Making Home Visits Research Articles

Improving Asthma Outcomes in Minority Children: A Randomized, Controlled Trial of Parent Mentors

Because asthma disproportionately affects minorities, we evaluated the effects of parent mentors (PMs) on asthma outcomes in minority children. This randomized, controlled trial allocated minority asthmatic children to the PM intervention or traditional asthma care. Intervention families were assigned PMs (experienced parents of asthmatic children who received specialized training). PMs met monthly with children and families at community sites, phoned parents monthly, and made home visits. Ten asthma outcomes and costs were monitored for 1 year. Outcomes were examined by using both intention-to-treat analyses and stratified analyses for high participants (attending >or=25% of community meetings and completing >or=50% of PM phone interactions). Patients were randomly assigned to PMs (n = 112) or the control group (n = 108). In intention-to-treat analyses, intervention but not control children experienced significantly reduced rapid-breathing episodes, asthma exacerbations, and emergency department (ED) visits. High participants (but not controls or low participants) experienced significantly reduced wheezing, asthma exacerbations, and ED visits and improved parental efficacy in knowing when breathing problems are controllable at home. Mean reductions in missed parental work days were greater for high participants than controls. The average monthly cost per patient for the PM program was $60.42, and net savings of $46.16 for high participants. For asthmatic minority children, PMs can reduce wheezing, asthma exacerbations, ED visits, and missed parental work days while improving parental self-efficacy. These outcomes are achieved at a reasonable cost and with net cost savings for high participants. PMs may be a promising, cost-effective means for reducing childhood asthma disparities.

Who Cares? We Do and We Always Will

Who Cares? We Do and We Always Will

Use of the Public Health Nursing Bag in the Academic Setting

The nursing bag has been a vital tool for public and community health nurses since the early 1900s. However, the practice of utilizing the nursing bag has declined. This study sought to determine whether the practice of teaching students to use a public health nursing bag when making home visits should continue. Deans and directors of all schools of nursing with baccalaureate programs listed on the Commission on Collegiate Nursing Education Web site (n=437) were e-mailed an exploratory, descriptive self-report survey. Although 32% of responding schools continued to utilize a standard public health bag during home visits, the majority did not. Lack of use of the bags was primarily related to cost and the lack of research demonstrating its efficiency in enhancing the home visit and its value in promoting infection control. The researchers concluded that they would continue to teach the use of the public health nursing bag. It provides a receptacle for equipment and supplies, reinforces the need to be prepared for a variety of situations, and serves as a reminder that handwashing is a routine part of every client's care, regardless of the setting.

A method to determine spatial access to specialized palliative care services using GIS

BackgroundProviding palliative care is a growing priority for health service administrators worldwide as the populations of many nations continue to age rapidly. In many countries, palliative care services are presently inadequate and this problem will be exacerbated in the coming years. The provision of palliative care, moreover, has been piecemeal in many jurisdictions and there is little distinction made at present between levels of service provision. There is a pressing need to determine which populations do not enjoy access to specialized palliative care services in particular.MethodsCatchments around existing specialized palliative care services in the Canadian province of British Columbia were calculated based on real road travel time. Census block face population counts were linked to postal codes associated with road segments in order to determine the percentage of the total population more than one hour road travel time from specialized palliative care.ResultsWhilst 81% of the province's population resides within one hour from at least one specialized palliative care service, spatial access varies greatly by regional health authority. Based on the definition of specialized palliative care adopted for the study, the Northern Health Authority has, for instance, just two such service locations, and well over half of its population do not have reasonable spatial access to such care.ConclusionStrategic location analysis methods must be developed and used to accurately locate future palliative services in order to provide spatial access to the greatest number of people, and to ensure that limited health resources are allocated wisely. Improved spatial access has the potential to reduce travel-times for patients, for palliative care workers making home visits, and for travelling practitioners. These methods are particularly useful for health service planners – and provide a means to rationalize their decision-making. Moreover, they are extendable to a number of health service allocation problems.

The “Home Ranger” Rides Again! Making Home Visits Safer and More Effective

The “Home Ranger” Rides Again! Making Home Visits Safer and More Effective

Telepharmacy in Mental Health Outpatient Case Management

Objective: To describe the use of videophones to augment community-based case management medical services, particularly for in-home pharmacy consultations. Discussion: Despite recent technologic advances, telepharmacy image applications, in which a patient and a pharmacist can see each other, are rather limited in number and variety. However, videophone technology can fill this role well, given its portability, low cost, reliability, privacy, ease of use, and minimal technologic requirements. Videophone deployment in our psychiatry community case-management program has improved both medical and pharmacist access to a population of seriously mentally ill patients. Specifically, the ability to reach a hospital-based pharmacist through videophone, while making home visits, has allowed clarification of medication preparation and authorization of refills as well as improving treatment adherence. In short, despite minor technical limitations, videophones provide a simple and, in our case, reliable solution for in-home care. To date, both patients and case managers have responded with satisfaction to this treatment adjunct. Conclusions: Despite some limitations, videophone technology can increase patient access to health care, particularly pharmacy consultations. Expanded use of this technology would allow for systematic studies to support or refute the successes documented at our institution.

Downstaging for cervical cancer: A community-based study in the rural areas of Udupi district, Karnataka, India

The objective of this study is to determine the feasibility of utilizing trained auxiliary nurse midwives (ANMs) in downstaging for cancer cervix in a rural area. The study population included all married women in the age group of 35-59 years in two villages of the field practice area. It was a cross-sectional study. Two ANMs were trained in history taking, visual inspection of the cervix, using of speculum and collecting Papanicolaou smears. After training, they made home visits and identified women with gynaecological symptoms suggestive of cervical cancer. These women were asked to report to Rural Maternity and Child Welfare whom homes where the ANMs did a visual inspection of the cervix and made a cervical smear. A total of 1402 women were registered of the ANMs could identify 368 women (26%) with symptoms. Only 192 (52.2%) of these women reported for examination. Chronic cervicitis accounted for the largest proportion of the cases (44.8%). In all, three cases were diagnosed as suspected cases of cancer cervix. On cytology, three cases (1.5%) turned out to be malignant. When clinical findings of the ANM were compared with results of cytological examination, a high degree of sensitivity (78.4%) and positive predictive value (97.1%) were observed in diagnosing abnormal cytological findings. However, the sensitivity for detecting specific conditions was generally low. Sensitivity for detecting erosion was 45%, for chronic cervicitis 30%, and malignancies were totally missed. In conclusion, this study clearly shows that ANMs, if trained, would be capable of identifying symptomatic women, differentiating a normal cervix from an abnormal one and taking an adequate smear for cytological examination.

Intermittent preventive treatment of malaria in pregnancy: Evaluation of a new delivery approach and the policy implications for malaria control in Uganda

The impact of intermittent preventive treatment (IPT) on malaria in pregnancy is well known. In countries where this policy is implemented, poor access and low compliance to this intervention has been widely reported. A study was designed to assess a new approach to deliver IPT to pregnant women through traditional birth attendants (TBAs), drug-shop vendors (DSVs), community reproductive health workers (CRHWs) and adolescent peer mobilisers (APMs); and compared this approach with IPT at health units. We evaluated this approach to assess user perceptions, its acceptability and sustainability. Results show that the new approach increased access and compliance to IPT. Mean gestational age at first dose of IPT was 21.0 weeks with the community approaches versus 23.1 weeks at health units, P > 0.0001. Health units accessed a high proportion of adolescents, 28.4%, versus 25.0% at the new approaches, P < 0.03; most primigravidae, 23.6%, versus 20.0% at the new approaches, P < 0.04. The proportion of women who received two doses of SP was 67.5.2% with the new approaches versus 39.9% at health units, P < 0.0001. The new approach was associated with a three-fold increase in use of ITNs from 8.8% at baseline to 23.4%. The factors that most influenced acceptability and use of IPT were trusted and easy accessible resource persons, their ability to make home visits especially with CRHWs and APMs; the support of spouses. Another factor was the high awareness on dangers of malaria in pregnancy and the benefits of IPT created by the resource persons. The women perceived better health using the first dose of sulphadoxine–pyremethamine (SP) and this compelled them to go for the second dose. IPT with this approach was highly acceptable with 89.1% of women at the new approaches intending to use it for the next pregnancy, while 48.0% of them had recommended it to other women. We suggest a review of the current policy on malaria prevention in pregnancy to allow provision of IPT through community structures that are feasible, practical and acceptable.

Home Care: A Key to the Future of Family Medicine?

This essay is about my transition from family medicine residency into house call/home-based primary care practice. Though some aspects of making home visits have been difficult and uncomfortable, I have found a higher level of satisfaction and sense of purpose than I had as a resident in a traditional outpatient clinic. This enhanced satisfaction is, in part, due to my discovery that a lower-volume, time-intensive house call practice is a more appropriate way than the brief office visit to care for older patients who have multiple morbidities. In light of the aging population, advances in portable medical technology, and changes in Medicare reimbursement, home care could become a key to the future success and ongoing relevance of family medicine.

Mental Health Services for Homebound Elders From Home Health Nursing Agencies and Home Care Agencies

Mental Health Services for Homebound Elders From Home Health Nursing Agencies and Home Care Agencies

Preferences for place of care and place of death among informal caregivers of the terminally ill

(1) To determine informal caregivers perceptions about place of care and place of death; and (2) to identify variables associated with a home death among terminally ill individuals who received in-home support services in a publicly funded home care system. A total of 216 informal caregivers participated in a bereavement interview. Data collection included care recipient and informal caregiver characteristics, the use of and satisfaction with community services, and preferences about place of death. Most caregivers reported that they and the care recipient had a preferred place of death (77 and 68%, respectively) with over 63% reporting home as the preferred place of death. Caregivers had a greater preference for an institutional death (14%) than care recipients (4.7%). While 30% of care recipients did not die in their preferred location, most caregivers (92%) felt, in retrospect, that where the care recipient died was the appropriate place of death. Most caregivers reported being satisfied with the care that was provided. The odds of dying at home were greater when the care recipient stated a preference for place of death (OR: 2.92; 95% CI: 1.25, 6.85), and the family physician made home visits during the care recipients last month of life (Univariate odds ratios (OR): 4.42; 95% CI: 1.46, 13.36). The ethic of self-control and choice for the care recipient must be balanced with consideration for the well being of the informal caregiver and responsiveness of the community service system.

Vivencias, expectativas y demandas de cuidadoras informales de pacientes en procesos de enfermedad de larga duración

Objectives To determine informal caregivers’ opinions and experiences of providing care and their expectations and needs concerning professional nurses who make home visits. Method A qualitative study was carried out in 1999 in the Autonomous Community of Andalusia. Participants: Female homecarers of terminally-ill patients with cancer or AIDS and elderly persons with dementia. Strategies for obtaining information: indepth interviews and discussion groups. The content analysis used Virginia Henderson's model as a framework. Results In the caregivers’ statements, six types of care that they carried out related to hygiene, food, excretion, mobility, wound care, and medicine administration were identified. The caregivers were satisfied with professional nurses’ technical and communication skills. However, their satisfaction with the number of visits and their own training was low. They requested training courses in specific skills (wound care, diet) and in prevention and health (postural changes, mobility exercises). Conclusions The tasks carried out by the caregivers are physically and emotionally demanding, and caregivers frequently lack the required technical skills. To improve home care services, visits should be more frequent and caregivers’ training should be up-graded.

Reduced Incidence of Neonatal Morbidities: Effect of Home-Based Neonatal Care in Rural Gadchiroli, India

We found a high burden of morbidities in a cohort of neonates observed in rural Gadchiroli, India. We hypothesised that interventions would reduce the incidence of neonatal morbidities, including the seasonal increase observed in many of them. This article reports the effect of home-based neonatal care on neonatal morbidities in the intervention arm of the field trial by comparing the early vs late periods, and the possible explanation for this effect. During 3 years (1995 to 1998), trained village-health-workers (VHWs) in 39 villages prospectively collected data by making home visits during pregnancy, home-delivery and during neonatal period. We estimated the incidence and burden of neonatal morbidities over the 3 years from these data. In the first year, the VHWs made home visits only to observe. From the second year, they assisted mothers in neonatal care and managed the sick neonates at home. Health education of mothers and family members, individually and in group, was added in the third year. We measured the coverage of interventions over the 3 years and evaluated maternal knowledge and practices on 21 indicators in the third year. The effect on 17 morbidities was estimated by comparing the incidence in the first year with the third year. The VHWs observed 763 neonates in the first year, 685 in the second and 913 in the third year. The change in the percent incidence of morbidities was (i) infections, from 61.6 to 27.5 (-55%; p<0.001), (ii) care-related morbidities (asphyxia, hypothermia, feeding problems) from 48.2 to 26.3 (-45%; p<0.001); (iii) low birth weight from 41.9 to 35.2 (-16%; p<0.05); (iv) preterm birth and congenital anomalies remained unchanged. The mean number of morbidities/100 neonates in the 3 years was 228, 170 and 115 (a reduction of 49.6%; p<0.001). These reductions accompanied an increasing percent score of interventions during 3 years: 37.9, 58.4 and 81.3, thus showing a dose-response relationship. In the third year, the proportion of correct maternal knowledge was 78.7% and behaviours was 69.7%. The significant seasonal increase earlier observed in the incidence of five morbidities reduced in the third year. The home-based care and health education reduced the incidence and burden of neonatal morbidities by nearly half. The effect was broad, but was especially pronounced on infections, care-related morbidities and on the seasonal increase in morbidities.

Pharmacist and physician collaboration in the patient's home.

To review the historical perspective and current incidence of home visits by physicians and pharmacists, discuss the concept of pharmacists providing care "incident-to" the physician, and introduce a new endeavor of collaborative, incident-to home visits by a pharmacist and physician. A literature search was performed using MEDLINE (1966-May 2003). The search terms used were home visit, house call, incident-to, collaborative care, physician, and pharmacist. All pertinent articles were evaluated. Home visits were once considered a hallmark of patient care, but have decreased to an average of 0.4 home visits per week for primary care physicians. Home visits are essential for patients unable to commute to the office due to a disability or illness. However, home visits also allow the physician to determine how conditions affect a patient's everyday life, in addition to assessing the living environment. Minimal documented evidence exists of pharmacists making home visits and no documented evidence exists of pharmacists and physicians collaboratively making home visits. The pharmacist complements the value of the visit by assessing medication appropriateness as well as medication administration, storage, accessibility, and adherence. Current practice styles often compromise services that were once paramount to patient care, as evidenced by a decline in home visits. Recent trends in health care attempt to compensate for high-volume practices and managed care restrictions. A collaborative relationship between a pharmacist and physician with visits into the patient's home is a movement toward improved continuity of care.

Utilizing parental observations and computer technology in developing a child‐screening instrument in Singapore

It is widely known that parent–teacher partnerships are vital to children's progress in their development and learning in schools. These partnerships involve parent–teacher conferences, parents helping in the classroom, teachers making home visits and parent education seminars. However, partnerships rarely extend to having parents involved in the assessment process of their children in a significant way. In Singapore, opportunities for parents to be involved in the assessment process exist but only when invited by a professional, and this is only to a limited extent. Routinely, when professionals assess a child, parents are asked for their observations of their progress at home. However, such information gathered from parents is informal, unorganized and used on a supplementary basis. Hence, it was the purpose of this research project to develop a child‐screening instrument that utilized observations of Singaporean parents in an organized fashion by the help of computer technology. With this, it is hoped that the involvement in the assessment process will educate and empower parents to make decisions and play a more active role in the identification of their children's learning needs. This paper reports the use of parents' observations of their children across five developmental domains in the device of a computer‐based child‐screening questionnaire in Singapore. The Developmental Screening Questionnaire (DSQ) is developed as an initial screening tool to detect potentially at‐risk children within the age range of one to six years. This paper also describes the validity and utility of the instrument, making use of computer technology in the test administration process.

District nurses are ‘short changed ’ by pay grades

Agenda for Change does not recognise the complex nature of making home visits

Perception of risk by administrators and home health aides.

Increasing numbers of persons over 65, decreased length of hospital stay, and need for chronic (custodial) health care have placed a strain on home health care agencies. The second largest group of persons providing care is home health aides (HHAs), who perform in-home, nonskilled, technical procedures with little or no on-site supervision. They are generally high school graduates or hold GEDs. The purpose of this study was to compare home health care administrators' (HHCAs) and HHAs' perceptions of risk involved in home visiting. Given HHAs' educational preparation and limited supervision, they are basically on their own for work performed. Although agencies provide orientation sessions for new workers, periodic in-services often relate to tasks and competency testing and little attention directed toward protecting the self-specifically, strategies to decrease personal risk. In order to determine to what extent HHCAs and HHAs perceive risk, the Home Health Care Perception of Risk Questionnaire, a self-report measure, was administered to a national random sample of 93 HHCAs and 227 HHAs. Findings suggest that these groups differ in perception of risk and level of agency support in making home visits. Suggestions for meeting the needs of this HHA provider group are offered.

Student Interest in Geriatric Medicine

The aging of the population has increased concern about how to motivate health profession students to choose careers in geriatric medicine. A cross-sectional survey of first-year medical (n = 83), nursing (n = 131) and pharmacy students (n = 127) was used to explore variation in students' interest in working in the field of geriatrics. One-third of all the students said they were at least somewhat interested in the field, with pharmacy students having the most interest. Significant determinants of student interest in geriatric medicine included having a previous course in aging, student age, and interest in making home visits.

Physician-patient congruence regarding medication regimens.

To characterize the degree of disparity between physicians' perceptions of older patients' medication regimen and patients' perceptions of their regimen. Prospective observational. Physicians and patients were blinded at index visit; after, trained medical students made home visits, collecting information about medications that was compared with physician questionnaires. Community family medicine residency program. Patients age 65 and older presenting for routine visit, taking at least four prescription medications, and seen by index physician three or more times in the past year. Physicians were family medicine faculty and second- and third-year residents. Fifty physician-patient pairs were analyzed. Average age was 75 (standard deviation (SD) +/-5.5); patients averaged 7.0 prescription medications (range 3-17, SD +/-2.89). Three hundred seventy-five prescription medications were identified; the most commonly prescribed were antihypertensives (134/375; 36%). Congruence, defined as agreement between physician and patient regarding all prescription medications, dosages, and frequency, averaged 70% for faculty (range 53-89%) and 58% for residents (range 41-81%) (P = .08). Fourteen percent (7/50) demonstrated complete congruence; 74% (37/50) had at least one medication that either the physician was unaware the patient was taking or the physician thought the patient was taking but that was not part of the patient's regimen; 12% (6/50) had dose and/or frequency discrepancies. This study demonstrates significant disparity in a population where it is crucial for healthcare providers and patients to be in close agreement about intended medication regimens.

Schools’ Efforts to Involve Latino Families of Students with Visual Impairments

This study found that Latino families thought that schools did well in providing information about their children with visual impairments and inviting families to school programs and poorly on encouraging families to volunteer at school, providing assistance to families in helping their children with self-care activities, and making home visits. The families’ ratings varied by the children's ages and reading modes, by the length of time the families had lived in the United States, and the languages the families spoke.