Families, Systems, & Health

Primary care for patient complexity, not only disease.
Primary care is increasingly geared toward standardized care and decision-making for common chronic conditions, combinations of medical and mental health conditions, and the behavioral aspects of care for those conditions. Yet even with well-integrated team-based care for health conditions in place, some patients do not engage or respond as well as clinicians would wish or predict. This troubles patients and clinicians alike and is often chalked up informally to "patient complexity.” Indeed, every clinician has encountered complex patients and reacted with “Oh my gosh”—but not necessarily with a patterned vocabulary for exactly how the patient is complex and what to do about it. Based on work in the Netherlands, patient complexity is defined here as interference with standard care and decision-making by symptom severity or impairments, diagnostic uncertainty, difficulty engaging care, lack of social safety or participation, disorganization of care, and difficult patient-clinician relationships. A blueprint for patient-centered medical home must address patient complexity by promoting the interplay of usual care for conditions and individualized attention to patient-specific sources of complexity—across whatever diseases and conditions the patient may have. (PsycINFO Database Record (c) 2009 APA, all rights reserved)
Managing childhood chronic illness: Parent perspectives and implications for parent-provider relationships.
When children have special health care needs, parents assume the roles of care coordinator, medical expert, and systems advocate as well as their typical parenting roles. They face many challenges in managing their child’s chronic condition in the context of everyday life. Health care providers are uniquely positioned to assist parents in meeting those challenges and to promote parent competency and confidence in their child’s care. The data for this analysis were collected during classes for parents of children with chronic conditions who took part in a randomized controlled study of a curriculum’s effectiveness. During facilitated discussions, parents discussed challenges they faced and generated strategies they found helpful. Qualitative data analysis revealed dominant themes across subject areas. Challenges included social isolation, strained relationships and ongoing frustrations with health care and educational systems. Helpful strategies focused on being prepared, connecting with peers, becoming an advocate, developing partnerships and caring for one’s self. Implications for health care providers include: understanding common challenges parents face; promoting parent-to-parent connections; and building partnerships with parents and their children with special needs. (PsycINFO Database Record (c) 2009 APA, all rights reserved)
Stress among fathers of young children with type 1 diabetes.
Although fathers’ stress has been shown to have important implications for children’s health and well-being, few studies of children with Type 1 diabetes have considered paternal parenting stress. The current study contributes to the literature by exploring correlates of fathers’ pediatric parenting stress in a sample of young children with Type 1 diabetes. Forty-three fathers of children 2–6 years old with Type 1 diabetes completed self-report questionnaires examining pediatric parenting stress, child behavior, participation in diabetes management tasks, and parental psychological resources. Results of multiple regression show that fathers’ pediatric parenting stress is positively associated with state anxiety and mother-reported difficult child behavior. These findings suggest that fathers may experience parenting stress differently than mothers, and that their experiences may have implications not only for their own level of anxiety, but also for their children’s behavior. (PsycINFO Database Record (c) 2009 APA, all rights reserved)
Maternal fatigue and its relationship to the caregiving environment.
For women with an autoimmune illness, fatigue can be a debilitating symptom that impacts many aspects of their life. There is scant research on maternal fatigue and its impact on the caregiving environment for either well women or women with chronic illnesses. The objective of this study was to examine the role maternal fatigue played in the caregiving environment, specifically in the mother’s experience of the daily hassles of parenting, the discipline style she employed, and how she monitored her child’s whereabouts. Two-hundred sixty-two mothers participated in this study: 103 mothers with multiple sclerosis (MS), 68 mothers with rheumatoid arthritis (RA), and a comparison group of 91 well mothers. Mothers completed questionnaires assessing their self-reported levels of fatigue, depression, quality and quantity of sleep, parenting daily hassles, discipline styles, and monitoring. After sleep, depression, and number of children were controlled for, fatigue explained additional variance in predicting monitoring for all three groups of mothers. Fatigue was also a significant predictor of parenting daily hassles for both well mothers and mothers with RA, but not for mothers with MS. For mothers with MS, it was the covariates (i.e., the number of children in the family and sleep quality and quantity) that were predictive of parenting daily hassles. Several explanations for mothers with MS not being as influenced by fatigue are discussed. (PsycINFO Database Record (c) 2009 APA, all rights reserved)
Barriers and facilitators of adolescent behavioral health in primary care: Perceptions of primary care providers.
Several major policy reports describe the central role of primary care in improving the delivery of behavioral health care services to children and adolescents. Although primary care providers are uniquely positioned to provide these services, numerous obstacles hinder the integration of these services, including time, clinic management and organization issues, training, and resources. Although many of these obstacles have been described in the literature, few studies have investigated these issues from the first-person perspective of front-line providers. The purpose of this study, therefore, is to provide an in-depth description of primary care providers’ attitudes and perceptions of adolescent behavioral health care across a diversity of primary care settings (i.e., Federally Qualified Health Center [FQHC], FQHC-Look Alike, school-based, military). Sixteen focus groups were conducted at 5 primary care clinics. Thematic analysis was used to analyze the focus group data. Obstacles to integration are presented as well as strategies to overcome these challenges, using training and education, working groups, and community collaboratives. (PsycINFO Database Record (c) 2009 APA, all rights reserved)
Family-centered maternity care for deaf refugees: The patient-centered medical home in action.
The intersection of 2 underserved populations—refugees and deaf individuals—presents novel challenges to health care systems and has not been described previously. A patient-centered medical home (PCMH) is uniquely equipped to provide outstanding primary care to disadvantaged groups. As an illustrative case study, we present our experience applying principles of the PCMH to address an extremely challenging clinical situation: providing high-quality maternity care to a recently immigrated Vietnamese refugee couple lacking formal language skills. We describe how enhanced access, continuity, coordination, and cultural appropriateness can facilitate favorable outcomes in even daunting circumstances. By collaborating with multiple interpreters, the health center staff, and the extended family, we effectively mobilized an expanded system of care to ensure informed consent and shared decision making, ultimately culminating in a successful labor and vaginal delivery. Through organizational and individual commitment to the tenets of the PCMH, we demonstrate the particular strengths of family medicine training sites in caring for similar patients and families with complex cultural and linguistic barriers to care. (PsycINFO Database Record (c) 2009 APA, all rights reserved)
Book reviews.
In this article, the new book review editor for Families, Systems, & Health introduces his first three selections for the book review section. Two of the books are related to collaborative care and the third is an excellent introduction to narrative medicine. (PsycINFO Database Record (c) 2009 APA, all rights reserved)
Review of Narrative in health care: Healing patients, practitioners, profession, and community.
Reviews the book, Narrative in health care: Healing patients, practitioners, profession, and community by John D. Engel, Joseph Zarconi, Lura L. Pethtel, and Sally A. Missimi (2008). This book provides the missing piece to the health care puzzle, guiding medical providers toward learning or rediscovering atrophied skills in accessing and connecting to the patient’s story. This book goes beyond advocating for an additional tool in the health care practitioner’s toolbox; it effectively embodies a paradigm shift by proposing a revolutionary way to alter health care and the provider–patient relationship as we know it. Potential readers, whether physician, nurse, physician’s assistant, medical assistant, psychologist, social worker, patient, or patient’s family, each with their own individual and ever-changing narrative, can expect to come away from this book changed as a result of interacting with this text. (PsycINFO Database Record (c) 2009 APA, all rights reserved)
Review of The collaborative psychotherapist: Creating reciprocal relationships with medical professionals.
Reviews the book, The collaborative psychotherapist: Creating reciprocal relationships with medical professionals by Nancy Breen Ruddy, Dorothy A. Borresen, and William B. Gunn Jr. (see record 2008-03695-000). This book extends the collaborative care model by exploring how to work collaboratively across the five models of care as proposed by Doherty, McDaniel, and Baird (1996) and offers ample guidance for mental health professionals who are not embedded in primary care settings, but rather work from their own independent practice or mental health agency offices. This volume is in some ways a “how to” book. We have all read “how to” books that oversimplify and suggest a “one size fits all” approach to health care delivery. This book is an exemplar of a “how to” book with significant depth and sophistication. (PsycINFO Database Record (c) 2009 APA, all rights reserved)
Review of Collaborative medicine case studies: Evidence in practice.
Reviews the book, Collaborative medicine case studies: Evidence in practice by Rodger Kessler and Dale Stafford (see record 2008-02218-000). This book is timely in that it introduces an inspiring compilation of case examples demonstrating that collaborative health care can work and is working in many places and with phenomenal outcomes. Many of the contributors included in this book are the same authors that have provided the conceptual and practical foundation of collaborative care over the last 20 years. The spirit of collaborative care really comes to life in this book as the voices of experts share case examples of their work through collaborative writing. However, this book is more than just a feel good, chicken soup for the collaborative care provider’s soul type book. This is an edited book that includes 80 contributors in 36 chapters. (PsycINFO Database Record (c) 2009 APA, all rights reserved)

Families, Systems, & Health - Vol 27, Iss 4