Using the Tasmanian Palliative and End of Life Care Policy Framework (2022) to assess service delivery in a rural general practice.

AIMS: This commentary uses the Tasmanian Palliative and End of Life Care Policy Framework (2022; the TPE Framework) to reflect upon palliative care services delivered by a rural Tasmanian general practice. CONTEXT: Rural populations have challenges in accessing many healthcare services, including palliative care. General practitioners (GPs) and other primary healthcare workers are frequently relied upon to deliver palliative care in rural Australia. Palliative care is often needed before the end-of-life phase and patients prefer this to be delivered in the community or at home. GPs face challenges and barriers in continuing to deliver home-based palliative care services. APPROACH: All Medical Benefit Scheme billings for after-hours or home-based palliative care provided by the practice, between September 2021 and August 2022, were identified and patient demographic and clinical details collated. To further understand this data, nine GPs were surveyed to explore their attitudes to provision of palliative care service to the local rural communities they serve. These data highlighted several priority areas of the TPE Framework. The TPE Framework is used here to add to the shared understanding of palliative care service delivery in a rural community, and to see if GP's responses align with the priorities of the TPE Framework. Of the 258 after-hours and home-visits delivered over a 12-month period, almost 58% (n = 150) were for palliative care. Patients receiving palliative care were generally older than non-palliative patients visited (79.9 years vs. 72.0 years respectively; p = 0.004). Patients not at imminent risk of death (64.0%) were more frequently recipients of home-visits. Of the nine GPs responding to the survey, most intended to continue home visits for palliative patients. Disincentives to providing palliative care during home visits included a lack of time during the day (or after hours), low levels of interdisciplinary coordination or role-definition, and inadequate remuneration. CONCLUSION: Existing frameworks can be used as an implementation and evaluation guide to help understand local palliative care services. Using a Framework, a rural general practice in Tasmania reflected on their provision of palliative care services. Providing holistic palliative care services from a rural general practice is desirable and achievable with a coordinated, team-based approach. Access to and integration with specialist services remains a key component of community-based palliative care pathways.

Transforming health care delivery: The role of primary health care nurses in rural and remote Australia.

AIM: This paper describes the policy context and approaches taken to improve access to primary health care in Australia by supporting nurses to deliver improved integrated care meeting community needs. CONTEXT: In Primary Health Care (PHC), the nursing workforce are predominantly employed in the general practice sector. Despite evidence that nurse-led models of care can bridge traditional treatment silos in the provision of specialised and coordinated care, PHC nurses' scope of practice varies dramatically. Nurse-led models of care are imperative for rural and remote populations that experience workforce shortages and barriers to accessing health care. Existing barriers include policy constraints, limited organisational structures, education and financing models. APPROACH: The Australian Primary Health Care Nurses Association (APNA) received funding to implement nurse-led clinics as demonstration projects. The clinics enable PHC nurses to work to their full scope of practice, improve continuity of care and increase access to health care in under serviced locations. We reviewed a range of peer-reviewed literature, policy documents, grey literature and APNA provided sources, particularly those relevant to rural and remote populations. We argue more focus is needed on how to address variations in the scope of practice of the rural and remote PHC nursing workforce. CONCLUSION: Despite growing evidence for the effectiveness of nurse-led models of care, significant policy and financial barriers continue to inhibit PHC nurses working to their full scope of practice. If their potential to transform health care and increase access to health services is to be realised these barriers must be addressed.

Association of home and community-based services and cognitive function of Chinese older adults: social participation as a mediator.

BACKGROUND: This study makes an effort to examine the impact of home and community-based services on maintaining cognitive function and understand the mediating effect of social participation on the relationship of community services and older adults' cognitive function in China. METHOD: The empirical data comes from the Chinese Longitudinal Healthy Longevity Survey (CLHLS). A total of 38,582 (person-time) respondents were gathered for this study. The two-way fixed effects regression model is used to estimate the associations between independent variables, mediating variables and cognitive ability after controlling for socio-demographic, family responsibility, and time variables. RESULT: This study has confirmed that participating in daily and social activities is associated with the cognitive functions of Chinese older adults. Social participation can stimulate cognition. Active participation in outdoor activities, doing housework or taking care of kids, daily playing cards or mah-jong, reading books and newspapers, watching TV, and listening to the radio can significantly promote the cognitive ability of older adults. In addition, the findings have indicated the importance of community services for older adults. This study shows personal daily care services, legal aid services, health education services, as well as dealing with family and neighborhood disputes have a positive effect on maintaining older adults' cognitive functions. Meanwhile, the provision of door-to-door medical services hurts their cognitive functions. This study also illustrates that community-based services can increase the level of older adults' social participation, and then enhance their level of cognitive function. CONCLUSION: This study can inform service provision agencies to develop targeted programs to support older adults' continued engagement.

Community-based service, psychological resilience and life satisfaction among Chinese older adults: A longitudinal study.

Previous research has suggested that community-based service is beneficial in promoting older adults' life satisfaction. However, there is limited knowledge of the mediating mechanisms that foster this relationship. Thus, the current study aims to explore the mediating role of psychological resilience in the association between community-based service and life satisfaction among older adults. Using data collected over four rounds of the Chinese Longitudinal Healthy Longevity Survey (CLHLS), this study analyzes the responses of 1439 older adults in China. The results reveal that community-based service is positively related to life satisfaction among older adults. Furthermore, psychological resilience partially mediates this association, highlighting its potential role in promoting life satisfaction. These findings contribute to a deeper theoretical understanding of the mechanisms underlying the relationship between community-based service and older adults' life satisfaction while offering practical implications for enhancing the life satisfaction of older adults in China.

What do rural young people want from their mental health service.

INTRODUCTION: Rural young people have high rates of mental illness and low rates of help-seeking making it crucial to extend research about service improvement in rural and remote Australia. OBJECTIVE: To describe what rural young people want from their headspace service, and what rural headspace clinicians understand they provide. DESIGN: This study used a qualitative methodology with reflexive thematic analysis to analyse participant interviews and systematically derive common themes. FINDINGS: Thirteen participants were interviewed comprising young people aged 16 to 18 years who had accessed one of three rural headspace services, together with clinicians working in those services. Key themes for both young people and clinicians comprised accessibility, flexibility, engagement, safety, youth-focus, and evidence-based treatment although there were some differences of emphasis amongst themes. There was also an additional theme for young people of awareness, and for clinicians of caring. DISCUSSION: The results supported that what young people were seeking was largely consistent with what headspace clinicians were providing. There were however some specific issues relevant to service provision in a rural context such as increased awareness of services, the need to focus on evidenced based interventions, and better promotion in schools and the local community. Service gaps such as unmet needs for young people with higher risk who might fall outside of agency requirements were also identified. CONCLUSION: Results of this study help inform better service delivery and increased awareness for mental health of young people in rural communities to improve access and outcomes.

Exploring nurse practitioner practice in Australian rural primary health care settings: A scoping review.

INTRODUCTION: Australians in rural areas experience limited access to services and poorer health outcomes than residents of metropolitan areas. Nurse practitioners (NPs) were introduced in 2000 to reduce pressure on the health system, address workforce shortages and improve rural populations' access to health care services. OBJECTIVE: This scoping review sought to identify, examine and synthesise research evidence of NP practice in Australian rural primary health care services to better understand how NPs are addressing service gaps in rural areas and to identify existing gaps in our knowledge. DESIGN: Peer-reviewed and grey literature from July 2012 to June 2022 was accessed from seven electronic databases, grey literature and hand searching of reference lists and citations. FINDINGS: From 154 articles, 19 articles of relevance were identified. Several projects describe the processes required for success, whilst others reported the challenges and barriers encountered. Limited research evidence of rural NP practice exists with a significant gap about how roles operate and their value in primary health care. DISCUSSION: Uptake and envisaged benefits of rural primary health care NP roles have yet to be realised, with barriers to implementing and sustaining NP roles persisting. Low-level awareness with ambiguity at health service and community level adversely impact on systematic implementation of NP roles. CONCLUSIONS: Robust evaluations demonstrating the value of NP skills and practice are needed in combination with bipartisan support from all levels of health care and government providing adequate funding to enable effective implementation of NP roles in poorly resourced rural areas.

Shared Site Intergenerational Programs: A National Profile.

Shared site intergenerational programs deliver ongoing services and shared programming to youth and older adults in a single setting. With the potential to benefit youth, older adults, families, and communities, they attract growing attention from practitioners, researchers, funders, and policy makers. Using national survey data we profile characteristics of 95 shared sites. Responding programs connected over 25,000 youth and older persons in 2017. The most common models consisted of adult day services and early childhood programs (i.e., preschool or childcare), though unique models offered diverse opportunities. Current priorities and challenges can be addressed with systematic data collection and access to resources, including incentives in the 2020 reauthorized Older Americans Act.

Americans prefer to receive care where multiple generations are served.Shared site intergenerational models vary; child and adult day programs are common.Practitioners need access to evaluation, interprofessional, and programming resources.The reauthorized Older Americans Act can help address the needs of shared site programs.

Teaching Advocacy Through Community-Based Service Learning: A Scoping Review.

OBJECTIVE: Advocacy has been identified as a core element within the practice of medicine and thus a key component to medical education. However, there are challenges regarding teaching and evaluation of advocacy within medical education. Community-based service learning (CBSL) has emerged as a valuable educational tool to foster knowledge and skills related to advocacy. CBSL is particularly relevant to psychiatry, given the extent of engagement with underserved communities and opportunities to advance learning in these environments. A scoping review was conducted to identify current educational strategies and outcomes related to advocacy training among medical learners in the context of CBSL. METHODS: Between July and October 2019, the authors searched PsycINFO, MEDLINE, Embase, ERIC, Web of Science, Scopus, and ProQuest for English language literature with no date limits and retrieved 2,813 articles and abstracts; 68 were included in this review. Two reviewers independently screened articles and extracted data. Data were then charted, analyzed, and discussed with the research team. RESULTS: Seven key themes related to approaches to advocacy education were identified: (1) type of community partner; (2) populations served; (3) program participants; (4) program structure; (5) evaluation of learner outcomes; (6) sustainability; and (7) challenges and limitations. CONCLUSIONS: This scoping review provides insights into the variety of CBSL-based advocacy program formats and evaluation methods, which is of particular importance to psychiatry. There is heterogeneity in the methodology by which CBSL is implemented and how outcomes are measured. A list of recommendations for future areas of inquiry is provided.

Consulting a Victorian Aboriginal community about their oral health.

BACKGROUND: The legacy of colonisation, assimilation, racism and victim blaming has created inequality in health for Aboriginal people, reflected in their oral health status. Despite the existence of community dental services, oral disease levels continue to be of concern. This study, initiated by a rural Victorian ACCHO (Aboriginal Community Controlled Health Organisation), aimed to consult their community about the barriers to and enablers of oral health and understand their lived experiences with dental services. METHODS: Using an Aboriginal knowledge framework and collaborative approach involving an Aboriginal researcher and Community Mentor, this study consulted an ACCHO community about their oral health. Following community engagement, 21 community members participated in digitally recorded yarning circles and semi-structured interviews. RESULTS: Themes emerging from the data included dental care history and past experiences involving pain and shame, the value of having community-centred services and engagement with patients and the community. DISCUSSION: Experiences of dental care are often related to pain driving attendance resulting in experiences that multiply fear and anxiety. While community-based care was considered a strength, approaches to individual dental care often resulted in increasing shame and diminishing trust. Increasing cultural safety and participatory approaches to designing and delivering dental care may increase engagement and trust. CONCLUSIONS: Important gaps in cultural and clinical understanding between the community and dental service providers have been identified. These findings will be used to inform the delivery of dental services and to develop oral health promotion programs at the ACCHO, and cultural safety preparation for student dental practitioners.

Minority Older Adults' Access to and Use of Programs of All-Inclusive Care for the Elderly.

Programs of All-Inclusive Care for the Elderly (PACE) are an effective approach to improve care quality and delay institutional admissions especially for Black and Hispanic older adults who have seen a disproportionate rise in nursing home use. Guided by Andersen's Behavioral Model of Health Services Use and employing focus groups and one-on-one interviews, we qualitatively examined factors influencing access to and use of PACE by Black and Hispanic older adults. The study sample consisted of thirty-two PACE enrollees, six marketing-team members, and four family-caregivers from three PACE sites in a northeast urban city. Informed knowledge, cultural beliefs, and attitudes toward PACE were found to affect access. Community resources, available services, and care quality facilitated enrollment/participation. Barriers identified included poor dissemination of information and inadequate emphasis on staff's sensitivity to enrollees' cultural and disability differences. Findings will help healthcare leaders capitalize on facilitators and address barriers to enhance access and use of PACE by racial and ethnic minority older adults.

Social Interactions between Family and Community-Based Service Providers in Dementia Caregiving.

Objectives: This study aimed to evaluate the psychosocial experiences in community-based dementia caregiving by assessing the characteristics of social interactions between family caregivers and community-based service providers and associated psychological responses.Methods: Two independent groups of participants (family caregivers and community-based service providers) completed a one-time survey to report their social interactions and psychological states. A linear regression model was fit for each outcome (satisfaction, 10-item CES-D) while controlling for significant relevant covariates.Results: Higher perceived levels of collaboration were associated with higher job satisfaction and lower depression score among service providers, and higher satisfaction with providers among family caregivers. Higher perceived social support from the provider was associated with higher satisfaction among family caregivers.Conclusions: Participants reported varying levels of provider-family collaboration. The extent of collaborations and support exchange may have implications on the psychological well-being of those providing care to individuals with dementia including families and providers.Clinical implications: It may be beneficial to identify providers and families who perceive low levels of collaboration and implement intervention to facilitate positive social interactions. Developing organizational culture and payment systems that value high-quality social interactions may help enhance the psychological well-being of service providers and satisfaction among families who receive their services.

Objectively measured mobility of rural community-dwelling people aged 80 and over is strongly associated with greater use of services for community integration and social support: An observational study.

OBJECTIVE: The objective of this study was to investigate the relationship between the objectively measured mobility status of rural community-dwelling older people and their use of formal and informal services. DESIGN: Observational cross-sectional study. SETTING: Community volunteers, rural New South Wales, Australia. PARTICIPANTS: Seventy community-dwelling people aged 80 years or older. MAIN OUTCOME MEASURES: The sum of formal and informal services used, expressed as both total hours per month and the risk of using five hours (the median) or more per month. Predictor variables were usual gait speed, Four Square Step Test, short physical performance battery and de Morton Mobility Index. RESULTS: Each predictor variable was significantly associated with service use as a continuous or dichotomous variable. The strongest associations were with gait speed and the short physical performance battery continuous scoring. These relationships remained significant after adjusting for likely confounders, including age, sex, nutritional risk status, cognition and negative affect. CONCLUSION: This study provides strong evidence that the worse an older person's objectively measured mobility scores, the greater their use of community services to remain living in their rural community. Every measure of mobility proved to be strongly associated with the hours of service use. This objective evidence enhances previous knowledge based on self-report measures. The impact on service use of strategies that enhance older people's mobility warrants investigation.

Senior Services that Support Housing First in Metro Vancouver.

Housing First is a model and philosophy for housing homeless people in immediate and permanent housing. In order to implement and deliver Housing First, research is essential to understand the system of support services as they currently exist. Guided by principles of community-based participatory research, this paper presents the findings from a senior-focused deliberative dialogue workshop in Metro Vancouver, Canada. Participants (16 service providers and 1 service recipient) identified services and resources available to support seniors in maintaining housing and barriers and facilitators for accessing services. Broadly, data were organized into seven themes: (1) Housing; (2) Home support; (3) Transportation; (4) Information availability, accessibility, and navigation; (5) Cultural diversity; (6) Discrimination; and (7) Funding and financial support. Results found that affordable housing that adapts to changing health conditions, income supports, health services, homecare, transportation, and culturally appropriate and nondiscriminatory informational resources are among the supports most needed for persons as young as 50 years old to succeed under the Housing First model in Metro Vancouver. Barriers to Housing First service provision, including rigid eligibility criteria for chronically and episodically homeless, should be revised to better support the growing number of older adults who are newly entering homelessness in Metro Vancouver.

Feasibility of an electronic participant information system for adult day services: A qualitative study of staff perspectives.

Adult day services (ADS) professionals have begun to explore assessment systems focused on participants. Barriers include inadequate technology, software costs, and personnel requirements. We present data from staff interviews at an ADS with an electronic participant information system. Contrary to reports about difficulties learning to use electronic systems, staff found the system manageable and data meaningful. We identify ways that community-based centers can build partnerships and utilize software to integrate assessment and electronic records to improve center performance and participant outcomes. ADS programs should explore how outcome data systems can be used to improve care, promote family caregiver engagement, optimize staff workload, and promote fiscal stability.

Trajectories of Community-Based Service Use: The Importance of Poverty and Living Arrangements.

This study examined how older adults' living arrangements and poverty status affected their use of in-home health, functional, and out-of-home services over time. Using eight waves of data from the Korea Welfare Panel Study, we employed a logistic mixed-effect model to analyze how poverty and living arrangements affect community-based service use. Living-alone older adults and elder-only couples were more likely than co-residing households to use services. Elder-only couples, when poor, were more likely to use in-home and out-of-home services over time. Understanding predictors of community-based service use over time enables researchers and policymakers to better understand the process of aging-in-place.

Caregivers Create a Veteran-Centric Community in VHA Medical Foster Homes.

The Veteran's Health Administration's Medical Foster Home program offers a unique long-term care option for veterans who require nursing-home- or assisted-living-level care. Veterans in a medical foster home reside with community-based caregivers who provide 24-hr-a-day care and monitoring. The veterans often remain in the medical foster home until end of life. Support and oversight is provided to the caregiver from the Veteran's Health Administration's community-based medical team. This qualitative descriptive study is based on secondary analysis of interviews with 20 medical foster home caregivers from 7 programs across the United States. The study's research aims are to describe and explain (a) the type of care backgrounds and skills these caregivers possess, (b) caregivers' primary motivations to open their homes to veterans who often have complex medical and social needs, and (c) how caregivers function in their role as primary caregiver for veterans. Findings indicated that caregivers interviewed had worked in long-term care settings and/or cared for family members. A strong desire to serve veterans was a primary motivation for caregivers, rather than financial gain. The caregivers' long-term care skills aided them in building and sustaining the unique medical foster home family-like community.

Practice model for a dementia outreach service in rural Australia.

OBJECTIVE: To investigate the nature and delivery of service model in a rural dementia outreach service. DESIGN: Participatory action research was used to collect data through four focus groups. Data analysis was an iterative process. SETTING: The Dementia Outreach Service of Northern NSW Local Health District. PARTICIPANTS: Twenty-one participants comprised staff of the service, representatives of the community dementia service sector, and medical and health staff with expertise in dementia. MAIN OUTCOME MEASURE: A visual representation of the service's practice model derived from the analysis. RESULTS: A practice model for a dementia outreach service is described. The target groups are not only people with dementia and their carers living in the community, but also the staff of the community service sector who support them. A theoretical framework of person-centred care and the biopsychosocial approach inform clinical practice. Five practice principles emerged: early intervention, outreach, clinical expertise, the multidisciplinary team and building a cohesive sector. Seven core activities were identified: sector leadership; flexible response; linking clients, clinicians and services; program innovation; building cohesion; clinical consultation; and case management. CONCLUSIONS: The practice model describes a clinically based, community-positioned dementia outreach service in rural Australia. The biopsychosocial approach, outreach, clinical expertise, the multidisciplinary team and building a cohesive community sector are aspects of the model valued by both clinicians and community sector staff. Flexibility and responsiveness within a rapidly changing environment are key for maintaining person-centred care.

Retention challenge facing Australia's rural community mental health services: Service managers' perspectives.

OBJECTIVE: This paper aims to contribute to the development of a more sustainable Australian rural community mental health workforce by comparing the findings from a literature search investigating impacting factors on retention with the experiences of community mental health service managers running services in rural Australia. DESIGN: Semi-structured interviews. SETTING: Public health sector, rural New South Wales. PARTICIPANTS: Five community mental health managers, running services in rural Australia. MAIN OUTCOME MEASURES: Interviews were undertaken as a pilot for a broader qualitative study investigating factors influencing the decision to stay or leave among community mental health professionals working in rural positions. The purpose of undertaking this pilot study was to test for validity and relevance of the retention phenomena and help inform the research design for the main study. RESULTS: Three key retention focussed themes were identified: (i) Staffing is a persistent challenge; (ii) Small remote towns pose the biggest challenge; and (iii) The decision to stay or leave is complex and multifactorial. CONCLUSIONS: The findings of this pilot study support previous research and contribute to the understanding of influences on retention among health professionals working in rural community mental health services. Importantly, those who have worked for several years in rural positions hold important information through which to explore factors that impact retention in rural and remote regions.

The Association Between Trajectories of Perceived Unmet Needs for Home and Community-Based Services and Life Satisfaction Among Chinese Older Adults: The Moderating Effect of Psychological Resilience.

This study examined whether trajectories of perceived unmet needs for Home and Community-Based Services (HCBS) were associated with life satisfaction among Chinese older adults and whether the association was moderated by psychological resilience. Data came from five waves (2005-2018) of the Chinese Longitudinal Healthy Longevity Survey (CLHLS). Latent class growth analysis revealed three distinct trajectories of perceived unmet HCBS needs: "increasing" (n = 977, 36.24%), "persistent" (n = 570, 21.14%), and "decreasing" (n = 1149, 42.62%). Multiple regression estimates showed that the increasing group was associated with lower life satisfaction, and the association was moderated by psychological resilience, especially for older adults who were male, living in rural, and oldest-old. Results indicate that inequalities in cumulative exposure to perceived unmet HCBS needs may further lead to increasing inequalities in life satisfaction. Interventions focused on minimizing the provision-need gap of HCBS and enhancing personal resilience should be considered to improve the life satisfaction of older adults.

A pre-post study design: evaluating the effectiveness of a new community-based integrated service model on patient outcomes.

This study aimed to evaluate a new service model, Specialists Together In the Community (STIC), in terms of patient outcomes. This model integrates Flexible Assertive Community Treatment (FACT)-principles with expertise of specialized teams that offer diagnosis-related outpatient treatment. In a pre-post design, symptoms and quality of life of 930 former FACT-patients were measured repeatedly pre- and post-STIC. Regarding patients in former specialized teams, pre- and post-treatment social functioning and symptoms were measured for the pre- (n = 944) and post-STIC (n = 544) groups. Against expectation, symptoms of former FACT-patients remained stable post-STIC compared to a slight decrease pre-STIC. According to expectation, pre- and post-STIC groups had an equal symptom reduction. Unexpectedly, the post-STIC group did not improve more on social functioning than the pre-STIC group. Explorative analysis showed less treatment contacts in the post-STIC group. The highly similar patient outcomes post-STIC could be improved by monitoring process outcomes and prolonging study duration.