Disability in America Toward a National Agenda for Prevention (1991) / Chapter Skim
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8 A Comperhensive Approach to Disability Prevention: Obstacles and Opportunities
8 A Comperhensive Approach to Disability Prevention: Obstacles and Opportunities
Pages 242-266
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From page 242... ...
Among national goals, disability prevention is akin to an orphan whose 242
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From page 243... ...
Disability prevention requires an effective system of longitudinal care, an integrated service delivery network that is responsive to the health, social, housing, and personal care needs of people who have disabling conditions or who have a high risk of developing them. Many of the elements of the desired network are already in place but now operate in isolation rather than as complementary parts of an integrated whole.
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From page 244... ...
Timely and appropriate medical intervention is an essential element of the committee's recommended approach to disability prevention an integrated system of longitudinal care. However, the committee agrees with Caplan (1988)
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From page 245... ...
When viewed as a complementary element of disability prevention, health care can move in new directions. For example, treatment protocols, as recommended in the previous chapter, would consider not only medical needs but also necessary environmental modifications, the availability of family support, and other nonmedical variables.
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From page 246... ...
The goal of disability prevention was only indirectly represented in the 226 health objectives, which were divided among 15 target areas such as control of high blood pressure, immunization, infant health, accident prevention and injury control, nutrition, and physical fitness. This is not to say, however, that accomplishing the objectives would not translate into significant advances against some disabling conditions.
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From page 247... ...
The establishment of a distinct set of national goals related to disability was proposed in 1986 in federal rehabilitation legislation, but the proposal did not pass (Vachon, 1989-1990~. The goal of disability prevention would be advanced significantly if it were fully incorporated into the nation's health objectives.
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From page 248... ...
In contrast, the Supplementary Security Income program, Medicaid, and vocational rehabilitation programs are jointly funded but administered at the state level, while municipalities manage most housing and transportation programs. This diffusion of administrative responsibility and direction manifests in fragmentation at the service delivery end.
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From page 249... ...
This requirement was waived in 1959, however, for applicants who were bedridden, institutionalized, or mentally ill, or who had a worsening impairment (Berkowitz and Fox, 1989~. At best, rehabilitation and disability prevention rank as subordinate goals of SSDI, an example of the underemphasis on promoting autonomy.
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From page 250... ...
Rehabilitation provisions of Social Security Administration disability benefit programs include federal reimbursement to states for vocational rehabilitation services provided to recipients of federal disability benefits. Among other restrictions, this provision applies only if the beneficiary returns to work and remains employed for nine consecutive months (Institute of Medicine, 19871.
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From page 251... ...
analysis of the disability risks of chronic impairments, which found that about 1 million people, or about 3 percent of the population with activity limitations, have a form of mental illness. However, the inference that people with a mental illness are not appropriate targets of public vocational rehabilitation services is likely to foster considerable disagreement.
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From page 252... ...
Insurance Status The few surveys that have investigated at least some aspects of health care coverage for the population with disabling conditions and chronic diseases yield only a cursory assessment. A 1984 National Health Interview Survey estimated that about 11 percent of 22.2 million people who are limited in the performance of their major activity do not have insurance (Table 8-2~.
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From page 253... ...
About half the uninsured with a work disability are not employed and not receiving Supplemental Security Income or SSDI (Griss, 1988~. Given higher-than-average levels of poverty and unemployment among people with disabling conditions, and given the fact that poverty and unemployment are strongly correlated with lack of health care coverage, the population with disabling conditions is especially at risk of not having financial access to medical services, despite its greater need for these services.
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From page 254... ...
Types of Health Care Services As noted in the preceding discussion, insurance coverage does not necessarily translate into coverage for the types of health care services required by people with disabling conditions. Generally, coverage is limited to acute care and for the most part excludes services recognized as important ele
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From page 255... ...
Common to Medicare, Medicaid, and private policies, another restriction is the stipulation that reimbursement will continue only for as long as the person receiving rehabilitation services continues to show improvement in functional capacity. Yet for many people for example, those with head injuries or chronic heart conditions improvement in functional capacity may not be apparent until long after the start of therapy.
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From page 256... ...
. On the basis of its national study, the World Institute on Disability concluded that public funds expended for attendant-care services could be used more efficiently, resulting in improved services for a greater number of people in need and at least delaying institutionalization and its higher costs.
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From page 257... ...
reimbursement for vision aids; and (4) related rehabilitation services.
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From page 258... ...
Thus, although tertiary prevention is an integral component of rehabilitation, disability prevention per se has not been a major theme of rehabilitation research, planning, or interagency coordination. The size and complexity of disability issues and the comprehensiveness of the public health approach required to address the compelling national need necessitate a large, well-coordinated program of disability prevention.
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From page 259... ...
Specialties of the multidisciplinary centers include functional electrical stimulation, musculoskeletal disorders, work-site modifications, deafness and communication disorders, blindness and low vision, mental illness, mental retardation, and developmental problems of newborns with disabilities and neuromuscular disorders. Separate from the centers is the NIDRR-supported network of 13 Model Spinal Cord Injury Care Systems, each providing an integrated set of services to patients with spinal cord injuries.
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From page 260... ...
Veterans Administration, 1988~. Disability Prevention The Injury Control and Disabilities Prevention Programs of the CDC's Center for Environmental Health and Injury Control embrace all three supporting elements surveillance, research, and services—of an integrated system of prevention and longitudinal care.
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From page 261... ...
Concentrating on such problems as urinary tract infections and decubitus ulcers in people with spinal cord injuries and late-developing complications in people with poliomyelitis, the epidemiologic studies are expected to yield more detailed understanding of the scope of such problems and to aid identification of cost-effective interventions. The CDC programs are notable for their public health approach to disability prevention.
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From page 262... ...
Although federal budget constraints are real, they do not preclude setting realistic goals for disability prevention, nor should immediate budgetary exigencies obscure the cost savings and increased productivity that will accrue to prevention measures. In addition, states and communities must act on their own, for they too will reap the benefits of disability prevention.
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From page 263... ...
Moreover, local efforts would benefit greatly from input and contributions from the private sector and individual members of the community. Clearly, all of the interrelated issues subsumed under the heading of disability prevention, from the need for affordable, widely accessible health care services to shortcomings of worker training and education programs, are of great concern to the private sector.
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From page 264... ...
The attitudes and behaviors of the public and those of health care workers, social workers, and other professionals can either facilitate the participation in society of people with disabling conditions or pose formidable obstacles. Thus, public education is an essential element of disability prevention.
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From page 265... ...
Yet effective care often depends on the coordinated contributions of many such professionals. The Sum of the Parts Viewed collectively, the disability prevention effort addresses many important public health issues.
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From page 266... ...
Quality of life can also be gauged in ways that measure how effective secondary and tertiary prevention measures are, for example, in promoting independence among people with disabling conditions or in reducing work absences among the population with disabling conditions. Fully embracing quality of life as a national health standard can bridge artificial boundaries between disciplines and between social and medical services.
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