Quality of life of individuals with heart failure: a randomized trial of the effectiveness of two models of hospital-to-home transition

BACKGROUND: The growing number of patients with congestive heart failure has increased both the pressure on hospital resources and the need for community management of the condition. Improving hospital-to-home transition for this population is a logical step in responding to current practice guidelines' recommendations for coordination and education. Positive outcomes have been reported from trials evaluating multiple interventions, enhanced hospital discharge, and follow-up through the addition of a case management role. The question remains if similar gains could be achieved working with usual hospital and community nurses. METHODS: A 12-week, prospective, randomized controlled trial was conducted of the effect of transitional care on health-related quality of life (disease-specific and generic measures), rates of readmission, and emergency room use. The nurse-led intervention focused on the transition from hospital-to-home and supportive care for self-management 2 weeks after hospital discharge. RESULTS: At 6 weeks after hospital discharge, the overall Minnesota Living with Heart Failure Questionnaire (MLHFQ) score was better among the Transitional Care patients (27.2 +/- 19.1 SD) than among the Usual Care patients (37.5 +/- 20.3 SD; P = 0.002). Similar results were found at 12 weeks postdischarge for the overall MLHFQ and at 6- and 12-weeks postdischarge for the MLHFQ's Physical Dimension and Emotional Dimension subscales. Differences in generic quality life, as assessed by the SF-36 Physical component, Mental Component, and General Health subscales, were not significantly different between the Transition and Usual Care groups. At 12 weeks postdischarge, 31% of the Usual Care patients had been readmitted compared with 23% of the Transitional Care patients (P = 0.26), and 46% of the Usual Care group visited the emergency department compared with 29% in the Transitional Care group (chi2 = 4.86, df 1, P = 0.03). CONCLUSIONS: There were significant improvements in health-related quality of life (HRQL) associated with Transitional Care and less use of emergency rooms.     

Supportive care for older people with frailty in hospital: An integrative review

BackgroundGrowing numbers of older people living with frailty and chronic health conditions are being referred to hospitals with acute care needs. Supportive care is a potentially highly relevant and clinically important approach which could bridge the practice gap between curative models of care and palliative care. However, future interventions need to be informed and underpinned by existing knowledge of supportive care.AimTo identify and build upon existing theories and evidence about supportive care, specifically in relation to the hospital care of older people with frailty, to inform future interventions and their evaluation.DesignAn integrative review was used to identify and integrate theory and evidence. Electronic databases (Cochrane Medline, EMBASE and CIHAHL) were searched using the key term ‘supportive care’. Screening identified studies employing qualitative and/or quantitative methods published between January 1990 and December 2015. Citation searches, reference checking and searches of the grey literature were also undertaken.Data sourcesLiterature searches identified 2733 articles. After screening, and applying eligibility criteria based on relevance to the research question, studies were subject to methodological quality appraisal. Findings from included articles (n = 52) were integrated using synthesis of themes.ResultsRelevant evidence was identified across different research literatures, on clinical conditions and contexts. Seven distinct themes of the synthesis were identified, these were: Ensuring fundamental aspects of care are met, Communicating and connecting with the patient, Carer and family engagement, Building up a picture of the person and their circumstances, Decisions and advice about best care for the person, Enabling self-help and connection to wider support, and Supporting patients through transitions in care. A tentative integrative model of supportive care for frail older people is developed from the findings.ConclusionThe findings and model developed here will inform future interventions and can help staff and hospital managers to develop appropriate strategies, staff training and resource allocation models to improve the quality of health care for older people.     

Innovative care models across settings: Providing nursing care to older adults

The aging demographic shift occurring world-wide is creating an opportunity for innovative care models to address the burgeoning care needs of the expanding population of older adults. Nursing and advanced practice nursing as well as interprofessional models past and present hold insights into how to meet the needs of older adults across the continuum of care. A review of past and present models of care is provided. These models across settings emphasize maximizing the role of nurses and advanced practice nurses. The models reviewed include: On LOK and Programs of All-inclusive Care for the Elderly (PACE); Community Aging in Place, Advancing Better Living for Elders (CAPABLE); Teaching Nursing Homes; Interventions to Reduce Acute Care Transfers (INTERACT); Missouri Quality Initiative (MOQI); Evercare/Optum; Nurses Improving Care for Health System Elders (NICHE); Acute Care for the Elderly Unit (ACE Unit); Hospital Elder Life Program (HELP); Age-Friendly Health Systems; and the Transitional Care Model. Each model emphasizes education on the special needs of older adults, providing easy access to evidence-based tools and interventions, as well as strong interprofessional collaboration. Sustainable evidence-based nursing and interprofessional innovations are present across health care settings from the community, long-term care and the acute care setting to address the complex needs of older adults.     

Strategies to support transitions from hospital to home for children with medical complexity: A scoping review

BackgroundChildren with medical complexity constitute a small but resource-intensive subgroup of children with special health care needs. Their medical fragility and resource-intensive needs put them at greater risk for inadequate transitions from hospital to home-based care, and subsequent adverse outcomes and hospital re-admissions.ObjectiveThis scoping literature review was conducted to map empirically researched interventions, frameworks, programs or models that could inform or support the transition from hospital to home for children with medical complexity.DesignWe conducted a scoping review using the methodology outlined by the Joanna Briggs Institute.Data sourcesIn consultation with an experienced librarian, we searched PubMed, EMBASE and CINAHL for English-language articles published from the date of origin to February 2016. We also hand-searched four high impact journals and searched the reference lists of relevant articles.Review methodsTwo reviewers independently screened the literature results according to inclusion criteria. Empirically designed studies that targeted children <18 years old who were specifically defined as medically complex or fragile and transitioning from acute care to home were included. Data were extracted using a predefined tool. Quality appraisal of the articles was conducted using the mixed methods appraisal tool (MMAT). Thematic analysis was carried out to identify existing patterns or trends in the included studies.ResultsOf the 2088 abstracts retrieved, 14 studies met the inclusion criteria. Following analysis, we identified three major categories of interventions: Comprehensive care plans (n = 3), Complex Care Programs (n = 8) and Integrated delivery models (n = 3). The overall quality of included studies was moderate, with 21% (n = 3) scoring 0.25, 29% (n = 4) scoring 0.50, 43% (n = 6) scoring 0.75, and 7% (n = 1) scoring 1.0.ConclusionsIn the absence of evidence-based guidelines to ensure adequate transitions from hospital to home for children with medical complexity, identification of potential models to support this transition is imperative. We identified interventions, frameworks, models and programs in the literature that might inform the development of such guidelines; however, there is a need for consensus around the definition for children with medical complexity and the limited number of these studies and lack of high quality of evidence signals the need for further research to improve the transition from hospital to home and ultimately, improve patient and family outcomes.     

Heutagogy: A self-determined learning approach for Midwifery Continuity of Care experiences

AimThe aim of this discussion paper is to discuss learning theories in midwifery education, as related to the Midwifery Continuity of Care Experience and to propose an original conceptual framework based on Heutagogy.BackgroundMidwifery education curricula include a number of midwifery practice experiences. One of the requirements is for students to provide Midwifery Continuity of Care. To achieve these experiences, students in Australia are required to provide care to at least ten (10) women through pregnancy, be on call for the woman’s birth and provide at least two visits post-birth. Continuity of care experiences appear to have been incorporated without sufficient consideration of the educational purpose of the experience, or how the experiences contribute to the development of the profession. Although we do know midwifery practice embraces woman-centred care as its philosophical underpinning, a learning approach that is congruent with this philosophy needs to be clearly articulated.DesignA discussion paper that compared and contrasted learning theories to align with Midwifery Continuity of Care experiences.MethodsA review of the literature on learning theories was conducted before comparing and contrasting the theories to arrive at a conceptual framework focused on learning theory and its application to the Midwifery Continuity of Care Experience.ResultsHeutagogy provides a potentially congruent educational learning approach to underpin the continuity of care experiences, in comparison to traditional learning theories of pedagogy and andragogy. With a paucity of research in the application of heutagogy to midwifery education, it’s conceptual underpinnings and the possible application to the Continuity of Care Experience, this paper explores the possible theoretical applications of heutagogy to midwifery education.ConclusionAs a learning theory, heutagogy is well - aligned with woman-centred care. Heutagogy provides a theoretical framework suitable to underpin strategies, including the conceptual framework proposed, that may assist in empowering students to participate in their own education by giving them the ability to be self-determined in both their approach to learning and to evaluate their own learning needs.     

Prehabilitation. An Interdisciplinary Patient-Centric Conceptual Framework

ObjectivesTo review the recent literature around patient-centric prehabilitation in oncology patients and propose a conceptual framework to inform development of interdisciplinary prehabilitation services leading to focused, individualized prehabilitation interventions.Data SourcesA review of recent peer-reviewed literature, national guidance, and government strategy on prehabilitation in oncology patients.ConclusionPatient- centric prehabilitation is key to improving patient's experiences of cancer throughout the cancer journey while improving population health and reducing financial costs. Successful personalized prehabilitation interventions are comprised of an interplay between individual interdisciplinary roles, as illustrated in the conceptual framework. The role of the nurse underpins this whole process in patient screening, assessment, implementation of the intervention, and patient reassessment, ensuring care is dynamic and tailored to patient need.Implications for Nursing PracticeThe review has discussed the key role that nurses play in the process but warrants more research in the area. The conceptual framework provides a basis to develop interdisciplinary prehabilitation services underpinned by the nurse's role. The review advocates the use of educational interventions to equip all health professionals with prehabilitation knowledge to enable interdisciplinary prehabilitation services to be developed.     

Concepts and Definitions for “Actively Dying,” “End of Life,” “Terminally Ill,” “Terminal Care,” and “Transition of Care”: A Systematic Review

ContextThe terms “actively dying,” “end of life,” “terminally ill,” “terminal care,” and “transition of care” are commonly used but rarely and inconsistently defined.ObjectivesWe conducted a systematic review to examine the concepts and definitions for these terms.MethodsWe searched MEDLINE, PsycINFO, Embase, and CINAHL for published peer-reviewed articles from 1948 to 2012 that conceptualized, defined, or examined these terms. Two researchers independently reviewed each citation for inclusion and then extracted the concepts/definitions when available. We also searched 10 dictionaries, four palliative care textbooks, and 13 organization Web sites, including the U.S. Federal Code.ResultsOne of 16, three of 134, three of 44, two of 93, and four of 17 articles defined or conceptualized actively dying, end of life, terminally ill, terminal care, and transition of care, respectively. Actively dying was defined as “hours or days of survival.” We identified two key defining features for end of life, terminally ill, and terminal care: life-limiting disease with irreversible decline and expected survival in terms of months or less. Transition of care was discussed in relation to changes in 1) place of care (e.g., hospital to home), 2) level of professions providing the care (e.g., acute care to hospice), and 3) goals of care (e.g., curative to palliative). Definitions for these five terms were rarely found in dictionaries, textbooks, and organizational Web sites. However, when available, the definitions were generally consistent with the concepts discussed previously.ConclusionWe identified unifying concepts for five commonly used terms in palliative care and developed a preliminary conceptual framework toward building standardized definitions.     

Person-Centered Rehabilitation Model: Framing the Concept and Practice of Person-Centered Adult Physical Rehabilitation Based on a Scoping Review and Thematic Analysis of the Literature

ObjectiveTo develop a cross-professional model framing the concept and practice of person-centered rehabilitation (PCR) in adult populations, based on a scoping review and thematic analysis of the literature.Data SourcesKey databases (PubMed, Scopus, Cumulative Index to Nursing and Allied Health), snowballing searches, and experts’ consultation were the data sources for English-language empirical or conceptual articles published from January 2007-February 2020.Study SelectionTwo independent reviewers selected adult-based articles addressing at least 1 of the 6 categories of PCR-related content, a priori specified in the published review protocol. From 6527 unique references, 147 were finally included in the analysis. Of those, 26 were exclusively conceptual articles.Data ExtractionTwo independent reviewers extracted textual data on what PCR entails conceptually or as a practice. No quality appraisals were performed as is typical in scoping reviews.Data SynthesisA thematic analysis produced thematic categories that were combined into an emergent model (the PCR Model), which was reviewed by 5 external experts. PCR was framed as a way of thinking about and providing rehabilitation services “with” the person. PCR is embedded in rehabilitation structures and practice across 3 levels: (1) the person-professional dyad; (2) the microsystem level (typically an interprofessional team, involving significant others); and (3) a macrosystem level (organization within which rehabilitation is delivered). Thematic categories are articulated within each level, detailing both the conceptual and practice attributes of PCR.ConclusionsThe PCR Model can inform both clinical and service organization practices. The PCR Model may benefit from further developments including obtaining wider stakeholders’ input, determining relevance in different cultural and linguistic groups, and further operationalization and testing in implementation projects.     

A transition care coordinator model reduces hospital readmissions and costs

BackgroundThe optimal structure and intensity of interventions to reduce hospital readmission remains uncertain, due in part to lack of head-to-head comparison. To address this gap, we evaluated two forms of an evidence-based, multi-component transitional care intervention.MethodsA quasi-experimental evaluation design compared outcomes of Transition Care Coordinator (TCC) Care to Usual Care, while controlling for sociodemographic characteristics, comorbidities, readmission risk, and administrative factors. The study was conducted between January 1, 2013 and April 30, 2015 as a quality improvement initiative. Eligible adults (N = 7038) hospitalized with pneumonia, congestive heart failure, or chronic obstructive pulmonary disease were identified for program evaluation via an electronic health record algorithm. Nurse TCCs provided either a full intervention (delivered in-hospital and by post-discharge phone call) or a partial intervention (phone call only).ResultsA total of 762 hospitalizations with TCC Care (460 full intervention and 302 partial intervention) and 6276 with Usual Care was examined. In multivariable models, hospitalizations with TCC Care had significantly lower odds of readmission at 30 days (OR = 0.512, 95% CI 0.392 to 0.668) and 90 days (OR = 0.591, 95% CI 0.483 to 0.723). Adjusted costs were significantly lower at 30 days (difference = $3969, 95% CI $5099 to $2691) and 90 days (difference = $5684, 95% CI $7602 to $3627). The effect was similar whether patients received the full or partial intervention.ConclusionAn evidence-based multi-component intervention delivered by nurse TCCs reduced 30- and 90-day readmissions and associated health care costs. Lower intensity interventions delivered by telephone after discharge may have similar effectiveness to in-hospital programs.     

The intersection of disability and healthcare disparities: a conceptual framework

Abstract

Purpose: This article provides a conceptual framework for understanding healthcare disparities experienced by individuals with disabilities. While health disparities are the result of factors deeply rooted in culture, life style, socioeconomic status, and accessibility of resources, healthcare disparities are a subset of health disparities that reflect differences in access to and quality of healthcare and can be viewed as the inability of the healthcare system to adequately address the needs of specific population groups. Methods: This article uses a narrative method to identify and critique the main conceptual frameworks that have been used in analyzing disparities in healthcare access and quality, and evaluating those frameworks in the context of healthcare for individuals with disabilities. Specific models that are examined include the Aday and Anderson Model, the Grossman Utility Model, the Institute of Medicine (IOM)’s models of Access to Healthcare Services and Healthcare Disparities, and the Cultural Competency model. Results: While existing frameworks advance understandings of disparities in healthcare access and quality, they fall short when applied to individuals with disabilities. Specific deficits include a lack of attention to cultural and contextual factors (Aday and Andersen framework), unrealistic assumptions regarding equal access to resources (Grossman’s utility model), lack of recognition or inclusion of concepts of structural accessibility (IOM model of Healthcare Disparities) and exclusive emphasis on supply side of the healthcare equation to improve healthcare disparities (Cultural Competency model). In response to identified gaps in the literature and short-comings of current conceptualizations, an integrated model of disability and healthcare disparities is put forth. Conclusion: We analyzed models of access to care and disparities in healthcare to be able to have an integrated and cohesive conceptual framework that could potentially address issues related to access to healthcare among individuals with disabilities. The Model of Healthcare Disparities and Disability (MHDD) provides a framework for conceptualizing how healthcare disparities impact disability and specifically, how a mismatch between personal and environmental factors may result in reduced healthcare access and quality, which in turn may lead to reduced functioning, activity and participation among individuals with impairments and chronic health conditions. Researchers, health providers, policy makers and community advocate groups who are engaged in devising interventions aimed at reducing healthcare disparities would benefit from the discussions.

• Implications for Rehabilitation

• Evaluates the main models of healthcare disparity and disability to create an integrated framework.

• Provides a comprehensive conceptual model of healthcare disparity that specifically targets issues related to individuals with disabilities.

• Conceptualizes how personal and environmental factors interact to produce disparities in access to healthcare and healthcare quality.

• Recognizes and targets modifiable factors to reduce disparities between and within individuals with disabilities.

     

Care managers can be useful for patients with depression but their role must be clear: a qualitative study of GPs’ experiences

Abstract

Objective: Explore general practitioners’ (GPs’) views on and experiences of working with care managers for patients treated for depression in primary care settings. Care managers are specially trained health care professionals, often specialist nurses, who coordinate care for patients with chronic diseases.

Design: Qualitative content analysis of five focus-group discussions.

Setting: Primary health care centers in the Region of Västra Götaland and Dalarna County, Sweden.

Subjects: 29 GPs.

Main outcome measures: GPs’ views and experiences of care managers for patients with depression.

Results: GPs expressed a broad variety of views and experiences. Care managers could ensure care quality while freeing GPs from case management by providing support for patients and security and relief for GPs and by coordinating patient care. GPs could also express concern about role overlap; specifically, that GPs are already care managers, that too many caregivers disrupt patient contact, and that the roles of care managers and psychotherapists seem to compete. GPs thought care managers should be assigned to patients who need them the most (e.g. patients with life difficulties or severe mental health problems). They also found that transition to a chronic care model required change, including alterations in the way GPs worked and changes that made depression treatment more like treatment for other chronic diseases.

Conclusion: GPs have varied experiences of care managers. As a complementary part of the primary health care team, care managers can be useful for patients with depression, but team members’ roles must be clear.

• KEY POINTS

• A growing number of primary health care centers are introducing care managers for patients with depression, but knowledge about GPs’ experiences of this kind of collaborative care is limited.

• GPs find that care managers provide support for patients and security and relief for GPs.

• GPs are concerned about potential role overlap and desire greater latitude in deciding which patients can be assigned a care manager.

• GPs think depression can be treated using a chronic care model that includes care managers but that adjusting to the new way of working will take time.

     

Effect of Social Determinants of Health Interventions on Adults Living With Disabilities: A Scoping Review

ObjectiveTo investigate social determinants of health (SDoH) interventions on individual health outcomes, population health, and cost for persons in the United States over age 18 living with disabilities and receiving long-term services and supports (LTSS) in noninstitutional settings.Data SourcesA review using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines was conducted of literature from PubMed, PsycINFO, REHABDATA, and Web of Science Core Collection published between January 1997 and July 2020.Study SelectionSearch terms were based on the primary SDoH domains identified by the Centers for Medicare and Medicaid's Accountable Health Communities Model. A total of 5082 abstracts were screened based on identification criteria of persons age 18 and above living in non-institutional, community-based settings receiving LTSS.Data ExtractionDuring Level 2 review, articles were reviewed based on population focus, type of LTSS (personal assistance services, home care, adult day care, home modification, durable medical equipment, community transition services, caregiver supports and/or prevention services related to home- and community-based care), SDoH intervention and association with health outcomes, population health and/or cost. A total of 1037 abstracts underwent Level 2 review, yielding 131 publications or 1.3% for full review.Data SynthesisStudies (n=33) designed a priori to test outcomes of interventions were rated according to Grading Recommendations Assessment Development and Evaluation (GRADE) criteria. Qualifying articles that did not include interventions (n=98) were included in our summary of the literature but were not assessed by GRADE.ConclusionsThe preponderance of research surrounding SDoH and health outcomes has focused on older adults living with disabilities, and most interventions scored low or very low using GRADE criteria. Evidence is limited to the extent SDoH interventions are measured against outcomes for persons of all ages living with disabilities. Robust evaluation of models that feature SDoH interventions in partnership with community-based organizations is recommended as home and community-based care infrastructure expands in response to the American Rescue Plan Act of 2021.     

A scoping literature review of studies assessing effectiveness and cost-effectiveness of prosthetic and orthotic interventions

Abstract

Purpose: Approximately 1.5% of the world’s population (～100 million people) need a prosthesis/orthosis. The objective of the study was to establish an overview of the literature that has examined prosthetic and orthotic interventions with a view to inform policy development.

Methods: Fourteen databases were searched from 1995–2015. Studies reporting primary research on the effectiveness or cost-effectiveness of prosthetic and orthotic interventions were examined. Metadata and information on study characteristics were extracted from the included studies.

Results: The searches resulted in a total of 28,958 articles, a focus on studies with the words “randomized” OR “randomized” OR “cost” OR “economic” in their citation reduced this total to 2644. Research has predominantly been conducted in Australia, Canada, Germany, Netherlands, UK and USA. A total of 346 randomized controlled trials were identified, with only four randomized controlled trials examining prosthetic interventions. The majority of research examined lower limb orthoses in the adult population and used a wide range of outcome measures.

Conclusions: While various international organizations have highlighted the value of providing prosthetic and orthotic services, both to the user and society as a whole, the availability of scientific research to inform policy is limited. Future structured evaluation of prosthetic and orthotic interventions/services is warranted to inform future policy developments.

• Implications for rehabilitation

• Research into prosthetic and orthotic interventions has grown substantially in the last 20 years, with most of this research conducted in a small number of countries and focusing on the use of lower limb orthotics in adult populations.

• Research to date has utilized an extensive range of outcome measures, the development of agreed standardized sets of outcomes would allow comparison and combination of results in future research.

• This study highlights the need for further research in this area, especially studies which examine the cost-effectiveness of prosthetic and orthotic provision.

     

What indicators are measured by tools designed to address palliative care competence among ‘generalist’ palliative care providers? A critical literature review

Abstract

Background

There is growing evidence that generalists may lack skills and knowledge in palliative care provision. This has led to consideration of what the core competencies for palliative care provision among generalists should be.

Aim

The objective of this review was to present the best available evidence related to indicators of competence in palliative care provision.

Method

A systematic review of both qualitative and quantitative literature was undertaken. Medline, Medline in Progress, PubMed and CINAHL databases with additional hand searches of Journal of Palliative Care, Palliative Medicine, and the International Journal of Palliative Nursing were undertaken for the period 1990–2010. Hawker et al.'s checklist was utilized to select and assess data.

Results

Nineteen of the 1361 articles met the inclusion criteria. The reviewed articles suggest a number of indicators of palliative care competence including: medical knowledge/skills, perceptions of knowledge/skills, confidence in palliative care skills, attitudes/opinions towards palliative care, and experience in palliative care delivery. None of the reviewed research provided definitive evidence as to which indicators best reflect competency to practice.

Conclusion

Multiple approaches, combined in a strategy of triangulation, must be incorporated in any appraisal in order to successfully measure palliative care competence.     

Effectiveness of transitional care interventions for chronic illnesses: A systematic review of reviews

AimThis systematic review of reviews aims to critically evaluate and synthesize findings from recent systematic reviews to analyze the effectiveness of transitional care interventions in the management of adult patients with chronic illnesses.BackgroundTransitional care interventions have been provided to patients with chronic illnesses for reducing fragmented care and hospital readmissions after discharge. However, the effectiveness of the interventions on outcomes other than hospital readmissions is still unclear.Review methodsThis study used the systematic review of systematic reviews methodology. From five electronic databases, systematic reviews published between January 2011 and December 2020 and those that met the inclusion and exclusion criteria were searched and screened to retrieve recent evidence.ResultsEight systematic reviews that met the inclusion criteria and had high methodological quality were included. All included transitional care interventions aimed to reduce fragmented care and hospital admissions and improve health care outcomes in chronically ill patients. On summarizing and synthesizing the data, four common outcomes—hospital readmissions, quality of life, mortality, and health care cost savings—were retrieved. There was evidence regarding the effectiveness of transitional care on health care cost savings; however, other outcomes showed mixed results.ConclusionsTransitional care interventions are effective for patients with chronic illnesses. It is important to have standardized outcome measures; therefore, it is recommended to fund research and reimbursement of transitional care practices. The findings and implications of this review are important to nurse managers, health care practitioners, researchers, and policymakers.     

Occupational Therapy Interventions and Outcomes Measured in Residential Care: A Scoping Review

Abstract

Aims: This scoping review identified the interventions and outcome measures used by occupational therapists working with older adults in residential care facilities.

Methods: A five-step approach was used to retrieve and screen studies from five databases. Included studies described an occupational therapy intervention with older adults living in residential care facilities, were published in English, between 1990 and 2019 in a peer-reviewed publication. Data were mapped using domains of the Canadian Model of Occupational Performance and Engagement.

Results: Findings from 51 studies revealed that occupational therapists most commonly implemented occupations as the intervention with little focus on aspects of the environment. Outcomes predominantly measured person factors and less commonly occupational performance and engagement.

Conclusion: The exploration of the past foci of practice and measurement of therapeutic impact enables occupational therapists to consider how their practice can enhance future occupational performance and engagement of residential care facility residents.     

Pediatric Palliative Care in Sub-Saharan Africa: A Systematic Review of the Evidence for Care Models,Interventions, and Outcomes

ContextThe progressive disease burden among children in sub-Saharan Africa means the provision of palliative care is essential and should be provided alongside treatment where it is available.ObjectivesTo systematically review the evidence for pediatric palliative care models, interventions, and outcomes to appraise the state of the science and inform best practice.MethodsA systematic review search strategy was implemented in eight electronic databases, the search results reported using a PRISMA statement, and findings tabulated.ResultsIn terms of evidence of palliative care provision and outcomes, only five articles were identified. These represent a small range of acute, community, and hospice care and offer some limited guidance on the development and delivery of services.ConclusionPediatric palliative care is a pressing clinical and public health challenge in sub-Saharan Africa. Explicit evidence-based models of service development, patient assessment, and evidence for control of prevalent problems (physical, psychological, social, spiritual, and developmental) are urgently needed. Greater research activity is urgently required to ensure an evidence-based response to the enormous need for pediatric palliative care in sub-Saharan Africa.