Discharging older patients from home care: who decides and when?

Who is involved in the decisions to discharge patients from home care and how much lead-in time for planning is observed? How does the process of discharging patients from home care differ by reason for discharge? These questions are addressed in this study of 383 Medicare-funded patients discharged from home care agencies in central Ohio.

Aerobic exercise: effects on parameters related to fatigue, dyspnea, weight and body composition in HIV-infected adults.

OBJECTIVES: The purpose of the study was to examine the effects of aerobic exercise on physiological fatigue (time on treadmill), dyspnea [rate of perceived exertion (RPE) and forced expiratory volume at 1 s (FEV1)], weight, and body composition in HIV-1-infected adults (200-499 x 106 CD4+ cells/l). DESIGN: The study was a randomized, wait-listed, controlled clinical trial of aerobic exercise in HIV-1-infected adults on signs and symptoms associated with HIV-1 infection or its treatment. METHODS: Sixty subjects were recruited and randomized to two groups. Experimental subjects completed a 12-week supervised exercise program. Control subjects continued usual activity from baseline to week 12 and were then were enrolled in the exercise program. RESULTS: At baseline, the groups were similar in age, weight, body mass index [mean body mass index (BMI) > 27], time since diagnosis, number of symptoms, CD4+ cell count, and number on protease inhibitor therapy (n = 7). Despite disproportionate attrition from the exercise group (38%), exercise subjects were able to remain on the treadmill longer, lost weight, decreased BMI, subcutaneous fat, and abdominal girth when compared to controls. The improvement in weight and body composition occurred without a decrease in kilocalories consumed. Exercise did not seem to have an effect on RPE, a surrogate for dyspnea, and FEV1. There was no significant difference in either the change in CD4+ cell count, percentage or copies of plasma HIV-1 RNA between groups. CONCLUSIONS: We conclude that supervised aerobic exercise training safely decreases fatigue, weight, BMI, subcutaneous fat and abdominal girth (central fat) in HIV-1-infected individuals. It did not appear to have an effect on dyspnea.

Hospital and emergency department use by young low-income children.

BACKGROUND: Limited data are available concerning determinants of health care service usage by low-income young children. OBJECTIVES: To explore predictors of hospitalization and emergency department (ED) use by young children of low-income families by using the Aday and Andersen Access Framework. METHODS: Low-income women (n = 474) with a child younger than 6 years completed a structured face-to-face interview at human service offices or Women, Infants, and Children (WIC) clinics in four central Ohio counties. Women were considered low-income if they or their child were Medicaid eligible or uninsured. Data were collected for both the mother and the index child on sociodemographic status, health services use, health status, and access to care. RESULTS: Fifteen percent of the children had been hospitalized the previous year, and half had an ED visit. Hospitalization was significantly related to maternal hospitalization the previous year (OR = 2.5), child age younger than 1 year old (OR = 2.1) and more than two chronic conditions (OR = 2.2). Maternal ED usage in the last year (OR = 2.2), Medicaid fee for service plan (OR = 1.7), and rural residence (OR = 2.0) were predictive of ED use. CONCLUSIONS: Predisposing characteristics (maternal hospital/ED use) were predictive of both hospitalization and ED use by the index child. Enabling characteristics (fee-for-service Medicaid plan, rurality) were only predictive of ED use, and need characteristics (child's health) were only predictive of hospitalization. Further research to explore linkages between maternal and child use of health care services as well as the effect of changes in health care access, managed care, and other innovations on hospitalization and ED use in young, low-income children is recommended.

Predictors of home care readiness for managed care: a multivariate analysis.

As home care agencies change from cost-based reimbursement to the managed care risk paradigm, many lack experience with organizational resources and functions needed to successfully operate in the managed care environment. This survey assessed the level of "readiness" for managed care reported by 162 randomly selected home care agencies in three mid-western states. Managed care readiness was measured by a 32-item mailed questionnaire addressing clinical, financial, operational, and informational systems within each agency. Higher levels of readiness were significantly related to the perception of being ready, proprietary auspices, and moderate agency size in a multivariate regression model. Agencies with these characteristics appear to be well positioned as home care moves into the managed care environment.

Self-reported health status of low-income mothers.

PURPOSE: To determine the self-reported health status of low-income mothers before major health and welfare policy reform in the state of Ohio, to compare the health status of this group with the general population age-based norms, and to examine differences in health status among insurance and racial subgroups. Policy makers and others have a need for key health-status information about low-income mothers, a topic for which little empirical data currently exist. DESIGN: Descriptive using a cross-sectional survey with convenience sampling; 502 women were interviewed at intake sites in four countries in central Ohio, 1995 to 1996. METHODS: Health status was measured using the general health status index developed by J. E. Ware and colleagues (1995). Two summary measures, one indicating physical health and one indicating mental health, were used and compared with published norms. Multivariate logistic models were examined for depression and physical health status. FINDINGS: A significant level of depression in the population of low-income mothers was found as were differences in physical health scores by insurance group. People insured privately had the highest physical health scores, while those enrolled in fee-for-service Medicaid had scores indicating the poorest health. No significant difference was found between racial groups in self-reported health status. CONCLUSIONS: Self-reported mental health status is low among some low-income female populations. Physical health is worse for the Medicaid-enrolled group compared to both uninsured and privately insured groups. This poor state of health will likely diminish the success of welfare reform to improve the economic self-sufficiency of these women unless comprehensive health services are available.

Sexual activity and knowledge of safe sex reported by HIV-infected persons receiving home care.

Sexual activity and knowledge of safe sex were assessed for 57 human immunodeficiency virus (HIV)-infected persons on admission to home care. More than one third of the individuals providing information were sexually active; 72% of the sexually active persons reported that they practiced safe sex. Definitions of safe sex were inconsistent, particularly regarding safety of oral sex. Needs for counseling on safe sex of HIV-infected persons receiving home care practices were clearly evident.

Preventive health counseling reported by uninsured women with limited access to care.

Low-income women in the childbearing years are at an increasing risk of becoming uninsured as welfare reforms are enacted and women enter minimum-wage jobs without insurance benefits. This study contrasts preventive counseling reported by low-income uninsured mothers and mothers insured through Medicaid. Low-income women attending Women, Infant, and Children (WIC) clinics and human services offices who had received health care during the previous 12 months (N = 406) were asked if they had received counseling from a health provider regarding any of seven types of preventive health behaviors. Uninsured women were less than half as likely to receive counseling on three or more preventive topics (OR = 0.42) as were mothers on Medicaid. Risk estimates were stable on bivariate analyses and logistic regression models. Findings indicate that opportunities for preventive health counseling need to be maximized for this group already experiencing compromised access to care.

Urinary tract infection during pregnancy: a risk factor for cerebral palsy?

OBJECTIVE: To assess a possible association of urinary tract infection (UTI) during pregnancy and cerebral palsy in offspring. DESIGN: Secondary analysis of a case-control study using structured telephone interviews and birth certificate reviews. SETTING: Cases from community-based agencies providing services to preschool children who were developmentally delayed. PARTICIPANTS: One hundred twelve preschool children with cerebral palsy and 153 children without cerebral palsy. MAIN OUTCOME MEASURES: Risk for cerebral palsy. RESULTS: The prevalence of UTI among case mothers was 17.9% compared with 5.2% among control mothers. The crude odds ratio for risk of cerebral palsy for a mother with a UTI was 3.9, whereas the adjusted odds ratio was approximately 5, indicating that the risk of having a child with cerebral palsy was 4 to 5 times greater for mothers who had a UTI during pregnancy. CONCLUSIONS: Urinary tract infection during pregnancy was found to be a risk factor for development of cerebral palsy in offspring. Assessment for UTI should occur at the initial prenatal visit and more frequently for women with symptoms or who are at risk. Pregnant women should be educated about preventive measures for UTI. Future research is needed to assess more directly the relationship between UTI during pregnancy and cerebral palsy in offspring.

Quality of life in nurse case management of persons with AIDS receiving home care.

Effects of case management on quality of life were tested with 57 home care patients with AIDS, randomly assigning individuals to either usual care or case-managed care over the duration of home services (ranging from 5 days to over 2 years). Participants were primarily male (93%), white (79%), and never married (82%). Quality of life was measured monthly using the quality of Well-Being Index (QWB). Case-managed patients showed advantages over the usual care group in descriptive analyses of quality of life and survival. Large standard deviations in the QWB scores resulting from high fatality among subjects impeded statistical analyses of effects.

Missed opportunities to immunize preschoolers.

Local health departments (n = 122) and private physician offices (n = 90) responded to a mailed survey assessing practices of immunizing children presenting with any of 17 conditions identified in the literature as invalid contraindications to immunizations. More than 30% of both provider groups withheld immunizations in the presence of six conditions identified as invalid, specifically tuberculosis, current antimicrobial therapy, recent exposure to infectious disease, mild diarrheal illness in an otherwise well child, any convalescent phase of an illness, and current or recent mild illness. These findings document provider contributions to the problem of inadequate childhood immunizations and underscore the importance of improved provider education on immunization practices.

Community nursing competencies: a comparison of educator, administrator, and student perspectives.

Perceptions of functioning levels of baccalaureate students nearing graduation were assessed, comparing views of 15 educators, 15 health department administrators, and 185 students. A modified list of the 47 essential public health nursing competencies identified through the U. S. Department of Health and Human Services Division of Nursing served as the basis for data collection and analyses. Student competencies in individual skills were ranked higher than group and community competencies by all three groups surveyed. Students ranked competencies at higher levels than educators and educators at higher levels than administrators. Although administrators continue to advise new graduates to work in acute care before entering community health, support for continuation of this practice was not observed based on administrator ratings.

Inadequate immunization among 2-year-old children: a profile of children at risk.

A community survey was conducted to assess the immunization status of 2-year-old children and barriers to immunization. The 299 respondents were more affluent and well-educated than the general population. Eighty-three percent of the respondents received immunizations from private physicians. Only 31.1% of the children were age-appropriately immunized with deficiencies primarily in receiving the 18-month dosages of diphtheria-tetanus-pertussis (DTP) and polio. Parents reported multiple barriers and beliefs about immunization amenable to change by health providers. A profile of risk factors differentiating nonimmunized from immunized children was developed.

Immunization status of 2-year-olds in middle/upper- and lower-income populations: a community survey.

Immunization rates of preschool children in the United States are well below recommended levels. Whereas low-income and minority groups have been targeted as at risk for inadequate immunization, the assumption is generally made that middle/upper-income children are adequately immunized through the private sector. We conducted a community-based survey that refutes this assumption. Only 31% of the 302 parents surveyed reported full immunization of their 2-year-olds. No significant differences were found in the immunization rates for middle/upper-income (34% immunized) versus lower-income children (28% immunized). Failure to receive the 18-month doses of DTP and polio was the most frequent cause of inadequate coverage for both groups. Barriers to immunization reported by middle/upper- and lower-income parents were similar, with over one-third of the parents identifying cost and lack of insurance coverage as problems. Additional barriers related to methods of operations of providers. Findings have immediate implications for public health nurses in terms of assessing coverage of their own preschool populations and introducing corrective actions to improve levels of immunization.

Cerebral palsy: evaluation of a model of risk.

The purpose of this study was to assess a model of risk for cerebral palsy (CP) in preschool children. The research was structured as a retrospective case-control study in which cases (n = 112) were children with CP while controls (n = 153) were either friend referrals or population-based. Data were collected via structured telephone interviews. While significant associations with CP were found on univariate analyses for a number of variables, only four variables--birth weight/gestational age, 5-min APGAR, medication for miscarriage, and urinary tract infection during pregnancy--were found predictive in multivariate analysis. These variables accounted for 36% of the log-likelihood explained by the model.

Home health care services for AIDS patients: one community's response.

The AIDS epidemic has challenged communities to develop and mobilize care networks for persons infected with the human immunodeficiency virus (HIV). A major part of that mobilization has been a push toward community- and home-based services. The movement of HIV care to the home/community setting is occurring, however, without investigation of either the problems that this change engenders for agencies providing care or the agencies' responses to these problems. This article from one health care market suggests that home care agencies may not be well positioned to meet the cyclical needs of HIV patients, that care is becoming increasingly fragmented with multiple agencies seeking to patch together a program of comprehensive services, and that agency policies may be limiting the numbers of community-based HIV patients eligible for home care.

Why aren't preschoolers immunized? A comparison of parents' and providers' perceptions of the barriers to immunizations.

A community-wide survey of 302 parents of 2-year-old children and 90 private medical practitioners in a large midwestern city revealed low immunization rates (31%) and differences in parent and provider perceptions of barriers to preschool immunizations. Parents most frequently identified barriers of system factors such as cost, lack of insurance coverage, and long office waits. System barriers were reported across differing sources of immunizations (private physician as well as public clinics) and were pervasive across income groups. Providers were more likely to report barriers of parental difficulties with forgetting immunizations or not knowing when the immunizations were due. Even though providers identified parental shortcomings with scheduling as problematic, only one fifth employed tracking and reminder systems. Implications of findings for modifications of the delivery of immunization services and for parent education are discussed.

Case-control design: an appropriate strategy for nursing research.

The case-control design is a well-established research method in epidemiology and has considerable potential for nursing research. It is particularly appropriate for studying health or service outcomes that occur relatively infrequently and offer advantages in time, sample size, and resource requirements. While the retrospective observational nature of the design presents challenges in selection of subjects, avoidance of biases, and control confounding, the processes for managing these pitfalls are increasingly being explored. The analysis is straightforward and presents estimates of risk that are clearly interpretable by the nurse researcher, the policy makers, and other research consumers.

AIDS research in the community: a case study in collaboration between researchers and clinicians.

This paper presents a practical guide for researchers-academicians and clinicians who are considering the development of a collaborative community-based project. It reports on a federally funded project developed by nurse-researchers at a large midwestern university and the nurse clinician directing home care services at the city health department. The focus of this study is to determine the service needs and to evaluate the effectiveness of a case management protocol for persons who are positive for the human immunodeficiency virus and in need of home care.

Public health nurse salaries: associations with nurse, agency, and community characteristics.

This study applied an economic framework to the analysis of public health nurse (PHN) salaries, assessing their relationships to nurse qualifications, agency resources, community economic base, and area competition for the nurse supply. Data were obtained through interviews with 125 Ohio health departments and from various state and local reports. Associations between salaries and explanatory variables were analyzed through correlations and stepwise regression models. The PHN salaries were significantly lower and more compressed than salaries for nurses in area hospitals. Agency and community characteristics were more important than nurse education and experience in explaining salary variations. Maximum PHN salary attainable was significantly related to level of health department funding and community unemployment rate. Health departments in rural locations paid lower salaries at both minimum and maximum levels. Evidence suggested the presence of entry-level wage competition by health departments with both area hospitals and other community nursing agencies. Each 1% increase in minimum hospital nurse salaries was linked to a 0.66% increase in PHN salaries. Findings support the need to improve competitive positions of health departments as nurse shortages intensify.