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PubMed1983

A home care program for children with chronic illness.

Pediatric Home Care (PHC) of Albert Einstein College of Medicine was designed as a special ambulatory care unit for children who are seriously or chronically ill and whose needs were not being met successfully through conventional programming. Services include: monitoring the patient's care: delivering direct services in the home, clinic, and hospital; teaching therapeutic programs to the family and patient; coordinating services; patient advocacy; health education; and supportive counseling. Each patient has a core team consisting of a generalist pediatrician, a PNP, and the patient's family. Visits are provided in the patient's home as needed, as well as in the traditional locations of the clinic, the inpatient units, and the PHC office. The program accepts patients with serious medical problems and who face any of a series of other difficulties, including: especially complex management problems that cannot be handled well in the customary outpatient settings; unstable family settings; or extended hospitalizations. Because it is not restricted to any single type of disease, the PHC provides a model that is applicable in a wide range of medical and community settings. Results of a program evaluation show that PHC is an effective intervention that has positive mental health outcomes and improves satisfaction with care.

Child↗

PubMed1994

Anticoagulation in atrial fibrillation. Does efficacy in clinical trials translate into effectiveness in practice?

BACKGROUND: Several recent randomized clinical trials of anticoagulation in atrial fibrillation have demonstrated significant reduction in stroke rates with a small incidence of bleeding complications. The objective of this study was to determine whether the recommendations resulting from these trials have been implemented into routine practice, and if the anticoagulation control, therapeutic efficacy, and low complication rates achieved in the trials have been matched in community practice. METHODS: We analyzed the anticoagulation practices and outcomes obtained for patients in atrial fibrillation at a large staff model health maintenance organization (HMO). We reviewed the medical records of all patients in atrial fibrillation as of April 1990. We compared demographic characteristics and clinical risk factors between HMO patients and those in the clinical trials. We also compared anticoagulation monitoring, adequacy of anticoagulation control, and clinical outcomes at the HMO with those achieved in the clinical trials. RESULTS: Of 238 HMO patients in atrial fibrillation, 198 were without contraindications and therefore eligible for anticoagulation. Of these, 168 were offered anticoagulation (84.8%) and 156 were receiving anticoagulation therapy (78.8% of those eligible). The HMO patients had a greater prevalence of comorbidities than those in the clinical trials. The routine monitoring interval at the HMO was estimated at between 36.3 and 40.9 days (compared with 21 to 28 days reported in the clinical trials). The prothrombin time ratios at the HMO were in the target range on 50% of days compared with 68% of days in the clinical trials. The annual stroke and major bleeding rates in the HMO patients (1.3% and 0.6%, respectively) were not significantly different from the rates in the clinical trials (1.3% and 1.1%, respectively). The annual minor bleeding rate of 13.6% at the HMO was greater than the 7.8% to 8.4% rates in the two trials with better anticoagulation control (Boston Area Anticoagulation Trial for Atrial Fibrillation and Stroke Prevention in Atrial Fibrillation Study) but was not significantly different than the rates of 12.7% and 13.7% of the two trials with poorer anticoagulation control (Canadian Atrial Fibrillation Anticoagulation Study and Stroke Prevention in Nonrheumatic Atrial Fibrillation Study). CONCLUSIONS: Anticoagulation practices in this community setting appear to be good in that a large majority of patients were receiving anticoagulation therapy, and there were few major adverse outcomes. However, this study illustrates two common problems in attempting to apply the results of randomized clinical trials to routine practice: (1) differences between community patient populations and those on which the conclusions of clinical trials are based, and (2) less successful application of therapeutic interventions in settings other than that of a controlled clinical trial. The greater prevalence of comorbidities in the HMO patient population appears to convey a greater overall risk of thromboembolism and bleeding complications than in the clinical trials. In addition, the suboptimal anticoagulation control achieved at the HMO may increase the risks and decrease the potential benefits compared with those achieved in the clinical trials. Thus, the efficacy demonstrated in the clinical trials of anticoagulation in atrial fibrillation may not be directly translated into effectiveness in practice.

Aged↗

PubMed2001

Beyond screening for domestic violence: a systems model approach in a managed care setting.

BACKGROUND: Implementation of screening guidelines for domestic violence has been challenging. The multifaceted "systems model" may provide an effective means to improve domestic violence screening, identification, and intervention in the healthcare setting. METHODS: We developed: (1) a systems model approach using tools for effective referral, evaluation, and reporting of domestic violence; (2) materials for distribution to female patients; (3) training for social service and mental health clinicians to provide domestic violence evaluation; and (4) strong links to the community. SETTING: A nonprofit, managed care facility in Richmond, California. PARTICIPANTS: Staff and members of the managed care plan. MAIN OUTCOME MEASURES: (1) Increased screening for domestic violence by clinicians; (2) increased awareness of the healthcare facility as a resource for domestic violence assistance; and (3) increased member satisfaction with the health plan's efforts to address domestic violence. RESULTS: The number of clinician referrals and patient self-referrals to an on-site domestic violence evaluator increased more than twofold. A pre-intervention and post-intervention phone survey of members seen for routine checkup showed an increase in member recall of being asked about domestic violence. After intervention, statistically significant increases were seen in members' perception that the health plan was concerned about the health effects of domestic violence (p<0.0001) and about members' satisfaction with the health plan's efforts to address this issue (p<0.0001). CONCLUSIONS: A systems model approach improved domestic violence services in a managed care health setting within 1 year and affected clinicians' behavior as well as health plan members' experience. This successful implementation makes it possible to address critical research questions about the impact of a healthcare intervention for victims of domestic violence in a managed healthcare setting.

Adolescent↗

PubMedDate not supplied

An approach to community assessment in medical practice.

An ethnographic model for community based medical practice is proposed. Its goal is to anticipate areas of value and expectation conflict between the physician and his or her practice community setting. Three types of ethnographic information gathering are outlined: (1) desk assessment, based on the ethnographic use of newspapers, maps, census records, (2) informant methods, and (3) participant observation. It is argued that these lead to an understanding of the community's health-related beliefs and practices and to the ability to deliver community oriented health care. Examples of this ethnographic approach are given from the authors' experiences. A method to represent graphically the process of community analysis is provided.

Attitude↗

PubMed2005

Community activities and individuals' satisfaction with them: quality of life in the first year after traumatic brain injury.

OBJECTIVE: To investigate the relations between community activities and satisfaction with these activities, desires to change them, and global life satisfaction. DESIGN: Interview study with follow-up 1 month after rehabilitation discharge and 12 months postinjury. SETTING: Community. PARTICIPANTS: One hundred sixty-two individuals hospitalized with mostly moderate-to-severe traumatic brain injury. About 90% were reached (mostly by phone) 1 month after rehabilitation discharge; 84.6%, at 12 months postinjury. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Community Integration Questionnaire-2, augmented by individuals' ratings of satisfaction or dissatisfaction with and desire to change each activity; and the Satisfaction With Life Scale. RESULTS: Although significant correlations were found for some items, most correlations between activities and ratings of global quality of life (QOL) were low and nonsignificant. Individuals reported that they were satisfied with most of their community activities, but there were exceptions (eg, paid work). Correlations between activity-specific satisfaction and general life satisfaction were generally weak and nonsignificant. Dissatisfaction with an activity correlated strongly with desire to change the activity, but general life satisfaction did not correlate with desire to change activities. CONCLUSIONS: The lack of association between frequency of activities and subjective appraisals of them is a challenge to outcomes measurement and has implications for the targeting of rehabilitative interventions and evaluation of their worth. More research is needed to understand how individualizing functional objectives might maximize the effects of rehabilitation on the QOL of persons served.

Adolescent↗

PubMed2000

A comparison of different approaches to promote community-wide dietary change.

BACKGROUND: Because public health education funds are limited, it is important to determine which methods are most effective for promoting healthy lifestyles to communities. We conducted interventions in two communities to further examine the effectiveness of various educational approaches for communicating the "1% Or Less" message to switch from high-fat (whole or 2%) to low-fat (1% or fat-free) milk. METHODS: One intervention used public relations and community-based educational activities in supermarkets, schools, worksites, and other community settings. The other used paid advertising in the absence of other programming. We used telephone surveys and supermarket milk sales data, collected before and after each campaign and in a comparison community, to determine changes in milk-usage patterns. RESULTS: After the campaign of community-based educational programs and public relations activities, the proportion of high-fat milk drinkers who reported drinking low-fat milk was 19.6% compared with 6.8% for the comparison city (p<0.0001). After the advertising-only campaign, 12.8% of high-fat milk drinkers reported drinking low-fat milk (p<0.01). Although supermarkets experienced increases in low-fat milk sales after both campaigns, the results were not statistically significant. CONCLUSIONS: The results show how well-designed public relations activities can attract news coverage and provide further evidence that such coverage can be an important component of health-promotion campaigns. Although the use of paid advertising in the absence of other media or programming appeared to change milk-drinking habits, the results were not sustained after the ads stopped airing.

Adult↗

PubMed2006

Effects of the implementation of a telemedical stroke network: the Telemedic Pilot Project for Integrative Stroke Care (TEMPiS) in Bavaria, Germany.

BACKGROUND: Telemedical networks are a new approach to improve stroke care in community settings. We aimed to assess the effects of a stroke network with telemedical support in Germany on quality of care, according to acute processes and long-term outcome. METHODS: Five community hospitals without pre-existing specialised stroke care were included in a network with telemedical support by two academic hospitals. In a non-randomised, open intervention study, five community hospitals without specialised stroke care served as the control group, matched individually to the network hospitals by predefined characteristics. Stroke patients admitted consecutively to one of the participating hospitals between July 7, 2003, and March 31, 2005, were included in the study. Patients in network and control hospitals were assessed in the same manner and were followed up for vital status, living situation, and disability at 3 months. Poor outcome was defined by death, institutional care, or disability (Barthel index <60 or modified Rankin scale >3). Predefined indicators for quality of acute stroke care were achieved. FINDINGS: A total of 5696 patients with a sudden, non-convulsive loss of neurological function who were diagnosed with having suspected stroke were admitted to the ten hospitals participating in the study. After exclusion, 3122 were included in the final analysis, of whom 1971 (63%) were treated in the network hospitals. All indicators related to quality of acute stroke care were more commonly met in the network than in the control hospitals. After 3 months, 44% of patients treated in network hospitals versus 54% treated in control hospitals had a poor outcome (p<0.0001). In multivariate regression analysis, treatment in network hospitals independently reduced the probability of a poor outcome (odds ratio 0.62, 95% CI 0.52-0.74; p<0.0001). INTERPRETATION: Telemedical networks with academic stroke centres offer new and innovative approaches to improve acute stroke care at community level for stroke patients living in non-urban areas.

Academic Medical Centers↗

PubMed1999

Characteristics of older adults with intellectual disabilities referred for crisis intervention.

The aim of the present study was to identify the age correlates of behavioural crises in adults with intellectual disability (ID) living in the community. The cohort consisted of 185 clients (IQ < 70), ranging in age from 20 to > 70 years, who were referred to a crisis intervention programme specializing in services to individuals with dual diagnosis over a 7-year period. A retrospective cross-sectional analysis of historical and contemporaneous variables was completed. Referrals for crisis intervention were not related to the age of the client Aggression and non-compliant behaviour occurred with similar frequency in all age groups. Other behaviours, including withdrawal, self-injury, stereotypy and symptoms of psychiatric disorders, occurred less often in older clients. Severity of ID affected the pattern of behavioural crises that resulted in referral. The results suggest that people with ID residing in community settings still experience behavioural crises as they grow older. Confirmation of the trends reported in the present study might signal a need for accelerating the development of comprehensive age-span community mental health and behavioural supports.

Adult↗

PubMed1993

Palliative care: a review of past changes and future trends.

Palliative care arose out of the change from acute to chronic causes of death and the emphasis of health care on improving quality of life. In the United Kingdom, specialist palliative care is provided mainly for cancer patients through hospices and support teams, which have grown rapidly in the last 30 years. Single sites and more recently several units have demonstrated their effectiveness, acceptability and efficiency. However, the majority of people who die will not receive these services but will receive much of their care in hospital, nursing home and community settings. The growing numbers of people who are likely to die from HIV/AIDS and the growing numbers of older people make it important that palliative care becomes more integrated with hospital, community and general practitioner services. Palliative care should become a gradually increasing part of care from diagnosis to death, rather than being concerned only with the terminal phase. A palliative care component and appropriate standards could be included in the needs assessment and the contracts for many hospital and community services. In research on new treatments, particularly for cancer and HIV/AIDS, palliative aspects should be measured along with survival and the usually fairly basic estimates of quality of life. Hospices, and in particular support teams and day care, require further evaluation if they are to extend their role to providing care for the younger people with HIV/AIDS and the older people who are dying from chronic diseases such as cardiovascular disease.

Acquired Immunodeficiency Syndrome↗

PubMed2000

Agreement between older subjects and proxy informants on history of surgery and childbirth.

OBJECTIVES: To assess the agreement between proxy informants' reports of history of surgery and childbirth and older index subjects' own recall. DESIGN: Interrater reliability study. SETTING: An outpatient family medicine clinic and a provincial electoral district in Montreal, Canada. PARTICIPANTS: Eighty-two subjects aged 65 years and older without cognitive impairment, identified from clinic and community settings, and each index subject's proxy respondent. MEASUREMENTS: Identical questionnaires were administered to index subjects and proxies. RESULTS: Proxies failed to report 39% of non-childbirth surgeries reported by index subjects, but failed to report only 10% of childbirths. Female proxies were significantly less likely than male proxies to underreport non-childbirth surgeries after controlling for age of index subject and interval since surgery. Longer interval since surgery was significantly associated with greater underreporting, whereas age of the index subject and relationship between proxy and index subject were not. Agreement between proxies and index subjects on date of surgery was much higher for childbirths than for non-childbirth surgeries. CONCLUSIONS: Our findings suggest that proxy respondents can provide reliable information on older women's history of childbirth but that use of proxy respondents for history of non-childbirth surgeries may result in substantial underreporting.

Age Factors↗

PubMed2003

Dental disease prevention and people with special needs.

People with special needs are the most underserved of the underserved in our society. They have more dental disease, more missing teeth, and more difficulty obtaining dental care than other segments of the population. Many individuals and groups, including the authors of this paper, have developed community-based systems to improve oral health for people with special needs. However, these systems have not been as successful as they might be because of lack of effective preventive protocols specifically designed for people with special needs. This paper reviews strategies for overcoming informational, physical, and behavioral barriers to oral health and presents a summary of the results of a conference titled "Practical Preventive Protocols for Prevention of Dental Disease in People with Special Needs in Community Settings." The rationale for using an Oral Health Care Plan is presented as well as a sample plan. These strategies and protocols are designed to complement the system of supported community-based oral health care. The goal of this system is to help people with special needs enjoy a lifetime of oral health the same as other members of our society.

Adult↗

PubMedDate not supplied

Clinical education initiative in the community: caring for patients with congestive heart failure.

With greater numbers of chronically ill clients cared for in their homes rather than in acute care hospitals, nursing schools need to create and implement innovative strategies for experiences in the community setting. A telephone intervention program was initiated in the last semester of the medical-surgical clinical course to promote the health of patients with congestive heart failure and provide meaningful community experiences for senior nursing students. Students' journals from this semester-long clinical experience were analyzed and showed outcome benefits to both patients and students.

Aged↗

PubMed1994

Movement to the community: reduction of behavioral difficulties.

Increased frequency of maladaptive behaviors regularly occurs with individuals moving from large institutions. This inquiry focused upon change in targeted behaviors exhibited after one full year living in a normalized community setting by 8 adults who had lived an average of 17 years in institutions. Results revealed that maladaptive behaviors exhibited in institutions decreased significantly after one year in a 4-person community group home. Group home staff anticipated adaptive behavior and did not recognize as many problems as did institutional staff. Appropriate behaviors started to increase very quickly and inappropriate behaviors decreased.

Adult↗

PubMed2005

Training community consultants to help family members improve dementia care: a randomized controlled trial.

PURPOSE: We investigated whether community consultants could be trained to teach family caregivers a systematic behavioral approach for reducing mood and behavior problems in persons with Alzheimer's disease. DESIGN AND METHODS: This study consisted of a randomized controlled trial; we randomly assigned 95 family caregivers and care recipients with Alzheimer's disease to STAR-caregivers (STAR-C) or control groups. Masked interviewers conducted assessments at baseline, after treatment, and after 6 months. Consultants were master's-level health care professionals who were currently practicing in community settings serving older adults. We assessed the extent to which consultants were able to learn and adhere to the treatment protocol, and the relationship between adherence and measures of caregiver mood, burden, and care recipient mood and behavior. RESULTS: Community consultants were able to learn and adhere to the behavioral treatment protocol. Caregivers receiving STAR-C training showed significant improvements in depression, burden, and reactivity to behavior problems in the care recipient. There were also significant reductions in the frequency and severity of care recipient behavior problems, and improved quality of life. Results were maintained at 6-month follow-up. IMPLICATIONS: Community-based consultants successfully implemented a behavioral intervention with family caregivers of persons with Alzheimer's disease. Consequently, STAR-C seems to be a practicable and reasonable evidenced-based approach to caregiver training in actual clinical settings.

Aged↗

PubMed2003

Training caregivers to change the sleep hygiene practices of patients with dementia: the NITE-AD project.

OBJECTIVES: To examine the feasibility of training caregivers to implement sleep hygiene recommendations in dementia patients. DESIGN: A randomized, controlled trial. SETTING: Community. PARTICIPANTS: Twenty-two community-dwelling patients with Alzheimer's disease (AD) and their family caregivers. INTERVENTIONS: All participants received written materials describing age- and dementia-related changes in sleep and standard principles of good sleep hygiene. Caregivers in active treatment (n=10) also received specific recommendations about setting up and implementing a sleep hygiene program for the dementia patient. Control subjects (n=12) received general dementia education and caregiver support. MEASUREMENTS: Success implementing sleep hygiene recommendations was measured using daily log reports to calculate the percentage of days that caregivers reported that patients met individualized sleep scheduling, daytime-napping, and walking goals. RESULTS: Caregivers in active treatment were more successful in setting goals related to sleep scheduling and increasing daytime activity than control caregivers who received written materials only. Among patients who were candidates for sleep hygiene changes, active treatment subjects were also significantly (P<.01) more likely than controls to maintain a consistent bedtime (83% vs 38% of days attempted) and a consistent rising time (96% vs 59%), to nap less during the day (70% vs 28%), and to walk daily (86% vs 7%). CONCLUSION: This study provides evidence that sleep hygiene interventions are feasible with community-dwelling AD patients. Caregivers were able to help patients change sleep scheduling, napping, and walking routines, but clinicians who recommend sleep hygiene changes for their dementia patients should be aware that many caregivers need active assistance setting up and implementing a sleep hygiene program. Simply providing caregivers with education is often insufficient.

Aged↗

PubMed1997

Multisystemic therapy with violent and chronic juvenile offenders and their families: the role of treatment fidelity in successful dissemination.

The effects of multisystemic therapy (MST) in treating violent and chronic juvenile offenders and their families in the absence of ongoing treatment fidelity checks were examined. Across 2 public sector mental health sites, 155 youths and their families were randomly assigned to MST versus usual juvenile justice services. Although MST improved adolescent symptomology at posttreatment and decreased incarceration by 47% at a 1.7-year follow-up, findings for decreased criminal activity were not as favorable as observed on other recent trials of MST. Analyses of parent, adolescent, and therapist reports of MST treatment adherence, however, indicated that outcomes were substantially better in cases where treatment adherence ratings were high. These results highlight the importance of maintaining treatment fidelity when disseminating complex family-based services to community settings.

Adolescent↗

PubMed2002

Outreach teaching: is this the future for dental education?

Increasingly clinical teaching for all health professionals is moving out of teaching hospitals and into community settings. A recent workshop reviewed the place of outreach teaching in undergraduate dental education. This paper defines outreach teaching in terms of its main components; identifies its benefits for different stakeholders; sets out what is required to make it work; and looks at current trends offering opportunities for expansion.

Community-Institutional Relations↗

PubMed1997

Epileptic seizures after a first stroke: the Oxfordshire Community Stroke Project.

OBJECTIVE: To describe the immediate and long term risk of epileptic seizures after a first ever stroke. DESIGN: Cohort study following up stroke survivors for 2 to 6.5 years; comparison with age specific incidence rates of epileptic seizures in the general population. SETTING: Community based stroke register. SUBJECTS: 675 patients with a first stroke, followed up for a minimum of 2 years. MAIN OUTCOME MEASURES: Occurrence of single and recurrent seizures. RESULTS: 52 patients had one or more post stroke seizures; in 25 the seizures were recurrent. The 5 year actuarial risk of a post stroke seizure in survivors (excluding 19 patients with a history of epilepsy and 3 patients in whom the seizure occurred shortly before death from another cause) was 11.5% (95% confidence interval 4.8% to 18.2%). The relative risk of seizures, in comparison with the general population, was estimated at 35.2 in the first year after stroke and 19.0 in year 2. The risk of seizures was increased in survivors of subarachnoid and intracerebral haemorrhage (hazard ratio for intracranial haemorrhage v cerebral infarction 10.2 (3.7 to 27.9)). The risk of seizures after ischaemic stroke was substantial only in patients presenting with severe strokes due to total anterior circulation infarction. Only 9 of 295 patients (3%) independent one month after stroke suffered a seizure between 1 month and 5 years (actuarial risk 4.2% (0.1% to 8.3%)). CONCLUSION: Stroke patients have about an 11.5% risk of single or recurrent seizures in the first 5 years after a stroke. Patients with more severe strokes or haemorrhagic strokes are at higher risk.

Adolescent↗