Addition of community paramedics to a physician home-visit program: A prospective cohort study.

BACKGROUND: Home-based primary care promotes aging in place but is not immediately responsive to urgent needs. Community paramedicine leverages emergency medical services clinicians to expedite in-home care, though limited evidence supports this model. We evaluated the primary care and acute care use of older adults evaluated urgently by a community paramedic with telemedicine physician compared to a physician home visit model. METHODS: This prospective cohort study enrolled older adults in home-based primary care who requested an urgent evaluation. We allocated participants to the physician home visit model or physician home visit plus community paramedic model by ZIP code. We observed primary care and acute care use for 6 months following enrollment. The primary outcome was the median number of primary care and acute care visits per participant. Secondary outcomes included 30-day readmission rates, median wait times, and physician productivity. Data analysis included descriptive statistics, comparison of means and proportions, and negative binomial regression modeling reported as incidence rate ratios (IRR). RESULTS: We screened 255 participants, determined 203 eligible, allocated 199, and completed observation for 167 (84 community paramedicine, 83 physician home visit). Participants were mostly female, age 76-86 years, with 3-5 comorbidities, living in a home/apartment. Community paramedic participants had 29% more primary care visits (IRR 1.29, 95% confidence interval [CI] 1.06-1.57) and shorter wait times for urgent evaluations (1 vs. 5 days, p < 0.001) without increasing acute care use (IRR 0.75, 95% CI 0.48-1.18) or 30-day readmissions (IRR 1.32, 95% CI 0.49-3.55). Physician productivity increased 81% (40 vs. 22 visits/week, p < 0.001). CONCLUSION: Older adults evaluated by a community paramedic for urgent needs were seen sooner, used acute care similarly to patients evaluated by a physician home visit, and nearly doubled physician efficiency. This suggests that older adults may benefit from combining emergency medical services and primary care resources for urgent evaluations.

Atendimento domiciliar do enfermeiro da Estratégia Saúde da Família na comunidade quilombola Sacopã: relato de experiência / Family Health Strategy nurse home care in the Sacopã quilombola community: experience report / Atención domiciliaria de la enfermería en la Estrategia de Salud Familiar en la comunidad quilombola Sacopã: informe de experiencia

A comunidade quilombola de Sacopã, cuja existência remonta a mais de 100 anos, está localizada na zona sul do Rio de Janeiro, na Lagoa Rodrigo de Freitas, e continua preservando cultura, ancestralidade e tradições do povo negro até os dias atuais. Neste estudo, tem-se como objetivo relatar a experiência das consultas do enfermeiro da Estratégia Saúde da Família (ESF) realizadas na comunidade quilombola Sacopã. Trata-se de um estudo do tipo relato de experiência, com abordagem qualitativa. As visitas domiciliares ocorreram nos dias 29 de setembro de 2021, no turno da tarde, e 6 de outubro de 2021, nos turnos da manhã e da tarde. O processo de enfermagem foi aplicado, incluindo triagem com aferição da pressão arterial e medição da glicemia capilar, renovação das prescrições de medicamentos, teste de sensibilidade plantar, agendamento de exames de colpocitologia e mamografias, avaliação dos registros de vacinação infantil, aconselhamento e educação em saúde. Essas ações visam atender às demandas da população quilombola e reparar os atrasos nas visitas domiciliares causados pela pandemia de covid-19. Vale ressaltar que realizar consultas de enfermagem no formato de atendimento domiciliar proporciona conforto, fortalece o vínculo entre a unidade de saúde e a comunidade, possibilita uma imersão na realidade local, aproxima os profissionais das famílias e reduz os custos de deslocamento, garantindo assim um cuidado holístico e abrangente aos usuários.

The Sacopã quilombola community, which has existed for over 100 years, is in the south of Rio de Janeiro, in Lagoa Rodrigo de Freitas, and continues to preserve culture, ancestry, and traditions of the black people to this day. This study aims to report the experience of consultations with the Family Health Strategy (FHS) nurse held in the Sacopã quilombola community. It is an experience report study with a qualitative approach. The home visits were conducted on September 29, 2021, in the afternoon shift, and on October 6, 2021, in the morning and afternoon shifts. The nursing process was applied, including screening with blood pressure and capillary blood glucose measurements, renewal of the drug prescriptions, plantar sensitivity tests, scheduling of Pap smears and mammograms, evaluation of children's vaccination records, counseling, and health education. These actions aim to meet the demands of the quilombola population and address the delays in home visits that occurred due to the COVID-19 pandemic. Note that conducting nursing consultations in a home care format provides comfort, strengthens the link between the health unit and the community, allows immersion in the local reality, brings professionals closer to families, and reduces travel costs, thus ensuring holistic and comprehensive care for users.

La comunidad quilombola de Sacopã que se remonta a más de cien años está ubicada en la zona sur de Río de Janeiro, en la Lagoa Rodrigo de Freitas, y viene preservando la cultura, ancestralidad y tradiciones del pueblo negro hasta la actualidad. Este estudio tuvo por objetivo informar la experiencia de consultas con la enfermería de la Estrategia de Salud Familiar (ESF) realizadas en la comunidad quilombola de Sacopã. Se trata de un estudio de tipo informe de experiencia, con enfoque cualitativo. Las visitas domiciliarias tuvieron lugar el 29 de septiembre de 2021, por la tarde, y el 6 de octubre de 2021, por la mañana y tarde. Se aplicó el proceso de enfermería, incluyendo el triaje con medición de la presión arterial y de la glucemia capilar, renovación de prescripciones de medicamentos, prueba de sensibilidad plantar, programación de exámenes de citología vaginal y mamografías, evaluación de los registros de vacunación infantil, asesoramiento y educación en salud. El objetivo de estas acciones fue atender las demandas de la población quilombola y compensar los retrasos en las visitas domiciliarias debido a la pandemia de la covid-19. Es importante destacar que la realización de las consultas de enfermería en atención domiciliaria proporciona comodidad, fortalece el vínculo entre la unidad de salud y la comunidad, permite una inmersión en la realidad local, acerca a los profesionales a las familias y reduce los costos de desplazamiento, garantizando así una atención holística y completa a los usuarios.

Home visits in rural areas: demands in primary care.

INTRODUCTION: The rural population suffers from important limitations in accessing health care, often lacking a public policy approach to the health and sanitation conditions of their environment. In this sense, primary care emerges with the objective of offering comprehensive care to the population, applying some of its principles as territorialization, person-centered care, longitudinality, and resolution in health care. The goal is to offer the basic health needs of the population considering the determinants and conditions of health in each territory. METHODS: The present study is an experience report that aimed to raise the main health demands of the rural population in the areas of nursing, dentistry, and psychology of a village in the state of Minas Gerais through home visits carried out as part of primary care. RESULTS: Depression and psychological exhaustion were identified as the main psychological demands. Related to nursing, the difficulty of controlling chronic diseases was notable. Regarding dental care, the high prevalence of tooth loss was evident. In an attempt to minimize the limitations of access to health care, some strategies were created targeting the rural population. A radio program that aimed to disseminate basic health information in an accessible way was the main one. DISCUSSION: Therefore, the importance of home visits is evident, especially in rural areas, favoring educational health and preventive practices in primary care and considering the adoption of more effective care strategies for rural populations.

A Thousand Days-A programme for vulnerable early childhood in Argentina: Targeting, dropout risk factors and correlates of time to graduation.

BACKGROUND: Mil Días (A Thousand Days) is a programme for the first thousand days of life, from gestation to 2 years of age, targeted at highly vulnerable children and/or mothers and pregnant women. The programme was implemented in August 2015 in the municipality of San Miguel, in Argentina. Mil Días is designed in a holistic and intersectoral way. The main form of intervention is through home visits, but other benefits are available depending on the 51 vulnerability criteria by which participants are admitted to the programme, most of which are related to health issues. Exits of the programme occur when the mother and/or child have reversed the deprivation/s of the entrance-criteria. METHODS: This paper provides an analysis of the programme's primary data between August 2015 and May 2019, with a total of 1,111 programme participants. First, we perform a statistical analysis of the targeted population of the programme. Second, using a logistic regression, we study factors associated to the withdrawal from the programme. Third, using survival analysis, we study the correlates of time to graduation from the programme. RESULTS: We find that the programme is well-targeted, as participants exhibit higher deprivation levels than those exhibited by beneficiaries of social programmes in general in the same municipality. We also find that programme participants in situations of most extreme vulnerability are more likely to abandon the programme and that successful exits from the programme take longer for more complex cases. CONCLUSIONS: Mil Días-San Miguel is a programme for early childhood development in Argentina, which was pioneer when it was first introduced. It is well targeted and exhibits encouraging results despite complex cases taking longer to sucessfully exit the programme. In addition, the poorest poor participants are more likely to abandon the programme and so additional actions could be taken to retain them, as intended by the 'Leave No One Behind' 2030 commitment.

A systematic review and qualitative meta-synthesis of the roles of home-visiting nurses working with women experiencing family violence.

AIMS: To systematically review and synthesize qualitative research exploring home-visiting nurses' roles and identify the challenges for nurses working with women experiencing family violence. DESIGN: We undertook a thematic synthesis of qualitative studies, focusing on the family violence work of nurse home visitors. DATA SOURCES: A systematic search of four scientific databases (ProQuest Central, CINAHL, MEDLINE, EMBASE) was undertaken in August 2021. Grey literature was searched, including government and non-government research documents, theses, clinical guidelines, policy documents and practice frameworks. REVIEW METHODS: Inclusion criteria included research from high-income countries, peer-reviewed qualitative studies in English published from 1985 to 2021, and included research on home-visiting nurse family violence practice. The first author conducted the data search and the initial screening. The first and second authors independently reviewed the full text of 115 papers, identifying 26 for inclusion in the thematic synthesis (Figure 1-PRISMA flowchart). RESULTS: The thematic synthesis identified two themes: (1) relationship building-with the client, with services and with colleagues/self; and (2) family violence practice-ask/screen, validate/name, assess risk/safety plan and safeguard children. CONCLUSION: The thematic synthesis confirmed the multiple roles fulfilled by home-visiting nurses and enabled insight into the challenges they face as they undertake complex and demanding work. The roles of the home-visiting nurse have evolved, with the initial focus on safeguarding children leading to broader family violence nursing practice roles, including the identification of family violence and safety planning discussions with women. IMPACT: Our meta-synthesis has confirmed the high-level communication and rapport-building skills required by nurses undertaking complex and conflicting roles. Nurses need support and supervision to undertake emotionally demanding work. Integrated health systems, clinical practice guidelines and tools, and training programmes need to encompass the breadth and complexity of the roles of these specialist practitioners.

Expectativas de mães e cuidadoras sobre participação em um programa de prevenção à violência / Expectations of mothers/caregivers regarding the participation in a violence prevention program / Expectativas de madres/cuidadoras sobre la participación en un programa de prevención de la violencia

O presente estudo qualitativo objetivou compreender as expectativas de mães e cuidadoras sobre a sua participação no Programa ACT para Educar Crianças em Ambientes Seguros na versão remota, no período da pandemia de covid-19. Também visou identificar a percepção das participantes sobre educar uma criança em um ambiente seguro. Foram realizadas entrevistas semiestruturadas on-line com doze mães e cuidadoras, antes da participação no Programa ACT. Os resultados indicaram diferentes expectativas sobre a participação no Programa ACT, entre elas: adquirir novos conhecimentos, aprimorar as habilidades parentais, trocar experiências, receber auxílio no momento da pandemia de covid-19 e possibilitar para a criança um desenvolvimento saudável. Na percepção das mães e cuidadoras, a versão remota do Programa ACT apresenta aspectos positivos; entre eles, a participação de pais e cuidadores que não residem na cidade em que é oferecida a intervenção. No entanto, apontaram como fatores negativos a ausência do contato físico e as interrupções que podem acontecer a partir das falhas de internet. Para as mães e cuidadoras, educar a criança em um ambiente seguro estava relacionado a promover os direitos estabelecidos no Estatuto da Criança e do Adolescente (ECA), como educação, saúde, lazer, cuidado, afeto, assim como protegê-la de situações de violência. Considera-se que as expectativas das participantes estavam alinhadas aos objetivos do Programa ACT. Torna-se prioritário oferecer programas de prevenção à violência aos pais e cuidadores, em especial em momentos adversos como o da pandemia de covid-19, a fim de promover o desenvolvimento e a saúde das crianças, assim como prevenir situações de violação de direitos.(AU)

This qualitative study aims to understand the expectations of mothers and caregivers about participating in the ACT Raising Safe Kids Program in its remote version, during the COVID-19 pandemic period. It also aims to identify the participants' perception of raising a child in a safe environment. Semi-structured on-line interviews were conducted with 12 mothers/caregivers, prior to participation in the ACT Program. The results indicated different expectations regarding the participation in the ACT Program, for example: acquiring new knowledge, improving parenting skills, exchanging experiences, receiving support during the COVID-19 pandemic, and enabling the child to have a healthy development. In the perception of mothers and caregivers, the remote version of the ACT Program has positive aspects, such as the participation of parents and caregivers who do not live in the city where the intervention is offered. However, they pointed out as negative factors absence of physical contact and interruptions due to internet failures. For the mothers/caregivers, educating children in a safe environment was related to promoting the rights established by the Brazilian Child and Adolescent Statute, namely education, health, leisure, care, affection, as well as protecting them from situations of violence. The expectations of the participants were aligned with the objectives of the ACT Program. Offering violence prevention programs to parents and caregivers is a priority, especially in adverse moments such as the COVID-19 pandemic, in order to promote the development and health of children, as well as prevent situations of violation of rights.(AU)

Este estudio cualitativo pretendió comprender las expectativas de madres y cuidadoras sobre la participación en el Programa de ACT para Educar a Niños en Ambientes Seguros en la versión remota, en el periodo de la pandemia de la COVID-19. También se propuso identificar la percepción de las participantes sobre educar a un niño en un ambiente seguro. Se llevaron a cabo entrevistas semiestructuradas en línea con 12 madres/cuidadoras, antes de la participación en el Programa ACT. Los resultados señalaron diferentes expectativas con la participación del Programa de ACT, entre ellas: adquirir nuevos conocimientos, perfeccionar las habilidades parentales, intercambiar experiencias, recibir auxilio en el momento de la pandemia de la COVID-19 y posibilitar al niño un desarrollo saludable. En la percepción de las madres y cuidadoras, la versión remota del Programa de ACT presenta aspectos positivos, como la participación de padres y cuidadores que no residen en la ciudad donde es ofrecida la intervención. Sin embargo, señalaron como factores negativos la ausencia del contacto físico y las interrupciones, que pueden ocurrir por fallas en Internet. Para las madres/cuidadoras, educar al niño en un ambiente seguro estaba relacionado a promover los derechos establecidos en el Estatuto del Niño y del Adolescente de Brasil, como educación, salud, ocio, cuidado, afecto, así como protegerlo de situaciones de violencia. Se considera que las expectativas de las participantes estaban alineadas con los objetivos del Programa de ACT. Es prioritario ofrecer programas de prevención a la violencia a los padres y cuidadores, en especial en momentos adversos como el de la pandemia de la COVID-19, con el fin de promover el desarrollo y la salud de los niños, así como prevenir situaciones de vulneración de derechos.(AU)

Characteristics of annual mold variations and association with childhood allergic symptoms/diseases via combining surveys and home visit measurements.

The presence of dampness and visible molds leads to concerns of poor indoor air quality which has been consistently linked with increased exacerbation and development of allergy and respiratory diseases. Due to the limitations of epidemiological surveys, the actual fungal exposure characteristics in residences has not been sufficiently understood. This study aimed to characterize household fungal diversity and its annual temporal and spatial variations. We developed combined cross-sectional survey, repeated air sampling around a year, and DNA sequencing methods. The questionnaire survey was conducted in 2019, and 4943 valid cases were received from parents; a follow-up case-control study (11 cases and 12 controls) was designed, and onsite measurements of indoor environments were repeated in typical summer, transient season, and winter; dust from floor and beddings in children's room were collected and ITS based DNA sequencing of totally 68 samples was conducted. Results from 3361 children without changes to their residences since birth verified the significant associations of indoor dampness/mold indicators and prevalence of children-reported diseases, with increased adjusted odd ratios (aORs) >1 for studied asthma, wheeze, allergic rhinitis, and eczema. The airborne fungal concentrations from air sampling were higher than 1000 CFU/m3 in summer, regardless of indoors and outdoors, indicating an intermediate pollution level. The DNA sequencing for dust showed the Aspergillus was the predominant at genus level and the Aspergillus_penicillioides was the most common at species level; while the fungal community and composition varied significantly in different homes and seasons, according to α and ß diversity analyses. The comprehensive research methods contribute to a holistic understanding of indoor fungal exposure, including the concentrations, seasonal variations, community, and diversity, and verifies the relations with children's adverse health outcomes. The study further elucidates the role of microbiome in human health, which helps setting health-protective thresholds and managing mold treatments in buildings, to promote indoor air quality and human well-beings.

Effect of a Short Course on Improving the Cadres' Knowledge in the Context of Reducing Stunting through Home Visits in Yogyakarta, Indonesia.

Background: Stunting is primarily a public health concern in Low- and Middle-Income Countries (LMIC). The involvement of Integrated Health Service Post (Indonesian: Posyandu) cadres is among the strategies to combat stunting in Indonesia. Objective: This study aimed to determine the effect of a short course on cadres' knowledge. Method: A single group pre-test post-test design was conducted in Yogyakarta, Indonesia, from March to May 2022. Thirty cadres were selected based on the following criteria: willingness to participate, the number of stunted children in their Posyandu, able to read and write, and full attendance at the short course. The knowledge scores were measured by a questionnaire using true and false answers after a short course (post-test 1) and 4 weeks later (post-test 2). We apply STATA 16 to calculate the Mean Difference (MD) using a t-test and a Generalized Estimated Equation (GEE). Furthermore, the adequacy of the short course was evaluated with in-depth interviews. Result: GEE analysis showed that after controlling for age, education, occupation, and years of experience, the short course improved cadres' knowledge significantly on post-tests 1 and 2, i.e., knowledge regarding Children Growth Monitoring (CGM) (Beta = 6.07, 95%CI: 5.10-7.03 and Beta = 8.57, 95%CI: 7.60-9.53, respectively), Children Development Monitoring (CDM) (Beta = 6.70, 95%CI: 5.75-7.65 and Beta = 9.27, 95%CI: 8.31-10.22, respectively), and Infant Young Children Feeding (IYCF) (Beta = 5.83, 95%CI: 4.44-7.23 and Beta = 11.7, 95%CI: 10.31-13.09, respectively). Furthermore, the short course increased their self-efficacy, confidence, and ability to assist stunted children through home visits. Conclusion: The short courses consistently and significantly boosted cadres' knowledge of CGM, CDM, and IYCF, and appropriately facilitated cadres in visits to the homes of stunted children's home.

Parent satisfaction with sustained home visiting care for mothers and children: an integrative review.

AIM: To synthesise and analyse the existing literature regarding parent satisfaction with sustained home visiting care for mothers and children. BACKGROUND: Sustained home visiting is a service delivery mechanism of both prevention and intervention, in which people receive structured support services within their home environment over an extended period of months or years. For the purposes of this paper, sustained home visiting refers to in-home nursing support to address health inequities for mothers and young children. Sustained home visiting programs have been found to support improved health, wellbeing, and developmental outcomes for children and families. However, there is limited knowledge with regards to the level of parent satisfaction with care provided at home, and the factors and elements of care parents perceive to be critical to their satisfaction. It is important for healthcare practitioners to understand what practices and process parents consider to be a priority in securing their ongoing engagement. DESIGN: Integrative review. DATA SOURCES: PubMed/Medline, CINAHL, Embase, and PsycINFO. METHODS: A multi-step approach was used to search and retrieve peer-reviewed studies from the databases. Study selection, data extraction, data synthesis and critical appraisal were undertaken by two independent researchers. RESULTS: A total of 13 studies met the inclusion criteria, including nine quantitative and four qualitative studies. The review found that parents provided with home visiting interventions had higher levels of satisfaction with care than those who received routine or facility-based care. Service dose was a factor associated with parent satisfaction, however, the direction of impact on parent satisfaction was mixed. Other elements of care parents perceived as important to service satisfaction included the nurse-client relationship, being treated with respect, empowerment, and emotional support. CONCLUSION: While it is critically important that home visiting practitioners provide evidence-based care and interventions, it is equally important that services are delivered in the context of positive and empowering relationships. Further research is recommended to understand the care process and mechanisms that enhance parent satisfaction and positive experiences, providing optimal quality of care.

The role of after-hours house-call medical service in the treatment of COVID-19 patients awaiting hospital admission: A retrospective cohort study.

ABSTRACT: Due to the increasing number of coronavirus disease 2019 (COVID-19) cases in Japan, hospitals are unable to provide admission and immediate inpatient care. The after-hours house call (AHHC) service offers telephone consultations and in-home care to patients awaiting admission. Currently, there is no report on the management of COVID-19 patients when inpatient beds are insufficient.We aimed to describe the clinical characteristics and outcomes of COVID-19 patients treated by an AHHC medical service in Osaka and Tokyo, between April and May 2021 (during the fourth wave in Japan). Patients were classified into 2 groups: Moderate I and Moderate II, according to the severity of infection under Japanese guidelines. A retrospective study of the hospital records and follow-up telephone consultations was performed.The AHHC treated a total of 55 COVID-19 patients (17 with Moderate I, 38 with Moderate II disease). The median ages (interquartile range) were 63 (49-80.5) and 64 (50.8-81), respectively. In each group, approximately 30% of AHHC patients received out-of-hospital oxygen therapy for the duration of their treatment until it was no longer required. Major symptoms, including shortness of breath or difficulty breathing (47.1% and 78.9%, respectively) and fever or chills (41.2% and 76.3%, respectively) were lower in the Moderate I group than in the Moderate II group. Overall, 16.4% of patients died, with 17.6% in the Moderate I group and 15.8% in the Moderate II group.We found the proportion of mortality in patients treated by the AHHC was slightly higher to that of patients treated in Japanese hospitals. This study will provide an alternative management of patients requiring oxygen in situations where hospital beds are in short supply.

An evaluation of community placements for GP registrars in Yorkshire and the Humber: 'a home visit not to a patient but to the community'.

BACKGROUND: GP registrars are required to demonstrate capabilities in 'community orientation', reflecting skills in developing and working with services that respond to community needs. These skills have sometimes been seen as vague and difficult to obtain. In the Yorkshire and the Humber Deanery of Health Education England we developed a novel programme of community placements to overcome this. Registrars spent two half-days with a community organisation of their choosing, working in their practice area. AIM: To evaluate if and how community placements enabled registrars to develop capabilities in community orientation. METHODS: All registrars completing placements were invited to participate in the evaluation; 13 (7%) accepted. Semi-structured, face-to-face and telephone interviews explored registrars' perceptions and experiences of the programme. Interviews were audio-recorded, transcribed verbatim and analysed thematically. RESULTS: The majority of participants reported that placements enabled them to attain a range of capabilities in community orientation. Registrars described an improved understanding of their practice community and the social determinants of health. Placements impacted their clinical practice by stimulating a holistic approach to the assessment and management of health needs. Our analysis described five key mechanisms for this learning: building confidence, building communities and networks of practice, gaining novel perspectives, generating a hunger for general practice and experiential learning. CONCLUSION: Community placements enabled GP registrars to attain capabilities in community orientation. Further research is required to determine the transferability of our findings and further evaluate mechanisms of learning through placements outside of training and their role in the development of professional practice.

Projeto Rede de Cuidados Territoriais em Saúde: cuidado integral e multiprofissional como prática de aprendizagem / Territorial Health Care Network Project: comprehensive and multiprofessional care as a learning practice

Na formação do profissional de saúde é essencial o conhecimento sobre o Sistema Único de Saúde (SUS) além da teoria, sendo importante a vivência prática da interdisciplinaridade e interprofissionalidade no cuidado integral dos indivíduos. O presente relato de experiência descreve, sob a visão de um aluno do curso de odontologia, as principais ações, como as visitas domiciliares, que tinham o enfoque na atenção primária à saúde, a busca ativa de demandas urgentes dos usuários e a importância delas no cuidado em saúde de uma comunidade incluída no Projeto Rede de Cuidados Territoriais, realizado pela Universidade de Passo Fundo, Brasil. O relato de experiência traz os aprendizados e reflexões gerados durante os encontros em equipe, como consequências das visitas domiciliares multidisciplinares, que ocorreram semanalmente, propiciando ao aluno o acompanhamento de famílias e a criação de vínculos, visando o cuidado e a atenção integral. As ações do projeto contribuíram para a formação acadêmica dos alunos de diversos cursos da área da saúde de uma Instituição de Ensino Superior (IES), permitindo a prática no território, na comunidade, sem simulações. A partir da realidade da população, o grupo acadêmico foi estimulado a conhecer o SUS, pela vivência das suas diretrizes e princípios, a realidade do sistema, incluindo suas fortalezas e fraquezas. Identifiquei, a partir dessa experiência, que ações voltadas as comunidades mais vulneráveis em seus territórios são desafiadoras, principalmente em relação a tomada de decisões na atenção integral à saúde dos indivíduos (AU).

In the education of health professionals, in addition to theory, knowledge about the Unified Health System (SUS) is essential, as this system providessignificant practical experience of interdisciplinarity and interprofessionality in the integral care of individualsto health professionals. Thisexperience report describes, fromthe viewpointof dentistry students,the main actionsincluded in the health care of a community in the Territorial Care Network Project, conducted by the University of Passo Fundo, Brazil; these actions includedhome visits, which focused on primary health care, and the active search for urgent demands of users. The experience report presents the learning and reflections generated during team meetingsheld to discussmultidisciplinary home visits, which occurred weekly,these provided the students with the information collected after monitoring the families in the target community; they alsoenabled the student to witness the creation of bonds among health care professionals and community members; thus, the students learned the significance of primary care and comprehensive care. The actions of the project contributed to the academic training of students from various courses in the health field of a Higher Education Institution (HEI), facilitatingtheirpractice in the territory, that is, in this case, the community, without simulation. Thus, the academic group was encouraged to learnthe roleof SUSin a community, by practically implementingits guidelines and principles, and the reality of the system, including its strengths and weaknesses. From this experience, weidentifythat actions aimed at the most vulnerable communities in their territories are challenging, especially in relation to decision-making in comprehensive health care of individuals (AU).

"House Calls" by Mobile Integrated Health Paramedics for Patients with Heart Failure: A Feasibility Study.

Background: Early readmissions following hospital discharge for heart failure (HF) remain a major concern. Among the various strategies designed to reduce readmissions, home evaluations have been observed to have a favorable impact. We assessed the feasibility of integrating community paramedics into the outpatient management of HF patients. Methods: Selected paramedics completed an educational HF curriculum. These Mobile Integrated Health Paramedics (MIHP) performed scheduled home visits 2- and 15-days post-discharge for patients with Stage C HF (Phase I) and patients with Stage D HF (Phase II). Facilitated by a Call Center, a process was created for performing urgent MIHP house calls within 60 minutes of a medical provider's request. A HF specialist, with an on-call emergency department command physician, could order an intravenous diuretic during home visits. During each phase of the study the incidence of 30-day HF readmissions, 30-day all-cause readmissions, emergency room evaluations, unplanned office encounters, as well as any adverse events were prospectively documented. Results: Collaborative relationships between our hospital network and local EMS organizations were created. There were 82 MIHP home visits. Eight patients received urgent home evaluations within 60-minutes post-request, one requiring transport to an ED. The incidence of all-cause 30-day readmissions in 20 Stage C and 20 Stage D patients was 15% and 40%, respectively. There were no adverse events attributable to the MIHP house calls. Conclusions: It is feasible to integrate MIHPs into the outpatient management of HF. Signals of effectiveness for reducing early readmissions were observed. Obstacles to creating an effective paramedic "House Calls" program were identified. A randomized trial is required to assess the value of this care process and its impact on early readmissions in patients with Stage C and Stage D HF.

Evaluating the effectiveness of Community Health Worker home visits on infant health: A quasi-experimental evaluation of Home Based Newborn Care Plus in India.

BACKGROUND: Home visits by community health workers are promoted to improve the coverage and uptake of evidence-based newborn services and behaviours. However, evidence on the effectiveness of these home visits delivered through government systems at scale is limited, as is evidence from the post-neonatal period. From 2013 to 2017, the Government of India piloted an intervention called Home Based Newborn Care Plus with the goal of reducing pneumonia- and diarrhoea-related morbidity and malnutrition. Village-based Accredited Social Health Activists were incentivised to make quarterly home visits to infants between three and 12 months of age. After the pilot, the intervention was adapted and scaled up nationally (with an additional visit at 15 months of age) as a new programme called Home Based Care for Young Child. METHODS: The study used a quasi-experimental, difference-in-differences method to assess the quantitative impact on key outcome indicators by comparing changes over time in treatment districts with matched control districts. This was supplemented by a quantitative health worker survey and qualitative data collected at worker and community level. RESULTS: The intervention led to a significant increase in the number of home visits, and their content became more aligned with Home Based Newborn Care Plus protocols. However, absolute levels of coverage remained low. The intervention had no detectable effect on the key outcomes of feeding practices, handwashing, iron and folic acid and oral rehydration solution supplementation, growth monitoring, and immunisation. CONCLUSIONS: Given the scale up of Home-Based Care for Young Child, there is a need to identify appropriate and comprehensive support for Accredited Social Health Activists to attain high coverage and quality and deliver impact. This will require reconsidering current design elements (such as incentives) and solving the underlying demand side and system level challenges (such as workload and supply chains) constraining Accredited Social Health Activists.

Early discharge from hospital after birth:How Norwegian parents experience postnatal home visits by midwives - A qualitative study.

BACKGROUND: According to the WHO, the quality of care is not conditioned by the length of stay at the postnatal ward. As long as the postnatal care provided is of high quality, it could be better for the family to stay in their home. AIM: Firstly, to examine parents' experiences of early discharge and home visits by the postnatal ward midwife, in cases where the mother and baby have been discharged within 24 h after birth. Secondly, to examine participants' motivation for opting for early discharge from the hospital. METHODS: 10 individual interviews were conducted, including five where both parents were present. The interviews were carried out 4-12 weeks after birth. The data were analysed using systematic text condensation. RESULTS: The choice of early discharge was influenced by external factors like a wish to be together as a family while receiving sufficient support from both family and midwife. Internal factors, like previous experience, were also significant. The presence and attitude of the midwife, both in professional and practical terms, affected how the parents perceived postnatal care. Home visits from the midwife also affected the parents' feeling of security. CONCLUSION: An offer of home visits from the midwife of the postnatal ward enables parents who wish to leave the hospital shortly after birth to receive the necessary care and support in the early postnatal period. This offer is suitable for healthy women who have given birth to a healthy baby and wish to return home not long after birth.

The effects of midwifery care provided to primiparous mothers during the postpartum period on maternal attachment and post-traumatic growth.

AIM: This study was conducted to determine the effects of midwifery care provided to primiparous mothers during the postpartum period on maternal attachment and post-traumatic growth. METHOD: The study was conducted based on a quasi-experimental model with a pre-test/post-test control group. The population of the study was composed of primiparous mothers who gave birth in a public hospital located in eastern Turkey, and the sample consisted of 128 postpartum women (64 women in the control group and 64 women in the experimental group); the sample size was determined via power analysis. Midwifery care was provided to the mothers in the experimental group throughout their hospitalisation in accordance with the Postpartum Care Management Guidelines (PCMG) published by the Republic of Turkey's Ministry of Health. In addition, 3 home visits were carried out between the postpartum 2nd and 5th days, 13th and 17th days and 36th and 42nd days. The mothers in the control group were not subjected to any intervention. The data were collected using a personal information form, the Maternal Attachment Inventory (MAI) and the Post-traumatic Growth Inventory (PTGI). Statistical analyses were conducted using percentage distribution, arithmetic mean, standard deviation, chi-square testing, independent samples t-testing and dependent samples t-testing. RESULTS: Based on the mean MAI and PTGI pre-test scores, it was determined that the mothers in the experimental and control groups were similar in terms of maternal attachment and post-traumatic growth characteristics (p>0.05). The mean MAI post-test score was 101.85±2.85 in the experimental group and 98.68±5.91 in the control group, and the difference between the groups was statistically significant (p<0.001). The mean PTGI post-test score was 86.21±20.39 in the experimental group and 79.54±22.32 in the control group, and the difference between the groups' mean scores was statistically significant (p<0.05). The mean post-test score of the PTGI Change in Philosophy of Life subscale was 19.37±6.04 in the experimental group and 16.17±6.83 in the control group, and the difference between the mean scores was statistically significant (p<0.05). CONCLUSION: It was determined that the midwifery care provided to primiparous mothers during the postpartum period had a positive effect on levels of post-traumatic growth and maternal attachment.

Home-Based Interventions may Increase Recruitment, Adherence, and Measurement of outcomes in Clinical Trials of Stroke Rehabilitation.

OBJECTIVE: This study aimed to investigate the completion rates of a home-based randomized trial, which examined home-based high-intensity respiratory muscle training after stroke compared with sham intervention. MATERIALS AND METHODS: Completion was examined in terms of recruitment (enrolment and retention), intervention (adherence and delivery of home-visits) and measurement (collection of outcomes). RESULTS: Enrolment was 32% and retention was 97% at post-intervention and 84% at follow-up. Adherence to the intervention was high at 87%. Furthermore, 83% of planned home-visits were conducted and 100% of outcomes were collected from those attending measurement sessions. CONCLUSION: This home-based randomized trial demonstrated high rates of enrolment, retention, adherence, delivery of home-visits, and collection of outcomes. Home-based interventions may help to improve completion rates of randomized trials.

In-hours acute home visits by advanced nurse practitioners in primary care: a qualitative study.

BACKGROUND: The extension of roles within the primary care team is one approach recommended to address the shortage of GPs in the UK. A key aspect of care that advanced nurse practitioners (ANPs) can undertake is acute home visits. AIM: To evaluate the perspectives of ANPs performing acute in-hours home visits in primary care. METHODS: Qualitative data were gathered in eight semi-structured interviews across a primary care locality, then analysed via a process of thematic analysis. FINDINGS: Three key themes were identified: providing holistic care; engaging with the home setting; and negotiating role ambiguity. CONCLUSION: Practices wishing to involve ANPs in acute home visits should ensure clear definition and good understanding of the ANP role. Effective interprofessional relationships should be fostered with appropriate mentorship and clinical supervision to support ANPs in optimising their contribution to acute home visits.

Evaluation of a package of continuum of care interventions for improved maternal, newborn, and child health outcomes and service coverage in Ghana: A cluster-randomized trial.

BACKGROUND: In low- and middle-income countries (LMICs), the continuum of care (CoC) for maternal, newborn, and child health (MNCH) is not always complete. This study aimed to evaluate the effectiveness of an integrated package of CoC interventions on the CoC completion, morbidity, and mortality outcomes of woman-child pairs in Ghana. METHODS AND FINDINGS: This cluster-randomized controlled trial (ISRCTN: 90618993) was conducted at 3 Health and Demographic Surveillance System (HDSS) sites in Ghana. The primary outcome was CoC completion by a woman-child pair, defined as receiving antenatal care (ANC) 4 times or more, delivery assistance from a skilled birth attendant (SBA), and postnatal care (PNC) 3 times or more. Other outcomes were the morbidity and mortality of women and children. Women received a package of interventions and routine services at health facilities (October 2014 to December 2015). The package comprised providing a CoC card for women, CoC orientation for health workers, and offering women with 24-hour stay at a health facility or a home visit within 48 hours after delivery. In the control arm, women received routine services only. Eligibility criteria were as follows: women who gave birth or had a stillbirth from September 1, 2012 to September 30, 2014 (before the trial period), from October 1, 2014 to December 31, 2015 (during the trial period), or from January 1, 2016 to December 31, 2016 (after the trial period). Health service and morbidity outcomes were assessed before and during the trial periods through face-to-face interviews. Mortality was assessed using demographic surveillance data for the 3 periods above. Mixed-effects logistic regression models were used to evaluate the effectiveness as difference in differences (DiD). For health service and morbidity outcomes, 2,970 woman-child pairs were assessed: 1,480 from the baseline survey and 1,490 from the follow-up survey. Additionally, 33,819 cases were assessed for perinatal mortality, 33,322 for neonatal mortality, and 39,205 for maternal mortality. The intervention arm had higher proportions of completed CoC (410/870 [47.1%]) than the control arm (246/620 [39.7%]; adjusted odds ratio [AOR] for DiD = 1.77; 95% confidence interval [CI]: 1.08 to 2.92; p = 0.024). Maternal complications that required hospitalization during pregnancy were lower in the intervention (95/870 [10.9%]) than in the control arm (83/620 [13.4%]) (AOR for DiD = 0.49; 95% CI: 0.29 to 0.83; p = 0.008). Maternal mortality was 8/6,163 live births (intervention arm) and 4/4,068 live births during the trial period (AOR for DiD = 1.60; 95% CI: 0.40 to 6.34; p = 0.507) and 1/4,626 (intervention arm) and 9/3,937 (control arm) after the trial period (AOR for DiD = 0.11; 95% CI: 0.11 to 1.00; p = 0.050). Perinatal and neonatal mortality was not significantly reduced. As this study was conducted in a real-world setting, possible limitations included differences in the type and scale of health facilities and the size of subdistricts, contamination for intervention effectiveness due to the geographic proximity of the arms, and insufficient number of cases for the mortality assessment. CONCLUSIONS: This study found that an integrated package of CoC interventions increased CoC completion and decreased maternal complications requiring hospitalization during pregnancy and maternal mortality after the trial period. It did not find evidence of reduced perinatal and neonatal mortality. TRIAL REGISTRATION: The study protocol was registered in the International Standard Randomised Controlled Trial Number Registry (90618993).

The Practice of Home Visiting by Community Health Nurses as a Primary Healthcare Intervention in a Low-Income Rural Setting: A Descriptive Cross-Sectional Study in the Adaklu District of the Volta Region, Ghana.

BACKGROUND: Home visit is an integral component of Ghana's PHC delivery system. It is preventive and promotes health practice where health professionals render care to clients in their own environment and provide appropriate healthcare needs and social support services. This study describes the home visit practices in a rural district in the Volta Region of Ghana. Methodology. This descriptive cross-sectional study used 375 households and 11 community health nurses in the Adaklu district. Multistage sampling techniques were used to select 10 communities and study respondents using probability sampling methods. A pretested self-designed questionnaire and an interview guide for household members and community health nurses, respectively, were used for data collection. Quantitative data collected were coded, cleaned, and analysed using Statistical Package for Social Sciences into descriptive statistics, while qualitative data were analysed using the NVivo software. Thematic analysis was engaged that embraces three interrelated stages, namely, data reduction, data display, and data conclusion. RESULTS: Home visit is a routine responsibility of all CHNs. The factors that influence home visiting were community members' education and attitude, supervision challenges, lack of incentives and lack of basic logistics, uncooperative attitude, community inaccessibility, financial constraint, and limited number of staff. Household members (62.3%) indicated that health workers did not adequately attend to minor ailments as 78% benefited from the service and wished more activities could be added to the home visiting package (24.5%). CONCLUSION: There should be tailored training of CHNs on home visits skills so that they could expand the scope of services that can be provided. Also, community-based health workers such as community health volunteers, traditional birth attendants, and community clinic attendants can also be trained to identify and address health problems in the homes.