Alternative Care Delivery Models Research Articles

Impact of the COVID-19 pandemic on delays in diagnosis and treatment of tick-borne diseases endemic to southeastern USA

BackgroundThe Coronavirus disease 2019 (COVID-19) pandemic was marked by an increase in diagnosis and treatment delays for a range of medical conditions. Yet the impact of the pandemic on the management of tick-borne diseases, which frequently manifest as an acute febrile illness similar to COVID-19, has not been well described.MethodsIn this retrospective cohort study of patients with suspected tick-borne disease attending the University of North Carolina Health facilities, we compared the timeliness of diagnosis and treatment in a “pre-COVID” period (March 2019 to February 2020) and a “post-COVID” period (March 2020 to February 2021). Participants included patients with an ICD-10 diagnosis code of spotted fever group rickettsiosis or ehrlichiosis and a positive Rickettsiarickettsii or Ehrlichia indirect immunofluorescence assay immunoglobulin G antibody test result. Of the 897 patients who had an eligible diagnosis, 240 (26.8%) met the inclusion criteria. The main outcome was time from initial presentation to definitive diagnosis and treatment.ResultsDuring the 2-year study period, 126 (52.5%) patients were grouped in the pre-COVID period and 114 (47.5%) were grouped in the post-COVID period; 120 (50.0%) were female; and 139 (57.9%) were aged > 50 years. Comparing the post-COVID to the pre-COVID period, the adjusted odds ratio (aOR) for delay in treatment > 0 days was 1.81 (95% confidence interval [CI] 1.07–3.07, P = 0.03), and for a treatment delay > 7 days, 1.65 (95% CI 0.94–2.90, P = 0.08). The odds of a delay in diagnosis were similar for patients in the post- and pre-COVID periods, with an aOR of 1.61 (95% CI 0.96–2.72, P = 0.07) for delays > 0 days, and aOR of 1.72 (95% CI 0.99–3.00, P = 0.05) for delays > 7 days.ConclusionsThe odds of a delay in treatment > 0 days were significantly higher in the post-COVID period than in the pre-COVID period. However, the odds of a delay in treatment > 7 days, or a delay in diagnosis, were similar between these two periods. Shifts in care-seeking, alternative care delivery models and prioritization of COVID-19 may contribute to diminished timeliness of treatment for patients with tick-borne diseases.Graphical

"Another tool in the toolkit"-Perceptions, suggestions, and concerns of emergency service providers about the implementation of a supervised consumption site.

As Supervised Consumption Sites (SCS) are implemented in the United States, it is important to consider the needs and perceptions of impacted stakeholders. Emergency service providers (ESP) have a central role in responding to the overdose epidemic. This study intended to assess the how ESP perceive the potential implementation of an SCS in their community, as well as solicit program design and implementation-related concerns and suggestions. In-depth interviews were conducted by videoconference with 22 ESP, including firefighters, paramedics, police, and social workers in King County, Washington, USA. Data were analyzed using a thematic analysis approach. Participants expressed the importance of feeling safe while responding to calls where drug use is involved and highlighted how this perception would be linked to ESP response times to calls from an SCS. Suggestions for improving the perceived safety of an SCS included training program staff in de-escalation as well as planning the layout of the SCS to accommodate ESP. The inadequacy of the emergency department as a point of care for PWUD was also identified as a theme, and some participants expressed enthusiasm regarding the prospect of the SCS as an alternative destination for transport. Finally, support for the SCS model was conditional on the appropriate utilization of emergency services and a reduction in call volume. Participants listed clarifying roles and pursuing opportunities for collaboration as ways to ensure appropriate utilization and maintain positive working relationships. This study builds on literature regarding stakeholder perceptions of SCS by focusing on the perceptions of a critically important stakeholder group. Results enhance understanding of what motivates ESP to support SCS implementation in their community. Other novel insights pertain to ESP thoughts about alternative care delivery models and strategies for emergency department visit diversion.

Engagement and Utilization of a Complete Remote Digital Care Program for Musculoskeletal Pain Management in Urban and Rural Areas Across the United States: Longitudinal Cohort Study.

Musculoskeletal (MSK) conditions are the number one cause of disability worldwide. Digital care programs (DCPs) for MSK pain management have arisen as alternative care delivery models to circumvent challenges in accessibility of conventional therapy. Despite the potential of DCPs to reduce inequities in accessing care, the outcomes of such interventions in rural and urban populations have yet to be studied. The aim of this study was to assess the impact of urban or rural residency on engagement and clinical outcomes after a multimodal DCP for MSK pain. This study consists of an ad hoc analysis of a decentralized single-arm investigation into engagement and clinical-related outcomes after a multimodal DCP in patients with MSK conditions. Patients were coded according to their zip codes to a specific rural-urban commuting area code and grouped into rural and urban cohorts. Changes in their engagement and clinical outcomes from baseline to program end were assessed. Latent growth curve analysis was performed to estimate change trajectories adjusting for the following covariates: age, gender, BMI, employment status, and pain acuity. Outcomes included engagement, self-reported pain, and the results of the Generalized Anxiety Disorder 7-item, Patient Health Questionnaire 9-item, and Work Productivity and Activity Impairment scales. A minimum clinically important difference (MCID) of 30% was considered for pain. Patients with urban and rural residency across the United States participated in the program (n=9992). A 73.8% (7378/9992) completion rate was observed. Both groups reported high satisfaction scores and similar engagement with exercise sessions, with rural residents showing higher engagement with educational content (P<.001) and higher program completion rates (P=.02). All groups showed a significant improvement in all clinical outcomes, including pain, mental health, and work productivity, without statistically significant intergroup differences. The percentage of patients meeting the MCID was similar in both groups (urban: 67.1%, rural: 68.3%; P=.30). This study advocates for the utility of a DCP in improving access to MSK care in urban and rural areas alike, showcasing its potential to promote health equity. High engagement, satisfaction, and completion rates were noted in both groups, as well as significant improvements in clinical outcomes. ClinicalTrials.gov NCT04092946; https://clinicaltrials.gov/ct2/show/NCT04092946.

Abstract P027: Interest and uptake rates for cancer risk genetic testing in the AHEAD early detection program

Abstract Genetic testing for hereditary breast and ovarian cancer syndrome (HBOC) and Lynch syndrome have both been defined as Tier 1 genomic applications for their significant potential for positive impact on public health, as early cancer interception could greatly reduce mortality among the millions of people at increased risk. However, the integration of this genetic screening into standard-of-care workflows has proven to be challenging due to factors such as clinical resources, patient access, cost and insurance, or patient education and perceptions. More recently, alternative care-delivery models such as tele genetics or “mainstreaming” genetic testing have been popularized as a route to providing more access and less burden that the traditional referral-based pre-test counseling model. This study analyzed the uptake of recommended genetic testing for hereditary cancer from the Adventist Health Early All-Around Detection (AHEAD) program, which is a system-wide initiative aimed at expanding access to genetic screening for cancer risk. The purpose of this analysis is to understand associations between the uptake of genetic testing, and factors such as population demographics, socioeconomics, or care-delivery models, in order to inform and improve the implementation design of the AHEAD program and similar efforts, ultimately improving care and outcomes for the whole patient population. A retrospective data analysis was performed from January 2021 to July 2022 of individuals from 48 clinical locations across California, Oregon, and Hawaii, who went through the AHEAD screening program. A total of 4,922 out of 19,258 individuals met NCCN criteria for HBOP and Lynch syndrome. Of these “high-risk” individuals, 2,666 (54.2%) were interested in genetic testing and of those, 2,313 (86.8%) underwent testing. The analysis demonstrated that interest in genetic testing differed among patient age groups (243, 49.4% in Under 30; 426, 58% in 30-40; 597, 60% in 40-50; 574, 56.7% in 50-60; 501, 50% in 60-70 and 325, 47.6% in 70 and above) and clinic types (1549, 62.5% RHC vs. 663, 52.5% non-RHC). Of patients that were interested, those who went through a single-appointment, point-of-care testing (POCT) model were more likely to follow through with testing than a multiple-appointment, non-POCT model (odds ratio of 1.5, 95% confidence interval of 1.18 to 1.91). The study results showed that interest and uptake of genetic testing may be influenced by demographic or socioeconomic factors, as well as care-delivery models. The difference in testing follow through may indicate that POCT could be a more effective model for increasing genetic testing in certain populations. These results from the AHEAD program suggest that alternative care-delivery models such as telegenetics or "mainstreaming" can provide patients access to genetic screening. Future work should focus on understanding barriers and attitudes among different groups and designing targeted strategies for increasing genetic testing uptake across all groups. Citation Format: Candace Theal Westgate. Interest and uptake rates for cancer risk genetic testing in the AHEAD early detection program. [abstract]. In: Proceedings of the AACR Special Conference: Precision Prevention, Early Detection, and Interception of Cancer; 2022 Nov 17-19; Austin, TX. Philadelphia (PA): AACR; Can Prev Res 2023;16(1 Suppl): Abstract nr P027.

Telehealth Use in the COVID-19 Pandemic: A Retrospective Study of Prenatal Care.

Telehealth is an alternative care delivery model to in-person care. It uses electronic information and telecommunication technologies to provide remote clinical care to patients, especially those living in rural areas that lack sufficient access to health care services. Like other areas of care affected by the COVID-19 pandemic, the prevalence of telehealth has increased in prenatal care. This study reports on telehealth use in prenatal care at a large academic medical center in Middle Tennessee, USA. We examine the electronic health records of over 2500 women to characterize 1) the volume of prenatal visits participating in telehealth, 2) disparities in obstetric patients using telehealth, and 3) the impact of telehealth use on obstetric outcomes, including duration of intrapartum hospital stays, preterm birth, Cesarean rate, and newborn birthweight. Our results show that telehealth mainly was used in the second and third trimesters, especially for consulting services. In addition, we found that certain demographics correlated with lower telehealth utilization, including patients who were under 26 years old, were Black and/or Hispanic, were on a state-sponsored health insurance program, and those who lived in urban areas. Furthermore, no significant differences were found on preterm birth and Cesarean between the patients who used telehealth in their prenatal care and those who did not.

Characteristics of community-dwelling older individuals who delayed care during the COVID-19 pandemic

BackgroundDisruptions and reductions in healthcare services, coupled with infection concerns in the public, have caused widespread delay in health care during the COVID-19 pandemic. Persons with disability were at increased risk for deferred care. This study aimed to examine the extent of delayed care among older US individuals by disability status, identify characteristics associated with delayed care, and explore potential barriers to care during the pandemic. MethodsData were drawn from the Health and Retirement Study (HRS) 2020 Core Early Release. Community-dwelling adults over age 50 (n = 15145) were classified as having ADL (or IADL) impairment versus no impairment. Distributions of demographic, clinical, and psychosocial characteristics, delayed care, and barriers to care were compared between disability groups. Characteristics associated with delayed care were identified with the multivariable logistic regression model with multiple imputation. Results30.7% of older individuals delayed care. ADL/IADL impairment was associated with delayed care overall and in specific domains. Sociodemographic (e.g., younger age and higher socioeconomic status), clinical (e.g., disability, psychiatric conditions, pain, and severe fatigue), and psychosocial (e.g., concerns about the pandemic, perceived financial insecurity, and loneliness) characteristics were associated with delayed care. Financial barrier to care and fear disproportionately affected those with social and clinical vulnerabilities, whereas reductions in healthcare services had a greater impact on those with socioeconomic well-being. ConclusionEfforts should be directed to increase receipt of needed care among vulnerable older individuals. Both pandemic-induced and long-standing barriers to care among disparate subpopulations should be considered in alternative care delivery models.

Nursing With the People: Reimagining Futures for Nursing.

We wish to advance a theory of nursing that intentionally engages in questions of politics and economics, centering equity and justice as a foundation for the provision of nursing care. As health care costs rise and health disparities widen, nurses have a clear imperative to develop alternative health care delivery models unmoored from the conventional employment and profit-driven structures that now disappoint us. This mandate arises from our disciplinary focus that emphasizes social justice as a social and moral good linked to the human services nurses provide. This kind of sociopolitical engagement is not auxiliary to nursing but rather central to our ethos. A health care environment that prioritizes profit over the well-being of people is an anathema to our disciplinary focus which, we believe, should center communities and people. The health care system that has forged nursing in the United States, transforms nursing into a commodity. This reinscribes inequality for those who are unable to access care, contributes to environmental harm through profligate hospital pollution and waste, and exploits nursing staff as workers. Nurses have a history of both upholding oppressive systems that disenfranchise segments of the public, usually poor, often People of Color, and engaging in innovative alternatives to the status quo. We wish to foster revolutionary alternative care delivery models that free us from the neoliberal confines of for-profit health care. Ultimately, we argue, nursing as a discipline and a science cannot neglect our role as whistleblowers and change agents. Nor can we presuppose that our dysfunctional and harmful health care structure in the United States is a foregone conclusion. Health care is constructed, which means it can be reconstructed. If we wish to realize our emancipatory potential as nurses, critically examining our role in upholding oppressive structures is a critical step toward a more robust future of nursing.

Derivation and Application of a Tool to Estimate Benefits From Multiple Therapies That Reduce Recurrent Stroke Risk.

Background and Purpose- Lowering blood pressure and cholesterol, antiplatelet/antithrombotic use, and smoking cessation reduce risk of recurrent stroke. However, gaps in risk factor control among stroke survivors warrant development and evaluation of alternative care delivery models that aim to simultaneously improve multiple risk factors. Randomized trials of care delivery models are rarely of sufficient duration or size to be powered for low-frequency outcomes such as observed recurrent stroke. This creates a need for tools to estimate how changes across multiple stroke risk factors reduce risk of recurrent stroke. Methods- We reviewed existing evidence of the efficacy of interventions addressing blood pressure reduction, cholesterol lowering, antiplatelet/antithrombotic use, and smoking cessation and extracted relative risks for each intervention. From this, we developed a tool to estimate reductions in recurrent stroke risk, using bootstrapping and simulation methods. We also calculated a modified Global Outcome Score representing the proportion of potential benefit (relative risk reduction) achieved if all 4 individual risk factors were optimally controlled. We applied the tool to estimate stroke risk reduction among 275 participants with complete 12-month follow-up data from a recently published randomized trial of a healthcare delivery model that targeted multiple stroke risk factors. Results- The recurrent stroke risk tool was feasible to apply, yielding an estimated reduction in the relative risk of ischemic stroke of 0.36 in both the experimental and usual care trial arms. Global Outcome Score results suggest that participants in both arms likely averted, on average, 45% of recurrent stroke events that could possibly have been prevented through maximal implementation of interventions for all 4 individual risk factors. Conclusions- A stroke risk reduction tool facilitates estimation of the combined impact on vascular risk of improvements in multiple stroke risk factors and provides a summary outcome for studies testing alternative care models to prevent recurrent stroke. Registration- URL: https://www.clinicaltrials.gov; Unique identifier: NCT00861081.

Implications of Consumerism in Health Care

Today, the banking, retail, and ride-hailing industries offer consumer-focused technology solutions that are better and more useful than the ones offered in health care. This trend has increased attention on health care transparency and alternative care delivery models. Health systems, hospitals, and individual physicians have the opportunity to lead these changes or risk becoming passive observers in this consumer-focused transition.

Collaboration Between Medical Providers and Dental Hygienists in Pediatric Health Care

Basic preventive oral services for children can be provided within the medical home through the collaborative care of medical providers and dental hygienists to expand access for vulnerable populations. BackgroundBecause dental caries is a largely preventable disease, it is untenable that it remains the most common chronic disease of childhood. Leveraging the multiple visits children have with medical providers has potential to expand access to early preventive oral services. Developing interprofessional relationships between dental providers, including dental hygienists, and medical providers is a strategic approach to symbiotically expand access to dental care. Alternative care delivery models that provide dental services in the medical home expand access to these services for vulnerable populations. The purpose of this article is to explore 4 innovative care models aimed to expand access to dental care. MethodsCurrent activities in Colorado and around the nation are described regarding the provision of basic preventive oral health services (eg, fluoride varnish) by medical providers with referral to a dentist (expanded coordinated care), the colocation of dental hygiene services into the medical home (colocated care), the integration of a dental hygienist into the medical care team (integrated care), and the expansion of the dental home into the community setting through telehealth-enabled teams (virtual dental home). Gaps in evidence regarding the impacts of these models are elucidated. ConclusionBringing preventive and restorative dental services to the patient both in the medical home and in the community has potential to reduce long-standing barriers to receive these services, improve oral health outcomes of vulnerable patients, and decrease oral health disparities.

Group prenatal care: review of outcomes and recommendations for model implementation.

The intent and delivery of prenatal care have evolved since its formal inception in the early 1900s. Group prenatal care offers an alternative care delivery model to the currently dominant prenatal care model. The group model has been associated with a number of improved perinatal outcomes including decreased preterm birth, higher birth weight, improved breast-feeding initiation and duration, decreased cesarean delivery, and greater patient satisfaction. This article outlines the tenets of CenteringPregnancy, the current dominant form of group prenatal care, reviews literature regarding perinatal outcomes related to group prenatal care, suggests future research agendas, and highlights relevant considerations when implementing this alternate model of prenatal health care delivery.

Task-Sharing of HIV Care and ART Initiation: Evaluation of a Mixed-Care Non-Physician Provider Model for ART Delivery in Rural Malawi

BackgroundExpanding access to antiretroviral therapy (ART) in sub-Saharan Africa requires implementation of alternative care delivery models to traditional physician-centered approaches. This longitudinal analysis compares outcomes of patients initiated on antiretroviral therapy (ART) by non-physician and physician providers.MethodsAdults (≥15 years) initiating ART between September 2007 and March 2010, and with >1 follow-up visit were included and classified according to the proportion of clinical visits performed by nurses or by clinical officers (≥80% of visits). Multivariable Poisson models were used to compare 2-year program attrition (mortality and lost to follow-up) and mortality by type of provider. In sensitivity analyses only patients with less severe disease were included.ResultsA total of 10,112 patients contributed 14,012 person-years to the analysis: 3386 (33.5%) in the clinical officer group, 1901 (18.8%) in the nurse care group and 4825 (47.7%) in the mixed care group. Overall 2-year program retention was 81.8%. Attrition was lower in the mixed care and higher in the clinical officer group, compared to the nurse group (adjusted incidence rate ratio [aIRR]=0.54, 95%CI 0.45-0.65; and aIRR=3.03, 95%CI 2.56-3.59, respectively). While patients initiated on ART by clinical officers in the mixed care group had lower attrition (aIRR=0.36, 95%CI 0.29-0.44) than those in the overall nurse care group; no differences in attrition were found between patients initiated on ART by nurses in the mixed care group and those included in the nurse group (aIRR=1.18, 95%CI 0.95-1.47). Two-year mortality estimates were aIRR=0.72, 95%CI 0.49-1.09 and aIRR=5.04, 95%CI 3.56-7.15, respectively. Slightly higher estimates were observed when analyses were restricted to patients with less severe disease.ConclusionThe findings of this study support the use of a mixed care model with well trained and regularly supervised nurses and medical assistants to provide HIV care in countries with high HIV prevalence.

Editorial introductions

Current Opinion in Critical Care was launched in 1995. It is one of a successful series of review journals whose unique format is designed to provide a systematic and critical assessment of the literature as presented in the many primary journals. The field of critical care is divided into 13 sections that are reviewed once a year. Each section is assigned a Section Editor, a leading authority in the area, who identifies the most important topics at that time. Here we are pleased to introduce the journal's Editor and Section Editor for this issue. EDITOR-IN-CHIEF Jean-Louis VincentJean-Louis VincentDr Vincent is Professor of intensive care at the University of Brussels, Belgium, and Head of the Department of Intensive Care at the Erasme University Hospital in Brussels, Belgium. He earned his medical degree from the Universite Libre de Bruxelles, Belgium, with magna cum laude, with a specialty in Internal Medicine and Intensive Care Medicine. His training included two years of fellowship in critical care medicine at the University of Southern California, USA with Prof. Max Harry Weil. Dr Vincent has signed more than 700 original articles, more than 280 book chapters and review articles, and around 800 original abstracts. He has edited 86 books including 63 in his own series Update in Intensive Care and Emergency Medicine and Yearbook in Intensive Care and Emergency Medicine published by Springer-Verlag (Heidelberg, Berlin, New York). He is co-editor of the Textbook of Critical Care (Elsevier Saunders, 5th Edition). He has also written a French Manual of Intensive Care and Emergency Medicine (Springer, France), and is the co-editor of the series Le point sur… (Springer, France). Dr Vincent is the editor-in-chief of Critical Care, Current Opinion in Critical Care, and ICU Management. He is member of the Editorial Boards of about 30 journals including Critical Care Medicine (senior editor), PLoS Medicine, Lancet Infectious Diseases, Intensive Care Medicine, Chest, Shock, and Journal of Critical Care. Dr Vincent is presently Secretary General of the World Federation of Societies of Intensive and Critical Care Medicine. He is a Past-President of the European Society of Intensive Care Medicine and the European Shock Society, and the Past-Chairman of the International Sepsis Forum. For 31 years he has organized an International Symposium on Intensive Care and Emergency Medicine which is held every March in Brussels. This symposium, which gathers 5,000 participants, has become one of the largest meetings in the field. He received the Foundation André Loicq award in 1986, the Foundation De Kerckheer award in 2000, the Distinguished Investigator award of the Society of Critical Care Medicine in 2001 and the College Medalist Award of the American College of Chest Physicians in 2003. He was the Recipient of the "Society Medal” (lifetime award) of the European Society of Intensive Care Medicine in 2009 and he received “ Prix Scientifique Joseph Maison-Sciences biomédicales cliniques” (scientific award of the FRS-FNRS) in 2010. SECTION EDITOR Arthur P. WheelerArthur P. WheelerArthur Wheeler is a Professor in the Division of Allergy, Pulmonary and Critical Care Medicine at Vanderbilt University, USA, and serves as the Director of the Vanderbilt ICU. He is a graduate of the University Of Maryland School Of Medicine, USA, then completed training programs in Internal Medicine, Pulmonary Disease and Critical Care at Vanderbilt University. Dr Wheeler's research interest in severe sepsis, acute lung injury and thromboembolic disease has resulted in more than 100 publications. He is also the co-author of a successful textbook of Critical Care Medicine now in its fourth edition. He has delivered hundreds of national and international lectures and is the recipient of numerous teaching awards. Most recently Dr Wheeler has been developing and testing the effectiveness of alternative care delivery models in critical care including the use of nurse practitioners.

Understanding the drivers of cancer care at the regional, state, and local levels.

142 Background: Regional, state, and local variations in cancer care necessitate a more thorough understanding of the key drivers of quality at these levels. In this study, Avalere sought to understand how local quality and health information technology (HIT) infrastructures may influence the quality of care to which a cancer patient has access. Methods: Avalere conducted an analysis of the primary influencers of quality and value in each state, cataloguing over 500 public and private quality improvement organizations, including payers; employer groups; and hospitals and alternative care delivery models, such as accountable care organizations and patient-centered medical homes, among others. Recognizing the critical role that health information technology (HIT) plays in underpinning quality improvement efforts, Avalere also catalogued the primary HIT organizations in each state. From this, Avalere conducted a sub-analysis of those initiatives with a specific focus on cancer care to determine how the number of cancer-related initiatives relates to the sophistication of a region’s or state’s quality and HIT sophistication. Results: Avalere found that the sophistication of the quality and HIT infrastructures varied widely from state-to-state and region-to-region, with some areas being significantly less developed than others. Similarly, the number of cancer-related quality initiatives also varied widely, with fewer initiatives found in areas with less sophisticated quality and HIT infrastructures. In addition, major urban areas tend to have significantly more sophisticated infrastructures—and an associated higher number of cancer-related initiatives—than non-urban areas, regardless of regional or state quality or HIT trends, more generally. Conclusions: While national quality improvement efforts receive the most media attention and funding, patient care, including cancer care, is delivered at the local level. As such, in order to improve the quality and value of care cancer patients receive, it is imperative to understand and improve local quality and HIT infrastructures and the barriers to quality associated therewith. This is particularly important in locales without major urban access, such as found in large parts of the Midwest and West.

Immigrant women’s experiences of receiving care in a mobile health clinic

This paper is a report of a study of the experiences of Portuguese-speaking immigrant women who used a mobile health clinic for their reproductive health care. Upon arrival in Canada, immigrant women often are in better health than their Canadian-born counterparts; however, this health status tends to deteriorate over time. One reason for this change is limited access to services. Data collection during 2004 and 2005 involved individual interviews with seven Portuguese-speaking women who received care in a mobile health clinic in Toronto, Canada, and with four clinic care providers. Non-participant observation of the interaction between clients and care providers was also conducted. Interviews conducted in Portuguese were translated into English and transcribed, along with those conducted in English. Interview transcripts were read and re-read in the context of observational notes to develop codes. Emerging codes were grouped together to develop subcategories and categories. Participants' experiences of accessing and receiving care in the mobile health clinic were shaped by their perceptions of health, which included physical, mental, social and spiritual aspects, and their pre- and postmigration care experiences. As an alternative model of care delivery, the mobile health clinic was perceived by participants to address their care needs and to help overcome postmigration barriers by providing accessible, holistic, and linguistically and culturally appropriate care. Mobile health clinics should be considered as an alternative care delivery model for immigrant women who may be at a disadvantage because of their socio-economic, cultural, and racialized statuses.

Comparison of Centering Pregnancy to Traditional Care in Hispanic Mothers

To compare maternal and infant outcomes in Hispanic women participating in the Centering Pregnancy Model (CPM) to those receiving prenatal care via the traditional model and determine acceptability of the CPM. Forty-nine women (n = 24 CPM; n = 25 traditional) participated in this quasi-experimental prospective comparative design. Participants self selected the model of care delivery. Data were collected via questionnaires at the initial visit, 34-36 weeks gestation, and postpartum. Outcome measures included: satisfaction with care delivery model, health behaviors, prenatal/postnatal care knowledge, self-esteem and depression. Breastfeeding initiation and continuation, infant birth weight, gestational age at delivery, mode of delivery and infant length of stay were also collected. Traditional participants had a history of more pregnancies, more living children, and higher levels of postpartum self-esteem compared to centering participants. Knowledge deficits and health behaviors were similar between groups. No differences were found for infant outcomes. This study provides information regarding Hispanic mothers' responses to an alternative care delivery model. Preliminary evidence suggests CPM compares with traditional care and yields a high degree of patient satisfaction. Specific pregnancy-related knowledge deficits were identified in both groups that could focus prenatal education. In light of similar outcomes in both groups; patient and provider satisfaction and economics would therefore be a factor when choosing a model of prenatal care delivery.

Economics of home vs. hospital breastfeeding support for newborns

This paper presents the findings of research comparing the incremental costs associated with the provision of home-based vs. hospital-based support for breastfeeding by nurse lactation consultants for term and near-term neonates during the first week of life. A consequence of both consumer demands and increasing health resource constraints is that alternative care delivery models for safe, efficacious and cost-effective breastfeeding programmes have steadily evolved. To date, the economic impact of the setting (home or hospital) where lactation support is delivered has received little research attention. Mother-infant dyads were stratified by gestational age as term (>37 weeks gestational age; n = 101) or near term (35-37 weeks gestational age; n = 37) and randomized to standard hospital care and postpartum follow-up (standard care), or to standard hospital care plus home support from certified nurse lactation consultants (experimental). Data collection occurred at study entry, hospital discharge and at a seventh day postpartum follow-up session. Costs to the family (out-of-pocket and time costs) and to the healthcare system (during hospitalization and after hospital discharge) were measured. Total societal costs were defined as the sum of both family and healthcare system costs. Compared with standard hospital-based care, home support by nurse lactation consultants showed no statistically significant differences in either time costs to the family or total societal costs. Term infants who received home support had statistically significantly greater postdischarge system costs (P < 0.0001), with a trend towards lower out-of-pocket expenses to their families (P = 0.12). There were no statistically significant differences between the two groups in overall combined family and healthcare system costs. These results suggest that the cost of home lactation support programmes were comparable with the costs of hospital-based standard care. Breastfeeding support at home by lactation consultants should be considered as an option as it was no more costly than support from lactation consultants in the hospital setting. The findings for near-term infants need to be interpreted with caution, given the small sample size.

Hospital in the home: constructions of the nursing role - a literature review.

Acute medical and nursing treatment in the home is increasingly seen as an alternative to hospitalization. Models such as hospital in the home (HITH) or acute home care are said to provide a safe, comfortable environment for patients that is conducive to healing. A review of the literature reveals the embryonic nature of the research and discussion related to this alternative care delivery model. In general, the benefits of hospital in the home programmes are presented in an uncritical manner. Medical practitioners have embraced the move to home care as a means of expanding the use of advanced technologies and improved drug regimes beyond the hospital walls. The nursing response has been mechanistic and recipe-like while advancing the HITH nursing role as an opportunity for specialty practice by virtue of the increased autonomy and independence required. This review demonstrates the influence of a professional mandate for specialization, and the ideological and scientific interests that have influenced the role of the nurse.

Case Management

Nurse executives have been challenged to "reinvent" hospital-based nursing through alternative care delivery models. These models also help eliminate a major barrier to quality: the lack of understanding and ability to control the care delivery process. The authors discuss a collaborative and multidisciplinary case management model which promises to positively affect the institution's total bottom-line patient, staff, and system, including financial, outcomes.