Health Service Delivery Models Research Articles

Comparison of patient-reported outcomes between alternative care provider-led and physician-led care for severe sleep disordered breathing: secondary analysis of a randomized clinical trial

BackgroundPrevious research has suggested that alternative (respiratory) care providers (ACP) may provide affordable, accessible care for sleep-disordered breathing (SDB) that decreases wait-times and improves clinical outcomes. The objective of this study was to compare ACP-led and sleep physician-led care for SDB on patient reported outcome and experiences, with a focus on general and health-related quality of life, sleepiness, and patient satisfaction.MethodsWe conducted a secondary analysis of a randomized trial in which participants with severe SDB were assigned to either ACP-led or physician-led management. We created longitudinal linear mixed models to assess the impacts of treatment arm and timepoint on total and domain-level scores of multiple patient-reported outcome measures and patient-reported experience measures.ResultsPatients in both treatment arms (ACP-led n = 81; sleep-physician = 75) reported improved outcomes on the Sleep Apnea Quality of Life Index, Health Utilities Index, and Epworth Sleepiness Scale. Patients in each group had similar and clinically meaningful improvements on domains assessing cognition, emotion, and social functioning. The linear mixed models suggested no significant difference between treatment arms on the patient-reported outcomes. However, scores significantly improved over time.ConclusionsManagement of SDB using ACPs was comparable to physician-led care, as measured bypatient-reported outcome and experience measures. While loss to follow-up limits our findings, these results provide some support for the use of this novel health service delivery model to improve access to high quality SDB care.Clinical trial registrationThis is analysis of data from the study registered Clinicaltrials.gov (NCT02191085).

A call for multi-agency collaboration in the Pacific Island countries' mental health - The World Federation for Mental Health viewpoint.

To introduce the World Federation for Mental Health (WFMH) viewpoint on the Pacific Island countries' mental health capacity building. Multi-agency collaboration guided by a nuanced understanding of the local context can enable a public health model of mental health service delivery in the Pacific Island countries.

Documenting Community Health Worker Compensation Schemes and Their Perceived Effectiveness in Seven sub-Saharan African Countries: A Qualitative Study.

Community health worker (CHW) incentives and remuneration are core issues affecting the performance of CHWs and health programs. There is limited documentation on the implementation details of CHW financial compensation schemes used in sub-Saharan African countries, including their mechanisms of delivery and effectiveness. We aimed to document CHW financial compensation schemes and understand CHW, government, and other stakeholder perceptions of their effectiveness. A total of 68 semistructured interviews were conducted with a range of purposefully selected key informants in 7 countries: Benin, Burkina Faso, Ghana, Malawi, Mali, Niger, and Zambia. Thematic analysis of coded interview data was conducted, and relevant country documentation was reviewed, including any documents referenced by key informants, to provide contextual background for qualitative interpretation. Key informants described compensation schemes as effective when payments are regular, distributions are consistent, and amounts are sufficient to support health worker performance and continuity of service delivery. CHW compensation schemes associated with an employed worker status and government payroll mechanisms were most often perceived as effective by stakeholders. Compensation schemes associated with a volunteer status were found to vary widely in their delivery mechanisms (e.g., cash or mobile phone distribution) and were perceived as less effective. Lessons learned in implementing CHW compensation schemes involved the need for government leadership, ministerial coordination, community engagement, partner harmonization, and realistic transitional financing plans. Policymakers should consider these findings in designing compensation schemes for CHWs engaged in routine, continuous health service delivery within the context of their country's health service delivery model. Systematic documentation of the tasks and time commitment of volunteer status CHWs could support more recognition of their health system contributions and better determination of commensurate compensation as recommended by the 2018 World Health Organization Guidelines on Health Policy and System Support to Optimize Community Health Worker Programs.

Value-led participatory design approach for improving public health clinic services

IMPACT This study details how to drive transformative collaboration with a health bureau to implement transformative tasks in public health clinic (PHC) using service design. Value-led participatory design is adopted to identify and address key challenges, enhance decision-making processes, and generate a new elevation model for public health service delivery. The article highlights the importance of continuous evaluation and adaptation of services based on stakeholder feedback and evolving community needs, emphasising the dynamic nature of healthcare service improvement. The insights gained from this collaboration provide practical solutions for common challenges faced by public health systems in various contexts.

Multidisciplinary, multicomponent interventions to reduce frailty among older persons in residents of residential care facilities: a scoping review

BackgroundFrailty reduction and reversal have been addressed successfully among older populations within community settings. However, these findings may not be applicable to residential care settings, largely due to the complex and multidimensional nature of the condition. Relatively, few attempts at frailty prevention exist in residential settings. This review aims to identify and describe best practice models of care for addressing frailty among older populations in residential care settings. This research also sets out to explore the impact of multidisciplinary health service delivery models on health outcomes such as mortality, hospitalisations, quality of life, falls and frailty.MethodsA scoping review of the literature was conducted to address the project objectives. Reference lists of included studies, bibliographic databases and the grey literature were systematically searched for literature reporting multidisciplinary, multidimensional models of care for frailty.ResultsThe scoping review found no interventions that met the inclusion criteria. Of the 704 articles screened, 664 were excluded as not relevant. Forty articles were fully assessed, and while no eligible studies were found, relevant data were extracted from 10 near-eligible studies that reported single disciplines or single dimensions rather than a model of care. The physical, nutritional, medicinal, social and cognitive aspects of the near eligible studies have been discussed as playing a key role in frailty reduction or prevention care models.ConclusionThis review has identified a paucity of interventions for addressing and reducing frailty in residential care settings. High-quality studies investigating novel models of care for addressing frailty in residential care facilities are required to address this knowledge gap. Similarly, there is a need to develop and validate appropriate screening and assessment tools for frailty in residential care populations. Health service providers and policy-makers should also increase their awareness of frailty as a dynamic and reversible condition. While age is a non-modifiable predictor of frailty, addressing modifiable factors through comprehensive care models may help manage and prevent the physical, social and financial impacts of frailty in the ageing population.

Leaving no one behind in armed conflict-affected settings of Africa: is universal health coverage a possibility or mirage?

The world is off track six years to the 2030 deadline for attaining the sustainable development goals and universal health coverage. This is particularly evident in Africa’s armed conflict-affected and humanitarian settings, where pervasively weak health systems, extreme poverty and inequitable access to the social dimensions and other determinants of health continue to pose significant challenges to universal health coverage. In this article, we review the key issues and main barriers to universal health coverage in such settings. While our review shows that the current health service delivery and financing models in Africa’s armed conflict-affected settings provide some opportunities to leapfrog progress, others are threats which could hinder the attainment of universal health coverage. We propose four key approaches focused on addressing the barriers to the three pillars of universal health coverage, strengthening public disaster risk management, bridging the humanitarian-development divide, and using health as an enabler of peace and sustainable development as panacea to addressing the universal health coverage challenge in these settings. The principles of health system strengthening, primary health care, equity, the right to health, and gender mainstreaming should underscore the implementation of these approaches. Moving forward, we call for more advocacy, dialogue, and research to better define and adapt these approaches into a realistic package of interventions for attaining universal health coverage in Africa’s armed conflict-affected settings.

“Discharge Doesn’t Mean the End” Exploring Success in Discharge to Community Self-management For Young Adults Living with Chronic Pain: A Qualitative Study

Background Living with chronic pain as a young adult (YA) can impact the physical, emotional, social, cognitive, and role function domains of life. Once YAs receive care for their specialist chronic pain care they are expected to self-navigate a complex healthcare system to transition to community-based care (i.e. primary care). Inadequate discharge planning may increase the unique difficulties YAs face in self-management, which may lead to adverse health outcomes, suboptimal discharge, and a need to re-access care. Aims The purpose of this qualitative study is to explore how YAs with chronic pain define a successful discharge transition from a health service delivery model of specialized chronic pain services setting to self-management in a community setting (i.e. primary care) and contextual factors that promote discharge success. Methods This qualitative study included young adults with chronic pain. Data were obtained through semi-structured interviews which were transcribed verbatim and analyed using inductive content analysis.. Results Ten participants identified that successful discharge includes the following consideration, 1) acknowledging the tension between moving forward and looking back, 2) a collaborative discharge process, and 3) the need for ongoing, relevant resources and support. Conclusion This study provided a deeper understanding of how YAs with chronic pain characterize success in the discharge transition from specialized chronic pain services to community self-management. Our findings highlighted the importance of provider-patient collaboration during the discharge planning process to develop a patient centered self-management plan that incorporates community resources tailored to the needs of the individual to promote an optimal discharge.

The emergence and regression of political priority for refugee integration into the Jordanian health system: an analysis using the Kingdon’s multiple streams model

BackgroundThe prolonged presence of Syrian refugees in Jordan has highlighted the need for sustainable health service delivery models for refugees. In 2012, the Jordanian government adopted a policy that granted Syrian refugees access, free of charge, to the national health system. However since 2012, successive policy revisions have limited refugee access. This paper seeks to understand factors that initially put refugee integration into the health system on the policy agenda, as well as how these same factors later affected commitment to sustain the policy.MethodsThis paper draws on data from a document review of 197 peer-reviewed and grey literature publications, a media analysis of newspaper articles retrieved from four officially recognized newspapers in Jordan, and 33 semi-structured key informant interviews. We used Kingdon’s Multiple Streams Model – a well-established tool for analyzing policy adoption – to understand how political priority developed for integration of refugees into the health system.ResultsWe find that several factors helped bring attention to the issue, namely concerns over infectious disease transmission to host communities, high rates of chronic conditions among the refugee population and the increasingly urban and dispersed nature of refugees. At the outset of the conflict, the national mood was receptive to refugees. Politicians and government officials quickly recognized the crisis as an opportunity to secure material and technical support from the international humanitarian community. At the same time, global pressures for integrating refugees into national health systems helped move the integration agenda forward in Jordan and the region more broadly. Since 2012, there were several modifications to the policy that signal profound changes in national views around the continued presence of Syrian refugees in the country, as well as reduced external financial support which has undermined the sustainability of the policy.ConclusionThis case study underscores the dynamic nature of policymaking and the challenge of sustaining government commitment to the right to health among refugees. Our analysis has important implications for advocates seeking to advance and maintain momentum for the integration of refugees into national health systems.

Health seeking behaviours and private sector delivery of care for non-communicable diseases in low- and middle-income countries: a systematic review

BackgroundGlobally, non-communicable diseases (NCDs) are the leading cause of mortality and morbidity placing a huge burden on individuals, families and health systems, especially in low- and middle-income countries (LMICs). This rising disease burden calls for policy responses that engage the entire health care system. This study aims to synthesize evidence on how people with NCDs choose their healthcare providers in LMICs, and the outcomes of these choices, with a focus on private sector delivery.MethodsA systematic search for literature following PRISMA guidelines was conducted. We extracted and synthesised data on the determinants and outcomes of private health care utilisation for NCDs in LMICs. A quality and risk of bias assessment was performed using the Mixed Methods Appraisal Tool (MMAT).ResultsWe identified 115 studies for inclusion. Findings on determinants and outcomes were heterogenous, often based on a particular country context, disease, and provider. The most reported determinants of seeking private NCD care were patients having a higher socioeconomic status; greater availability of services, staff and medicines; convenience including proximity and opening hours; shorter waiting times and perceived quality. Transitioning between public and private facilities is common. Costs to patients were usually far higher in the private sector for both inpatient and outpatient settings. The quality of NCD care seems mixed depending on the disease, facility size and location, as well as the aspect of quality assessed.ConclusionGiven the limited, mixed and context specific evidence currently available, adapting health service delivery models to respond to NCDs remains a challenge in LMICs. More robust research on health seeking behaviours and outcomes, especially through large multi-country surveys, is needed to inform the effective design of mixed health care systems that effectively engage both public and private providers.Trial registrationPROSPERO registration number CRD42022340059.

EConsent administered by Community Health Workers in a study using the Trials within Cohorts (TwiCs) design-Experiences from the Community-Based chronic Care Lesotho (ComBaCaL) project.

Improving access to essential health services requires the development of innovative health service delivery models and their scientific assessment in often large-scale pragmatic trials. In many low- and middle-income countries, lay Community Health Workers (CHWs) play an important role in delivering essential health services. As trusted members of their communities with basic medical training, they may also contribute to health data collection. Digital clinical decision support applications may facilitate the involvement of CHWs in service delivery and data collection. Electronic consent (eConsent) can streamline the consent process that is required if the collected data is used for the scientific purposes. Here, we describe the experiences of using eConsent in the Community-Based chronic Care Lesotho (ComBaCaL) cohort study and multiple nested pragmatic cluster-randomized trials assessing CHW-led care delivery models for type 2 diabetes and arterial hypertension using the Trials within Cohorts (TwiCs) design. More than a hundred CHWs, acting both as service providers and data collectors in remote villages of Lesotho utilize an eConsent application that is linked to a tailored clinical decision support and data collection application. The eConsent application presents simplified consent information and generates personalized consent forms that are signed electronically on a tablet and then uploaded to the database of the clinical decision support application. This significantly streamlines the consent process and allows for quality consent documentation through timely central monitoring, facilitating the CHW-led management of a large-scale population-based cohort in a remote low-resource area with continuous enrollment-currently at more than 16,000 participants.

"Integration as organising principle to strengthen quality of chronic care: Scoping Review results (First part of work commissioned by the World Health Organization on specifications of quality of care for chronic conditions)"

Introduction & Who Is It For? There is a need to strengthen quality of chronic care to benefit people with chronic conditions (PwCC). Cascades of care for chronic conditions consistently show marked decline from “overall prevalence” to “good control”[1,2]. Qualitative studies demonstrate that user-related barriers redound on care quality, e.g. accessibility (geographically inaccessible, service non-availability), (non-)affordability, and affective concerns (not person-centered)[3,4]. Hence, many do not complete the “journey”: those screened do not return for confirmatory diagnosis, those diagnosed do not return for treatment; and those on treatment are not adherent. The WHO recognizes this and has proposed putting forth financing mechanisms to strengthen chronic care quality. However, there is currently no existing sound conceptualization of good quality chronic care.
 Involvement & Methodology: For a comprehensive overview of dimensions of chronic care quality, a multi-disciplinary team (PwCC, general practitioner, public health/health system/policy researcher, anthropologist, sociologist, health economist) conducted scoping review. We reviewed 48 scientific articles studying implementation of (new/established) models and/or dimensions of chronic care quality. We purposively retrieved 26 grey literature. 
 Results: We retained the Institute of Medicine’s quality aims/dimensions: effectiveness; efficiency; safety; equitability; accessibility, affordability, timeliness; and person-centredness[5]; and added continuity of care. We considered the health system determinants groups: leadership and governance; financing; resources; and service delivery[6]. 
 Learnings: Analysis indicates that acting on determinants would achieve chronic care quality dimensions. Applying integration principles[7] can organize actions. Akin to population-based integrated care models, we envision an integrated health service delivery model for PwCC, including those at risk. This model offers community-based and facility-based chronic care services responsive to population and individual needs, encompassing health promotion, and primary, secondary, tertiary prevention; addressing risks, social determinants; involving different sectors, disciplines; and with virtual integration[8] of care levels/organisations. This way, multi-sectoral strategies and chronic care services at different levels delivered by various healthcare providers are integrated to include population actions, incorporate mechanisms connecting PwCC with various resources, and assure seamless access to all care levels, including informal caregiver- and self-management. Thus, covering all steps of the “journey”. 
 At the same time, functional integration[9] would organize actions on: 
 -Leadership and governance (policies,engagement). PwCC engagement is crucial to co-formulate policies and co-design and co-implement interventions with greater likelihood for success. Multi-sectoral engagement is relevant for co-designing/co-implementing interventions on risks and determinants of chronic conditions.
 -Financing (generation/sharing, [re-]allocation), and 
 -Resources (generation/sharing/augmentation, re-distribution). 
 These integrative approaches can increase efficiency, effectiveness and person-centredness; ensure continuity; feasibly make services equitably accessible; and motivate people to complete the “journey” to prevent/control risks, augment adherence, and achieve good control.
 We previously demonstrated integration of integrated primary diabetes care with other ongoing health care activities in a lower-middle-income country, which improved diabetes care quality[10,11]. 
 Successful integration of “integrated chronic care services” to improve chronic care quality is therefore plausible. Chronic care quality dimensions can then be measured through specific indicators (structures, processes, outcomes) and corresponding financing mechanism(s) put in place. 
 Next Step: The chronic care quality indicators will be finalised through Delphi surveys with various stakeholders from the different WHO regions.

IMPLEMENTATION SCIENCE IN THE DEVELOPMENT OF RECRUITMENT PROCEDURES AND MATERIALS: A CASE STUDY

Abstract Recruiting long-term care organizations, administrators, and direct-care staff to participate in research has become increasingly challenging after the pandemic due to staffing shortages, limited resources, and numerous competing priorities. In light of these challenges, it is especially important to develop recruitment procedures and materials that are fine-tuned to the participant group based on best practices. This presentation will describe the use of implementation science principles and an expert focus group in the design of recruitment procedures and materials for a NIA-funded clinical trial “Evaluating a National Person-Centered Training Program to Strengthen the Dementia Care Workforce.” The project is especially well-suited to employ and critique best practices given that recruitment is at both the organizational-level (assisted living communities) and the person-level (staff within those communities). Recruitment materials were designed in accordance with the Considering Determinants of Diffusion, Dissemination, and Implementation of Innovations in Health Service Delivery and Organization conceptual model, which emphasizes highlighting the advantages of the training, how the training fits into existing systems, the process of training, the endorsement of organizational leaders, and the transfer of the knowledge conveyed by the training into practice. Best practices from the literature were discussed with a focus group of assisted living experts to evaluate the draft procedures and materials. This presentation will share the resulting procedures and materials and explain their evolution to their final form; the process and results are widely applicable to other clinical trials and other studies. Funded by a grant from the National Institute on Aging (R01 AG079124).

Optimizing rural healthcare through improved team function: a case study of the Rural Surgical Obstetrical Networks programme

ABSTRACT We explored enablers and mechanisms of optimal team function within rural hospital teams, and the impact of these factors on health service sustainability in British Columbia. The data were drawn from interviews and focus groups with healthcare providers and administrators (n = 169) who participated in the Rural Surgical Obstetrical Networks (RSON) initiative to support low-volume rural surgical and obstetrical services in British Columbia, Canada. The 5-year programme (2018–2022) provided evidence-based system interventions across eight rural sites with the objective of providing sustainable, quality health services to meet population needs. To explore the impact of RSON interventions on local team function, we performed a scoping review, to assess the current literature surrounding enablers of effective rural hospital teamwork. Through inductive thematic analysis of interview data, we identified five enablers of good team function at RSON sites, including emphasis on local leadership, shared direction, commitment to sustainability, respect and solidarity among colleagues, and meaningful communication. The RSON project led to a shift in team culture in participating sites, improved team function, and contributed to improved clinical processes and patient outcomes. The findings have implications for rural health policy and practice in British Columbia and other jurisdictions with similar health service delivery models and geographic contexts.

OP163 Applying A Local Economic Evaluation Framework To Make Evaluations More Relevant For Local Decision Makers

IntroductionEconomic evaluation is infrequently used by local health services. To be useful to local decision makers, economic evaluations need to synthesize published evidence on effective interventions with local data and local stakeholder knowledge regarding patient and organizational contexts. A framework for local economic evaluation was applied by health economists working with a local health service to inform their decision-making regarding funding of health service delivery models to reduce hospital-acquired complications.MethodsThe framework engaged with local stakeholders to set priorities, assess the relevance of the published evidence, interpret local data, provide insight on the local context, and make recommendations to decision makers. It involved: (i) synthesizing the published evidence in a pragmatic review; (ii) determining local root causes and baseline incidence rates using local clinical and administrative data; and (iii) using expert elicitation to adjust published intervention effects to reflect the local context. This information was synthesized in a cost-consequence analysis that estimated the likely costs and effects of relevant interventions if they were implemented locally.ResultsLocal stakeholders selected hypoglycemia and urinary tract infections as targets for intervention. Tools and resources developed for each case study included: clinical audit tools and analysis files; pragmatic literature reviews with templates to present interventions to local stakeholders; an expert elicitation framework; and R code for cost-consequence analyses that apply published and elicited intervention effects to local data.ConclusionsThe framework provided a feasible and acceptable process for undertaking local economic evaluations. Engagement with local stakeholders ensured the evaluations produced were relevant and tailored to the local setting and were therefore useful to local decision makers. The tools and resources developed can be applied by other local health services. The framework itself can be used for other case studies. However, the time and cost associated with the evaluations was not sustainable and alternative models for applying the framework need to be explored.

A Pilot Study Exploring the Feasibility and Acceptability of Digitally Mediated Team Communication in Primary Schools

With high demand on specialist child mental health services internationally, there is significant interest in prevention and early intervention, as well as innovative and efficient approaches for increasing access to high-quality care. Digital communication technologies can improve communication between different professionals and agencies involved in young people’s lives, which is especially important in rural locations and became more necessary during the COVID-19 pandemic. This study examined the perceived value, feasibility, and acceptability of digitally mediated team communication for responding to emerging social, emotional, and mental health support needs in primary school settings in a rural county in the UK. A pre-/post-study design was used as a process evaluation of digitally mediated team communication and pilot test of feasibility and perceived value. Fifteen individual children (aged 4–9 years) were referred to a digitally mediated multidisciplinary team (with representation from relevant children’s services) where formulation was used to develop specialised action plans implemented by education staff and parents/carers. Findings suggest that digitally mediated team communication was highly valued for enhancing practice in supporting individual children by education staff and for making progress towards personalised goals by both education staff and parents/carers. Analysis further suggests that digitally mediated team communication was feasible and acceptable to education staff and parents/carers. A digitally mediated model for an early and multidisciplinary team response holds promise for empowering education staff as an extended mental health workforce, with a need for future research with larger samples to investigate service efficiency and outcomes of this health service delivery model.

The oral health landscape in Singapore: A commentary on key features, challenges and future policies.

Over the last decade, Singapore has grappled with substantial healthcare challenges, chiefly a bourgeoning aging population and a mounting burden of chronic diseases. The oral health landscape has also changed, with the Ministry of Health placing a greater focus on a life-course approach supported by policies that facilitate Singaporeans to receive dental care appropriately and affordably. A pivotal oral health policy is the National Dental Strategy, a comprehensive framework governing dental services in the public sector. This strategy encompasses aspects such as financing, workforce management, and capacity considerations. To facilitate affordability and accessibility to dental services in the public sector, the government extends subsidies to reduce out-of-pocket costs. Those attending private dental clinics also benefit from the Community Health Assist Scheme, introduced in 2012, which alleviates treatment costs for enrolled Singaporeans. Furthermore, additional age-banded subsidies have been introduced for older Singaporeans born before 1960, enhancing financial support when accessing dental services in both private and public sectors. In 2019, a national adult oral health survey was commissioned to gauge the oral health status of Singaporeans aged 21 and above. The findings reported 34.8% having untreated dental caries, and 15.7% and 41.2% experiencing moderate and severe periodontitis, respectively. While over half (53.9%) of respondents visited the dentist at least annually, about 60% of eligible individuals did not utilize their government dental subsidies. In response, the Ministry of Health is committed to strengthening oral disease prevention, integrating oral health into general healthcare services, expanding dental financing schemes to enhance service utilization, improving the quality and transparency of dental care, and leveraging advancements in tele-dentistry and other modes of dental services. It is imperative to adapt Singapore's oral health policies and service delivery models to meet the evolving needs of the population and ensure a sustainable, equitable and resilient oral healthcare system.

Decentralization and Corruption in Public Service Delivery: Local Institutional Arrangements That Can Help Reduce Governance Risks

Abstract Decentralization reform has both advantages and risks. Bringing service delivery “closer to the people” can improve information flows and strengthen accountability, but it may also leave systems vulnerable to elite capture and corruption by municipal government officials. While past research has acknowledged the possibility of corruption under decentralization, relatively little work has connected those risks to features of these reforms or specific local institutional arrangements. To explore the conditions that can help mitigate the risks of corruption under decentralization, we study the case of health sector reform in Honduras where municipal governments, associations, and NGOs each serve as intermediary-managing organizations under a common decentralized health service delivery model. We argue that three types of institutional arrangements reflecting local accountability practices serve as checks on the authority granted through decentralization and can help guard against corruption: external supervision, civil society engagement, and public participation. Empirically, we draw on data from more than 600 street-level bureaucrats, valuable but under-utilized informants about municipal corruption, across a matched sample of 65 municipalities with contrasting forms of administration. We find that reported corruption is highest under decentralization led by municipal governments, as compared to association- or NGO-led varieties. Both external supervision and civil society engagement help attenuate the positive association between decentralization and corruption, but public participation does not. Overall, this research highlights the importance of considering reform features and local conditions when designing policies to help manage risks and support effective social sector decentralization.

18 Early supported discharge for older adults admitted to hospital with medical complaints: a qualitative study exploring the views of stakeholders

Abstract Background Early Supported Discharge (ESD) is well established as a model of health service delivery for people with stroke. Emerging evidence indicates that ESD reduces length of stay for older medical inpatients. There is a dearth of evidence exploring the views of stakeholders on ESD as a model of care for older medical inpatients. The overall aim of this study is to explore the views and perceptions of older adults, family carers and healthcare professionals on the potential role of ESD for older adults admitted to hospital with medical complaints. Methods We conducted a qualitative interview and focus group study at University Hospital Limerick (UHL) from November 2021 to January 2022. Purposeful sampling was used to recruit older adults and family carers for interview. For Healthcare Professionals (HCPs), snowball purposeful sampling was used for focus groups. Braun and Clarke’s approach to thematic analysis was used. Ethical approval was granted by the HSE Mid-Western Area Regional Ethics Committee in November 2021 (REC Ref. 096/2021). Results Fifteen HCPs took part across three focus groups, with six older adults and two family members participating in one-to-one interviews. Three themes were identified: (1) Pre-ESD experiences of providing and receiving older adult inpatient care, (2) Navigating discharge procedures from acute hospital services and (3) A vision for more integrated model of care and a medical ESD team. Conclusion This qualitative study was the first to explore the views and perceptions of older adults and healthcare professionals on the potential role of ESD for older adults admitted to hospital with medical complaints. The current experiences and barriers to efficient and safe discharge home from hospital were highlighted by stakeholders. The potential role for ESD in this population group was discussed, as well as the key factors to be considered in running an ESD service for medical older adults.

Health seeking behaviours and private sector delivery of care for non-communicable diseases in low- and middle-income countries: protocol for a systematic review

IntroductionThe burden of non-communicable diseases (NCDs) has increased substantially in low- and middle-income countries (LMICs), and adapting health service delivery models to address this remains a challenge. Many patients with...

Development of Training to Prepare Army Medics to Address Behavioral Health Needs of Soldiers in Far-Forward Environments Utilizing Mobile App Technology.

Multi-domain operational combat environments will likely restrict key components of current behavioral health (BH) service delivery models. Combat teams in far-forward outposts or extended missions may need to rely on their own internal assets to manage combat and operational stress reactions for extended periods of time. As such, combat medics are expected to take on additional responsibilities as providers of BH support for isolated teams. As they receive limited BH training, medics require additional training to sufficiently respond to combat and operational stress reactions in their assigned teams. This study provided combat medics with a BH training and a mobile application-based support tool that would assist them in identifying and responding to BH concerns in their soldiers. The current analysis examines pre- to post-training changes in attitudes related to utilizing BH skills. We created a brief training aimed to increase medics' ability and confidence regarding managing BH issues. Its development was part of a study on the feasibility of the Soldier and Medic Autonomous Connectivity Independent System for Remote Environments (AIRE) apps (NOCTEM, LLC), a digital system designed for far-forward BH and sleep monitoring and management. Participants were combat medics from two Army combat brigades preparing for a training rotation through a combat training center (CTC). A total of 16 medics consented to participation with nine medics available at the follow-up after the field exercise. Medics were surveyed before the training and after their return from the CTC. In pre-training surveys, most medics indicated it was within their scope to assess for stress/anxiety, suicidal risk, stress reaction, and sleep problems; assist soldiers with optimizing work performance; and provide interventions for BH concerns and sleep problems. Less than half believed it was within their scope to assess and address team communication issues or provide intervention for stress reactions. After the CTC rotation, more medics endorsed that it was in their scope to provide interventions for acute stress reactions to traumatic events. Before the CTC rotation, at most 60% of the group felt at least moderately confident in utilizing the BH skills of discussing problems, assessing for concerns, and providing interventions. After CTC, the confidence levels for each skill increased or remained the same for most medics. Intervention skills had the highest proportion of medics (66%) reporting increased confidence in using the skills. A larger proportion of medics believed it was within their scope of work and felt confident in assessing BH problems, and a smaller proportion believed it is within their scope of work and felt confident in applying interventions. The training increased most medics' confidence to administer interventions for BH and team communication issues. Similar training programs can help medics serve as support for a wide variety of circumstances when the brigade's mental health teams are inaccessible. Additionally, the Medic AIRE app expanded the ability to evaluate and provide interventions without extensive training in treatment modalities or BH conditions. This concept shows promise for providing medics with actionable tools when training time is limited such as during preparation for extended deployments.