A planning model for needs analysis for subacute care

The purpose of this study is to produce a model to be used by state regulating agencies to assess demand for subacute care. In accomplishing this goal, the study refines the definition of subacute care, demonstrates a method for bed need assessment, and measures the effectiveness of this new level of care. This was the largest study of subacute care to date. Research focused on 19 subacute units in 16 states, each of which provides high-intensity rehabilitative and/or restorative care carried out in a high-tech unit. Each of the facilities was based in a nursing home, but utilized separate staff, equipment, and services. Because these facilities are under local control, it was possible to study regional differences in subacute care demand. Using this data, a model for predicting demand for subacute care services was created, building on earlier models submitted by John Whitman for the American Hospital Association and Robin E. MacStravic. The Broderick model uses the "bootstrapping" method and takes advantage of high technology: computers and software, databases in business and government, publicly available databases from providers or commercial vendors, professional organizations, and other information sources. Using newly available sources of information, this new model addresses the problems and needs of health care planners as they approach the challenges of the 21st century.

Predictors of Independent Living Outcomes Among Older Women Receiving Informal Care

This study examined the predictors of independent living outcomes among community–living older women who received informal care. The central hypothesis was that older women’s level of functioning is influenced by their relationship with their informal caregiver. The study attempted to understand the independence of older women through the perspective of both informal caregivers and the older women themselves. The following eight variables were measured: 1) the older women’s independence (dependent variable); 2) the relationship between older women and their informal caregivers (independent variable); 3) roles of both the informal caregiver and older women (independent variable); 4) the older women’s attitudes toward aging (independent variable); 5) the older women’s age identity (independent variable); 6) the older women’s health (control variable); 7) the older women’s level of social support (control variable); and 8) the older women’s level of depression (control variable). The variables were measured from the perspective of the older woman herself and her informal caregiver. This study used an ecological and developmental framework along with role theory to understand the interaction among the aforementioned variables through a cross-sectional design. The recruited older women participants of this study were receiving ongoing care and personal assistance from two large home care agencies located in Miami, FL. An analysis was conducted through a mixed-methods incorporated into the study design. The present study aimed to contribute to the understanding of how the relationship between older women and their informal caregivers influences older women’s ability to maintain independent outcomes. The primary finding of this study was that there were both positive and negative experiences within the relationship dynamic of older women and their informal caregivers and that this relationship was either unidirectional or bi-directional.

Estratégias de cuidados por familiares de portadores de transtornos mentais severos residentes na zona rural do alto sertão paraibano

In the current configuration of the Brazilian Psychiatric Reform, family plays a key role in mental health care: shared responsibility and active participation in the process of rehabilitation of people with severe mental disorders. It´s considered that the family member who cares can help users in their daily tasks and articulating trajectories, networks and ways to potentiate social connections. This research was motivaded by interest in the subject and by the lack of research and studies about this reality in rural areas. This study aimed to identify ways of mental health care by relatives of severe mental disorder patients living in rural zone located at sertão of Paraiba. Methodologically was made a work with qualitative research structured in two moments. In the first one, was held a Documentary Research in CAPS II in order to identify: a) users living in rural that had a history of at least one psychiatric hospitalization, b) users who no longer use the reference service (CAPS II) for at least one year. The second stage consisted by home visits and semi-structured interviews with eleven families in rural areas. Results pointed out a profile composed by 56 users: 56 women and 26 men aged between 50 and 64 years, unmarried, without study, farmers and housewives, living six miles from CAPS II and carriers with severe mental disorders. Strategies and resources used by the families for mental health care were: religion, work, medication and help from relatives, neighbors and community. Factors related to non-use of substitute services were lack of internment in CAPS II and lack of money and transportation. The hospital, the house arrest, the police aid and religion were strategies used by family members as support to psychiatric crises. The data pointed to non-solving of care offered by psychosocial support network and the importance of redirecting practices aligned to the asylum model in favor of psychosocial strategies that aimed at rehabilitation and community participation in mental health care

The development of an online neonatal intensive care unit family education

Background: British Columbia’s Fraser Health Authority (FHA) neonatal intensive care units (NICUs) value family centered care (FCC). Nevertheless, there is limited evidence that FCC is actually incorporated into practice, as well as some concern that FHA NICU education is inaccessible, inconsistent, or disorganized. Purpose: The mission of this project is to support the principles of FCC throughout the development of an FHA online NICU family education guide by reflecting upon the needs of families throughout their NICU journey. Methods: A needs assessment was initially completed and included literature reviews, consultations, and an environmental scan. This data informed development of an online NICU family education guide which plots current education materials along key stages of the NICU journey: prenatal, admission, early days, growing and developing, discharge and at home. For the purposes of this practicum, only the prenatal stage was fully developed and will serve as a template for other stages following a formative evaluation. A pamphlet and revised FHA Neonatal Checkpoint will also be developed to augment teaching by health care professionals. Implementation and evaluation plans were adapted from the Center for Disease Control Framework for Program Evaluation in Public Health. Results: The needs assessment validates and directs the development, implementation, and evaluation of the online guide illustrating an FCC approach. The online guide centralizes and organizes education by selecting education topics that relate to each stage of the NICU journey. This family-directed design enables families’ access to consistent and reliable information and offers them an opportunity to learn at their own pace. Conclusion: The process of creating, implementing, and evaluating an online family education program for FHA NICUs elucidates the intricacies and the advantages of integrating FCC into NICU practice.

A primary care web-based intervention modelling experiment replicated behaviour changes seen in earlier paper-based experiment

Acknowledgements and funding We would like to thank the GPs who took part in this study. We would also like to thank Marie Pitkethly and Gail Morrison for their help and support in recruiting GPs to the study. WIME was funded by the Chief Scientist Office, grant number CZH/4/610. The Health Services Research Unit, University of Aberdeen, is core funded by the Chief Scientist Office of the Scottish Government Health Directorates.

Care-less spaces and identity construction:transition to secondary school for disabled children

There is a growing body of literature which marks out a feminist ethics of care and it is within this framework we understand transitions from primary to secondary school education can be challenging and care-less, especially for disabled children. By exploring the narratives of parents and professionals, we investigate transitions and self-identity, as a meaningful transition depends on the care-full spaces pupils inhabit. These education narratives are all in the context of privileging academic attainment and a culture of testing and examinations. Parents and professionals, as well as children are also surveyed. Until there are care-full education processes, marginalisation will remain, impacting on disabled children’s transition to secondary school and healthy identity construction. Moreover, if educational challenges are not addressed, their life chances are increasingly limited. Interdependent caring work enables engagement in a meaningful education and positive identity formation. In school and at home, care-full spaces are key in this process.

Caesarean wound care for midwives

With a rise in caesarean births there is a rise in wound care management issues for midwives and the potential for surgical site infections (SSIs). The burden of SSIs include increases in maternal mortality, morbidity, length of hospital stay and cost. Sepsis is currently the leading cause of maternal mortality, with 50 per cent of the women who die having had a caesarean birth (Centre for Maternal and Child Enquiries (CMACE) 2011). Wound management and the prevention of sepsis are therefore issues of great concern to midwives. This article considers the incidence of wound infections and presents the guidance available to help address this problem.

Electronic health records: essential tools in integrating substance abuse treatment with primary care.

While substance use problems are considered to be common in medical settings, they are not systematically assessed and diagnosed for treatment management. Research data suggest that the majority of individuals with a substance use disorder either do not use treatment or delay treatment-seeking for over a decade. The separation of substance abuse services from mainstream medical care and a lack of preventive services for substance abuse in primary care can contribute to under-detection of substance use problems. When fully enacted in 2014, the Patient Protection and Affordable Care Act 2010 will address these barriers by supporting preventive services for substance abuse (screening, counseling) and integration of substance abuse care with primary care. One key factor that can help to achieve this goal is to incorporate the standardized screeners or common data elements for substance use and related disorders into the electronic health records (EHR) system in the health care setting. Incentives for care providers to adopt an EHR system for meaningful use are part of the Health Information Technology for Economic and Clinical Health Act 2009. This commentary focuses on recent evidence about routine screening and intervention for alcohol/drug use and related disorders in primary care. Federal efforts in developing common data elements for use as screeners for substance use and related disorders are described. A pressing need for empirical data on screening, brief intervention, and referral to treatment (SBIRT) for drug-related disorders to inform SBIRT and related EHR efforts is highlighted.

Design, fabrication and characterization of resonant waveguide grating based optical biosensors

The absence of rapid, low cost and highly sensitive biodetection platform has hindered the implementation of next generation cheap and early stage clinical or home based point-of-care diagnostics. Label-free optical biosensing with high sensitivity, throughput, compactness, and low cost, plays an important role to resolve these diagnostic challenges and pushes the detection limit down to single molecule. Optical nanostructures, specifically the resonant waveguide grating (RWG) and nano-ribbon cavity based biodetection are promising in this context. The main element of this dissertation is design, fabrication and characterization of RWG sensors for different spectral regions (e.g. visible, near infrared) for use in label-free optical biosensing and also to explore different RWG parameters to maximize sensitivity and increase detection accuracy. Design and fabrication of the waveguide embedded resonant nano-cavity are also studied. Multi-parametric analyses were done using customized optical simulator to understand the operational principle of these sensors and more important the relationship between the physical design parameters and sensor sensitivities. Silicon nitride (SixNy) is a useful waveguide material because of its wide transparency across the whole infrared, visible and part of UV spectrum, and comparatively higher refractive index than glass substrate. SixNy based RWGs on glass substrate are designed and fabricated applying both electron beam lithography and low cost nano-imprint lithography techniques. A Chromium hard mask aided nano-fabrication technique is developed for making very high aspect ratio optical nano-structure on glass substrate. An aspect ratio of 10 for very narrow (~60 nm wide) grating lines is achieved which is the highest presented so far. The fabricated RWG sensors are characterized for both bulk (183.3 nm/RIU) and surface sensitivity (0.21nm/nm-layer), and then used for successful detection of Immunoglobulin-G (IgG) antibodies and antigen (~1μg/ml) both in buffer and serum. Widely used optical biosensors like surface plasmon resonance and optical microcavities are limited in the separation of bulk response from the surface binding events which is crucial for ultralow biosensing application with thermal or other perturbations. A RWG based dual resonance approach is proposed and verified by controlled experiments for separating the response of bulk and surface sensitivity. The dual resonance approach gives sensitivity ratio of 9.4 whereas the competitive polarization based approach can offer only 2.5. The improved performance of the dual resonance approach would help reducing probability of false reading in precise bio-assay experiments where thermal variations are probable like portable diagnostics.

Graded Exercise Therapy Guided Self-Help Trial for Patients with Chronic Fatigue Syndrome (GETSET): Protocol for a Randomized Controlled Trial and Interview Study

Background: Chronic fatigue syndrome, also known as myalgic encephalomyelitis (CFS/ME), is characterized by chronic disabling fatigue and other symptoms, which are not explained by an alternative diagnosis. Previous trials have suggested that graded exercise therapy (GET) is an effective and safe treatment. GET itself is therapist-intensive with limited availability. Objective: While guided self-help based on cognitive behavior therapy appears helpful to patients, Guided graded Exercise Self-help (GES) is yet to be tested. Methods: This pragmatic randomized controlled trial is set within 2 specialist CFS/ME services in the South of England. Adults attending secondary care clinics with National Institute for Health and Clinical Excellence (NICE)-defined CFS/ME (N=218) will be randomly allocated to specialist medical care (SMC) or SMC plus GES while on a waiting list for therapist-delivered rehabilitation. GES will consist of a structured booklet describing a 6-step graded exercise program, supported by up to 4 face-to-face/telephone/Skype™ consultations with a GES-trained physiotherapist (no more than 90 minutes in total) over 8 weeks. The primary outcomes at 12-weeks after randomization will be physical function (SF-36 physical functioning subscale) and fatigue (Chalder Fatigue Questionnaire). Secondary outcomes will include healthcare costs, adverse outcomes, and self-rated global impression change scores. We will follow up all participants until 1 year after randomization. We will also undertake qualitative interviews of a sample of participants who received GES, looking at perceptions and experiences of those who improved and worsened. Results: The project was funded in 2011 and enrolment was completed in December 2014, with follow-up completed in March 2016. Data analysis is currently underway and the first results are expected to be submitted soon. Conclusions: This study will indicate whether adding GES to SMC will benefit patients who often spend many months waiting for rehabilitative therapy with little or no improvement being made during that time. The study will indicate whether this type of guided self-management is cost-effective and safe. If this trial shows GES to be acceptable, safe, and comparatively effective, the GES booklet could be made available on the Internet as a practitioner and therapist resource for clinics to recommend, with the caveat that patients also be supported with guidance from a trained physiotherapist. The pragmatic approach in this trial means that GES findings will be generalizable to usual National Health Service (NHS) practice.

The Affordable Care Act and the Transformation of US Health Care

The neoliberal period was accompanied by a momentous transformation within the US health care system.  As the result of a number of political and historical dynamics, the healthcare law signed by President Barack Obama in 2010 ‑the Affordable Care Act (ACA)‑ drew less on universal models from abroad than it did on earlier conservative healthcare reform proposals. This was in part the result of the influence of powerful corporate healthcare interests. While the ACA expands healthcare coverage, it does so incompletely and unevenly, with persistent uninsurance and disparities in access based on insurance status. Additionally, the law accommodates an overall shift towards a consumerist model of care characterized by high cost sharing at time of use. Finally, the law encourages the further consolidation of the healthcare sector, for instance into units named “Accountable Care Organizations” that closely resemble the health maintenance organizations favored by managed care advocates. The overall effect has been to maintain a fragmented system that is neither equitable nor efficient. A single payer universal system would, in contrast, help transform healthcare into a social right.

“Work of Kinship” done by Families in Santiago de Chile

This paper reports the progress achieved in an anthropological investigation based on which there is now a more in depth understanding of some dimensions of the “kinship work” carried out by families in Chile. The main objective is to analyze the work of maintaining family links performed primarily by women within families and show how this work reproduces gender inequalities within them. On the basis of a longitudinal methodology based on semi-structured interviews, it is concluded that the work of maintaining family links performed by women is crucial but goes unnoticed because kinship obligations are seen as a naturally being part of women’s role in the family.

Moral Emotions in Palliative Care: Empirical Insights from Austria and Canada

Research aims: Moral emotions as one specific group of emotions play a vital role in delivering palliative care as e.g. ethical issues and moral distress belong to daily routine.
Moral emotions are oriented to the welfare of other persons or the society as a whole. To better understand moral emotions in Palliative Care the aims of the presented study are to ana- lyze care situations from Austria and Canada in different care settings and identify families of moral emotions on one hand and describe influencing contextual factors on the other hand. Methods: Within a qualitative study design a reanalysis of Austrian narratives on ethical issues and Canadian narra- tives on moral distress were conducted. Data in Austria encompass 36 narratives that were generated through qual- itative questionnaires in nursing homes. Canadian data are based on qualitative interviews with home care palliative specialists and encompass 47 critical incidents. The reanal- ysis of data was conducted with narrative analysis. Results: Preliminary results show that moral emotions in palliative care can be found in families around “empathy and relatedness”, “sadness, isolation and bereavement”, “anger, frustration and powerlessness”, “guilt and shame” and “being touched and feel close”. Contextual factors influencing moral emotions can be summarized as “suffer- ing and decline of client”, “expectations and dynamics of family”, “structural conflicts and power issues” and “lack of resources and information”.
Conclusion: The diversity of moral emotions reflects the everyday experiences in palliative care. It became obvious that most of the moral emotions that have been expressed appear to be interconnected within a bundle of other emo- tions. Contextual factors influencing moral emotions in pal- liative care are relatively independent of care settings. In Palliative Care moral emotions and their contextual factors constitute an important source of insight for reflection in organizational ethics.

Nurses' experiences of pain management for people with advanced dementia approaching the end of life: a qualitative study

AIMS AND OBJECTIVES: To explore hospice, acute care and nursing home nurses' experiences of pain management for people with advanced dementia in the final month of life. To identify the challenges, facilitators and practice areas requiring further support.

BACKGROUND: Pain management in end-stage dementia is a fundamental aspect of end of life care; however, it is unclear what challenges and facilitators nurses experience in practice, whether these differ across care settings, and whether training needs to be tailored to the context of care.

DESIGN: A qualitative study using semi-structured interviews and thematic analysis to examine data.

METHODS: 24 registered nurses caring for people dying with advanced dementia were recruited from ten nursing homes, three hospices, and two acute hospitals across a region of the United Kingdom. Interviews were conducted between June 2014 and September 2015.

RESULTS: Three core themes were identified: challenges administering analgesia, the nurse-physician relationship, and interactive learning and practice development. Patient-related challenges to pain management were universal across care settings; nurse- and organisation-related barriers differed between settings. A need for interactive learning and practice development, particularly in pharmacology, was identified.

CONCLUSIONS: Achieving pain management in practice was highly challenging. A number of barriers were identified; however, the manner and extent to which these impacted on nurses differed across hospice, nursing home and acute care settings. Needs-based training to support and promote practice development in pain management in end-stage dementia is required.

RELEVANCE TO CLINICAL PRACTICE: Nurses considered pain management fundamental to end of life care provision; however, nurses working in acute care and nursing home settings may be under-supported and under-resourced to adequately manage pain in people dying with advanced dementia. Nurse-to-nurse mentoring and ongoing needs-assessed interactive case-based learning could help promote practice development in this area. Nurses require continuing professional development in pharmacology. This article is protected by copyright. All rights reserved.

Behaviour change techniques in home-based cardiac rehabilitation: a systematic review

BACKGROUND: Cardiac rehabilitation (CR) programmes offering secondary prevention for cardiovascular disease (CVD) advise healthy lifestyle behaviours, with the behaviour change techniques (BCTs) of goals and planning, feedback and monitoring, and social support recommended. More information is needed about BCT use in home-based CR to support these programmes in practice.

AIM: To identify and describe the use of BCTs in home-based CR programmes.

DESIGN AND SETTING: Randomised controlled trials of home-based CR between 2005 and 2015 were identified by searching MEDLINE(®), Embase, PsycINFO, Web of Science, and Cochrane Database.

METHOD: Reviewers independently screened titles and abstracts for eligibility. Relevant data, including BCTs, were extracted from included studies. A meta-analysis studied risk factor change in home-based and comparator programmes.

RESULTS: From 2448 studies identified, 11 of good methodological quality (10 on post-myocardial infarction, one on heart failure, 1907 patients) were included. These reported the use of 20 different BCTs. Social support (unspecified) was used in all studies and goal setting (behaviour) in 10. Of the 11 studies, 10 reported effectiveness in reducing CVD risk factors, but one study showed no improvement compared to usual care. This study differed from effective programmes in that it didn't include BCTs that had instructions on how to perform the behaviour and monitoring, or a credible source.

CONCLUSION: Social support and goal setting were frequently used BCTs in home-based CR programmes, with the BCTs related to monitoring, instruction on how to perform the behaviour, and credible source being included in effective programmes. Further robust trials are needed to determine the relative value of different BCTs within CR programmes.