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PubMed1997

HIV prevention and drug treatment services for drug misusers: a national study of community pharmacists' attitudes and their involvement in service specific training.

AIMS: To investigate the attitudes of community pharmacists towards HIV prevention services for drug misusers and the relationship between these and their involvement in service provision. DESIGN: Postal survey of a one in four random sample of community pharmacies (N = 2654) in England and Wales, stratified by Family Health Service Authority, in 1995, using up to four mailshots. SETTING: Community pharmacies in England and Wales. PARTICIPANTS: The community pharmacist in charge of the dispensary at the random sample of community pharmacies. MEASUREMENTS: Information on attitudes and behaviour were collected through self-completion and postal return of structured questionnaires using questions with both category responses and Likert scales. FINDINGS: A 74.8% response rate was achieved. Community pharmacists were positive about their role in HIV prevention and the provision of clean injecting equipment to injecting drug users--positive attitudes that were more evident among those pharmacists already providing these services. However, they had concerns over the effect drug misusers may have on business and indicated a need for more training and for more role support. Only a minority had taken part in training on drug misuse and HIV prevention (34.7% and 21.3%, respectively). Many community pharmacists supported the proposal that there should be extensions of their involvement, to include services such as supervising the consumption of methadone in the pharmacy (38.6%) and collecting used prescribed ampoules from patients (33.8%). Positive relationships were identified between training and attitude, and between attitude and service provision. Changes in attitude responses between this 1995 survey and the earlier 1988 survey are also presented. CONCLUSIONS: Recommendations are made for further training and greater communication between prescriber/carer and the community pharmacists, for involvement of community pharmacies in new possible forms of service provision, and for there to be greater attention to the value of role support.

Attitude of Health Personnel↗

PubMed2002

Early rehabilitation service utilization patterns in young children with developmental delays.

OBJECTIVE: There is a growing demand for interdisciplinary rehabilitation services for children with developmental disabilities, however, information is lacking on service utilization patterns. This study describes the type, frequency and location of initial rehabilitation services provided to young children recently diagnosed with a developmental delay. METHODS: A telephone survey was conducted on a consecutive cohort of children referred to subspecialists for the first investigation of their delay. RESULTS: Out of 129 respondents, only 30 (23%) did not receive any rehabilitation services within the first 6 months following medical evaluation, and 61 (47%) received two or more services. Services were provided most frequently in the hospital setting, especially for occupational or physical therapy (73-80%). Services were less often rendered in a rehabilitation centre (5-13%) or in the community (< 10%). Services were provided privately for a subset, particularly for speech language pathology and psychology (34% and 30% respectively). Interventions were typically given weekly or bi-weekly. Children receiving physical therapy were significantly younger whereas children referred to speech language pathology were older than the age of our cohort at intake. Overall, parents' educational level did not influence services received with the exception of private services, which were more likely to occur in children of fathers with university education. CONCLUSIONS: The findings would suggest that long waiting times and lack of resources may limit access to comprehensive services, particularly in community settings. Service utilization patterns were not consistent within types of developmental disability, suggesting that formal and co-ordinated interdisciplinary programmes are not in place for this population of interest.

Child, Preschool↗

PubMed2006

Comparisons of community-associated methicillin-resistant Staphylococcus aureus (MRSA) and hospital-associated MSRA infections in Sacramento, California.

Methicillin-resistant Staphylococcus aureus (MRSA) has long been a common pathogen in healthcare facilities, but in the past decade, it has emerged as a problematic pathogen in the community setting as well. A retrospective case series study of patients from whom MRSA was isolated from December 1, 2003, through May 31, 2004, was conducted at the University of California, Davis, Medical Center. Patient data were collected from electronic medical records and traditional chart reviews to determine whether MRSA acquisition was likely to have been in the community or in the hospital. Antimicrobial susceptibility testing and pulsed-field gel electrophoresis (PFGE) were performed for all confirmed isolates. Skin and soft tissue were the most common infection sites for all MRSA patients. Among the 283 MRSA infections, 127 (44.9%) were defined as community-associated (CA)-MRSA. Ninety-six percent of the CA-MRSA isolates were susceptible to clindamycin. Double-disk diffusion tests were performed to examine inducible clindamycin resistance by erythromycin induction on both CA and hospital-associated (HA) clindamycin-susceptible and erythromycin-resistant isolates. Ten percent (17 of 183) were positive. Most CA-MRSA isolates were identified by PFGE as a unique strain, genotype USA300, which was not genetically related to the predominant genotype, USA100, in the HA-MRSA isolates. Injecting drug users accounted for 49% of CA-MRSA infections but only 19% of the HA-MRSA infections (odds ratio, 4.2; 95% confidence interval, 2.4 to 7.4). Our study shows that a single clone of CA-MRSA accounts for the majority of infections. This strain originated in the community and is not related to MRSA strains from healthcare settings. Injecting drug users could be a major reservoir for CA-MRSA transmission.

Adolescent↗

PubMed1980

Sex therapy in an in-patient and out-patient setting.

This paper summarizes the experience with sex therapy in an in-patient ward for neurotics (N = 82), where it could be combined with interpersonally oriented group psychotherapy in a therapeutic community setting. Outcome data are compared with an out-patient form of sex therapy, used in several counseling centers (N = 111). The in-patient form of therapy had a success rate of 76% at completion of treatment and 52% after a follow-up period of 15 months. The out-patient therapy was successful in 71% but no follow-up was carried out. Almost 50% of the couples who originally started therapy dropped out. Three illustrative successful cases are described.

Adult↗

PubMedDate not supplied

Community resources for clients with mobility problems.

Clients are leaving the hospital "quicker and sicker," and they frequently have acute care needs that must be met by resources outside the hospital setting. Community resources are diverse, vary widely from place to place, and have no central administration. Thus, using them can be challenging for both the nurse, client, and family. Reimbursement mechanisms underlie a person's ability to use resources and receive health care. By presenting two actual case scenarios where clients have mobility problems commonly seen by orthopaedic nurses, the authors discuss the community resources available, avenues of access to them, and their reimbursement mechanisms.

Activities of Daily Living↗

PubMed2005

Monitoring falls in cohort studies of community-dwelling older people: effect of the recall interval.

OBJECTIVES: To determine whether the interval over which patients are asked to remember their falls affects fall reporting. DESIGN: Systematic literature review. SETTING: Community. PARTICIPANTS: Individuals being monitored for falls in prospective studies that asked participants to recall falls over varying intervals. MEASUREMENTS: Sensitivity and specificity of retrospective recall compared with a criterion-standard prospective assessment using some form of ongoing fall monitoring. RESULTS: Six studies met the inclusion criteria. Recall of falls in the previous year was specific (specificity 91-95%) but less sensitive (sensitivity 80-89%) than the criterion standard of ongoing prospective collection of fall data using fall calendars or postcards. Patients with injurious falls were more likely to recall their falls. Lower Mini-Mental State Examination score was associated with poorer recall of falls in the one study addressing this issue. CONCLUSION: Whenever accurate data on all falls are critical, such as with interventions to decrease the rate of falls, researchers should gather information on falls every week or every month from study participants. The optimal method of fall monitoring--postcard, calendar, diary, telephone, or some combination of these--remains unknown.

Accidental Falls↗

PubMed2005

The efficacy of hypertonic saline nasal irrigation for chronic sinonasal symptoms.

OBJECTIVE: To assess quality of life (QOL) in patients with sinonasal symptoms in response to hypertonic saline nasal irrigation (HSNI), and to assess HSNI use patterns. STUDY DESIGN AND SETTING: The study was an uncontrolled 12-month follow-up to a randomized controlled trial (RCT) and used HSNI in a community setting. We included 54 participants with recurrent or chronic sinonasal symptoms. Forty participants had been in the intervention group of a previous study; 14 had been control participants. Primary outcome measures were the Rhinosinusitis Disability Index (RSDI), a sinus-symptom severity assessment (SIA), and the Sino-Nasal Outcomes Test (SNOT-20). Secondary outcome measures were frequency and pattern of HSNI use, side effects and satisfaction. RESULTS: Among participants using HSNI in the prior RCT, RSDI scores continued to improve, from 73.2 +/- 2.6 points to 80.6 +/- 2.4 points (P < 0.001). SIA and SNOT-20 scores remained stable. Former control participants reported QOL improvement similar to that of HSNI users in the prior RCT. RSDI scores improved from 62.0 +/- 3.9 points to 79.7 +/- 3.7 points (P < 0.05), SNOT-20 scores improved from 43.5 +/- 5.7 points to 28.4 +/- 4.8 points, and SIA scores improved from 4.2 +/- 0.3 points to 2.6 +/- 0.3 points (P < 0.01). Mean HSNI use for all participants was 2.4 irrigations per week; 33% of participants used HSNI regularly, 55% when symptomatic. Side effects were minor; satisfaction was high. CONCLUSIONS: Participants with chronic sinonasal symptoms reported improved QOL and frequent, satisfying use of HSNI. SIGNIFICANCE: HSNI is an effective adjunctive treatment of chronic sinonasal symptoms.

Adult↗

PubMed2000

Characteristics of patient and staff victims of assaults in community residences by previously nonviolent psychiatric inpatients.

There currently exists a large body of empirical research examining patient assaults in inpatient psychiatric facilities. These studies have focused primarily on staff and have found younger, male mental health workers with lower levels of formal education and experience as well as nurses involved in restraint procedures to be most at risk. However, despite the increased utilization of community-based services, little attention has been directed toward patient assaults on patients and staff in community settings, particularly residential services. This study began to respond to this need by examining patient assaults toward other patients and staff in community residences during the first twelve months post-discharge for a group of newly discharged patients who were not violent as inpatients. This study found female patients and staff to be at greater risk for assault than male patients. Lack of experience by staff was also a risk factor. The clinical, administrative, and research implications of these findings are discussed.

Activities of Daily Living↗

PubMed2006

Health-related quality of life among children and adolescents: associations with obesity.

OBJECTIVE: To assess the impact of obesity on health-related quality of life (HRQOL) of children, and to compare HRQOL scores of obese children in a hospital versus community setting. DESIGN: A cross-sectional study in two clinical samples. SUBJECTS: A total of 182 children and adolescents recruited from the community pediatric clinics and a hospital-based obesity clinic. MEASUREMENTS: Obesity was defined as body mass index (BMI) >95th percentile for age and gender. Subjects were divided into quartiles of BMI Z-scores each containing 45 or 46 children. The first two quartiles correspond to normal BMI, 3rd and 4th quartiles represent moderate and severe obesity, respectively. HRQOL was assessed by the Pediatric Quality of Life Inventory (PedsQL) questionnaire submitted by both children and their parents. RESULTS: Obese children reported significantly lower HRQOL in physical, social and school domains compared with normal weight children (P<0.01). Analyzing results of HRQOL by BMI quartiles showed that the emotional and school domains scores of the moderately obese children were similar to the normal BMI quartiles. Only in the 4th quartile, that of children with severe obesity, were scores significantly lower. In contrast, in both physical and social domains scores decreased progressively with increased BMI Z-scores. In the obese group, parents' scores were lower than the children's in all domains. HRQOL scores of obese children assessed in the hospital clinic were similar to that of obese children assessed in the community. CONCLUSIONS: Moderately obese children had similar emotional and school HRQOL scores as normal weight children, whereas in the physical domain, a significant difference was documented even in moderate obesity. Parents of obese children perceived their child's HRQOL lower than the children themselves. We believe that intervention programs aimed at improving HRQOL should be directed to both parents and children. Understanding the resilience of moderately obese children in school and emotional domains may assist us in the management of childhood obesity.

Adolescent↗

PubMed2005

Mortality risk and prospective medicare expenditures for persons with dementia.

OBJECTIVES: To determine whether an index that stratifies dementia patients into high- and low-mortality-risk groups can be effective in prospectively identifying persons with high and low expenditures. DESIGN: A mortality risk index developed for persons with dementia was used to stratify persons into groups at high and low risk of 12-month mortality. Expenditures were compiled from Medicare claims for 12 months after the predicted mortality classification. SETTING: The Medicare Alzheimer's Disease Demonstration Evaluation (MADDE) operated in eight sites across the United States. Subjects were living in a community setting at time of their mortality risk classification. PARTICIPANTS: Participants (N=2,255) were volunteer enrollees in MADDE; all had a diagnosis of irreversible dementia and two or more limitations in activities of daily living (ADLs). MEASUREMENTS: Outcomes were Medicare Part A expenditures. Risk factors included age, sex, ADL limitations, selected chronic conditions, prior year hospital stays, and relationship to caregiver. RESULTS: Patients predicted as at high risk of death had higher average monthly Medicare expenditures than those predicted to be at low risk of death. At the 50th sensitivity percentile for mortality, differences in average expenditures exceeded 700 dollars per month. CONCLUSION: It is not known whether it is possible to achieve reductions in expenditures for patients with advanced dementia at high risk of mortality, but study findings support consideration of an advanced illness model that would attempt to generate acute services savings and use these savings for palliative services that might improve patients' and caregivers' quality of life.

Activities of Daily Living↗

PubMed1984

Brewster v Dukakis: developing community services through use of a consent decree.

Filed against the state of Massachusetts in 1977, Brewster v Dukakis involved the claim that psychiatric patients living in state hospitals or at risk of being hospitalized in these facilities have a right to treatment in community settings. The decree that emanated from the suit resulted over a 5-year period in a tenfold increase in state expenditures for community mental health services, a 48% decline in the state hospital census, and a 15% drop in the state hospital admission rate in the region of the state targeted by the suit. Factors that facilitated this outcome are described, as well as the dangers and limitations of exclusive reliance on the judicial process to promote the development of community services.

Community Mental Health Services↗

PubMed2006

Randomised controlled trial of welfare rights advice accessed via primary health care: pilot study [ISRCTN61522618].

BACKGROUND: Little research has directly evaluated the impact of increasing financial or material resources on health. One way of assessing this lies with assisting people to obtain full welfare benefit entitlements. In 2000-1, 2.3 million pensioners were living in poverty in the UK and estimates suggest that around one million do not claim the financial support to which they are entitled. The effectiveness of welfare rights advice services delivered via primary health care to promote health and reduce health inequalities is unknown. METHODS: The main objectives of this study were to assess the feasibility and acceptability of a randomised controlled trial of welfare rights advice in a community setting and identify appropriate health and social outcome measures in order to plan a definitive trial. This was a single blind, community-based, pilot randomised controlled trial. 126 men and women aged 60 years and over, recruited from 4 general practices in Newcastle upon Tyne, UK, participated. The intervention comprised a structured welfare rights assessment followed by active assistance with welfare benefit claims over the following 24 months. The control group received the intervention after a six month delay. A range of socio-economic, health, behavioural and psycho-social outcomes were measured. RESULTS: 126 out of 400 people invited agreed to participate and 109 were followed up at 24 months. Both the intervention and research procedures were feasible and acceptable to participants and professionals involved. 68 (58%) of all participants received a welfare benefit award (31 financial, 16 non-financial and 21 both). Median time to receipt of benefits from initial assessment was 14 (range 1 to 78) weeks and median financial award was pounds 55 (Euro 81, dollar 98) per household per week. There was little evidence of health-related differences between groups or over time, which could be due to limitations of the study design. CONCLUSION: Modification of the study design, including selection of study participants, timing of interventions and length of follow up are recommended for a definitive trial. More appropriate health and psycho-social outcome measures relevant to the elderly population should be sought, particularly focussing on those issues highlighted in the accompanying qualitative study.

Aged↗

PubMed2002

[Research, training and community links in today's hospitals].

The role of hospitals in research, medical training and their relationship with the community is challenged by socio-economical, epidemiological, demographic and technological changes western health care systems are facing today. This paper enhances that: 1. beside the experimental, high tech and biotechnological model of research, there is still a great need for studies in areas such as: doctor-patient relationship, disability, access to care and patient satisfaction; 2. medical training should open to community settings in order to avoid excess in medical specialisation and future shortage of primary health care professionals; 3. a close link with community health care should be established through strategic and operational planning between hospital and community services and a formalised role for family physicians within hospital-based Departments of Family and Community Medicine.

Community-Institutional Relations↗

PubMed1990

Working families and eldercare: a national perspective in an aging America.

The competing demands of employment and caring for a dependent elderly family member can create stress for families, and some employers are becoming concerned about the impact of eldercare on the workplace. This first national survey of workers examined the extent of eldercare and its impact on workers. In this article, the authors profile the employees who described themselves as caregivers, the older people they were caring for, the care they were giving, the extent to which they reported conflict between their work and caregiving responsibilities, and the workplace supports they would have found helpful in managing these roles. Women were devoting more time to caregiving and were more likely to report work and caregiving conflict than were men. Social workers in occupational and community settings can play a key role in providing information about eldercare services, in counseling caregivers, and in advocating for employee benefits and community services to help workers maintain both work and family roles.

Activities of Daily Living↗

PubMed1985

Stigma perception: social comparison among mentally retarded persons.

Two studies were conducted in order to determine whether a group concept problem (i.e., relatively unfavorable opinions of other retarded persons; Gibbons, 1981): (a) includes retarded persons' perceptions of their peers' social desirability, such as dating appeal and physical attractiveness; (b) occurs among persons living in community settings; and (c) differs by sex. Results provided affirmative answers for all questions and indicated that the problem is most severe among community women. In addition, there was evidence of self-derogation among both community-based and institutionalized retarded persons in terms of social success (e.g., dating behavior). I suggested that this type of person perception may be interfering with retarded persons' social behavior and their adjustment to community-based and institutional environments.

Adolescent↗

PubMed1994

Psychiatric reimbursement reform in New York State: lessons in implementing change.

The failure of an innovative and ambitious reform in the psychiatric reimbursement system of New York State is examined for specific lessons of value for other states as they implement new payment strategies to encourage improved treatment of the mentally ill in general hospitals and community settings. The New York payment system was comprehensive, embracing both inpatient and outpatient care, and had significant support in the hospital and professional communities. Still, its impact on hospital performance was small and only partially consistent with its goals. For mental health reimbursement reform to succeed, state administrators must provide more clear, sustained, and forceful signals that take account of the real barriers to implementation; they must also ensure that the financial incentives and rewards are recognized by those who carry out the actions needed to translate goals into reality.

Episode of Care↗

PubMed2004

Critical incidents of nonadherence with standard precautions guidelines among community hospital-based health care workers.

OBJECTIVE: To identify, categorize, and assess critical incidents of nonadherence to standard precautions. DESIGN: Qualitative and quantitative analysis of a written, mail-out survey. SETTING: Community hospitals. PARTICIPANTS: Statewide stratified random sample of community hospital-based health care workers at risk for blood exposure. MAIN VARIABLE: Responses to the question: "Think of an incident during the past year when you didn't adhere to universal precautions. Please describe the situation and why you didn't adhere." RESULTS: Reasons given for not using precautions included: belief that stopping to use standard precautions would have put the patient at risk (22%); using precautions would have interfered with patient care (20%); precautions were not warranted in a specific situation (14%); did not anticipate the potential for exposure (14%); and high job demands that had caused respondent to be in a hurry (11%). Less often, equipment was not available (7%), respondent forgot (6%), respondent thought that the patient did not pose a risk (4%), or the available equipment was not effective (3%). In terms of overall exposure rates, 34% of those who described an incident had experienced a sharps injury during the previous 3 months and 42% had experienced a mucocutaneous exposure. In terms of overall nonadherence, 44% wore gloves less than 100% of the time, while 61% washed their hands less than 100% of the time. Needlestick injuries were lowest among those who had forgotten to use precautions, while mucocutaneous exposures were highest among those who had not anticipated potential exposure while performing the task. Failure to wear gloves routinely was highest among those who said that following precautions interfered with their ability to provide care and among those who believed a particular patient to be low risk; failure to wash hands routinely was also highest among the latter group and lowest among those who said necessary equipment was not available. CONCLUSIONS: Using specific information about local incidents of nonadherence to standard precautions may enhance training, especially if the program identifies incidents of unanticipated exposure and helps workers plan for them in the future. Closer examination of job demands and responsibilities that interfere with standard precautions may increase the likelihood of adherence.

Blood-Borne Pathogens↗

PubMedDate not supplied

Developing comprehensive health care for an underserved population.

An especially vulnerable population is the disadvantaged and underserved older adult population residing in urban communities. This article describes a hospital-sponsored program in an urban community developed to improve access to health promotion and chronic disease control services for older adults. As part of the newly designed service, the hospital also sought to change its image from simply that of a "hospital" to that of a "community setting" dedicated to serving the comprehensive needs of older adults.

Aged↗