Investigation of a pandemic H1N1 influenza outbreak in a remote First Nations community in northern Manitoba, 2009.

OBJECTIVES: First Nations communities in Manitoba were significantly affected by the pandemic H1N1 influenza virus (pH1N1) in 2009. Our objective was to conduct an epidemiologic investigation of a pH1N1 outbreak in one remote First Nations community (population 3,300) in northern Manitoba to inform a timely public health response and provide recommendations for preventing future outbreaks. METHODS: Chart reviews were conducted at the nursing station for patients meeting the influenza-like illness (ILI) case definition during the study period (April 20 to June 11, 2009). Descriptive analyses examined age, gender, clinical presentation, management, outcomes and risk factors. Comparisons were made for hospitalized versus non-hospitalized cases and laboratory-confirmed versus possible cases using Pearson's chi-square test for gender and symptoms and using a t-test for age. RESULTS: There were 180 ILI cases, including 23 laboratory-confirmed cases of pH1N1. Forty percent of children < 1 year old in the community and 9.4% of pregnant women presented to the nursing station with ILI. Most ILI cases were managed through the community nursing station, although 18.3% of cases (n = 33) were medically evacuated and 16.1% (n = 29) were hospitalized. There were no differences between hospitalized versus non-hospitalized or laboratory-confirmed versus possible cases. Risk factors identified in a subset of cases included exposure to an individual with ILI prior to illness onset, overcrowding and inadequate access to household water. CONCLUSIONS: Early arrival and rapid transmission of pH1N1 rendered usual non-pharmacological control measures largely ineffective. Recommendations for prevention of future outbreaks include an effective communications strategy and daily surveillance for disease detection and monitoring. Key determinants of health should be addressed in remote First Nations communities to prevent disease and protect the health of these populations.

A six-month profile of community case coordinated older adults.

The purpose of this study was to assess the needs of older case coordinated clients receiving community health services, by examining changes in cognitive status, physical and mental health status, social support, risk for institutionalization, and service use over a 6-month period from initial intake into home care. Significant predictors of professional and supportive home care, as well as emergency room use and hospital days, were also examined. Standardized interviews were conducted with 234 clients at the time of referral; follow-up interviews were conducted with 179 of these clients after 6 months of case coordination. Results reveal that physical and mental health improved, while cognitive status remained stable. Although social interaction and instrumental support decreased, subjective support remained stable. Risk of institutionalization decreased. Occupational therapy, nursing, and homemaking were the most frequently used services. The best predictor of professional and supportive home care was a risk of institutionalization score. The needs of this older adult population changed even within the relatively short span of 6 months. Frequent review of needs in some form may be warranted in order to maintain effective service plans.

The cost of developing and implementing a pathway for Congestive Heart Failure: not an inexpensive journey.

This article describes the cost of developing and implementing an integrated care pathway (ICP) for Congestive Heart Failure. Costs were tracked prospectively and allocated to either development or implementation. The development took 1,980 hours of staff time at a salary cost of $67,800. The ICP implementation took 2,083 hours of personnel time at a salary cost of $66,900. Even though an available pathway was adapted for local use, a substantial amount of time and money was required. This article may be useful to others who are interested in monitoring costs of pathways.

Utility of The Regina Risk Indicator Tool among case managed elderly clients.

The Regina Risk Indicator Tool (RRIT) is used to identify how at risk clients are for requiring admission to long-term care. This study examined the potential use of this tool by case managers of older community dwelling clients receiving home care. The RRIT exhibited moderate to good inter-rater reliability and good predictive validity as clients of varying degrees of risk differed in amount of case management and services used. Healthcare managers may wish to consider using the tool to support decision-making related to case management and home care service.

Development and results of a Case Coordination Activity Tracking tool.

This study describes the development of a tool used to track the who, what, when, and how much of case coordination for elderly, community-based clients. The Case Coordination Activity Tracking Form measures phase of coordination (assessment, plan development, plan implementation, monitoring reassessient, and discharge), type of activity (in-person, telephone, documentation, research, travel, case conference), with whom contact took place (client, family, client/family together, supervisor/colleague, service provider, physician, program access committee), and special circumstances (e.g., infection control). Over a 6-month span, we used the tool to study case coordination of services for elderly, community-based clients. The average amount of coordination time was 5.15 hours (n = 234), with 71% of the clients requiring between 2 and 6hours of coordination, and 26% of the clients accounting for 49% of the total coordination time. Frequency and average amount of coordination declined greatly after the first month. Not all clients required coordination each month, and monitoring was the most common activity in later months. The tool was found to be reliable and easy to use, and of benefit to decision makers, managers, and case coordinators in measuring, analyzing, and describing case coordination. This tool could be readily used with other client groups.

Development of a case management quality questionnaire.

This study documents the development of a new tool to measure the quality of community case management for elderly clients. Information obtained from literature review, client focus groups, and pilot surveys with clients served as the basis for the development of a Case Management Quality Questionnaire (CMQQ). This measure, along with satisfaction, health status, and demographic questions, was administered to 174 home care clients and 78 family members of long term care residents for evaluation of case management services that clients had received in the last 2 to 6 months. Principal components analysis with oblique (Oblimin) rotation identified three subscales of the CMQQ: (1) accessibility, (2) efficiency, and (3) assessment/coordination skill. Study findings suggest that the CMQQ is reliable, valid, and of value in understanding satisfaction with case coordination. Based on client feedback and analysis of the results, some future modifications to the measure are worthy of study. Others interested in measuring and improving case management may similarly benefit from the use of the CMQQ.

Linklng guidelines for case management to risk of institutionalization.

In this study, we developed time-and-need-based community case management guidelines by tracking case management activity for 234 elderly clients over their first 6 months of care. Clients were interviewed at the time services began and again 6 months later to determine physical, emotional, and cognitive status. We found that the Regina Risk Indicator Tool (RRIT), a brief measure of risk for requiring institutional care, differentiated clients needing varying amounts of case management. Using these results, an expert panel devised guidelines for ranges of case management time for clients at different levels of need: low risk, some risk, and high risk. Quality measures, response times for initial contact and assessment, and service review parameters were also incorporated into the guidelines. Tools for workload measurement, quality review, client satisfaction, and service provider communication were developed. Focus group analysis of the guidelines with various stakeholders and a pilot implementation guided further revision. Future directions are outlined in the article, including the need to focus on outcomes of the guidelines and study of guideline implementation processes.