The evaluation of the National Long Term Care Demonstration. 10. Overview of the findings.

The channeling demonstration sought to substitute community care for nursing home care through comprehensive case management and expanded community services. The channeling intervention was implemented largely according to design. Although the population served was, as intended, extremely frail, it turned out not to be at high risk of nursing home placement. The costs of the additional case management and community services--provided in most cases to clients who would not have entered nursing homes even without channeling--were not offset by reductions in the cost of nursing home use. Hence, total costs increased. The expanded formal community care did not, however, result in a substantial reduction in informal caregiving. Moreover, channeling benefited clients, and the family and friends who cared for them, in several ways: increased services, reduced unmet needs, increased confidence in receipt of care and satisfaction with arrangements for it, and increased satisfaction with life. Expansion of case management and community services beyond what already exists, then, must be justified on the basis not of cost savings but of benefits to clients and their caregivers.     

A person‐centred approach to family carer needs assessment and support in dementia community care in Western Australia

This feasibility study aimed to identify and address the support needs of family carers (FCs) of people living with dementia and to assess whether the use of the Carer Support Needs Assessment Tool (CSNAT) intervention in home‐based care was acceptable and relevant to FCs. The CSNAT intervention comprised two FC support needs assessment visits, 7 weeks apart, plus associated actions addressing prioritised needs by the Client Care Advisors of a community care service in Western Australia in 2015. Telephone interviews were conducted with FCs on their experience using the CSNAT at the end of the intervention. Twenty‐one FCs were involved in the intervention and 15 of them completed the feedback interviews. Care recipients had moderate to severe dementia. The top five support needs reported by FCs were: having time to yourself in the day; knowing what to expect in the future; practical help in the home; looking after your own health and dealing with your feelings and worries. Three themes summarised their experience: a straightforward structured approach; awareness, acknowledgement and acceptance of their situation; and provision of support. FCs appreciated the opportunity to be heard and acknowledged, to have their practical and psychosocial support needs facilitated, to identify what is important to them and to receive a response in a timely manner. The CSNAT approach offered a structured carer‐led, person‐centred, supportive intervention that facilitated discussion between the family carer and the service provider about support needs and strategies to address them.     

Evaluation of an Innovative Program to Address the Health and Social Service Needs of Drug-Using Women with or at Risk for HIV Infection

Drug-using women with or at risk for HIV infection have many competing unmet needs, especially for social services, drug treatment, and medical care. High-risk drug-using women were recruited through street outreach, at needle exchange sites, a prison, and local community based organizations in New Haven, Connecticut for a study of the service needs of out-of-treatment drug users and the ability of an interactive case management intervention (ICM) to address those needs. These women were administered baseline and follow-up interviews to identify their health and social service needs and the degree to which these needs were resolved. The women who chose to enroll in the interactive case management intervention (n = 38) did not differ demographically nor in their HIV risk behaviors from those not receiving case management (n = 73). Provision of ICM was most successful in meeting needs for supportive mental health counseling, basic services, and long term housing. The impact of interactive case management was less evident for the acquisition of medical and dental services, which were accessed comparably by women not receiving the intervention. Overall, the women who enrolled in the ICM intervention showed a significant decrease in the number of unmet service needs as compared to those who did not enroll. Multiple contacts were required by the case manager to establish trust and to resolve the unmet service needs of these high-risk women. Women with or at risk for HIV infection can be effectively engaged in an ICM intervention in order to meet their multiple unmet service needs, although such interventions are time-and-labor intensive.     

The interests of three stakeholders in independent personal care for disabled elders

There is concern throughout developed countries about how sufficient services can be mounted in this century to care for all older, disabled persons who want to remain at home. With declining availability of family care and high turnover among paid workers, cost, care supply, and quality dilemmas abound. Therefore, how can home care be improved? One suggestion is to revise the care "contract" by simply eliminating the costly bureaucratic and controlling dimensions of agency oversight and management. In consumer-directed or self-managed care, independent workers are hired directly by consumers or their family members. Consumers spend their own private money or government provides authorization for them to "hire" their own workers. Such arrangements may be more responsive to the needs of consumers, more directly accountable to them, and less costly for both individuals and government. This article examines 41 cases of consumer-directed care in Milwaukee. Extended interviews with three "stakeholders" in care--the disabled, older client, the family caregiver, and the personal assistant--were conducted, including both private pay and government subsidized arrangements. This analysis identifies some essential, but disparate interests of the three partners in care.     

城市母亲孕期睡眠健康认知现状研究

【目的】 了解城市地区孕妇对婴儿睡眠健康的认知情况及人群分布特点。 【方法】 采用自填式问卷调查469名孕妇对婴儿睡眠健康相关知识的认知情况。选择多元logistic回归模型探索母亲孕期认知的社会人口学分布特征。 【结果】 城市孕妇对婴儿期睡眠时间变化趋势、睡眠/觉醒状态判断知晓率分别为75.3%和55.9%,88.3%的母亲选择同室独床或单独卧室,67.0%的母亲认为应在婴儿完全清醒或犯困未睡着时将婴儿放到床上睡觉,68.7%的母亲认为应在婴儿夜醒后不安抚或先观察再安抚。母亲学历、年龄及家庭收入与孕期母亲的睡眠健康认知水平存在相关性。 【结论】 城市地区母亲孕期在婴儿睡眠健康认知方面状况较好,但仍有相当比例母亲尤其是低学历者存在一定误区,相关睡眠健康教育有待强化。     

Negotiating concrete needs: short-term training for high-risk cancer patients

Advances in the diagnosis and treatment of cancer and revisions in health care financing and reimbursement have changed the experience of living with cancer. The disease now is diagnosed earlier and patients are likely to live longer with the disease. Patients and their families, thus, will require more concrete service needs. The authors review the psychosocial oncology literature and the literature on case management theories. They present their findings of a survey of the concrete needs of 413 cancer patients who were undergoing chemotherapy. Based on this survey, they developed a short-term case management intervention model to improve patient problem-solving skills. The intervention is designed to increase patient and family autonomy and mastery, reduce unmet needs, and counteract common feelings of helplessness associated with serious illness.     

Awareness, understanding and attitudes of Italians regarding palliative care

There are numerous difficulties encountered in the diffusion of palliative care (PC) in developed countries. A correct and widespread awareness of PC among the general public represents an important factor for its enhanced diffusion and use. The aim of this study is to verify the level of awareness of PC among Italians and their perception of the needs of patients with incurable illness. A random sample of 1897 adult subjects, aged 18 to 74 years, representative of the Italian population, was interviewed after stratification by gender, age (6 strata), education (3 levels), geographic area of residency (4 areas) and town of residency (4 dimensions). 59.4% of those interviewed had heard of PC, but only 23.5% of them believed that they had an adequate or precise idea of what PC is; 27% of them did not know or had a mistaken idea about the nature of PC. The most accepted perception was that PC alleviates pain and improves quality-of-life. The principal concerns attributed to incurable patients were: fear of suffering and of death, and the principal needs were perceived as: relief from pain and physical suffering. The primary needs of the family were identified in: medical and nursing care at home, followed by: care provided by volunteers and psychological support. The most appropriate care-setting for these patients was indicated as their home, possibly with the support of professional carers. In the case of children, the main concern indicated was that of being "separated" from family, friends, home and toys. Only 45.2% of interviewees thought that they knew a person who had experienced PC. In conclusion, the awareness of the Italian population of PC is scarce and often incorrect. In order to achieve a greater diffusion and better use of PC in our country, this awareness needs to be improved by appropriate intervention.     

Crisis intervention in a newborn nursery intensive care unit.

Premature birth of a defective infant challenges personal and family integrity, and immediate intervention is optimal in reaching a positive outcome. The G. case exemplifies many aspects of crisis theory; worker intervention was built around them. As the G. family struggled with the impact of a severely damaged infant, a broad range of worker techniques, based on the parents' strengths and personal backgrounds, was required. Intervention was significant in effecting a positive resolution. This article details the events endured by the G. family, and the way in which they experienced them during their baby's first 3 weeks of life.     

‘Outsourced’ patients and their companions: Stories from forced medical travellers

In this paper, I describe the experience of ‘outsourced’ patients who are sent by their governments or insurers through contractual arrangements to a hospital in another country for treatment. I present case studies of nine patients and their accompanying families from the Gulf Cooperation Council (GCC) who were interviewed in a Thai hospital as part of a broader study of medical travel from patients' perspectives. The health systems of the GCC suffer shortages in infrastructure, human resources and management skills, and as a consequence patients with particular needs, especially in neurology, orthopaedics and oncology may be sent overseas for treatment. Patients experience long stays overseas producing a considerable burden to their families supporting them. Such patients complicate notions of medical travel but their status also contrasts markedly from stereotypes held about Gulf patients within Thailand. Despite their appreciation of government sponsoring, for many patients the experience of care in Thailand underscored perceived inadequacies of their home health systems and governments. For some, outsourcing represented a betrayal of the obligations of their states to its citizens.     

A Home Care Program for Children with Chronic Illness

Pediatric Home Care (PHC) of Albert Einstem College of Medicine was designed as a special ambulatory care unit for children who are seriously or chronically ill and whose needs were not being met successfully through conventional programing Services include monitoring the patient's care, delivering direct services in the home, clinic, and hospital, teaching therapeutic programs to the family and patient, coordinating services, patient advocacy, health education, and supportive counseling Each patient has a core team consisting of a generalist pediatrician, a PNP, and the patient's family Visits are provided in the patient's home as needed, as well as in the traditional locations of the clinic, the inpatient units, and the PHC office The program accepts patients with serious medical problems and who face any of a series of other difficulties, including especially complex management problems that cannot be handled well in the customary outpatient settings, unstable family settings, or extended hospitalizations Because it is not restricted to any single type of disease, the PHC provides a model that is applicable in a wide range of medical and community settings Results of a program evaluation show that PHC is an effective intervention that has positive mental health outcomes and improves satisfaction with care.     

Circumstances of post-neonatal deaths in Ceara, Northeast Brazil: mothers' health care-seeking behaviors during their infants' fatal illness

Promotion of oral rehydration therapy (ORT) for the treatment of diarrheal diseases and the WHO case management strategy for acute respiratory infections (ARI) have contributed to significant reductions in infant mortality, but these two conditions remain the leading causes of infant deaths in most developing countries. Identification of the factors contributing to these deaths may contribute to reduce infant mortality from preventable causes. To gain insight into the circumstances and maternal and health services factors that may contribute to infant deaths we used a verbal autopsy method to interview mothers of all infants who died during the previous 12 months (June 1995-May 1996) in 11 municipalities in the State of Ceara, Northeast Brazil. Our results revealed that one-third of the deaths occurred in a hospital and two-thirds at home. Almost all the infants who died at home, however, had been examined one or more times by a doctor, and 36% of them had been hospitalized during the disease episode that resulted in death. For most (85%) of these children the causes of death were diarrhea or acute respiratory infection, and it is likely that death could have been averted if appropriate treatment had been initiated promptly. Three major groups of factors that alone or in combination appeared to contribute to most deaths were delays in seeking medical care on behalf of the parents, medical interventions reported as ineffective by mothers and delays in providing medical care to children who arrived at the hospital too late in the day to be scheduled for consultation. Our findings suggest that government efforts to further reduce infant mortality in Ceara should focus on health education interventions that address quality of home care, recognition of signs of severity and danger and importance of seeking timely medical care: and on improving the quality of care provided at community health centers and hospitals. Measures likely to improve infants' chance of survival include: ensuring prompt access to medical consultation for young children brought to health centers or hospitals with potentially life-threatening symptoms related to infections, health education to mothers on the need for continued home care after discharge and to return to the medical care facility if the child does not recover, and that they have access to medicine prescribed by hospital physicians. Further benefits could be obtained by using community health workers, now integrated into the Family Medicine Program (PSF) health teams, to provide health education, supervise home care, refer mothers to health centers and facilitate their access to hospitals.     

Bridging the gaps in geriatric care. Volunteers help meet the elderly's nonmedical needs

Concerned about the paucity of services for elderly who need care but prefer to live at home, Our Lady of Lourdes Medical Center, Camden, NJ, embarked on an effort to obtain grant funds while seeking creative ways to meet the elderly's nonmedical needs. One of the first programs developed was a Senior Companion Program. This federally funded program recruits low-income elderly citizens, trains them, and places them in the homes of seniors who need nonmedical services to remain in the community. The program's success led to the establishment of Helping Hands in the Community, which recruits volunteers of all ages and incomes to serve as companions for seniors. An extension of this program, Helping Hands in Business, sought to help employers reduce the costs associated with lost productivity because of employees' responsibilities as care givers for elderly family members. Finally, the Camden Senior Community Support Program uses aggressive case management in the emergency room and the hospital to determine whether the elderly need to be admitted to the hospital or can receive support from family or others to remain in the community.     

A Home Care Program for Children with Chronic Illness

Pediatric Home Care (PHC) of Albert Einstem College of Medicine was designed as a special ambulatory care unit for children who are seriously or chronically ill and whose needs were not being met successfully through conventional programing Services include monitoring the patient's care, delivering direct services in the home, clinic, and hospital, teaching therapeutic programs to the family and patient, coordinating services, patient advocacy, health education, and supportive counseling Each patient has a core team consisting of a generalist pediatrician, a PNP, and the patient's family Visits are provided in the patient's home as needed, as well as in the traditional locations of the clinic, the inpatient units, and the PHC office The program accepts patients with serious medical problems and who face any of a series of other difficulties, including especially complex management problems that cannot be handled well in the customary outpatient settings, unstable family settings, or extended hospitalizations Because it is not restricted to any single type of disease, the PHC provides a model that is applicable in a wide range of medical and community settings Results of a program evaluation show that PHC is an effective intervention that has positive mental health outcomes and improves satisfaction with care.     

Breast-feeding counselling in a diarrhoeal disease hospital.

Lactation counsellors were trained to advise mothers of partially breast-fed infants who were admitted to hospital because of diarrhoea, so that they could start exclusive breast-feeding during their hospital stay. Infants (n = 250) up to 12 weeks of age were randomized to intervention and control groups. Mothers in the intervention group were individually advised by the counsellors while mothers in the control group received only routine group health education. During follow-up at home by the counsellors a week later, only the mothers in the intervention group were counselled. All the mothers were evaluated for infant feeding practices at home two weeks after discharge. Among the 125 mother-infant pairs in each group, 60% of mothers in the intervention group were breast-feeding exclusively at discharge compared with only 6% in the control group (P < 0.001); two weeks later, these rates rose to 75% and 8% in the intervention and control groups, respectively (P < 0.001). However, 49% of mothers in the control group reverted back to bottle-feeding compared with 12% in the intervention group (P < 0.001). Thus, individual counselling had a positive impact on mothers to start exclusive breast-feeding during hospitalization and to continue the practice at home. Maternal and child health facilities should include lactation counselling as an integral part of their programme to improve infant feeding practices.     

Preventive Intervention for Children with Cancer and Their Families at the End-of-Life

Preventive intervention, based on a theoretical model of crisis denoted as the Perceived Personal Control Crisis model, is discussed with respect to pediatric cancer patients at the end-of-life and their families. In this article, the emphasis is on preventive intervention on the Personal Interaction level, namely intervention administered by a network of natural and organized support systems, such as parents and the primary care physician, nurses, and mental health professionals, with special emphasis on the role of the mental health expert. The objective of preventive intervention is to enhance the quality of life of children with cancer at the end-of-life and allow them to die well without unnecessary pain and fear, surrounded by their loved ones, in hospital or, preferably, at home. The objective of preventive intervention for parents and siblings is to ease their grief process, ensure a healthy resolution and safeguard the integrity of the family after the death of the child.     

Addressing Social Determinants of Health for Dual-Use Veterans

An estimated 40% of Veterans are eligible for community care. Veterans who access care both outside of the Veterans Health Administration (VA) and at the VA are at risk for fragmented care and adverse outcomes. These dual-use Veterans often do not receive necessary follow-up care or linkage to resources addressing social determinants of health (SDOH) post–non-VA emergency department (ED) visits. We created a social worker–led advanced care coordination (ACC) program to reduce fragmented care, enhance care coordination, and provide longitudinal case management to address SDOH for dual users who access non-VA EDs. ACC collaborated with internal and external stakeholders (ie, clinicians and staff) to enhance care and address SDOH for dual users. The ACC social worker had regular contact with stakeholders through phone calls, emails, and in-services to enhance relationships and program buy-in. Stakeholders asked each patient if they were a Veteran and informed ACC of the Veteran’s non-VA ED visit. Postdischarge, the ACC social worker called the Veteran to complete a comprehensive assessment identifying SDOH needs. The ACC social worker provided case management via phone calls and home visits to the Veteran up to 90 days addressing SDOH needs and reconnected the Veterans to their primary care team through electronic closed-loop communication. We analyzed VA claim data postimplementation to compare intervention participants with nonparticipants. Using propensity score, Veterans were matched 3 to 1 on age, gender, comorbidities, and number of hospitalization and primary care physician (PCP) visits in the past year. Dual-use Veterans who accessed non-VA EDs in Denver, Colorado, and Omaha, Nebraska, metro areas. Veterans had to be eligible to receive care through the VA. When compared to a matched control group, Veterans who received the ACC intervention had significantly lower rates in readmission to the ED within 30 days of ED discharge (16.1% vs. 30.5%, P < 0.01). ACC connected Veterans to services addressing SDOH they may not have otherwise accessed due to lack of knowledge and resources. Using our program database to evaluate Veterans enrolled in ACC since April 2018, we found they were connected to: (1) VA PCP appointments (82%), (2) VA benefits including enrollment (33%), (3) home health care (21%), (4) financial assistance (ie, food benefits, rental and utility assistance, disability benefits, 18%), (5) homeless resources including housing vouchers and shelters (9%), (6) mental health treatment (9%) and transportation assistance (9%), and (7) substance use treatment (4%). Dual-use Veterans often fall through the cracks after receiving non-VA care. ACC addressed gaps in transitions by connecting Veterans to resources addressing SDOH needs and linking Veterans back to their VA primary care teams. Gaps in care will continue as Veterans increasingly access non-VA care. ACC bridged these gaps by enhancing relationships and communication between VA and non-VA providers. ACC addressed Veteran’s SDOH by connecting them to resources post–non-VA ED discharge. Programs similar to ACC should be implemented across health care systems to assist dual-use Veterans with SDOH needs and increase linkage to resources. The study was funded by QUERI.     

智障儿童的社区管理与家庭关怀

目的探讨针对智障儿童实施社区管理以及家庭关怀后获得的效果。方法选取智障儿童150例作为本次实验的研究对象,对患儿实施必要的社区管理干预,并给予必要的家庭关怀,主要包括对患儿开展健康教育、生存教育以及鼓励患儿参加活动训练等。对比干预前后患儿的心理状态以及生活质量评分情况。结果干预后患儿在运动能力、理解能力以及生活质量评分方面表现了极其显著的提高(p<0.05)。在患儿内心的感受方面,干预后也获得了显著效果,患儿内心感觉到足够的温暖。结论对智障儿童给予必要的社区管理以及家庭关怀,在提高其生活质量以及增强患儿内心情感等方面,都表现了极其显著的意义,成功凸显了社区管理与家庭关怀的应用意义。     

Support in a time of need. The team approach at Mercy Medical Hospice addresses medical, emotional, and spiritual needs

Mercy Medical Hospice, Daphne, AL, uses an interdisciplinary team approach, which includes medical, nursing, social work, pastoral care, pharmacy, therapies, volunteer, and bereavement services. Mercy Medical has two home care offices and offers inpatient respite care for short periods, which is helpful for those who have an inadequate care giver system or need time to work out a better alternative to care in the home. An assessment of medical and nursing care needs, mental and emotional state, and psychological and spiritual needs is the first step after patients enter hospice. The entire team develops a care plan for the patient and family. Among the issues they address are education about the disease process, medication for pain control and symptom management, and how the patient and family cope with the patient's imminent death. Working with the dying and their families can be stressful for staff members, and they offer each other a lot of support. Working in hospice requires good stress management techniques, but staff feel that it is a calling that enriches their lives.     

Verbesserung der Versorgung bei Vergiftungsunfällen im Kleinkindalter Wirksamkeit und Kosten einer Interventionsmaßnahme

At the beginning of 1995 the Poison Centre of Berlin developed a plan which made the Poison Centre more known publicly and provided first aid measures (pediatric emergency set). The delivery of the emergency set was based on the assumption that in three quarters of poisoning accidents suitable first aid measures carried out at home would make a further stationary therapy in hospital unnecessary. Moreover, the problem consciousness of parents is to be raised regarding the dangers of accidents at the infant age, and their ability to take preventive measures and give first aid is to be strengthened. The non-monetary effectiveness can be summarised as follows: in contrast to 33% of the control group (emergency set missing), 50% of the intervention group (emergency set available) made the poison emergency call immediately after the accident. In the case of the intervention group, 90% of the parents or family members knew about the possibility of calling the poison information centre and did not need any support from their neighbours; only 73% of those without an emergency set knew about this possibility and did not need any help from outside. As for the cases in which a therapy with Activated Charcoal (6%) or Dimeticon (22%) was recommended, these substances were available in the intervention group within 10 minutes, but in the control group only after 40 minutes. The results show that the emergency set improves the information about such accidents, and thus, it is especially effective in families with a first child. The annual direct costs that arise from the surface-covering introduction of the pediatric emergency set to the target population of Berlin exceed the monetary benefit of the intervention measure around twenty times. The direct benefit of the emergency set, however, is to be estimated more highly than proven in the calculations. From the point of view of the authors, the introduction of the intervention study is highly recommendable to validate the results in hand to a non-urban German state.     

A manual for community mental health activities for a public health center in Japan]

A system for treatment of persons with chronic mental disease such as schizophrenics in the present structure of the Japanese public Health Center is proposed. Presently, while cases are handled by responsible staff members, incorporation into the health center system with full utilization of its personnel and resources is seldom accomplished. There is a necessity for a systems approach in order to organize essential programs that would provide care for the mentally diseased. Health centers would have three main roles in this system: as a coordinator of mental health resources in the community, as a specialized agency for case management, and responsibility for public relations in its service area. For proper administration of its system, health centers should follow a team concept. The team would consist of a director of health centers, physicians, part-time psychiatrists, public health nurses, psychiatric social workers and clerical staff. At case conferences discussion of whether a prospective case should be registered, assessment of the needs, and development of management plans for all of the registered cases would be conducted. The files and documents of each case would be deleted or re-registered 5 years after initial registration. Cases would have a case-manager to coordinate public health care, including home visits, family care, psycho-educational consultation and crisis intervention. Health centers would be responsible for bringing together available social resources such as sheltered workshops and transient residential programs. The goal of health centers' mental health activities would be to facilitate the normalization of the mentally diseased within the community.