Cocreation as a Caring Phenomenon: Nurses' Experiences in Palliative Home Care.

A new concept in palliative care, cocreation, appears to be a part of caring in nursing but has not yet been explored as a caring phenomenon. The aim was to, from a caring science perspective, explore how cocreation can be experienced as a phenomenon by nurses working in palliative home care. A hermeneutical approach and thematic analysis were used. The material consisted of texts from in-depth interviews with 12 nurses in a home care context. Informed consent regarding study participation and the storage and handling of data for research purposes were sought from participants. One main theme and 4 subthemes emerged. Cocreation can be viewed as an essential part of caring and being involved in patients' health and holistic care is a profound endeavor. Further research should focus on illuminating cocreation from patients' perspectives.

Nursing practice in home care: the mediation of care by reflexivity.

OBJECTIVE: To analyze the practice of nurses in home care, considering the mediation of care by reflexivity. METHOD: Unique, qualitative case study, anchored in the dialectical framework. The participants were 13 nurses who work in home care in Minas Gerais. Data were obtained by participant observation and interview, and submitted to critical discourse analysis. RESULTS: Nursing care at home involves the repetitions of everyday actions and a degree of unpredictability. Reflexivity, according to Schön's theoretical framework, emerges as a component of professional practice that leads to the practice of care as a continuous assessment of work, and also to reflection on the challenges imposed by conflicting situations. Reflexivity also stems from professionals' search for improvements in their practices. FINAL CONSIDERATIONS: We identified the presence of actions and knowledge mobilized by the reflexivity of the nurse in the home care setting. The following were the elements of this reflexive practice: knowing-in-action, reflection-in-action and reflection reflection-in-action.

Nursing practice in home care: the mediation of care by reflexivity / La práctica de enfermería en la atención a domicilio: la mediación del cuidado por la reflexividad / Prática da enfermeira na atenção domiciliar: o cuidado mediado pela reflexividade

ABSTRACT Objective: To analyze the practice of nurses in home care, considering the mediation of care by reflexivity. Method: Unique, qualitative case study, anchored in the dialectical framework. The participants were 13 nurses who work in home care in Minas Gerais. Data were obtained by participant observation and interview, and submitted to critical discourse analysis. Results: Nursing care at home involves the repetitions of everyday actions and a degree of unpredictability. Reflexivity, according to Schön's theoretical framework, emerges as a component of professional practice that leads to the practice of care as a continuous assessment of work, and also to reflection on the challenges imposed by conflicting situations. Reflexivity also stems from professionals' search for improvements in their practices. Final considerations: We identified the presence of actions and knowledge mobilized by the reflexivity of the nurse in the home care setting. The following were the elements of this reflexive practice: knowing-in-action, reflection-in-action and reflection reflection-in-action.

RESUMEN Objetivo: Analizar la práctica de enfermería en la atención a domicilio, desde la mediación del cuidado por la reflexividad. Método: Estudio de caso único, cualitativo, en base de la dialéctica referencial. Han participado 13 enfermeras que trabajan en la atención domiciliaria en Minas Gerais, Brasil. En la recolección de datos se utilizó la observación participante y las entrevistas, pasando a un análisis crítico del discurso. Resultados: El cuidado de enfermería a domicilio consiste en repeticiones de acciones cotidianas e imprevisibilidad. La reflexividad, desde el marco teórico de Schön, emerge como un componente de la práctica profesional que conduce al logro del cuidado en una evaluación continua del trabajo y la reflexión sobre los desafíos que enfrentan con situaciones conflictivas y la búsqueda de la mejora en sus prácticas. Consideraciones finales: Se identificaron la presencia de quehaceres y saberes influidos por la reflexividad en la enfermería a domicilio, y los siguientes elementos de la práctica reflexiva: el conocimiento-en-la-acción, la reflexión-en-la-acción y su reflexión.

RESUMO Objetivo: Analisar a prática de enfermeiras na atenção domiciliar, considerando a realização do cuidado mediado pela reflexividade. Método: Estudo de caso único, qualitativo, ancorado no referencial dialético. Participaram 13 enfermeiras que atuam na atenção domiciliar em Minas Gerais. Os dados foram obtidos por observação participante e entrevista e submetidos à análise de discurso crítica. Resultados: O cuidado da enfermeira no domicílio é composto por repetições de ações cotidianas e pela imprevisibilidade. A reflexividade, segundo referencial teórico de Schön, emerge como um componente da prática profissional que leva à realização do cuidado em uma avaliação contínua do trabalho e da reflexão acerca dos desafios diante de situações conflitantes e da busca de melhoria em suas práticas. Considerações finais: Identificou-se a presença de fazeres e saberes mobilizados pela reflexividade da enfermeira no domicílio, e os seguintes elementos de uma prática reflexiva: o conhecer-na-ação, a reflexão-na-ação e a reflexão sobre este último.

Evolving Changes in the Delivery of Health Services: A Place for Urological Homecare?

The ongoing pressure to improve quality while reducing costs is leading to increased uptake of various urological homecare models. Urological homecare can involve reductions in hospital usage and costs, traveling time for the patient, and hospital deaths and can improve patient experience and satisfaction.

Care Needs of Patients at the End of Life With a Noncancer Diagnosis Who Live at Home.

BACKGROUND: As the population ages, the prevalence of various chronic diseases increases. Palliative care for patients at the end of life with a noncancer diagnosis is currently limited because of the difficulties of demarcating the boundaries of the end-of-life care period and of determining the various care needs of patients at the end of life. PURPOSE: This study aimed to investigate the levels of importance and difficulty of the multidimensional care needs for patients with a noncancer diagnosis during various end-of-life stages. METHODS: This study is a retrospective survey. Home healthcarenurse specialists (HHNS) reviewed medical and nursing records and responded to a structured questionnaire. The caring experiences of HHNS with 115 patients, who were 40 years or older, had received home care nursing throughout the stable (between the onset of the end-of-life stage and 1 week before death) and near-death (1 week before death) stages at Seoul St. Mary's Hospital in Korea, and had died between September 1, 2014, and December 31, 2015, were analyzed. RESULTS: The care needs of "coordination among family or relatives" and "support for fundamental needs" were more important in the stable stage than in the near-death stage. The care need of "loss, grief care" was more important in the near-death stage than in the stable stage. The care need of "physical symptoms management" was the most difficult to meet in both stages. Lower Palliative Performance Scale score was associated with a higher level of care need, particularly in the "management of physical symptoms" and "psychological support" realms in the stable stage and in the "coordination among family or relatives" realm in both stages. CONCLUSIONS: End-of-life stage and initial score on the Palliative Performance Scale were found to have a significant influence on the multidimensional care needs of patients with a noncancer diagnosis. Thus, healthcare professionals should assess patient care needs according to disease trajectory to provide continuous and holistic care.

Merging current health care trends: innovative perspective in aging care.

Current trends in health care delivery and management such as predictive and personalized health care incorporating information and communication technologies, home-based care, health prevention and promotion through patients' empowerment, care coordination, community health networks and governance represent exciting possibilities to dramatically improve health care. However, as a whole, current health care trends involve a fragmented and scattered array of practices and uncoordinated pilot projects. The present paper describes an innovative and integrated model incorporating and "assembling" best practices and projects of new innovations into an overarching health care system that can effectively address the multidimensional health care challenges related to aging patient especially with chronic health issues. The main goal of the proposed model is to address the emerging health care challenges of an aging population and stimulate improved cost-efficiency, effectiveness, and patients' well-being. The proposed home-based and community-centered Integrated Healthcare Management System may facilitate reaching the persons in their natural context, improving early detection, and preventing illnesses. The system allows simplifying the health care institutional structures through interorganizational coordination, increasing inclusiveness and extensiveness of health care delivery. As a consequence of such coordination and integration, future merging efforts of current health care approaches may provide feasible solutions that result in improved cost-efficiency of health care services and simultaneously increase the quality of life, in particular, by switching the center of gravity of health delivery to a close relationship of individuals in their communities, making best use of their personal and social resources, especially effective in health delivery for aging persons with complex chronic illnesses.

[Paradigm Shift in the Quality of Regional Medical Care: Cooperative Treatment of Onychomycosis].

　In a superaging society, the medical paradigm should include both less coverage of medical-care work flow by human resources and high-quality care for patients. Strategies such as establishing medical-care teams and community medicine systems mainly for home medical care should be implemented. However, a well-organized system for home-based medical treatment of elderly patients is not yet in place, as evidenced by the lack of care, problems with long-term polypharmacy resulting from visits to multiple healthcare providers, and declines in their physical strength. It is assumed that care might not be provided in association with treatment because planning based on the paradigm of "home medical care" has not been fully established. Therefore, in this study, we aimed to determine the "paradigm shift in home medical care" based on the treatment of onychomycosis. We also hoped to identify the types of medical support required to improve the general well-being of individuals and what needs to be done to ensure a high quality of life for patients. All those (including patients themselves) involved in patient care should together formulate a protocol for medical treatment and cooperate based on the role each can play. Although it may be difficult to maintain cooperation among healthcare workers, improvements in the medical quality of an entire region can be achieved by planning a life design including medical treatment for each patient.

Integrated platform for home services using new products and services for senior citizens Call CNAV-CARSAT 2015.

This project is part of: i) the risks of ageing prevention policy of the French retirement and occupational health insurance agency of Languedoc Roussillon (Carsat-LR) and ii) the European innovation partnership on active and healthy ageing (EIP on AHA). It aims to support senior citizens who live independently and have been identified at risk of frailty on a social or health level. The purpose is to increase legibility as well as technical and financial access to innovations for vulnerable seniors who are remote from the digital era, through a multiservice user-friendly platform. Launched at the end of 2015, the project rallies over 10 actors of the silver economy currently developing personalised ICT tools to improve the safety and comfort of seniors and the coordination between health and social care. The objective is threefold: i) developing new adapted technologies, ii) having them evaluated by retirees and professionals and iii) making them accessible to the ICT web platform which will provide tutorials and prices and collect opinions from users and professionals. 500 retirees selected by CARSAT-LR will be testing these new devices and solutions which will be provided without charge. The following will be evaluated: i) feedback from users; ii) benefits gained through accessing comprehensive and appropriate information; iii) coordination of caregivers and professionals; iv) enjoyment from using the products (access to games, social links, customer confidence, sense of safety). This is a unique opportunity to mobilise solutions in a structured manner, bringing together competing businesses under a consortium agreement. Advantages for these businesses include acceleration of development and availability of their adapted solutions as well as the possibility to test their products on a significant panel of people. Professional caregiver's data follow-up will identify seniors at risk of frailty, proposing preventive actions and local services tailored to their needs.

[Relations with emergency medical care and primary care doctor, home health care].

Medical care for an ultra-aging society has been shifted from hospital-centered to local community-based. This shift has yielded the so-called Integrated Community Care System. In the system, emergency medical care is considered important, as primary care doctors and home health care providers play a crucial role in coordinating with the department of emergency medicine. Since the patients move depending on their physical condition, a hospital and a community should collaborate in providing a circulating service. The revision of the medical payment system in 2014 clearly states the importance of "functional differentiation and strengthen and coordination of medical institutions, improvement of home health care". As part of the revision, the subacute care unit has been integrated into the community care unit, which is expected to have more than one role in community coordination. The medical fee has been set for the purpose of promoting the home medical care visit, and enhancing the capability of family doctors. In the section of end-of-life care for the elderly, there have been many issues such as reduction of the readmission rate and endorsement of a patient's decision-making, and judgment for active emergency medical care for patient admission. The concept of frailty as an indicator of prognosis has been introduced, which might be applied to the future of emergency medicine. As described above, the importance of a primary doctor and a family doctor should be identified more in the future; thereby it becomes essential for doctors to closely work with the hospital. Advancing the cooperation between a hospital and a community for seamless patient-centered care, the emergency medicine as an integrated community care will further develop by adapting to an ultra-aging society.

Integrating oncology and palliative home care in Italy: the experience of the "L'Aquila per la Vita" Home Care Unit.

AIM: To evaluate the efficacy of a home care program, closely integrated with a medical oncology department. PATIENTS AND METHODS: The charts, prospectively recorded, of all the patients treated at home by the "L'Aquila per la Vita" Home Care Unit from August 2006 to December 2011, were reviewed. The number of patients, home accesses, length of the home care, hospital admission, emergency calls, and the place of death were recorded. Data were analyzed considering the origin of the patients (medical oncology department or other). RESULTS: A total of 461 patients was followed at home for a total of 10,503 home accesses (median accesses/patient, 20; range, 1-159). The median length of home care was 76 days (range, 2-643 days). The median was 101 days for patients coming from the medical oncology department and 53 days for patients coming from other origins (P <0.0005). There were 428 emergency calls (4.1% of all the home accesses). Emergency calls accounted for 253 of 7,364 home accesses (3.4%) among patients coming from the medical oncology department and for 175 of 3,139 home accesses (5.6%) among patients coming from other origins (P = 0.00005). Eighty of 461 patients (17.3%) required one in-hospital admission and 19/461 patients (4.1%) more than one. Fifty-nine of 259 (17.8%) patients coming from the medical oncology department and 40 of 186 (26.9%) coming from other origins required in-hospital admissions (P = 0.04). A total of 311 patients died (163 coming from the medical oncology department and 148 from other origins). Twenty-eight of 163 (17.1%) coming from the medical oncology department and 52 of 148 (35.1%) coming from other origins died in the hospital (P = 0.0002). CONCLUSIONS: A multidisciplinary and expert team, closely integrated with the hospital, can guarantee a long length of home care, avoiding hospitalization and closing the gap between the patients' preferences and the services offered regarding the place of death.

Relación entre el estado nutricional y el riesgo de presentar úlceras por presión en pacientes incluidos en el programa de atención domiciliaria / Relationship between nutritional status and the risk of having pressure ulcers in patients included in a home care program

Objetivos: Se evaluó el grado de relación entre estado nutricional y riesgo de presentar úlceras por presión (UPP) en pacientes de atención domiciliaria (ATDOM). Secundariamente, se valoró la relación entre el grado de deterioro cognitivo, dependencia física, patologías de base y estado nutricional. Ámbito: Pacientes de atención domiciliaria (ATDOM) en atención primaria.Pacientes100 pacientes ATDOM. Variables principales: Edad, sexo, cuidador, enfermedades, IMC, hemoglobina, hematocrito, linfocito S, albúmina, colesterol, Barthel, Pfeiffer, valoración nutricional (MNA) y Braden. Resultados: Un 14% de los pacientes ATDOM presentaron malnutrición y un 46% riesgo de desnutrición. El incremento del grado de dependencia y el deterioro cognitivo aumentó (p<0,001) el riesgo UPP. Además, el estado nutricional afectó al riesgo de UPP (p<0,001) con una OR 3,73 superior en aquellos pacientes malnutridos. Valores de albúmina de 3,76±0,05g/dL y de colesterol de 176,43±6,38 se relacionaron con un mayor riesgo de ulceración. En cuanto al estado nutricional existió una relación significativa (p<0,01) con el grado de dependencia. En pacientes malnutridos los niveles de albúmina disminuyeron a 3,46±0,098, con medias de colesterol de 154,95mg/dL±11,41. Finalmente, IMC menores se relacionaron significativamente con malnutrición. Conclusiones: El presente estudio demuestra que el 14% de pacientes ATDOM presentaron malnutrición y un 46% riesgo de desnutrición. La malnutrición, el grado de dependencia física, el deterioro cognitivo severo y los parámetros sanguíneos básicos se relacionan significativamente con un aumento del riesgo de ulceración, justificando la necesidad de llevar a cabo medidas de corrección y mejoría personalizada en los pacientes ATDOM(AU)

Objective: The objective of the present study was to evaluate the relationship between the nutritional status and the risk of pressure ulcers (PU) in patients within home care programs (ATDOM). We also evaluated the relationship between the level of cognitive impairment, physical dependence, underlying diseases and the nutritional status. Scope: Patients in home care program in Primary Health Care.Patients100 home care patients. Main variables: age, sex, caregiver, illness, BMI, haemoglobin, haematocrit, lymphocyte count, albumin, cholesterol, Barthel index, Pfeiffer, nutritional assessment (MNA) and Braden scale. Results: Fourteen percent of the ATDOM patients had malnutrition and 46% a high risk of malnutrition. The degree of dependency, and the level of cognitive impairment increased (P<001) the risk of pressure ulcers. Furthermore, the nutritional status affected the risk of pressure ulcers (P<001) with OR 3.73 higher in malnourished patients. Values of 3.76±0.05g/dL albumin and cholesterol of 176.43±6.38 were associated with an increased risk of ulceration. There was a significant relationship between nutritional status (P<01) and the degree of dependence. In malnourished patients albumin levels decreased to 3.46±0.098, with averages of 11.41±154.95mg/dL cholesterol. Finally, a lower BMI was significantly related to malnutrition. Conclusions: The present study demonstrates that 14% of the ATDOM patients showed malnutrition, and 46% a high risk of malnutrition. Malnutrition, the degree of physical dependence and severity of cognitive impairment is associated with an increased risk of ulceration, which justify the need for carrying out some personalised measurements on ATDOM patients(AU)

Meeting the home-care needs of disabled older persons living in the community: does integrated services delivery make a difference?

BACKGROUND: The PRISMA Model is an innovative coordination-type integrated-service-delivery (ISD) network designed to manage and better match resources to the complex and evolving needs of elders. The goal of this study was to examine the impact of this ISD network on unmet needs among disabled older persons living in the community. METHODS: Using data from the PRISMA study, we compared unmet needs of elders living in the community in areas with or without an ISD network. Disabilities and unmet needs were assessed with the Functional Autonomy Measurement System (SMAF). We used growth-curve analysis to examine changes in unmet needs over time and the variables associated with initial status and change. Sociodemographic characteristics, level of disability, self-perceived health status, cognitive functioning, level of empowerment, and the hours of care received were investigated as covariates. Lastly, we report the prevalence of needs and unmet needs for 29 activities in both areas at the end of the study. RESULTS: On average, participants were 83 years old; 62% were women. They had a moderate level of disability and mild cognitive problems. On average, they received 2.07 hours/day (SD = 1.08) of disability-related care, mostly provided by family. The findings from growth-curve analysis suggest that elders living in the area where ISD was implemented and those with higher levels of disability experience better fulfillment of their needs over time. Besides the area, being a woman, living alone, having a higher level of disability, more cognitive impairments, and a lower level of empowerment were linked to initial unmet needs (r2 = 0.25; p < 0.001). At the end of the study, 35% (95% CI: 31% to 40%) of elders with needs living in the ISD area had at least one unmet need, compared to 67% (95% CI: 62% to 71%) in the other area. In general, unmet needs were highest for bathing, grooming, urinary incontinence, walking outside, seeing, hearing, preparing meals, and taking medications. CONCLUSIONS: In spite of more than 30 years of home-care services in the province of Quebec, disabled older adults living in the community still have unmet needs. ISD networks such as the PRISMA Model, however, appear to offer an effective response to the long-term-care needs of the elderly.

The future of telehealth monitoring.

Among senior hospital executives, integrated health care delivery networks (IDNS) and managed care organizations around the country, chronic patient population management is fast becoming a frequent topic of discussion. More than 100 million people in the U.S. suffer from some type of chronic condition, an astounding number for the country's health and pocketbook. The objective with these chronic patient populations is to keep them connected to the existing care continuum, managing their health while at home, as well as to control their entry into acute care setting, if and when that level of care is required.

Outcomes of a home cycling program using functional electrical stimulation or passive motion for children with spinal cord injury: a case series.

BACKGROUND/OBJECTIVE: Children with spinal cord injury (SCI) are at risk for musculoskeletal and cardiovascular complications. Stationary cycling using functional electrical stimulation (FES) or passive motion has been suggested to address these complications. The purpose of this case series is to report the outcomes of a 6-month at-home cycling program for 4 children with SCI. METHODS: Two children cycled with FES and 2 cycled passively at home for 1 hour, 3 times per week. OUTCOME MEASURES: Data collected included bone mineral density of the left femoral neck, distal femur, and proximal tibia; quadriceps and hamstring muscle volume; stimulated quadriceps and hamstring muscle strength; a fasting lipid profile; and heart rate and oxygen consumption during incremental upper extremity ergometry testing. RESULTS: The 2 children cycling with FES and 1 child cycling passively exhibited improved bone mineral density, muscle volume, stimulated quadriceps strength, and lower resting heart rate. For the second child cycling passively, few changes were realized. Overall, the lipid results were inconsistent, with some positive and some negative changes seen. CONCLUSIONS: This case series suggests that cycling with or without FES may have positive health benefits and was a practical home exercise option for these children with SCI.