Clinical outcomes for low-income adults with hypertension and diabetes

BACKGROUND: Long-term management of hypertension and diabetes, which are more prevalent in minority and socioeconomically disadvantaged populations, presents challenges for healthcare providers in community health centers. OBJECTIVES: The purpose of the study was twofold: to examine health outcomes for persons with hypertension and diabetes and to compare these outcomes for disparities in patients who were Black, Hispanic, or White. METHODS: Medical records (N = 280) from an urban community health center that serves predominantly uninsured adults were reviewed for selected clinical outcomes of primary care. Measures included outcomes of hypertension and diabetes control, lifestyle behaviors, preventive care, and patient status. Chi-square tests, t tests, and one-way analysis of covariance were used to analyze racial/ethnic group differences. RESULTS: Data revealed significant differences in smoking status, influenza immunization, and blood pressure. Racial/ethnic group differences were minimal compared with the overall high prevalence of risk factors such as smoking and obesity. Regular access to primary care did not result in improved clinical outcomes. CONCLUSION: The findings support the need for more effective interventions that promote healthy lifestyle if health disparities in low-income populations with chronic conditions are to be reduced.     

Nursing clinics in elder housing: providing access and improving health care outcomes

This article describes one approach to helping elder individuals residing in subsidized senior housing achieve better health outcomes by providing health promotion and disease prevention services at on-site student nursing clinics. Clinics operate 2 days a week in the community room at the elderly housing sites and are staffed by senior baccalaureate nursing students who are in their community health clinical rotation. The student nursing clinic outcomes demonstrate improvement in residents' health through increased access to care, better identification and management of hypertension, more involvement for residents with diabetes in monitoring and management of their conditions, and better preparation for emergency medical situations.     

How Values Affect the Mutual Goal Setting Process With Multiproblem Families

This article describes one approach to helping elder individuals residing in subsidized senior housing achieve better health outcomes by providing health promotion and disease prevention services at on-site student nursing clinics. Clinics operate 2 days a week in the community room at the elderly housing sites and are staffed by senior baccalaureate nursing students who are in their community health clinical rotation. The student nursing clinic outcomes demonstrate improvement in residents' health through increased access to care, better identi-fication and management of hypertension, more involvement for residents with diabetes in monitoring and management of their conditions, and better preparation for emergency medical situations.     

Aboriginal people with chronic HCV: The role of community health nurses for improving health-related quality of life

IntroductionThere is a lack of knowledge about Health-Related Quality of Life (HRQL) of Aboriginal Australians with self-reported hepatitis C infection in Western Australia. This marginalised group of people is disproportionally affected by the hepatitis C virus (HCV) for which there is no preventative vaccine. This study provides data that help understand the long-term consequences of living with HCV infection within the Aboriginal community. It outlines opportunities for nursing interventions for hepatitis care that focus on supporting mental health and drug and alcohol issues within this population.MethodsWe surveyed 123 Aboriginal people living with HCV in a community setting. Survey data included demographics, drug use history, length of time since diagnosis, changes in lifestyle since diagnosis, fatigue, social support, alcohol consumption, and physical and mental health measures.ResultsMost participants reported amphetamine injecting frequently in the last six months and their duration of injecting drug ranged from 8 to more than 11 years. Additionally, half of the participants were classified as high-risk alcohol users. Overall 52% of participants were in poor physical and 60% of participants were in poor mental health.DiscussionThis survey of Aboriginal people with self-reported hepatitis C infection indicates substantial problems of mental and physical comorbidities among this population.ConclusionThere is a need for the development of HCV community clinics in Aboriginal health care settings with trained Aboriginal community health nurses to reduce problematic alcohol consumption, assess liver health and subsequently provide HCV treatment in a culturally appropriate way.     

Health care for the homeless: a self-care approach

Homelessness has become a problem of national concern. Providing accessible, effective health care to this population in the face of today's economic climate is a problem facing community health clinical nurse specialists (CNSs) with increasing frequency. Homeless health care currently places an enormous financial burden on inner city hospitals. In addition lack of access to health care and the very nature of the homeless lifestyle makes this population a reservoir for the propagation and spread of infectious disease. The community health CNS must address these problems by developing strategies to improve homeless health care. Utilizing Orem's model of self-care provides a systematic approach to problem solving and provides the CNS with a perspective from which to assess patient problems and devise nursing care strategies. Homeless health care from Orem's self-care perspective would increase utilization of services by fostering dignity and self-esteem, as well as promote more efficient use of services.     

Establishing prevention, education and community awareness through a comprehensive diabetes, hypertension and hypercholesterolaemia screening programme: The Smith Island, Maryland, USA experience

Glucose screening is essential in providing early detection for diabetes. Screening for hypertension and hypercholesterolaemia in diabetics can help identify clients at an increased risk for morbidity and mortality. Free health screening clinics, which included components based on the ABCs of Diabetes, were set up on Smith Island, Maryland, USA in January 2001. An extensive health history was performed on each clinic attendee and baseline assessment data were collected. To date, 273 residents have been screened at the clinics. Clinic education adopted from the National Diabetes Education Program was provided to all attendees. This programme provided members of the community with a baseline assessment and general information on diabetes prevention, detection and treatment. Positive lifestyle strategies were introduced within the community. Barriers to future disease prevention were identified during the programme.     

Meeting health care needs of a vulnerable population: perceived barriers

This study utilized the qualitative methodology of focus groups to explore health care needs and perceived barriers to obtaining health care for urban and rural women and children in areas served by nurse practitioner (NP) and certified nurse midwife (CNM) clinics. The clinics operate in a southeastern county with a rural health professional shortage area designation, and an urban ZIP code area with high rates of infant mortality and serious pediatric conditions. The aim of the study was to delineate barriers to health care in order to develop appropriate services at the clinics and to improve access. Four focus groups with a total of 31 women from the communities were convened. Content analysis shows that access to the clinics is hampered by the community women's limited knowledge of CNMs and NPs and their specific roles in providing health care services. The women suggested that clinics counter their low profile by a more vigorous outreach promotion.     

“一专多能”医护整合模式在家庭医生责任制服务中的探索

【】: 目的 评价“一专多能”医护整合模式在本社区家庭医生责任制服务中的效果,探索社区家庭医生责任制服务中个体化的慢病特色服务和社区适宜技术推进新模式。方法 自2017年1月在“1+1+1家庭医生团队”签约的基础上,本中心组建了糖尿病、高血压、脑卒中、腹膜透析、社区压力性损伤、PICC维护六大领域的专科医护整合团队,目的为每个家庭医生团队这六大领域中高危签约居民通过专科医护整合团队进行个体化的干预,从疾病专科诊疗、专业性的健康咨询、针对性的健康照顾、权威性的健康指导和持续性的健康关怀和社区适宜新技术推进。结果 以“一专多能”医护整合团队在一年中的干预,慢病患者中的糖尿病护理门诊教育和高血压自我管理同伴教育,对改善血压、血糖效果明显(P<0.05)；四大适宜技术的并发症率明显减低、治愈率和普及率明显提升(P<0.05)。结论 “一专多能”医护整合团队在家庭医生制服务中的模式得到同行认可和居民的肯定,四大社区适宜技术真正做到方便百姓,惠及居民。     

Perceptions of people with Type 2 diabetes about self-management and the efficacy of community based services

Self-management has become a key strategy for managing the health care of people with diabetes. This study explored issues people with type 2 diabetes experienced in their self-management practices and access to regional community based services. Using a qualitative interpretative design data was collected from four participants who were interviews about their perceptions of facilitators, barriers and issues they encountered in their diabetes care in a regional setting. The findings indicate difficulties participants experienced in gaining access to quality services in regional areas, including long waiting times, difficulties making appointments, and their perception that healthcare professionals fail to acknowledge patients self-management knowledge and practices. Additionally, participants reported food choices affected their family relationships and experience of social stigma. These issues compromised their self-management decisions. The findings support other studies that show a need for health professionals to develop strategies to improve community based services for people with type 2 diabetes and to increase public awareness of the scope of diabetes management.     

石河子市老年人健康状况和护理需求现状调查

目的了解新疆石河子市老年人的健康状况及护理服务需求,为老年人的健康保健及医疗服务提供参考依据。方法采用自制问卷对500名社区老年人的一般人口学资料、健康状况、个人健康行为和护理服务需求等进行调查。结果老年人慢性病患病率为72．60％,其中46．60％的老年人患有2种及以上的慢性病;近2周患病率为49．40％;前10位慢性病依次为高血压、冠心病、风湿性关节炎、糖尿病、骨质增生、慢性支气管炎、胆道疾病、脑梗塞、胃肠疾病、前列腺疾病。老年人中有吸烟史者占28．20％,有饮酒史者占18．20％;62．80％的老年人从未体检;老年人所需的保健知识依次为安全用药、慢性病、饮食指导、传染病和常见病等;老年人急需的卫生服务项目：建立健康档案（47．80％）、定期体检（46．60％）、健康指导（43．80％）、社区紧急救护（37．40％）。结论社区老年人慢性病患病率高,针对社区老年人的健康状况和护理服务需求,开展健康教育及社区卫生服务,提高社区老年人的健康水平和生活质量。     

Case-finding in the community: the results 2

Improving the health and well-being of the population is at the centre of policy development, and the vision is to involve individuals, families and communities. The Case-finding in the Community Project was designed to build upon the established relationship between district nursing and the local community of East Belfast, working together to improve the health of adults in the community using a case-finding approach. The aims were to improve the early detection of long-term conditions, to increase access to primary care and the specialist nursing services, and to further develop the working partnership with East Belfast Community Health Information Project. Between September 2006 and March 2007, 351 people attended 17 health fairs in East Belfast at a range of venues. There were 115 people with identified risk factors for respiratory, cardiac, diabetes and hypertension. From the results of this project, there is a need for 'case-finding' patients with the potential to develop chronic disease management.     

Unstructured cardiac rehabilitation and secondary prevention in rural South Australia: does it meet best practice guidelines?

Comprehensive cardiac rehabilitation programs that address risk factors, psychological problems, and physical activity are essential in optimizing health and reducing the risk of further cardiac events. Behavioural and lifestyle modification support offered through these programs is predicated on initial identification of risk. Many rural populations in Australia do not have access to structured cardiac rehabilitation (CR) programs, and the level of support available to them in the form of unstructured CR is unclear. A retrospective analysis of medical records of patients presenting to hospital with myocardial infarction in rural South Australia over a 12 month period was undertaken to identify documented evidence of assessment of and intervention for lifestyle and behavioural risk factors in-hospital and at follow up in general practice (GP) clinics. Of 77 eligible participants, permission was received to access the medical records of 55 patients in the hospital setting, and 34 of these 55 patients in GP clinic follow up. Documented evidence of assessment of modifiable risk factors was inadequate for the majority of participants, with the exception of smoking status, hypertension and diabetes. This suggests that the majority of these participants did not receive lifestyle and behavioural interventions in line with current National Heart Foundation Recommendations for Cardiac Rehabilitation. Barriers to comprehensive CR and secondary prevention services in Australia must be addressed, particularly in high risk rural and remote populations. Future research must focus on the ongoing monitoring and evaluation of rural health care services to analyse existing levels of CR and secondary prevention to ensure current guidelines are being implemented, to support the further development and resourcing of CR services and to evaluate the subsequent impact on patient outcomes.     

Providing care to a culturally diverse community: a mobile academic nursing center

Health care institutions are increasingly collaborating with nursing education programs to provide quality and cost-effective primary health care services to the community. Mobile academic nursing centers are emerging as viable alternative sites for these services because they can provide immediate access to health care services and circumvent logistical problems in access to care. Although not a new concept, their development as an integral component of the nursing academic unit is being reexamined in light of health care reform and nursing's role in this reformation. Unlike stationary clinics, these "clinics on wheels" provide multisite access to diverse populations and communities. This article describes how a mobile academic nurse managed center can provide nurses and students with opportunities to develop competencies in community-based experiences.     

Inability to access primary care clinics among people who inject drugs in a Canadian health care setting

ObjectiveTo examine the prevalence and correlation of self-reported inability to access community primary care clinics among people who inject drugs (PWID).DesignSelf-report questionnaire data.SettingVancouver, BC.ParticipantsData were derived from 3 prospective cohort studies of PWID between 2013 and 2016.Main outcome measuresMultivariable generalized estimating equations were used to determine prevalence of and reasons for self-reported inability to access primary care, as well as factors associated with inability to access care.ResultsOf 1396 eligible participants, including 525 (37.6%) women, 209 (15.0%) persons were unable to access a primary care clinic at some point during the study period. In the multivariable analysis, factors independently associated with inability to access clinics included ever being diagnosed with a mental health disorder (adjusted odds ratio [AOR] = 1.63, 95% CI 1.14 to 2.35), dealing drugs (AOR = 1.60, 95% CI 1.15 to 2.22), using emergency services (AOR = 1.51, 95% CI 1.13 to 2.02), being female (AOR = 1.49, 95% CI 1.08 to 2.08), and testing positive for HIV (AOR = 0.47, 95% CI 0.30 to 0.72) (for all factors, P < .05).ConclusionSpecific exposures were linked to challenges in accessing primary care among the sample of PWID, even in a publicly funded health care setting. Notably, models designed for care of people with HIV appear to increase access to primary care among PWID. Further research is needed to determine how to effectively treat accompanying mental illness, how to provide women-centred services, and how to connect people with primary care who would likely otherwise go to the emergency department.     

Health care and health status and outcomes for patients with type 2 diabetes

OBJECTIVE: To evaluate access and utilization of medical care, and health status and outcomes that would be influenced by recent medical care, in a representative sample of patients with type 2 diabetes. RESEARCH DESIGN AND METHODS: A national sample of 733 adults with type 2 diabetes was studied from 1991 to 1994 in the Third National Health and Nutrition Examination Survey. Structured questionnaires and clinical and laboratory assessments were used to determine the frequencies of physician visits, health insurance coverage, screening for diabetes complications, treatment for hyperglycemia, hypertension, and dyslipidemia; and the proportion of patients who met treatment goals and established criteria for health outcome measures including hyperglycemia, albuminuria, obesity, hypertension, and dyslipidemia. RESULTS: Almost all patients had 1 source of primary care (95%), 2 or more physician visits during the past year (88%), and health insurance coverage (91%). Most (76%) were treated with insulin or oral agents for their diabetes, and 45% of those patients taking insulin monitored their blood glucose at least once per day The patients were frequently screened for retinopathy (52%), hypertension (88%), and dyslipidemia (84%). Of those patients with hypertension, 83% were diagnosed and treated with antihypertensive agents and only 17% were undiagnosed or untreated; most of the patients known to have dyslipidemia were treated with medication or diet (89%). Health status and outcomes were less than optimal: 58% had HbA1c >7.0, 45% had BMI >30, 28% had microalbuminuria, and 8% had clinical proteinuria. Of those patients known to have hypertension and dyslipidemia, 60% were not controlled to accepted levels. In addition, 22% of patients smoked cigarettes, 26% had to be hospitalized during the previous year, and 42% assessed their health status as fair or poor. CONCLUSIONS: Rates of health care access and utilization, screening for diabetes complications, and treatment of hyperglycemia, hypertension, and dyslipidemia in type 2 diabetes are high; however, health status and outcomes are unsatisfactory. There are likely to be multiple reasons for this discordance, including intractability of diabetes to current therapies, patient self-care practices, physician medical care practices, and characteristics of U.S. health care systems.     

Lifestyle interventions are cost-effective in people with different levels of diabetes risk: results from a modeling study

OBJECTIVE: In the current study we explore the long-term health benefits and cost-effectiveness of both a community-based lifestyle program for the general population (community intervention) and an intensive lifestyle intervention for obese adults, implemented in a health care setting (health care intervention). RESEARCH DESIGN AND METHODS: Short-term intervention effects on BMI and physical activity were estimated from the international literature. The National Institute for Public Health and the Environment Chronic Diseases Model was used to project lifetime health effects and effects on health care costs for minimum and maximum estimates of short-term intervention effects. Cost-effectiveness was evaluated from a health care perspective and included intervention costs and related and unrelated medical costs. Effects and costs were discounted at 1.5 and 4.0% annually. RESULTS: One new case of diabetes per 20 years was prevented for every 7-30 participants in the health care intervention and for every 300-1,500 adults in the community intervention. Intervention costs needed to prevent one new case of diabetes (per 20 years) were lower for the community intervention (2,000-9,000 euros) than for the health care intervention (5,000-21,000 euros). The cost-effectiveness ratios were 3,100-3,900 euros per quality-adjusted life-year (QALY) for the community intervention and 3,900-5,500 euros per QALY for the health care intervention. CONCLUSIONS: Health care interventions for high-risk groups and community-based lifestyle interventions targeted to the general population (low risk) are both cost-effective ways of curbing the growing burden of diabetes.     

PS1-62: Assessing Readiness for Team Care in Community-based Clinics: Barriers and Facilitators to Implementing an Evidence-based Intervention to Improve BP Control

Background/Aims Understanding the barriers and facilitators to implementing evidence-based models of care in typical community settings is critical to the successful translation of research-tested interventions into practice. The Electronic Communications and Home Blood Pressure Monitoring trial (e-BP), implemented in a large, integrated group practice, demonstrated that team-care and incorporating a pharmacist to manage hypertension via secure e-mail communications in an existing patient-shared electronic health record (EHR) resulted in almost twice the rate of BP control compared to usual care. We sought to assess whether e-BP could be implemented in community-based primary care clinics with very different contextual features (e.g. inexperience with pharmacist team members, limited IT infrastructure, and vulnerable patient populations). Methods We conducted interviews with purposive samples of health care providers, pharmacists and patients associated with four community-based, primary care clinics. Using template analysis incorporating a priori codes drawn from the Chronic Care Model and the Consolidated Framework for Implementation Research, we identified themes illuminating contextual barriers and facilitators, as well as strategies for adapting core components of e-BP for implementation to control hypertension in community practice settings. Results Community-based patients, pharmacists, providers and staff expressed eagerness to participate in an intervention like e-BP. They characterized its approach to healthcare as "the right thing to do" and expressed hope that participation would yield enough evidence about the benefits of this care model to support significant reimbursement reform. The intervention's sustainability was of paramount importance to stakeholders and needs to be considered in planning for implementation. Stakeholders were more concerned about being able to overcome barriers related to regulations and reimbursement than to clinic-level factors. Discussion Community-based clinic stakeholders would like to improve hypertension control and the care of other chronic conditions using team care and communications outside of office visits. However, ensuring a business case for implementation and sustainability of these models was a persistent theme. Using this case study, we will discuss methods and models for adaptation and implementation of evidence-based interventions into community practice.     

The diabetes health care of Aboriginal people in South Australia (Part 1)

Although type 2 diabetes is a recognised health priority in South Australia, Aboriginal people with diabetes do not utilise the mainstream diabetes health services on a regular basis for health care. This means that Aboriginal clients have the potential to develop diabetes-related problems and, furthermore, are not in a position to make informed decisions about health care issues. This lack of client empowerment is contrary to the goals of contemporary diabetes health care and, as a result, Aboriginal clients suffer the consequences of ineffective management with a compromised lifestyle. To identify how this situation might be improved, a qualitative study funded by Diabetes Australia was undertaken in South Australia. The overall goal was, firstly, to identify the reasons why Aboriginal people with diabetes do not attend mainstream health agencies on a regular basis and secondly, if possible, to improve attendance. Thus, Aboriginal health professionals (n = 43) were recruited from the 8 statistical divisions of South Australia and interviewed about Aboriginal diabetes health care issues. In Part 1 of this series, the research findings indicated the beliefs and attitudes held by clients about diabetes, their lack of knowledge about management issues, their responses to diabetes, the effects of diabetes on their lifestyle and the strategies that diabetes health professionals used to help their clients deal with diabetes health issues. In Part 2 the research findings indicated the importance of the Aboriginal health worker to the successful diabetes management of Aboriginal clients, the constraints that affect the delivery of diabetes health care and the recommendations made by health professionals to improve the standard of diabetes health services.