The experiences of emergency department use by street-involved youth: Perspectives of health care and community service providers

Street-involved (SI) youth represent a significant proportion of urban homeless populations. While previous research has identified SI youth as substantial users of emergency department (ED) services and has examined their experiences of ED care, little is known about the experiences and perceptions of the service providers who assist these youth with health care related issues. Using grounded theory, individual interviews and focus groups were conducted with 20 community agency staff serving SI youth, 17 health service providers, two hospital administrators, and two hospital security personnel regarding their experiences in providing or facilitating ED care for SI youth. Results identify differences in expectations between SI youth and hospital staff, along with service issues and gaps, including relational barriers and resource constraints. Implications for practice and policy development are offered.     

Early Access to Health Care Services Through a Rural School-Based Health Center

ABSTRACT: School-based health centers (SBHCs) and school-linked health centers (SLHCs) represent relatively new models for health care service delivery. This article examines the question: Are SBHCs accessible as defined by four criteria of accessibility: available, community-based, affordable, and culturally acceptable? A literature review and an examination of a rural SBHC providing care to young children are presented in this paper. Both support the hypothesis that SBHCs are accessible to children and families in the school community. In particular, this SBHC's enrollment rate of 98% and its usage rate of 99% provide strong evidence that SBHCs are culturally acceptable. Ten strategies for a successful SBHC are presented to assist in planning and implementation of other SBHCs.     

Utility of psychosocial screening at a school-based health center

School-based health centers (SBHC) have substantial potential to improve the recognition and treatment of adolescents' mental health problems. This study was undertaken as a quality improvement project to evaluate utility of the Pediatric Symptom Checklist when completed by youth (PSC-Y) among 383 adolescents seen at a SBHC, and the extent to which identification of psychosocial dysfunction and referral to mental health services improved academic functioning. Adolescents identified by the PSC-Y were significantly more likely to be insured by Medicaid, be a teen-age parent, and to have higher rates of absenteeism and tardiness in comparison to those not identified. Adolescents identified with the PSC-Y who were referred to mental health services significantly decreased their rates of absences and tardiness. Study results provide support for the utility of psychosocial screening and referral in the SBHC environment in facilitating recognition and treatment of adolescent mental health problems and improving student academic functioning.     

Mismatches between health service delivery and community expectations in the provision of secondary prophylaxis for rheumatic fever in New Zealand

Objective : Rheumatic fever (RF) recurrence prevention requires secondary prophylaxis for at least ten years. However, recurrences of rheumatic fever (RRF) persist disproportionately affecting Māori and Pacific youth. Reasons for recurrence rates are not well understood and commonly attributed to patient non‐adherence. This research explored Māori and Pacific family experiences of RRF to better understand barriers to accessing secondary prophylaxis to inform health service improvements. Methods : Participants were Māori and Pacific patients who had RRF or unexpected rheumatic heart disease and their family; and health professionals working in RF contexts. Kaupapa Māori, Talanga and Kakala Pacific qualitative methodologies were employed. Data were thematically analysed using a general inductive approach. Results : Data collection included 38 interviews with patients and families (n=80), six focus group interviews and nine interviews with health providers (n=33) from seven geographic regions. Three key themes were identified where mismatches occurred between services and community needs: 1. Model of delivery; 2. Interpersonal approaches to care; and 3. Adolescent care. Conclusions and Public health implications : Successful RRF prevention requires interventions to address structural causes of inequity, appropriate clinical guidelines and quality health services. Service‐delivery models should provide regular prophylaxis in an accessible manner through culturally‐safe, community‐based, age‐appropriate care.     

On the game: women and sex work

Latinos living with HIV residing in the US-Mexico border region frequently seek care on both sides of the border. Given this fact, a border health perspective to understanding barriers to care is imperative to improve patient health outcomes. This qualitative study describes and compares experiences and perceptions of Mexican and US HIV care providers regarding barriers to HIV care access for Latino patients living in the US-Mexico border region. In 2010, we conducted in-depth qualitative interviews with HIV care providers in Tijuana (n = 10) and San Diego (n = 9). We identified important similarities and differences between Mexican and US healthcare provider perspectives on HIV care access and barriers to service utilisation. Similarities included the fact that HIV-positive Latino patients struggle with access to ART medication, mental health illness, substance abuse and HIV-related stigma. Differences included Mexican provider perceptions of medication shortages and US providers feeling that insurance gaps influenced medication access. Differences and similarities have important implications for cross-border efforts to coordinate health services for patients who seek care in both countries.     

Rural School-Based Clinics: Are Adolescents Willing to Use Them and What Services Do They Want?

ABSTRACT: Using a theoretical model of access, factors associated with rural adolescents' willingness to use primary care services through a school-based health center (SBHC) were examined. Standardized measures of health status and use were administered to 633 adolescents in grades 7–12 who resided in one rural western Maryland county. Although only 6.5% (n = 41) of the sample indicated a willingness to change their regular source of care to an SBHC, greater numbers of adolescents reported a willingness to use SBHC services, with 18%, 38%, 25%, and 16%, indicating interest in routine, acute medical, miscellaneous, and reproductive health care services, respectively. Logistic regression analysis found those adolescents who reported eligibility for free-reduced lunch and no regular source of care for illness were 3.3 and 5.4 times more likely, respectively, to use an SBHC as a primary care site than those unwilling to change their source of care. Data suggest that initially many rural adolescents appear unwilling to change their primary care site to an SBHC, but do express a willingness to use offered services.     

Mental health characteristics and health-seeking behaviors of adolescent school-based health center users and nonusers

BACKGROUND: The purpose of this study is to compare the mental health risk profile and health utilization behaviors of adolescent school‐based health center (SBHC) users and nonusers and discuss the role that SBHCs can play in addressing adolescent health needs. METHODS: The sample included 4640 students in grades 9 and 11 who completed the California Healthy Kids Survey between fall 2000 and spring 2005 at 4 high schools in Alameda County, California. Chi‐squared tests of significance and multivariate logistic regression were used to compare characteristics of SBHC users and nonusers and identify demographic, health status, and behavioral characteristics predictive of SBHC use. RESULTS: Controlling for demographic variables and general health status, students who reported frequent feelings of sadness, trouble sleeping, suicide ideation, alcohol or marijuana use, the recent loss of a close friend or relationship, or other difficult life event were significantly more likely to seek SBHC services than their peers. Neither health insurance status nor a student's “usual” source of health care was predictive of general SBHC use, but being on public assistance or having no insurance was predictive of a student seeking SBHC mental health services. CONCLUSIONS: These findings suggest that SBHCs are able to attract students with the most serious mental health concerns and can play an important role in meeting needs that might otherwise go unmet. The provision of SBHC mental health services in particular may fill a need among adolescents with public or no insurance.     

老年居家卫生服务模型研究

目的：改善老年人的健康状况、提高其卫生服务可及性。方法：采用了专家研讨会和概念建模的方法。结果：老年卫生服务的目标是实现其健康老龄化和积极老龄化，途径是为他们提供连续的、全方位的、没有灰色带的、能够提高他们独立生活能力的综合性服务。老年居家卫生服务模型主要包括4个微观系统领域：自我管理支持、决策支持、递送系统设计和临床信息系统；服务内容包括初级卫生保健服务和社会服务两部分。结论：居家卫生服务对于提高老年人卫生服务可及性、提高其独立生活能力、改善其健康状况具有很强针对性。     

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.     

Co-morbid drug and alcohol and mental health issues in a rural New South Wales Area Health Service

Objective: In 2003 the New South Wales (NSW) Centre for Rural and Remote Mental Health (CRRMH) conducted an analysis of co‐morbid drug and alcohol (D&A) and mental health issues for service providers and consumers in a rural NSW Area Health Service. This paper will discuss concerns raised by rural service providers and consumers regarding the care of people with co‐morbid D&A and mental health disorders. Design: Current literature on co‐morbidity was reviewed, and local area clinical data were examined to estimate the prevalence of D&A disorders within the mental health service. Focus groups were held with service providers and consumer support groups regarding strengths and gaps in service provision. Setting: A rural Area Health Service in NSW. Participants: Rural health and welfare service providers, consumers with co‐morbid D&A and mental health disorders. Results: Data for the rural area showed that 43% of inpatient and 20% of ambulatory mental health admissions had problem drinking or drug‐taking. Information gathered from the focus groups indicated a reasonable level of awareness of co‐morbidity, and change underway to better meet client needs; however, the results indicated a lack of formalised care coordination, unclear treatment pathways, and a lack of specialist care and resources. Discussion: Significant gaps in the provision of appropriate care for people with co‐morbid D&A and mental health disorders were identified. Allocation of service responsibly for these clients was unclear. It is recommended that D&A, mental health and primary care services collaborate to address the needs of clients so that a coordinated and systematic approach to co‐morbid care can be provided.     

Innovative health service delivery models in low and middle income countries - what can we learn from the private sector?

Background  

The poor in low and middle income countries have limited access to health services due to limited purchasing power, residence in underserved areas, and inadequate health literacy. This produces significant gaps in health care delivery among a population that has a disproportionately large burden of disease. They frequently use the private health sector, due to perceived or actual gaps in public services. A subset of private health organizations, some called social enterprises, have developed novel approaches to increase the availability, affordability and quality of health care services to the poor through innovative health service delivery models. This study aims to characterize these models and identify areas of innovation that have led to effective provision of care for the poor.     

Ethnic minority status and adolescent mental health services utilization

Adolescents who are members of ethnic minority groups constitute a large and ever increasing proportion of the population. While the information base regarding mental health problems and mental health services utilization in adolescents in general is slowly increasing, relatively little knowledge has accumulated about the particular needs and practices of youth of color. The purpose of this article is to review the available literature about adolescent mental health needs and service utilization as well as literature regarding adult ethnicity and mental health service utilization. The conclusion of this review is that significant gaps exist in our knowledge base regarding ethnicity in adolescents and its implications for the utilization of mental health services. The limited data available suggest that significant numbers of adolescents of color have multiple needs for mental health care and that a complex set of barriers exists to prevent them from obtaining appropriate servicies. A variety of suggestions are offered to improve the opportunities for and the quality of mental health services for ethnic minority adolescents. This research was supported by Grant MH 47786 from the National Institute of Mental Health.     

Trends in health care financing: opportunities for family planning agencies

In response to spiraling health care costs in the US, several alternative health care delivery systems have evolved. The delivery of subsidized family planning services in particular is being affected by declining levels of government support. The most rapidly growing of alternative delivery systems is the health maintenance organization (HMO). HMOs provide a voluntarily enrolled population a guaranteed, specific range of physician and hospital services in return for a fixed periodic payment. There are 3 types of HMO: the group model, in which doctors are members of a partnership or service corporation that contracts with employers or individuals to provide medical services; the taff model, in which physicians are direct employees of the HMO; and the independent practice association (IPA) model, a physicians' group that enters into a contract with an HMO and receives reimbursement for every patient seen. In 1986, over 21 million Americans were enrolled in approximately 262 HMOs around the country. HMOs are unequaled in their success at reducing hospital utilization; they have achieved savings of hospital costs of 20-40%. Another system for delivering and financing health care is the preferred provider organization (PPO) under which patients are assigned to a designated panel of health care providers who offer services according to a discounted fee schedule. New hybrid systems that combine many of the features of both systems are emerging. Most of the newly organized health care delivery systems described focus on utilization control and keeping costs down. A common way of ensuring coordinated health care delivery is through primary care case management. To initiate or establish relationships with HMOs or other health care delivery systems, family planning agencies should consider such activities as: undertaking surveys to study the market; training new employees on developments in health care financing; and recruiting board members with HMO experience.     

Exploring stakeholder experiences of dietetic service and care delivery: A systematic qualitative review

Background

There is limited understanding of patients' and healthcare professionals' perceptions and experiences of receiving and delivering dietetic care, respectively. This systematic review of the literature used qualitative synthesis to explore the perceptions and experiences of multiple stakeholders involved in the delivery of nutrition care and dietetic service.

Methods

MEDLINE, Embase, CINAHL, Cochrane Library, Scopus, ISI Web of Science, PsycINFO and ProQuest were systematically searched. Study characteristics and perceptions of stakeholders regarding nutrition care services were extracted. Qualitative synthesis was employed and thematic analysis conducted.

Results

Five themes were identified from 44 studies related to stakeholders' perceptions of dietetic services. Studies included quantitative, qualitative and mixed methods involving patients, families, dietitians and other healthcare professionals. The themes were (1) patients desiring a personalised approach to nutrition care; (2) accessing dietetic service; (3) perceived impact of nutrition care on the patient; (4) relationships between stakeholders; and (5) beliefs about nutrition expertise. Two themes were specific to patients; these were the desire for individualised care and the impact of nutrition care. Within each theme perceptions varied with patients' views often contrasting with those of dietetic service providers.

Conclusions

Experiences of dietetic service do not always meet stakeholder expectations which impacts on patient engagement. Seeking stakeholder input is imperative to design dietetic services that engage patients in positive and supportive clinical partnerships.     

Overlapping and Non-overlapping Practices in Usual and Evidence-Based Care for Youth Anxiety

This study compared consistencies and discrepancies in usual care with practices derived from the evidence-base (PDEB) for youth anxiety in a public mental health system. Youth-level factors (diagnosis, functional impairment) as predictors of the discrepancies were also examined. Psychosocial and service data from 2485 youth with an anxiety disorder and/or receiving services for an anxiety treatment target were extracted. Therapists (N?=?616) identified the treatment targets and practices youth received. Although many PDEB for youth anxiety were used by therapists in this sample, Exposure was only used in 15% of cases. Practices not consistent with youth anxiety treatment were also reported and included: PDEB for other conditions, practices common to all therapies, and practices that are not consistent with evidence-based care. Age and diagnosis predicted the delivery of PDEB for youth anxiety. Usual care incorporated many components of evidence-based care but was more diffuse and less focused on well-supported practices.     

Support networks for Chinese older immigrants accessing English health and social care services: the concept of Bridge People

As Chinese immigrants in the United Kingdom age, they experience an increasing need to access health and care services. It has, however, been reported that older Chinese immigrants have difficulties in accessing these services. This study explored the experiences of this population in using health and care services and the strategies that they adopted to address their difficulties. A grounded theory method with a two‐staged research design was used. Stage 1 explored the participants’ experiences of ageing and use of health and social care services through focus group interviews. Stage 2 investigated the strategies individuals used to support access to and use of services through individual interviews. Forty‐four older Chinese people and 15 supporters participated in interviews during August 2011 and May 2013. These older Chinese immigrants were challenged in knowing about and in accessing services. Their difficulties were attributed to language barriers, lack of information and instrumental support, and emotional and cultural issues regarding use of health and care services. Their supporters facilitated access to services and acted as a bridge between the service and the user; therefore, they were given the title ‘Bridge People’. Bridge People have different backgrounds: family and friends, public sector workers and staff from community‐based Chinese organisations. The defining attributes of these supporters were: bilinguality, bicultural, multifunctionality and accessibility. There is no charge for this support; and the relationship between the Bridge Person and recipient involves trust and influence over decisions regarding use of health and care services. Bridge People should be recognised and identified by health, social care and housing services to promote engagement and use of services by older immigrant Chinese people.