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PubMed1995

Long-term outcome of state hospital patients discharged into structured community residential settings.

OBJECTIVE: This longitudinal study examined various dimensions of the lives of patients with chronic mental illness immediately before and again several years after their discharge from a state hospital into well-staffed structured community residential settings. METHODS: Fifty-three patients with chronic mental illness and long histories of hospitalization were evaluated shortly before their state hospital discharge using a comprehensive structured assessment of nine dimensions of functioning and symptomatology. A follow-up assessment was undertaken a mean of 7.5 years after discharge into four structured group home settings. RESULTS: At follow-up, 57 percent of the patients continued to live in structured community residential settings, 28 percent had moved on to independent living, and 16 percent had returned to an institutional setting. Fifty-five percent needed hospital readmission, but the total sample spent only 11 percent of the time after discharge in the hospital. At follow-up, patients showed significant improvements in cognitive and social functioning, and 94 percent expressed a preference for life in the community. CONCLUSIONS: Many patients discharged to structured community residential settings seem to prefer them to the state hospital, are able to graduate to independent settings, and show improvement in important dimensions of functioning after several years in the community. Other dimensions seem resistant to change despite the structure and support afforded by residential settings.

Activities of Daily Living↗

PubMed1998

Effects of physical activity interventions in youth. Review and synthesis.

INTRODUCTION: Physical inactivity has been identified as an important public health concern for youth. School and community settings can be important infrastructures for promoting physical activity (PA). This paper reviews studies of physical activity in school and community settings among preschool through college-aged persons to determine characteristics and effects of interventions. Studies in progress are included. METHODS: Studies from 1980 to 1997 testing physical activity interventions in schools and community settings were identified by computerized search methods and reference lists of published reviews. Studies needed to have used a quantitative assessment of PA, used a comparison or control group, included participants who were preschool through college age, and be conducted in the United States or foreign school or community settings. Significance of effects was examined overall and for various types of interventions. RESULTS: Twenty-two school-based studies were reviewed, 14 completed and 8 in progress. Three studies were in countries other than the United States. The 8 studies in progress were all in the United States. Only 7 community studies were reviewed, all in the United States. Four studies were in progress. Several community studies involved a high percentage of African-American or Hispanic youth and their families. Studies showing the best results used randomized designs, valid and reliable measurements, and more extensive interventions. Some follow-up results showed PA was sustained after interventions ended. CONCLUSIONS: The collection of school and community studies is limited for several age groups with none below third grade and only three at college age. There are few community studies. The most is known about upper-elementary-age-students, including the first multicenter randomized trial to report significant results for increasing moderate to vigorous physical activity (MVPA) in physical education (PE) and increase vigorous PA outside of school. A number of older study designs were weak and assessments less than optimal, but studies in progress are stronger. Special attention is needed for girls, middle schools, and community settings for all youth. More objective assessments are needed for measuring PA outside of school and in younger children, since they cannot provide reliable self-report.

Adolescent↗

PubMed2001

Starting a successful bariatric surgical practice in the community hospital setting.

BACKGROUND: 3% of the population is morbidly obese and experience many associated medical problems. Surgical procedures have been shown to achieve sustained weight loss not attainable by other measures, lessening the co-morbidities. However, most general surgeons have been reluctant to expand their practice to include bariatric surgery. The current study demonstrates the benefits of including bariatric surgery in a general surgeon's practice in a community hospital. METHODS: Hospital charts of patients undergoing a gastric bypass procedure between 1997 and 2000 were reviewed. Demographic data, co-morbid conditions, intra-operative times, and post-operative weight loss were recorded. Follow-up data was obtained using a mailed survey based on the BAROS survey. RESULTS: 168 patients underwent a Roux-en-Y gastric bypass procedure. Follow-up was obtained for 86 patients. Average pre-operative weight was 141 kg (BMI = 50). There was an average loss of 55% of excess weight by the second post-operative year. Operative times decreased as the number of the procedures performed by the surgeon increased. Over half of the patients surveyed reported improvements for each of the co-morbid conditions that were assessed (i.e., diabetes, back pain, etc.). Five categories of quality of life were assessed, and over 66% of patients reported improvements in all areas. In 44% of the patients, payment was obtained from private insurance and 56% from Medicare or Medicaid. There were no deaths. CONCLUSION: Adding bariatric surgery to a general surgeon's practice in the community setting can be beneficial to patients, intellectually stimulating and emotionally rewarding for the surgeon, and economically feasible for the institution.

Adult↗

PubMed1996

Laparoscopic hernia repair in the community hospital setting.

Eighty-three patients (108 repairs) with inguinal hernias underwent laparoscopic transabdominal preperitoneal repair in the community hospital setting. The patients included 82 men and one woman, ranging in age from 15 to 82 years. Concomitant procedures included umbilical hernia repairs, lysis of adhesions, and varicocoelectomy. Ninety-four percent of these patients were discharged the same day, with only one patient requiring more than an overnight stay. Postoperative complications included five cases of urinary retention requiring overnight catherization (4.6%) and one case each of labile hypertension (0.9%), vasovagal reaction (0.9%), dizziness (0.9%), and ileus (0.9%); there were 12 cases of groin swelling with ecchymosis (11%). With follow-up of almost 2 years, there has been one known recurrence (0.9%). This study demonstrates that laparoscopic hernia repair can be performed safely and successfully in the community hospital setting and can be a sound alternative to the standard open hernia repair.

Adolescent↗

PubMed2005

Integrating prevention in residential and community care settings: a multidimensional program evaluation.

As people with HIV live longer and healthier lives, ongoing prevention with positive individuals has become a new focus of care. Effective prevention with positives interventions are emerging and new interventions continue to be developed. This article discusses the development and evaluation of the prevention for positives intervention developed for a large AIDS service organization in Chicago. The intervention consists of case manager based HIV prevention education and support within residential and community settings. The article describes the intervention and presents the methods and findings of the program evaluation. The multidimensional evaluation includes formative and process evaluation elements as well as qualitative and quantitative measures (N = 94). The article concludes with a discussion of the challenges and opportunities associated with integrating prevention into care.

Adult↗

PubMed1989

The view from Walter's window: social environment and the communicative competence of adults with a mental handicap.

This paper reports on a study of the communicative competence of adults with a mental handicap living in hospital and community settings. One hundred and twenty subjects, half from hospital settings and half from community settings, were assessed on the Communication Assessment profile (CASP). Significant differences were found between the hospital and community groups on pragmatic competence. The communication environment was shown to be an important determinant of pragmatic skills. The implications of this finding are discussed.

Adaptation, Psychological↗

PubMed2003

Client-level predictors of adherence to MST in community service settings.

This study examined the association of youth and family characteristics with therapist fidelity to an evidence-based treatment provided in real world practice settings. Participants were 233 families that reported on the 66 therapists organized into 16 teams in nine organizations providing multisystemic therapy (MST). Therapist adherence ratings were lower for youths referred for both criminal offenses and substance abuse than for youths referred either for substance abuse or status offenses, and was negatively associated with pretreatment arrests and school suspensions. Adherence ratings were positively associated with educational disadvantage and caregiver-therapist ethnic match and marginally positively associated with economic disadvantage. The findings suggest directions for future research on the implementation of evidence-based treatments in community settings.

Adolescent↗

PubMed1993

Frequent and difficult problems perceived by nurses caring for the dying in community, hospice and acute care settings.

A total of 167 practising nurses from three practice settings--community, hospice and acute care--were asked to identify the five most common problems encountered when caring for the dying and the five most difficult problems to manage. Nine main categories of problems were elicited, including physical, work-related, nurse-related, death-related and spiritual problems. Key categories have been selected for discussion in this paper. Specific differences in the responses obtained from the three practice settings may be related to differences in the ethos of care of the dying patient in each area, particularly between hospice/community care and acute care. The findings of the survey will serve as a basis for planning initiatives in education and research in palliative care nursing.

Attitude of Health Personnel↗

PubMed2001

Cost utility of public clinics to increase pneumococcal vaccines in the elderly.

BACKGROUND: Pneumococcal immunization has been shown to be cost effective, is recommended by the Advisory Committee on Immunization Practices, and is covered by Medicare. Despite that, over 50% of the population aged > or =65 is not vaccinated, leading to significant mortality and morbidity. The objective of this study is to evaluate the costs and the cost utility of immunization in nontraditional settings (community clinics set up to provide influenza and pneumococcal vaccinations) as a strategy to increase pneumococcal immunization rates. METHODS: A cost-utility analysis of public immunization clinics in Monroe County, New York, during the fall of 1998. The study included 1207 adults aged > or =65. Costs of operating the clinics and of vaccine administration were measured. The cost of health sequela and estimates of quality-adjusted life years (QALYs) were obtained from prior studies. Sensitivity analyses were performed to test several important assumptions. RESULTS: Unlike immunizations in physician offices, immunizations in nontraditional settings are not cost saving. Estimates of incremental cost-utility ratios ranged from $4215 per QALY to $12,617 per QALY, depending on the underlying assumptions of the model. CONCLUSIONS: Clinics in nontraditional settings offering pneumococcal immunization have cost-utility ratios near and below those of other recommended vaccines. These results suggest that such clinics should be considered a viable strategy for increasing pneumococcal immunization rates.

Aged↗

PubMedDate not supplied

The impact of assistive technology and environmental interventions on function and living situation status with people who are ageing with developmental disabilities.

PURPOSE: A longitudinal study of 109 people with developmental disabilities, age 35 and older, was done to study the additive impact of mid to later life assistive technology and environmental interventions (AT-EI) on function and living situation status. All subjects were trying to transition out of institutional settings to community settings. METHOD: Functional status were measured at two times (Time I baseline and Time 2 an average of three years post intervention) on 32 functional activities under two conditions: without AT (person only) and with AT (environment adjusted). Rasch analysis was performed to convert ordinal functional scores to equal interval measures, with 95% confidence intervals computed to compare differences in function, with and without AT, across time. RESULTS: Results indicated that over 70% of subjects had better function with AT versus without AT at both time points. Over time, function did not change when rated without AT; however, when rated with AT, 13.6% had better function at Time 2. Subjects living in the community at Time 2 had significantly higher functional scores as compared to subjects in institutions, regardless of AT condition. Additional quantitative and qualitative data on AT-EI use, needs, and barriers and supports to its integration into everyday activities are reported. CONCLUSIONS: Results suggest a beneficial impact of later life AT-EI assessment and programming for people who are ageing with developmental disabilities, and qualitatively point to the influence of the social and physical living context upon AT-EI use and relationship to community living decisions long term.

Adult↗

PubMedDate not supplied

Role of a paediatric nurse in primary care 2: research findings.

This article is the second of a two-part article that presents the findings of a study focusing on the role and function of two qualified children's nurses, each working within a different primary healthcare team (PHCT). The first part described the variation in settings for community paediatric nurses, the paucity of literature discussing the role of a paediatric nurse working as a member of a PHCT, the application of a research methodology that incorporated practitioner values and experience, the application of naturalist inquiry and the use of a formative evaluation strategy which enabled the researcher to be involved in directing and supporting the research nurses with the data collection (Vol 11(22): 1452-60). This second part focuses on the findings and discussions where it was demonstrated that qualified children's nurses working in community setting contributes to raising the overall support and quality of care for a whole range of conditions currently perceived as low profile. There was evidence that these nurses catered for unmet needs and were, at times, functioning as nurse practitioners and on occasions as advanced practitioners. These findings may contribute as a catalyst for change in informing the development of children's nursing services as part of the Children's National Service Framework.

Community Health Nursing↗

PubMed1996

Some unchanging values of pediatric education during a time of changing technology and practice.

A few of the opportunities and difficulties of educating pediatric residents in a particular community-based setting, the managed care organization, are discussed in this article. Some of these organizations have deliberately recruited corporate employees with young families, offering relatively complete coverage. Quality problems remain, however. Children may benefit, because managed care arrangements may reduce overdiagnosis and overtreatment, but children may also be deprived, particularly in Medicaid managed care programs, of needed, appropriate care. Pediatric faculties must be confident about the quality of care, the quality of teaching, and the opportunity for residents to develop interpersonal skills before residents are placed in managed care settings. First, however, important, broader aspects of contemporary pediatric education are discussed. These essentials of contemporary pediatric education apply in any setting, community based or not, and not only to physicians in training, but to those who are delivering ongoing care as well. A case study illustrates the impact of technologic advances on medical diagnosis and management. Such advances may lead to the chance for better outcomes but also to confusion, including misperceptions about disease prevalence, the natural history of disease, and therapeutic effectiveness. To meet patient needs and to provide a medically educated physician, the understanding of biology and disease that grows out of scientific advances must be balanced with the illness-related functions of the physician. Two approaches to this goal are suggested: (1) the epidemiologic and demographic anatomy of the health of populations and the socioeconomic kinetics of our society and its diverse value systems relevant to health care should be deliberately structured into all phases of medical education; and (2) the sites of the educational process should be diversified so that residents are placed, perhaps as much as half the time, in those settings in which most patients interact with physicians.

Adolescent↗

PubMed1999

Mild cognitive impairment: clinical characterization and outcome.

BACKGROUND: Subjects with a mild cognitive impairment (MCI) have a memory impairment beyond that expected for age and education yet are not demented. These subjects are becoming the focus of many prediction studies and early intervention trials. OBJECTIVE: To characterize clinically subjects with MCI cross-sectionally and longitudinally. DESIGN: A prospective, longitudinal inception cohort. SETTING: General community clinic. PARTICIPANTS: A sample of 76 consecutively evaluated subjects with MCI were compared with 234 healthy control subjects and 106 patients with mild Alzheimer disease (AD), all from a community setting as part of the Mayo Clinic Alzheimer's Disease Center/Alzheimer's Disease Patient Registry, Rochester, Minn. MAIN OUTCOME MEASURES: The 3 groups of individuals were compared on demographic factors and measures of cognitive function including the Mini-Mental State Examination, Wechsler Adult Intelligence Scale-Revised, Wechsler Memory Scale-Revised, Dementia Rating Scale, Free and Cued Selective Reminding Test, and Auditory Verbal Learning Test. Clinical classifications of dementia and AD were determined according to the Diagnostic and Statistical Manual of Mental Disorders, Revised Third Edition and the National Institute of Neurological and Communicative Disorders and Stroke-Alzheimer's Disease and Related Disorders Association criteria, respectively. RESULTS: The primary distinction between control subjects and subjects with MCI was in the area of memory, while other cognitive functions were comparable. However, when the subjects with MCI were compared with the patients with very mild AD, memory performance was similar, but patients with AD were more impaired in other cognitive domains as well. Longitudinal performance demonstrated that the subjects with MCI declined at a rate greater than that of the controls but less rapidly than the patients with mild AD. CONCLUSIONS: Patients who meet the criteria for MCI can be differentiated from healthy control subjects and those with very mild AD. They appear to constitute a clinical entity that can be characterized for treatment interventions.

Aged↗

PubMed1995

Changes in myocardial perfusion abnormalities by positron emission tomography after long-term, intense risk factor modification.

OBJECTIVE: To quantify changes in size and severity of myocardial perfusion abnormalities by positron emission tomography (PET) in patients with coronary artery disease after 5 years of risk factor modification. DESIGN: Randomized controlled trial. SETTING: Outpatient community setting. INTERVENTION: Randomization of patients to risk factor modification consisting of very low-fat vegetarian diet, mild to moderate exercise, stress management, and group support (experimental group, n = 20) or to usual care by their own physicians, consisting principally of antianginal therapy (control group, n = 15). MAIN OUTCOME MEASURES: Quantitative coronary arteriography and PET at baseline and 5 years after randomization. Automated, objective measures of size and severity of perfusion abnormalities on rest-dipyridamole PET images and of stenosis severity on arteriograms were made by computer algorithms. RESULTS: Size and severity of perfusion abnormalities on dipyridamole PET images decreased (improved) after risk factor modification in the experimental group compared with an increase (worsening) of size and severity in controls. The percentage of left ventricle perfusion abnormalities outside 2.5 SDs of those of normal persons (based on 20 disease-free individuals) on the dipyridamole PET image of normalized counts worsened in controls (mean +/- SE, + 10.3% +/- 5.6%) and improved in the experimental group (mean +/- SE, -5.1% +/- 4.8%) (P = .02); the percentage of left ventricle with activity less than 60% of the maximum activity on the dipyridamole PET image of normalized counts worsened in controls (+13.5% +/- 3.8%) and improved in the experimental group (-4.2% +/- 3.8%) (P = .002); and the myocardial quadrant on the PET image with the lowest average activity expressed as a percentage of maximum activity worsened in controls (-8.8% +/- 2.3%) and improved in the experimental group (+4.9% +/- 3.3%) (P = .001). The size and severity of perfusion abnormalities on resting PET images were also significantly improved in the experimental group as compared with controls. The relative magnitude of changes in size and severity of PET perfusion abnormalities was comparable to or greater than the magnitude of changes in percent diameter stenosis, absolute stenosis lumen area, or stenosis flow reserve documented by quantitative coronary arteriography. CONCLUSIONS: Modest regression of coronary artery stenoses after risk factor modification is associated with decreased size and severity of perfusion abnormalities on rest-dipyridamole PET images. Progression or regression of coronary artery disease can be followed noninvasively by dipyridamole PET reflecting the integrated flow capacity of the entire coronary arterial circulation.

Adult↗

PubMed2004

Community-based screening for cardiovascular disease and diabetes using HbA1c.

BACKGROUND: Persons from inner-city immigrant and mixed-ethnic communities are known to be at high risk for cardiovascular disease and diabetes. Such communities may also be underserved for preventive medical care. The authors hypothesized that hemoglobin A1c (HbA1c) could be used as a screening test for a community-based program to detect new cases of diabetes and persons at risk for diabetes and cardiovascular disease. METHODS: Screenings took place in churches, group homes, shelters, community centers, and street corners of the Bronx. Screening data included history of diabetes, age, ethnicity, body mass index, blood pressure, lipid panel, random glucose, and HbA1c. Data were analyzed for number of cases of new diabetes (HbA1c > or =7%), for patients at risk for diabetes (HbA1c 6%-6.99%), and for associations between HbA1c and other variables. The effect of location of screening and self-reported ethnicity on outcome variables was also analyzed. RESULTS: Seven hundred four persons were screened in 25 different sessions. HbA1c and lipid profile were obtained on 539 persons, which formed the cohort for analysis. Mean HbA1c for the cohort was 6.00%. Thirty-two percent of the cohort had HbA1c of more than 6%, and 11.4% had HbA1c of more than 7%. Excluding known diabetics (13% of cohort), 24% had HbA1c of more than 6%, and 3.4% had HbA1c of more than 7%. HbA1c was significantly correlated with total cholesterol, triglycerides, low-density lipoprotein, systolic blood pressure, body mass index, and age; in all cases, correlation coefficients were higher with HbA1c than with random glucose. In addition, significantly higher cardiovascular disease risk factors were found in persons with HbA1c of more than 6%; 6% may be a threshold value for the metabolic syndrome. Mean HbA1c was higher in persons from the South Bronx (which has a higher poverty rate) than the North Bronx (6.08% v 5.74%, p=0.013). There were no statistically significant differences between self-reported ethnic groupings. CONCLUSIONS: There was a high prevalence of undiagnosed diabetes, and of patients at risk for diabetes, in this community setting. Community-based screening can be used as a method for identifying high percentages of patients at risk for diabetes or with undiagnosed diabetes in an inner city, immigrant, mixed-ethnic population.

Adult↗

PubMed2004

Water-based exercise for cardiovascular fitness in people with chronic stroke: a randomized controlled trial.

OBJECTIVE: To evaluate the effect of an 8-week, water-based exercise program (experimental group) with that of an upper-extremity function program (control group) to increase cardiovascular fitness within a community setting for people with stroke. DESIGN: Single-blind randomized controlled trial. SETTING: Public community center. PARTICIPANTS: A volunteer sample of 12 community-dwelling people with stroke with mild to moderate residual motor deficits. INTERVENTION: Study subjects participated in group exercise programs for 1 hour, 3 times a week for 8 weeks. The experimental group exercised in chest-deep water at targeted heart rates. The control group performed arm and hand exercises while sitting. Main outcome measures The primary outcome measure was cardiovascular fitness (V(O2)max). Secondary measures were maximal workload, muscle strength, gait speed, and the Berg Balance Scale score. RESULTS: The experimental group attained significant improvements over the control group in cardiovascular fitness, maximal workload, gait speed, and paretic lower-extremity muscle strength. The relatively short program (8 wk) of water-based exercise resulted in a 22% improvement in cardiovascular fitness in a small group of people with stroke who had relatively high function. CONCLUSIONS: A water-based exercise program undertaken as a group program may be an effective way to promote fitness in people with stroke.

Aged↗

PubMedDate not supplied

Implementing evidence-based guidelines for radiography in acute low back pain: a pilot study in a chiropractic community.

OBJECTIVE: To evaluate the ability of a systematic educational intervention strategy to change the plain radiography ordering behavior of chiropractors toward evidence-based practice for patients with acute low back pain (LBP). DESIGN: A quasi-experimental method was used comparing outcomes before and after the intervention with those of a control community. SETTING: Two communities in southern Ontario. DATA SOURCE: Mailed survey data on the management of acute LBP. Outcome Measures Plain radiography use rates for acute LBP based on responses to mailed surveys. RESULTS: Following the intervention, there was a 42% reduction in the self-report need for plain radiography for uncomplicated acute LBP (P <.025) and a 50% reduction for patients with acute LBP < 1 month (P <.025) in the intervention community. There was no significant change in the self-report need for plain radiography in the control community (P >.05). CONCLUSIONS: The educational intervention strategy used in this study appeared to have an effect in reducing the perceived need for plain radiography in acute LBP.

Adult↗

PubMed1995

A community-based, interagency approach by dietitians to provide meals, medical nutrition therapy, and education to clients with HIV/AIDS.

Dietitians have the opportunity to be leaders in providing medical nutrition therapy and home-delivered meals for people with human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) in the community setting. Four community agencies developed the Visiting Nurse Service HIV/Home Delivered Meals Program. Fifty clients with the diagnosis of HIV and/or AIDS were served for a 6-month period. The program provided convenient, energy-enhanced nutritious meals. Participants received daily hot and cold, energy- and protein-enhanced home-delivered meals; weekly high-energy, high-protein, shelf-stable Snack Packs; a Medical Nutritional Supplement Sampler Pack; and two home visits from dietitians. Different diet options were available. Dietitians completed 47 initial nutrition assessment and food safety education visits 1 to 2 weeks after meal delivery began, and 35 participants received follow-up nutrition counseling visits 4 to 8 weeks later. Participant data (including weights) were self-reported. Dietitians reported that 13 of 35 participants gained weight (mean = 6 lb), 11 of 35 remained the same weight, and 11 of 35 lost weight (mean = 5 lb). Initially, 14 of 35 participants were considered to be "doing well"; this improved to 19 of 35 participants 1 to 2 months later. Snack Packs were effective means to help participants meet some of their increased nutrient needs. The Medical Nutritional Supplement Sampler Pack was effective in familiarizing each participant with available products. Medical nutrition therapy by registered dietitians helped most participants improve their food consumption.

Acquired Immunodeficiency Syndrome↗