融入社区的医疗与养老

医疗与养老一直都是大众和学界的热门话题,是国家持续推进的两项重要民生事业,关乎我们未来健康生活的保障问题.三甲医院、养老机构越来越多,硬件设施和软件服务越来越好,但是仍旧无法满足社会的需求.推行分级诊疗、预防保健、居家养老是适合我国当前国情和实际的卫生保障和卫生服务之路.这不仅是机制的转变,也是社会观念、生活习惯的重新...     

Effectiveness of a Community Health Worker Cardiovascular Risk Reduction Program in Public Health and Health Care Settings

Objectives. We evaluated whether a program to prevent coronary heart disease (CHD) with community health workers (CHWs) would improve CHD risk in public health and health care settings.Methods. The CHWs provided point-of-service screening, education, and care coordination to residents in 34 primarily rural Colorado counties. The CHWs utilized motivational interviewing and navigated those at risk for CHD into medical care and lifestyle resources. A software application generated a real-time 10-year Framingham Risk Score (FRS) and guideline-based health recommendations while supporting longitudinal caseload tracking. We used multiple linear regression analysis to determine factors associated with changes in FRS.Results. From 2010 to 2011, among 4743 participants at risk for CHD, 53.5% received medical or lifestyle referrals and 698 were retested 3 or more months after screening. We observed statistically significant improvements in diet, weight, blood pressure, lipids, and FRS with the greatest effects among those with uncontrolled risk factors. Successful phone interaction by the CHW led to lower FRS at retests (P = .04).Conclusions. A CHW-based program within public health and health care settings improved CHD risk. Further exploration of factors related to improved outcomes is needed.The US Affordable Care Act specifies implementation of a national partnership for disease prevention and health promotion, with a focus on reducing health disparities.1 Although the Affordable Care Act includes community outreach as a key component, it provides little detail on optimal methods for integrating community and health care silos. One potential linkage is the community health worker (CHW) who is a lay person trained to carry out specific health interventions. There is considerable evidence supporting the positive impact of CHWs on the health of diverse populations with hypertension and other chronic conditions.2–6 However, systematic reviews of CHW effectiveness suggest important gaps in the evidence base,7,8 and studies of coronary heart disease (CHD) risk factor interventions, in particular, were isolated within health care delivery settings. In addition, no studies to date have demonstrated a reduction in global CHD risk, the strongest predictor of long-term fatal and nonfatal cardiovascular events.9Although the burden of CHD continues to decline,10 it remains the leading cause of morbidity and mortality in the United States11 where substantial health disparities persist among underserved populations, particularly geographically isolated residents.12–14 In addition to limited access to primary care, rural medical centers have significantly fewer clinical capabilities, worse measured processes of care, and higher mortality rates among patients presenting with acute cardiovascular conditions.15From 2006 to 2009, a previous statewide CHW-based network provided CHD screening to medically underserved populations including urban, rural, and frontier regions of Colorado.16 The CHWs were deployed to provide point-of-service health screenings and education. In this population of 17 995 individuals, 82% were unaware of their risk for CHD, which suggested an important unmet public health need. This previous program was not designed to track health outcomes and focused primarily on the first step in the health improvement continuum by raising awareness among vulnerable individuals. Given this background, we enhanced the framework of the previous program by integrating best practices from multiple public health and health care models. This included:

1. creating a decision-support algorithm that would generate tailored health messages based upon national treatment guidelines,
2. assessing participant readiness to change,
3. utilizing motivational interviewing techniques to promote healthy behavior change,
4. incorporating longitudinal follow-up for at-risk participants,
5. improving navigation into medical care and community resources, and
6. integrating health care provider educational detailing.

These enhancements were incorporated into an electronic data collection system designed to assist the CHWs’ workflow within the overall program framework. The program was adapted to the culture of the community to effectively link community outreach with local medical clinics. We sought to demonstrate whether a CHW-based program that integrated both public health and health care models would reduce CHD risk. We assessed outcomes from 2010 to 2011, and investigated factors associated with changes in Framingham Risk Score (FRS).     

The Impact of Birth Spacing on Subsequent Feto-Infant Outcomes among Community Enrollees of a Federal Healthy Start Project

Numerous studies have shown an association between shorter birth intervals, and several adverse fetal outcomes, including low birth weight (LBW), preterm birth (PTB), and small for gestational age (SGA). However, there is little evidence on the effectiveness of interconception care on fetal outcomes associated with sub-optimal interpregnancy interval (IPI). The purpose of this study is to examine the influence of the Federal Healthy Start’s interconception care services on IPI and fetal growth outcomes. This is a retrospective cohort study used records from the Central Hillsborough Healthy Start program in Tampa, Florida linked to Florida vital statistics data covering the period 2002–2009. Only first and second pregnancies were considered, and interpregnancy interval (IPI), the exposure of interest, was categorized in months as 0–5, 6–17, 18–23, and ≥24. The following feto-infant morbidities were considered as primary outcomes: LBW, PTB, and SGA. A composite variable coding the presence of any of the aforementioned adverse fetal events was also created. Multivariate logistic regression modeling was applied Overall, mothers with the shortest IPI (0–5 months: AOR = 1.39, 95% CI 1.23–1.56) and longest IPI (≥60 months: AOR = 1.13, 95% CI 1.03–1.23) were at a greater risk for adverse fetal growth outcomes, compared to the referent category (18–23 months). Our findings support the need for inter conception care that addresses IPI and delayed childbearing among women.     

Interdisciplinary collaboration within Quebec Community Health Care Centres

Central to the success of many recent health system reforms is the implementation of new primary health care delivery models. The central characteristic common to these new models usually emphasises interdisciplinary collaboration. Using empirical research, this paper studies interdisciplinary collaboration among various groups of professionals within an original Canadian primary health care delivery model, the Quebec Community Health Care Centres (CCHCs). The entire population of more than 150 CHCCs have been surveyed. The goals of this study are (1) to measure the achieved intensity of inter-professional collaboration among Quebec CHCCs, and (2) to identify the organisational and professional factors fostering or limiting interdisciplinary collaboration. The results show that Quebec CHCCs have reached modest results in achieving interdisciplinary collaboration especially since interdisciplinary collaboration is a central objective that has been pursued for more than 25 years. This study demonstrates that the main factors associated with interdisciplinary collaboration are closely linked to work group internal dynamics. Interdisciplinary collaboration is linked to the simultaneous and antagonistic effect of some central intragroup process factors. Conflicting values and beliefs are present that both enhance and limit interdisciplinary collaboration. The presence of conflicting stimuli seriously undermines the strength of the CHCC work group's shared beliefs and strongly limits interdisciplinary collaboration. The results also stress the importance of administrative formalisation initiatives to enhance collaboration among different professions. The efficacy of formalisation in this context is based on its capacity to offer an articulated and operative interdisciplinary framework that can generate a counteractive effect to the traditional professional framework. It offers concrete rules that help align the work group beliefs with interdisciplinary values. The formalisation of functions and processes appears thus to be an interesting means to further interdisciplinary collaboration.     

培训家庭保健员在社区健康教育中的作用

综合基层卫生服务应以妇女、儿童、老年、残疾人为重点 ,融预防、医疗、保健、康复、健康教育为一体。培训家庭保健员 ,充分发挥其在健康教育中的作用 ,是值得研究的新课题。浙江省诸暨市人民医院和中医院 ,从培训家庭保健员入手 ,使其在家庭和社会中发挥卫生保健和健康教育的独特作用 ,成效明显。培训对象本组共培训家庭保健员 81 6人 ,女 796人 ,男 2 0人 ,年龄最大的 56岁 ,最小的 1 8岁 ,平均 3 0岁 ,均为具有初中以上文化程度的家庭主妇或患者子女。其中视力残疾患者保健员 568人 ,高血压患者保健员 98人 ,脑栓塞、脑出血、脑肿瘤、脑…     

The Unique Role of the Child Life Worker in Children's Health Care Settings

The author expresses his concern that many child life workers are not aware of the uniqueness of their role in child health care settings He comments on four ways in which he perceives the child life workers role to be unique He concludes that the child life worker is irreplaceable in the child health care environment.     

The Unique Role of the Child Life Worker in Children's Health Care Settings

The author expresses his concern that many child life workers are not aware of the uniqueness of their role in child health care settings He comments on four ways in which he perceives the child life workers role to be unique He concludes that the child life worker is irreplaceable in the child health care environment.     

Strengthening the Healthy Start Workforce: A Mixed-Methods Study to Understand the Roles of Community Health Workers in Healthy Start and Inform the Development of a Standardized Training Program

Introduction Healthy Start (HS) is dedicated to preventing infant mortality, improving birth outcomes, and reducing disparities in maternal and infant health. In 2014, the HS program was reenvisioned and standardization of services and workforce development were prioritized. This study examined how HS community health workers (CHW), as critical members of the workforce, serve families and communities in order to inform the development of a CHW training program to advance program goals. Methods In 2015, an online organizational survey of all 100 HS programs was conducted. Ninety-three sites (93%) responded. Three discussion groups were subsequently conducted with HS CHWs (n = 21) and two discussion groups with HS CHW trainers/supervisors (n = 14). Results Most (91%) respondent HS programs employed CHWs. Survey respondents ranked health education (90%), assessing participant needs (85%), outreach/recruitment (85%), and connecting participants to services (85%) as the most central roles to the CHW’s job. Survey findings indicated large variation in CHW training, both in the amount and content provided. Discussion group findings provided further examples of the knowledge and skills required by HS CHWs. Conclusions The study results, combined with a scan of existing competencies, led to a tailored set of competencies that serve as the foundation for a HS CHW training program. This training program has the capacity to advance strategic goals for HS by strengthening HS CHWs’ capacity nationwide to respond to complex participant needs. Other maternal and child health programs may find these results of interest as they consider how CHWs could be used to strengthen service delivery.

     

The Role of Community Health Centers in Providing Behavioral Health Care

The prevalence of behavioral health problems is higher for low-income individuals, yet this population is less likely to receive behavioral health treatment. Community health centers have their advantages as behavioral health-care providers because they serve a majority low-income population and are located in medically underserved areas. Their role in providing behavioral health care is expected to expand under health reform as they are expected to double their patient capacity, and due to increased insurance coverage for individuals with behavioral health problems. However, the ability of community health centers to provide behavioral health care is compromised by provider shortages and funding shortfalls.     

Violence Against Women and Reproductive Health: Toward Defining a Role for Reproductive Health Care Services

Since a large proportion of U.S. women receive reproductive health care services each year, reproductive health care settings offer an important opportunity to reach women who may be at risk of or experiencing intimate partner violence (IPV). Although screening women for IPV in clinical health care settings has been endorsed by national professional associations and organizations, scientific evidence suggests that opportunities for screening in reproductive health care settings are often missed. This commentary outlines what is known about screening and intervention for IPV in clinical health care settings, and points out areas that need greater attention. The ultimate goal of these recommendations is to increase the involvement of reproductive health care services in sensitive, appropriate, and effective care for women who may be at risk of or affected by IPV.     

Reducing the Risk of Postpartum Depression in a Low-Income Community Through a Community Health Worker Intervention

Objectives To clarify the effectiveness of perinatal social support interventions in reducing postpartum depression among minority, low-income women. Methods The Transdisciplinary Research Consortium for Gulf Resilience on Women’s Health supported a community-based participatory research project to improve perinatal health among low-income, first-time pregnant women living in a vulnerable Gulf Coast region. Community health workers (CHWs) were partnered with recruited women, and used a mix of mobile technology and home visits to develop a supportive relationship during the perinatal period. Results Women enrolled in the CHW-led intervention had lower (F: 2.38, p?=?0.04) average postpartum depression scores (EPDS) 6 months postpartum than a comparison population. The difference, however, was not seen among women in the intervention group who reported relatively poor relationships with their CHWs. Conclusions for Practice Results reinforce the evidence that perinatal social support can affect postpartum depression outcomes. CHWs are increasingly utilized by public programs to reach at-risk populations. We discuss the potential efficacy of CHW programs, but also, the need to pair outreach with effective monitoring and evaluation of the relationship development between CHW and clients.     

Care Coordination with Schools: The Role of Family-Centered Care for Children with Special Health Care Needs

Objectives Family-centered care has been associated with positive outcomes for children with special health care needs. The purpose of the current study was to examine the relationship of family-centered care as associated with care coordination with schools and school absences (e.g., missed days) as reported by parents of children with special health care needs. Methods The current study utilized data from the National Survey of Children with Special Health Care Needs 2009-201 (N?=?40,242) to achieve this purpose. The National Survey of Children with Special Health Care Needs may be considered a nationally-representative and community-based sample of parent responses for children with special health care needs across the United States. Results Results from the current study indicate that family-centered care is associated with fewer absences and improved care coordination with schools when applicable. The variables of functional difficulties, poverty level, and the number of conditions were statistically controlled. Conclusions We suggest that the positive influence of family-centered care when practiced extends beyond the family and interacts with educational outcomes. We also suggest that the role of schools appears to be under-studied given the role that schools can play in family-centered care.     

我国社区护士的教育及其在卫生保健中的作用

为了适应世界卫生组织提出的“2 0 0 0年人人享有卫生保健”战略目标的要求 ,我国于 1997年颁布的《中共中央、国务院关于卫生改革与发展的决定》明确提出了我国社区卫生保健的基本方针是“改革城市卫生服务 ,积极发展社区卫生服务 ,逐步形成功能合理、方便群众的卫生服务网络。基层卫生机构要以社区、家庭为服务对象 ,开展疾病预防、常见病与多发病的诊治、医疗与伤残康复、健康教育、计划生育技术服务和妇女儿童与老年人、残疾人保健等工作。”随着卫生改革的不断深入 ,我国社区卫生服务工作得到进一步发展 ,截止 1999年 ,我国社区卫生服…     

浅议农村社区卫生服务在服务体系中的地位和作用

将在近期出台的《关于大力发展城市社区卫生服务的决定》中已经勾勒明确，对于城市社区卫生服务，“东中部地区地级以上城市和西部地区省会城市应加快发展，提前实现。”而且，“经济较发达的县和乡镇，可以借鉴城市社区卫生服务的做法，加强农村社区卫生服务建设”。