The involvement of volunteers in palliative care and their collaboration with healthcare professionals: A cross‐sectional volunteer survey across the Flemish healthcare system (Belgium)

Volunteers occupy a specific space in the delivery of palliative care (PC), addressing specific aspects of care and providing a link between professional healthcare providers and informal care. Engaging and empowering these volunteers can be an important strategy to deliver more integrated and comprehensive PC. Insights into current actual volunteer involvement and collaboration across different healthcare services providing generalist and specialist PC is lacking. This study aims to describe volunteers’ involvement in the organisation of PC, collaboration with professionals and how they evaluate this. A cross‐sectional postal survey of volunteers was conducted between June and November 2018 using a written questionnaire. A two‐step disproportionately stratified cluster randomised sample of 2,273 registered volunteers was taken from different strata of healthcare organisations providing care for people with serious illnesses in the Flemish healthcare system (Belgium). Overall response was 35% (15%–60% for individual strata). About 67% of volunteers were often to always informed about the organisation of patient care and 48% felt the organisation often to always takes their opinion into account, while a minority report having decision rights (18%) or autonomy (24%). For some, their organisation failed to inform (17%), consult (27%), take into account their opinion (21%), give them decision rights (20%) or autonomy (16%) over certain aspects of patient care provision often enough. Overall, volunteer–professional collaboration was low, and mostly limited to information sharing. Dedicated PC volunteers collaborated extensively with nurses, often involving task coordination (46%). Ambiguity regarding tasks, agreements and/or rules (15%) and lack of information exchange (14%) were the most cited barriers to volunteer–professional collaboration. Many volunteers were open to stronger involvement in the organisation of care in PC services. Collaboration with professionals seemed lacking in width and depth. Particularly, nursing home volunteers indicated a desire and large potential for more involved and collaborative roles in PC provision.     

The boundaries of care work: a comparative study of professionals and volunteers in Denmark and Australia

This paper explores the manner in which two hospices – one located in Denmark and one in Australia – negotiate and determine the boundaries of volunteer workers vis‐à‐vis paid staff. A comparative case study approach was used to juxtapose organisations with similar activity fields located in different welfare state systems, i.e. a social democratic welfare state and a liberal welfare state. This study involved non‐participant observation of volunteers at work and unstructured interviews with volunteers, staff and management in the hospices (n = 41). Data were collected between August 2012 and February 2013. Data were managed using NVivo and analysed thematically. A key finding is that volunteers in the Danish hospice were excluded from all direct care work due to the effective monopoly of the professional care providers, whereas the Australian volunteers participated in the provision of care to the extent that risk could be eliminated or mitigated to an acceptable level. The findings suggest two different models of the roles of volunteers in tension with professional care providers. Both models recognise that volunteers add to the level of care delivered by the organisations and allow for a discussion that moves away from the normative discussions of ‘not taking somebody's job’, while also recognising that volunteers must be more than just the ‘nice extra’ if they are to be of any real value to the organisation and to care receivers.     

The healthcare experiences of Koreans living in North Carolina: a mixed methods study

This study examined the healthcare experiences of Korean immigrants aged 40–64 living in the North Carolina Triangle area of the Southeastern United States. Using a mixed methods design, we collected quantitative data via a questionnaire from 125 participants and conducted a focus group with 10 interviewees from December 2010 to February 2011. The quantitative data were analysed using t‐tests and chi‐square tests, and a thematic analysis was used for the focus group study. Questionnaire findings showed that only 27.2% had sufficient English skills to communicate adequately. Participants with insurance were significantly more likely to be employed (P < 0.001), had higher incomes (P = 0.011) and higher education (P < 0.001), and had greater English‐speaking ability (P = 0.011) than those without insurance. Participants who did not use healthcare services showed significantly less knowledge (P < 0.001) of and less satisfaction (P = 0.034) with the healthcare system than those using healthcare services. Sixty‐two participants (49.6%) reported having no health insurance for one or more of the following reasons: high costs (75.8%), medical tourism (22.6%) and lack of information or knowledge (6.5%). The following themes emerged from the data collected during the focus group: (i) barriers to utilisation of healthcare services; (ii) facilitators of utilisation of healthcare services; and (iii) social support seeking for health management. Our mixed methods study findings indicate that healthcare disparities exist among Korean immigrants and that a number of factors, including health literacy, may contribute to their poor health outcomes. Continued collaboration among community members, healthcare professionals and academicians is needed to discuss the community's health concerns and to develop sustainable programmes that will ensure meaningful access to care for those with limited English proficiency and medically underserved populations.     

Factors affecting general practice collaboration with voluntary and community sector organisations

Collaborative working between general practice (GP) and voluntary and community sector (VCS) organisations is increasingly championed as a means of primary care doing more with less and of addressing patients’ “wicked problems”. This paper aims to add to the knowledge base around collaborative practice between GPs and VCS organisations by examining the factors that aid or inhibit such collaboration. A case study design was used to examine the lived‐experience of GPs and VCS organisations working collaboratively. Four cases, each consisting of a GP and a VCS organisation with whom they work collaboratively, were identified. Interviews (n = 18) and a focus group (n = 1) were conducted with staff within each organisation. Transcribed data were analysed thematically. Whilet there are similarities across cases in their use of, for example, Health Trainers and social prescribing, the form and function of GP‐VCS collaborations were unique to their local context. The identified factors affecting GP‐VCS collaboration reflect those found in previous service evaluations and the broader literature on partnership working; shared understanding, time and resources, trust, strong leadership, operational systems and governance and the “negotiation” of professional boundaries. While the current political environment may represent an opportunity for collaborations to develop, there are issues yet to be resolved before collaboration—especially more holistic and integrated approaches—becomes systematically embedded into practice.     

Solidarity or dissonance? A systematic review of pharmacist and GP views on community pharmacy services in the UK

There has been a strong policy emphasis over the past decade on optimising patient‐centred care and reducing general practitioners’ (GPs’) workload by extending community pharmacy services and collaboration between pharmacists and GPs. Our aim was to review current evidence of pharmacists’ and GPs’ views of extended community pharmacy services and pharmacists’ roles in the United Kingdom (UK). A systematic review was undertaken looking at UK studies investigating pharmacists’ and/or GPs’ views of community pharmacy services or roles from 2005 to 2017. A range of databases were searched including EMBASE, PubMed, Scopus, Web of Science, International Pharmaceutical Abstracts (IPA), PsycINFO, Science Direct and The Cumulative Index to Nursing and Allied Health Literature (CINAHL). In addition, reference lists of included studies were screened and grey literature was searched. Following the application of inclusion/exclusion criteria, the quality of papers was critically analysed, findings were extracted into a grid and subjected to narrative synthesis following thematic analysis. The search strategy yielded a total of 4,066 unique papers from which 60 were included. Forty‐seven papers covered pharmacists’ views, nine combined both pharmacists’ and GPs’ views and four covered GPs’ views. Study designs included interviews (n = 31, 52%), questionnaire surveys (n = 17, 28%) and focus groups (n = 7, 12%). Three main themes emerged from the data: “attitudes towards services/roles”, “community pharmacy organisations” and “external influences”. Pharmacists and GPs perceived a number of barriers to successful implementation and integration of pharmacy services. Moreover, collaboration between pharmacists and GPs remains poor despite the introduction of extended services. Overall, extending community pharmacy services require quality‐driven incentives and joint working between community pharmacists and GPs to achieve better integration within the patient's primary care pathway.     

Direct and indirect costs of home healthcare in Japan: A cross‐sectional study

To tackle the rising healthcare expenditure in an ageing society in Japan, home healthcare has been promoted over the past several years. However, there is a dearth of literature on total costs incurring for home healthcare. In this study, we conducted a cross‐sectional study among patients, who received home healthcare in the month of May, 2018. Direct healthcare costs and patients’ clinical characteristics were collected from medical records and long‐term care databases (n = 166). Indirect costs were estimated using a questionnaire survey which obtained information on job absenteeism and care time from the caregiver. A total of 112 patients responded to the survey. The median age was 82 years (interquartile range: 74–88). Total per‐person per month home‐care costs averaged USD 6,163 with direct costs (USD 2,547) and indirect costs (USD 3,596) accounted for 41.3% and 58.3% of the total costs, respectively. The largest components of direct costs were long‐term care costs (48%) and medical costs (47%). Multivariable adjusted model showed that those with heavy healthcare were more likely to incur higher total as well as direct and indirect home healthcare cost (p<.05 for each). Patients aged >75 years (p = .041) were less likely and those who used oxygen at home were more likely to incur direct home healthcare cost (p = .001) than their counterpart. Our study findings show that indirect cost is a major contributor to total home healthcare costs in Japan. Also for patients who need heavy healthcare, both direct and indirect costs are large burden.     

Impact of a pay for performance program to improve diabetes care in the safety net

ObjectiveTo evaluate the impact of a “piece-rate” pay for performance (P4P) program aimed at improving diabetes care processes, outcomes and related healthcare utilization for patients enrolled in a not-for-profit Medicaid-focused managed care plan.MethodsTo evaluate Hudson Health Plan's P4P program in New York (2003–2007), we conducted: (1) a case-comparison difference-in-difference study using plan-level administrative data; (2) a patient-level claims data analysis; and (3) a cross-sectional survey.ResultsThe case-comparison study found that diabetes care processes (e.g., HbA1c, lipid, and dilated eye exam rates) and outcomes (e.g., LDL-C < 100 mg/dL) did not improve significantly over the study period. Claims analysis showed that younger adults had significantly increased odds (OR 3.50–3.56, p < 0.001) of using emergency and hospital-based services and similarly decreased odds of receiving recommended care process (OR 0.22–0.36, p < 0.01–0.001). Survey study indicated that practices lack fundamental quality improvement infrastructures and training.ConclusionsRecent health legislation mandates the use of P4P incentives in government programs that disproportionately care for patients with lower socioeconomic or minority backgrounds (e.g., Medicaid, Veterans Health Administration, and Tricare). More research is needed in order to understand how to tailor P4P programs for vulnerable care settings.     

Difficulties in navigating the intersection of generalist and specialist palliative care services: A cross-sectional study of bereaved family's experiences of care at home in New Zealand

A generalist–specialist model of palliative care is well established as a framework for the provision of community care in resource-rich countries. However, evidence is lacking regarding how the model is experienced by family carers and the extent to which access to both generalist and specialist palliative care is equitable. A cross-sectional postal survey was undertaken to explore bereaved family's experiences of generalist palliative care and its intersection with hospice services in the last 3 months of life. A modified version of the Views of Informal Carers—Evaluation of Services survey was sent to 4,778 bereaved family. Data were collected between February 2017 and October 2018. Chi-square was utilised to identify factors that impacted on experiences of generalist palliative care; analysis of free text data comprising 45,823 words was undertaken using a directed content analysis approach. Eight hundred and twenty-six questionnaires were returned (response rate = 21%). Seventy per cent of people (n = 579) spent some time at home in the last 3 months prior to death. People who received support from hospice were more likely to receive support from multiple other services. Those who received no community services were less likely to feel supported by their general practitioner, less likely to spend the last 2 days of life or die at home. Feeling supported had a strong association with services working well together, being involved in decision-making and being aware of the poor prognosis. The provision of palliative care is complicated by a lack of integration with specialist palliative care and may be the basis of continuing inequities in the provision of community care at the end of life. The assumption at a policy level that “generalists” are willing and able to play a key role in palliative care provision needs to be further challenged.     

The Impact of Palliative Medicine Consultation on Readmission Rates and Hospital Costs in Surgical Patients Requiring Prolonged Mechanical Ventilation

BackgroundThe use of palliative care for critically ill hospitalized patients has expanded. However, it is still underutilized in surgical specialties. Postsurgical patients requiring prolonged mechanical ventilation have increased mortality and costs of care; outcomes from adding palliative care services to this population have been poorly investigated. The objective of this study was to determine the impact of palliative medicine consultation on readmission rates and hospitalization costs in postsurgical patients requiring prolonged mechanical ventilation.MethodsThe Nationwide Readmissions Database was queried for adults (> 18 years) between the years 2010 and 2014 who underwent a major operation (Healthcare Cost and Utilization Project [HCUP] data element ORPROC = 1), required mechanical ventilation for ≥ 96 consecutive hours (ICD-9-CM V46.1), and survived until discharge. Among these, patients who received a palliative medicine consultation during hospitalization were identified using the ICD-9-CM diagnosis code V66.7.ResultsOf 53,450 included patients, 3.4% received a palliative care consultation. Compared to patients who did not receive a palliative care consultation, patients who did receive a consultation had a lower readmission rate (14.8% vs. 24.8%, p < 0.001) and lower average cost of hospitalization during the initial admission ($109,007 vs. $124,218, p < 0.001), findings that persisted after multivariable logistic regression.ConclusionUtilization of palliative care in surgical patients remains low. Palliative care consultation in postsurgical patients requiring prolonged mechanical ventilation was associated with lower cost and rate of readmission. Further work is needed to integrate palliative care services with surgical care.     

Association of culturally competent care with influenza vaccination coverage in the United States

BackgroundCultural minority groups in the United States have lower vaccination rates or worse influenza-related outcomes. Culturally competent care, which aims to engage the social, cultural, and linguistic needs of all patients, may address some of these disparities.ObjectiveWe investigate how self-reported measures of culturally competent care is associated with influenza vaccination rates in the United States.MethodsThe National Health Interview Survey (NHIS) 2017 was queried for respondents asked a set of questions which assessed respondents’ access to culturally competent care in the past year. The outcome of interest was self-reported receipt of the annual influenza vaccine. Sample-weighted multivariable logistic regressions estimated the adjusted odds ratios and 95 % confidence intervals (95 %CI) of influenza vaccination with response to the cultural competency survey questions as the dependent variable of interest. Subsequent marginal modeling predicted the adjusted vaccination rates among cultural minorities (racial/ethnic minorities, LGBTQ + adults, foreign-born individuals, and non-English speakers) and respondents with high-risk comorbidities for worse influenza outcomes. Models were adjusted for other known determinants of vaccination coverage.Results20,303 sample adults were included in the analyses. There were significantly higher odds of influenza vaccination among respondents who were “always” or “most of the time” treated with respect by their providers (aOR 1.53, 95 %CI [1.23–1.90], P < 0.001), given easy-to-understand information (aOR 1.37, 95 %CI [1.19–1.58], P < 0.001), asked about their opinions or beliefs about their care (aOR 1.29, 95 %CI [1.19–1.39], P < 0.001), and seen by providers who shared or understood their culture (aOR 1.15 95 %CI [1.01–1.30], P = 0.03), compared to their counterparts who responded with “some” or “none of the time” to the same survey questions. Higher adjusted influenza vaccination rates were seen among multiple racial/ethnic groups, LGBTQ + adults, foreign-born individuals, non-English speakers, and individuals with high-risk comorbidities who reported positive responses to the cultural competency survey questions.ConclusionsWe demonstrate a positive association between self-reported frequency of access to culturally competent care and receipt of the annual influenza vaccine. These findings support future efforts to evaluate vaccination outcomes among patients who receive components of culturally competent care, such as linguistically appropriate services, race-concordant healthcare workforce, and community engagement.     

Reforming foodservice in elderly care: National actions and local outcomes

Aim

The aim was to explore the outcome, on a local level, of steering, organisation and practices of elderly care foodservice by Swedish municipalities, and changes relative to national actions.

Methods

A survey using a web‐based questionnaire about elderly care foodservice targeting all Swedish municipalities (n = 290) was conducted in 2006 and 2013/2014. The questionnaire included the topics: organisation of foodservice, its practice in elderly care and steering devices such as guidelines and policies. Based on the share of a rural population, municipalities were divided into groups: rural (≥50%), urban (<50%) and city (≤20%).

Results

The response rate from municipalities was 80% in 2006 and 56% in 2013/2014; 45% participated in both surveys. The results showed increased use of local food policies (P = 0.03) and meal choice (P < 0.001), while access to clinical/community dietitians declined (P = 0.01) between the surveys. In home‐help services, daily delivered cook‐serve meals declined (P < 0.001) and chilled meals delivered three times a week increased (P = 0.002) between the surveys. City municipalities used private foodservice organisations the most (P < 0.001), and reported reduced use of cook‐serve systems in favour of chilled. In rural municipalities, the use of public providers (98%) and a cook‐serve system (94%) were firmly established. Urban municipalities were placed between the other groups.

Conclusions

National actions such as soft governance and benchmarking appear largely to determine local level outcomes. However, conditions for adapting these measures vary between municipality groups. While efficiency enhancing trends were prominent, questions remain whether national actions should be expanded beyond performance to also examine their consequences.     

Healthcare Barriers and Utilization Among Adolescents and Young Adults Accessing Services for Homeless and Runaway Youth

Homeless and runaway youth are at disproportionate risk for adverse health outcomes. Many barriers to accessing healthcare have been documented; however, the relative impact of discrete barriers on homeless youth healthcare utilization behavior is not firmly established. We administered a survey examining reported barriers and healthcare utilization among adolescents and young adults accessing services at three community centers for homeless and runaway youth. Of 180 respondents, 57?% were male, 80?% non-White, and 21?% identified as a sexual minority. Stepwise logistic regression models, controlling for age and study site, explored associations between barriers and 3 healthcare utilization outcomes (doctor visit in past 12 months; regular care provider; frequent emergency department (ED) visits). The most commonly reported barriers were “don’t have a ride” (27.2?%), “no insurance” (23.3?%), and “costs too much” (22.8?%). All fear-based barriers (e.g., “I don’t trust the doctors”) were reported by <5?% of surveyed youth. Significant predictors of having seen a doctor in the past 12 months included sexual minority status (OR 2.8, p?=?0.04) and possession of health insurance (OR 4.9, p?<?0.001). Female sex (OR 5.2, p?<?0.001) and reported external barriers other than health insurance (OR 0.2, p?<?0.001) were associated with having a regular care provider. Fear-based concerns were associated (OR 3.8, p?=?0.02) with frequent ED visits, as was being insured (OR 2.2, p?=?0.03). These results underscore the need to clearly define healthcare outcomes when investigating barriers to care among homeless and runaway youth as the impact of discrete barriers varies depending on outcome of focus.     

Adherence to the Mediterranean diet and weight status in children: the role of parental feeding practices

Abstract

The study examines Parental Feeding Practices (PFP) in relation to adherence to the Mediterranean Diet (MD) and children’s weight status. It’s a cross-sectional study of 402 parents (68.4% mothers), with children aged 2–12 years. Parents completed the Comprehensive Parental Feeding Questionnaire and the Mediterranean Diet Quality Index for children and adolescents (KIDMED), evaluating children’s adherence to the MD. Logistic regression showed that in children aged 2–<6 years, “emotion regulation/food as reward” and “pressure” decrease MD adherence (OR?=?0.186, p?<?0.0001 and OR?=?0.496, p?=?0.004), and “monitoring” decrease excess body weight (OR?=?0.284, p?=?0.009). In older children (6–12 years), “healthy eating guidance” and “monitoring” increase MD adherence (OR?=?3.262, p?=?0.001 and OR?=?3.147, p?<?0.0001), “child control” decreases MD adherence (OR?=?0.587, p?=?0.049), “pressure” decrease excess body weight (OR?=?0.495, p?<?0.0001) and “restriction” increase excess body weight (OR?=?1.784, p?=?0.015). “Healthy eating guidance” and “monitoring” seem to be the best PFP employed, in terms of children’s MD adherence and weight status.     

Evaluation of a community based dental clinic for youth experiencing homelessness in Brisbane

The relationship between homelessness and ill health is complex, and many risk factors for homelessness such as unemployment, low income, and substance abuse are also risk factors for poor oral health. In order to overcome barriers to access dental care, previous studies have recommended integrating dental care, referral pathways, and information within the overall care provided by support services available to people at risk of homelessness. This study aimed to evaluate a dental service developed and implemented to improve access to oral health care of disadvantaged youth in Brisbane. A mobile dental clinic run by volunteer dental professionals was implemented into a community organisation for disadvantaged youth. Participants were clients of Brisbane Youth Services who were disadvantaged youth, ≤25 years and attended the dental clinic in a 1 year period. A questionnaire collected demographic information, a self‐assessment of oral health and an evaluation of their experiences with the dental clinic. Clinical data including DMFT, appointment attendance and items of service provided were collected. One hundred and twelve clients participated in the four dental clinic weeks and its evaluation. Cost was the greatest reported barrier to accessing dental care among participants. More than half (57%) of participants who pre‐booked an appointment failed to attend. A total of 640 services were delivered, with an estimated value of $48,000. The majority (69%, n = 444) of the services provided were preventative services. Almost all of the clients felt the service they received was suitable for them (97%, n = 98) and would use the service again (98%, n = 99). This dental clinic model is feasible and sustainable due to its integration into an existing homeless youth service, low running costs, acceptability to clients and an interest by dental practitioners to volunteer. It provides a useful model which could be scaled up and implemented in other regions.     

Factors associated with the perception of parents and children regarding obesity-related terminology used by healthcare professionals in a sample of Korean children and adolescents with obesity

ObjectiveThis study aimed to compare how children with overweight or obesity and their parents perceive the obesity-related terms used by healthcare professionals and investigate the factors associated with these perceptions.MethodsChildren and adolescents aged 8–16 years with overweight or obesity (n = 192) and their parents participated in the cross-sectional study by responding to a 5-point Likert-scale questionnaire on 10 obesity-related terms, including “chubby,” “weight problem,” “weight,” “overweight,” “BMI,” “obese,” “heavy,” “fleshy,” “fat,” and “severely obese.”ResultsFor both children and parents, “chubby” was the most desirable term (mean ± standard deviation: 3.50 ± 1.12 and 2.95 ± 0.83, respectively), and “severely obese” was the least acceptable term (2.83 ± 1.17 and 2.02 ± 1.02, respectively). Although the parents preferred all the terms less than the children did (p < 0.001), “weight problem” was considered most motivating for a child to lose weight (3.93 ± 0.94). Among children, older age and a larger self-perceived body size were associated with a more positive response towards obesity-related terms, whereas having internalized or externalized problems were negatively associated with these terms. Parents with a history of cardiovascular disease considered “severely obese” (β = ?0.419, [95% CI: ?0.739, ?0.099]) and “fat” (β = ?0.457, [95% CI: ?0.750, ?0.164]) less desirable.ConclusionsChildren and adolescents had a higher preference for obesity-related terms than their parents and preferred that healthcare professionals use euphemistic terms such as “chubby,” or neutral terms such as “weight problem.” Children with larger self-perceived body sizes or older age had a higher preference for obesity-related words. The terms used by healthcare professionals to describe excess weight must be motivating and respectful for all family members participating in the treatment.     

Cultural competence in healthcare in the community: A concept analysis

This study aims to conduct a concept analysis on cultural competence in community healthcare. Clarification of the concept of cultural competence is needed to enable clarity in the definition and operation, research and theory development to assist healthcare providers to better understand this evolving concept. Rodgers’ evolutionary concept analysis method was used to clarify the concept's context, surrogate terms, antecedents, attributes and consequences and to determine implications for further research. Articles from 2004 to 2015 were sought from Medline, PubMed, CINAHL and Scopus using the terms “cultural competency” AND “health,” “cultural competence” OR “cultural safety” OR “cultural knowledge” OR “cultural awareness” OR cultural sensitivity OR “cultural skill” AND “Health.” Articles with antecedents, attributes and consequences of cultural competence in community health were included. The 26 articles selected included nursing (n = 8), health (n = 8), psychology (n = 2), social work (n = 1), mental health (n = 3), medicine (n = 3) and occupational therapy (n = 1). Findings identify cultural openness, awareness, desire, knowledge and sensitivity and encounter as antecedents of cultural competence. Defining attributes are respecting and tailoring care aligned with clients’ values, needs, practices and expectations, providing equitable and ethical care, and understanding. Consequences of cultural competence are satisfaction with care, the perception of quality healthcare, better adherence to treatments, effective interaction and improved health outcomes. An interesting finding is that the antecedents and attributes of cultural competence appear to represent a superficial level of understanding, sometimes only manifested through the need for social desirability. What is reported as critical in sustaining competence is the carers’ capacity for a higher level of moral reasoning attainable through formal education in cultural and ethics knowledge. Our conceptual analysis incorporates moral reasoning in the definition of cultural competence. Further research to underpin moral reasoning with antecedents, attributes and consequences could enhance its clarity and promote a sustainable enactment of cultural competence.