Doulas as Professional and Institutional Allies: The Upsides of Doula Disruption

Transforming care through leadership and research alignment

As described in detail in the literature, patients identified with malnutrition are at increased risk for poor clinical outcomes. Despite this knowledge, malnourished patients do not always receive optimal nutrition management while admitted into a hospital because of what we describe as gaps in care throughout their admission. We hypothesized that the 3 main gaps in care were poor dietitian-doctor communication, excessive time spent nil per os (NPO) for procedures and testing, and/or inaccurate or incomplete dietary discharge instructions. The objectives of this study were to determine and to characterize gaps in nutrition care after a malnutrition diagnosis. This retrospective study involved postdischarge chart reviews of malnourished adult medicine patients admitted to an acute care facility from September 1, 2014, to November 30, 2014 (n = 242). Of the malnourished patients, 76% had at least 1 gap in care. The most prevalent gap (68%) involved discharge diet instructions, most often because of the omission of the dietitian recommendation for oral supplementation. Thirty-five percent of malnourished patients had a gap in care because of procedures or testing extending the period held NPO, and 13% had a gap in care because of poor communication, thus delaying orders and/or interventions. This is the first study to evaluate gaps in care of patients diagnosed with malnutrition. Identification of these gaps allows us the opportunity to develop strategies for this vulnerable population to improve areas such as discharge documentation and time spent NPO to provide the best and safest nutrition care.

One factor potentially driving healthcare and hospital worker (HHW)’s declining mental health during the COVID-19 pandemic is feeling betrayed by institutional leaders, coworkers, and/or others’ pandemic-related responses and behaviors. We investigated whether HHWs’ betrayal-based moral injury was associated with greater mental distress and post-traumatic stress disorder (PTSD) symptoms related to COVID-19. We also examined if these associations varied between clinical and non-clinical staff. From July 2020 to January 2021, cross-sectional online survey data were collected from 1,066 HHWs serving COVID-19 patients in a large urban US healthcare system. We measured betrayal-based moral injury in three groups: institutional leaders, coworkers/colleagues, and people outside of healthcare. Multivariate logistic regression analyses were performed to investigate whether betrayal-based moral injury was associated with mental distress and PTSD symptoms. Approximately one-third of HHWs reported feeling betrayed by institutional leaders, and/or people outside healthcare. Clinical staff were more likely to report feelings of betrayal than non-clinical staff. For all respondents, 49.5% reported mental distress and 38.2% reported PTSD symptoms. Having any feelings of betrayal increased the odds of mental distress and PTSD symptoms by 2.9 and 3.3 times, respectively. These associations were not significantly different between clinical and non-clinical staff. As health systems seek to enhance support of HHWs, they need to carefully examine institutional structures, accountability, communication, and decision-making patterns that can result in staff feelings of betrayal. Building trust and repairing ruptures with HHWs could prevent potential mental health problems, increase retention, and reduce burnout, while likely improving patient care.

This study aims to explore the managerial role of leaders of pesantren-based rehabilitation institutions in tackling juvenile delinquency in Pondok Bukit Mahabbah Darul Adni majalengka, and its impact on the character and mental development of students. This research was conducted through in-depth interviews, participatory observation, and document analysis using qualitative case study methods. A thematic analysis approach was applied to identify key themes from the data collected over the six-month research period. The results of this study show that institutional leaders have successfully carried out managerial roles in tackling juvenile delinquency originating from various regions in Indonesia, which is reflected. This is reflected in the interpersonal role of the leader of the institution, the informational role and the decisional role performed by the leader of the institution in carrying out its institutional management. This research opens up opportunities for further study on juvenile delinquency handling in other educational institutions and broadens the scope of research on the managerial role of agency leaders in tackling juvenile delinquency

Individuals with serious mental illness often are unable to access consumer- and family-oriented community care, resulting in repeated hospitalizations, incarceration, and homelessness. The "medical home" concept was developed in primary care to provide accessible and accountable services for individuals with chronic medical conditions. Building on the work done in primary care, the authors propose a "mental health home." The model of care incorporates medical home characteristics, such as access to and coordination of services, integration of primary and preventive care, adoption of recovery orientation and evidence-based practices, and family and community outreach. Barriers to and strategies for implementation of mental health homes are discussed.

A New Kind of Homelessness for Individuals With Serious Mental Illness? The Need for a "Mental Health Home"

Specialty centers improve care for patients with Down syndrome. The cohort of adults with Down syndrome is increasing, but the capacity for specialty centers to meet their medical care needs is unknown. Electronic survey of staff of specialty clinics for adults with Down syndrome was conducted. Review of online clinic listings, and calculation of the number of adults with Down syndrome were performed. Analysis identified the percent of adults with Down syndrome who could have their medical care needs met in a current specialty clinic. Fourteen specialty clinics report providing care for 4038 adults with Down syndrome. Respondents reported gaps in care including: limitations of existing clinics, need for additional clinics, and knowledgeable health professionals in Down syndrome. Survey-respondent clinic capacity would meet needs of 3% of adults with Down syndrome. Twenty-five clinics for adults with Down syndrome were listed online with capacity to care for 6517 adults with Down syndrome meeting the needs of 5% of the population. Additional clinic capacity is needed to meet the needs of adults with Down syndrome. Survey of existing clinics provides guidance to create additional clinics, including: must-have team members, current sources of clinic financial support, and gaps in current clinical care.

Introduction: Lifelong continuity of care is crucial for patients with significant congenital heart disease (CHD). Unfortunately, gaps in care (GIC) are common and may be attributed to vulnerable developmental periods, changes in insurance status, lack of symptoms or knowledge regarding follow-up, and inability to access specialty care. There is limited understanding of socioeconomic and demographic factors that contribute to GIC in CHD. Hypothesis: Socioeconomic factors including U.S. neighborhood socioeconomic score(SES) are associated with GIC in patients with significant CHD. Methods and Results: A total of 8674 patients followed at Boston Children's Hospital (BCH) with moderate to severe CHD(as defined by AHA/ACC 2008 guidelines) were seen in clinic between January 2013 and December 2015. Socioeconomic characteristics including language, race, ethnicity, and U.S. neighborhood socioeconomic score (SES) were analyzed. GIC of > 3.25-years were identified in 33% (2829) of patients. GIC were associated with being an adolescent or young adult (13-23 years) (P<0.001), non-English speaking (P<0.002), non-white (P<0.001), Hispanic ethnicity (P = 0.02), and a low SES (P <0.001). Conclusions: A third of patients with significant CHD experienced a substantial GIC (>3.25 years). Adolescent young adult age and socioeconomic factors, including race, ethnicity, language, and a low SES were associated with GIC in patients with significant CHD. Interventions to identify and support these vulnerable populations could improve patient continuity of care and overall outcomes. Further studies are needed to understand the reasons for such GIC in vulnerable populations.

Listening Styles and Challenges of ESL Instructional Leaders in Institutions of Higher Learning

To explore the challenges of clinical education from the perspective of clinical instructors and clinical staff at Dire Dawa University College of Health Science. An institutional-based phenomenological qualitative study was conducted. Clinical instructors and staff provided data through in-depth interviews and key informant discussions, which were facilitated by a semistructured tool and a voice recorder. A total of 17 participants, including 11 in-depth interviews (IDIs) with clinical instructors (including two key informants) and six IDIs with clinical staff were included in this study. A purposive sampling method was used to select study participants, and the data were analyzed thematically using the computer-assisted qualitative data analysis software Atlas.ti7. The thematic analysis with an inductive approach involves six steps: familiarization, coding, generating themes, reviewing themes, defining and naming themes, and writing. Clinical instructors and clinical staff noted a number of challenges in clinical education, including insufficient medical equipment, low incentives, clinical site repetition, unfavorable clinical practice sites, lack of communication from instructors, skill attrition, lack of orientation for instructors and students, client/patient unwelcomingness, uncooperative healthcare workers, and poor university cooperation. The aforementioned issues contributed to the quality of clinical education and its desired impact, as outlined in this research. A multidisciplinary and collaborative effort is needed to address these challenges.

Future Role of the Clinical Lab in Population Health.

Development and Evaluation of a Global Malnutrition Composite Score

<i>Pursuing Excellence</i>: Integrating Clinical Learning Environment Staff and Learners Into the Pursuit of Quality, Safety, Equity, and Value

Purpose: The HIV Medicine Association recommends anal Pap tests for women living with HIV (WLWH) with a history of abnormal cervical Pap tests, ano-receptive intercourse, or genital warts. This study describes current anal cancer screening practices and provider- and staff-identified challenges conducting anal cancer screening for WLWH in an integrated safety-net healthcare institution and community healthcare organization serving underinsured patients in a metropolitan city in Texas. Findings inform our understanding of factors that need to be addressed prior to implementation of system-level anal cancer screening policies and protocols for WLWH, a population at increased risk for anal cancer due to persistent HPV infection. Methods: We purposefully sampled providers, clinical staff, and administrative staff to participate in in-person semi-structured interviews assessing participant experiences with anal cancer screening, documentation, and follow up, and attitudes toward future anal cancer screening among WLWH. Audio-recorded interviews and field notes were transcribed and thematically analyzed using an iterative deductive and inductive coding scheme. Results: We completed interviews with 25 individuals: providers (n=11: 7 safety-net, 4 community), clinical staff (n=10: 8 safety-net, 2 community), and administrative staff (n=4: safety-net). Current practices. No system-level policies or protocols for anal cancer screening existed within the safety-net institution or community organization for WLWH. Instead, HIV providers performed anal Pap tests ad hoc, most frequently as diagnostic evaluations based on visual inspections or patient-reported symptoms. To follow up on abnormal test results, providers referred patients to Proctology Clinic, where wait for an appointment was about one year. Challenges. Without anal cancer screening policies or protocols, clinical teams were unclear on whether the HIV team or gynecology specialty team should lead screening efforts. Electronic health records only recorded cervical Pap test results in the “Pap” field, leaving providers to record anal Pap results in a notes section. This limited the ability to produce systematic reports or track screening. Finally, providers and staff expressed reluctance to conduct systematic anal cancer screening until greater infrastructure existed to manage referrals for abnormal anal Pap test results. Conclusions: Anal cancer screening and follow-up for WLWH require organization and coordination between multiple care teams, and protocols should clarify clinical pathways and responsibilities as patients transition between HIV, gynecology, and proctology teams. Further, clinical information systems must be updated to facilitate teams’ communication and to support anal Pap test ordering and documentation. Finally, downstream infrastructure to support follow-up must accompany upstream implementation of an anal cancer screening policy. Citation Format: Serena A Rodriguez, Robin T Higashi, Andrea B Betts, Cynthia Ortiz, Jasmin A Tiro, Amneris Luque, Arti Barnes. Challenges implementing anal cancer screening for women living with HIV: Clinical providers and staff perspectives [abstract]. In: Proceedings of the Twelfth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2019 Sep 20-23; San Francisco, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl_2):Abstract nr C126.

The Freedom to Learn the Independent Campus Policy (MBKM) is an Indonesian government initiative that aims to encourage innovation in higher education and give students freedom to choose courses, colleges and learning methods that suit their interests, talents and needs. This study aims to evaluate the implementation of the MBKM policy at University, as well as explore the perspectives of students and lecturers regarding the implementation of the policy. The research method used is a qualitative approach with data collection techniques through in-depth interviews and participatory observation. The respondents of this study consisted of 317 students who had participated in the MBKM program and 18 lecturers who were involved in implementing the policy. Data analysis was carried out through the coding stage and the themes that emerged from the interviews and data triangulation with observation. The results showed that the implementation of the MBKM policy at University had a significant impact on students and lecturers. From a student perspective, the MBKM policy gives them the freedom to choose courses, access learning resources, and participate in extracurricular activities according to their interests and talents. From the perspective of lecturers, the MBKM policy requires changes in teaching and mentoring approaches. Overall, the evaluation of the implementation of the MBKM policy at University shows significant benefits for students and lecturers. However, there are also challenges that need to be overcome, such as managing student time and adjusting lecturer teaching approaches.