Utilisation of pharmacy-based sexual and reproductive health services: a quantitative retrospective study

OBJECTIVES

To explore the utilisation of pharmacy-based sexual and reproductive health services (SRHS) in order to optimise delivery and identify barriers to access.

METHODS

The health provider Umbrella offers six SRHS from over 120 pharmacies in Birmingham (England). In this retrospective study, data collected between August 2015 and August 2018 were used to analyse uptake, user characteristics and attendance patterns according to day of the week.

RESULTS

A total of 60 498 requests for a pharmacy service were included in the analysis. Emergency contraception (50.4%), condoms (33.1%) and STI self-sampling kits (9.6%) accounted for more than 90% of all requests. A lower uptake of services was observed for the contraceptive injection (0.6%), oral contraception (5.4%) and chlamydia treatment (1.0%). Services were most likely to be requested by those self-identifying as female (85.6%), and those aged 16-24 years (53.8%). Based on available ethnicity data (n=54 668), most requests for a service were made by White/White British individuals (43.4%) and Asian/Asian British people (23.1%). The largest number of services were delivered on Mondays (20.9%) and the lowest on Sundays (5.0%). A high proportion of requests for services on Saturdays (57.0%), Sundays (67.6%) and Mondays (54.4%) were made by females presenting for emergency contraception.

CONCLUSION

The evaluation of healthcare utilisation is important to help refine and optimise the delivery of services. However, information relating to pharmacy-based SRHS is scarce and often limited to a single type of service provision. Overall, a wide range of pharmacy-based services were accessed by a diverse range of people, suggesting that pharmacies are a suitable provider of many SRHS. However, the routinely collected data analysed in the study had several limitations restricting the analysis. Sexual health providers should ensure they collect data which are as comprehensive as is possible in order to help understand the utilisation of services.

Mind the gap: Comparing perspectives of service providers to the needs of people with dementia living in the community

INTRODUCTION

Research with West Australian people with dementia and their carers living in the community identified that they have a diverse range of needs. However, little is known about the needs of people with dementia and their carers from the perspectives of service providers who provide formal support. This study aimed to investigate the needs of people with dementia and their carers living in the community from the perspectives of service providers, and compare this to service recipients.

METHOD

This interpretive descriptive study used focus groups to collect qualitative data from service providers (N = 10). Data were analysed using a hybrid inductive-deductive approach to compare the needs identified by service providers to those identified by people with dementia and their carers.

RESULTS

Three major themes were identified: (i) services and supports required by people with dementia and their carers should be flexible, tailored, and equitable; (ii) building capacity to support carers and people with dementia; and (iii) systems designed to care were fragmented and difficult to navigate. Service providers prioritise needs that are limited to their current capacity to provide in contrast to the holistic needs of people with dementia and their carers.

CONCLUSION

There was poor alignment between the perceived needs of people with dementia and their carers and the needs prioritised by service providers in the West Australian community. This gap may reduce the ability of services to effectively support people with dementia to remain living in the community.

Community service providers' roles in supporting communication disability rehabilitation in Majority World contexts: An example from Ghana

Purpose: In Majority World countries, where speech-language pathology services are extremely limited, people with communication disabilities (PWCD) may seek help from a range of service providers. This qualitative research aimed to explore the nature of community services offered to people with communication disabilities who seek help in Accra, Ghana.Method: Semi-structured interviews were conducted with nine individuals from three professions: pastors (3), doctors (3), and herbalists (3) exploring services that they may offer to PWCD seeking help. Interviews were analysed using Thematic Network Analysis.Result: Six global themes described beliefs about communication disability, types of intervention, explanations provided to people with communication disabilities, promoting communication, processes for selecting treatments, and links between service providers. Interventions encompassed physical, spiritual, psychosocial and environmental approaches, with the notion of plural beliefs interwoven through a number of themes.Conclusion: In Ghana, and other Majority World contexts, service providers in sectors not commonly associated with communication disability rehabilitation may have important roles to play in supporting people with communication disabilities. Understanding the contributions of other service providers may assist the growing profession of speech-language pathology to collaborate across sectors, to develop specific, culturally responsive approaches to service development.

Predictors and moderators of improved social-emotional functioning in mothers with substance use disorders and their young children enrolled in a relationship-based case management program

Mothers with substance use disorders (SUDs) typically have trauma histories and psychosocial difficulties that lead to poor social-emotional functioning and disrupted mother-child relationships. This 12-month study explored associations of family adverse circumstances and services (case management, therapeutic, and community-based) received by 57-mothers with SUDs and their infants (less than 24-months-old) with changes in social-emotional functioning. All mothers were enrolled in a relationship-based case management program (Parent-Child Assistance Program [PCAP]) that emphasized connecting mothers to appropriate community services. A subset of mothers was additionally provided a trauma-focused psychotherapeutic intervention (infant-parent psychotherapy [IPP]). Dyads in both treatment groups improved in overall social-emotional functioning as assessed by the Functional Emotional Assessment Scale (FEAS). A combined-sample regression analysis revealed that improved FEAS scores were significantly predicted by the number of community services received but not by PCAP case management hours (IPP was not included in this analysis). More adverse circumstances were associated with less improvement in social-emotional functioning in the children; but among the mothers trauma level did not predict FEAS scores. We also found a moderating effect of trauma: Dyads with relatively more adversity showed a significantly greater association of community services received with improvement in FEAS scores than did those with relatively less adversity.

Simplifying Medication Regimens for People Receiving Community-Based Home Care Services: Outcomes of a Non-Randomized Pilot and Feasibility Study

Purpose

Being able to manage a complex medication regimen is key to older people continuing to live at home. This study determined the feasibility of a multi-component intervention to simplify medication regimens for people receiving community-based home care services.

Patients and Methods

Research nurses recruited people receiving community-based home care services to participate in this non-randomized pilot and feasibility study (Australian New Zealand Clinical Trials Registry ACTRN12618001130257). Participants received a one-off clinical pharmacist intervention comprising medication reconciliation, assessment of capacity to self-manage medications, and application of a structured 5-step tool to identify medication simplification opportunities. A mixed-methods feasibility assessment with an explanatory design was undertaken to assess recruitment, protocol adherence and stakeholder acceptability. Data from interviews with 12 stakeholders were thematically analyzed. Secondary outcome measures, including medication discrepancies, and changes in number of medication administration times per day, quality of life, medication adherence and health service utilization, were determined over a 4-month follow-up.

Results

Twenty-five out of the target 50 participants were recruited. Initial recruitment was impacted by apparent uncertain role responsibilities in medication management, with some clients who declined to participate perceiving they would be unlikely to benefit or being reluctant to change regimens. However, with few exceptions, participants who received intervention did so with a high degree of protocol adherence and acceptability. Stakeholders valued the intervention and supported wider implementation. Discrepancies between the baseline medication history from the general medical practitioner and the pharmacist-compiled “best possible medication history” were identified for all participants’ regimens (median of 6 per participant), with one-third resolved at follow-up. Simplification was possible for 14 participants (56%) and implemented for 7 (50%) at follow-up. No significant changes in other secondary outcomes were observed.

Conclusion

The intervention was delivered as planned, and valued by stakeholders. Recruitment barriers should be addressed before wider implementation.

Understanding ageing well in Australian rural and regional settings: Applying an age-friendly lens

OBJECTIVE

This study investigates how rural community-dwelling older adults' views on what is important in maintaining health and wellbeing align with the eight age-friendly domains proposed by the World Health Organisation, and which domains are most salient.

DESIGN

Data were gathered through open-ended response postcards distributed using a whole-of-community approach.

SETTING

The Rural City of Wangaratta, a rural local government area located in north-east Victoria.

PARTICIPANTS

262 postcards were returned by rural older adults, carers and family members.

MAIN OUTCOME MEASURE

Thematic analysis of open-ended responses to the following question: what is important to you as you grow older (or your loved one), in terms of keeping healthy and well?

RESULTS

Even though all eight age-friendly domains were identified as important for health and wellbeing, community and health services was the most frequently discussed domain, followed by transportation and access to outdoor spaces and buildings. However, individual-level factors, inclusive of personal activities, attitudes and capacities, were also identified as important to rural older adults.

CONCLUSION

Findings support the use of the World Health Organization's age-friendly city framework in assessing what is important to rural older adults' health and wellbeing, with the community and health services domain most salient. However, individual-level activities, attitudes and capacities must also be considered.

Protocol for a non-randomised pilot and feasibility study evaluating a multicomponent intervention to simplify medication regimens for people receiving community-based home care services

INTRODUCTION

Managing medication regimens is one of the most complex and burdensome tasks performed by older people, and can be prone to errors. People living with dementia may require medication administration assistance from formal and informal caregivers. Simplified medication regimens maintain the same therapeutic intent, but have less complex instructions and administration schedules. This protocol paper outlines a study to determine the feasibility of a multicomponent intervention to simplify medication regimens for people receiving community-based home care services.

METHODS AND ANALYSIS

This is a non-randomised pilot and feasibility study. Research nurses will recruit 50 people receiving community-based home care services. All participants will receive the intervention from a clinical pharmacist, who will undertake medication reconciliation, assess each participant's capacity to self-manage their medication regimen and apply a structured tool to identify opportunities for medication simplification. The pharmacist will communicate recommendations regarding medication simplification to registered nurses at the community-based home care provider organisation. The primary outcome will be a description of study feasibility (recruitment and retention rates, protocol adherence and stakeholder acceptability). Secondary outcomes include the change in number of medication administration times per day, medication adherence, quality of life, participant satisfaction, medication incidents, falls and healthcare utilisation at 4 months.

ETHICS AND DISSEMINATION

Ethical approval was obtained from the Monash University Human Research Ethics Committee and the community-based home care provider organisation's ethical review panel. Research findings will be disseminated to consumers and caregivers, health professionals, researchers and healthcare providers through the National Health and Medical Research Council Cognitive Decline Partnership Centre and through conference presentations, lay summaries and peer-reviewed publications. This study will enable an improved understanding of medication management and administration among people receiving community-based home care services. This study will inform the decision to proceed with a randomised controlled trial to assess the effect of this intervention.

TRIAL REGISTRATION NUMBER

ACTRN12618001130257; Pre-results.

Home care service utilisation by people with dementia-A retrospective cohort study of community nursing data in Australia

Progressive aged care reforms are shifting dementia care into the community. These efforts have been shown to prevent transition to residential aged care facilities and hospitals. There is a paucity of studies examining the utilisation of home care services for people living with dementia. This study aims to address the current knowledge gap by providing a comprehensive summary of older adults receiving home care and comparing service use for people with and without dementia. A retrospective secondary data analysis was conducted using routine data prospectively collected from a cohort (n = 2,703 with dementia matched to 9,224 without dementia; total 11,927) using a community home nursing service in metropolitan Melbourne, Australia, in 2014. Descriptive statistics compared individuals with and without dementia on client-level demographics and their episode of home care service use. A comparative analysis on select variables was also performed using a conditional Poisson regression to estimate relative risk (RR). Compared to older adults without dementia, people with dementia were more likely to be born overseas (RR 1.10, 95% CI [1.03-1.19]), require an interpreter (RR 1.41, 95% CI [1.26-1.59]), and live with family (RR 1.09 [1.01-1.16]). When examining an individual's episode of care, people with dementia were more likely to require acute care (RR 1.07, 95% CI [1.01-1.14]) and be discharged from home care with personal care services (RR 1.46, 95% CI [1.24-1.72]). People with dementia were less likely to be referred from a hospital (RR 0.73, 95% CI [0.69-0.77]), achieve their home care goals (RR 0.91, 95% CI [0.87-0.94]), or die while in receipt of home care services (RR 0.82, 95% CI [0.72-0.94]). Our findings suggest that people with dementia have different socio-demographic characteristics and interactions with home care services compared to people without dementia.

Systematic Review Investigating Multi-disciplinary Team Approaches to Screening and Early Diagnosis of Dementia in Primary Care - What are the Positive and Negative Effects and Who Should Deliver It?

BACKGROUND

Primary care services frequently provide the initial contact between people with dementia and health service providers. Early diagnosis and screening programmes have been suggested as a possible strategy to improve the identification of such individuals and treatment and planning health and social care support.

OBJECTIVE

To determine what early diagnostic and screening programmes have been adopted in primary care practice, to explore who should deliver these and to determine the possible positive and negative effects of an early diagnostic and screening programme for people with dementia in primary care.

METHODS

A systematic review of the literature was undertaken using published and unpublished research databases. All papers answering our research objectives were included. A narrative analysis of the literature was undertaken, with the CASP tools used appropriately to assess study quality.

RESULTS

Thirty-three papers were identified of moderate to high quality. The limited therapeutic options for those diagnosed with dementia means that even if such a programme was instigated, the clinical value remains questionable. Furthermore, accuracy of the diagnosis remains difficult to assess due to poor evidence and this raises questions regarding whether people could be over- or under-diagnosed. Given the negative social and psychological consequences of such a diagnosis, this could be devastating for individuals.

CONCLUSION

Early diagnostic and screening programmes have not been widely adopted into primary care. Until there is rigorous evidence assessing the clinical and cost-effectiveness of such programmes, there remains insufficient evidence to support the adoption of these programmes in practice.

Training and service provision for people with intellectual disability and mental illness: the views of psychiatrists

  Objectives: The objectives of this mixed methods study are to 1) investigate the knowledge and skills of mainstream psychiatrists in managing patients with Intellectual Disability (ID) and comorbid mental health disorders, 2) assess their perception of the quality and accessibility of services for this population, and 3) establish the local implementation of the Green Light Toolkit. Method: We surveyed mainstream psychiatrists in the Thames Valley region working in general adult, forensic, and older adult services, to ascertain their opinions about their knowledge and skills in managing patients with ID and comorbid mental disorder, as well as quality and accessibility of services. We compared our findings with previous UK and international research. Results: Respondents mirrored views expressed in earlier studies that inpatient care should be provided in dedicated units for people with ID, rather than general adult inpatient wards. Limited resources, training and competence, and lack of collaborative working were highlighted as key barriers to provision of effective care. Conclusion: Psychiatrists broadly support a specialist service model for people with ID. In the UK, specialist psychiatric services for people with ID have been delivered through inpatient and community services, but there is a current shift towards integrating ID with mainstream service models. Participants expressed concern that mainstream services fail to meet the mental health needs of this patient group, and lead to increased patient vulnerability. The Green Light Toolkit was not well known or used within services. A number of ways of improving collaborative care between services are suggested.

Geriatric Forensic Medicine - A Specialty that can no Longer Wait to be Realised

The rise in the population and the growth in the proportion of the elderly in our population are changing the structure of many of our communities and placing increasing demands on our social and health care services. "Scandals" regarding conditions and standards of care in residential aged care facilities have raised concerns about the regulation, assessment and auditing of these community services for the elderly. At the same time longer working lives change the age factors related to employment opportunities and the cadre of older employees presents a different range of human resource issues and occupational health and safety problems for employers. While there is evidence that an older workforce can bring a wider experience and understanding of critical issues to many work disciplines, ageing practitioners may pose professional regulatory issues for the community when considerations of cognitive and technical/physical ability arise. It is in these settings that the need for a forensic focus on gerontology and medical geriatrics arises.

Students' perceptions on community-based education at Avalon University School of Medicine during the first two years of the program

This article was migrated. The article was marked as recommended. Objectives The socio-cultural learning theory can be divided into a social and cultural process. Learner's learning occurs within the context rather than anticipating and preparing for the future context. It may happen in the workplace through apprenticeship, experiential learning, or community-based learning. Community-based education and community services have always been part of the students' volunteer services at Avalon University School of Medicine. The importance of community-based education has led to its recent integration into the curriculum. The objective of this study is to observe the community services in the field and to record the perceptions of students regarding community-based education at Avalon University School of Medicine. Methods This is a qualitative study. The research was conducted in the form of an observational study and framework analysis was done. The community-based education and community services were observed and recorded along with individual interviews. Students from different semesters were selected randomly for the interviews. The interviews were audio-recorded and transcribed. Results All interviewed students (100%) reported that they are involved in community services. 53.8% of students were not able to recognize the health issues of Curacao. 84.6% of students recognized and acknowledged the local health issues after reminding them of the activities conducted in the community services. 84.6% of students believed community services enhanced their clinical skills and increased their confidence in communication skills. Conclusion Community-based education enhances the competency of future physicians in clinical and communication skills.

Predictors in use of mental health resources: The role of behaviour problems in patients with severe mental illness

BACKGROUND

In recent years, more variables are being included in the use of mental health resource prediction models. Some studies have shown that how well the patient can function is important for this prediction. However, the relevance of a variable as important as behaviour problems has scarcely been explored.

AIM

This study attempted to evaluate the effect of behaviour problems in patients with severe mental illness on the use of mental health resources.

METHOD

A total of 185 patients at a Community Mental Health Unit were evaluated using the Behaviour Problem Inventory. Later, a bivariate logistic regression was done to identify what behaviour problems could be specific predictors of use of mental health resources.

RESULTS

The results showed that the general index of behaviour problems predicts both use of hospitalization resources and outpatient attention. Underactivity/social withdrawal is the best predictor of all the different areas.

CONCLUSION

These results confirm the role of behaviour problems as predictors of the use of mental health resources in individuals with a severe mental illness.

Opportunities and barriers to STI testing in community health centres in China: a nationwide survey

BACKGROUND

China has strengthened its primary care workforce and implemented a wide network of community health centres (CHCs). However, STI testing and management are not currently included in the 'Essential Package of Primary Health Care in China'. Legislation change to encourage STI service delivery would be important, but it is also critical to determine if there are also provider-related opportunities and barriers for implementing effective STI programmes through CHCs if future legislation were to change.

METHODS

A national representative survey was conducted between September and December 2015 in a stratified random sample of 180 CHCs based in 20 cities in China. Primary care practitioners (PCPs) provided information on current experiences of STI testing as well as the barriers and facilitators for STI testing in CHCs. Multivariate logistic regression was conducted to determine factors associated with PCPs performing STI testing.

RESULTS

3580 out of 4146 (86%) invited PCPs from 158 CHCs completed the survey. The majority (85%, 95% CI 84% to 87%) of doctors stated that STI testing was an important part of healthcare. However, less than a third (29%, 95% CI 27% to 31%) would perform an STI test if the patients asked. Barriers for performing STI testing included lack of training, concerns about reimbursement, concerns about damage to clinics' reputations and the stigma against key populations. Respondents who reported that they would perform an STI test were likely to be younger, received a bachelor degree or higher, received specific training in STIs, believed that STI test was an important part of healthcare or had resources to perform STI testing.

CONCLUSIONS

There is potential for improving STI management in China through upskilling the primary care workforce in CHCs. Specific training in STIs is needed, and other structural, logistical and attitudinal barriers are needed to be addressed.

Leadership in practice: an analysis of collaborative leadership in the conception of a virtual ward

The National Health Service (NHS) in the UK is evolving to meet the needs of society, but success depends on effective leadership. The World Health Organization identified intersectoral and multidisciplinary working as key to improving the quality and sustainability of the service, highlighting the need for a new leadership style. This article describes how collaborative leadership was used to successfully implement a virtual ward in the primary care setting in south-east Powys, Wales. The author describes the leadership style and addresses strategies used to manage the change process. The journey demonstrates how collaborative leadership and working collectively enabled a new service to be developed, and established a mutual respect for different professionals' roles.

Independent older adults perspectives on oral health

OBJECTIVES

The purpose of this study was to explore oral health experiences from the perspective of older adults' living in community dwellings. The two objectives of this study were to identify facilitators and barriers to oral health care, and to determine how utilization of oral health services compares to utilization of other healthcare services.

METHODOLOGY

An interpretive descriptive methodology was employed with a purposive sample of 12 adults, aged 70 years or older. The inclusion criterion was English-speaking seniors residing in community dwellings. Community dwellings were defined as any housing outside of long-term care or other supportive living facilities. Semi-structured interviews were 30-80 min, audio-recorded and transcribed verbatim. Three researchers participated in the comparative analysis process to develop codes, generate categories, interpret patterns and construct themes.

RESULTS

Three central themes surfacing from the data were as follows: life course influences on oral health, transparency in delivery of oral health services and interrelationships between oral health and overall health.

CONCLUSIONS

Older adults in this study emphasized the value of establishing collaborative and trusting relationships between oral health practitioners and older adults. Oral health practitioners should be clear and transparent when communicating information about oral health costs and be cognizant of different circumstances from childhood to older adulthood that inhibit or promote routine utilization of oral health services. Including oral health services as part of interdisciplinary care teams could help promote understandings of the reciprocal relationship between oral health and general health and improve oral health status for older adults.

Impact of drug awareness and treatment camps on attendance at a community outreach de-addiction clinic

BACKGROUND

Substance misuse is an increasing problem in urban and rural India. The utility of community-based interventions and preventive strategies are increasingly emphasized in this context. The drug de-addiction and treatment center, Department of Psychiatry, Postgraduate Institute of Medical Education and Research, has been running a drug de-addiction and treatment clinic at Kharar Civil Hospital, Kharar, District Mohali, Punjab, since 1998. As part of an effort to enhance this community outreach program, community-based drug awareness and treatment camps have been organized since March 2004 in villages in and around Tehsil Kharar of Mohali.

AIM

To study the impact of the drug awareness and treatment camps on the attendance of patients at the community outreach drug de-addiction and treatment clinic at Kharar Civil Hospital.

METHODS

Sociodemographic and clinical variables, including treatment outcome-related variables, of patients attending the clinic at Kharar Civil Hospital, before and after the camps were compared.

DISCUSSION AND CONCLUSION

The study showed a positive impact on drug awareness and treatment camps held in the community on outpatient attendance at a community outreach clinic, with attendance increasing more than 1.8 times.

Intermediate care in nursing home after hospital admission: a randomized controlled trial with one year follow-up

BACKGROUND

Intermediate care is intended to reduce hospital admissions and facilitate early discharge. In Norway, a model was developed with transfer to intermediate care shortly after hospital admission. Efficacy and safety of this model have not been studied previously.In a parallel-group randomized controlled trial, patients over 70 years living at home before admission were eligible if clinically stable, without need for surgical treatment and deemed suited for intermediate care by attending physician. Intervention group patients were transferred to a nursing home unit with increased staff and multidisciplinary assessment, for a maximum stay of three weeks. Patients in the control group received usual care in hospital. Blinding to group assignment was not possible.The primary outcome was number of days living at home in a follow-up period of 365 days. Secondary outcomes were mortality, hospital admissions, need for residential care and home care services. Data were obtained from patient records and registers.

RESULTS

376 patients were included, 74% female and mean age 84 years. There was no significant differences between intervention (n=190) and control group (n=186) for number of days living at home (253.7 vs 256.5, p=0.80) or days in hospital (10.4 vs 10.5, p=0.748). Intervention group patients spent less time in nursing home (40.6 days vs. 55.0, p=0.046), and more patients lived independently without home health care services (31.6% vs 19.9%, p=0.007). For orthopaedic patients (n=128), mortality was higher in the intervention group; 15 intervention patients and 7 controls died (25.1% vs 10.3%, p=0.049). There was no significant difference in one-year mortality for medical patients (n=150) or the total study population.

CONCLUSIONS

This model of rapid transfer to intermediate care did not significantly influence number of days living at home during one year follow-up, but reduced demand for nursing home care and need for home health care services. In post-hoc analysis mortality was increased for orthopedic patients.

TRIAL REGISTRATION

The trial was registered 26. July 2013 at Current Controlled Trials and assigned with registration number ISRCTN21608185.

How can dental public health competencies be addressed at the undergraduate level?

OBJECTIVES

To discuss the extent to which an undergraduate dental module addresses dental public health competencies via its different learning pedagogies and to explore the relevance of students' written reflections on these dental public health competencies.

METHODS

This article uses a literature review to situate the extent to which dental public health competencies are addressed by the University of British Columbia undergraduate dental module entitled "Professionalism and Community Services" (PACS). It also uses students' written individual self-reflections (between 100 and 500 words) on community service learning activities to critically illustrate how dental public health competencies support their learning.

RESULTS

The PACS dental module is delivered to undergraduate students in all 4 years, more than 190 in total, and addresses six dental public health competencies, including oral health promotion, ethics, and evidence-based practice. The multifaceted pedagogical approach employed to discuss aspects of dentistry related to dental public health includes guest lectures, community activities, small group activities, self-reflection, and reports.

CONCLUSIONS

Given the falling number of dental public health professionals in North America, the discussed undergraduate pedagogy aims to sensitize future dentists to a career focused on dental public health. Through reflections, students pondered ideas related to dental public health; they also engaged in developing meaningful activities in various underserved communities. Further studies are needed to evaluate the influence of this community-based curriculum upon students' practice choice.

The Ecology of Sustainable Implementation: Reflection on a 10-Year Case History Illustration

The primary aim of this paper is to illustrate the strategic and ecological nature of implementation. The ultimate aim of implementation is not dissemination but sustainability beyond the implementation effort. A case study is utilized to illustrate these broad and long-term perspectives of sustainable implementation based on qualitative analyses of a 10-year implementation effort. The purveyors aimed to develop selective community prevention services for children in families burdened by parental psychiatric or addictive problems. Services were gradually disseminated to 23 sites serving 40 municipalities by 2013. Up to 2013, only one site terminated services after initial implementation. Although many sites suspended services for shorter periods, services are still offered at 22 sites. This case analysis is based on project reports, user evaluations, practitioner interviews, and service statistics. The paper focuses on the analyses and strategies utilized to cope with quality decay and setbacks as well as progress and success in disseminating and sustaining the services and their quality. Low-cost multilevel strategies to implement services at the community level were organized by a prevention unit in child psychiatry, supervised by a university department (purveyors). The purveyors were also involved in national and international collaboration and development. Multilevel strategies included manualized intervention, in-practice training methods, organizational responsibility, media strategies, service evaluation, staff motivation maintenance, quality assurance, and proposals for new law regulations. These case history aspects will be discussed in relation to the implementation literature, focusing on possible applicability across settings.

Enhancing patient-centered care: pilot study results of a community care team intervention

Health care reform focuses on primary care and development of Health Care Homes to improve patient-centered chronic illness care. This pilot study evaluated a community care team intervention that linked chronically ill older patients, support persons, and nurse care coordinators from a Health Care Home with community resources using an adaptation of the Wraparound process. A pragmatic clinical trial design was used. Patient-centered chronic illness care; physical, mental, and social health; service use; and study feasibility were evaluated. Differences between groups were compared using two-sample t, Wilcoxon rank sum, chi-square, or Fisher's exact tests. At 3 months, the intervention group reported higher patient-centered chronic illness care (mean total Patient Assessment of Chronic Illness Care change scores were 0.39 for the intervention group and -0.11 for the control group, p = .03). Results indicate that the integrated community care team intervention is a promising strategy to support patient-centered chronic illness care.

Barriers to the routine collection of health outcome data in an Australian community care organization

For over a decade, organizations have attempted to include the measurement and reporting of health outcome data in contractual agreements between funders and health service providers, but few have succeeded. This research explores the utility of collecting health outcomes data that could be included in funding contracts for an Australian Community Care Organisation (CCO). An action-research methodology was used to trial the implementation of outcome measurement in six diverse projects within the CCO using a taxonomy of interventions based on the International Classification of Function. The findings from the six projects are presented as vignettes to illustrate the issues around the routine collection of health outcomes in each case. Data collection and analyses were structured around Donabedian's structure-process-outcome triad. Health outcomes are commonly defined as a change in health status that is attributable to an intervention. This definition assumes that a change in health status can be defined and measured objectively; the intervention can be defined; the change in health status is attributable to the intervention; and that the health outcomes data are accessible. This study found flaws with all of these assumptions that seriously undermine the ability of community-based organizations to introduce routine health outcome measurement. Challenges were identified across all stages of the Donabedian triad, including poor adherence to minimum dataset requirements; difficulties standardizing processes or defining interventions; low rates of use of outcome tools; lack of value of the tools to the service provider; difficulties defining or identifying the end point of an intervention; technical and ethical barriers to accessing data; a lack of standardized processes; and time lags for the collection of data. In no case was the use of outcome measures sustained by any of the teams, although some quality-assurance measures were introduced as a result of the project.

Integrating Care in Norfolk (ICN)—A case study on a two-year programme to improve integrated working between primary care, community health services and social care in six localities

The ICN programme was designed to test ways of integrating health and social care services in six localities with a population of nearly 300,000 residents with the objective of improving patient and staff satisfaction, and reducing demands on secondary care. The ICN programme is one of 16 national integrated care pilots in England.

Data were sourced from questionnaires, focus groups, interviews, and recorded service activity. A core group of practitioners in each locality focused on redesigning services according to their local circumstances in order to improve care for adults and older people with complex care needs. Local arrangements included developing multidisciplinary teams based in GP practices, with coordinators operating in a local hub. 845 patients received ICN interventions.

The study showed high levels of satisfaction from patients and staff, with surveyed staff being unanimous that this way of working should continue. A study of 12 of the 32 GP practices that engaged early in the programme showed a 31% reduction in unplanned admissions to hospital between the first and second year of the pilot. Issues included the time required for building trust and communication, the importance of building a platform for integrating care locally and extending to a whole-system approach.

Decision aids for respite service choices by carers of people with dementia: development and pilot RCT

BACKGROUND

Decision aids are often used to assist individuals confronted with a diagnosis of a serious illness to make decisions about treatment options. However, they are rarely utilised to help those with chronic or age related conditions to make decisions about care services. Decision aids should also be useful for carers of people with decreased decisional capacity. These carers' choices must balance health outcomes for themselves and for salient others with relational and value-based concerns, while relying on information from health professionals. This paper reports on a study that both developed and pilot tested a decision aid aimed at assisting carers to make evaluative judgements of community services, particularly respite care.

METHODS

A mixed method sequential study, involving qualitative development and a pilot randomised controlled trial, was conducted in Tasmania, Australia. We undertook 13 semi-structured interviews and three focus groups to inform the development of the decision aid. For the randomised control trial we randomly assigned 31 carers of people with dementia to either receive the service decision aid at the start or end of the study. The primary outcome was measured by comparing the difference in carer burden between the two groups three months after the intervention group received the decision aid. Pilot data was collected from carers using interviewer-administered questionnaires at the commencement of the project, two weeks and 12 weeks later.

RESULTS

The qualitative data strongly suggest that the intervention provides carers with needed decision support. Most carers felt that the decision aid was useful. The trial data demonstrated that, using the mean change between baseline and three month follow-up, the intervention group had less increase in burden, a decrease in decisional conflict and increased knowledge compared to control group participants.

CONCLUSIONS

While these results must be interpreted with caution due to the small sample size, all intervention results trend in a direction that is beneficial for carers and their decisional ability. Mixed method data suggest the decision aid provides decisional support that carers do not otherwise receive. Decision aids may prove useful in a community health services context.

TRIAL REGISTRATION NUMBER

ISRCTN: ISRCTN32163031.