Habitantes de calle: entre el mito y la exclusión / Homeless people: between myth and exclusion

Al hablar del habitante de calle, resulta importante mencionar que es un fenómeno que ha tenido presencia milenaria, y que ha estado siempre permeado por las lógicas sociales de gobernanza, religión, cultura y economía. Han sido tan diversas las representaciones que se han tenido de esta población, que hoy inclusive sobreviven algunas de esas ideas que han hecho difícil su abordaje y comprensión. El objetivo de este texto es dar a conocer las reflexiones que han surgido de un ejercicio inicial de formación investigativa, en cuanto al fenómeno habitante de calle en Medellín. Para esta acción se revisaron algunos artículos sobre esta población, y se realizó una pequeña pasantía por el sistema de Atención al Habitante de Calle de Medellín, de donde surgieron algunas ideas referentes al concepto, historia y estrategias de intervención que se han implementado desde las diferentes administraciones para intentar dar solución a dicho fenómeno.

It is important to mention that homeless people is a phenomenon that has had a millennial presence, and that has always been permeated by the social logics of governance, religion, culture and economy. There had been so diverse representations about this population, that even today survive some of those ideas that have made it difficult to approach and understand them. The main objective of this text is to make known the reflections that have arisen from an initial exercise of investigative training, regarding that phenomenon of the homeless people in Medellin. Some articles on this specific population were reviewed, and a small internship was carried out by the Medellin homeless people Care System, emerging some ideas about the concept, history and intervention strategies that have been implemented since the different Governmental Administrations to try to solve this phenomenon.

A student operated, faculty mentored dental clinic service experience at the University of Texas Health Science Center at San Antonio for the underserved refugee community: an interprofessional approach.

BACKGROUND: As the number of refugees settling in San Antonio increases, so will their health care needs. Due to limited resources and stress, they suffer from acute and chronic diseases, reducing their potential for success in their new host country. The need for proper health education coupled with a stable holistic health care facility is essential for their future success. OBJECTIVES: In 2009, nursing students began serving the San Antonio refugee population. By 2011, dental and medical students joined to create the student-run San Antonio Refugee Health Clinic (SARHC). SARHC serves the refugees by providing free health care/education while connecting them to San Antonio's primary health care system. METHODS: Select dental, medical, and nursing students under the mentorship of their faculty operate the SARHC clinic. The students work in collaborative teams where select members of the refugee community and bilingual students provide translational assistance. The nursing students take vital signs and medical students perform physical exams after gathering a history of present illness. Dental students provide oral health/nutritional education and screenings inclusive of head and neck examination and oral cancer risk assessment. RESULTS: Thirty-two dental, 83 medical, and 118 nursing students rotated through the clinic last year, serving patients with the most common chief complaints of dental, musculoskeletal, dermatological, and gastrointestinal nature. The most common dental findings for this population have been dental caries, periodontal disease, and other dental diseases requiring urgent care. Sub-programs such as the student interpreter program, ladies' health education, and the Refugee Accompaniment Health Partnership have resulted from the SARHC initiative to meet the refugees' needs. Currently under development is a future collaboration with local San Antonio clinics such as the San Antonio Christian Dental Clinic to serve as their dental home. CONCLUSION: The use of this interprofessional model has resulted in holistic and accessible health care for the refugees in San Antonio. Patients receive complimentary comprehensive care while students benefit from development of cultural competence reinforcement of humanitarian values. It is difficult to conclude which group is the biggest beneficiary of attending SARHC. As the dental students reflected, "We started attending the clinic as a service learning project. We then became their advocates, treated them at our dental school, and became knowledgeable about our community's dental clinics while offering tailored referrals."

The magnitude, share and determinants of unpaid care costs for home-based palliative care service provision in Toronto, Canada.

With increasing emphasis on the provision of home-based palliative care in Canada, economic evaluation is warranted, given its tremendous demands on family caregivers. Despite this, very little is known about the economic outcomes associated with home-based unpaid care-giving at the end of life. The aims of this study were to (i) assess the magnitude and share of unpaid care costs in total healthcare costs for home-based palliative care patients, from a societal perspective and (ii) examine the sociodemographic and clinical factors that account for variations in this share. One hundred and sixty-nine caregivers of patients with a malignant neoplasm were interviewed from time of referral to a home-based palliative care programme provided by the Temmy Latner Centre for Palliative Care at Mount Sinai Hospital, Toronto, Canada, until death. Information regarding palliative care resource utilisation and costs, time devoted to care-giving and sociodemographic and clinical characteristics was collected between July 2005 and September 2007. Over the last 12 months of life, the average monthly cost was $14 924 (2011 CDN$) per patient. Unpaid care-giving costs were the largest component - $11 334, accounting for 77% of total palliative care expenses, followed by public costs ($3211; 21%) and out-of-pocket expenditures ($379; 2%). In all cost categories, monthly costs increased exponentially with proximity to death. Seemingly unrelated regression estimation suggested that the share of unpaid care costs of total costs was driven by patients' and caregivers' sociodemographic characteristics. Results suggest that overwhelming the proportion of palliative care costs is unpaid care-giving. This share of costs requires urgent attention to identify interventions aimed at alleviating the heavy financial burden and to ultimately ensure the viability of home-based palliative care in future.

Advanced primary care in San Antonio: linking practice and community strategies to improve health.

Improving health among people living in poverty often transcends narrowly focused illness care. Meaningful success is unlikely without confronting the complex social origins of illness. We describe an emerging community of solution to improve health outcomes for a population of 6000 San Antonio, Texas, residents enrolled in a county health care program. The community of solution comprises a county health system, a family medicine residency program, a metropolitan public health department, and local nonprofit organizations and businesses. Community-based activities responding to the needs of individuals and their neighborhoods are driven by a cohort of promotores (community health workers) whose mission encompasses change at both the individual and community levels. Centered on patients' functional goals, promotores mobilize family and community resources and consider what community-level action will address the social determinants of health. On the clinical side, care teams implement population-based risk assessment and nurse care management with a focus on care transitions as well as other measures to meet the needs of patients with high morbidity and high use of health care. Population-based outcome metrics include reductions in hospitalizations, emergency department and urgent care visits, and the associated charges. Promotores also assess patients' progress along the trajectory of their selected functional goals.

A primary care-public health partnership addressing homelessness, serious mental illness, and health disparities.

BACKGROUND: People with histories of homelessness and serious mental illness experience profound health disparities. Housing First is an evidenced-based practice that is working to end homelessness for these individuals through a combination of permanent housing and community-based supports. METHODS: The Jefferson Department of Family and Community Medicine and a Housing First agency, Pathways to Housing-PA, has formed a partnership to address multiple levels of health care needs for this group. We present a preliminary program evaluation of this partnership using the framework of the patient-centered medical home and the "10 Essential Public Health Services." RESULTS: Preliminary program evaluation results suggest that this partnership is evolving to function as an integrated person-centered health home and an effective local public health monitoring system. CONCLUSION: The Pathways to Housing-PA/Jefferson Department of Family and Community Medicine partnership represents a community of solution, and multiple measures provide preliminary evidence that this model is feasible and can address the "grand challenges" of integrated community health services.

Catholic identity and charity care in the era of health reform.

Catholic healthcare institutions live amidst tension between three intersecting primary values, namely, a commitment of service to the poor and vulnerable, promoting the common good for all, and financially sustainability. Within this tension, the question sometimes arises as to whether it is ever justifiable, i.e., consistent with Catholic identity, to place limits on charity care. In this article we will argue that the health reform measures of the Affordable Care Act do not eliminate this tension but actually increase the urgency of addressing it. Moreover, we will conclude that the question of limiting charity care in a manner that is consistent with the obligations of Catholic identity around serving the poor and vulnerable, promoting the common good, and remaining financially sustainable is not a question of if, but of how such limits are established. Such limits, however, cannot be established in light of one overriding moral consideration or principle, but must be established in light of a multitude of principles guiding us to a holistic understanding of the interrelatedness of the moral dimensions of Catholic identity.

Access to musculoskeletal specialists and resources in free and charitable clinics: a survey of clinic directors.

OBJECTIVE: To evaluate the capabilities and resources of free and charitable clinics in the United States to deliver musculoskeletal care to an indigent population. DESIGN: A voluntary, anonymous, cross-sectional survey. SETTING: Electronic mailing list for the National Association of Free and Charitable Clinics in September 2011, and in person at the Annual Summit for the National Association of Free and Charitable Clinics in October 2011. At the time of survey, 427 member-clinics were eligible for participation. PARTICIPANTS: One hundred forty-five (34%) respondents were included in data analysis. INTERVENTIONS: None. MAIN OUTCOME MEASURES: Answers to a questionnaire regarding access to musculoskeletal care. RESULTS: The average annual clinic volume was 5690 patient visits. Low back pain was the most common orthopedic complaint. Access to musculoskeletal specialty consultants was rated as poor or worse in 83% of clinics surveyed. The majority of respondents (63%) believed that their staff was able to treat only half or fewer of the patients who presented with musculoskeletal complaints in their clinic. The resource most needed to treat these conditions was musculoskeletal physician consultants. CONCLUSIONS: Indigent populations have a strong need for musculoskeletal care, but affordable access to physiatrists and other musculoskeletal specialists is extremely limited. Personnel at surveyed clinics believed that the greatest need to improve care is better access to these specialty physicians.

Dental hygienist attitudes toward providing care for the underserved population.

PURPOSE: The purpose of this study was to investigate registered dental hygienists' attitude toward community service, sensitivity to patient needs, job satisfaction and their frequency to volunteer care for the underserved population. METHODS: A 60 question survey instrument was developed and distributed to 306 participants. The survey instrument ad dressed the following variables: community service, sensitivity to patient needs, job satisfaction, social responsibility, spirituality and willingness to volunteer care. A total of 109 surveys were returned yielding a 33.9% response rate. SPSS version 19.0 was utilized for data analysis. Based on the factor analysis, the 6 original variables were reduced to 3 variables, which included attitude toward community service, job satisfaction and sensitivity to patient needs. RESULTS: For registered dental hygienists their level of education, membership in their professional association, attitude toward community service and sensitivity to patients were associated with their frequency of volunteering care for the underserved population. Additionally, a discriminant analysis indicated a strong prediction among registered dental hygienists attitude toward community service and job satisfaction to their frequency of volunteering care for the underserved population. CONCLUSION: This research study of the factors that influence registered dental hygienists' frequency of volunteering care indicates how important oral health care preparatory norms and dispositions are to the underserved population. Understanding what persuades registered dental hygienists to volunteer care provides valuable information to registered dental hygienists, as well as dental hygiene programs regarding volunteering care for the underserved population and the importance of attitudes toward community service, sensitivity to patient needs and job satisfaction.

Safety-net providers in some US communities have increasingly embraced coordinated care models.

Safety-net organizations, which provide health services to uninsured and low-income people, increasingly are looking for ways to coordinate services among providers to improve access to and quality of care and to reduce costs. In this analysis, a part of the Community Tracking Study, we examined trends in safety-net coordination activities from 2000 to 2010 within twelve communities in the United States and found a notable increase in such activities. Six of the twelve communities had made formal efforts to link uninsured people to medical homes and coordinate care with specialists in 2010, compared to only two communities in 2000. We also identified key attributes of safety-net coordinated care systems, such as reliance on a medical home for meeting patients' primary care needs, and lingering challenges to safety-net integration, such as competition among hospitals and community health centers for Medicaid patients.

Healthcare for migrants and for marginalized individuals: The Marienambulanz in Graz, Austria.

The Marienambulanz in Graz, which was founded in 1999, is an outpatient clinic aiming to provide free medical services for marginalized groups. Medical and socioeconomic data of patients at the outpatient clinic have been collected electronically since 2003. The purpose of this study was to find out which persons were treated at the Marienambulanz in the last seven years (2003-2009) and to find out the most frequent reasons for attending the Marienambulanz. We analysed existing medical data descriptively in order to find out the four most frequent reasons for going to the outpatient clinic, the nationality of the patients and whether or not the patients had insurance coverage. Since 2003, 3,652 patients (2,342 men and 1,310 women) have been treated at the Marienambulanz. The majority of patients came either for an initial medical examination, for medication or for further thorough examinations including advice about general health and - if necessary - for childcare. Interestingly, more than 60% of the patients were insured. The Marienambulanz provides medical assistance for uninsured persons and for marginalized insured persons who do not make use of the regular health care system. It can be argued that the regular Austrian health care system fails to provide health care for marginalized groups. The Marienambulanz in Graz, as a low-threshold institution, serves the purpose of bridging the gap to the regular health care system for marginalized groups.

[Cost analysis of contrast-enhanced cranial MRI at a German university hospital]. / Kostenanalyse einer kontrastgestützten MRT des Schädels an einem Universitätsklinikum.

PURPOSE: Detailed evaluation and cost analysis of a cranial contrast-enhanced MRI (c-ceMRI) in outpatients, inpatients, patients in an intensive care unit and children under anesthesia. MATERIALS AND METHODS: Based on a detailed process-oriented model, we calculated the cost of a cranial MRI for the four situations mentioned above. A comprehensive evaluation of the overhead and personnel costs was performed. RESULTS: We performed 5108 MRI examinations on 2 scanners in the year 2008. 2150 examinations (42 %) were identified as c-ceMRI. For inpatients we calculated a total cost of € 242.46 per examination with a personnel cost of € 81.71 for the radiological department. In outpatients we calculated total costs of € 181.97 with radiological personnel costs of € 68.67. Patients coming from an intensive care unit were treated by an intensive care team, which resulted in total costs of € 416.58 with € 283 in costs for radiological personnel (32.8 %). MRI examinations of children under anesthesia resulted in costs of € 616.79 for the hospital, of which € 285.78 were radiological personnel costs (34.5 %). CONCLUSION: In this study we evaluated for the first time different radiological scenarios of a c-ceMRI at a university hospital. Considering the present reimbursement situation, all outpatients covered by statutory health insurance resulted in a deficit for the hospital. Particularly high costs for patients in intensive care units as well as for children under anesthesia have to be taken into account and are currently not adequately covered by care providers.

The interface of primary and oncology specialty care: from diagnosis through primary treatment.

In this article, we review the challenges and opportunities related to developing effective, collaborative relationships between primary care and oncology providers during the initial cancer treatment period. This point in the cancer care continuum is complex and often represents the first major transition in care between primary care providers and oncology specialists. Patients often receive care from multiple providers in a number of different settings and are faced with making treatment decisions in a short, concentrated period of time. Patients consistently report having significant informational and emotional needs that are often unmet during this period. Using the published literature, we have identified a number of challenges during this part of the treatment continuum that may limit providers' ability to deliver effective care, including provider care discontinuities, information exchange problems, and gaps in provider role clarity that may be especially problematic within the context of managing comorbid health conditions. The limited published literature specific to this step in the cancer care trajectory supports the importance of ongoing primary care-specialist collaboration during this phase in the care continuum for both medical and psychosocial care. How to best achieve effective collaboration between providers requires further research in information exchange and tools to support it, evaluation of shared care models specific to the cancer context, and studies of the potential role of multidisciplinary case conferencing that include the primary care provider.

[The involvement of the apothecaries of Nancy in the medical consultation of the Royal College of Medicine, from 1764 to 1793]. / La participation de la communauté des apothicaires de Nancy à la consultation des pauvres malades des campagnes, organisée par le Collège royal de médecine, de 1764 à 1793.

A medical consultation reserved to poor sick persons of countries around Nancy was organized by the Royal College of Medicine from 1752. Concerning the drugs, the College thout first to use an apothecary companion, then it agreed, in 1764, with the proposal of the apothecaries of the city to distribute them free of charge, each in turn for two months, one in winter and one in summer. In 1788, the apothecaries complained from the abuses committed in the writing of the consultation tickets. The gardener had to furnish plants, gratuitously or not, in order the consultants to prepare drugs at home. These practices lasted until the extreme end of year 1793 where the College was cancelled.