Community Care Providers Research Articles

Management of ankle fractures in children.

Ankle fractures are a common injury in children and adolescents - 1 in 1000 children will sustain an ankle fracture each year. Understanding the diagnosis and management of these injuries is vital for any doctor or clinician working in the emergency department, orthopaedics or providing community care. This review identifies the important features of high- and low-risk ankle fractures, how to prevent the use of unnecessary radiation and the management of these injuries. Fractures may be at high or low risk of instability and are managed accordingly. Many can be treated with conservative management in a cast, including unstable injuries following reduction. However, particular fracture patterns associated with the tibial growth plate need careful assessment of fracture reduction with cross-sectional imaging before committing to conservative management.

Evaluation of the performance of a nutrition rehabilitation centre in a tertiary care hospital in Eastern India

Background: Severe acute malnutrition (SAM) places extraordinary challenges in the way of survival, growth and development of the child under five years of age. Our aim was to evaluate the functioning and performance of facility based management of SAM children admitted in the nutrition rehabilitation centre (NRC) and to identify the existing bottlenecks in the NRC.Methods: Children above 1 month and less than 5 years of age with severe acute malnutrition were included during the study period. Demographic details of the SAM children, clinical features during admission were recorded. Anthropometric measurements like MUAC, weight, height/length and WHZ scores were taken at admission and compared with the findings at discharge. Statistical analysis: the data after collection, compilation was analysed by SPSS.Results: Majority 277 (78.47%) of them belonged to rural areas. 300 (85%) SAM children were referred by medical officers. Bilateral oedema was recorded in 12 (17.9%) admitted children during 2014-2015, 22 (17.9%) children in 2015-2016 and in 37 (22.7%) children during 2016-2017. There was significant improvement in the mean weight (kg) and mean MUAC (cm) at discharge was in comparison to the weight and MUAC of the children at admission and this difference in increase in the mean weight and MUAC were found to be statistically significant.Conclusions: Implementation of WHO feeding guidelines resulted in adequate weight gain of inpatient malnourished children, however the frontline workers in the community and health care providers of PHCs should be trained and given hands on training for early identification and referral of SAM cases.

Informal mental health interventions for people with severe mental illness in low and lower middle-income countries: A systematic review of effectiveness.

The effectiveness of interventions for people with severe mental illness delivered by informal community care providers in low and lower middle-income countries is not known. The aim was to conduct a systematic review of the impact of community-based interventions implemented by the informal sector for people with severe mental illness in these settings. Five electronic databases (MEDLINE, EMBASE, PsycINFO, CINAHL, and Cochrane Central Register of Controlled Trials) were searched for English-language publications using both keywords and MeSH terms. All study designs were included. Five papers, reporting data from five studies conducted in four low and lower middle-income countries in 2017, met the inclusion criteria for the review. Of the five included studies, three had a before and after design, one was a randomized controlled trial, and one a qualitative investigation. Most interventions with a low-moderate quality of evidence used informal community care providers to deliver either self-help groups, traditional healing treatments, and/or a rehabilitation program. The investigators reported data about improvements in the outcomes of intervention participants (psychosocial functioning, psychotic symptoms, and social inclusion) and positive impacts on their families (family's knowledge and skills of mental illness management, caregiving burden, social exclusion/stigma against people with severe mental illness, and financial burden). Cost-effectiveness of the intervention (in one study) found that it had a higher financial cost but greater effectiveness than the usual standard of care. Although only a small number of studies were identified, the review provides promising evidence of the professionally developed interventions for people with severe mental illness, delivered by the informal community workforce in low and lower middle-income settings. Training and supportive supervision for informal community care providers are crucial components of effective interventions.

Assessment of staffing need through a workload analysis in Jhenaidah and Moulvibazar, Bangladesh: a Workload Indicator of Staffing Need (WISN) study

Abstract Background Improvement of health workers' performance is vital for the improvement of health-care service delivery, and workload management is an important factor in improving performance. This study aimed to assess the current workload and staffing need for delivering optimum health-care services in the public-sector district health system in Bangladesh. Methods Between July 2, 2017, and Nov 30, 2017, we followed the steps of WHO's Workload Indicator of Staffing Need (WISN) methodology. We combined qualitative (document reviews, key informant interviews, in-depth interviews, observations) and quantitative methods (time-motion survey), to collect data in 24 health facilities from district hospitals up to community clinics in Jhenaidah and Moulvibazar districts, Bangladesh. The study included physicians, nurses, medical assistants, family welfare visitors, community care providers, and family welfare assistants. Workload components were defined on the basis of inputs from experts (n=5), refined further by actual service providers (n=87). We used WHO WISN software to calculate standard workload, category allowance factor, individual allowance factor, total required number of staff, WISN difference, and WISN ratio. Findings Seven of the 20 staff categories had a very high workload (WISN ratio 0·30–0·49), and five staff categories had extremely high workload (0·10–0·29) indicating an overall high workload in the service providers studied. Medical consultants had the highest workload (WISN ratio 0·16), followed by other specialists. The staff category with the most number of positions needing to be filled was nurses at district hospitals (a mean of 136 vacant positions per facility), followed by general physicians (35). We noted that nurses were predominantly occupied with support activities (60% in the case of district nurses and 50% in sub-district facilities), instead of actual nursing care. If the vacant posts were filled, the workload for existing workers is reduced. However, simply filling the vacant posts would not be sufficient to reduce staff workload in some staff categories, such as nursing. Interpretation WISN method of estimating workload and staff requirements can aid policymakers in making the best uses of existing human resources. Thus, WISN should be incorporated as a planning tool for managers at the district level. Implementation research should be carried out on how the workload-based staffing decisions can be effectively integrated into health systems. Funding WHO Bangladesh.

The salt between the beans: a qualitative study of the role of auxiliary midwives in a hard-to-reach area of Myanmar

BackgroundAuxiliary Midwives (AMWs) are unpaid volunteer health workers assisting qualified paid midwives in maternal and child health care mainly in hard-to-reach areas of Myanmar. This paper describes the relationship between AMWs and the health system in providing maternal and child services as perceived by the community, AMWs themselves and health care providers in one remote township of Myanmar.MethodA qualitative study was conducted in Ngape Township, Myanmar. A total of 15 focus group discussions with midwives, AMWs, community members and mothers were conducted. Ten key informant interviews were performed with national, district and township level health planners and implementers of maternal and child health services. Thematic analysis was done using the ATLAS.ti software.ResultsAMWs occupy a unique position between the community and the health sector in the study township. The relationship and trust with the community is built upon prolonged presence providing health care, skill building and fulfilling community expectations. Health care providers’ expectations to provide only preventive care, health promotion and education and childbirth care are often exceeded in reality when emergencies occur in hard-to-reach areas. This challenge to handle emergency situations with no support and limited skills and training is considered as most difficult by the AMWs. This mismatch of service provision expectations by both the community and other health care providers has put AMWs in a position which they describe as being the “salt between the beans” an essential ingredient but often invisible between the beans.ConclusionThe trust and relationship developed by AMWs over four decades of community practice serving as the mediator role is an untapped resource that can facilitate future community-based maternal and child health interventions in Myanmar.

The Changing Profile of Patients in a Geriatric Medicine Led Memory Clinic over 12 Years.

Memory clinics play an important role in enabling early dementia diagnosis and intervention. Few studies have investigated the changing patient profiles at memory clinics over time. We studied the trend of patient characteristics in a geriatric medicine-led memory clinic over 12 years to improve services and care to meet their needs. Data from 2340 first-visit patients seen at a memory clinic from 2005-2017 were extracted from a registered database and analysed. ANOVA, Pearson chi-square and non-parametric tests were used to describe and compare between patients with dementia (PWD) and patients with no dementia (PND). Data included diagnoses of dementia and mild cognitive impairment, age, education, MMSE scores and comorbidities. Patients averaged 77.2 ± 8.3 years of age with mean MMSE score of 16.2 ± 6.7. Those diagnosed with dementia were older (78.3 ± 7.9 years) and almost half (48.4%) had moderate or moderately severe dementia (FAST 5-6). Over time, there was a growing proportion of patients with mild cognitive impairment (MCI) and mild Alzheimer's dementia. Many PWD had co-morbidities of hypertension (65.9%), hyperlipidemia (55.1%), diabetes (33.5%) and 28.4% were frail. The findings call for services to better diagnose and manage patients at the earlier stages of cognitive impairment and provide holistic interventions for those with frailty and other co-morbidities. The continued rise in number of patients presenting to memory clinics provides impetus to expedite integration of tertiary-based memory clinics with primary and community care providers to better support PWD and their families.

Evaluation of Collaborative Medication Reviews for High-Risk Older Adults

Despite the widespread use of medication reviews, many older adults are still exposed to the risks of polypharmacy. To quantify and describe the drug therapy problems identified and interventions undertaken by pharmacists before and after implementation (on July 1, 2015) of collaborative medication review for high-risk older adult patients (> 80 years of age). A retrospective single-centre pre-post cohort study was conducted between July 1, 2014, and July 31, 2016, to characterize the impact of collaborative medication reviews-consisting of a thorough medication review by a pharmacist and care conferences with the hospitalist and family physician-on prescribing patterns in an Acute Care for Elders unit. A standardized template was used to conduct medication reviews for the post-implementation group, whereas a chart review was conducted for the pre-implementation group. The primary outcomes were the number of drug therapy problems identified by the clinical pharmacists and the associated interventions by the pharmacists, which were categorized as clinical or compliance interventions. Secondary outcomes included the number of medications at discharge, the rate of hospital readmission within 30 days, and the length of hospital stay. A total of 137 patients were identified for inclusion in either the pre-implementation group (n = 70) or the post-implementation group (n = 67). After implementation of collaborative medication reviews, there were statistically significant increases in the mean number of drug therapy problems identified (p < 0.001), the mean number of interventions undertaken (p = 0.004), and the median length of hospital stay (p < 0.001). There was no difference between the 2 groups in the number of medications at discharge, the proportion of patients taking more than 5 medications at discharge, or readmission within 30 days. At the study institution, implementation of a quality improvement program that included pharmacist-led medication reviews and collaborative care conferences involving community and hospital care providers helped to improve documentation by clinical pharmacists of potential medication-related problems and led to more interventions to optimize patients' medication regimens.

Access to rehabilitation for patients with stroke in Australia.

To identify factors associated with receiving acute goal-directed treatment, being assessed for ongoing rehabilitation, and receiving post-acute rehabilitation after having a stroke. Retrospective analysis of National Stroke Audit data for patients with acute stroke treated at Australian hospitals during 1 September 2014 - 28 February 2015. 112 Australian hospitals that admit adults with acute stroke. Associations between patient-related and organisational factors and the provision of rehabilitation interventions. Data for 3462 patients were eligible for analysis; their median age was 74 years, 1962 (57%) were men, and 2470 (71%) had received care in a stroke unit. 2505 patients (72%) received goal-directed treatment during their acute admission; it was not provided to 364 patients (10.5%) who were responsive, had not fully recovered, and did not refuse treatment. Factors associated with higher odds of receiving goal-directed treatment included goal-setting with the patient and their family (odds ratio [OR], 6.75; 95% CI, 5.07-8.90) and receiving care in a stroke unit (OR, 2.08; 95% CI, 1.61-2.70). 1358 patients (39%) underwent further rehabilitation after discharge from acute care; factors associated with receiving post-acute rehabilitation included care in a stroke unit (OR, 1.73; 95% CI, 1.34-2.22) and having an arm or speech deficit. Dementia was associated with lower odds of receiving acute goal-directed treatment (OR, 0.49; 95%, 0.33-0.73) and post-acute rehabilitation (OR, 0.43; 95%, 0.30-0.61). Access to stroke units and to early and ongoing rehabilitation for patients after stroke can be improved in Australia, both to optimise outcomes and to reduce the burden of care on underresourced community and primary care providers.

A qualitative evaluation of health care in the Maroantsetra region of Madagascar.

Individuals in rural communities in Madagascar must frequently travel long distances, over difficult terrain, to obtain basic care. The quality of care is often inconsistent and inadequate. An exploratory mixed-methods study was conducted in select coastal communities in the Maroantsetra region of Madagascar to generate a more robust understanding of community and health care provider perceptions and how patients decide to seek health care, including the decision to use traditional medicine vs allopathic medicine. A total of 69 free-listing exercises and 21 facility assessments were conducted in eight communities. Symptoms most commonly reported as reasons to seek health care included headaches, fever and cough. Decisions to access allopathic health care facilities depended on the intersection of geographic and financial access to health care facilities, perceived severity of the illness and the availability and confidence in traditional plant-based medications. Traveling salespeople, staff at local stores and pharmacy workers very often lacked formal training. The decision to use allopathic medicine was determined by the perception of disease severity and when vulnerable populations, such as children and the elderly, were involved. Results provide insight into patterns, motivations and obstacles to health care utilization and decision making in the Maroantsetra region of Madagascar.

A patient-centered, coordinated care approach delivered by community and pediatric primary care providers to promote responsive parenting: pragmatic randomized clinical trial rationale and protocol

BackgroundEconomically disadvantaged families receive care in both clinical and community settings, but this care is rarely coordinated and can result in conflicting educational messaging. WEE Baby Care is a pragmatic randomized clinical trial evaluating a patient-centered responsive parenting (RP) intervention that uses health information technology (HIT) strategies to coordinate care between pediatric primary care providers (PCPs) and the Special Supplemental Nutrition Program for Women, Infant and Children (WIC) community nutritionists to prevent rapid weight gain from birth to 6 months. It is hypothesized that data integration and coordination will improve consistency in RP messaging and parent self-efficacy, promoting shared decision making and infant self-regulation, to reduce infant rapid weight gain from birth to 6 months.Methods/designTwo hundred and ninety mothers and their full-term newborns will be recruited and randomized to the “RP intervention” or “standard care control” groups. The RP intervention includes: 1) parenting and nutrition education developed using the American Academy of Pediatrics Healthy Active Living for Families curriculum in conjunction with portions of a previously tested RP curriculum delivered by trained pediatric PCPs and WIC nutritionists during regularly scheduled appointments; 2) parent-reported data using the Early Healthy Lifestyles (EHL) risk assessment tool; and 3) data integration into child’s electronic health records with display and documentation features to inform counseling and coordinate care between pediatric PCPs and WIC nutritionists. The primary study outcome is rapid infant weight gain from birth to 6 months derived from sex-specific World Health Organization adjusted weight-for-age z-scores. Additional outcomes include care coordination, messaging consistency, parenting behaviors (e.g., food to soothe), self-efficacy, and infant sleep health. Infant temperament and parent depression will be explored as moderators of RP effects on infant outcomes.DiscussionThis pragmatic patient-centered RP intervention integrates and coordinates care across clinical and community sectors, potentially offering a fundamental change in the delivery of pediatric care for prevention and health promotion. Findings from this trial can inform large scale dissemination of obesity prevention programs.Trial registrationRestrospective Clinical Trial Registration: NCT03482908. Registered March 29, 2018.

An ethnographic inquiry into the psychosocial care for oncology patients in the community: Healing from the 4Es.

The aim of this study was to explore how the provision of community care in a cancer support center can help cancer patients and survivors cope with the demands of cancer and its treatment. A focused ethnographic approach was adopted. Data were collected through participant observations and focus groups with various stakeholders. The data from the focus groups were transcribed verbatim and analyzed using constant comparative analysis. Four main themes emerged: 1. Enabling users to achieve mental well-being on their coping journey, 2. Empowering users to deal with their uncertainties, 3. Enhancing meaningful nurturing interactions through the design of spaces and colors in the Centre, and 4. Evolving through seeing more value in themselves. These 4Es occurred through intimate human interaction in the Centre, which resulted in psychological renewal and the rebuilding of a sense of self among the users. This study provides insights on the provision of community support services for cancer patients/users, specifically on how to help them to regain control over their lives, not only through providing services for psychosocial renewal by engaging in intimate human interactions, but also by contributing to an understanding of the effect of the physical environment and space on healing. The results also reveal a virtuous circle of the 4Es as the synergies from the services, activities and the environment in the Centre, which provide a harmonious context for the users in coping with their cancer journey.

Implementation of maternal influenza immunization in El Salvador: Experiences and lessons learned from a mixed-methods study

IntroductionThe World Health Organization (WHO) recommends that countries prioritize pregnant women for influenza vaccination, yet few low- or middle-income countries (LMICs) have implemented maternal influenza immunization programs. To inform vaccine decision-making and operational planning in LMICs, there is a need to document and share experiences from countries that provide seasonal influenza vaccine to pregnant women, particularly those with high coverage, like El Salvador. MethodsIn 2015 and 2016, PATH and country researchers conducted a mixed-methods study to document the experience and lessons learned from maternal influenza immunization delivery and acceptance in El Salvador as part of a collaborative effort between WHO and PATH. Researchers conducted focus group discussions, semi-structured interviews, antenatal clinic exit interviews, and key informant interviews with 326 participants from two municipalities in each of the country’s three regions. Respondents included pregnant and recently pregnant women, family members, community leaders, health personnel, public health managers and partners, and policymakers. ResultsFactors perceived as positively influencing maternal influenza immunization delivery and acceptance in El Salvador include the use of multiple vaccine delivery strategies, targeted education and community engagement efforts, and a high degree of trust between the community and health care providers. Influenza vaccine acceptance by pregnant women is high and has improved over time, largely attributed to education targeting health care advisors. Perceived challenges to pregnant women receiving health care and vaccination include the need for permission to attend services and limited access to health services in insecure areas related to the presence of criminal gang activity. ConclusionsWe identified approaches and barriers perceived to affect maternal influenza vaccine delivery in El Salvador. This information will be useful to public health decision-makers and implementers in El Salvador and other countries considering introduction of new maternal vaccines or striving to increase coverage of vaccines currently provided.

P083: Developing an interview guide to explore physicians perceptions about unmet palliative care needs in Albertas emergency departments

Introduction: Many patients with advanced or end-stage diseases spend months or years in need of optimal physical, spiritual, psychological, and social care. Despite efforts to provide community care, those with severe illness often present to emergency departments (EDs). This abstract presents preliminary results on the qualitative component of an ED-based mixed methods pilot study. The objective of this qualitative component is to develop and test an interview guide to collect qualitative data on physicians perceptions about unmet palliative care (PC) and end of life care (EOLC) needs in EDs. Methods: A scan of the literature on PC and EOLC in EDs was conducted to develop propositions about what might be expected through the clinician interviews, as well as an interview guide. The interview guide will be piloted with up to four ED physicians. During the interview each physician will describe a case where a PC patient had unmet care needs and the impacts they believe these unmet needs had on patients and families. Interview transcripts will be coded descriptively and then conceptually themed by the researcher who conducted the interview. Interpretations drawn from the interview data, with supporting quotations and comparison to initial propositions, will be presented to members of the research team with experience providing ED care, for further interpretation. Advice of a second trained qualitative researcher will be sought on the richness and relevance of data obtained and how the interview guide could be improved to elicit richer and/or more relevant data. A revised interview guide will be produced alongside rationales for why the proposed revisions will elicit richer data. Results: After reviewing 27 articles on PC and EOLC, propositions and an initial interview guide were developed based on themes from the literature and the study groups experiences. One of the primary results of this pilot work will be an enhanced understanding of PC and EOLC in our local ED context, as reflected in an interview guide revised to elicit richer data than achieved through the initial interview guide. Conclusion: The comparison between our propositions and the study findings will help identify how biases may have influenced interview questions and/or the interpretation of the data. This pilot work to develop an interview guide enhances the rigour of this qualitative work on unmet PC and EOLC needs in EDs.

Routine Assessment and Promotion of Physical Activity in Healthcare Settings: A Scientific Statement From the American Heart Association.

Physical inactivity is one of the most prevalent major health risk factors, with 8 in 10 US adults not meeting aerobic and muscle-strengthening guidelines, and is associated with a high burden of cardiovascular disease. Improving and maintaining recommended levels of physical activity leads to reductions in metabolic, hemodynamic, functional, body composition, and epigenetic risk factors for noncommunicable chronic diseases. Physical activity also has a significant role, in many cases comparable or superior to drug interventions, in the prevention and management of >40 conditions such as diabetes mellitus, cancer, cardiovascular disease, obesity, depression, Alzheimer disease, and arthritis. Whereas most of the modifiable cardiovascular disease risk factors included in the American Heart Association's My Life Check - Life's Simple 7 are evaluated routinely in clinical practice (glucose and lipid profiles, blood pressure, obesity, and smoking), physical activity is typically not assessed. The purpose of this statement is to provide a comprehensive review of the evidence on the feasibility, validity, and effectiveness of assessing and promoting physical activity in healthcare settings for adult patients. It also adds concrete recommendations for healthcare systems, clinical and community care providers, fitness professionals, the technology industry, and other stakeholders in order to catalyze increased adoption of physical activity assessment and promotion in healthcare settings and to contribute to meeting the American Heart Association's 2020 Impact Goals.

Team Based Care - Connecting Providers to put Consumers First

The HBDHB Mental Health Service provides care to 3,000 clients at any one time. Mental Health Service (MHS), range from inpatient through to intensive care, community-based services and community-based case consultation. While the MHS had moved to the use of an electronic record, the system did not provide the ability to create a living, updatable ‘Assessment’ and ‘Plan’ document leading to many issues: Clients having to repeat their story multiple times Clinicians spending considerable time recreating assessments which were not updatable Multiple documents confusing providers and clients – introducing the potential for clinical risk No capacity to audit or generate reports on provider compliance/ carry out analytics on client wellbeing/targets met. The Mental Health Service wanted to develop new plans that were ‘living documents’ to ensure one ‘Assessment’ and one ‘Plan’ per client available at the click of a button and to guarantee that all carers were working on the ‘same’ plan making it consumer centric. Whānau Tahi Limited (WTL) was chosen as the provider of choice for MHS services to be delivered safely and successfully using its Connected Care platform. This allows us to hold a single care plan in a single place accessible by whānau and their authorised care providers. Team Based Care - Connecting Providers to put consumers first. This approach is recognised world-wide through organisations such as the International Foundation for Integrated Care. An integrated care model requires partnering with providers across the social and health care continuum focussed on a client’s specific needs and desires – aspirations for well-being belong to the client - our role is to weave services around whānau to help them achieve their goals. MHS engaged consumers/providers from inpatient through to intensive care, community-based services and community-based case consultation. to define pathways for the ‘Plans’ to ensure that we met needs of consumers, multiple clinical disciplines and health care providers, along with various treatment settings (e.g. child and adolescent mental health, substance use treatment through to inpatient mental health). This served to gain early ‘buy-in’ as we had developed clinical champions before the plans were developed into electronic forms in collaboration with Whānau Tahi. Significant benefits have emerged from the introduction of the Whānau Tahi solution: Consumers have one collaborative (shared care) plan accessible at the click of a button by the multi-disciplinary team members who share care delivery across secondary, primary and community care provider organisations. Reduced administration of records means more time for clinicians delivering frontline care The full audit functionality means that we can measure our progress at the click of a button and have information available for analysis to improve: - health outcomes for our clients - efficiency, productivity, auditability and consumer satisfaction Lessons learned: Have high expectations and encourage a feeling of excitement about innovation and change Be clear about what you want and why and share your vision – using sponsors and champions including consumers Engage a vendor as a partner willing to collaborate to do something different

The role of joint working between primary and secondary care in supporting people with type 1 diabetes

The role of joint working between primary and secondary care in supporting people with type 1 diabetes

Abstract ES5-1: Place as a cause of breast cancer disparities in Appalachia

Abstract While breast cancer incidence rates in Ohio are similar to US rates, mortality rates are 10% higher, with Ohio having the 5th highest breast cancer mortality rate in the US. Ohio has several underserved population groups including African-Americans and women living in Appalachian and rural counties. Using a place-based perspective, higher mortality rates were found in counties with higher proportions of African-American women, and in several Appalachian and rural counties. While biologic characteristics (e.g. triple negative disease) may explain the higher burden in urban counties with higher proportions of African-American women, other factors may be related to disparities among women living in Appalachian and rural counties. Higher proportions of late stage diagnoses were found in these two groups of counties. Prevalence of mammography in Ohio did not differ for black vs white women; however, women with lower levels of income and educational attainment were less likely to report a mammogram in the past 2 years, with lower prevalence in Appalachian and rural counties. Using a multi-level framework, based on a socio-ecologic model of disparities, reasons for disparities observed in Appalachian Ohio were examined. The multi-level model posits that the causes (and solutions) to disparities are not solely due to individual behavior but are caused by the interplay of factors from multiple levels of influence ranging from biology to policy. For the specific case of breast cancer disparities in Appalachia, using data from several sources, including ongoing research studies, a model was developed to explain, investigate and intervene on these disparities. At the biologic level, stress, related to socioeconomic conditions, contributes to more aggressive tumor characteristics and impacts individual risk factors such as smoking, obesity, alcohol and drug use. Lack of exercise and a higher prevalence of food deserts increase the prevalence of obesity. At the social relationship level, poor behaviors such as smoking, alcohol use and obesity are reinforced as a result of few role models for health promoting behaviors. The social and physical context contributes as access to mammography and treatment and genetic testing facilities, is challenging. Institutional level factors include poor quality mammography, lack of coverage for genetic testing and lack of quality treatment and screening services. Lastly, the social condition and policy level focuses on conditions in the region including lower economic resources and policies to assure screening, treatment and access to genetic testing services. Solutions to these problems encompass strategies at individual, social, institutional and policy levels including: transportation assistance, navigation, mobile mammography with outreach, telemedicine to improve genetic testing and treatment access, community and health care provider attention to modifiable behaviors such as diet/exercise, alcohol use and smoking, and legislation to assure quality screening, treatment and access to genetic testing. While some strategies are currently being implemented in Appalachia to address determinants of risk and access, more focus from the policy perspective must be directed toward reducing disparities related to place. Citation Format: Paskett ED. Place as a cause of breast cancer disparities in Appalachia [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr ES5-1.

Bundling Care for Cardiac Surgery Patients

Patients returning to the community after surgery often experience a disconnect when transitioning from hospital to community home care. Many receive little organized/planned care following discharge sometimes resulting in unplanned expensive care in hospital emergency departments and inpatient readmissions. Trillium Health Partners, a large community/teaching hospital, in partnership with community care provider Saint Elizabeth Health Care, designed and implemented a seamless "bundled care program" for cardiac surgery patients extending from hospitalization to 30 days after discharge. With a risk/gain sharing model, the bundled care program enabled a novel integrated clinical patient care model. This included integrated care coordinators embedded within the hospital team, 24/7 patient phone line, integrated medical records and a tracking board that enabled performance monitoring and improvement. Evaluation results revealed: a 16% reduction in post-operative length of stay; a 38% reduction in readmission rates; and a 13% decrease in total system cost per patient, together with markers of improved patient experience.

Impact of community based training on medical undergraduates skills upgradation regarding infant and young child feeding practices: A mixed method study

Background: Despite various reforms brought in health care service delivery there is always a gap between community and health care providers. Hence there is a need to explore the successful strategies to reorient the medical students towards public health relevant community needs. Objective: This study aimed to assess the feasibility and impact of community based field training imparted among medical undergraduates to identify problems related to infant and young child feeding practices and design appropriate interventions. Material and Methods: This study is a mixed method study where improvement of knowledge were assessed quantitatively through quasi experimental pre-post study design. Difference in cumulative score obtained after training was compared using student's t test. Perception of students and mentor's views on this approach in terms of benefits and challenges were explored during in-depth interviews. Transcripts of qualitative interviews were analysed using manual content analysis. Results: Total of 781 infant and young children from 30 villages were surveyed by 36 medical undergraduates. There was significant improvement in knowledge on feeding practices from the baseline [baseline mean (SD) score: 3.3 (1.5); post training mean (SD) score: 6.5 (1.1), p

Oral Chinese herbal medicine for psoriasis vulgaris: protocol for a randomised, double-blind, double-dummy, multicentre clinical trial

IntroductionPsoriasis vulgaris is a common skin disease that is characterised by persistent localised erythematous scaly plaques. Yinxieling is a Chinese herbal formula for psoriasis that has been used for more...