Community Care Plans Research Articles

Digital solutions to health care: patient-centred Gastrostomy community care plans with digital content

Digital solutions to health care: patient-centred Gastrostomy community care plans with digital content

Co-designing a culturally-sensitive theory-driven advance care planning game with Chinese older adults and healthcare providers

Background: Advance care planning can be challenging because discussing end-of-life care often has negative connotations. Gamification is a novel approach to encourage advance care planning conversations in Western culture. Aim: To co-design a game with multiple stakeholders to promote advance care planning in Chinese communities. Design: A two-phase design guided by the Medical Research Council framework for developing complex interventions was adopted between May 2019 and August 2020. In phase I, a game prototype was developed based on literature review, expert consultation and end-user consultation. In Phase II, the game prototype was tested among end-users and refined according to their feedback and expertise of a multi-disciplinary team through an iterative process. Setting/participants: Experts in the field of aged care, palliative care, life education and game development and Chinese community-dwelling adults aged 60 years or older. Results: A board game called ‘The Five Tastes Found in a Grocery Store’ was developed. The game design was shaped by Bandura’s Self-efficacy theory and feedback from experts and end-users. The participants generally found the gaming experience enjoyable and appreciated the opportunity to discuss end-of-life care openly. Conclusions: This study is the first to develop an evidence-informed, theory-based, culturally sensitive game for promoting advance care planning in the Chinese community using a co-design approach.

Alcohol relapse prevention health care after alcohol withdrawal in New South Wales prisons, Australia: A patient file review.

People who enter custody have complex health issues and comorbidities may include alcohol use disorders. We investigated clinical service provision and comorbidities recorded among individuals with a likely alcohol withdrawal syndrome within prison in New South Wales, Australia. For this clinical case series review, electronic medical data were used to identify 50 people entering custody between August and November 2018 who likely had a treated alcohol withdrawal syndrome. We aimed for a 3:2 ratio of men and women, and a 1:1 ratio of Aboriginal and non-Aboriginal individuals. Data were extracted using a purposefully designed tool which included current alcohol withdrawal management, comorbidities and alcohol relapse prevention approaches used or recommended. Thirty-eight men and 12 women, of whom 22 were Aboriginal, were included. Twenty-nine individuals (58%) reported a history of medical comorbidities. Thirty-five (70%) reported using other substances and over half (60%) had a diagnosis of mental health disorders. Fourteen (28%) individuals had a record of receiving brief intervention and five (10%) of motivational interviewing. Twenty-three individuals (46%) were referred to and seen by drug and alcohol clinicians. Only seven (14%) of the sample had pre-release community care plans. Individuals treated for an alcohol withdrawal syndrome in New South Wales prisons have a high prevalence of medical comorbidities and other substance use. Clinical interventions focused on alcohol withdrawal management, and relapse prevention interventions were not recorded for most individuals. Service innovation and expansion are needed to increase the provision of post-withdrawal management.

"Advocating for what we need": A CBPR approach to advance care planning in the Latinx older adult community.

Advance care planning (ACP) is low among Latinx older adults. We used community-based participatory research (CBPR) to identify ACP barriers/facilitators and design community-based ACP events. In partnership with community-based organizations, clinicians, and local government, we formed a Latinx Community Committee (n=13 community members). We then conducted 6 focus groups with Latinx-identifying, English or Spanish-speaking older adults (age ≥ 55), caregivers, and community leaders to assess ACP barriers/facilitators. We analyzed transcripts using thematic analysis and, based on these learnings, designed and implemented community-based ACP events. Using a validated survey, we assessed acceptability and pre-to-post-event ACP readiness (4-point scale; 4=most ready; 0.2 change considered meaningful) with Wilcoxon signed-rank tests. Focus groups included 10 Spanish-speaking older adults, 8 caregivers, and 10 community leaders. Themes highlighted the importance of ACP (e.g., means of advocacy), barriers (e.g., how to start conversations), and facilitators (e.g., trusted community spaces) in the Latinx community. Ninety-seven people attended 5 events targeting 3 Latinx populations (LGBTQI+, intergenerational, and older adults broadly). Overall pre-to-post-event ACP readiness increased (2.62 (SD 0.97) to 2.95 (SD 0.93); p=0.05). Readiness to document wishes increased significantly (2.44 (SD 1.0) to 2.98 (SD 0.95); p=0.003). Most reported being comfortable attending events (85%) and would recommend them to others (90%). This study describes a feasible, acceptable, and effective CBPR ACP intervention. Co-developed community events represent a promising approach to reducing disparities in ACP among the Latinx population.

Community Innovation and Regional Sustainability: A Case Study of Environmental Health Education in Siaogang Hospital, Kaohsiung Medical University

Kaohsiung Municipal Siaogang Hospital is located in southern Kaohsiung City, a major nexus of land, sea, and air transportation. Thus, the hospital is on the frontlines of strengthening Kaohsiung International Airport's epidemic prevention measures and preventing the spread of COVID-19 and other epidemic viruses to Taiwan from other countries. Kaohsiung Medical University integrates on-campus academic research, teaching services, and medical institution resources and has long promoted community care plans in conjunction with the public sector. A disused public sector space repurposed by the university into a distinctive day care center is being further used as a service-learning platform linking medical education to communities, allowing university students to enter the community and apply what they have learned to improve quality of life, community health, and well-being. "Happy Kaohsiung Healthy City-Siaogang District Environmental Education and Health Promotion Sustainable Development Plan", which responds to the issues and needs of air pollution and health promotion in the city's Siaogang District, designates Kaohsiung Municipal Siaogang Hospital as the core base of local practice, connecting multidisciplinary schools and units as well as cross-regional resources to promote practical programs such as air quality talent education, environmental testing and research, campus health education and publicity, air pollution syllabus, and community care and care, fulfilling the university's social responsibilities.

ICT-based person-centered community care platform (IPC3P) to enhance shared decision-making for integrated health and social care services

BackgroundCommunity care is a care model with the aim of shifting care services from being hospital based toward community-based care. Advances in platforms based on information and communications technology (ICT) with a person-centered approach provide the potential to improve the delivery of health and social care services toward community-based settings. ObjectivesThe aims of this study were to describe the ICT-Based Person-Centered Community Care Platform (IPC3P) and to determine its impact on health- and social-care-related shared decision-making and quality of life among community residents. MethodsAn online platform was developed with the aim of enhancing community care. The platform had four components: (1) comprehensive health and social needs assessment system, (2) personalized community care planning, (3) needs-based health and social care services delivery, and (4) health community engagement. Community residents were invited to use and evaluate the impact of the IPC3P on their quality of life and shared decision-making regarding health and social care services. They provided feedback about the platform by completing two surveys: at baseline (before using the platform) and 6 months after using the platform. ResultsData of 164 community residents were analyzed in this study. Between baseline and after using the platform, the quality of life reported by the participants increased significantly in all domains, with clear improvements also noted for shared decision-making about health and social care services. The IPC3P received positive feedback from the participants for its usability, familiarity, and ease of use. Some participants also reported their desire for the addition of more functions that support health communities. ConclusionThe IPC3P has the potential to enhance the involvement of community residents in their own care. The findings of this study can be used to support the wider implementation of the IPC3P to promote person-centered community care.

Community treatment orders and care planning: How is engagement and decision‐making enacted?

BackgroundIn many jurisdictions worldwide, individuals with a mental illness may be forced to receive care and treatment in the community. In Australia, legislation states that such care should be driven by a care plan that is recovery‐focussed. Key components in the care planning process include engagement and decision‐making about a person's support needs and care options, with trust being an essential component of care planning relationships.ObjectiveThis study examines how these components were enacted during service care contacts for individuals on community treatment orders.MethodsThe study was located at two community mental health teams in South Australia. Ethnographic observations of care planning discussions between consumers, their carers and clinicians, and interviews with individuals from these groups, were conducted over 18 months. Carspecken's critical ethnography provided a rigorous means for examining the data to identify underlying cultural themes that were informing day‐to‐day care interactions.ResultsCare planning was not occurring as it was intended, with service culture and structures impeding the development of trusting relationships. Clinicians striving to work collaboratively with consumers had to navigate a service bias and culture that emphasized a hierarchy of ‘knowing’, with consumers assumed to have less knowledge than clinicians.ConclusionsServices and clinicians can challenge prejudicial ethical injustice and counter this through testimonial justice and implementation of tools and approaches that support genuine shared decision‐making.Patient or Public ContributionThis study included individuals with lived experience of mental illness, their carers and clinicians as participants and researchers.

Community stakeholder and opinion formation toward end-of-life planning in Chinese community in Australia

We examine the role of stakeholders in constructing new socio-cultural narratives of advance care planning in the Chinese community in Australia. Applying the communication theory of opinion leader(ship) and drawing on data from 41 interviews and field observation notes, we explore how stakeholders establish their authority and perform their expertise. Data analysis shows stakeholders have gained their opinion leadership status through demonstrating their ability to link the Chinese cultural values of family harmony and parental duty and the notions of self-empowerment and independence in official advance care planning promotions in Australia.

Use of Do-Not-Resuscitate Orders for Critically Ill Patients with ESKD.

Despite having high comorbidity rates and shortened life expectancy, patients with ESKD may harbor unrealistically optimistic expectations about their prognoses. Whether this affects resuscitation orders is unknown. To determine whether do-not-resuscitate (DNR) orders differ among patients with ESKD compared with other critically ill patients, including those with diseases of other major organs, we investigated DNR orders on admission to intensive care units (ICUs) among 106,873 patients in the United States. Major organ disease uniformly associated with increased risk of hospital mortality, particularly for cirrhosis (adjusted odds ratio [aOR], 2.67; 95% confidence interval [95% CI], 2.30 to 3.08), and ESKD (aOR, 1.47; 95% CI, 1.31 to 1.65). Compared with critically ill patients without major organ disease, patients with stroke, cancer, heart failure, dementia, chronic obstructive pulmonary disease, and cirrhosis were statistically more likely to have a DNR order on ICU admission; those with ESKD were not. Findings were similar when comparing patients with a single organ disease with those without organ disease. The disconnect between prognosis and DNR use was most notable among Black patients, for whom ESKD (compared with no major organ disease) was associated with a 62% (aOR, 1.62; 95% CI, 1.27 to 2.04) higher odds of hospital mortality, but no appreciable difference in DNR utilization (aOR, 1.06; 95% CI, 0.66 to 1.62). Unlike patients with diseases of other major organs, critically ill patients with ESKD were not more likely to have a DNR order than patients without ESKD. Whether this reflects a greater lack of advance care planning in the nephrology community, as well as a missed opportunity to minimize potentially needless patient suffering, requires further study.

The Effects of a Tripod Approach for Cancer Patients on Illness Stress, Health-Promoting Lifestyle, Hope, and Resilience.

Health-related exercise and education program for cancer patients are necessary to provide physical and emotional support to enable efficient and appropriate self-management at home. This study aimed to investigate the effects of a tripod approach including physical exercise, education, and emotional support program on illness stress, health promotion lifestyle, hope, and resilience in cancer patients. This was a quasi-experimental repeated-measures study using a pre-post design with a nonhomogeneous control group. A total of 72 cancer patients (experimental group = 37, control group = 35) who were currently receiving treatment and staying at home were enrolled. The experimental group showed significantly lower illness stress scores (F = 17.35, P < .001) and increase in health promotion lifestyle scores (F = 4.05, P = .048) compared with the control group, especially social relationships (t = 1.85, P = .073) and stress management (t = 2.30, P = .027). However, there were no effects on hope and resilience. Also, illness stress showed significant changes after 6 weeks (t = -3.35, P = .001) and after 10 weeks (t = -5.04, P < .001). Overall health promotion lifestyle showed changes after 10 weeks (t = 2.25, P = .030), with meaning of life (t = 2.57, P = .014), stress management (t = 2.30, P = .027), and medical behaviors (t = 2.46, P = .019) especially showing significant changes. The results showed that the tripod approach had positive effects on illness stress and health promotion lifestyle of cancer patients staying at home. Further study to improve positive emotions such as hope and resilience is needed. Based on our findings, combining nursing intervention with physical exercise, education, and emotional support could be incorporated into cancer patients in community and early survivorship care plans in clinical practice.

Facilitators and barriers of managing patients with multiple chronic conditions in the community: a qualitative study

BackgroundApproximately one-third of all adults worldwide are diagnosed with multiple chronic conditions (MCCs). The literature has identified several challenges facing providers and patients coping with managing MCCs in the community, yet few studies have considered their viewpoints in combination. A qualitative study involving healthcare providers and users was thus conducted to examine facilitators and barriers of managing patients with MCCs in the community in Singapore.MethodsThis study involves 26 semi-structured interviews with 10 physicians, 2 caregivers and 14 patients seeking treatment in the polyclinics that provide subsidised primary care services. Topic guides were developed with reference to the literature review, Chronic Care Model (CCM) and framework for patient-centred access to healthcare.ResultsDespite the perceived affordability and availability of the support system, some patients still encountered financial difficulties in managing care. These include inadequacy of the nation-wide medical savings scheme to cover outpatient treatment and medications. Half of healthcare users did not know where to seek help. While patients could access comprehensive services in polyclinics, those who did not visit the clinics might not receive timely care. Furthermore, patients reported long consultation waiting time.Physicians were able to propose and drive quality improvement projects to improve care quality. However, there were challenges to delivering safe and quality care with limited consultation duration due to the need to manage high patient load and waiting time, inadequate communication with specialists to coordinate care, and resource constraints in managing complex patients.Although providers could equip patients with self-management and lifestyle-related guidelines, patients’ actions are influenced by multiple factors, including work requirements, beliefs and environment.ConclusionsThere were barriers on care access, delivery and self-management. It is crucial to adopt a whole-of-society approach involving individuals, community, institutions and policymakers to improve and support MCC management. This study has also highlighted the importance of considering the different viewpoints of healthcare providers and users in policy formulation and community care planning.

Caregiving as Role Transition: Siblings’ Experiences and Expectations when Caring for a Brother or Sister with Schizophrenia

Using a qualitative design, this study examines changes in the caregiving relationship in ten siblings caring for a brother or sister with severe schizophrenia. Siblings reported mourning the loss of a person they once knew and struggled to accept the brother or sister’s dependency in day-to-day living. As the relationship progressed, siblings became closer to their ill brother or sister and learned to appreciate modest accomplishments as evidence of success. Siblings expressed ambivalence toward transitioning into a primary caregiving role as their parents aged. Including these siblings in community care planning is a necessary step in supporting them toward this transition later in life.

Advance Care Planning in Community: An Evaluation of a Pilot 2-Session, Nurse-Led Workshop.

Engaging patients in advance care planning (ACP) is challenging but crucial to improving the quality of end-of-life care. Group visits and multiple patient-clinician interactions may promote advance directive (AD) completion. Facilitate ACP discussions with patients and caregivers and the creation of notarized AD's at a comprehensive cancer center. Two-session, nurse-led ACP workshops for patients and their family caregivers. The workshop was offered to patients with cancer at a comprehensive cancer center and their family caregivers. Validated 4-question ACP engagement survey, creation of a notarized AD by end of the workshop, and semistructured interviews. Thirty-five patients participated in 10 workshops held March 2017 to February 2018. Median age was 52. Of 35, 24 (68.5%) patients completed pre- and postworkshop evaluation surveys. Mean preworkshop ACP readiness was 3.64 of 5; postworkshop readiness increased to 4.26 of 5 ( P = .001). Of 26, 17 (65.4%) of the patients who attended both workshop sessions had a new notarized AD scanned into the electronic medical record at the completion of the workshop series. Three family caregivers completed and had their own ADs notarized. Patient and family member response was overwhelmingly positive, with participants citing opportunities for group discussion and inclusion of family caregivers as important. The ACP workshop was well received by participants and increased ACP readiness, discussion, and completion. Attendance at the workshop was low and barriers to attending workshops must be explored.

Improving care for older people with long-term conditions and social care needs in Salford: the CLASSIC mixed-methods study, including RCT

BackgroundThe Salford Integrated Care Programme (SICP) was a large-scale transformation project to improve care for older people with long-term conditions and social care needs. We report an evaluation of the ability of the SICP to deliver an enhanced experience of care, improved quality of life, reduced costs of care and improved cost-effectiveness.ObjectivesTo explore the process of implementation of the SICP and the impact on patient outcomes and costs.DesignQualitative methods (interviews and observations) to explore implementation, a cohort multiple randomised controlled trial to assess patient outcomes through quasi-experiments and a formal trial, and an analysis of routine data sets and appropriate comparators using non-randomised methodologies.SettingSalford in the north-west of England.ParticipantsOlder people aged ≥ 65 years, carers, and health and social care professionals.InterventionsA large-scale integrated care project with three core mechanisms of integration (community assets, multidisciplinary groups and an ‘integrated contact centre’).Main outcome measuresPatient self-management, care experience and quality of life, and health-care utilisation and costs.Data sourcesProfessional and patient interviews, patient self-report measures, and routine quantitative data on service utilisation.ResultsThe SICP and subsequent developments have been sustained by strong partnerships between organisations. The SICP achieved ‘functional integration’ through the pooling of health and social care budgets, the development of the Alliance Agreement between four organisations and the development of the shared care record. ‘Service-level’ integration was slow and engagement with general practice was a challenge. We saw only minor changes in patient experience measures over the period of the evaluation (both improvements and reductions), with some increase in the use of community assets and care plans. Compared with other sites, the difference in the rates of admissions showed an increase in emergency admissions. Patient experience of health coaching was largely positive, although the effects of health coaching on activation and depression were not statistically significant. Economic analyses suggested that coaching was likely to be cost-effective, generating improvements in quality of life [mean incremental quality-adjusted life-year gain of 0.019, 95% confidence interval (CI) –0.006 to 0.043] at increased cost (mean incremental total cost increase of £150.58, 95% CI –£470.611 to £711.776).LimitationsThe Comprehensive Longitudinal Assessment of Salford Integrated Care study represents a single site evaluation, with consequent limits on external validity. Patient response rates to the cohort survey were &lt; 40%.ConclusionsThe SICP has been implemented in a way that is consistent with the original vision. However, there has been more rapid success in establishing new integrated structures (such as a formal integrated care organisation), rather than in delivering mechanisms of integration at sufficient scale to have a large impact on patient outcomes.Future workFurther research could focus on each of the mechanisms of integration. The multidisciplinary groups may require improved targeting of patients or disease subgroups to demonstrate effectiveness. Development of a proven model of health coaching that can be implemented at scale is required, especially one that would provide cost savings for commissioners or providers. Similarly, further exploration is required to assess the longer-term benefits of community assets and whether or not health impacts translate to reductions in care use.Trial registrationCurrent Controlled Trials ISRCTN12286422.FundingThis project was funded by the NIHR Health Services and Delivery Research programme and will be published in full inHealth Services and Delivery Research; Vol. 6, No. 31. See the NIHR Journals Library website for further project information.

Advance Care Planning in a Multicultural Family Centric Community: A Qualitative Study of Health Care Professionals', Patients', and Caregivers' Perspectives

ContextAdvance care planning (ACP) has been shown to improve end-of-life care, but it was developed in the U.S., and most research has been conducted in western communities. ObjectivesWe aimed to study the attitudes and perceptions of patients with life-limiting illnesses, informal caregivers, doctors, nurses, and medical social workers regarding ACP in a multicultural family centric community. MethodsWe conducted an explorative qualitative study, using focus groups and individual in-depth interviews. We used purposive sampling techniques to recruit 61 adults (15 doctors, 13 nurses, 5 medical social workers, 15 patients, and 13 caregivers) from multiple health care settings across the country. ResultsThe participants are genuinely anxious about the implementation of ACP. They had positive and negative expectations of ACP. Many were confused about the legal framework for health care decision-making and expected ACP to be of limited value because family members, rather than the patient, were usually the key decision makers. ConclusionA nuanced approach to ACP that considers the family network is required in multicultural family centric communities. Policies should be reconciled to create a more consistent message that respects patients, the family, and is legally coherent. Further research could focus on adaptations of ACP to promote its acceptance in such communities.

Advance care planning in community: Evaluation of a two-session workshop.

14 Background: Engaging patients in advance care planning (ACP) is challenging. Group visits and multiple patient-clinician interactions appear to promote advance directive (AD) completion. We evaluated the effectiveness of a two-session ACP workshop. Methods: We conducted a nurse-led ACP workshop for patients and their family caregivers in a comprehensive cancer center. Patients were invited by their outpatient palliative care physician and an assistant helped coordinate attendance. Monthly sessions were 2 hours long and 2 weeks apart. The first session detailed the ACP process, featured the “Go Wish” card game, and introduced the “Five Wishes” AD. In the time between sessions, patients were encouraged to play Go Wish with family and to begin filling out their AD. The second session included questions and discussion, and helped patients complete, notarize, and scan their AD into the EMR. Workshop evaluation included the validated 4-question Sudore ACP Readiness Survey as well as semi-structured participant interviews. Results: Ten of 11 participants from 4 workshop offerings completed surveys. Median age was 48 years (range 41-72). Most patients (10/11, 90.9%) had breast cancer. Mean pre-workshop ACP readiness was 4.0 out of 5; post-workshop readiness increased nearly significantly to 4.325 (p = .057). Eight of the workshop participants (72.7%) had a new notarized AD scanned into the EMR. Participants most appreciated the chance to talk with other patients (“The most important thing was having a group there. I don’t think I ever would have read that packet if it had just been handed to me.”) and the chance to include their family caregivers (“My family and I had a rich and bonding talk, which was helpful for their own thinking about the AD for themselves as well.”). Two family caregivers completed their own AD. Patients who declined a workshop invitation most commonly reported they “did not have time” because of medical appointments. Conclusions: The ACP workshop was well received by participants and increased ACP readiness, discussion, and completion. The opportunities for group discussion and inclusion of family caregivers were important to participants. Barriers to attending workshops must be explored.

Exploring the knowledge, attitudes and needs of advance care planning in older Chinese Australians.

To identify factors that influence the engagement of Chinese Australians with advance care planning. Despite the benefits of advance care planning, there is a low prevalence of advance care planning in the Chinese Australian community. Reasons for this are often cited as cultural considerations and taboos surrounding future medical planning and death; however, other logistical factors may also be important. This qualitative study used a thematic analysis grounded theory approach to explore facilitators and barriers to engagement in advance care planning. Semistructured interviews were conducted in-language (Mandarin or Cantonese) exploring the views of a purposive sample of 30 community-dwelling older Chinese Australians within Victoria, Australia. Three key themes were identified: knowledge of, attitudes towards and needs for undertaking advance care planning amongst the Chinese Australians. There was a low awareness of advance care planning amongst the participants and some confusion regarding the concept. Most participants reported positive attitudes towards advance care planning but acknowledged that others may be uncomfortable discussing death-related topics. Participants would want to know the true status of their health and plan ahead in consultation with family members to reduce the burden on the family and suffering for themselves. Language was identified as the largest barrier to overcome to increase advance care planning awareness. In-language materials and key support networks including GPs, family and Chinese community groups were identified as ideal forums for the promotion of advance care planning. The participants of this study were open to conversations regarding future medical planning and end-of-life care, suggesting the low uptake of advance care planning amongst Chinese Australians is not culturally motivated but may be due a lack of knowledge relating to advance care planning. The results highlight the need to provide access to appropriate in-language advance care planning resources and promotion of advance care planning across the Chinese community.

Nursing Competencies Needed for Electronic Advance Care Planning in Community

Advance care planning implementation occurs across the world using different legislative frameworks, different language to describe both the process and the outcome, and different models to develop these plans. Many countries are in the process of developing personally controlled electronic health records. Including advance care plans as part of this record is proposed in Australia. The Electronic Advance Care Plan (eACP) in Community project aimed to develop a model that will engage community dwelling older adults with chronic lifelimiting illnesses in the process of advance care planning that is person-centred, evidence-based and has a focus of dignity of life. A systematic review was conducted to identify models of advance care planning information sharing and to examine the nurses’ role. A realist review comprising a metasynthesis of 8 qualitative studies and 9 quantitative studies was conducted. Nursing competencies need to be developed to include the medico-legal framework around advance care plan development, as well as information technology competencies and communication competencies so that nurses around the world are better informed for end-of-life care planning and practice in a digital world. - See more at: http://dl4.globalstf.org/?wpsc-product=nursing-competencies-needed-for-electronic-advance-care-planning-in-community#sthash.S3cVvh6u.dpuf

College raises concerns over community care plans

By Sally Gillen and Nick Lipley Ministers are expected next month to publish an action plan supporting their ‘new vision and service model’ for district nursing. the document, Care in Local Communities, builds on the three-year strategy for nurses, midwives and care staff drawn up by chief nursing officer for england Jane Cummings and director of nursing at the Department of Health Viv Bennett; the focus of the strategy is the ‘6Cs’: care, compassion, competence, communication, courage and commitment. nursing leaders suggest, however, that shortages of district nurses could undermine the community nursing plan. the document states that community nurses are providing increasingly complex care to many, often frail, older people. it sets out a model that includes working with community matrons to provide palliative care, advice on nutrition and helping patients care for themselves. it also outlines developments to ensure services can meet future needs: ■ ■ Make every contact count: provide opportunistic public health interventions and support carers’ health and wellbeing.

H.R. 1589: addressing racial and ethnic disparities in advance care planning among medicare beneficiaries

U.S minorities continue to have poorer health outcomes and are more likely to have worse quality of care. These gaps are partly attributed to socioeconomic status, public health practices, and...