Received Home Visits Research Articles

The Effects of a Disaster Preparedness app on Community Knowledge and Intentional Behavior in Hurricane Risk Areas.

With the advancement of technology, disaster preparedness related to hurricane hazards can be taught through an app. This study aimed to examine the effect of using an android-based disaster preparedness app on community knowledge and intentional behavior in hurricane risk areas. A quasi-experimental study was conducted from October to November, 2020 and a total of 80 respondents were recruited using cluster sampling. The treatment group was given the intervention in the form of the disaster preparedness app for 2 weeks. Meanwhile, the control group received home visits and conventional education about hurricane disasters twice throughout the same period. We then used a Wilcoxon Signed Rank test to analyze the pre-test and post-test and a Mann-Whitney U test to compare between treatment and control groups. After the implementation of the SiBen app, we found a statistically significant difference in knowledge between treatment and control groups (P < 0.003) and intentional behavior between treatment and control groups (P < 0.001). The findings indicate that the disaster preparedness app was an effective educational program able to improve the knowledge and intentional behavior among community members in a hurricane risk area.

New clinical prediction model for early recognition of sepsis in adult primary care patients: a prospective diagnostic cohort study of development and external validation.

BackgroundRecognising patients who need immediate hospital treatment for sepsis while simultaneously limiting unnecessary referrals is challenging for GPs.AimTo develop and validate a sepsis prediction model for adult patients in primary care.Design and settingThis was a prospective cohort study in four out-of-hours primary care services in the Netherlands, conducted between June 2018 and March 2020.MethodAdult patients who were acutely ill and received home visits were included. A total of nine clinical variables were selected as candidate predictors, next to the biomarkers C-reactive protein, procalcitonin, and lactate. The primary endpoint was sepsis within 72 hours of inclusion, as established by an expert panel. Multivariable logistic regression with backwards selection was used to design an optimal model with continuous clinical variables. The added value of the biomarkers was evaluated. Subsequently, a simple model using single cut-off points of continuous variables was developed and externally validated in two emergency department populations.ResultsA total of 357 patients were included with a median age of 80 years (interquartile range 71–86), of which 151 (42%) were diagnosed with sepsis. A model based on a simple count of one point for each of six variables (aged >65 years; temperature >38°C; systolic blood pressure ≤110 mmHg; heart rate >110/min; saturation ≤95%; and altered mental status) had good discrimination and calibration (C-statistic of 0.80 [95% confidence interval = 0.75 to 0.84]; Brier score 0.175). Biomarkers did not improve the performance of the model and were therefore not included. The model was robust during external validation.ConclusionBased on this study’s GP out-of-hours population, a simple model can accurately predict sepsis in acutely ill adult patients using readily available clinical parameters.

\u201cI had to change my attitude\u201d: narratives of most significant change explore the experience of universal home visits to pregnant women and their spouses in Bauchi State, Nigeria

BackgroundUniversal home visits to pregnant women and their spouses in Bauchi State, northern Nigeria, discussed local evidence about maternal and child health risks actionable by households. The expected results chain for improved health behaviours resulting from the visits was based on the CASCADA model, which includes Conscious knowledge, Attitudes, Subjective norms, intention to Change, Agency to change, Discussion of options, and Action to change. Previous quantitative analysis confirmed the impact of the visits on maternal and child outcomes. To explore the mechanisms of the quantitative improvements, we analysed participants’ narratives of changes in their lives they attributed to the visits.MethodsLocal researchers collected stories of change from 23 women and 21 men in households who had received home visits, from eight male and eight female home visitors, and from four government officers attached to the home visits program. We used a deductive thematic analysis based on the CASCADA results chain to analyze stories from women and men in households, and an inductive thematic approach to analyze stories from home visitors and government officials.ResultsThe stories from the visited women and men illustrated all steps in the CASCADA results chain. Almost all stories described increases in knowledge. Stories also described marked changes in attitudes and positive deviations from harmful subjective norms. Most stories recounted a change in behaviour attributed to the home visits, and many went on to mention a beneficial outcome of the behaviour change. Men, as well as women, described significant changes. The home visitors’ stories described increases in knowledge, increased self-confidence and status in the community, and, among women, financial empowerment.ConclusionsThe narratives of change gave insights into likely mechanisms of impact of the home visits, at least in the Bauchi setting. The compatibility of our findings with the CASCADA results chain supports the use of this model in designing and analysing similar interventions in other settings. The indication that the home visits changed male engagement has broader relevance and contributes to the ongoing debate about how to increase male involvement in reproductive health.

Perinatal Mental Health Support and Early Childhood Home Visitation During COVID-19.

COVID-19 has disrupted many of the preventive service sectors designed to serve mothers at-risk for developing postpartum depression, forcing a rapid transition to telehealth-based modes of delivery. The purpose of this study was to explore differences in early childhood home visitation service provision (enrollment and depression screening) among mothers receiving home visitation services prior to and after the onset of the COVID-19 pandemic. Additional factors related to receipt of virtual home visitation services, family risk factors, and the maternal depressive symptoms were examined. Linear and logistic regression were utilized to examine whether there were differences in family risk factors, the percentage of mothers being screened for depression and maternal depressive symptoms, and associations between risk factors and positive depression screenings, while accounting for clustering by site. Samples compared outcomes for families enrolled during the pre-pandemic period (defined as March 16th to July 27th, 2019, n = 4,743) and the post-pandemic period (defined as March 16th to July 27th, 2020, n = 2,049). Families enrolled after the onset of the pandemic were significantly less likely to be impacted by housing instability, have a child with a disability, or be involved with the military, but more likely to have a history of child abuse or neglect. Fewer mothers were screened for depression during the pandemic and maternal report of depressive symptoms decreased. Virtual home visitation is currently attracting some groups of mothers who are experiencing fewer stressors, which may place them at decreased risk for exhibiting depressive symptoms. There may be aspects of the virtual depression screening experience that make detection more difficult. As a result, many mothers at risk for maternal depression may not receive adequate prevention services.

Norwegian fathers' experiences with a home visiting program.

To explore fathers' experiences with a Norwegian home visiting program during the prenatal period and the first-year postpartum. Qualitative design with interpretive description (ID) as the methodological approach. Individual interviews with fathers (n=13) who received home visits by a public health nurse (PHN) within the New Families home visiting program. Interviews were guided by a semi-structured interview-guide, which contained open-ended questions encouraging informants to reflect on their experiences with home visits. The analysis of the data was informed by content analysis. Two main themes that reflect the fathers' experiences emerged: (1) The importance of being on their home ground captures the fathers' experience of receiving home visits and building a trusting relationship with the PHN. (2) Including fathers in the home visit represents their thoughts about the content and focus of the home visits. Fathers experienced the universal New Families home visiting program as an important contribution towards a more available and tailored service, with the home environment as a suitable arena for developing a trusting relationship with the PHN. However, the fathers often felt insufficiently included in the home visits, with only scant attention towards them as independent caregivers, their emotional reactions, roles, and family relationships. Pre-birth home visits might contribute to strengthening preparations for fatherhood and increase fathers' engagement in the Child Health Service.

Home Se-Cure: A Home Care Service for Cancer Patients during the COVID-19 Pandemic.

Cancer patients are exposed to a greater risk of COVID-19 infection, resulting in treatment delays and unnecessary hospitalizations. International authorities have suggested reducing visits to hospitals and guarantee continuity of care. We developed a home care project called Home Se-Cure (HSC) to guarantee the continuity of oral, intramuscular, and subcutaneous cancer therapy during COVID-19. The Home Se-Cure project included cancer patients living near Galliera Hospital. Patients received home visits by registered nurses (RNs), whoperformed blood tests and delivered cancer therapies. Patients were instructed to take drugs after blood test results and therapy confirmation by oncologists. Sixty-six patients decided to participate and 38 declined the service. A customer satisfaction questionnaire was administered to a subgroup of patients participating in the project. The most prevalent disease in the HSC group was prostate cancer. The mean age of the patients in HSC was 78.4 years and 68.9 in the decliner group. The majority of the HSC participants appreciated the project because they could stay at home (71%) and reduce the risk of COVID-19 contagion (67.7%). Compared to decliners, the time the study group saved was 2033 hours. HSC guaranteed the continuity of care during the COVID-19 pandemic by reducing the number of patients in the hospital and avoiding crowds in the waiting room.

Frequency of home visits where general practitioners are exposed to a problem different from that foreseen - a Swiss cross-sectional study.

When a home visit is considered, patients' suspected health problems are important for correct triage, the decision for or against the visit and allocation of the visit to a general practitioner (GP) or a nurse practitioner. Misjudgment might lead to suboptimal patient outcomes. We aimed to evaluate the accuracy of suspected health problems (based on pre-visit assessments) by comparing them with the actual health problems (post-visit assessments) and investigating associated factors. GPs of the Swiss Sentinel Surveillance Network (Sentinella) reported pre-visit and post-visit assessments and patient characteristics for up to 20 consecutive home visits, which they conducted in 2019. Using multivariable logistic regressions, we investigated associations between patient and clinical factors and unconfirmed suspected health problems from pre-visit assessments and unforeseen actual health problems from post-visit assessments. Overall, 114 GP practices participated. The GPs reported 1496 patient visits with a total of 1789 and 1762 health problems from pre-visit and post-visit assessments, respectively, that were included in the analysis. Musculoskeletal and circulatory problems were the most common in patients receiving home visits. The health problems from pre-visit and post-visit assessments were unconfirmed and unforeseen in15% and 13% of the cases, respectively. Older age (odds ratio [OR] 1.1 in 10-year steps; 95% confidence interval [95% CI] 1.0-1.3) and urgent visits (OR 1.7 compared with regular visits; 95% CI 1.1-2.6) showed a trend for more unforeseen health problems. When home visits were conducted, about one out of seven health problems from pre-visit and post-visit assessments were unconfirmed and unforeseen. Particularly when patients were older or visits were urgent, there were higher odds of unconfirmed and unforeseen health problems.These results should be considered when triaging patients.

Infant Injury Prevention Education for Pregnant Women Attending Antenatal Class: A Quasi-Experimental Study.

It is important to educate caregivers in order to prevent infant injuries. However, there have been few studies on the effects of education on pregnant women. This study aimed to evaluate the effects of injury prevention group education on this group. Study participants were recruited from a group of pregnant mothers attending an antenatal class in Tokyo. Participants were assigned to either the intervention or control group based on the month in which they attended the existing antenatal class. Both groups received a leaflet on injury prevention, but only the intervention group received an additional short one-shot lecture. The implementation of each of the nine safety practices was assessed during home visits after childbirth. Of the 131 study participants (56 in the control group and 75 in the intervention group), 106 (80.9%) received home visits after birth. Mothers in the intervention group implemented three practices significantly more than those in the control group: Keep soft objects away from the baby’s head (38.3% vs. 13.0%), Do not place your baby on a high surface (74.6% vs. 52.2%), and Use the baby carrier correctly (93.3% vs. 76.1%). In the future, we plan to follow up the participants to evaluate the program’s long-term effects, and to continue to improve the program.

COVID-19 Disrupted Provision and Utilization of Health and Nutrition Services in Uttar Pradesh, India: Insights from Service Providers, Household Phone Surveys, and Administrative Data.

ABSTRACTBackgroundThe coronavirus (COVID-19) pandemic may substantially affect health systems, but little primary evidence is available on disruption of health and nutrition services.ObjectivesThis study aimed to 1) determine the extent of disruption in provision and utilization of health and nutrition services induced by the pandemic in Uttar Pradesh, India; and 2) identify how adaptations were made to restore service provision in response to the pandemic.MethodsWe conducted longitudinal surveys with frontline workers (FLWs, n = 313) and mothers of children <2 y old (n = 659) in December 2019 (in-person) and July 2020 (by phone). We also interviewed block-level managers and obtained administrative data. We examined changes in service provision and utilization using Wilcoxon matched-pairs signed-rank tests.ResultsCompared with prepandemic, service provision reduced substantially during lockdown (83–98 percentage points, pp), except for home visits and take-home rations (∼30%). Most FLWs (68%–90%) restored service provision in July 2020, except for immunization and hot cooked meals (<10%). Administrative data showed similar patterns of disruption and restoration. FLW fears, increased workload, inadequate personal protective equipment (PPE), and manpower shortages challenged service provision. Key adaptations made to provide services were delivering services to beneficiary homes (∼40%–90%), social distancing (80%), and using PPE (40%–50%) and telephones for communication (∼20%). On the demand side, service utilization reduced substantially (40–80 pp) during the lockdown, but about half of mothers received home visits and food supplementation. Utilization for most services did not improve after the lockdown, bearing the challenges of limited travel (30%), nonavailability of services (26%), and fear of catching the virus when leaving the house (22%) or meeting service providers (14%).ConclusionsCOVID-19 disrupted the provision and use of health and nutrition services in Uttar Pradesh, India, despite adaptations to restore services. Strengthening logistical support, capacity enhancement, performance management, and demand creation are needed to improve service provision and utilization during and post-COVID-19.

Impacts of COVID-19 on Provision and Utilization of Health and Nutrition Services in Uttar Pradesh, India: Insights From Phone Surveys and Administrative Data

ObjectivesThe COVID-19 pandemic has significant potential implications for health systems, but little primary evidence is available on effects on health and nutrition services. We aimed to examine changes in service provision and utilization during the pandemic in Uttar Pradesh, India and identify positive adaptations to service delivery. MethodsWe conducted longitudinal surveys with frontline workers (FLW, n = 313) and mothers of children < 2 years (n = 659) in December 2019 (in-person) and July 2020 (by phone). We also interviewed block-level managers and obtained administrative data. We examined changes in service provision and utilization using Wilcoxon matched-pairs signed-rank tests. ResultsCompared to pre-pandemic, service provision reduced substantially during lockdown (83–98 percentage points, pp), except for home visits and take-home-rations (∼30%). Most FLWs (68–90%) resumed service provision in July 2020, except for immunization and hot-cooked meals (< 10%). Administrative data showed similar patterns of disruption and resumption. FLW fears, increased workload, inadequate personal protective equipment (PPE), and manpower shortages challenged service delivery. Key adaptations made to provide services included: delivering services to beneficiary homes (∼40–90%), social distancing (80%), using PPE (40–50%), and telephones for communication (∼20%). On the demand side, service utilization also reduced substantially (40–80pp) during the lockdown, but about half of mothers received home visits and food supplementation. Utilization for most services did not improve after the lockdown, bearing challenges of limited travel (30%), non-availability of services (26%), fear of catching virus when leaving the house (22%) or meeting service providers (14%). ConclusionsCOVID-19 affected the provision and use of health and nutrition services despite efforts at service restoration and adaptations. Strengthening logistics support, capacity enhancement, performance management, and demand creation are needed to improve service provision and utilization during and post-COVID-19. Funding SourcesBill & Melinda Gates Foundation through POSHAN, led by International Food Policy Research Institute; and Alive & Thrive, led by FHI Solutions.

Risk indicators in families with abused children and young people: scoping review

The promotion of rights and the protection of children implies involvement between state agencies and families in the evaluation processes, having developed in the child Welfare systems Internation...

Racial and Ethnic Differences in Depressive Profiles of Child Welfare-Involved Families Receiving Home Visitation Services.

Profiles of depressive symptoms were identified among Hispanic, Black, and White parents involved in the child welfare service system, including changes in symptoms over time. Participants (N=2,109) were parents receiving SafeCare, a home visitation intervention provided in a large, diverse child welfare system. Depressive symptoms were assessed with the Centers for Epidemiological Studies Depression Scale at baseline and at approximately every sixth home visit, up to a total of four times. Univariate tests examined the relationship between baseline symptoms, race-ethnicity, and service participation. Latent class growth analyses identified trajectories of depressive symptoms during participation in child welfare services. Participation in services was affected by depressive symptoms. Forty percent of parents did not remain long enough in the program to complete a second CES-D assessment, and those who reported more symptoms at baseline were significantly less likely to do so. Among parents who engaged in services, distinct profiles of depressive symptoms emerged that differed by race-ethnicity. For non-Hispanic Black parents, no changes in depressive symptoms over time were noted, regardless of level of severity at baseline. Parents with the highest levels of symptoms did not improve over time. Despite receipt of supportive and recovery-oriented services specifically focused on empowering child welfare-involved parents, many experienced elevated depressive symptoms. Integration of child welfare and community mental health systems may improve both service engagement and mental health among child welfare-involved families.

Effects of Health Promotion Program on Physical Fitness and Quality of Life of Elderly Women Receiving Home Visiting Health Care Services

Effects of Health Promotion Program on Physical Fitness and Quality of Life of Elderly Women Receiving Home Visiting Health Care Services

Utilizing Home Visits to Assess Social Determinants of Health During Family Medicine Residency.

Home visits can improve quality of care and health outcomes and provide a unique opportunity to learn more about patients' social context and assess patients' various social determinants of health (SDH). The objectives of this study were to assess patient self-reported SDH, resident reflections on patient social status, the utility of a SDH survey during home visits, and resident comfort levels addressing patient SDH. This was a mixed-methods pilot study utilizing patient self-reported data and open-ended reflection questions. Participants included adult patients aged more than 18 years from an urban safety-net clinic and family medicine residents who provide their care. We received forty-two surveys from 42 home visits. Most patients were female (61.9%) and African-American (45.2%), aged from 25 to 88 years (mean=60.24). Top patient-reported SDH include transportation, paying bills, and food insecurity. Common themes of resident responses included positive utility of the survey for assessing patient SDH; variation in comfort level when inquiring about patient SDH with positive influence from prior experience, assistance from colleagues, or prior good relations with patients; and expressed intention to include SDH assessment in future practice. Residents recognized the value of assessing SDH during home visits and expressed intent to include it in future practice. Thorough assessment of patient SDH may help to craft a more robust and standardized system to prioritize patients who would most benefit from receiving home visits.

Postpartum Depressive Symptoms and Screening Opportunities at Health Care Encounters.

Background: The American College of Obstetricians and Gynecologists recommends that providers screen women for depression at the postpartum checkup. If this checkup is the only screening opportunity, women who do not attend or whose depressive episode occurs at a different time may not be identified. We evaluated women's encounters with postpartum health care to identify screening opportunities for postpartum depressive symptoms (PDS). Materials and Methods: Pregnancy Risk Assessment Monitoring System (PRAMS) data for 2012-2015 from eight jurisdictions (n = 23,990, representing 1,939,865 women) were used to calculate percentage of women reporting attendance at postpartum checkups, well-child visits, or postpartum home visitation, by presence of PDS. PDS were assessed using a modified two-item Patient Health Questionnaire. Using Modified Poisson regression, adjusted prevalence ratios (aPR) and confidence intervals (95% CI) were calculated to compare health services by PDS, adjusted for sociodemographic characteristics. Results: Almost all women with or without PDS attended a postpartum checkup (85.1% and 91.4%; aPR: 0.96; 95% CI: 0.93-0.99) and their infants attended a well-child visit (97.3% and 98.9%; aPR: 0.99; 95% CI: 0.98-1.00); 13.7% and 10.9% received home visitation (aPR: 1.18; 95% CI: 1.02-1.35). Of women with PDS who missed their postpartum checkup, 13.5% reported infant attendance at well-child visits, and 2.0% received home visitation. Of women with PDS, 98.8%, 86.1%, and 11.2% attended 1, 2, or 3 health services. Conclusion: A large percentage of women with PDS may attend well-child visits or receive home visitation, representing opportunities for depression screening and referral for care.

Home visits by community health workers in rural South Africa have a limited, but important impact on maternal and child health in the first two years of life

BackgroundMore than 50% of Africa’s population lives in rural areas, which have few professional health workers. South Africa has adopted task shifting health care to Community Health Workers (CHWs) to achieve the Sustainable Development Goals, but little is known about CHWs’ efficacy in rural areas.MethodsIn this longitudinal prospective cohort study, almost all mothers giving birth (N = 470) in the Zithulele Hospital catchment area of the OR Tambo District were recruited and repeatedly assessed for 2 years after birth with 84.7–96% follow-up rates. During the cohort assessment we found that some mothers had received standard antenatal and HIV care (SC) (n = 313 mothers), while others had received SC, supplemented with home-visiting by CHWs before and after birth (HV) (n = 157 mothers, 37 CHWs). These visits were unrelated to the cohort study. Multiple linear and logistic regressions evaluated maternal comorbidities, maternal caretaking, and child development outcomes over time.ResultsCompared to mothers receiving SC, mothers who also received home visits by CHWs were more likely to attend the recommended four antenatal care visits, to exclusively breastfeed at 3 months, and were less likely to consult traditional healers at 3 months. Mothers in both groups were equally likely to secure the child grant, and infant growth and achievement of developmental milestones were similar over the first 2 years of life.ConclusionCHW home visits resulted in better maternal caretaking, but did not have direct benefits for infants in the domains assessed. The South African Government is planning broad implementation of CHW programmes, and this study examines a comprehensive, home-visiting model in a rural region.

Medication management through pharmacist‐provided home‐based services

AbstractIntroductionPharmacists play an important role in helping patients manage their medications across the continuum of care. Pharmacist home visits support continuity of care and provide a unique opportunity to identify medication‐related problems.ObjectiveThe primary objective of this study was to describe a cohort of patients who received home visits and the subsequent actions taken by the pharmacist towards the goal of optimizing medication regimens. The evolution of the service is also described.MethodsA retrospective chart review was used to gather demographic information. Clinical documentation was reviewed to gather information on medication problems identified by the pharmacist and recommendations made to prescribers. Institutional and city databases were used to collect data on readmissions and socioeconomic status, respectively. Descriptive statistics were used to analyze data.ResultsBetween February 2012 and December 2018, 485 home visits were conducted. Patients were taking a mean of 13 (SD ±5.5) medications; 1890 medication discrepancies were identified and 862 recommendations were made to prescribers. The relative risk reduction in readmissions for those patients who received a home visit was 6.6%. The average yearly income for citizens who live in neighborhoods where many of the home visits took place was $37 000. Details regarding the evolution of the home visit service were described.ConclusionsA large cohort of 485 home visits demonstrated that medications are often not being taken as prescribed, and that the pharmacist is in a unique position to educate patients and work with providers toward the goal of optimizing medication regimens and behaviors. This model of care, focused on high‐risk patients, has been sustained over 7 years. Ongoing efforts are underway to improve communication with prescribers, increase the referral to home visit conversion rate, and enhance longitudinal outcome tracking. Opportunity exists to further expand the service through partnerships with regional payers.

Use of health services by elderly people post-stroke: a randomized controlled trial.

To verify the relation of a nursing home care educational intervention in the use of health services by elderly people post-stroke. A randomized controlled trial conducted with 44 family caregivers of elderly people post-stroke. Data was collected between May/2016 and July/2018 in a hospital in the South of Brazil and at the participants' homes. The intervention group (IG=21) received home visits by nurses after hospital discharge. The control group (CG=23) had a conventional follow-up in a conventional health services. The Pearson's Chi-Square Test or the Fisher's Exact Test was performed for assessment of the outcome at 60 days and 1 year after discharge. Clinical Trial registration NCT02807012. There was a significant difference regarding the use of hospital outpatient service (IG=100%, CG=78.3%, p<0.050) 60 days after discharge. The great use of outpatient service by the IG demonstrates the effectiveness of nursing educational intervention focused on health care network after discharge.

Effect of continuation of antiplatelet therapy on survival in patients receiving physician home visits

BackgroundLittle is known about the effects of continued antiplatelet therapy in patients who receive physician home visits. This study aimed to evaluate the association of survival with the continuation of antiplatelet drugs in patients who received physician home visits.MethodsA retrospective cohort study was conducted in a teaching hospital in Toyota, Japan, from April 2015 to October 2018. All patients who received home visits by physicians from the department of Family Medicine of the hospital were included. The primary outcome was the difference in all-cause mortality between patients who were taking antiplatelet drugs and those who were not. The Cox proportional hazards model was applied, adjusted for the patient’s demographic features, activities of daily living, comorbidities, and primary disease requiring home care.ResultsA total of 815 patients were included, of whom 61 received antiplatelet drugs (n = 42 for aspirin, n = 17 for clopidogrel, and n = 8 for cilostazol) and 772 received no antiplatelet drugs. The mean age of the patients was 78.3 years, 409 (49.1%) were male, and 314 (37.7%) had end-stage cancer. During a median follow-up period of 120 days (interquartile range, 29–364), 54.3% of the patients died. Compared with patients not taking antiplatelet drugs, patients taking antiplatelet drugs had a better outcome (p < 0.01, log-rank test) and a significantly lower hazard ratio (0.34; 95% confidence interval, 0.17–0.65; Cox proportional hazards regression).ConclusionsThe continuous prescription of antiplatelet drugs may have beneficial effects on mortality among patients who receive physician home visits.

Impact of Health Literacy on Hypertension Control of Elderly Women Patients Receiving Home Visiting Health Care Services

Impact of Health Literacy on Hypertension Control of Elderly Women Patients Receiving Home Visiting Health Care Services