Community-based Medical Services Research Articles

Improving the well-being of adolescents through community-based medical services at the public health centers

Adolescence is an important stage in a child’s developmental transition to adulthood. Internal and external factors are believed to extensively influence teenage sexual behaviors, including self-concept. Consequently, several unwanted pregnancies were reported in Dlingo village. Therefore, community-based preventive interventions appear very necessary. These efforts tend to increase awareness after series of psycho-educational activities. The results showed a significant improvement among adolescents, in terms of demonstrating sufficient psychological development and positive self-concept. Furthermore, the cadres also demonstrated an increasing comprehension of adolescent and effective communication. Therefore, it is expected that the provisions of integrated healthcare services are without severe obstacles.

Health Service Utilization Patterns Among Medicaid-Insured Adults With Intellectual and Developmental Disabilities: Implications for Access Needs in Outpatient Community-Based Medical Services.

Limited existing evidence suggests that adults with intellectual and developmental disabilities (IDD) experience substantial disparities in numerous areas of health care, including quality ambulatory care. A multistate cohort of adults with IDD was analyzed for patterns of inpatient admissions and emergency department utilization. Utilization was higher (inpatient [RR = 3.2], emergency department visits [RR = 2.6]) for adults with IDD, particularly for ambulatory care-sensitive conditions (eg, urinary tract [RR = 6.6] and respiratory infections [RRs = 5.5-24.7]), and psychiatric conditions (RRs = 5.8-15). Findings underscore the importance of access to ambulatory care skilled in IDD-related needs to recognize and treat ambulatory care-sensitive conditions and to manage chronic medical and mental health conditions.

Competing priorities and second chances - A qualitative exploration of prisoners' journeys through the Hepatitis C continuum of care.

High levels of undiagnosed and untreated HCV infection exist in prison populations globally. Prisons are a key location to identify, treat and prevent HCV infection among people who inject drugs (PWID). Understanding prisoners’ lived experiences of the HCV continuum of care informs how HCV care can be effectively delivered to this marginalised and high-risk population. This study aimed to explore Irish prisoners’ experience of prison and community-based HCV care. We conducted one-to-one interviews with 25 male prisoners with chronic HCV infection. Data collection and analysis was informed by grounded theory. The mean age of participants and first incarceration was 39.5 and 18.3 years respectively. The mean number of incarcerations was eight. The following themes were identified: medical and social factors influencing engagement (fear of treatment and lack of knowledge, HCV relevance and competing priorities), adverse impact of HCV on health and wellness, positive experience of prison life and health care and the transformative clinical and non-clinical changes associated with HCV treatment and cure. Findings suggest that prison release was associated with multiple stressors including homelessness and drug dependence which quickly eroded the health benefits gained during incarceration. The study generated a substantive theory of the need to increase the importance of HCV care among the routine competing priorities associated with the lives of PWID. HCV infected prisoners often lead complex lives and understanding their journeys through the HCV continuum can inform the development of meaningful HCV care pathways. Many challenges exist to optimising HCV treatment uptake in this group and incarceration is an opportunity to successfully engage HCV infected prisoners who underutilise and are underserved by community-based medical services. Support and linkage to care on release is essential to optimising HCV management.

Comparison of Accessibility, Cost, and Quality of Elective Coronary Revascularization Between Veterans Affairs and Community Care Hospitals

The Veterans Affairs (VA) Community Care (CC) Program supplements VA care with community-based medical services. However, access gains and value provided by CC have not been well described. To compare the access, cost, and quality of elective coronary revascularization procedures between VA and CC hospitals and to evaluate if procedural volume or publicly reported quality data can be used to identify high-value care. Observational cohort study of veterans younger than 65 years undergoing an elective coronary revascularization, controlling for differences in risk factors using propensity adjustment. The setting was VA and CC hospitals. Participants were veterans undergoing elective percutaneous coronary intervention (PCI) and veterans undergoing coronary artery bypass graft (CABG) procedures between October 1, 2008, and September 30, 2011. The analysis was conducted between July 2014 and July 2017. Receipt of an elective coronary revascularization at a VA vs CC facility. Access to care as measured by travel distance, 30-day mortality, and costs. In the 3 years ending on September 30, 2011, a total of 13 237 elective PCIs (79.1% at the VA) and 5818 elective CABG procedures (83.6% at the VA) were performed in VA or CC hospitals among veterans meeting study inclusion criteria. On average, use of CC was associated with reduced net travel by 53.6 miles for PCI and by 73.3 miles for CABG surgery compared with VA-only care. Adjusted 30-day mortality after PCI was higher in CC compared with VA (1.54% for CC vs 0.65% for VA, P < .001) but was similar after CABG surgery (1.33% for CC vs 1.51% for VA, P = .74). There were no differences in adjusted 30-day readmission rates for PCI (7.04% for CC vs 7.73% for VA, P = .66) or CABG surgery (8.13% for CC vs 7.00% for VA, P = .28). The mean adjusted PCI cost was higher in CC ($22 025 for CC vs $15 683 for VA, P < .001). The mean adjusted CABG cost was lower in CC ($55 526 for CC vs $63 144 for VA, P < .01). Neither procedural volume nor publicly reported mortality data identified hospitals that provided higher-value care with the exception that CABG mortality was lower in small-volume CC hospitals. In this veteran cohort, PCIs performed in CC hospitals were associated with shorter travel distance but with higher mortality, higher costs, and minimal travel savings compared with VA hospitals. The CABG procedures performed in CC hospitals were associated with shorter travel distance, similar mortality, and lower costs. As the VA considers expansion of the CC program, ongoing assessments of value and access gains are essential to optimize veteran outcomes and VA spending.

Professional, structural and organisational interventions in primary care for reducing medication errors.

Professional, structural and organisational interventions in primary care for reducing medication errors.

Evaluation methodology for a home-based integrated care program targeting frequently hospitalized older adults in Singapore

Background: In Singapore, the proportion of individuals over 65 years old is increasing rapidly: from 7% in 2000 to a projected 23% in 2030. Population aging presents substantial challenges for hospitals, community-health services, and long-term care providers as health systems attempt to provide high-quality treatments to older adults across the continuum of care. Khoo Teck Puat Hospital is a public hospital in the North Region of Singapore and serves a community of approximately 500,000 individuals. The occupancy rate within the government-subsidized inpatient wards exceeded 90% within six months of opening in July 2010. Administrative review identified a relatively small cohort of individuals who were repeatedly admitted for inpatient treatment within very short time periods. In early 2011, the Aging-in-Place (AIP) program was implemented to provide comprehensive patient-centered care to individuals with complex care needs as they transitioned from the hospital back into the community. Patients who experienced three or more inpatient episodes within a six month period were eligible to join the program at no cost regardless of diagnosis. Through home-visits and telephone consultations, community nurses and community health workers provided medical monitoring, decision making support, and facilitated linkages to additional services. The goal of this program was to integrate primary care with preventive and social services to help decrease individuals’ dependency on inpatient treatment. In this presentation, we outline a three-phase mixed-methods evaluation designed to measure the effectiveness of the AIP program. Literature review: Patients transitioning from inpatient settings back into the community often encounter difficulties in maintaining continuous care. Fragmentation of services increases the potential for a number of adverse events including serious medication errors. In fact, an estimated 40% to 50% of older adults in the United States experience an adverse event in the peridischarge period. Qualitative studies indicate that patients and their caregivers are often unprepared to manage complex health conditions, do not fully comprehend patients’ care needs, and feel under supported from hospital staff during the transition phase. Formal transitional care programs typically incorporate home-health components comprised of caregiver training, medication monitoring, and care coordination in an attempt to integrate services between the hospital and community settings. Existing programs typically include a combination of face-to-face visits and telephone follow-ups by which professionally trained staff draw upon a constellation of health management techniques to help patients and their caregivers successfully navigate the transition from the hospital back into the community. Results for transitional care programs are mixed due to differences between specific programs and patient populations, but high-quality programs have demonstrated reduced readmission rates, shorter inpatient lengths of stay, improved quality of life, as well as substantial cost savings. Discussion: We designed a three-part evaluation to assess the effectiveness of the AIP program. The first part consisted of a retrospective analysis of administrative data to determine the extent to which the AIP program altered patients’ hospital-based service use. AIP intervention patients were compared to a group of control individuals who also experienced three hospitalizations in a six month period but did not live within the AIP catchment area. Using hospital administrative data, we employed a difference-in-difference design comparing hospitalization rates, inpatient lengths of stay, and emergency service utilization between the intervention and control groups. Secondly, we conducted a prospective cohort study of AIP intervention patients and control individuals. This portion of the evaluation determined if the financial costs of implementing the AIP program were offset by savings in both hospital- and community-based medical services. The third portion of the evaluation consisted of a qualitative study of AIP program participants, their caregivers, and individuals who were referred to the program but decided not to participate. Information from semi-structured interviews informed us of participants’ satisfaction with the intervention, caregivers’ assessments of the assistance they received from staff, and reasons behind declining the services for those who rejected the program. Conclusion: Our goal was to design a comprehensive mixed-methods evaluation to assess the effectiveness of the AIP program. The results from the two quantitative phases determined whether the integrated care intervention reduced unplanned hospital-based service use and whether the program was cost effective from both financial and societal standpoints. The qualitative portion allowed us to evaluate patients’ and caregivers’ experiences of the program while uncovering why frequently hospitalized patients chose not to participate in the intervention. Through the use of multiple data sources, we aimed to identify areas where this program succeeded in improving patients’ and caregivers’ lives, and determined areas where further developments were needed.

The FOOTPRINTS model of pediatric palliative care.

Little is known about the optimal context in which to provide care for the more than 53,000 children who die each year in the United States. Poor training in pediatric palliative care contributes to care that is often fragmented and may neglect the physical, psychosocial, and spiritual needs of the child and family. Pediatric hospice care is frequently not available or not chosen by the family or health care providers. In response to a critical need to move beyond the disease oriented, hospital-based model with a lack of continuity between hospital and community-based medical services, we developed FOOTPRINTS, an innovative program of advanced care planning and care coordination. A continuity physician directs the treatment plan regardless of site of care. Staff members coordinate follow up and communication among hospital and community-based care providers. Spiritual support continues through bereavement. Education in the hospital and community supports provision of excellent palliative care by current providers. Satisfaction with this model of care has been high. More than 90% of health care providers and families perceived that the child and family needs as well as the health care provider needs were met by the advanced care planning process and written care plan. All continuity providers would refer another patient. The FOOTPRINTS program promotes quality of care and family and health care provider satisfaction with care. It has been developed to serve as a "best practice" model for care at life's end.

Access to community-based medical services and number of hospitalizations among patients with HIV disease: are they related?

To assess whether better access to community-based outpatient medical services was associated with fewer HIV-related hospitalizations, we studied 217 patients hospitalized at seven southern California hospitals. During hospital admission, patients completed an interview that included one item about the reported difficulty or ease of access to community-based medical services prior to their first hospitalization for HIV-related illness. After discharge, medical records were abstracted for data on prior hospitalizations. CD4 counts, and illness severity. About one-half of patients reported that medical services were readily accessible. Medical records revealed that since the time of HIV infection 49% had two or more total hospitalizations (mean = 2. SD = 2). In multiple logistic regression analysis, better reported access to services was significantly associated with not having been hospitalized (vs. having been hospitalized) over the same time period (OR = 0.73, 95% CI = 0.55-0.97), controlling for CD4 count, illness severity, duration of diagnosed HIV infection, having a regular source of care, type of hospital care, insurance coverage, and other patient characteristics. Improving access to community-based medical services for ambulatory HIV-infected patients may help to avert costly hospital care. Prospective studies are needed to assess whether a causal relationship between greater community-based access and reduced hospitalizations exists and, if so, whether community-based services may be cost-effective substitutes for hospital HIV care.