RESUMEN
BACKGROUND: Universal health visiting has been a cornerstone of preventative healthcare for children in the United Kingdom (UK) for over 100 years. In 2016, Scotland introduced a new Universal Health Visiting Pathway (UHVP), involving a greater number of contacts with a particular emphasis on the first year, visits within the home setting, and rigorous developmental assessment conducted by a qualified Health Visitor. To evaluate the UHVP, an outcome indicator framework was developed using routine administrative data. This paper sets out the development of these indicators. METHODS: A logic model was produced with stakeholders to define the group of outcomes, before further refining and aligning of the measures through discussions with stakeholders and inspection of data. Power calculations were carried out and initial data described for the chosen indicators. RESULTS: Eighteen indicators were selected across eight outcome areas: parental smoking, breastfeeding, immunisations, dental health, developmental concerns, obesity, accidents and injuries, and child protection interventions. Data quality was mixed. Coverage of reviews was high; over 90% of children received key reviews. Individual item completion was more variable: 92.2% had breastfeeding data at 6-8 weeks, whilst 63.2% had BMI recorded at 27-30 months. Prevalence also varied greatly, from 1.3% of children's names being on the Child Protection register for over six months by age three, to 93.6% having received all immunisations by age two. CONCLUSIONS: Home visiting services play a key role in ensuring children and families have the right support to enable the best start in life. As these programmes evolve, it is crucial to understand whether changes lead to improvements in child outcomes. This paper describes a set of indicators using routinely-collected data, lessening additional burden on participants, and reducing response bias which may be apparent in other forms of evaluation. Further research is needed to explore the transferability of this indicator framework to other settings.
Asunto(s)
Datos de Salud Recolectados Rutinariamente , Humanos , Escocia , Preescolar , Lactante , Atención de Salud Universal , Femenino , Servicios de Salud del Niño/organización & administración , Masculino , Evaluación de Resultado en la Atención de Salud , Lactancia Materna/estadística & datos numéricos , Recién Nacido , Niño , Indicadores de Calidad de la Atención de Salud , Visita Domiciliaria/estadística & datos numéricosRESUMEN
BACKGROUND: Residential polarization shaped by racial segregation and concentrations of wealth (hereafter neighborhood racialized economic polarization) results in both highly deprived and highly privileged neighborhoods. Numerous studies have found a negative relationship between neighborhood racialized economic polarization and birth outcomes. We investigated whether community-informed home visiting programs achieve high rates of service coverage in highly deprived neighborhoods and can attenuate the deleterious effect of neighborhood polarization on birth outcomes. METHODS: We used 2016-2019 data from Michigan's statewide database that links birth records, Medicaid claims, and program participation (N = 211,412). We evaluated whether 1) home visiting programs achieved high rates of service coverage in highly deprived neighborhoods, 2) participation in home visiting may help to mitigate the negative relationship between neighborhood polarization and birth outcomes, and 3) the reductions in preterm birth and low birthweight were larger among Black birthing individuals. Data were examined using multilevel generalized linear models and mediation analysis. RESULTS: The statewide home visiting program achieved higher rates of coverage in the most deprived neighborhoods (21.0% statewide, 28.3% in the most deprived vs. 10.4% in the most privileged neighborhoods). For all, home visiting participation was associated with a decrease in the relationship between neighborhood polarization and preterm birth by 6.8% (mean indirect effect, -0.008; 95% confidence interval, -0.011 to -0.005), and by 5.2% (mean indirect effect, -0.013; 95% confidence interval, -0.017 to -0.009) for low birthweight, adjusting for individual-level risk factors. The decrease was larger among Black individuals. CONCLUSIONS: A statewide Medicaid-sponsored home visiting program achieved high rates of service coverage in highly deprived neighborhoods. Program participation may help to mitigate the negative relationship between neighborhood polarization and birth outcomes, and more so among Black individuals. Continued support for home visiting services is required to better engage birthing individuals in neighborhoods with concentrated deprivation and to decrease disparities.
Asunto(s)
Visita Domiciliaria , Medicaid , Resultado del Embarazo , Nacimiento Prematuro , Características de la Residencia , Humanos , Femenino , Estados Unidos , Visita Domiciliaria/estadística & datos numéricos , Embarazo , Adulto , Michigan , Resultado del Embarazo/etnología , Nacimiento Prematuro/etnología , Características del Vecindario , Recién Nacido de Bajo Peso , Recién Nacido , Negro o Afroamericano/estadística & datos numéricos , Factores SocioeconómicosRESUMEN
OBJECTIVE: To establish prevalence and associations of provision of nursing home visits (NHV) and home visits (HV) by early-career specialist GPs. Of particular interest were associations of rurality with performing NHVs and HVs. METHODS: A cross-sectional study. DESIGN: A questionnaire-based study. SETTING: Australian general practice. PARTICIPANTS: Early-career specialist GPs, practising in Australia, who attained Fellowship between January 2016 and July 2018, inclusive, having completed GP training in NSW, the ACT, Eastern Victoria or Tasmania. MAIN OUTCOME MEASURES: Current provision of NHV and HV. RESULTS: NHV were provided by 34% of participants (59% in rural areas) and HV by 41% of participants (60% in rural areas). Remote, rural or regional practice location, as compared to major-city practice, was strongly associated with performing NHV as an early-career specialist GP; multivariable OR 5.87 (95% CI: 2.73, 12.6), p < 0.001, and with the provision of HV; multivariable OR 3.64 (95% CI: 1.63, 8.11), p = 0.002. Rurality of GP training (prior to attaining Fellowship) was significantly univariably associated with providing NHV and with providing HV as an early-career specialist GP. On multivariable analyses, these were no longer statistically significant. CONCLUSION: Early-career specialist GPs located in regional/remote areas are more likely than their urban colleagues to provide NHV and HV.
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Médicos Generales , Visita Domiciliaria , Casas de Salud , Humanos , Estudios Transversales , Femenino , Masculino , Casas de Salud/estadística & datos numéricos , Médicos Generales/estadística & datos numéricos , Visita Domiciliaria/estadística & datos numéricos , Encuestas y Cuestionarios , Prevalencia , Servicios de Salud Rural/estadística & datos numéricos , Adulto , Persona de Mediana Edad , Australia , TasmaniaRESUMEN
OBJECTIVE: This hypothesis-generating study sought to assess the impact of home-based hospice and palliative care (HBHPC) provider home visits (HV) on healthcare use. STUDY DESIGN: Retrospective review of individuals ages 1 month to 21 years receiving an in-person HBHPC provider (MD/DO or APN) HV through 2 HBHPC programs in the Midwest from January 1, 2013, through December 31, 2018. Descriptive statistics were calculated for healthcare use variables. Paired t test or Wilcoxon signed-rank test compared the changes in healthcare use the year before and year after initial provider HVs. RESULTS: The cohort included 195 individuals (49% female), with diagnoses composed of 49% neurologic, 30% congenital chromosomal, 11% oncologic, 7% cardiac, and 3% other. After implementation of HBHPC services, these patients showed decreases in the median (IQR) number of intensive care unit days (before HV, 12 [IQR, 4-37]; after HV, 0 [IQR, 0-8]; P < .001); inpatient admissions (before HV, 1 [IQR, 1-3]; after HV, 1 [IQR, 0-2]; P = .005); and number of inpatient days (before HV, 5 [IQR, 1-19]; after HV, 2 [IQR, 0-8]; P = .009). There was an increase in clinically relevant phone calls to the HBHPC team (before HV, 1 [IQR, 0-4] vs after HV, 4 [IQR, 1-7]; P < .001) and calls to the HBHPC team before emergency department visits (before HV, 0 [IQR, 0-0] vs after HV, 1 [IQR, 1-2]; P < .001). CONCLUSION: HBHPC provider HVs were associated with fewer inpatient admissions, hospital days, and intensive care unit days, and increased clinically relevant phone calls and phone calls before emergency department visit. These findings indicate that HBHPC HV may contribute to decreased inpatient use and increased use of the HBHPC team.
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Servicios de Atención de Salud a Domicilio , Cuidados Paliativos al Final de la Vida , Cuidados Paliativos , Aceptación de la Atención de Salud , Humanos , Femenino , Cuidados Paliativos/estadística & datos numéricos , Masculino , Estudios Retrospectivos , Preescolar , Lactante , Niño , Adolescente , Cuidados Paliativos al Final de la Vida/estadística & datos numéricos , Servicios de Atención de Salud a Domicilio/estadística & datos numéricos , Adulto Joven , Aceptación de la Atención de Salud/estadística & datos numéricos , Visita Domiciliaria/estadística & datos numéricosRESUMEN
BACKGROUND: Socio-economic situation is associated with inequalities in access to health care and health-related resources. This also applies to pregnancy, birth and the postpartum period. Compared to other European countries, Germany has very good care options for the postpartum period. It has an unique system of postpartum care, which comprises home visits by midwives for 12 weeks after birth and beyond in problem cases and thus has structurally good care options. So far, however, there are hardly any studies based on routine data that show which mothers receive homevisits in postpartum care and to what extent. METHOD: The study population comprised 199,978 women insured with BARMER who gave birth to at least one child in the years 2017-2020. Some women were pregnant several times in this period of time. The services billed by freelance midwives for outreach midwifery care in the puerperium were considered for 227,088 births, taking into account the socioeconomic situation of the mothers. RESULTS: According to the definition of the German Institute for Economic Research, 26% of the mothers belonged to a low income group, 46% to a medium income group and 29% to a high income group. Similar to what was shown for midwifery care during pregnancy, large differences were also found with regard to postpartum care: While 90.5% of the women with a high income received home visits, only 83.5% of women with a medium income did so, and only 67.9% of women with a low income. The groups did not differ with regard to other characteristics such as rate of caesarean section, preterm births, twins, age or concomitant diseases to an extent that could explain the differences in care. Women who had received midwifery services in pregnancy were much more likely to receive home visits by a midwife in the postpartum period. Furthermore, there was a correlation with the density of midwives in the respective region. CONCLUSIONS: The results suggest that access to home-based postpartum care by freelance midwives is significantly limited for low-income women. In contrast to antenatal care, women in the postpartum period cannot switch to other service providers, as outreach postpartum care is a reserved activity of midwives. Women with low incomes thus receive less midwifery care, although they have a higher need for support (Eickhorst et al. 2016).
Asunto(s)
Partería , Atención Posnatal , Clase Social , Humanos , Femenino , Alemania , Partería/estadística & datos numéricos , Adulto , Atención Posnatal/estadística & datos numéricos , Embarazo , Adulto Joven , Programas Nacionales de Salud/estadística & datos numéricos , Accesibilidad a los Servicios de Salud/estadística & datos numéricos , Persona de Mediana Edad , Disparidades en Atención de Salud/estadística & datos numéricos , Visita Domiciliaria/estadística & datos numéricosRESUMEN
Importance: Improving birth outcomes for low-income mothers is a public health priority. Intensive nurse home visiting has been proposed as an intervention to improve these outcomes. Objective: To determine the effect of an intensive nurse home visiting program on a composite outcome of preterm birth, low birth weight, small for gestational age, or perinatal mortality. Design, Setting, and Participants: This was a randomized clinical trial that included 5670 Medicaid-eligible, nulliparous pregnant individuals at less than 28 weeks' gestation, enrolled between April 1, 2016, and March 17, 2020, with follow-up through February 2021. Interventions: Participants were randomized 2:1 to Nurse Family Partnership program (n = 3806) or control (n = 1864). The program is an established model of nurse home visiting; regular visits begin prenatally and continue through 2 postnatal years. Nurses provide education, assessments, and goal-setting related to prenatal health, child health and development, and maternal life course. The control group received usual care services and a list of community resources. Neither staff nor participants were blinded to intervention group. Main Outcomes and Measures: There were 3 primary outcomes. This article reports on a composite of adverse birth outcomes: preterm birth, low birth weight, small for gestational age, or perinatal mortality based on vital records, Medicaid claims, and hospital discharge records through February 2021. The other primary outcomes of interbirth intervals of less than 21 months and major injury or concern for abuse or neglect in the child's first 24 months have not yet completed measurement. There were 54 secondary outcomes; those related to maternal and newborn health that have completed measurement included all elements of the composite plus birth weight, gestational length, large for gestational age, extremely preterm, very low birth weight, overnight neonatal intensive care unit admission, severe maternal morbidity, and cesarean delivery. Results: Among 5670 participants enrolled, 4966 (3319 intervention; 1647 control) were analyzed for the primary maternal and neonatal health outcome (median age, 21 years [1.2% non-Hispanic Asian, Indigenous, or Native Hawaiian and Pacific Islander; 5.7% Hispanic; 55.2% non-Hispanic Black; 34.8% non-Hispanic White; and 3.0% more than 1 race reported [non-Hispanic]). The incidence of the composite adverse birth outcome was 26.9% in the intervention group and 26.1% in the control group (adjusted between-group difference, 0.5% [95% CI, -2.1% to 3.1%]). Outcomes for the intervention group were not significantly better for any of the maternal and newborn health primary or secondary outcomes in the overall sample or in either of the prespecified subgroups. Conclusions and Relevance: In this South Carolina-based trial of Medicaid-eligible pregnant individuals, assignment to participate in an intensive nurse home visiting program did not significantly reduce the incidence of a composite of adverse birth outcomes. Evaluation of the overall effectiveness of this program is incomplete, pending assessment of early childhood and birth spacing outcomes. Trial Registration: ClinicalTrials.gov Identifier: NCT03360539.
Asunto(s)
Cuidados de Enfermería en el Hogar , Visita Domiciliaria , Complicaciones del Embarazo , Niño , Preescolar , Femenino , Cuidados de Enfermería en el Hogar/economía , Cuidados de Enfermería en el Hogar/estadística & datos numéricos , Visita Domiciliaria/economía , Visita Domiciliaria/estadística & datos numéricos , Humanos , Recién Nacido de Bajo Peso , Recién Nacido , Medicaid/economía , Medicaid/estadística & datos numéricos , Mortalidad Perinatal , Pobreza/economía , Pobreza/estadística & datos numéricos , Embarazo , Complicaciones del Embarazo/economía , Complicaciones del Embarazo/epidemiología , Complicaciones del Embarazo/enfermería , Complicaciones del Embarazo/prevención & control , Resultado del Embarazo/epidemiología , Nacimiento Prematuro/epidemiología , Nacimiento Prematuro/prevención & control , South Carolina/epidemiología , Estados Unidos/epidemiología , Adulto JovenRESUMEN
BACKGROUND: Maternal complications, including psychological/mental health problems and neonatal morbidity, have commonly been observed in the postpartum period. Home visits by health professionals or lay supporters in the weeks following birth may prevent health problems from becoming chronic, with long-term effects. This is an update of a review last published in 2017. OBJECTIVES: The primary objective of this review is to assess the effects of different home-visiting schedules on maternal and newborn mortality during the early postpartum period. The review focuses on the frequency of home visits (how many home visits in total), the timing (when visits started, e.g. within 48 hours of the birth), duration (when visits ended), intensity (how many visits per week), and different types of home-visiting interventions. SEARCH METHODS: For this update, we searched the Cochrane Pregnancy and Childbirth Group's Trials Register, ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (ICTRP) (19 May 2021), and checked reference lists of retrieved studies. SELECTION CRITERIA: Randomised controlled trials (RCTs) (including cluster-, quasi-RCTs and studies available only as abstracts) comparing different home-visiting interventions that enrolled participants in the early postpartum period (up to 42 days after birth) were eligible for inclusion. We excluded studies in which women were enrolled and received an intervention during the antenatal period (even if the intervention continued into the postnatal period), and studies recruiting only women from specific high-risk groups (e.g. women with alcohol or drug problems). DATA COLLECTION AND ANALYSIS: Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy. We used the GRADE approach to assess the certainty of the evidence. MAIN RESULTS: We included 16 randomised trials with data for 12,080 women. The trials were carried out in countries across the world, in both high- and low-resource settings. In low-resource settings, women receiving usual care may have received no additional postnatal care after early hospital discharge. The interventions and controls varied considerably across studies. Trials focused on three broad types of comparisons, as detailed below. In all but four of the included studies, postnatal care at home was delivered by healthcare professionals. The aim of all interventions was broadly to assess the well-being of mothers and babies, and to provide education and support. However, some interventions had more specific aims, such as to encourage breastfeeding, or to provide practical support. For most of our outcomes, only one or two studies provided data, and results were inconsistent overall. All studies had several domains with high or unclear risk of bias. More versus fewer home visits (five studies, 2102 women) The evidence is very uncertain about whether home visits have any effect on maternal and neonatal mortality (very low-certainty evidence). Mean postnatal depression scores as measured with the Edinburgh Postnatal Depression Scale (EPDS) may be slightly higher (worse) with more home visits, though the difference in scores was not clinically meaningful (mean difference (MD) 1.02, 95% confidence interval (CI) 0.25 to 1.79; two studies, 767 women; low-certainty evidence). Two separate analyses indicated conflicting results for maternal satisfaction (both low-certainty evidence); one indicated that there may be benefit with fewer visits, though the 95% CI just crossed the line of no effect (risk ratio (RR) 0.96, 95% CI 0.90 to 1.02; two studies, 862 women). However, in another study, the additional support provided by health visitors was associated with increased mean satisfaction scores (MD 14.70, 95% CI 8.43 to 20.97; one study, 280 women; low-certainty evidence). Infant healthcare utilisation may be decreased with more home visits (RR 0.48, 95% CI 0.36 to 0.64; four studies, 1365 infants) and exclusive breastfeeding at six weeks may be increased (RR 1.17, 95% CI 1.01 to 1.36; three studies, 960 women; low-certainty evidence). Serious neonatal morbidity up to six months was not reported in any trial. Different models of postnatal care (three studies, 4394 women) In a cluster-RCT comparing usual care with individualised care by midwives, extended up to three months after the birth, there may be little or no difference in neonatal mortality (RR 0.97, 95% CI 0.85 to 1.12; one study, 696 infants). The proportion of women with EPDS scores ≥ 13 at four months is probably reduced with individualised care (RR 0.68, 95% CI 0.53 to 0.86; one study, 1295 women). One study suggests there may be little to no difference between home visits and telephone screening in neonatal morbidity up to 28 days (RR 0.97, 95% CI 0.85 to 1.12; one study, 696 women). In a different study, there was no difference between breastfeeding promotion and routine visits in exclusive breastfeeding rates at six months (RR 1.47, 95% CI 0.81 to 2.69; one study, 656 women). Home versus facility-based postnatal care (eight studies, 5179 women) The evidence suggests there may be little to no difference in postnatal depression rates at 42 days postpartum and also as measured on an EPDS scale at 60 days. Maternal satisfaction with postnatal care may be better with home visits (RR 1.36, 95% CI 1.14 to 1.62; three studies, 2368 women). There may be little to no difference in infant emergency health care visits or infant hospital readmissions (RR 1.15, 95% CI 0.95 to 1.38; three studies, 3257 women) or in exclusive breastfeeding at two weeks (RR 1.05, 95% CI 0.93 to 1.18; 1 study, 513 women). AUTHORS' CONCLUSIONS: The evidence is very uncertain about the effect of home visits on maternal and neonatal mortality. Individualised care as part of a package of home visits probably improves depression scores at four months and increasing the frequency of home visits may improve exclusive breastfeeding rates and infant healthcare utilisation. Maternal satisfaction may also be better with home visits compared to hospital check-ups. Overall, the certainty of evidence was found to be low and findings were not consistent among studies and comparisons. Further well designed RCTs evaluating this complex intervention will be required to formulate the optimal package.
Asunto(s)
Visita Domiciliaria , Atención Posnatal/organización & administración , Sesgo , Lactancia Materna/estadística & datos numéricos , Depresión Posparto/epidemiología , Femenino , Necesidades y Demandas de Servicios de Salud/estadística & datos numéricos , Visita Domiciliaria/estadística & datos numéricos , Humanos , Lactante , Mortalidad Infantil , Recién Nacido , Mortalidad Materna , Satisfacción del Paciente , Mortalidad Perinatal , Atención Posnatal/estadística & datos numéricos , Periodo Posparto , Ensayos Clínicos Controlados Aleatorios como Asunto , Factores de TiempoRESUMEN
BACKGROUND: Our grant from the Patient-Centered Outcomes Research Institute (PCORI) focused on the use of nurse home visits postdischarge for primarily pediatric hospital medicine patients. While our team recognized the importance of engaging parents and other stakeholders in our study, our project was one of the first funded to address transitions of care issues in patients without chronic illness; little evidence existed about how to engage acute stakeholders longitudinally. OBJECTIVE: This manuscript describes how we used both a short-term focused feedback model and longitudinal engagement methods to solicit input from parents, home care nurses, and other stakeholders throughout our 3-year study. RESULTS: Short-term focused feedback allowed the study team to collect feedback from hundreds of stakeholders. Initially, we conducted focus groups with parents with children recently discharged from the hospital. We used this feedback to modify our nurse home visit intervention, then used quality improvement methods with continued short-term focus feedback from families and nurses delivering the visits to adjust the visit processes and content. We also used their feedback to modify the outcome collection. Finally, during the randomized controlled trial, we added a parent to the study team to provide longitudinal input, as well as continued to solicit short-term focused feedback to increase recruitment and retention rates. CONCLUSION: Research studies can benefit from soliciting short-term focused feedback from many stakeholders; having this variety of perspectives allows for many voices to be heard, without placing an undue burden on a few stakeholders.
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Cuidados Posteriores/estadística & datos numéricos , Visita Domiciliaria/estadística & datos numéricos , Evaluación del Resultado de la Atención al Paciente , Participación de los Interesados/psicología , Cuidado de Transición/estadística & datos numéricos , Academias e Institutos , Cuidados Posteriores/psicología , Niño , Grupos Focales , Hospitales Pediátricos , Humanos , Padres/psicología , Alta del Paciente , Participación del Paciente , Factores de TiempoRESUMEN
BACKGROUND: Racism is a significant source of toxic stress and a root cause of health inequities. Emerging evidence suggests that exposure to vicarious racism (i.e., racism experienced by a caregiver) is associated with poor child health and development, but associations with biological indicators of toxic stress have not been well studied. It is also unknown whether two-generation interventions, such as early home visiting programs, may help to mitigate the harmful effects of vicarious racism. OBJECTIVE: The purpose of this study was to examine associations between maternal experiences of racial discrimination and child indicators of toxic stress and to test whether relationships are moderated by prior participation in Minding the Baby (MTB), an attachment-based early home visiting intervention. METHODS: Ninety-seven maternal-child dyads (n = 43 intervention dyads, n = 54 control dyads) enrolled in the MTB Early School Age follow-up study. Mothers reported on racial discrimination using the Experiences of Discrimination Scale. Child indicators of toxic stress included salivary biomarkers of inflammation (e.g., C-reactive protein, panel of pro-inflammatory cytokines), body mass index, and maternally reported child behavioral problems. We used linear regression to examine associations between maternal experiences of racial discrimination and child indicators of toxic stress and included an interaction term between experiences of discrimination and MTB group assignment (intervention vs. control) to test moderating effects of the MTB intervention. RESULTS: Mothers identified as Black/African American (33%) and Hispanic/Latina (64%). In adjusted models, maternal experiences of racial discrimination were associated with elevated salivary interleukin-6 and tumor necrosis factor-α levels in children, but not child body mass index or behavior. Prior participation in the MTB intervention moderated the relationship between maternal experiences of discrimination and child interleukin-6 levels. DISCUSSION: Results of this study suggest that racism may contribute to the biological embedding of early adversity through influences on inflammation, but additional research with serum markers is needed to better understand this relationship. Improved understanding of the relationships among vicarious racism, protective factors, and childhood toxic stress is necessary to inform family and systemic-level intervention.
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Relaciones Madre-Hijo , Madres/psicología , Racismo/psicología , Estrés Psicológico/complicaciones , Biomarcadores/análisis , Índice de Masa Corporal , Niño , Preescolar , Femenino , Visita Domiciliaria/estadística & datos numéricos , Humanos , Madres/estadística & datos numéricos , Psicometría/instrumentación , Psicometría/métodos , Racismo/etnología , Racismo/estadística & datos numéricos , Saliva , Estrés Psicológico/psicologíaRESUMEN
BACKGROUND: Trends in the characteristics and disease severity of patients using an after-hours house call (AHHC) medical service changed during the coronavirus disease (COVID-19) pandemic. However, there have been no reports on this issue since the start of the COVID-19 pandemic. This study aimed to investigate patients' tendencies to utilize an AHHC medical service for fever or common cold symptoms during the COVID-19 pandemic. METHODS: This retrospective cohort study compared the characteristics and disease severity of patients with fever or common cold symptoms utilizing an AHHC medical service offered by a single large company between the control period (December 1, 2018 to April 30, 2019) and the COVID-19 pandemic exposure period (December 1, 2019 to April 30, 2020). We also assessed the proportion of these patients in relation to all patients calling the service for any reason. RESULTS: During the control and COVID-19 pandemic exposure periods, a total of 6462 and 10,003 patients consulted the AHHC medical service, respectively. Of these, 5335 (82.6%) and 7423 (74.2%) patients had fever and common cold symptoms, respectively, during the control and COVID-19 pandemic exposure periods (P < 0.001). The corresponding median (interquartile range) ages were 8 (3-11) and 10 (4-33) years, respectively. The distribution of disease severity differed between the groups. The proportions of patients with mild, moderate, and severe illness were 71.1, 28.7, and 0.2% in the control period and 42.3, 56.7, and 0.9% in the COVID-19 pandemic exposure period, respectively (P < 0.001). CONCLUSIONS: During the COVID-19 pandemic, the proportion of patients with fever or common cold symptoms was lower than that in the control period, but disease severity was significantly higher.
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Atención Posterior/estadística & datos numéricos , COVID-19/epidemiología , Resfriado Común/epidemiología , Fiebre/epidemiología , Visita Domiciliaria/estadística & datos numéricos , Índice de Severidad de la Enfermedad , Adulto , COVID-19/terapia , Continuidad de la Atención al Paciente/estadística & datos numéricos , Humanos , Japón , Masculino , Persona de Mediana Edad , Estudios RetrospectivosRESUMEN
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.
Asunto(s)
Enfermería en Salud Comunitaria , Visita Domiciliaria , Enfermeros de Salud Comunitaria , Atención Primaria de Salud/organización & administración , Enfermería Rural , Adolescente , Adulto , Anciano , Áreas de Influencia de Salud , Enfermería en Salud Comunitaria/organización & administración , Enfermería en Salud Comunitaria/estadística & datos numéricos , Estudios Transversales , Recolección de Datos , Presentación de Datos , Atención a la Salud/organización & administración , Atención a la Salud/estadística & datos numéricos , Demografía , Femenino , Ghana , Educación en Salud , Visita Domiciliaria/estadística & datos numéricos , Humanos , Renta , Entrevistas como Asunto , Masculino , Persona de Mediana Edad , Enfermeros de Salud Comunitaria/estadística & datos numéricos , Proyectos Piloto , Investigación Cualitativa , Enfermería Rural/organización & administración , Enfermería Rural/estadística & datos numéricos , Muestreo , Factores Socioeconómicos , Encuestas y Cuestionarios , Adulto JovenRESUMEN
El avance de las tecnologías de soporte vital ha aumentado la sobrevida de niños con patologías y secuelas graves, categorizados como NANEAS (Niños y Adolescentes con Necesidades Especiales de Atención en Salud) de mediana y alta complejidad. En el Hospital de Niños Dr. Roberto del Río se organizó un equipo de atención para NANEAS en 2014, que realiza visitas domiciliarias desde 2015 a pacientes médicamente complejos. OBJETIVO: Caracterizar la población atendida en domicilio y la modalidad de atención. PACIENTES Y MÉTODO: Estudio retrospectivo descriptivo mediante revisión de registro clínico electrónico y ficha clínica de NANEAS atendidos en domicilio del 2015 al 2018. RESULTADOS: Se analizaron 581 visitas a 81 pacientes, mediana 8 años, 78% hombres, 64% institucionalizados, 78% con patología neurológica de base, 75% de alta y mediana complejidad según clasificación SOCHIPE. De las visitas, 71% fue en comunas rurales, la mediana de tiempo de viaje 60 minutos y de atención 26 minutos. Un 60% de las visitas se realizó a pacientes con dispositivos médicos. En un 99% asistió pediatra, 33% enfermera y 68% otro profesional, que en 61% correspondió al neuropediatra. CONCLUSIONES: La mayor proporción de pacientes atendidos son de alta y mediana complejidad, usuarios de dispositivos médicos y la mayoría con patología neurológica de base, por lo que resulta fundamental contar con un neurólogo en el equipo interdisciplinario. Las visitas se realizan principalmente a comunas distantes por la dificultad de traslado de estos pacientes. Esta modalidad de atención promueve una mejor calidad de vida para niños y niñas médicamente complejos y para sus familias.
The advancement of life support technologies has increased the survival of children with serious pathologies and sequelae, categorized as NANEAS (Children and Adolescents with Special Health Care Needs) of medium and high complexity. At the Hospital de Niños Dr. Roberto del Río, a care team for NANEAS was organized in 2014, which has made home visits to medically complex patients since 2015. OBJECTIVE: To characterize the population attended at home and the care modality. PATIENTS AND METHOD: Retrospective descriptive study by reviewing the clinical file of NANEAS patients seen at home in this period. RESULTS: 581 visits were analyzed in 81 patients, median 8 years, 78% men, 63% institutionalized, 78% with neurological diseases. 75% were of high and medium complexity according to the SOCHIPE classification. Of the visits, 71% were in rural places, median travel time 60 minutes and direct attention 26 minutes. 60% of the visits were made to patients with medical devices, 99% attended by a pediatrician, 33% a nurse and 68% another professional, who in 61% corresponded to the child neurologist. CONCLUSIONS: The highest proportion of patients seen are of high and medium complexity with medical devices and with underlying neurological pathology, so it is important to have a neurologist in the interdisciplinary team. Many of the visits are made in places distant from the hospital center due to the difficulty of transferring these patients. This modality of care promotes a better quality of life for medically complex children and their families.
Asunto(s)
Humanos , Masculino , Femenino , Lactante , Preescolar , Niño , Adolescente , Niños con Discapacidad , Atención Domiciliaria de Salud/estadística & datos numéricos , Visita Domiciliaria/estadística & datos numéricos , Cuidados Paliativos , Estudios Retrospectivos , Necesidades y Demandas de Servicios de Salud , Hospitales PediátricosRESUMEN
The COVID-19 pandemic created an opportunity to incorporate nurse-led virtual home care visits into heart failure patients' plan of care. As a supplemental nurse visit to traditional in-person home visits, the Virtual Nurse Visit (VNV) service was deployed using Zoom teleconferencing technology enabling telehealth nurses to remotely communicate, assess, and educate their patients. This mixed methods study explored heart failure patients' abilities, experience, and satisfaction to use and adopt a virtual nurse visit. Sociodemographic, semi-structured interview questions, and the System Usability Scale data were collected. Thirty-four participants completed the study. Over half of participants perceived the VNV usable and four qualitative themes emerged: perceived safety during COVID-19, preferences for care delivery, user experiences and challenges, and satisfaction with the VNV service. Findings from this study builds the science around telehealth that will inform future studies examining this type of nurse-led virtual visit and subsequent patient outcomes.
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COVID-19/epidemiología , Insuficiencia Cardíaca/terapia , Servicios de Atención de Salud a Domicilio/estadística & datos numéricos , Visita Domiciliaria/estadística & datos numéricos , Telemedicina/métodos , COVID-19/rehabilitación , Manejo de la Enfermedad , Humanos , Tecnología de Sensores Remotos/instrumentaciónAsunto(s)
COVID-19/prevención & control , Accesibilidad a los Servicios de Salud/organización & administración , Disparidades en Atención de Salud/estadística & datos numéricos , Servicios de Atención de Salud a Domicilio/organización & administración , Servicios de Atención de Salud a Domicilio/estadística & datos numéricos , Visita Domiciliaria/estadística & datos numéricos , Pandemias/prevención & control , Humanos , SARS-CoV-2 , Estados UnidosRESUMEN
BACKGROUND: Community health worker (CHW) programs have been positioned as a way to meet the needs of those who experience marginalization and inequitable access to health care, and current global health narratives also emphasize their adaptable nature to meet growing health burdens in low-income settings. However, as CHW programs adopt more technical roles, the value of CHWs in building relationships with clients tends to be overlooked. More importantly, these programs are often reframed and redeployed without attending to the interests and needs of program clients themselves. We set out to gather perspectives of program and CHW engagement from clients of a maternal and child health program in rural South Africa. METHODS: We conducted 26 interviews with pregnant or recently-delivered clients of the Enable Mentor Mother program between February-March 2018. After obtaining informed consent, a trained research assistant conducted all interviews in the clients' home language, isiXhosa. Interviews, translated and transcribed into English, were organized and coded using ATLAS.ti software and thematically analyzed. RESULTS: We found that clients' home-based interactions with Mentor Mothers were generally positive, and that these engagements were characterized by two core themes, instructive roles and supportive relationships.. Instructive roles facilitated the transfer of knowledge and uptake of new information for behavior change. Relationships were developed within the home visit setting, but also extended beyond routine visits, especially when clients required further instrumental support. Clients further discussed a sense of agency gained through these interactions, even in cases where they chose not to, or were unable to, heed their Mentor Mother's advice. CONCLUSIONS: These findings highlight the important roles that CHWs can assume in providing both instructive and supportive care to clients; as deepening relationships may be key for encouraging behavior change, these findings pinpoint the need to bolster training and support for CHWs in similar programs. They also emphasize the importance of integrating more channels for client feedback into existing programs, to ensure that clients' voices are heard and accounted for in shaping ongoing engagement within the communities in which these programs operate.
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Agentes Comunitarios de Salud/normas , Visita Domiciliaria/estadística & datos numéricos , Atención Posnatal/estadística & datos numéricos , Población Rural/estadística & datos numéricos , Confianza , Agentes Comunitarios de Salud/psicología , Femenino , Humanos , Mentores , Madres/educación , Embarazo , Investigación Cualitativa , Sudáfrica , Adulto JovenRESUMEN
In an era of increasing technology and interaction with the patient bedside, we explore the role of relocating the bedside from the hospital to the home using telemedicine. The COVID-19 pandemic pushed telemedicine from small and pilot programs to widespread practice at an unprecedented rate. With the rapid implementation of telemedicine, it is important to consider how to create a telehealth system that provides both good care for patients and families while maintaining an excellent education environment for trainees of all levels. To this end, we developed telemedicine educational milestones to describe novel skills required to provide high quality telemedicine care, and allow trainees and clinical educators a metric by which to assess trainee progress. We also created methods and tools to help trainees learn and families feel comfortable in their new role as virtual collaborators. We envision a time when safety does not set the venue; instead the needs of the patient will dictate whether a virtual or in-person visit is the right choice for a family. We expect that pediatric medical genetics and metabolism groups across the country will continue to set a standard of a hybrid care system to meet the unique needs of each individual patient, using telemedicine technology.
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Genética Médica , Visita Domiciliaria/estadística & datos numéricos , Pandemias/estadística & datos numéricos , COVID-19/epidemiología , COVID-19/virología , Niño , Educación Médica , Genética Médica/métodos , Personal de Salud , Hospitales Pediátricos , Humanos , Atención al Paciente , Mejoramiento de la Calidad , Calidad de la Atención de Salud , SARS-CoV-2 , Telemedicina/métodos , Telemedicina/estadística & datos numéricosRESUMEN
OBJECTIVES: To evaluate the effects of a home-based disability prevention program on life-space and falls efficacy among low-income older adults. DESIGN: Single-blind two-arm randomized controlled trial. SETTING: Participants' homes. PARTICIPANTS: Participants were low-income cognitively intact older adults (≥65 years old) with restricted daily activities. Our analytic sample for life-space (n = 194) and falls efficacy (n = 233) varied as the life-space measure was introduced 4 months after the trial began. INTERVENTION: Up to six 1-hour home visits with an occupational therapist; up to four 1-hour home visits with a registered nurse; and up to $1,300 worth of home repairs, modifications, and assistive devices with a handyman, during a course of 4 months. MEASUREMENTS: Life-space was measured by the Homebound Mobility Assessment; falls efficacy was measured using the 10-item Tinetti Falls Efficacy Scale at baseline and 5 months. RESULTS: Participants were on average 75 years old, predominantly Black (86%) and female (85%-86%). Compared with participants in the control group, participants receiving the intervention were more likely to have improved versus decreased life-space in areas of bathroom (adjusted odds ratio (OR) = 3.95; 95% confidence interval (CI) = 1.20-12.97), front or back porch, patio, or deck (adjusted OR = 2.67; 95% CI = 1.05-6.79), stairs (adjusted OR = 4.09; 95% CI = 1.34-12.48), leaving the house for any reason other than for health care (adjusted OR = 2.40; 95% CI = 1.01-5.73), and overall life-space (adjusted OR = 2.15; 95% CI = 1.10-4.19). Participants who received the intervention also had an 11% improvement in falls efficacy in performing daily activities (exponentiated coefficient = 1.12; 95% CI = 1.04-1.21). CONCLUSION: Life-space and falls efficacy were improved through a multicomponent, person-directed, home-based disability prevention intervention. Findings suggest that this intervention should be translated into different settings to promote independent aging.
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Accidentes por Caídas/prevención & control , Visita Domiciliaria/estadística & datos numéricos , Vida Independiente , Enfermeros de Salud Comunitaria , Terapia Ocupacional/enfermería , Dispositivos de Autoayuda , Actividades Cotidianas , Anciano , Femenino , Humanos , Masculino , Pobreza , Método Simple CiegoRESUMEN
OBJECTIVE: Priorities of the Centers for Disease Control and Prevention's 6|18 Initiative include outpatient asthma self-management education (ASME) and home-based asthma visits (home visit) as interventions for children with poorly-controlled asthma. ASME and home visit intervention programs are currently not widely available. This project was to assess the economic sustainability of these programs for state asthma control programs reimbursed by Medicaid. METHODS: We used a simulation model based on parameters from the literature and Medicaid claims, controlling for regression to the mean. We modeled scenarios under various selection criteria based on healthcare utilization and age to forecast the return on investment (ROI) using data from New York. The resulting tool is available in Excel or Python. RESULTS: Our model projected health improvement and cost savings for all simulated interventions. Compared against home visits alone, the simulated ASME alone intervention had a higher ROI for all healthcare utilization and age scenarios. Savings were primarily highest in simulated program participants who had two or more asthma-related emergency department visits or one inpatient visit compared to those participants who had one or more asthma-related emergency department visits. Segmenting the selection criteria by age did not significantly change the results. CONCLUSIONS: This model forecasts reduced healthcare costs and improved health outcomes as a result of ASME and home visits for children with high urgent healthcare utilization (more than two emergency department visits or one inpatient hospitalization) for asthma. Utilizing specific selection criteria, state based asthma control programs can improve health and reduce healthcare costs.
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Asma/terapia , Visita Domiciliaria/estadística & datos numéricos , Educación del Paciente como Asunto/organización & administración , Automanejo/educación , Adolescente , Niño , Preescolar , Análisis Costo-Beneficio , Servicio de Urgencia en Hospital/economía , Servicio de Urgencia en Hospital/estadística & datos numéricos , Femenino , Gastos en Salud/estadística & datos numéricos , Servicios de Salud/economía , Servicios de Salud/estadística & datos numéricos , Estado de Salud , Humanos , Masculino , Cadenas de Markov , Medicaid/economía , Medicaid/estadística & datos numéricos , Modelos Estadísticos , Aceptación de la Atención de Salud/estadística & datos numéricos , Educación del Paciente como Asunto/economía , Automanejo/economía , Índice de Severidad de la Enfermedad , Estados UnidosRESUMEN
INTRODUCTION: Many factors influence women's use of alcohol and other drugs while pregnant and postpartum. Substance use impacts the maternal-child relationship during the critical neonatal period. The first days and months of human development lay the foundation for health and well-being across the lifespan, making this period an important window of opportunity to interrupt the transmission of trauma and stress to the next generation. Pregnant and postpartum women with a history of substance use require specialized support services. METHODS: The Team for Infants Exposed to Substance abuse (TIES) Program provides a holistic, multi-disciplinary, community-based model to address the complex needs of families with young children affected by maternal substance use. RESULTS: A multi-year implementation study of the model yielded results that indicate the effectiveness of this home-based family support intervention. The model focuses on reducing maternal alcohol and other drug use, increasing positive parenting, promoting child and maternal health, and improving family income and family housing. A key component of the model is establishing a mutual, trusting relationship between the home visiting specialists and the family. Foundational to the TIES model is a family-centered, culturally competent, trauma-informed approach that includes formal interagency community partnerships DISCUSSION: This article describes elements of the model that lead to high retention and completion rates and family goal attainment for this unique population.
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Visita Domiciliaria/estadística & datos numéricos , Relaciones Madre-Hijo , Responsabilidad Parental/psicología , Atención Posnatal/métodos , Trastornos Relacionados con Sustancias/psicología , Adolescente , Adulto , Niño , Consejo , Femenino , Humanos , Lactante , Masculino , Salud Materna , Atención Posnatal/organización & administración , Embarazo , Evaluación de Programas y Proyectos de Salud , Apoyo Social , Adulto JovenRESUMEN
BACKGROUND: Government of India and the World Health Organization have guidelines for outpatient management of young infants 0-59 days with signs of Possible Serious Bacterial Infection (PSBI), when referral is not feasible. Implementation research was conducted to identify facilitators and barriers to operationalizing these guidelines. METHODS: Himachal Pradesh government implemented the guidelines in program settings supported by Centre for Health Research and Development, Society for Applied Studies. The strategy included community sensitization, skill enhancement of Accredited Social Health Activists (ASHA), Auxiliary Nurse Midwives (ANMs) and Medical Officers (MOs) to identify PSBI and treat when referral was not feasible. The research team collected information on facilitators and barriers. A technical support unit provided training and oversight. FINDINGS: Among 1997 live births from June 2017 to January 2019, we identified 160 cases of PSBI in young infants resulting in a coverage of 80%, assuming an incidence of 10%. Of these,29(18.1%) had signs of critical illness (CI), 92 (57.5%) had clinical severe infection (CSI), 5 (3.1%)had severe pneumonia (only fast breathing in young infants 0-6 days), while 34 (21%) had pneumonia (only fast breathing in young infants 7-59 days). Hospital referral was accepted by 48/160 (30%), whereas 112/160 (70%) were treated with the simplified treatment regimens at primary level facilities. Of the 29 infants with CI, 18 (62%) accepted referral; 26 (90%) recovered while 3 (10%) who had accepted referral, died. Of the 92 infants who had CSI, 86 (93%) recovered, 65 (71%) received simplified treatment and one infant who had accepted referral, died. All the five infants who had severe pneumonia, recovered; 3 (60%) had received simplified treatment. Of the 34 pneumonia cases, 33 received simplified treatment of which 5 (15%) failed treatment; two out of these 5 died. Overall, 6/160 infants died (case-fatality-rate 3.4%); 2 in the simplified treatment (case-fatality-rate 1.8%) and 4 in the hospital group (case-fatality-rate 8.3%). Delayed identification and care-seeking by families and health system weaknesses like manpower gaps and interrupted supplies were challenges in implementation. CONCLUSIONS: Implementation of the guidelines in program settings is possible and acceptable. Scaling up would require creating community awareness, early identification and appropriate care-seeking, strengthening ASHA home-visitation program, building skills and confidence of MOs and ANMs, uninterrupted supplies and a dependable referral system.