Stanley R. Ingman

Medicalization, public policy and the elderly: Social services in jeopardy?

This paper examines the medicalization of community-based services for the elderly; a process of restructuring to provide more highly medical services to a frail older population at the expense of providing a broader range of social and supportive services to older persons with varying levels of need. Medicalization is tied to changes in government policy (particularly Medicare reimbursement) which have led to increased competition within the health and social service sector. The paper utilizes data on services, policy impact and staffing from the DRG Impact Study conducted at the Institute for Health and Aging (UCSF), a 3-year study of the impacts of federal policy on 7 types of community providers of services to the elderly. Data are presented from telephone interviews conducted at two points in time (1986 and 1987) with directors of a representative sample of home health agencies (HHAs). Findings include: HHAs were more likely to report adding highly medical services and cited social/supportive services (as opposed to highly medical and/or highly technical services) as the most commonly requested services they cannot provide. Policy effects and societal implications of the medicalization of home care are considered.

Reliability of Palpation of Pedal Pulses As Ascertained by the Kappa Statistic

An improved statistic (weighted Kappa) was tested for reviewing the reliability of the palpation of pedal pulses by three observers. Significant improvement was noted after training. Reliability also persisted with respect to a reduced form of the conventional ordinal grading system. The findings indicated that problems of usefulness or reliability may arise when more than five distinctions are made in describing the pulses or when the data are completely reduced to only a dichotomous (present‐absent) system.

GERONTOLOGY/ENVIRONMENTAL LINKS IN AGING EDUCATION: TOWARD AN INTERGENERATIONAL VIEW OF SUSTAINABILITY

This article documents the growing involvement of older adults in applied environmental concerns. The article further links this growing involvement to efforts undertaken by various educational forces, many located in the higher education arena. Education is viewed as contributing to individual empowerment. This empowerment is the rationale for senior engagement and changing societys perception of seniors and their rightful roles as stewards and contributors to future sustainability.

The pros, cons and pitfalls of “self-help” rehabilitation programs

Abstract This paper reports on the findings of an in-depth case study of a residentially based self-help program for alcoholics. Semi-structured interviews with the programs ex-alcoholic staff and with its clients, observation of on-going program activities, and examination of program documents were used to investigate the programs developmental history and present functioning. Data collection centered on the unique service possibilities associated with the self-help approach to rehabilitation, and on organizational problems encountered in implementing and maintaining such potential in a residential setting. Unique aspects of the program under study included an aggressive and wide-ranging client recruitment policy, a balanced attack on social as well as emotional obstacles to abstinence, heavy reliance on client input in therapeutic activities and program planning, and the presence of successful role models with whom clients could easily identify. These qualities were, however, frequently threatened in leadership struggles, by resource crises, and by internal and external pressures to professionalize. Drawing upon the literature, the authors suggest that such problems may be typical of developing self-help programs.

An Alternative Model in Geriatric Care

ABSTRACT: An analysis is presented of one long‐term care facilitys attempt to develop a comprehensive geriatric program including care of the patient in a hospital, a skilled nursing home, a day hospital, or a clinic for care of the ambulatory aged. The goal was to raise issues for debate and discussion, especially in terms of the evolving role of medical directors in long‐term care. The need for group professionalism in cooperation with the Board of citizens in community geriatric practice is emphasized.

ESRD and the Elderly: Cross-National Perspective on Distributive Justice

As the proportion of aged and our clinical ability to treat the ill aged increase in the U.S., the news media, health care planners and politicians are asking whether we can afford ever-increasing increments of medical care. Within the various sub-worlds of medical treatment, debates about cost vs. benefits are also more frequent. Questions of rationing vs. open access are being raised by various authorities. To try to clarify the issues in terms of both national health policy as well as the allocation of scarce resources, we believe that a review of geriatric and renal care in the US, the UK and Switzerland is useful. Our basic concern is to explore the consequences of collectivist contrasted with individualist approaches in the allocation of resources to care for the elderly and persons with End Stage Renal Disease (ESRD). What we mean by ‘individualist’ compared with ‘collectivist’ orientations toward the allocation of resources will become increasingly clear in what follows.

Toward a Comprehensive Geriatric Educational Experience

ABSTRACT: A description of the goals and the accomplishments of a program in geriatric education and training is presented. Emphasis is laid on the potential role of departments of family and community medicine, even though vast resources may not be available. Such a program is of great importance, but it must be viewed as only the first step in the development of a comprehensive training model for either a school of medicine or a residency program in primary care. Upon graduation in Family Medicine, residents should not only be aware of the specific health needs of the elderly, but also be clinically competent to meet those needs.

Health care provision and distributive justice: End stage renal disease and the elderly in Britain and America

Considerations of distributive justice impacting upon the provision of geriatric care and the treatment of patients with end stage renal disease (ESRD) are compared and contrasted between the U.S. and the U.K. Comparisons are drawn from differing degrees of individualist and collectivist idealogies between the two countries and analysis is further developed through use of the concepts of equity, uniformity and public accountability. Notwithstanding the predominance of an individualist ideology in the United States the provision of ESRD services is based on a collectivist format. Geriatric care and other welfare services more directly reflect the differences between collectivist and individualist ideologies in the two countries.

FAMILY MEDICINE AND GERIATRIC MEDICINE: ECONOMIC AND IDEOLOGICAL CONFLICT

As the needs for geriatric medical care increase, it becomes important to identify sources of care for this expanding population. This paper focuses on the supports and impediments inherent in the provision of geriatric medical care by family physicians. Supports include a community and family oriented approach, a generalist perspective, experience in coordination of inpatient and outpatient services, and an educational commitment to geriatric training. Impediments include an excessive and inaccessible knowledge base, the conflict between biomedical and psychosocial approaches to care, inadequate reimbursement for comprehensive care, and difficulties in educating family practice residents. As family physicians have traditionally provided the majority of geriatric health care, particularly in the rural United States, these issues are important to address.