Local Health Services Research Articles

Population differences in completeness and reliability of Dutch COVID-19 registry data: The influence of testing policy, test readiness, and registration policy from an epidemiological perspective.

During the COVID-19 pandemic, the bidirectional relationship between policy and data reliability has been achallenge for researchers of the local municipal health services. Policy decisions on population specific test locations and selective registration of negative test results led to population differences in data quality. This hampered the calculation of reliable population specific infection rates needed to develop proper data driven public health policy.

Interpreter use in sustained nurse home visiting: interpreter experience and support

BackgroundThe aim of this study was to explore the experiences of healthcare interpreters working with child and family health nurses (CFHNs) in providing child and family health nursing (CFHN) services and sustained nurse home visiting (SNHV) programs to culturally and linguistically diverse (CALD) families with limited English proficiency.MethodsA mixed methods longitudinal research design was conducted to develop, implement and evaluate a training and practice support model for healthcare interpreters working with nurses and CALD families in providing CFHN services and SNHV programs in three major local health services in Sydney, Australia. One pre-training survey with 24 healthcare interpreters was conducted; field notes were recorded during training and implementation; and a post-implementation focus group with six healthcare interpreters was conducted. Quantitative survey data were analysed descriptively using Alchemer. The focus group was audio-recorded for transcription purposes, and this and the field notes were thematically analysed applying a socioecological framework.ResultsThree themes were identified from the initial, pre-training survey: facilitate communication and delivery accurately; a bridge linking the clients and the healthcare practitioners; and make everybody feel comfortable. Practice support implementation was negatively impact by system and COVID-19 related barriers. Four themes were developed from evaluative phase of the study including: system-related issues; interpreters’ challenges; working with nurses; and client session related issues.ConclusionQuality interpreting was favourably influenced by adequate time for interpreting the session including a pre- and post-briefing session with CFHNs, an appropriate mode of interpretation, allocation of female interpreters and the same interpreters with CALD mothers and clarity about interpreter role and cultural comfort. These strategies support the quality of communication and relationships in delivery of CFHN services and SNHV programs to CALD mothers with limited English proficiency.

Assessment of Excess Mortality in Italy in 2020–2021 as a Function of Selected Macro-Factors

Excess mortality (EM) can reliably capture the impact of a pandemic, this study aims at assessing the numerous factors associated with EM during the COVID-19 pandemic in Italy. Mortality records (ISTAT 2015-2021) aggregated in the 610 Italian Labour Market Areas (LMAs) were used to obtain the EM P-scores to associate EM with socioeconomic variables. A two-step analysis was implemented: (1) Functional representation of EM and clustering. (2) Distinct functional regression by cluster. The LMAs are divided into four clusters: 1 low EM; 2 moderate EM; 3 high EM; and 4 high EM-first wave. Low-Income showed a negative association with EM clusters 1 and 4. Population density and percentage of over 70 did not seem to affect EM significantly. Bed availability positively associates with EM during the first wave. The employment rate positively associates with EM during the first two waves, becoming negatively associated when the vaccination campaign began. The clustering shows diverse behaviours by geography and time, the impact of socioeconomic characteristics, and local governments and health services' responses. The LMAs allow to draw a clear picture of local characteristics associated with the spread of the virus. The employment rate trend confirmed that essential workers were at risk, especially during the first wave.

Can Smart Home Technologies Help Older Adults Manage Their Chronic Condition? A Systematic Literature Review.

The management of chronic diseases requires personalized healthcare that allows older adults to manage their diseases at home. This systematic review aimed to describe the smart home technologies used in the management of chronic diseases in older people. A systematic literature review was conducted on four databases and was reported following the PRISMA statement. Nineteen articles were included. The intervention technologies were classified into three groups: smart home, characterized by environmental sensors detecting motion, contact, light, temperature, and humidity; external memory aids, characterized by a partnership between mobile apps and smart home-based activity learning; and hybrid technology, with the integration of multiple technologies, such as devices installed at patients' homes and telemedicine. The health outcomes evaluated are vital signs, medication management, ADL-IADL, mobility, falls, and quality of life. Smart homes show great potential in the management of chronic diseases by favouring the control of exacerbations and increasing patients' safety by providing support in disease management, including support for cognitively impaired older people. The use of smart homes in the community could bring numerous benefits in terms of continuity of care, allowing the constant monitoring of older people by local and hospital health services.

Enhancing the local workforce outcomes for rural LICs: what is the role of the local health service in leading innovation in medical education?

It is now 25 years since the Riverland health service began its partnership with Flinders University to create the Parallel Rural Community Curriculum (PRCC) in rural South Australia. What started as a workforce program quickly became a successful disruptive technology for broader pedagogy in medical education. Despite more graduates of the PRCC choosing rural practice compared with their urban rotation-based colleagues, local medical workforce crises have persisted. In February 2021, the Local Health Network decided to implement the National Rural Generalist Pathway in its local region. It created the Riverland Academy of Clinical Excellence (RACE) as its vehicle for taking responsibility for training its own health professional workforce. RACE has increased the region's medical workforce by over 20% in 1 year. It gained accreditation as a provider of junior doctor and advanced skills training and recruited five interns (all of whom had previously undertaken 1-year rural clinical school placements), six second year and above doctors, and four advanced skills registrars. RACE has linked with GPEx Rural Generalist registrars and formed a Public Health Unit from those registrars who also have MPH qualifications. RACE and Flinders University are expanding teaching facilities in the region and enabling medical students to complete their MD in the region. Health services can facilitate vertical integration of rural medical education, supporting a full pathway to rural practice. Providing length of training contracts is proving attractive for junior doctors who are interested in establishing a rural home base for their training.

Condições de saúde e relação com os serviços de saúde na perspectiva de pessoas de quilombo

Abstract Objectives to analyze the perceptions of the Quilombola population of Caldeirão about their health conditions and to identify the possibilities and difficulties in the relationship with the health services in their territory. Method a qualitative, descriptive and exploratory study, carried out in the Quilombola Community from Caldeirão, Marajó Island, Pará, Brazil. Data production took place from March to April 2021, through individual semi-structured interviews with 30 residents, and thematic content analysis was applied. Results two empirical categories originated, revealing the Quilombola population’s perceptions about their health conditions and the health-disease process, the relationship that the community had with the local health services and the strengths and weaknesses inherent to this relationship. Conclusions and implications for practice Quilombola people’s perceptions showed a predominance of biomedical knowledge and a hospital-centric view, in addition to their weakened relationship with local health services. It is expected that the research results will encourage dialogue about these populations, considering that they represent a traditional group in a vulnerable situation. It is necessary to carry out further research to investigate/strengthen the Family Health Strategy role and unveil/problematize traditional knowledge in the face of biomedical knowledge hegemony in the scenario of Quilombola populations.

A framework for local-level economic evaluation to inform implementation decisions: health service interventions to prevent hospital-acquired hypoglycemia.

Published evidence on health service interventions should inform decision-making in local health services, but primary effectiveness studies and cost-effectiveness analyses are unlikely to reflect contexts other than those in which the evaluations were undertaken. A ten-step framework was developed and applied to use published evidence as the basis for local-level economic evaluations that estimate the expected costs and effects of new service intervention options in specific local contexts. Working with a multidisciplinary group of local clinicians, the framework was applied to evaluate intervention options for preventing hospital-acquired hypoglycemia. The framework included: clinical audit and analyses of local health systems data to understand the local context and estimate baseline event rates; pragmatic literature review to identify evidence on relevant intervention options; expert elicitation to adjust published intervention effect estimates to reflect the local context; and modeling to synthesize and calibrate data derived from the disparate data sources. From forty-seven studies identified in the literature review, the working group selected three interventions for evaluation. The local-level economic evaluation generated estimates of intervention costs and a range of cost, capacity and patient outcome-related consequences, which informed working group recommendations to implement two of the interventions. The applied framework for modeled local-level economic evaluation was valued by local stakeholders, in particular the structured, formal approach to identifying and interpreting published evidence alongside local data. Key methodological issues included the handling of alternative reported outcomes and the elicitation of the expected intervention effects in the local context.

Perceived benefits of digital health and social services among older adults: A population-based cross-sectional survey.

The aim of this study was to describe the benefits of digital health and social services perceived by older adults and to examine factors associated with perceiving these benefits. Several factors related to (a) sociodemographic characteristics, (b) area of residence, (c) physical, cognitive, psychological, and social functioning, and (d) Internet use, were examined. The present sample included 8019 respondents aged between 75 and 99 years. The inverse probability weighting method was used to correct for bias. Linear regression analyses were used to examine the associations. The ease of use of the services regardless of the time and location was perceived as the most beneficial. Convenient distance to local health or social services (parameter estimate = 0.15 [0.08-0.23]), good functional ability (PE = 0.08 [0.01-0.14]), good vision (PE = 0.15 [0.04-0.25]), ability to learn (PE = 0.05 [0.01-0.10]) and living with someone (PE = 0.08 [95% CI 0.04-0.13]) were associated with perceiving more benefits. In addition, access to the Internet (PE = 0.12 [0.06-0.19]) and independent use of the Internet (PE = 0.23 [0.17-0.29]) were associated with perceiving more benefits. Older adults who are healthier, have a social relationship in their everyday life or have easier access to traditional services seem to perceive more benefits from digital health and social services. Digital services should be developed to correspond with special needs caused by disadvantages in health and the social environment. To facilitate the use of digital health and social services, more efforts should be made to enhance older adults' perceptions of their benefits.

Homes and health in the Outer Hebrides: A social prescribing framework for addressing fuel poverty and the social determinants of health.

Health services are increasingly being reshaped with reference to addressing social determinants of health (SDoH), with social prescribing a prominent example. We examine a project in the Outer Hebrides that reshaped and widened the local health service, framing fuel poverty as a social determinant of health and mobilising a cross-sector support pathway to make meaningful and substantive improvements to islanders' living conditions. The 'Moving Together' project provided support to almost 200 households, ranging from giving advice on home energy, finances and other services, to improving the energy efficiency of their homes. In so doing, the project represents an expansion of the remit of social prescribing, in comparison with the majority of services currently provided under this banner, and can be seen as a more systemic approach that engages with the underlying conditions of a population's health. We present a framework through which to understand and shape initiatives to address fuel poverty through a social prescribing approach.

The processes and context of innovation in mental healthcare: Oxfordshire as a case study.

This article introduces the four following articles and the Classic Text. They describe the development of a sequence of innovative local mental health services in Oxfordshire, and explore the processes of innovation, led by the humane pragmatism practised by Dr Bertram Mandelbrote, who was Physician Superintendent at Littlemore Hospital in Oxford from 1959 to 1988. The articles describe emerging patterns of therapeutic community practice, and trace the events leading to a set of discrete service developments outside the hospital. Together, they suggest a positive role for chance in these developments, and a focus on the then prevailing national and local regulatory culture. The Classic Text by David Millard provides an overview of the origins of the therapeutic community movement.

Strategic Options and Performance of National Non-Governmental Organizations in the Health Sector in Kenya

Non-governmental organizations (NGOs) in the health sector help achieve national health objectives by delivering local health services. However, diminishing organization performance impacts their work and overall social impact. The purpose of this study was to assess the influence of strategic options on the performance of health NGOs in Kenya. The study was grounded on contingency theory and it utilized positivistic research philosophy and cross-sectional research design. The target population of the study was 564 chief executive officers (CEOs) and program directors of 282 national NGOs registered with the NGO coordination board. A sample size of 234 was selected using a random stratified sampling technique that involved 8 regions as strata. Data collection was through a structured questionnaire, while inferential (confirmatory factor analysis – CFA, and structural equation modelling – SEM) and descriptive statistical techniques (frequencies, percentages, means and standard deviations) were used for data analysis. SPSS Version 26 and Analysis of Moment Structures (AMOS) version 26 software were used for the analysis. The study findings established that strategic options have a significant positive influence on organization performance among national health NGOs in Kenya (r squared = 0.57, beta = 0.756, CR = 7.446, p < 0.05). The study concludes that selecting the strategic option that aligns with the organization’s context is essential for the organization performance of national health NGOs in Kenya. The study recommends that senior management of national health NGOs should critically consider the three generic strategies of cost leadership, focus and differentiation and select the one that aligns with their contexts to attain their organization performance objectives.

PENYULUHAN KEBERSIHAN DIRI SAAT MENSTRUASI PADA SISWI SMPN 3 KURIPAN LOMBOK BARAT

WHO said that adolescence is a period of rapid physical, cognitive, and psychosocial growth [2]. The physical growth of this teenager is marked by menstruation as the beginning of entering the puberty process [3]. Menstruation is regular bleeding from the uterus as a sign that the uterine organs are functioning properly. At this time the uterine blood vessels are very susceptible to infection and can cause diseases of the reproductive tract, urinary tract infections, and skin irritation, therefore cleanliness must be maintained [1,3]. Based on the results of research in 2019 at SMPN 3 Kuripan it was found that the level of knowledge of most of the VII and VIII grade students about personal hygiene during menstruation was still lacking [6]. Partners already have a UKS unit, but the students have never received information about personal hygiene during menstruation either from the local health service agency or the school. Based on the problems above, community service "Self-hygiene counseling during menstruation for students of SMPN 3 Kuripan" was carried out.
 This community service partner is the Principal of SMPN 3 Kuripan along with the student body and UKS officers. The distance between STIKes Yarsi Mataram and SMPN 3 Kuripan is 18.5 km. This community service uses the counseling method. Counseling begins with a pre-test and ends with a post-test. The measurement of students' knowledge level was done using a questionnaire. The counseling was carried out using a question and answer lecture method. 
 Counseling on personal hygiene during menstruation to students of SMPN 3 Kuripan was able to increase students' knowledge about menstruation and personal hygiene during menstruation from 78% with sufficient knowledge to 60.3% with good knowledge. It is hoped that schools will continue to collaborate with health education institutions or health service agencies in an effort to apply personal hygiene behavior during menstruation at SMPN 3 Kuripan. 
 Keywords: Personal hygiene, Menstruation, SMPN

Exploration of Perceived Determinants of Disordered Eating Behaviors in People with Mental Illness-A Qualitative Study.

Disordered eating behaviors are common in people with a serious mental illness (SMI) such as schizophrenia, bipolar disorder and major depressive disorder. This study employed qualitative exploration to understand the perceived determinants of eating behaviors, in particular those connected to disordered eating patterns, in people with SMI. In total, 28 semi-structured interviews were conducted in a consecutive sample of people with SMI under treatment in local mental health services in Australia (n = 12), Germany (n = 8) and Austria (n = 8) (mean age: 43.3 years, proportion of female participants: 61%, proportion of participants with ICD-10 F2 diagnosis: 57%, proportion of participants with ICD-10 F3 diagnosis: 64%). A thematic analysis approach, the framework method, was applied using MAXQDA 2020. Three main themes of determinants were derived: (i) impacts to daily functioning, (ii) disrupted physical hunger cues and (iii) emotional hunger. For impacts to daily functioning, the following themes emerged: lack of daily structure, time and drive, and difficulty planning ahead. For physical hunger, themes emerged for disrupted hunger and satiety cues, and mindless eating. All motives listed in the Palatable Eating Motives Scale (PEMS), i.e., coping, reward, social and conformity, have been reported by participants to be drivers for their emotional eating behavior. Subsequent reported behaviors were eating too much or too little, binge eating, night eating and food cravings. We conclude that interprofessional approaches should target daily functioning, disrupted physical hunger cues and emotional eating to reduce disordered eating behaviors in people with SMI.

Pilot randomised controlled trial of a remotely delivered online intervention for adolescent mental health problems in India: lessons learned about low acceptability and feasibility during the COVID-19 pandemic.

'POD Adventures' is a gamified problem-solving intervention delivered via smartphone app, and supported by non-specialist counsellors for a target population of secondary school students in India during the COVID-19 pandemic. To evaluate the feasibility and acceptability of undertaking a randomised controlled trial of POD Adventures when delivered online with telephone support from counsellors. We conducted a parallel, two-arm, individually randomised pilot-controlled trial with 11 secondary schools in Goa, India. Participants received either the POD Adventures intervention delivered over 4 weeks or usual care comprising information about local mental health services and national helplines. Outcomes were assessed at two timepoints: baseline and 6 weeks post-randomisation. Seventy-nine classroom sensitisation sessions reaching a total of 1575 students were conducted. Ninety-two self-initiated study referrals (5.8%) were received, but only 11 participants enrolled in the study. No intervention arm participants completed the intervention. Outcomes at 6 weeks were not available for intervention arm participants (n = 5), and only four control arm participants completed outcomes. No qualitative interviews or participant satisfaction measures were completed because participants could not be reached by the study team. Despite modifications to address barriers arising from COVID-19 restrictions, online delivery was not feasible in the study context. Low recruitment and missing feasibility and acceptability data make it difficult to draw conclusions about intervention engagement and indicative clinical outcomes. Prior findings showing high uptake, adherence and engagement with POD Adventures when delivered in a school-based context suggest that an online study and delivery posed the biggest barriers to study participation and engagement.

The effectiveness of a telemedical program for COVID-19 positive high-risk patients in domestic isolation

Abstract Background For almost two years, the Covid-19 pandemic has posed an enormous challenge to healthcare systems. Recurrent waves of disease brought the health systems to the limit of their resilience. Purpose The Tele-Covid telemedicine care program was installed in December 2020 to monitor high-risk patients in home isolation. Close monitoring allows early detection of disease deterioration and timely intensification of therapy, ideally avoiding intensive care. Conversely, if the course of the disease is stable, unnecessary hospitalisation can be avoided, thus reducing the burden on the healthcare system. Methods Patient acquisition was performed in collaboration with the local public health service and primary care physicians. Covid-19 positive high-risk patients (age >65 years and/or severe comorbidities) from the greater Innsbruck area were fitted with an ear sensor-based home monitoring system. The ear sensor measures SpO2, respiratory rate, body temperature and heart rate. The monitoring team (25 medical students supervised by 6 physicians) provided continuous monitoring of vital signs (24/7). After validation of the measurements, the collected parameters were evaluated using a specially developed risk score. If a defined risk score was exceeded, the patient was contacted by telephone. The combination of the clinical condition and the risk score determined the further course of action: (a) wait and see, (b) notify the primary care physician, or (c) refer for inpatient admission. The program was active from December 2020 to March 2022. In Summer 2021, the program was temporarily paused due to the epidemiological situation. Results A total of 132 patients (59.8% women) were monitored. The median age was 74 years (IQR: [67.3–80.8]). 91 patients (68.9%) had at least one relevant comorbidity. During the monitoring period, hospitalisation was required in 20 patients (15.2%), 3 of whom were transferred to the intensive care unit. Of the hospitalised patients, 3 (15%) patients died. During the same monitoring period, the Austrian Ministry of Health reported a mortality rate of 20.5% of all hospitalised patients in Austria aged 70–79 years. Subjectively, the patients felt safe due to close monitoring. Conclusion The Tele-Covid program is the successful implementation of a remote monitoring system in a pandemic situation. In the future, a broad application of the program is feasible. Funding Acknowledgement Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Funded by the Region of the Tyrol

Injection drug use in an affluent beachside community in Sydney: An exploratory qualitative study.

Social research on injection drug use has focussed on marginalised groups and communities, leaving a large gap in the field's understanding of how it is experienced in other settings, including in relatively affluent communities. This research is based on fieldwork and 18 in-depth qualitative interviews conducted in suburban beach-side communities in Sydney collectively known as the Northern Beaches. Participants did not experience stigmatisation by local health services as the norm or as a deterrent to access. Drug acquisition on the Northern Beaches occurred among closed networks of friends and acquaintances, and injecting use rarely occurred in public settings. Police contact was minimal, resulting in lower levels of criminalisation. Unlike many of the participants featured in the literature, our study participants grew up in middle and upper middle-class households, typically experiencing comfortable childhoods with little to no exposure to injection drug use. In this setting injection drug use operates covertly within the normal rhythms of middle-class life, hidden in amongst the bustle of cafés and shopping centres, and through the friendliness of neighbourhood driveway and doorstep interactions. Drug use is described as common in the area, with injecting behaviours stigmatised in ways that set it against the 'good' families and neighbourhoods of this beach-side enclave. In contrast to much of the Australian qualitative literature which frames injection drug use as a means of psychological relief or a subcultural norm, our participants described injecting as motivated by the desire to enhance pleasure and social connection.

SOSIALISASI MENJAGA KESEHATAN MATA UNTUK MENINGKATKAN PENGETAHUAN TENTANG KATARAK PADA LANSIA DI SARANGAN

The study aims to find out how well people understand cataract disease, while also inducing people to better protect their eyes from exposure to sunlight. This research uses qualitative methods with a literature descriptive approach with observation and interview techniques. The subject of the study is a citizen active on the coast of the lagoon at the age of 50 years and more. The results show that the residents of the nest tend not to know cataracts that care less about or care for eye health. The socialization absence of local health services is one factor that makes people less aware of cataracts, less concerned about their eye health

Improving evaluations and management of the appropriate application of modern anticancer drug therapy

Introduction. Evaluation and further improvement of the use of resources of the oncological service (including drug therapy) can lead to a subsequent qualitative gain in the availability of new types of effective antitumor technologies for a larger number of patients with severe oncological pathology. The experience of the Netherlands in managing the cancer care is useful for the local regional health services. Purpose of the study. Study of approaches to economically and clinically feasible use of anticancer therapy in real hospital practice. Material and methods. The scientific study was performed on the base of the search results in the databases of the Dutch digital educational platform, in the PubMed/Medline database and the Google search engine. The queries used the words: doelmatigheid, kanker, doelgerichte therapie, rationality, cancer, targeted therapy, etc. We analyzed the results published in 2021-2022. Results. There hаve bеen studied methods for increasing the expediency of clinical application of therapeutic regimens in oncology including a) rationalization of chemotherapy regimens; b) ensuring the mobility of patients receiving chemotherapy: chemotherapy on the principle of “connect and go” technology, self-administration of anticancer drugs; c) lean use of immunotherapy: drug therapy shelf life extension, vial count rounding and immunotherapy hybrid dosing; justified reduction in the duration of the course of immunotherapy. Limitations. In general, initiatives being put forward to improve the appropriateness of anticancer therapy should be previously tested in pilot projects. Conclusions. If positive opinions are received from expert institutions and regulatory authorities based on the results of pilot projects, innovative schemes for the appropriate use of drugs can be included in the list of services and programs reimbursed by the health insurer on an ongoing basis.

A realist approach to understanding alliancing within Local Government public health and social care service provision.

Within the current context of continued austerity and post-pandemic recovery, it remains important that Local Government services address the increasing needs of residents as cost-effectively as possible. Alliancing, whereby services work collaboratively focusing on the 'whole-system', has gained popularity as a tool with the potential to support collaborative whole systems approaches. This synthesis aims to identify how alliancing can be successfully operationalised in the commissioning of public health, wider National Health Service (NHS) and social care-related services. A realist literature synthesis was undertaken in order to identify underlying generative mechanisms associated with alliancing, the contextual conditions surrounding the implementation and operationalisation of the alliancing approach mechanisms, and the outcomes produced as a result. An iterative approach was taken, using a recent systematic review of the effectiveness of Alliancing, online database searches, and grey literature searches. Three mechanistic components were identified within the data as being core to the successful implementation of alliances in public health and social care-related services within Local Government: (i) Achieving a system-level approach; (ii) placing local populations at the heart of the system; and (iii) creating a cultural shift. Programme theories were postulated within these components. The alliancing approach offers an opportunity to achieve system-level change with the potential to benefit local populations. The realist synthesis approach taken within this study has provided insights into the necessary contextual and mechanistic factors of the Alliancing approach, above and beyond effectiveness outcomes typically collected through more conventional evaluation methodologies.

A value-based approach to prostate cancer image-guidance in a regional radiation therapy centre: a cost-minimisation analysis.

Usual practice for the insertion of prostate fiducial markers involves at least one week delay between insertion and simulation. An evidence-based practice change was implemented whereby fiducial marker insertion occurred on the same day as radiotherapy simulation. The aim of this study was to quantify the health service costs and clinical outcomes associated with this practice change. A cost-minimisation analysis was undertaken from the perspective of the local health service. A retrospective chart audit was conducted to collect data on 149 patients in the pre-implementation cohort and 138 patients in the post-implementation cohort. Associated costs with insertion and simulation were calculated and compared across the two cohorts; this included subsided travel costs for rural and remote patients. Fiducial marker positions on planning CT and first treatment CBCT were measured for all patients as the surrogate clinical outcome measure for oedema. The health service saved an average of AU$ 361 (CI $311 - $412) per patient after the practice change. There was no significant difference in fiducial marker position pre- and post- implementation (p<0.05). The practice change to perform insertion and radiotherapy simulation on the same day resulted in substantial savings to the health system, without compromising clinical outcomes. The decrease in number of required patient attendances is of real consequence to rural and remote populations. The practice change increases both the value and accessibility of best-practice health care to those most at risk of missing out.