Moving beyond More of the Same, but Better - How Campuses of Care Can Transform Long-Term Care.

For decades, there have been calls for innovative care solutions to address the growing numbers of people living with complex health and social needs, including dementia. In 2020-2021, the toll of the COVID-19 pandemic on vulnerable populations exposed many of the same issues and spurred renewed calls for transformative change. As we look forward, it is imperative to consider options not just for improving residential long-term care but also for integrating it into broader continuums of health and social care, where people can receive supports and services in the most appropriate setting. This commentary spotlights campuses of care as one homegrown solution to address individuals' and system needs and contexts.

Seniors' campus continuums: local solutions for broad spectrum seniors care.

BACKGROUND: As demand and desire to "age-in-place" grows within an aging population, and new areas of need emerge, governments nationally and internationally are focusing effort and attention on innovative and integrative approaches to health and well-being. Seniors' Campus Continuums are models of care that seek to broaden access to an array of services and housing options to meet growing health and social needs of aging populations. The objective of this study is to increase understanding of this model and factors that influence their evolution, development, ongoing functioning and capacity to integrate care for older adults wishing to age in their own home and community. METHODS: This research uses a comparative case study approach across six-bounded cases offering four geographically co-located components (mixed housing options, internal and external community supports, and a long-term care home) in various contexts across Ontario, Canada. Onsite in-person and phone interviews with senior campus staff (N = 30), and campus partners (N = 11), enhanced by direct observation at campuses explored historical and current efforts to offer health, housing and social care continuums for older adults. RESULTS: Analysis highlighted eight key factors. Enabling factors include i. rich historical legacies of helping people in need; ii. organizational vision and readiness to capitalize on windows of opportunity; iii. leveraging organizational structure and capacity; iv. intentional physical and social design; v. broad services mix, amenities and innovative partnerships. Impeding factors include vi. policy hurdles and rigidities; vii. human resources shortages and inequities; and viii. funding limitations. A number of benefits afforded by campuses at different levels were also observed. CONCLUSION: Findings from this research highlight opportunities to optimize campus potential on many levels. At an individual level, campuses increase local access to a coordinated range of health and social care services, supports and housing options. At an organizational level, campuses offer enhanced collaboration opportunities across providers and partners to improve consistency and coordination of care, and improved access to shared resources, expertise and infrastructure. At a system level, campuses can address a diversity of health, social, financial, and housing needs to help seniors avoid premature or inappropriate use of higher intensity care settings.

Parent and Provider Perspectives on the Diagnosis and Management of Autism in a Chinese Immigrant Population.

OBJECTIVE: Minority families experience disparities in the diagnosis and management of autism spectrum disorder (hereafter "autism"). To date, the experiences of Chinese immigrant families in the United States have not been explored. Utilizing parent and provider perspectives, this research sought to identify barriers and facilitators to the diagnosis and management of autism among Chinese immigrant children. METHODS: We conducted semistructured qualitative interviews with 16 parents of Chinese children diagnosed with autism and 16 providers who assist in the diagnosis and management of autism. Participant characteristics were analyzed utilizing descriptive statistics. Interviews were audiorecorded, transcribed, translated, and independently coded by 2 researchers until consensus was reached. Coded data were analyzed using a modified grounded therapy approach. RESULTS: Parents and providers both identified cultural beliefs as an influence on the understanding and acceptance of autism as a diagnosis. There was a high degree of alignment in themes related to barriers to health care access and parent-provider communication. Recommendations to improve the system of care include (1) supporting communication, (2) cultural sensitivity, and (3) care coordination programming. CONCLUSION: Findings reinforce that diagnosis and treatment of autism should take into account culturally specific beliefs about child developmental norms and should address systems-, provider-, and family-level barriers.

Towards a Community-Based Dementia Care Strategy: How do We Get There from Here?

As recent policy reports in Ontario and elsewhere have emphasized, most older persons would prefer to age at home. This desire does not diminish for the growing numbers of persons living with dementia (PLWD). Nevertheless, many PLWD end up in residential long-term care (LTC) or in hospital beds. While LTC is valuable for PLWD with highly progressed cognitive and functional impairment requiring high-intensity care, it can be a costly and avoidable option for those who could remain at home if given early access to a coordinated mix of community-based supports. In this lead paper, we begin by exploring the "state of the art" in community-based care for PLWD, highlighting the importance of early and ongoing intervention. We then offer a brief history of dementia care policy in Ontario as an illustrative case study of the challenges faced by policy makers in all jurisdictions as they aim to re-direct healthcare systems focused on "after-the-fact" curative care towards "before-the-fact" prevention and maintenance in the community. Drawing on results from a "balance of care" study, which we conducted in South West Ontario, we examine how, in the absence of viable community-based care options, PLWD can quickly "default" to institutional care. In the final section, we draw from national and international experience to identify the following three key strategic pillars to guide action towards a community-based dementia care strategy: engage PLWD to the extent possible in decisions around their own care; acknowledge and support informal caregivers in their pivotal roles supporting PLWD and consequently the formal care; and enable "ground-up" change through policies and funding mechanisms designed to ensure early intervention across a continuum of care with the aim of maintaining PLWD and their caregivers as independently as possible, for as long as possible, "closer to home."

"You've got to look after yourself, to be able to look after them" a qualitative study of the unmet needs of caregivers of community based primary health care patients.

BACKGROUND: There is growing reliance on unpaid caregivers to provide support to people with care needs. Integrated care approaches that aim to coordinate primary care with community care known as community based primary health care (CBPHC) has been a key policy initiative across health systems; however most attention has been paid to the needs of patients and not caregivers. The objective of this paper was to explore the unmet needs of caregivers of older adults with complex care needs receiving CBPHC. METHODS: This qualitative descriptive study entailed one-to-one interviews with 80 caregivers from Canada and New Zealand where roles, experiences and needs were explored. Interview text related to unmet need was reviewed inductively and core themes identified. RESULTS: Three themes were identified across CBPHC sites: unrecognized role; lack of personal resources; and no breaks even when services are in place. CONCLUSIONS: To support caregivers, models of care such as CBPHC need to look beyond the patient to meaningfully engage caregivers, address their needs and recognize the insight they hold. This knowledge needs to be valued as a key source of evidence to inform developments in health and social care.

Rebalancing health systems toward community-based care: The role of subsectoral politics.

There has been increased policy discourse urging a "rebalancing" of health systems from institutionally-based to community-based approaches. This paper offers an analysis of the subsectoral dynamics that condition opportunities to strengthen community-based care relative to acute care. We report on the results of a policy study in Ontario, Canada that explored factors impacting on the capacity to expand community-based care. In so doing, we highlight the challenges associated with the community subsector's ability to develop 'critical' status and challenge the dominance of the acute subsector. We conclude that attempts to rebalance health systems toward community-based care should begin by understanding that health care is not a monolithic policy sector, but rather a collection of proximate policy sub-sectors, inclusive of community care, acute care, and institutional care, each with their own internal characteristics and dynamics that impact sectoral directions.

How do Policy and Institutional Settings Shape Opportunities for Community-Based Primary Health Care? A Comparison of Ontario, Québec and New Zealand.

Community-based primary health care describes a model of service provision that is oriented to the population health needs and wants of service users and communities, and has particular relevance to supporting the growing proportion of the population with multiple chronic conditions. Internationally, aspirations for community-based primary health care have stimulated local initiatives and influenced the design of policy solutions. However, the ways in which these ideas and influences find their way into policy and practice is strongly mediated by policy settings and institutional legacies of particular jurisdictions. This paper seeks to compare the key institutional and policy features of Ontario, Québec and New Zealand that shape the 'space available' for models of community-based primary health care to take root and develop. Our analysis suggests that two key conditions are the integration of relevant health and social sector organisations, and the range of policy levers that are available and used by governments. New Zealand has the most favourable conditions, and Ontario the least favourable. All jurisdictions, however, share a crucial barrier, namely the 'barbed-wire fence' that separates funding of medical and 'non-medical' primary care services, and the clear interests primary care doctors have in maintaining this fence. Moves in the direction of system-wide community-based primary health care require a gradual dismantling of this fence.

Religion and Subjective Well-Being: Western and Eastern Religious Groups Achieved Subjective Well-Being in Different Ways.

Culture can moderate which variables most influence subjective well-being (SWB). Because religion can be conceptualized as culture, religious differences can be considered cultural differences. However, there have been few studies comparing how different religious groups evaluate SWB at any given time. This study is among the first to investigate this issue. The present study compared Buddhists, Taoists, Christians, and atheists. In addition to demographic items, 451 Chinese adults completed Chinese version of the Socially Oriented Cultural Conception of SWB Scale. Religious belief was distributed as follows: 10 % Christian, 20 % Buddhist, 25 % Taoist, and 43 % atheists. As predicted, the socially oriented cultural conception of SWB was found to be highest among Buddhists, followed in order by Taoists, atheists, and Christians. It was concluded that the various religious groups achieved SWB in different ways.

Towards a Community-Based Dementia Care Strategy: How Do We Get There from Here?

As recent policy reports in Ontario and elsewhere have emphasized, most older persons would prefer to age at home. This desire does not diminish for the growing numbers of persons living with dementia (PLWD). Nevertheless, many PLWD end up in residential long-term care (LTC) or in hospital beds. While LTC is valuable for PLWD with highly progressed cognitive and functional impairment requiring high-intensity care, it can be a costly and avoidable option for those who could remain at home if given early access to a coordinated mix of community-based supports. In this lead paper, we begin by exploring the "state of the art" in community-based care for PLWD, highlighting the importance of early and ongoing intervention. We then offer a brief history of dementia care policy in Ontario as an illustrative case study of the challenges faced by policy makers in all jurisdictions as they aim to re-direct healthcare systems focused on "after-the-fact" curative care towards "before-the-fact" prevention and maintenance in the community. Drawing on results from a "balance of care" study, which we conducted in South West Ontario, we examine how, in the absence of viable community-based care options, PLWD can quickly "default" to institutional care. In the final section, we draw from national and international experience to identify the following three key strategic pillars to guide action towards a community-based dementia care strategy: engage PLWD to the extent possible in decisions around their own care; acknowledge and support informal caregivers in their pivotal roles supporting PLWD and consequently the formal care; and enable "ground-up" change through policies and funding mechanisms designed to ensure early intervention across a continuum of care with the aim of maintaining PLWD and their caregivers as independently as possible, for as long as possible, "closer to home."

Diagnosis and Management of Hepatitis C Virus Infection.

The hepatitis C virus (HCV) infects more than 200 million people globally, with increasing incidence, especially in developing countries. HCV infection frequently progresses to chronic liver disease, creating a heavy economic burden on resource-poor countries and lowering patient quality of life. Effective HCV diagnosis, treatment selection, and treatment monitoring are important in stopping disease progression. Serological assays, which detect anti-HCV antibodies in the patient after seroconversion, are used for initial HCV diagnosis. Qualitative and quantitative molecular assays are used to confirm initial diagnosis, determine viral load, and genotype the dominant strain. Viral load and genotype information are used to guide appropriate treatment. Various other biomarker assays are performed to assess liver function and enable disease staging. Most of these diagnostic methods are mature and routinely used in high-resource countries with well-developed laboratory infrastructure. Few technologies, however, are available that address the needs of low-resource areas with high HCV prevalence, such as Africa and Southeast Asia.

Caring for Caregivers: Bridging the Care Gap.

While drawing on different perspectives, the insightful responses of our commentators all highlight the increasingly crucial role of informal, and mostly unpaid caregivers. They also raise key questions. The first question, "how should we refer to caregivers," pushes us to acknowledge the diversity of caregiver characteristics, contexts and roles. The second, "how should we understand the caregiver 'problem'," reminds us that although often thought of as an individual matter, caregiving is a public policy issue requiring broader systems thinking and approaches. The third, "what should we do about it," draws attention to the importance of building and strengthening social networks to support caregivers and bridge a "growing care gap." We offer the example of Japan which, as part of its national dementia care policy, is now encouraging the development of inter-generational dementia-friendly communities.

Religion and health: anxiety, religiosity, meaning of life and mental health.

We examined the association among anxiety, religiosity, meaning of life and mental health in a nonclinical sample from a Chinese society. Four hundred fifty-one Taiwanese adults (150 males and 300 females) ranging in age from 17 to 73 years (M = 28.9, SD = 11.53) completed measures of Beck Anxiety Inventory, Medical Outcomes Study Health Survey, Perceived Stress Scale, Social Support Scale, and Personal Religiosity Scale (measuring religiosity and meaning of life). Meaning of life has a significant negative correlation with anxiety and a significant positive correlation with mental health and religiosity; however, religiosity does not correlate significantly anxiety and mental health after controlling for demographic measures, social support and physical health. Anxiety explains unique variance in mental health above meaning of life. Meaning of life was found to partially mediate the relationship between anxiety and mental health. These findings suggest that benefits of meaning of life for mental health can be at least partially accounted for by the effects of underlying anxiety.

Discovery of potential new gene variants and inflammatory cytokine associations with fibromyalgia syndrome by whole exome sequencing.

Fibromyalgia syndrome (FMS) is a chronic musculoskeletal pain disorder affecting 2% to 5% of the general population. Both genetic and environmental factors may be involved. To ascertain in an unbiased manner which genes play a role in the disorder, we performed complete exome sequencing on a subset of FMS patients. Out of 150 nuclear families (trios) DNA from 19 probands was subjected to complete exome sequencing. Since >80,000 SNPs were found per proband, the data were further filtered, including analysis of those with stop codons, a rare frequency (<2.5%) in the 1000 Genomes database, and presence in at least 2/19 probands sequenced. Two nonsense mutations, W32X in C11orf40 and Q100X in ZNF77 among 150 FMS trios had a significantly elevated frequency of transmission to affected probands (p = 0.026 and p = 0.032, respectively) and were present in a subset of 13% and 11% of FMS patients, respectively. Among 9 patients bearing more than one of the variants we have described, 4 had onset of symptoms between the ages of 10 and 18. The subset with the C11orf40 mutation had elevated plasma levels of the inflammatory cytokines, MCP-1 and IP-10, compared with unaffected controls or FMS patients with the wild-type allele. Similarly, patients with the ZNF77 mutation have elevated levels of the inflammatory cytokine, IL-12, compared with controls or patients with the wild type allele. Our results strongly implicate an inflammatory basis for FMS, as well as specific cytokine dysregulation, in at least 35% of our FMS cohort.

Recognition of tactile relief by children and adults.

This study was designed to compare tactile sensitivity of children and adults on printed target stimuli covering a wide range of elevations and requiring different resolutions. A recognition-relief task using 9 digits at 6 levels of elevation from a surface (0.5, 0.4, 0.3, 0.2, 0.1, and 0.05 mm) was presented to 24 young adults and 24 children. As predicted, relief elevations as low as 0.05 mm were recognized above chance. As predicted, children performed significantly more poorly than the adults on recognition at all elevations, although the difference increased as elevation increased. Adults performed significantly better than children on high-resolution digit 8, but there was no reliable age difference on low-resolution digit 1. Recognition difference between the high- and low-resolution digits decreased nonlinearly as elevation increased, irrespective of age. Overall, the findings support previous research indicating greater tactile sensitivity in adults than in children, but the superiority was moderated by the elevation and resolution requirements of the stimuli.

Paranormal beliefs and religiosity: Chinese version of the Revised Paranormal Belief Scale.

This paper reports an initial study investigating the relations of paranormal beliefs with religiosity in a Chinese sample, as well as the development of a Chinese version of the Revised Paranormal Belief Scale and a test of its psychometric properties with 310 college students (5.5% Christians, 21.3% Buddhists, 61% believers in traditional Chinese religions, and 12% atheists). The reliability and validity of the Chinese version were satisfactory. In general, traditional Chinese religious believers had higher scores on paranormal belief than did Christians and atheists, and the mean total score of the Chinese participants was higher than previously reported in a Western sample. It was concluded that the greater involvement of practitioners of traditional Chinese religions in activities emphasizing paranormal experiences might contribute to their greater paranormal belief, especially as compared to the minority Christian group. The results are consistent with the idea that Christianity may offer the least support for paranormal belief.

Missense mutations in the MEFV gene are associated with fibromyalgia syndrome and correlate with elevated IL-1beta plasma levels.

BACKGROUND: Fibromyalgia syndrome (FMS), a common, chronic, widespread musculoskeletal pain disorder found in 2% of the general population and with a preponderance of 85% in females, has both genetic and environmental contributions. Patients and their parents have high plasma levels of the chemokines MCP-1 and eotaxin, providing evidence for both a genetic and an immunological/inflammatory origin for the syndrome (Zhang et al., 2008, Exp. Biol. Med. 233: 1171-1180). METHODS AND FINDINGS: In a search for a candidate gene affecting inflammatory pathways, among five screened in our patient samples (100 probands with FMS and their parents), we found 10 rare and one common alleles for MEFV, a gene in which various compound heterozygous mutations lead to Familial Mediterranean Fever (FMF). A total of 2.63 megabases of genomic sequence of the MEFV gene were scanned by direct sequencing. The collection of rare missense mutations (all heterozygotes and tested in the aggregate) had a significant elevated frequency of transmission to affecteds (p = 0.0085, one-sided, exact binomial test). Our data provide evidence that rare missense variants of the MEFV gene are, collectively, associated with risk of FMS and are present in a subset of 15% of FMS patients. This subset had, on average, high levels of plasma IL-1beta (p = 0.019) compared to FMS patients without rare variants, unaffected family members with or without rare variants, and unrelated controls of unknown genotype. IL-1beta is a cytokine associated with the function of the MEFV gene and thought to be responsible for its symptoms of fever and muscle aches. CONCLUSIONS: Since misregulation of IL-1beta expression has been predicted for patients with mutations in the MEFV gene, we conclude that patients heterozygous for rare missense variants of this gene may be predisposed to FMS, possibly triggered by environmental factors.

Evidence that cathelicidin peptide LL-37 may act as a functional ligand for CXCR2 on human neutrophils.

LL-37, derived from human cathelicidin, stimulates immune responses in neutrophils. Although FPR2 and P2X7 were proposed as LL-37 receptors, we have shown that among 21 neutrophil receptors only CXCR2 was down-regulated by LL-37. LL-37 functions similarly to CXCR2-specific chemokines CXCL1 and CXCL7 in terms of receptor down-regulation and intracellular calcium mobilization on freshly isolated neutrophils. Neutrophils pretreated with CXCL8, a chemokine that binds both CXCR1/2, completely blocked the calcium mobilization in response to LL-37, while LL-37 also partially inhibited (125)I-CXCL8 binding to neutrophils. SB225002, a selective CXCR2 antagonist, blocked LL-37-induced calcium mobilization and migration of neutrophils. LL-37 stimulates calcium mobilization in CXCR2-transfected HEK293 cells, CXCR2(+) THP-1 cells and monocytes, but not in CXCR1-transfected HEK293 cells. WKYMVm peptide (ligand for FPR2) does not block LL-37-stimulated calcium flux in either THP-1 (FPR2(-)) or monocytes (FPR2(high)), further confirming the specificity of LL-37 for CXCR2 and not FPR2. Among all ligands tested (ATP, BzATP, WKYMVm, CXCL1, and LL-37), only LL-37 stimulated migration of monocytes (CXCR2(+) and FPR2(+)) and migration was inhibited by the CXCR2 inhibitor SB225002. Moreover, CXCR2 but not CXCR1 was internalized in LL-37-treated neutrophils. Thus, our data provide evidence that LL-37 may act as a functional ligand for CXCR2 on human neutrophils.