Client Health Outcomes Research Articles

Testing a service integration model: Results from the HIV/AIDS initiative, ConnectHIV

Staff of 20 AIDS Service Organizations (ASOs), grantees of the initiative ConnectHIV in the United States, developed a theoretical model of five categories of factors – external, community, organizational, staff, and client – that lead to effective service integration (SI) and took part in a self-assessment related to the model. The model was tested empirically using GEE analysis to assess the effect of ASO SI scores on client outcomes from participation in HIV/AIDS interventions involving case management with persons living with HIV/AIDS. Results showed that clients served by ASOs with more effective SI were more knowledgeable of HIV disease, healthier (higher CD4, lower viral load) and perceived themselves as healthier than clients in ASOs with less effective SI. In addition, clients at ASOs with more effective SI more often showed stronger gains in CD4 count over their time in the HIV/AIDS intervention than those at ASOs with less effective SI. Further research is needed on models and measurement of SI in order to effectively investigate the impact of HIV SI on client health outcomes.

Qualitative study of the influence of antidepressants on the psychological health of patients on antiretroviral therapy in Uganda

The study set out to explore how HIV-positive individuals conceptualise and describe depression and its manifestation in their lives, and how this may change over time in the context of antiretroviral therapy (ART) and antidepressant treatment. We conducted in-depth interviews using a semi-structured interview guide with 26 adult HIV-positive clients receiving ART in Uganda. We asked the participants to describe their depression and its impact on their general health, physical functioning and psychological wellbeing, as well as the influences of receiving ART or antidepressant treatment. Although depressive experience among the patients was largely described in terms of criteria in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR), some of the symptoms used to describe depression, such as ‘thinking too much’ or worrisome thoughts, did not fit into the DSM-IV criteria. The participants attributed their depression to news of the HIV diagnosis, a fear of dying, the potential socioeconomic consequences of their HIV infection on their family, ART side-effects and continued bad health. Their subjective reports indicated that the treatment of depression with antidepressants had made a positive impact on their general and psychological health. These findings highlight the need for models of HIV care that integrate mental health services and promote the diagnosis and treatment of depression in culturally sensitive ways so as to improve the quality of life and health outcomes for clients. However, keeping the particular study design in mind, these findings should be interpreted as preliminary.

The development and implementation of a nurse-led hepatitis C protocol for people with serious mental health problems

Hepatitis C (HCV) is a significant health issue for people with serious mental health problems (SMHP). Factors associated with this include high rates of substance use, injecting drug use, and lack of knowledge regarding the transmission and prevention of HCV. This population are at higher risk of experiencing conditions where transmission rates are high, e.g. night shelters and homelessness. People with SMHP also often have factors associated with acceleration of the disease, including excessive alcohol use and poor physical health. Nurses across services collaborated to develop and implement a protocol to address the needs of clients of an Assertive Outreach Team with or at risk of HCV. It has been successful in developing an effective approach to addressing the needs of people with or at risk of HCV and serious mental health problems. It guides staff in providing a flexible, accessible service for clients delivered across organizational boundaries. It has demonstrated improved health outcomes for clients. It is believed that this project can be used as a template to address other health needs of this client group for example diet, obesity and smoking.

Building a Community-Academic Partnership to Improve Health Outcomes in an Underserved Community

East Garfield Park, IL, is an impoverished community with 59.7% of residents falling below twice the poverty level and 42.6% of its children in poverty. In 2001, the leading causes of hospitalizations were heart disease (10.3%), diabetes (2%), and asthma (3.9%), all of which occur at frequencies 33% greater than the Chicago average. Finally, a review of the health care facilities in the community suggests that there is a need for accessible primary health care services in the area. The purpose of this project was to improve health outcomes in an impoverished, underserved community with documented health care needs and lack of adequate health care services by creating a community-academic partnership to provide on-site, interdisciplinary, health care services within an established and trusted community-based social service agency, Marillac House. The short-term objectives for this project included creating a community-academic partnership between Marillac House and Colleges of Nursing, Medicine, and Health Sciences; providing comprehensive health care services; and developing an innovative clinical education model for interdisciplinary care across specialties. Long-term objectives included providing preventative services; evidenced-based management of acute and chronic illness; evaluating client's health outcomes; and creating a sustainability plan for the long-term success of the health center.

Reflecting on Issues of Enacting a Critical Pedagogy in Nursing

This article explores the contributions critical analytic perspectives offer for understanding the conditions that contribute to inequalities in health and considers the ways these may be taken up in nursing education. This article proposes that if there is commitment in effecting transformation of, and articulating the opportunities for, action within systems of health care, to achieve more equitable health outcomes for clients, then insights generated in the critical paradigm must be translated into formative education and practice. The aim of this article is to examine and reflect on a range of critical pedagogical strategies with a view to identifying their potential for fostering uptake of insights from research generated in the critical paradigm in order to achieve transformations in practice. It is argued that insights from this work can be drawn on to inform the design of learning experiences and educational practices.

What is the (Net) Cost to Government of Homelessness Programs?

Homelessness programs may improve the health, well‐being, financial security, labour market and housing outcomes of clients. This, in turn, may result in decreased utilisation of health and justice services, reduced child residential care costs, lower housing management costs, lower income support payments and higher revenue from increased income tax payments. When costed, such impacts represent whole‐of‐government savings or cost offsets to the provision of homelessness programs. This paper provides indicative estimates of the value of potential savings or cost offsets in two areas, namely, the health and justice fields from homelessness program interventions. Our key finding is that homelessness programs have the potential to save over twice the value of the capital and recurrent funding of homelessness programs on the basis of health and justice cost offsets alone.

Challenges in getting workforce research in nursing used for decision‐making in policy and practice: a Canadian perspective

This paper draws upon empirical research and other published sources to discuss nursing workforce issues, the challenges of using health human resource research in policy decisions and the importance of evidence-based policies and practices for nursing care and outcomes. Increasing evidence points to the critical relationship between registered nurse care and improved patient outcomes. The negative impact that insufficient nurse staffing has on patient, nursing and system outcomes has influenced health human resource researchers to further examine nurses' work environments to determine factors that are amenable to policy change. Survey of literature was conducted. Electronic databases were searched using keywords. Sustained health human resource planning efforts by policy makers are difficult given changing governments and political agendas. The health human resource conceptual framework provides researchers and planners with a guide to decision-making that considers current circumstances as well as those factors that need to be accounted for in predicting future requirements. However, effective use of research depends on communication of findings between researchers and policymakers. Health care managers and other decision-makers in health care organisations often lack an understanding of the research process and do not always have easy access to current evidence. Also, managerial decisions are often constrained by organisational requirements such as resource availability and policies and procedures. Unless nursing workplace issues are addressed, the physiological and psychological stress in the work environments of nurses will continue. Effective health human resource policy and planning (at the macro level) and management strategies (at the micro level) would stabilise the nursing workforce and reduce job stress. Furthermore, the efficiency and cost-effectiveness of the health system could be enhanced through improved health outcomes of care providers and health care clients.

Today’s Challenge, Tomorrow’s Excellence: the Practice of Evidence-Based Education

Nurse educators are being challenged to maintain quality in light of increasing numbers of students, declining numbers of experienced faculty, societal mandates, and rapid changes in health care. The scholarship underlying the practice of nursing education, or evidence-based education, must continue to be explored through the design, testing, and refinement of education strategies from nursing and other disciplines. The involvement of every educator in this process will help create institutional valuing that serves to retain inquisitive and reflective educators in academic settings, while expanding evidence-based education in nursing. This article describes a literature review of the scholarship of nursing education practice and suggests approaches to generate a dynamic explosion of growth in nursing education to inform our students, promote optimal client health outcomes, and challenge each of us to reach higher levels of excellence in the practice of nursing education.

Evaluating reproductive health outcomes for microcredit clients

An increasingly popular scheme for poverty alleviation and health improvement is microcredit, the awarding of small loans to individuals, usually women, who are too poor to take advantage of traditional financial services. Several studies have questioned the ability of microcredit programs to positively impact the financial standing of borrowers and their families, and only a handful have examined whether the added income improves health outcomes. This study aimed to determine how microcredit services affect women's reproductive health.

The implementation and impact of different funding initiatives on access to multidisciplinary primary health care and policy implications

To review the implementation and impact of different funding initiatives across the health systems of three different countries - England, New Zealand and Australia - on the achievement of multidisciplinary primary health care (PHC) and to reflect on policy implications for Australia. A systematic review of the literature involving three stages: (i) identification and description of initiatives; (ii) a systematic review of their implementation and impact from 1995 to mid 2006; and (iii) an updated review of published literature from mid 2006 to mid 2007. Few studies employed control groups, and the results should therefore be interpreted with caution. In all three countries, funding has supported general practitioner access to a broad range of providers. In Australia, financial incentives have been the main mechanism for bringing about change, whereas in both England and New Zealand, they are part of a broader range of funding reforms including the introduction of capitation and practice-based commissioning. The lack of patient data makes it difficult to assess the extent to which the Australian financial incentives have generally improved population access to a broader range of PHC providers. Individual, patient-level, financial incentives may present significant impediments for population subgroups with complex needs. Alternative funding arrangements, such as capitation and contracting, could be more widely adopted in Australia to enhance access to care for vulnerable population groups without fundamentally changing the overall fee-for-service financing arrangements.

The Relationship between Characteristics of Home Care Nursing Service Contracts under Managed Competition and Continuity of Care and Client Outcomes: Evidence from Ontario

The purpose of this study was to investigate the impact of the Request for Proposal (RFP) process - specifically, the profit status of provider agencies awarded contracts, the service volume awarded and contract duration - on the quality of home care services and outcomes. A cross-sectional (contract characteristics) and repeated measures (clients) design was used to collect data on the study variables. Primary data were collected in 2002-2003 from 11 Community Care Access Centres (CCACs) and 11 nursing provider agencies in Ontario. The sample included 750 home care clients recruited consecutively from home care referrals. Follow-up assessments were completed on 498 clients. CCACs and provider agencies completed written questionnaires about profit status, contract volume, duration of contract, potential for renewal, number of visits made by a principal nurse and number of visits made by a registered nurse. Data were collected on client health outcomes either at admission to home care service for new clients or at entry to the study for long-term clients, and then at discharge from service or at the end of six weeks, whichever came first, using the eight subscales of the Medical Outcome Study SF-36. Analysis was conducted using hierarchical linear modelling.For the most part, contract characteristics were not related to the consistency of principal nurse visits or client outcomes. Where differences existed, they were small. Clients of agencies awarded longer contracts received greater consistency in principal nurse visits than clients of agencies awarded shorter contracts. Clients cared for by for-profit agencies reported slightly higher satisfaction with care and better mental health outcomes than clients cared for by not-for-profit agencies. The percentage of visits made by a registered nurse was positively associated with social function outcome for clients at follow-up. In conclusion, the study findings suggest that contract characteristic variables had a small effect on home care client outcomes.

Client acceptability and quality of life – telepsychiatry compared to in-person consultation

We evaluated client satisfaction and one-month mental health outcomes for telepsychiatry clients compared with those undergoing a face-to-face psychiatric consultation. Clients were asked to complete an SF-12 health survey before the consultation, a satisfaction survey after the consultation, and were contacted for a one-month follow-up SF-12 survey by telephone. Forty-eight of the 62 initial responders (77%) were available for contact by telephone after one month. Telepsychiatry clients demonstrated significant improvements on pre- and post-SF-12 mental health measures (t = 3.7; P = 0.001), while there was no change for the in-person group (t = 1.0; P = 0.35). Telepsychiatry clients felt that they could present the same information as in person (93%), were satisfied with their session (96%), and were comfortable in their ability to talk (85%); this was similar to the in-person clients. They reflected slightly lower levels of satisfaction regarding feeling supported and encouraged than did the in-person clients. Both telepsychiatry clients and traditional face-to-face psychiatry clients were satisfied with their experience of mental health care service provision, and mental health improvements were evident in the telepsychiatry patients.

Posttraumatic stress disorder: An exploratory study examining rates of trauma and PTSD and its effect on client outcomes in community mental health

BackgroundRates of trauma and Posttraumatic Stress Disorder (PTSD) were examined in order to compare the profile in clients of an Australian Public Mental Health Service with that reported in the international literature for clients with major mental illness and to explore the effect of this on client health outcomes. Potential factors contributing to increased levels of trauma/PTSD in this group of clients and the issue of causality between PTSD and subsequent mental illness was also explored.MethodsA convenience sample of 29 clients was screened for trauma and PTSD using the Posttraumatic Stress Diagnostic Scale™ (PDS) and selected outcome measures. Paired and independent samples t-test and ANOVA were applied to the data.ResultsHigh levels of undocumented trauma and PTSD were found. Twenty clients, (74%) reported exposure to multiple traumatic events; 33.3% (9) met DSM IV diagnostic criteria for PTSD. Significant difference was found for PTSD symptomatology, severity and impairment and for client and clinician-rated scores of Quality of Life (QOL) outcomes in the PTSD group. No effect for PTSD symptomatology on the Working Alliance (WA) was found. Factors that may influence higher rates of PTSD in this group were identified and included issues associated with the population studied, the predominance of assaultive violence found, and vulnerability and risks factors associated with re-traumatisation within the social and treating environments.ConclusionA similar trauma and PTSD profile to that reported in the international literature, including greater levels of trauma and PTSD and a poorer QOL, was found in this small sample of clients. It is postulated that the increased levels of trauma/PTSD as reported for persons with major mental illness, including those found in the current study, are primarily related to the characteristics of the population that access public mainstream psychiatric services and that these factors have specific implications for service delivery, and raise issues of efficiency and effectiveness of resource use in achieving successful outcomes in public mental health services for clients with co-morbid PTSD. Further research with a more rigorous design is needed to test these preliminary findings within Australian Community Mental Health Services.

Health ‘care’ interventions: making health inequalities worse, not better?

The aim of this paper is to present a model, the 'Effect of the Professional Ego', which provides a psychodynamically informed analytical framework for examining professional practice in arenas where issues of inequalities need to be addressed. There is a great deal of literature on the psychosocial aspects of inequalities in health care provision. However, the impact of intrapsychic and professional cultural elements has not been explored in this context. Moreover, the body of work which does explore these elements in relation to health care workers does not address how they might impact on health inequalities. Drawing on empirical work, we discuss ways in which intrapsychic and professional cultural elements feed into the dynamic between clients and health care professionals in a way which can subvert espoused, positive client health outcomes. Based on this discussion, we propose the Effect of the Professional Ego model, which identifies two main aspects of the professional ego - the grandiose self and self-preservation - and how they influence the professional/client dynamic. Systematic self-reflection on the part of professionals would be a valuable contribution to the development of professional practice. This applies particularly to conceptualizing the links between the actions of service providers and the adverse health of clients.

Medication decision-making by persons with serious mental illness

The Interaction Model of Client Health Behavior (IMCHB) has been established as a useful model in guiding research and development of individually tailored clinical interventions. The constructs of client singularity, client-provider interaction, and health outcomes guided an examination of medication decision-making by persons with serious mental illness (SMI). Client motivation is discussed as it relates to participation in the client-provider interaction and subsequent medication adherence and quality of life. Decisional control, the specific element of the client-provider interaction that affects medication decision-making, is considered in relation to consumer roles and responsibility for medication management. As psychotropic medications remain the single most effective treatment for reducing the active symptoms of psychosis, this look at medication decision-making may have significant implications for nursing.

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Introducing coordinated care (2): evaluation of design features and implementation processes implications for a preferred health system reform model

The study investigated why the goals of the Australian Coordinated Care trials for clients with complex care needs were not achieved. Significantly higher health service use and costs were incurred in the absence of clear evidence of improved client health outcomes. The validity of assumptions underpinning trial design and the success of implementation at each step in application of the model were examined. There were failures in both design and implementation. Many clients did not require care coordination. The funds pooling arrangements contributed to limited possibilities for service substitution and training of GP care coordinators was inadequate. Trial design did not focus on either clinical guidelines or consumer empowerment. Furthermore, the expectations of the overall national trial were unrealistic both in trial design and expected outcomes given the rigidities and realities of the Australian health care system. Broader system reform in the form of funds pooling and health services planning at the regional level, based on large populations, may be a more effective means to address problems of care coordination and an inflexible supply system.

Does public health nurse home visitation make a difference in the health outcomes of pregnant clients and their offspring?

Public health nurses (PHNs) at Lincoln-Lancaster County Health Department have used the Care Pathway tool to track client progress. Conceptually similar to critical pathways used in hospital settings, the Care Pathway is used by the PHN to document milestones of progress by trimester of pregnancy. Data for this research was gathered from chart review of 55 prenatal clients. Study results demonstrate that subjects who had from five to nine home visits by a PHN during pregnancy showed a higher average hemoglobin for the mothers and a higher average birthweight for the babies than those visited four or fewer times. None of the low birthweight babies was born to mothers in the "more visits" category. Furthermore, more breastfeeding was recorded for those who had received more PHN visits. This documentation enabled us to describe better the referent population and to begin to estimate the effect of PHN home visitation on the health outcomes of clients. In essence, we addressed the questions: (1) "Does PHN home visitation make a difference in health outcomes of clients and their families?" and (2) "If so, how can effects be measured?"

Academic nursing clinic: Impact on health and cost outcomes for vulnerable populations

The purpose of this study was to examine selected health and cost outcomes of clients who used an academic nursing clinic (ANC) located in a high-rise public housing facility for low-income citizens. Service use, health promotion and screening, quality of care, satisfaction and costs were examined. Health outcomes were improved. Estimated cost savings were about $36,000 during the first year with reduced paramedic and police calls, hospitalizations, and emergency room visits. Findings show that advanced practice nurses can positively influence health outcomes by providing cost-effective quality health care. Copyright 2003, Elsevier Science (USA). All rights reserved.

Empowerment in healthcare

Explores the trends of health care delivery and how health care workers will need to develop different ways of relating to each other and their clients. These different ways of relating will improve health status and outcomes of clients. The model is described as a way an organization can pursue the strategies to achieving different ways of relating to their clients. The article gives pragmatic ideas about how to begin developing these different relationships.