Who are those most likely to be institutionalized,the elderly who receive comprehensive home care services or those who do not?

Three samples of clients aged 65 and over from three different home care and homemaker programs are compared to elderly persons with a risk of institutionalization chosen from three random samples of people aged 65 and over living in the catchment areas of the three programs. The most important differences between the clienteles and the populations with a risk of institutionalization appear when examining the availability of help. The populations at risk generally have access to a source of help living with the elderly person while the clienteles of comprehensive home care programs depend on outside help. Home care and homemaker programs therefore replace in-home services with out-of-home services. These services will be effective insofar as they succeed in reproducing some of the essential characteristics of in-home care.     

Service learning in health care higher education: risk or not to risk

The explosion of service learning as a teaching methodology in higher education has generated increased awareness of the potential for liability related to student experiences with service partnerships all over the world. At present, there are few instances of legal problems occurring using service learning with students, but risk management not risk avoidance may be the best form of preventing legal problems from occurring. Reviewing areas of potential liability with the service partner, the student, faculty and college institution for possible risks may reduce future problems. Strategies for dealing with potential identified risks are discussed in this article including identified agency risks, the capacities of the students, employment status, liability insurance, and agency incorporation. Reducing the risk with students includes evaluating the harm to and by students, assessing the student population, prerequisite courses, assumptions, developmental age of the student, good communication and use of an honor Code. The higher education institutions and faculty may reduce risk by instituting student contracts, maintaining student privacy, and using waivers. Good risk management through preparation of all involved in service learning projects is the key to success.     

Obesity: a diet that is acceptable is more likely to succeed

Obesity is a serious and increasing public health problem in the UK. The author discusses current evidence which suggests that intervention with individual clients is worthwhile, and that the priorities for promoting a healthy body weight are to reduce dietary fat and eat a diet high in carbohydrates, in conjunction with moderate daily physical activity. The client is unlikely to achieve an maintain a healthy body weight unless they find a diet and forms of exercise that they enjoy. Health professionals can help by providing evidence-based advice tailored to the individual client's preferences. For example, clients can eat more of the fruits and vegetables they like, and sugar need not be excluded from the carbohydrate components of the diet and may be beneficial in making the diet more palatable. Slow, steady weight loss should be the aim leading to maintaining a healthy body weight in the long-term. Small acceptable changes to the diet, which can be maintained lifelong, should be encouraged. Some practical suggestions for low energy diets and ways of increasing exercise are included.     

Who is the family doctor? Relating primary care to family care

Many families receive care as intact family units. To determine which specialists provide this family care, a subset of families (N = 447) enrolled in the Rand Health Insurance Experiment were examined. Among families designating a single primary care physician, family physicians and general practitioners provided 65.9% to 89.7% of their family care. Internists provided 20.0% and 27.3% of family care for younger and older couples, respectively. The remaining specialties, including pediatrics and obstetrics-gynecology, each provided less than 5% of family care; these small proportions of family care may reflect the specialists' self-imposed limits in primary care roles. As family members matured, families used fewer pediatricians and obstetrician-gynecologists for primary care and concurrently increased their use of family physicians or general practitioners. Care for intact families is provided predominantly by family physicians or general practitioners, although in families without children, internists also play an important role. Self-defined limits in primary care roles by physicians in various specialties and the changing use of specialties during the family life cycle largely determined which specialties provided family care.     

Diabetes care management participation in a primary care setting and subsequent hospitalization risk.

Scant evidence exists that examines the impact of participation in primary care diabetes management programs and their educational components on the risk of subsequent significant patient morbidity. This study examined the association between participation in a diabetes management program in a primary care setting and the risk of subsequent hospitalization. Ten thousand nine hundred eighty patients with diabetes mellitus receiving some type of treatment in a large primary care clinic network in Houston, TX were examined for incidence of hospitalization in the year 2002. Information from the year preceding the hospitalization was obtained on several demographic, clinical, and diabetes care management participation related variables. Multivariate logistic regressions were used to examine the relationship between primary care diabetes management participation as well as individual educational components and the likelihood of subsequent-year hospitalization. Patients participating in some type of primary care diabetes management were 16% less likely to have an incidence of hospitalization (p = 0.05). When individual educational components of the diabetes care management program were examined, diabetes education sessions were more beneficial than certified diabetes educator visits in reducing the incidence of hospitalization. Patients with controlled blood glucose levels and a diabetes education session seemed to have the most significant reduction in hospitalization risk (odds ratio [OR] = 0.62; 95% CI: 0.40, 0.95). There seem to be beneficial effects associated with participation in primary care diabetes management programs in terms of reduced hospitalization risk. Attendance at diabetes educational sessions in primary care settings coupled with maintenance of blood glucose control seem to be associated with greatest risk reduction.     

Developing a standard of care for patients at risk for long-term hospitalization

At one hospital, during 1 month, charts of patients whose length of stay was greater than or equal to 60 days were reviewed to determine current dietetics practice. Several areas that affect overall nutrition care were identified: consistent follow-through on recommendations, continuity of care, consistent protocol for addition of supplements, communication of results of calorie counts, and assessment of nutritional status over the course of hospitalization vs documentation on a particular day. A protocol was developed to provide weekly information about patient weight for ongoing nutrition assessment. A profile of patients at risk for increased length of hospital stay was developed using historical information. Patient age and diagnosis at the time of admission were the basis of the profile, which was incorporated into the screening program. A standard of care was designed to provide early, aggressive nutrition intervention to patients at risk. Clinical managers can follow the steps outlined to develop consistent nutrition care standards. Such standards can be incorporated into a quality improvement program to assess the effectiveness of the nutrition care methods and improve the quality of care provided.     

Who is at risk of osteoporosis?

This contribution assesses who is at risk of osteoporosis, by delineating the key risk factors involved in the condition. Osteoporosis represents a major public health problem through its association with fragility fractures, primarily of the hip, spine and distal forearm. Some risk factors for fragility fracture act through bone mineral density (BMD), for example female gender, asian or Caucasian race, premature menopause, primary or secondary amenorrhoea, primary and secondary hypogonadism in men, prolongued immobilisation, low dietary calcium intake, vitamin D deficiency. However, a number of others contribute significantly to fracture risk over and above their association with BMD (age, high bone turnover, poor visual acuity, neuromuscular disorders, previous fragility fracture, glucocorticoid therapy, family history of hip fracture, low body weight, cigarette smoking, excess alcohol consumption).     

Who is at risk of what?

If you have calculated the sample size required for an employee survey or an observational study of departmental practices but found that the number of observations required is larger than the number of employees, chances are the error is due to use of approximation formulae. Many of us unknowingly were taught to use approximations that fail to include the finite population correction factor. Depending on the objective of a study and the proportion of a population sampled, it may be necessary to consider this correction factor in order to estimate standard error and sample size accurately.     

Profile of the foster child likely to experience unstable care: a re-examination

This research reports the results of a survey exploring characteristics associated with the stability of foster care. The survey was developed from a national profile of the child likely to experience unstable foster care. Findings and implications are discussed.     

The importance of continuity of care in the likelihood of future hospitalization: is site of care equivalent to a primary clinician?

OBJECTIVES: This study examined the effect of continuity with clinicians and health care sites on likelihood of future hospitalization. METHODS: Delaware Medicaid patient data were analyzed. Logistic regression models supplied adjusted effects of continuity on hospitalization. RESULTS: Patients in the high clinician continuity group had lower odds of hospitalization than patients in the high site/low clinician continuity group (odds ratio [OR] = 0.75, 95% confidence interval [CI] = 0.66, 0.87). The latter group did not differ from the low site/low clinician continuity group (OR = 0.93, 95% CI = 0.80, 1.08). CONCLUSIONS: A location providing health care without clinician continuity may not be sufficient to ensure cost-effective care.     

Home care program for patients at high risk of hospitalization

Objective: To assess the efficacy of a home care program designed to improve access to medical care for older adults with multiple chronic conditions who are at risk for hospitalization. Study Design: Randomized controlled trial in which participants were assigned to the home care intervention (Choices for Healthy Aging [CHA]) program or usual care. Methods: The intervention group consisted of 298 older adults at risk of hospitalization as determined by a risk stratification tool. Measures included satisfaction with medical care, medical service use, and costs of medical care. Results: The intervention group reported significantly greater satisfaction with care than usual care recipients (t test = 2.476; P = .014). CHA patients were less likely than usual care patients to be admitted to the hospital (25.6% and 37.1%, respectively; P = .02). There were no differences in terms of costs of care between the home care and usual care groups. Conclusions: Provision of home care to older adults at high risk of hospitalization may improve satisfaction with care while reducing hospitalizations. Lack of difference in medical costs suggests that managed care organizations need to consider targeting rather than using risk stratification measures when designing programs for high-risk groups.     

Characteristics of men most likely to respond to an invitation to be screened.

Some of the characteristics of men, with known risk factors, who were most likely to respond to an invitation to be screened in a national randomized clinical trial to prevent heart disease were determined in 18,872 men, 35-57 years of age, members of the Kaiser Foundation Health Plan of Oregon. Demographic characteristics and risk factor variables (blood pressure, blood cholesterol, and cigarette smoking levels) were abstracted from medical records. The men were ranked high priority or low priority according to level of risk. All age-eligible men in the health plan received at least one invitation to be screened, with high-priority men receiving more invitations. Despite concentrated efforts to bring them in, less than one-half the high-priority men were screened. Participants were older and wealthier than non-participants, and more likely to have more dependents and to routinely use medical services. Whether or not a man received a medical care service within the preceding two years was a powerful discriminating variable in both the univariate and multivariate analyses reported. The findings suggest that health care programs serving a stable population group should give more consideration to screening in routine medical care.     

The distance to community medical care and the likelihood of hospitalization: is closer always better?

OBJECTIVES: This study examined the influence that distance from residence to the nearest hospital had on the likelihood of hospitalization and mortality. METHODS: Hospitalizations were studied for Maine. New Hampshire, and Vermont during 1989 (adults) and for 1985 through 1989 (children) and for mortality (1989) in Medicare enrollees. RESULTS: After other known predictors of hospitalization (age, sex, bed supply, median household income, rural residence, academic medical center, and presence of nursing home patients) were controlled for, the adjusted rate ratio of medical hospitalization for residents living more than 30 minutes away was 0.85 (95% confidence interval [CI] = 0.82, 0.88) for adults and 0.78 (95% CI = 0.74, 0.81) for children, compared with those living in a zip code with a hospital. Similar effects were seen for the four most common diagnosis-related groups for both adults and children. The likelihood of hospitalization for conditions usually requiring hospitalization and for mortality in the elderly did not differ by distance. CONCLUSIONS: Distance to the hospital exerts an important influence on hospitalization rates that is unlikely to be explained by illness rates.