiguous situations that require a generalizable model for managing multiple roles. Rather than recommend specific modifications to existing ethical guidelines, a new model emphasizing role awareness and decision making when challenges in healthcare training settings arise is proposed. Recommendations for the case example using the model are offered. All professionals are prone to boundary transgressions; explicit training about and the maintenance of appropriate role balance will help to ensure high-functioning relationships and maximize the quality of patient care, resident education, faculty and resident satisfaction, and modeling of professional behavior to improve competencies as clinicians and educators.

From colleague to patient: ethical challenges in integrated primary care.

Abstract: Ethical codes and guidelines for mental health professionals focus on traditional avenues of practice, leaving considerable gaps for clinicians in unique settings, such as behavioral health providers in integrated primary care. In this article, an ethical scenario is presented, where a behavioral health provider is faced with a colleague physician seeking assistance for emotional distress. The scenario highlights important ethical questions about multiple relationships/conflict of interest, impaired colleagues, informed consent, and confidentiality. We review gaps in ethical guidance pertinent to the scenario and provide an eight-step rubric for ethical clinical decision making in integrated primary care.

Ethical issues facing providers in collaborative primary care settings: do current guidelines suffice to guide the future of team based primary care?

Abstract: This special issue discusses the ethical issues providers face in collaborative primary care settings. It is organized in three sections: (a) Common Themes, (b) Context-Specific Quandaries, and (c) Research and Training. It provides case examples to illustrate ethical dilemmas, describe professional ethical standards pertinent to the case, identifies gaps in available guidance and how guidelines might be elucidated in state statues (without going into detail about specific states), offers feasible recommendations to BHCs for deciding an ethical course when extant guidance was lacking, and then demonstrates and applies the recommendations to achieve an ethical resolution to the case example.

Individual and family predictors of psychological control in parents raising children with type 1 diabetes.

Abstract: The purpose of this research is to examine how metabolic control, parents' marital conflict, and parental caregiver burden are related to parents' use of psychological control in families raising a child with Type 1 diabetes (T1D). Differences between mothers and fathers are also considered. In this cross-sectional study, parents of 85 children with T1D independently completed self-report questionnaires; metabolic control levels were obtained through patient medical records. Structural equation modeling showed that better metabolic control is related to lower levels of fathers' caregiver burden, and marital conflict is positively related to both mothers' and fathers' ratings of caregiver burden. Mothers' caregiver burden is positively related to their psychological control (a type of parental behavior that threatens children's autonomous thoughts and feelings) and, similarly, fathers' caregiver burden is positively related to their psychological control. Paths in the model differed by parent gender, but there were no crossover effects. Future research is needed to develop new, effective interventions for children with diabetes and their parents, focusing not only on the child but on multiple family systems.

Primary care behavioral health: ethical issues in military settings

Abstract: The rapid expansion of integrated behavioral health care in primary care medical settings introduces a number of ethical challenges faced by teams of health professionals from different disciplines. As military health care settings have increasingly implemented primary care behavioral health models of service delivery, distinct ethical dilemmas have emerged. This article examines two of these ethical issues, competence and multiple relationships, through presentation of clinical scenarios in military integrated primary care settings. Relevant professional ethical guidelines for psychologists, social workers, and physicians are examined. Recommendations for the ethical practice of primary care behavioral health, as well as suggestions for future development of professional ethical guidelines, are discussed.

Shifting processes model: a conceptual model for sustainable weight management.

Abstract: Weight-loss maintenance is widely accepted to be a difficult and often elusive process. The transtheoretical model (TTM) provides a useful description of five stages of change. Applied to weight management, weight loss occurs during the action stage and weight-loss maintenance occurs during the maintenance stage. Despite its broad utility, the TTM does not adequately explain the complexity involved with a shift from action to maintenance. Based on Engel’s (G. L. Engel, 1977, The need for a new medical model: A challenge for biomedicine, Science, Vol. 196, pp. 129‐136) biopsychosocial model and family systems theory, a shifting processes model is proposed to describe the potential differences and shift that occurs between weight loss and weight-loss maintenance processes within relational contexts.

Ethical matters in rural integrated primary care settings.

Abstract: Integrated primary care is particularly valuable to rural communities. Behavioral health care is often in short supply, and small or close-knit communities can intensify the stigma of seeking specialty mental health in rural settings. These and other barriers result in reduced access to needed behavioral health care. Nonetheless, rural practice of integrated primary care presents unique challenges to practitioners of multiple disciplines, including issues of competence, confidentiality, and dual relationships. This article provides an illustrative vignette to describe ethical issues in the rural practice of integrated primary care. It will review discipline-specific guidance in approaching these challenges and will offer recommendations for addressing disparities in the approaches of various disciplines engaged in the practice of integrated primary care.

Similarity, agreement, and assumed similarity in proxy end-of-life decision making.

Abstract: Medical decisions near the end of life are often made by proxies who can be inaccurate in their judgments of patient preferences. Given that accuracy in surrogate decision making is an important goal in end-of-life decision making, and in light of that previously seen levels of accuracy reflect substantial disagreement, error, or both, this study examined both relationship and individual factors that potentially affect surrogate accuracy. Specifically, this study examined similarity, agreement, and assumed similarity-a process whereby raters use their own traits and preferences to rate another person-in spousal ratings of end-of-life treatment. This study expands on previous research by examining the potential influence of relationship factors and assumed similarity on end-of-life decision making among a sample of newlyweds. Newly married couples (n = 197) completed self and spouse measures of hypothetical end-of-life preferences and scales assessing marital satisfaction, personality, and attitudes. Results indicate a moderate level of similarity on husband and wife self-rated end-of-life treatment preferences (rs = .18-.29) and a moderate level of agreement between self and proxy ratings (rs = .17-.41). The largest correlations were seen between self ratings and proxy ratings (e.g., husband self ratings and husband proxy ratings of wife preferences, rs = .46-.69), reflecting strong assumed similarity in proxy ratings. For wives, similarity with husbands on a few attitudinal variables (i.e., spirituality, moral strictness, and conservatism) influenced proxy accuracy. Recognizing the potential impact of personal preferences on proxy ratings, as well as the potential influence of relationship factors, may help improve proxy accuracy and end-of-life care for patients and families.

Transporting integrated primary care to the private sector: addressing the business challenges.

Abstract: The primary care literature provides some useful information and several project examples for clinicians attempting to develop an integrated care practice, but prior discussion has been based largely on projects developed in government-funded or HMO systems. The current paper focuses on the business challenges of establishing an integrated care practice in a private, fee-for-service setting. Despite increasing commitment to the concept of the medical home, which embraces behavioral health care, physicians in the private sector remain cautious about proposed practice changes such as integrated care. There are additional obstacles that can impede successful implementation of integrated primary care in the private sector. The authors identify five major challenges and suggest potential strategies to address these challenges, drawing, in part, on their experience with a 4-year integrated primary care demonstration project.

Characteristics of collaborative care in increasing access to mental health service in the Asian community.

Abstract: This study examined the use of thematic analysis to determine how characteristics of collaborative care facilitate accessibility to mental health services among the Asian community in the United States. This investigation explored characteristics of collaborative care in patient treatment, barriers that prevent the Asian community from utilizing care, and how collaborative settings can facilitate mental health care access in the Asian community. Mental health providers with relevant experiences in collaborative care were recruited through snowball sampling to participate in a telephone interview with the researchers. The results suggested a collectivistic culture, valuing authority, acculturation, language, and stigma as themes of Asian patients as well as key providers (mental and medical health providers), colocation, the physician's leading role, the provider's language, and collaboration among providers as themes for collaborative care. The study suggests that collaborative care's foundational characteristics can promote easier access to mental health care for the Asian community.