The Effect of Community-Based Specialist Palliative Care Teams on Place of Care

BACKGROUND: Prior research on community-based specialist palliative care teams used outcome measures of place of death and/or dichotomous outcome measures of acute care use in the last two weeks of life. However, existing research seldom measured the diverse places of care used and their timing prior to death.

OBJECTIVE: The study objective was to examine the place of care in the last 30 days of life.

METHODS: In this retrospective cohort study, patients who received care from a specialist palliative care team (exposed) were matched by propensity score to patients who received usual care in the community (unexposed) in Ontario, Canada. Measured was the percentage of patients in each place of care in the last month of life as a proportion of the total cohort.

RESULTS: After matching, 3109 patients were identified in each group, where 79% had cancer and 77% received end-of-life home care. At 30 days compared to 7 days before death, the exposed group's proportions rose from 33% to 41% receiving home care and 14% to 15% in hospital, whereas the unexposed group's proportions rose from 28% to 32% receiving home care and 16% to 22% in hospital. Linear trend analysis (proportion over time) showed that the exposed group used significantly more home care services and fewer hospital days (p < 0.001) than the unexposed group. On the last day of life (place of death), the exposed group had 18% die in an in-patient hospital bed compared to 29% in usual care.

CONCLUSION: Examining place of care in the last month can effectively illustrate the service use trajectory over time.

Mindful Living in Older Age: a Pilot Study of a Brief, Community-Based, Positive Aging Intervention

Although mindfulness-based interventions have been successfully used with older adults, there have been few interventions that, (a) are created specifically for older adults, (b) are delivered in the community, and (c) aim to promote ‘successful aging’ (rather than just treating dysfunction/disorder). To this end, the current study piloted a brief ‘positive aging’ intervention, comprising two 150 minute sessions, with six female older adults living in the community. Data were gathered through focus groups that were interwoven throughout the intervention. Using thematic analysis, four main themes were identified: (a) aging as a mixed blessing; (b) understanding mindfulness; (c) the challenges of mindfulness; and (d) the benefits of mindfulness. Overall, the intervention was successful in introducing participants to mindfulness and potentially forming the basis of a longer term practice. However, the study also highlighted important points on the challenges of practising mindfulness, in relation to which the paper makes recommendations pertaining to the teaching of mindfulness with older adults.

Wellspring: an intrinsic case study of community-based education for adults living with cancer /

This paper presents education research as vital to addressing the issues faced by adults living with cancer. This qualitative study looked at philosophies of practice for cancer patient education. It was about understanding how values and beliefs shape the way program planners and managers operationalize their knowledge of adult education and how this has significant impact on meeting the needs of those touched by cancer. Improved technology has extended life expectancy, so that Canadians living with cancer, or even dying with cancer now spend less time in direct medical care. The notion of cancer as simply a medical concern is outdated. This study found that informational and support needs of adults living with cancer are often unmet, ignored or unknown. This research investigated a community-based education initiative that is inviting, accessible, and promotes a sense of hope. More specifically, this case study uncovered factors contributing to the success of Wellspring, a grass-roots cancer patient support centre which has been recognized nationally for its ability to effectively meet the diverse non-medical supportive care needs of as many cancer patients and caregivers as possible. Therefore, Wellspring was selected as a case study. Educating people to take charge of their own lives and supporting them in making informed decisions about their lifestyle choices made Wellspring part of a social action movement that focused on improving social attitudes toward people living with cancer. Results of this descriptive inquiry and philosophical inquiry evolved into data that was used to devise an organic model of community-based education that encompasses Adler's (1993) four dimensions of philosophy within a socio-cultural context.

KAIRON PROJECT : assessing the role of expressive arts in community-based breast cancer support systems in the Niagara Region

Research Report Written for the Canadian Breast Cancer Foundation.

Community Recreation and Leisure Activities in Adults with Developmental Disabilities who have Recently Relocated to Community-based Residences in Ontario

In 2009, the Ontario Government closed the last three remaining large-scale institutions for people with Developmental Disabilities (DD). The purpose of this study is to examine the community-based recreation and leisure activities of 87 adults with DD who have recently moved into the community. Study 1 provided a descriptive insight into the community recreation and leisure activities, and revealed that people with DD engage in low levels of community activities, however are reported to have the desire to engage more often. Staff reported that people with DD do not have the opportunities to engage in their preferable activities. Study 2 investigated the prbspective predictors of the number and frequency of community, recreation and leisure activities and found that a higher level of functioning predicted a greater number of community activities ([beta] = .26, P < .05), while both a higher level of functioning ([beta] = .38,p < .001) and greater preference ([beta] = .23. p < .05) predicted more frequent access to community activities. Future research and the implications of the findings for clinical practice and policy development were discussed.

Managing Risk in a Culture of Rights: Providing Support and Treatment in Community-Based Settings for Persons with Intellectual Disabilities who Sexually Offend

People with intellectual disability who sexually offend commonly live in community-based settings since the closing of all institutions across the province of Ontario. Nine (n=9) front line staff who provide support to these individuals in three different settings (treatment setting, transitional setting, residential setting) were interviewed. Participants responded to 47 questions to explore how sex offenders with intellectual disability can be supported in the community to prevent re-offenses. Questions encompassed variables that included staff attitudes, various factors impacting support, structural components of the setting, quality of life and the good life, staff training, staff perspectives on treatment, and understanding of risk management. Three overlapping models that have been supported in the literature were used collectively for the basis of this research: The Good Lives Model (Ward & Gannon, 2006; Ward et al., 2007), the quality of life model (Felce & Perry, 1995), and variables associated with risk management. Results of this research showed how this population is being supported in the community with an emphasis on the following elements: positive and objective staff attitude, teamwork, clear rules and protocols, ongoing supervision, consistency, highly trained staff, and environments that promote quality of life. New concepts arose which suggested that all settings display an unequal balance of upholding human rights and managing risks when supporting this high-risk population. This highlights the need for comprehensive assessments in order to match the offender to the proper setting and supports, using an integration of a Risk, Need, Responsivity model and the Good Lives model for offender rehabilitation and to reduce the likelihood of re-offenses.

A Comparative Analysis of Community-Based Service Providers for "Extreme" Case ASD: Exploring Activity Program Options

The purpose of my research was to examine how community-based organizations in the Niagara region provide programs for children with Autism Spectrum Disorder (ASD), who are considered to represent “extreme” or “severe” cases. A qualitative, comparative case study was conducted that focused on three organizations who provide summer recreation and activity programs, in order to examine the issues these organizations face when determining program structure and staff training; and to understand what the threshold for physical activity is in this type of setting, and how the unique needs surrounding these “severe” cases are met while attending the program. Purposeful sampling was employed to select a supervisor and senior staff member from each organization to discuss the training process, program development and implementation, and the resources and strategies used within their organization’s community-based program. A confirming comparative analysis was comparative analysis of a parents survey with six mothers whose children are considered “severe” indicated that camp staffs’ expectations are unrealistic where as the parents and supervisors have more realistic expectations within the “real world” of camp. There is no definition of “severe” or “extreme” and therefore severity is dependent upon the context.

Perspectives of Parents of Children with Autism Spectrum Disorder on a Community-Based Parent Education Program

In 2012 a community-based agency that oversees Intensive Behaviour Intervention services for young children diagnosed with Autism Spectrum Disorder (ASD) began delivering newly developed curricula to parents of eligible children. The curricula’s intent was to inform parents about ASD and Applied Behaviour Analysis, to increase their awareness of available community resources, and assist them to be active and engaged in their child’s learning. This mixed-method study used a program-specific survey and focus groups to explore the perspectives parents had on their involvement in these education sessions. Through constant comparison analysis 4 major and 3 minor themes emerged. In general, parents acknowledged that this parent education program included relevant content and a favourable delivery format. The study summarized a number of well-articulated, practical suggestions parents provided. Implications for practice would be applicable to educators interested in providing quality group-based education to parents of young children with ASD.

Certification of community-based forest enterprises (CFEs): limits of the Brazilian experiences

The Brazilian Amazon is one of the world’s largest tropical forests. It supplies more than 80 % of Brazil’s timber production and makes this nation the second largest producer of tropical wood. The forestry sector is of major importance in terms of economic production and employment creation. However, the Brazilian Amazon is also known for its high deforestation rate and for its rather unsustainably managed timber resources, a fact which puts in the balance the long-term future of the forestry sector in the region. Since the mid- 1990s, with strong support from World Wildlife Fund (WWF), the number of tropical forests certified by the Forest Stewardship Council (FSC) has significantly increased. This is especially true for projects sponsored by large scale companies. The number of community- based forest management projects has also increased. Certification of community-based forest enterprises (CFEs) was initially a goal for the sponsors and community members. Certification is viewed as a way to reach alternative timber markets. In Brazil, the state of Acre has the highest concentration of CFEs certified by FSC. Most of them have been implemented with the support of environmental NGOs and public funds. Environmental NGOs strongly defend the advantages of certification for communities; however, in reality, this option is not that advantageous. Despite all the efforts, the number of participants in each project remains low. Why is this occurring? In this paper, we analyze the underlying motives of a few individual’s participation in CFEs certification projects. We aim to present and discuss some factors that shape the success of CFEs and their later certification. The results are based on surveys conducted in two certified CFEs in the state of Acre.

Follow-up of three large community-based programs to reduce anaemia among children 24-59 months in Ghana, Malawi and Tanzania

L'anémie de l'enfant reste un problème d'importance pour la santé mondiale, malgré les décennies de recherche visant à comprendre son étiologie et à développer des interventions efficaces pour réduire sa prévalence et ses conséquences. Bien que les facteurs de risque individuels de l'anémie soient connus, y compris les facteurs liés à la malnutrition et à la morbidité, l'interaction entre lesdits facteurs est moins documentée dans des contextes où les enfants sont fréquemment exposés à plusieurs facteurs en même temps. Cette étude vise à documenter les efforts de lutte contre l'anémie du programme MICAH qui a été mis en oeuvre au Ghana, au Malawi et en Tanzanie. Ensuite, en utilisant les données relatives à la fois au processus et à l'évaluation colligées au cours du programme, elle vise à mieux comprendre les facteurs de risque d'anémie chez les jeunes enfants dans ces contextes et à comprendre comment les relations entre ces facteurs peuvent avoir changé au fil du temps lors de l'intervention. Spécifiquement, cette étude vérifie s‘il y a des preuves d'une réduction de la vulnérabilité des enfants aux facteurs de risque associés à l'anémie dans chaque contexte. Un examen de la documentation a été réalisé afin de caractériser le contexte du programme et des interventions, leur l'intensité et étendue. Les données transversales sur la nutrition et l'état de santé des enfants âgés de 24 à 59 mois (N = 2405) obtenues en 2000 et 2004 à partir des enquêtes d'évaluation du programme MICAH au Ghana, au Malawi et en Tanzanie, ont été utilisées pour décrire la prévalence de l'anémie. Les modèles polynomiaux de régression logistique et linéaire ont été utilisés pour estimer les risques d'anémie légère et d'anémie modérée / sévère et les niveaux d‘hémoglobine associés à des groupes de variables. Les estimations du risque attribuable à une population (RAP) ont aussi été calculées. Une anémie (Hb <110 g/L) a touché au moins 60% des enfants dans les trois pays; l'anémie modérée / sévère (<100 g/L) constituait la majorité des cas. Une forte diminution de l'anémie a été observée entre 2000 et 2004 au Ghana, mais seulement une légère baisse au Malawi et en Tanzanie. Le risque d'anémie modérée / sévère était associé au retard de croissance chez les enfants du Ghana (OR 2,68, IC 95% 1,70-4,23) et du Malawi (OR 1,71; 1,29-2,27) mais pas de la Tanzanie (OR 1,29; 0,87- 1,92). Le paludisme et les maladies récentes étaient associées à une hémoglobine plus basse. Une atténuation de cette association en 2004 a été observée seulement au Malawi pour le paludisme et au Ghana pour les maladies récentes. Le risque d'anémie modérée / sévère était 44% moindre chez les enfants âgés de 48 à 59 mois comparativement aux enfants de 24 à 35 mois dans les trois pays et cela n'a pas changé entre 2000 et 2004. Les RAP estimés ont montré qu‘environ un cinquième des cas d‘anémie modérée à sévère était attribuable au retard de croissance au Ghana et Malawi, mais pas en Tanzanie. Des RAP moindres et dépendants des contextes ont été trouvés pour le paludisme et les maladies récentes. Dans ces zones d‘intervention intégrées de santé et de nutrition la relation de certains facteurs de risque à l'anémie se modifia avec le temps. Le retard de croissance est resté toutefois un facteur de risque indépendant et non mitigé de l'anémie. Une réduction efficace des causes de la malnutrition chronique est nécessaire afin de réduire la vulnérabilité des enfants et de garantir un impact maximum des programmes de lutte contre l'anémie. Une mitigation de l'impact du paludisme peut par contre être visée dans les régions endémiques.