Community-based Care Settings Research Articles

Child and Family Therapy Process: Concordance of Therapist and Observational Perspectives

The objective of this study is to examine the characteristics of outpatient mental health services delivered in community-based outpatient clinics, comparing information obtained from two different sources, therapists serving children and families, and observational coders viewing tapes of the same treatment sessions. Videotaped therapy sessions were rated by therapists and independent coders regarding goals and strategies pursued during each session. Sixty-three sessions were taped of outpatient care provided to 18 children and their caregivers by 11 therapists. Children were 4–13 years old and families were receiving services at least in part due to reported child behavior problems, confirmed by ratings from the Child Behavior Checklist and Conners Parent Rating Scale—Revised. Analyses assessed the frequency, type, and intensity of goals and strategies pursued in therapy sessions from both therapist and observational coders’ perspectives. Reliability of observer ratings and correspondence between therapist and observer reports were also examined. The reliability of observational coding of goals and strategies was moderate to good, with 76% of 39 codes having ICCs of .5 or greater. Therapists reported pursuing 2.5 times more goals and strategies per session, on average, than identified by observational coders. Correspondence between therapists and coders about the occurrence of specific goals and strategies in treatment sessions was low, with 20.5% of codes having a Kappa of .4 or higher. Substantial differences exist in what therapists and independent coders report as occurring in outpatient treatment sessions. Both perspectives suggest major differences between the content of services provided in community-based outpatient clinics and the structure of evidence-based programs, which emphasize intense pursuit of a small number of goals and strategies in each treatment session. Implications of the findings for quality improvement efforts in community-based mental health care settings are discussed.

HIV Prevention and Primary Care for Transgender Women in a Community-Based Clinic

Male-to-female transgender individuals, or transgender women (TW), are at high risk for HIV infection and face multiple barriers to HIV care. Advocates agree that numerous factors need to be addressed concurrently to prevent HIV infection in TW, including primary health care. This article examines how a community-based clinic that offers free or low-cost care addresses the health care needs of TW. A total of 20 TW who attended a health care clinic dedicated to community-based health were interviewed regarding best practices for HIV prevention and primary care. In-depth interviews were conducted, transcribed, coded, and analyzed. Factors reported to be effective for HIV prevention and primary care included (a) access to health care in settings not dedicated to serving transgender and/or gay communities, (b) a friendly atmosphere and staff sensitivity, and (c) holistic care including hormone therapy. Community-based health care settings can be ideal locales for HIV prevention and primary care for TW.

Chapter 8; Alzheimer's Disease and Related Dementias

SUMMARY The number of individuals with Alzheimer's disease or a related dementia is growing at a staggering rate. Thus, it is essential that social workers in geriatric settings are knowledgeable about this disorder and the appropriate interventions to use at all stages of the disease. The purpose of this article is to examine the types of non-pharmacological, psychosocial treatments that are used to manage the behavioral manifestations and changes in the mood of individuals with Alzheimer's disease or a related dementia. While great strides have been made in pharmacological treatments of Alzheimer's disease, less attention has been given to the types of psychosocial interventions that are readily employed in community-based and long-term care settings to assist in the care of these individuals. This article provides an overview of psycho-social interventions, as well as identifies the direction for future evidence-based treatment studies, for individuals with Alzheimer's disease and related dementia.

Are there Racial Differences in Attitudes Toward Hospice Care? A Study of Hospice-Eligible Patients at the Visiting Nurse Service of New York

Research on African American and white attitudes, perceptions, and knowledge of hospice care has focused predominantly on patients and providers in institutions and community-based care settings. Little is known about patients receiving home health services, despite growing trends toward noninstitutional care in the United States. This study of home health clients who are eligible for hospice, but not currently receiving it, found few differences between racial groups with regard to attitudes about end-of-life care. An alarming proportion of African American and white home health clients held erroneous ideas about hospice care and had not discussed this option with their providers. These findings suggest that increased referrals to home-based hospice care among home health clients depend on the availability and professional dissemination of accurate, spiritually sensitive information.

Conducting Research in Community-Based Care Facilities: Ethical and Regulatory Implications

Successful research in community-based care settings requires collaboration between facility staff and researchers. The ethical conduct of research involves respect for persons, beneficence, and justice. Research must comply with specific federal regulations and state laws. Interviews with 15 community-based care facility administrators revealed differences in understanding how research is regulated and the influence that research might have when a facility provides access to researchers. A Facility Bill of Rights describes principles related to the ethical conduct of research and questions to consider when deciding whether to provide researchers with access to a facility.

A Project Investigating Music Therapy Referral Trends within Palliative Care: An Australian Perspective

The purpose of this project is to analyze music therapy (MT) referral trends from palliative care team members across nine Australian inpatient and community-based palliative care settings. For each referral 6 items were collected: referral source, reason and type; time from Palliative Care Program (PCP) admission to MT referral; time from MT referral to death/discharge; and profile of referred patient. Participants (196 female, 158 male) were referred ranging in age from 4-98 years and most were diagnosed with cancer (91%, n = 323). Nurses (47%, n = 167) referred most frequently to music therapy. The mean average time in days for all referrals from PCP admission to MT referral was 11.47 and then 5.19 days to time of death. Differences in length of time to referral ranged from 8.19 days (allied health staff) to 43.75 days (families). Forty-eight percent of referrals (48.5%, n = 172) were completed when the patient was rated at an Eastern Cooperative Oncology Group Performance (ECOG) of three. Sixty-nine percent (n = 244) were living with others at the time of referral and most were Australian born. Thirty-six percent (36.7%, n = 130) were referred for symptom-based reasons, and 24.5% (n = 87) for support and coping. Implications for service delivery of music therapy practice, interdisciplinary care and benchmarking of music therapy services shall be discussed.

Usability and acceptance of automated home-based symptom monitoring by urban and rural cancer patients in community-based care settings in Indiana

8085 Background: Experts recommend that providers routinely and regularly ask patients about pain, depression, fatigue and other cancer-related symptoms, using brief, validated assessment tools. Current paper-based symptom assessment is costly, inefficient, and limited to the point of care. We tested the usability and acceptance by patients of an automated symptom assessment system, incorporating interactive voice response (IVR) telephone technology and the Internet, to track symptoms while patients are away from the clinic. Methods: We recruited 120 cancer patients at 7 community-based, urban and rural cancer care sites to test the system. Patients were instructed to use the system and asked to choose the day and time of day to receive scheduled calls to their home, work, or mobile phone. Patients could also call a toll-free number or log onto a secure site on the Internet to provide a self-report. The M.D. Anderson Symptom Inventory was used to measure severity and interference of 13 common cancer symptoms. After using the system, we called each participant for debriefing. Results: Participants used the system from one to 13 weeks. Over 67% of patients used the system more than 5 times. Participants averaged 10 self-reports each. Ages ranged from 28 to 87 years. Participants preferred the telephone to complete their surveys - 95 percent of surveys were done by IVR; 5 of surveys were completed on the Internet. Patient satisfaction with the system was high –8.2 on a 0 (lowest) to 10 (highest) scale; 74 percent of patients rated their satisfaction at 8 or higher. The system was easy to use for 86%; 81% found it convenient. Over 65% of patients said they would participate in automated symptom monitoring if it were offered as standard care. Conclusions: Community-based cancer patients of all ages readily accept automated symptom monitoring as part of their routine cancer care. They prefer to self-report using the telephone. Patients of all ages have little difficulty learning to use the system; they are very willing and able to provide regular, complete symptom severity self-reports. They would welcome such a system as an integral part of their standard care. No significant financial relationships to disclose.

'It's different from my culture; they're very different': Providing community-based, 'culturally competent' palliative care for South Asian people in the UK.

This article investigates the challenges faced by those trying to develop 'culturally competent' palliative care for South Asian cancer patients in Luton, UK. It discusses the findings of a phenomenological study of service providers' attitudes to and experiences of caring for South Asian patients. Ten semi-structured in-depth interviews were carried out with a range of staff who work in home and community-based palliative care settings, including nurses, community liaison personnel and representatives of non-statutory organisations. The authors begin by considering how these service providers construct ideas of cultural difference and how these relate to philosophies of palliative care. They then examine attempts to deal with cultural diversity in everyday practice, focusing in particular on the social context of care in the home. The paper considers the ways in which staff attempt to incorporate the cultural needs of patients, family, kin and community. Rather than criticising current working practices, the authors highlight the complexity of delivering culturally competent services from the perspective of those working directly with patients. In doing so, they contribute to ongoing debates about the development of anti-discriminatory practice in health and social care.

Navigating federalwide assurance requirements when conducting research in community-based care settings.

There is an urgent need for research on quality of life and healthcare delivery for older adults living in community-based care settings, yet implementing current federalwide assurance (FWA) requirements can be a challenge in these settings. This paper discusses FWA requirements for engagement in federally funded research as the requirements pertain to community-based care settings. Factors that impede community facilities in achieving FWA approval include lack of organizational structure to provide oversight for the ethical conduct of research, administrator concerns regarding potential liability associated with obtaining the FWA, lack of resources to complete required paperwork, and lack of staff knowledge about human subjects protection and federal requirements for participating in research. Effects of the FWA process on investigators include the burden of extra time needed to support community-based facilities to acquire a FWA and concerns that studies may be limited to only those community facilities with the resources to complete the FWA process. Investigator-initiated strategies for conducting research in community-based settings include considering study designs that are exempt from the FWA process and proactively assisting community-based facilities to acquire FWA status. Investigators need to work with potential research sites and the office for human research protections to ensure that subjects are protected without shifting the burden of protection to ill-prepared community administrators.

Aging and community care

Aging Clin Exp Res, Vol. 16, No. 4 257 The World Health Report 2000 produced by the World Health Organisation illustrated the variance in performance of health care systems between nations (1). That the league tables in this report generated so much controversy demonstrated the high levels of interest and concern about matters of health in the minds of those who govern and those who are governed. The proportion of population aged over 65 in most European nations will be around 20% by 2015 and nearly 25% by 2030. The increase in the number of people reaching old age is accelerating fastest in developing nations. These facts have profound implications for nations’ economies and health and social care systems, facts that are presented in stark numerical descriptions by Kinsella and Velkoff (2). Performance of health and social care services becomes critically important as the proportion of older people increases, as it is in older age that chronic diseases and disability are most prevalent. Evidence-Based Medicine (EBM) is today’s health care mantra, but the evidence upon which we can base decisions intended to produce best outcomes for whole systems of health and social care is sorely lacking. In reporting ‘the state of the art’, the OECD noted that most health systems are still at an early stage in implementing effective methods of performance measurement and improvement (3). This is especially true when addressing the needs of people with physical and cognitive impairment and those with multiple pathologies, nearly all of whom will be living in community-based or long-term care settings. The challenges are complex, the solutions are multi-factorial, and the research is difficult and expensive to conduct. This issue of the journal reports 11 projects on the care of older people in the community and long-term care from 8 different countries, from Bahrain to the United States, and the first 11 country comparative analysis of the recipients of community care in 11 European countries. The variety of methodologies applied and the focus of the studAging and community care

Developing a Training Program on Issues in Aging for Correctional Workers

Older adults who are incarcerated and living in prisons represent an increasing, yet invisible, group among the aging population. Two factors in particular have contributed to this growth: the aging of the general population and the escalating number of prisoners serving long sentences. Working effectively with older inmates poses a challenge for correctional workers who are accustomed to dealing with a much younger clientele. In many states, correctional employees are required to obtain annual training, and educational institutions can play a major role in providing the expertise necessary in the development of quality training materials on issues related to aging. While continuing education programs to address the needs of workers in community-based and long-term care settings have grown rapidly, they have made negligible progress in more obscure settings such as prisons. This paper discusses the development of a 6-hour training program entitled “Issues in Aging for Correctional Workers.” The training was developed through the interdisciplinary collaborative efforts of two faculty members who teach in the criminal justice and sociology/social work departments at a medium-sized liberal arts university in the upper Midwest.

Nursing Education in a Home Health Care Practicum

As our health care delivery system has undergone profound change in the past decade, providers are expanding services from inpatient facilities to a variety of alternative settings, including home health care. Academic programs offering nursing education are recognizing the need to parallel this trend and have been placing student nurses in community-based and home care settings for clinical experience. Careful attention to curriculum development and effective management of students in a home care practicum can help ensure adequate preparation of graduate nurses who are likely to be employed in a variety of outpatient settings, including home health care.

Interdisciplinary Cross-National Program on Dementia for Health Professionals in Japan

Dementia is a major concern in serving the older population. Understanding it has become essential to the curriculum in geriatrics education in Japan. Given the untreatable nature of the disease, the goal of care is often to maximize independence of dementia-impaired elders in community-based long-term care settings by preventing disabilities caused by an excess of care that might exacerbate the symptoms of dementia. To prepare future front-line health professionals who will work in the allied health professions, we provided students from three associate degree colleges in Japan with a two-week summer institute at Harvard Medical School which trains them to become dementia specialists. The training experience increased participants' knowledge and interests in dementia care. Implications of these training efforts for future interdisciplinary care for dementia are discussed.

Health System Changes Portend Drop in Physicians’ Charity Care

Health System Changes Portend Drop in Physicians’ Charity Care

A model for the delivery of culturally competent community care.

To describe the proposed Culturally Competent Community Care (CCCC) model, and the process of development and testing of the model. Community health nurses are challenged to provide culturally competent care in all types of communities. However, existing models have not provided community nurses with specific guidelines, and none attempt to explain the effects of culturally competent care on populations in community settings. Therefore, it is necessary to develop a model that is comprehensive in its description of the dimensions of culturally competent care in community-based settings and that also requires a focus on ethnic populations. The model is essential for reducing racial and ethnic health disparities. Based on literature review and concept analysis, three constructs of the Culturally Competent Community Care Model were developed. Two of the constructs, the health care system and health outcomes, were developed based on a literature review. The main construct of the model, cultural competence, was developed after a concept analysis, following the development and testing of the Cultural Competence Scale (CCS). Interviews with eight community health nurses and a survey by five community nurse experts were conducted in order to refine and confirm the dimensions of cultural competence and its impact on health outcomes. The proposed dimensions of culturally competent care are caring, cultural sensitivity, cultural knowledge, and cultural skills. This model focuses on the relationship between cultural competence and health outcomes for culturally diverse populations. The framework provides specific guidelines for community nurses in developing and assessing cultural competence and meeting the health needs of diverse communities.

Balancing freedom with risks: The experience of nursing task delegation in community-based residential care settings

Background: In 1995, Washington State implemented law reforming the state's long-term care system, favoring provision of service in less restrictive, lower-cost settings. Purpose: The purpose was to systematically evaluate one facet of the new law regarding the implementation of a policy authorizing delegation of designated nursing tasks by registered nurses in community-based residential care settings. Method: This was a descriptive study driven by the inductive process of grounded theory. Qualitative data sources included interviews, public forums, document review, and open-ended survey questions to facility operators, nurses, nursing assistants, and inspectors. Discussion: The study identified an overarching social process, balancing freedom with risks involving tension at the intersections, which is evident from 3 main perspectives: consumer, professional, and the health care system. Conclusions: The study has implications for regulatory consistency, nursing practice and education, collaboration between overlapping providers of skilled nursing services in residential settings, and subsequent health policy.Nurs Outlook 2001;49:193-201.

Self-, Informal and Formal Care: Partnerships in Community-Based and Residential Long-Term Care Settings

RÉSUMÉUn accent croissant est mis sur le besoin de regrouper les efforts des personnes âgées, de leur famille et des fournisseurs de services constitués dans un contexte de collaboration ou de partenariat en ce qui a trait aux soins de longue durée, que ce soit en établissement ou dans la communauté. Il est donc nécessaire d'établir de quelle façon ces relations sont actuellement structurées. L'auteur procède à un examen systématique des résultats des études réalisées entre 1985 et 1998 sur les relations entourant les soins personnels, l'assistance formelle et l'assistance informelle dans ces deux environnements. Les résultats tendent à démontrer que les soins formels ne viennent pas remplacer les services informels mais qu'ils sont plutôt utilisés en supplément ou en complément des soins assurés par le réseau informel, et ce tant en établissement que dans la collectivité. La structure exacte de ces partenariats et la relation entre les soins personnels et les soins assurés par les systèmes formels ou non apparaissent moins clairs. Les résultats montrent qu'il faut recentrer l'attention sur des préoccupations plus larges de soutien des partenariats déjà en place plutôt que sur la création de partenariats et la protection contre les substitutions inutiles.

Nursing attire: indicators of professionalism?

The purpose of this qualitative research was to explore the effect that current nursing attire has on the image of the nursing profession. A number of nurses and a nonnurse were interviewed to determine how attire affected their perception of today's nurses. The two research questions were as follows: (1) is the changing dress of nurses projecting a negative image to the public? and (2) What components of a nurse's apparel indicate professionalism? Content analysis was performed on transcriptions from the tape-recorded responses of a purposeful sample of health care workers: 12 registered nurses, 1 bachelor of nursing student, and 1 layperson. The responses for the first research question were not directly addressed by the participants. However, one overall theme emerged, which was labeled "I can't tell you what it is, but I know it when I see it." The main theme that emerged for the second research question was labeled "total package," with role identification and competency being related themes. As a result of this research, nursing administrators and other health care professionals could gain an understanding of the importance of nursing attire as an indicator of nursing professionalism. Future research needs to examine the same research questions with health care consumers in a variety of acute and community-based health care settings.

Linking postdoctoral general dentistry programs with community‐based clinical care settings

This article presents the results of a small workgroup convened by the American Association of Dental Schools to examine experiences related to establishing and conducting dental education programs that have significant affiliations with community-based clinical care settings. The workgroup meeting is a component of the association's effort to identify and promote innovative and non-traditional methods by which the number of postdoctoral general dentistry (PGD) positions can be increased to meet current demand for PGD education. The participants identified factors and conditions believed to be critical to successful program linkages. The information should be helpful to others as they consider opportunities to establish PGD programs or increase their number of PGD training positions.

Predictive Properties of Serum Prostate-Specific Antigen Testing in a Community Setting

We read with interest the recent article by Jacobsen et al¹on the predictive properties of prostate-specific antigen (PSA) as a screening test for prostate cancer in a population-based setting. This study demonstrates an important point when considering operating characteristics of screening or diagnostic tests when used with different populations. In the urology practice setting, the prevalence of prostate cancer and benign prostate disease (a primary source of false-positive results) is far higher than in the general population. It should be expected that the specificity of the screening test will be greater in the general population, where there are proportionately fewer men with benign disease and more men free of disease. In community-based and primary care settings, the distributions of PSA levels among men with and without prostate cancer are more disparate than in the specialty setting. We want to draw attention to 2 additional points that are crucial