by Rick Ybarra
As we know, health professionals and health care organizations are experimenting with new ways to improve care and lower health care costs, especially for persons experiencing severe, chronic health conditions. The Commonwealth Fund recently released six principles for improving value for patients and health systems and an issue brief highlighting new models of care delivery.
For a “deeper dive” and better understanding of health care costs, check out their recent post, Better Care at Lower Cost: Is It Possible?
The Commonwealth Fund also launched three animated videos (each video approximately 90 seconds) illustrating new approaches in the delivery and financing of health care services. The videos also examine how these reforms could make life better for persons who seek health care and persons who deliver health care, as well as for health care organizations (hospitals, networks, health care systems and community based providers). Take a 4-1/2 minute break out of your busy schedule to check these videos out. They help clarify some of the myths and misconceptions on what we are attempting to achieve through health care reform.
Only by evaluating, refining and then fully implementing to scale new models of care for persons with the highest health care needs, coupled with looking more upstream at prevention and early intervention of chronic health conditions that lead to high costs will we be able to demonstrate that these transformations contribute to people living healthier lives and controlling health care costs.
by Rick Ybarra
There is quite the buzz about the Quadruple Aim. Most of you are familiar with the Institute for Healthcare Improvement’s Triple Aim: enhancing patient experience, improving population health, and reducing costs. The Triple Aim is widely accepted as the end point of health reform. The Quadruple Aim takes this one step further. Simply put: the care of the patient requires care of the provider.
The authors of the Annuals of Family Medicine article make a strong case for a fourth dimension, the health care of the provider, as essential to achieve the Triple Aim. Although taken from a physician perspective, the implications of the Quadruple Aim are HUGE when we consider the totality of all those who work in the health care sector (physicians, nurse prescribers, physician assistants, nurses, psychologists, social workers, OT/PT, case/care managers, peers, just to name a few).
I would also argue that the mental health and wellness of our workforce should not be overlooked in the quest for the Quadruple Aim.
Why is this fourth dimension important? The issue of burnout impacts the quality and continuity of health care. We know that expectations for providers have heightened, resulting in organizational reconfigurations and changes in service delivery practices. The move to more robust, coordinated care and network development/sufficiency, the need to demonstrate outcomes (while meeting the contracted number of encounters), and a push for innovations without the necessary financing to fully implement integrated health care, all add to the strain and potentially impacts our workforce.
How can health care organizations work toward the fourth aim? The authors offer some practical steps, such as use of EMRs; expanding the role and scope of practice for nurses and medical assistants; standardizing and synchronizing workflows; providing team based care including co-location of team members; training; and assessing current workflows and practices and “reengineering” unnecessary work out of the practice. The adage, “because we have always done it this way” will no longer be acceptable if providers are attempting to actualize the Quadruple Aim.
The authors remind us that patient-centeredness is essential to the health care relationship. Health care is a relationship between those who provide health care and those who receive health care. It is a relationship that can only prosper if it is truly collaborative, respectful and seeking the same health care goals and outcomes. Patient-centeredness must be at the core for the health care relationship to thrive.
The authors conclude that the Triple Aim has provided us a vision of what a reformed health care system can look like. They present a compelling case that the health care workforce is of paramount importance in achieving one of the primary goals of the Triple Aim: improving population health. Heathy people, healthy communities, and a healthy nation. Collective impact. Only a truly healthy health care workforce can achieve the Triple Aim of improved care, better health, and lower costs – the true aim of health care reform!
Chris Divin, a doctoral student in the School of Nursing at The University of Texas at Austin, and a 2014 recipient of the Frances Fowler Wallace Award from the Hogg Foundation, has recently completed her dissertation, “Exploring the Lived Experience of Intimate Partner Violence and Salutogenesis in Aging Mexican-American Women.” Her study attempts to bring to light the experience of intimate partner violence among elderly Mexican American women.
Frances Fowler Wallace, the award’s namesake, was married to John Forsythe Wallace, who served as a member of the Texas House of Representatives and the State Board of Control. She died July 18, 1972, in Austin at the age of 80. The Wallace Award provides partial support for doctoral students’ dissertation research on “the cause, treatment, cure, and prevention of mental disease, mental illness, and mental disorders,” as directed in her will. The award provides up to $1,500 for research-related expenses.
We talked to Chris Divin about her research.
Tell us about yourself. At what point did you decide to pursue a career in mental health research, and what influenced that decision? I have been a nurse for almost 40 years! My nursing career has provided me with profound experiences in several interesting places in both the Northern and Southern hemispheres. It was while working in a marginalized community in Barquisimeto, Venezuela, in the mid 1980s with a group of health promoters that I became aware of intimate partner violence (IPV) as a serious public health issue. In the barrio where my family and I lived and worked men, women, and children came together on the “Día Internacional de la Mujer” International Day of Women to paint murals throughout the barrio to raise awareness about violence against women. In 2003, I began working with frail elderly in El Paso as a nurse practitioner and it was during that time that I realized that for some women there was no aging out of violence. I also realized that others were still trying to heal and integrate their lived experience. At that time, I was not aware of the dearth of studies on IPV and aging, and sensed that it was a phenomenon that merited further exploration.
Your dissertation is titled, “Exploring the Lived Experience of Intimate Partner Violence and Salutogenesis in Aging Mexican-American Women.” What questions are you trying to answer with this work? Salutogenesis, a term coined by Aaron Antonovsky, a medical sociologist, focuses on what resources sustain health in the midst of adversity as opposed to pathogenesis that searches for the causes of disease. Before beginning my PhD program, I had not heard the term however have found it to be an interesting lens for exploring issues of health in adversity. Much of the research on intimate partner violence has focused on the serious and often long-term adverse effects of IPV yet researchers have called for increased understanding of the strengths that women garner to not only survive intimate partner violence but to heal and move beyond their experience. Therefore, my dissertation asked the following three questions:
• What is the lived experience of IPV in aging Mexican-American women?
• How do social and cultural factors shape the IPV experience for aging Mexican-American women?
• How do aging Mexican-American women with a history of IPV, sustain health and well-being throughout and beyond the IPV experience?
I searched for the “experts” or aging Mexican-American women with a history of IPV to seek answers to my questions.
What led to your taking a professional interest in this particular topic? It was not until the 1990s that researchers began to explore aging and intimate partner violence. Before that time it was very much a hidden phenomenon. Although physical violence does seem to decrease with age, psychological abuse continues and some women have suggested that it is even more painful. There have been a handful of studies in the US exploring IPV and aging; however, these studies have been with Caucasian and African-American women. Although some studies on IPV and Hispanics have included a few aging women, research conducted specifically to capture the wisdom of aging Mexican-American women who have experienced intimate partner violence is non-existent. I hope that the wisdom shared by the 12 aging Mexican-American women interviewed for this study will shed light not only for health care professionals caring for an increasingly growing aging and Hispanic population but will also benefit other women still living with IPV. When a problem is a serious public health issue such as IPV, affecting one in three women in the U.S. an interdisciplinary approach throughout the life span is needed. One of the major themes in this study was a “desire to break the cycle of abuse” for future generations.
How do you think your research methods and approach will help you to answer the questions that you’re posing? My dissertation was guided by Denzin’s Interpretive Interactionism. His methodology brings light to personal problems such as IPV that also have serious public health implications. Rich data, obtained through conducting two separate hour-long interviews, answered my three research questions. It was important to meet with each of the women more than once to establish trust and rapport and provide an opportunity for reflection and further insight. For some of the women, this was the first time that they had told their story. The sensitizing framework that guided my work was Antonovsky’s Salutogenic Theory; exploring what resources help foster a person’s ability to comprehend, manage and find meaningfulness in their lived experiences and remain healthy in spite of adversity. These two frameworks complemented one another as both value the lived experience and historical and sociocultural factors that shape a person’s story.
Are there any suggested readings you can recommend for those who might be interested in learning more about this topic? I would recommend one of the most recent literature reviews on aging and IPV:
Finfgeld-Connett, D. (2013). Intimate partner abuse among older women: Qualitative systematic review. Clinical nursing research, xx(x), 1-20. doi : 10.1177/1054773813500301
In April of this year, UT’s Institute for Domestic Violence and Sexual Assault invited Dr. Devaney, a sociologist from Ireland to present his work on IPV and older women in the UK. I was fortunate to attend one of his lectures at Safe Place, the local shelter in Austin for those affected by violence. He and his colleagues have used the Salutogenic Framework in their studies on aging and IPV as well:
Lazenbatt, A., & Devaney, J. (2014). Older women living with domestic violence: coping resources and mental health and wellbeing. Current Nursing Journal, 1(1), 10-22.In 2011 I began a secondary data analysis utilizing data that Dr. Tracie Harrison had collected for a larger ethnographic study on health disparities and disablement in Mexican-American and non-Hispanic white women aged 55-75:
Divin, C.,Volker, D., & Harrison, T. (2013) Intimate partner violence in Mexican-American women aging with mobility impairments: A secondary data analysis of cross-language research. Advances in Nursing Science 36(3), 243-257.
Two other recent studies conducted in Texas with Mexican-American women provided further insight for my study:
Montalvo‐Liendo, N., Wardell, D. W., Engebretson, J., & Reininger, B. M. (2009). Factors influencing disclosure of abuse by women of Mexican descent. Journal of Nursing Scholarship, 41(4), 359-367.
Brabeck, K. M., & Guzmán, M. R. (2008). Frequency and perceived effectiveness of strategies to survive abuse employed by battered Mexican-origin women. Violence Against Women, 14, 1274−1294. doi:10.1177/1077801208325087.
I am truly grateful to the Hogg Foundation for your support of my dissertation as the Frances Fowler Wallace Award paid for much of my travel to the border communities where my interviews were conducted. Thank you for all the good work that you do to improve health and well-being in the state of Texas and beyond.
by Ike Evans
Courtney Valentine, a doctoral candidate in the Department of Educational Psychology at The University of Texas at Austin, and a 2014 recipient of the Harry E. and Bernice M. Moore Fellowship from the Hogg Foundation, has recently completed her dissertation, “The Impact of Post-Traumatic Stress Symptoms and Protective Factors on Transition Factors for Youth Investigated for Maltreatment During Adolescence.” Her study is an important contribution to the literature on transition-age youth (TAY), young adults who are transitioning out of the foster care system.
Since its establishment in 1995, the Harry E. and Bernice M. Moore Fellowship has been awarded to students from The University of Texas at Austin to complete a dissertation on the human experience in crises resulting from natural or other major disasters or, in a broader sense, stress and adversity.
In recent years, the Hogg Foundation has made identifying and addressing the needs of TAY a strategic priority of its grantmaking. This interest is driven by research and experience that shows that TAY with mental health conditions require special services and supports in order to cope with the challenges of aging out of one system and transitioning into a new adult system that may not be prepared to meet their developmental needs. In 2013, the foundation launched its Transition-Age Youth and Families initiative, with a focus on Houston/Harris County.
We spoke with Courtney Valentine about her research.
Tell us about yourself. At what point did you decide to pursue this particular line of research, and what influenced that decision?
I joined the Jesuit Volunteer Corps after college and spent the year a case manager in a group home for foster and probation adolescents. My job was to help many of the youth transition out of foster care. I realized then how vulnerable this population is and how many services are needed to help these youth. I have continued to work with transitioning aged foster youth as a CASA volunteer and therapist for many years.
Your dissertation is titled, “The Impact of Post-Traumatic Stress Symptoms and Protective Factors on Transition Factors for Youth Investigated for Maltreatment During Adolescence.” What questions are you trying to answer with this work?
I was interested in better understanding things that influenced youth’s successful transition to adulthood from foster care. Specifically, I was interested in the role of trauma and other protective factors impacting this transition.
What gap in the literature will be filled by your study? Who stands to benefit from it?
I hope that this study will highlight the importance of protective factors for adolescents in the foster care system. This study is unique in its inclusion of both risk and protective factors in the process. The aim of this study is to inform both future research and practice for this vulnerable population.
How do you think your research methods and approach will help you to answer the questions that you’re posing?
I chose to use latent variable structural equation modeling (SEM) for my analysis because it allows for the construction of causal models based on previous research and theory to estimate not only direct effects between variables, but also indirect effects of mediating variables, which allows further understanding of how one variable affects another. In addition, latent variable SEM allows for the estimation of latent variables using multiple measured indicators to more closely approximate the construct being tested.
Are there any suggested readings you can recommend for those who might be interested in learning more about the topic?
The National Child Traumatic Stress Network’s website has many wonderful free resources for children, parents, teachers, and clinicians.
In September and October of 2014, the Hogg Foundation — along with the Bernard and Audre Rapoport Center for Human Rights and Justice at the UT School of Law, the Dell Medical School, and the St. David’s Center for Health Promotion and Disease Prevention Research in Underserved Populations —brought together scholars and a diverse group of leaders in health promotion for two half-day summits on the theme of “Creating Model Health Communities.”
The goal for both summits was to build on the tremendous work that had already been done by many people and organizations inside and outside the university to address health inequities, and to catalyze new ideas and innovative collaborations that might contribute to the future of Austin and Travis County as model health (and healthy) communities.
Because the events were among the first in which the Dell Medical School would participate, the goal was also to help the new school connect with existing health stakeholders in Austin-Travis County and to begin the process of defining the particular role it would play within the broader health ecosystem.
This report aims to distill the presentations and conversations that took place at the summits. It also offers some recommendations for harnessing the wealth of expertise and resources among medical, academic, and community partners in Central Texas to ensure future coordination and cooperation. These recommendations include:
- Any Austin–Travis County model health community must be guided by principles of equity and social justice, focused on the social determinants of health.
- Innovative, interdisciplinary pilot programs should be fostered to address priority health concerns.
- To ensure the integration of existing work with new diverse collaborations and partnerships, an advisory committee should be created with the goal of making Austin–Travis County a model health community.
- The advisory committee should consider the feasibility of developing an information–sharing platform to be built from existing databases in Austin–Travis County.
Interdisciplinary and cross–sectoral (education, housing, racial equity) working groups should be formed around specific priority health issues to encourage further collaboration among individuals and entities working on seemingly disparate areas.
These principles and recommendations aren’t intended to be a rigid prescription for how to move forward, toward the shared goal of model healthy communities, but rather to add to the ongoing conversation. To that end, I’d also like to encourage readers to attend the upcoming conference (October 1) hosted by Partners in Austin Transforming Health (PATH), which consists of academic, health service and community partners committed to developing collaborative efforts to promote health equity.
The conference, which is free and open to the public, is on the theme of Social Inequality and Health. To register please go to: http://centexpath.org/conference.
by Rick Ybarra
National Recovery Month (Recovery Month) is a national observance held every September to increase awareness that mental health services and substance use treatment can enable those with a mental and/or substance use condition to live a healthy, productive and rewarding life and become a contributing member of our community and society.
Not only does the Hogg Foundation for Mental Health wholeheartedly embrace these convictions, but through our grantmaking and advocacy, we are ensuring that these convictions gain a secure foothold in the Texas mental health and health care landscape.
Here is the evidence: there are millions of people whose lives have been transformed through recovery. Contributing to the recovery movement are the advances of psychosocial treatments, evidenced based practices, innovations such as integrated health care, peer and recovery supports, and improved psychopharmacological interventions. But the main driver is people: people who begin their journey of recovery, families that support their loved ones, and communities who embrace that recovery is possible.
The main take-away is this: behavioral health is essential to overall health, prevention works, treatment is effective, and people can and do recover.
The Substance Abuse and Mental Health Services Administration (SAMHSA) has a webpage dedicated to National Recovery Month: http://www.recoverymonth.gov/home.
Spread the word and let’s celebrate National Recovery Month together! Recovery happens! Recovery is possible!
by Alison Mohr
The Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) is one of the most impactful pieces of legislation in recent decades.
Enacted in 2008, MHPAEA was meant to ensure that individuals with a mental health or substance use condition would receive benefits equal to the medical/surgical benefits covered by their individual health plan. The law does not require plans to offer mental health or substance use disorder benefits, but if the plan does so, it must offer the benefits equally with the other medical and surgical benefits covered under the plan otherwise known as “parity”.
The Patient Protection and Affordable Care Act (ACA) requires marketplace plans to provide ten categories of Essential Health Benefits (EHB), which includes mental health and substance use conditions. Through the intersection of MHPAEA and the ACA, many health plans should offer mental health and substance use disorder benefits, creating a new group of individuals in the U.S. who could gain access to treatment if needed.
Yet, seven years later many individuals with health plans still have difficulty gaining access to treatment when it should be legally provided.
The issue of parity under MHPAEA focuses on individuals who have health insurance. Even if a plan covers mental health benefits there are often ways of limiting treatment. Before MHPAEA, insurers would place caps on the quantity of treatment, high copays, or separate deductibles for people seeking mental health treatment. Now some insurers will claim that a mental health visit is not “medically necessary” or require prior authorization to meet with mental health professional, which may not be required for other medical diagnoses.
According to the Department of Labor, to date, the U.S. government has not taken a single public enforcement action against an insurer or employer for violating the laws established through MHPAEA. 
Former Congressman Patrick Kennedy, who helped write the parity legislation, boiled down the government’s enforcement into two words: slow and sparse. Kennedy stated that the ACA took attention away from the newly implemented parity law, which resulted in little enforcement. Insurance companies were on coalitions that helped pass the ACA, which means that enforcing the parity law against the same companies could complicate political ties.
Mental Health America released a report highlighting the challenges faced in achieving true parity. The report found that among the 50 state benchmark plans*, 22 of the plans had quantitative limits on mental health services. Some plans guarantee more coverage than others, while some exclude certain services, like family or marital counseling or bereavement counseling, explicitly in their fine print. Further limitations exist on the type or severity of the condition that qualifies for treatment. Often exclusions occur for “non-biologically based” conditions or certain types of disorders like a learning disability or eating disorders.
Texas was ranked 47th on rates of access to mental health care and 44th on adults with any mental illness who received treatment. When we look at the numbers, it is hard to deny that Texans need the enforcement of MHPAEA for greater access to desired treatment.
Enforcement of current parity laws is both necessary and dire if we want to promote recovery and mental wellness both in Texas and across the country.
*A benchmark plan is a health plan selected by each state as a standard for other health plans. Any health plan that wants to be sold on the state’s health insurance marketplace must cover the same benefits as a benchmark plan, thought it may require higher deductibles and copayments. The benchmark plan is usually based on a typical health plan offered by a large employer in that state.
 National Alliance on Mental Illness. (2015). A Long Road Ahead: Achieving True Parity in Mental Health and Substance Use Care. Retrieved from https://www.nami.org/About-NAMI/Publications-Reports/Public-Policy-Reports/A-Long-Road-Ahead/2015-ALongRoadAhead.pdf
 Gold, Jenny. (2015). Health Insurers Face Little Enforcement of Federal Mental Health Parity Law. Retrieved from http://www.wbur.org/npr/427464632/health-insurers-flout-federal-parity-law-for-mental-health-coverage
 Mental Health America. (2015). Parity or Disparity: The State of Mental Health in America. Retrieved from http://www.mentalhealthamerica.net/sites/default/files/Parity%20or%20Disparity%202015%20Report.pdf