The Perniciousness and Promise of School-Based Mental Health Service Delivery for Youth.

Rates of child and adolescent mental disorder have risen sharply while access to community-based mental health care options continues to be elusive for many families. Substantial and persistent barriers to community-based mental health care have prompted multiple stakeholders to pursue an approach that emphasizes health promotion and intervention practices within the context of ecologically valid and more accessible environments. The most prominent of these environments has been schools that can serve as local and centralized access points to various services, including mental health care. The rapid expansion of school-based mental health service delivery systems, however, carries both risk of perniciousness as well as significant promise with respect to effective and equitable care. This article summarizes key concerns surrounding school-based mental health service delivery systems, including non-beneficence and harm, support disparities, unsustainable implementation, oppressive school climate, and linkage to punitive and discriminatory practices. Broad-based recommendations to help realize the promise of effective and equitable care for students with mental health and behavioral challenges are also presented vis-à-vis each of these concerns. At the same time, natural tensions between various mandates assigned to schools as well as between schools and their surrounding communities will need to be addressed to reach the full potential of school-based mental health service delivery systems.

Unmet Needs and Factors Impacting Home- and Community-Based Service Use Among Rural Appalachian Caregivers of People With Alzheimer's and Dementia.

Family caregivers of persons with Alzheimer's disease and related dementias (ADRD) living in rural areas face significant health and healthcare challenges. Limited research, however, has explored factors shaping their use of home- and community-based services (HCBS). This study identifies unmet needs among caregivers of people with ADRD in rural Western North Carolina and highlights contextual factors that facilitate HCBS use. Nineteen qualitative interviews were conducted with 21 family caregivers and 1 person with ADRD between 2021 and 2022. Thematic analyses revealed unmet needs among caregivers for information, service navigation, and caregiving support. HCBS use was shaped by multiple factors including illness needs, cultural beliefs, preferences for home-based care, and place-based resources. These findings suggest that culturally tailored HCBS are needed to support people with ADRD and their caregivers in rural Appalachian communities, especially those which facilitate access to paid caregiving, clearly communicate program eligibility requirements, and emphasize service availability.

Can formal home and community-based care substitute informal care? Evidence from Chinese Longitudinal Healthy Longevity Survey.

BACKGROUND: Formal home and community-based care are often considered as the preferable option to institutional care, offering older individuals the convenience of receiving care in their homes. Although research has found that these services may alleviate the burden on informal caregivers, there is a lack of research on which specific types of formal home and community-based care influence informal care provision. METHODS: Employing fixed-effects and quantile regression models, this study seeks to explore the effects that various formal home and community-based care services have on reducing the burden of informal care. This study draws data from the Chinese Longitudinal Healthy Longevity Survey 2005, 2008, 2011, 2014, and 2018. RESULTS: Our findings indicate that two types of formal care substantially influence the provision of informal care. The availability of daily living assistance services correlates with reduced informal caregiving hours, especially for those with extensive care needs. The availability of community-based health care services is linked to a reduction in the direct expenses incurred from informal caregiving, especially for those incurring greater direct caregiving costs. These effects are more prominent among urban residents. Other services, such as mental health support and legal advice services, do not demonstrate significant effects on reducing informal care hours and costs. CONCLUSIONS: Daily living assistance and community-based health care services play a crucial role in benefiting informal caregivers. It is important to prioritize the expansion of these services, especially among those with greater care needs.

Outcomes of Medicaid Rebalancing May Differ Across Enrollee Populations.

Access to home- and community-based services (HCBS) may prevent or delay nursing home transitions among older adults. Medicaid's Balancing Incentive Program (BIP) (2011-2015) provided assistance for U.S. states to increase access to HCBS through infrastructure changes and spending benchmarks. We combined longitudinal data from the 2008-2019 Medicare Current Beneficiary Survey and Minimum Data Set and used survival modeling to examine the association between BIP exposure (living in a BIP-participant state vs. not) and time to long-term institutionalization (LTI, defined as a nursing home episode of 90+ days) among dual enrollees ages 65 and older. In the main effects model, BIP exposure was not associated with hazard of LTI. Interaction models showed that BIP exposure was associated with a lower hazard of LTI among Hispanic/Latinx enrollees, while the opposite was true among non-Hispanic White enrollees. Our findings suggest the outcomes of Medicaid rebalancing efforts may differ across enrollee subgroups.

Integrated service delivery for individuals with fetal alcohol spectrum disorder.

BACKGROUND: Individuals with fetal alcohol spectrum disorder (FASD) experience complex needs that often necessitate support from multiple systems. There is growing evidence that people with FASD may benefit from integrated service delivery (ISD), but little is known about ISD elements and processes for this population. METHOD: Using a multi-method approach involving a literature review, analysis of programme data, and staff interviews, we examined how ISD is enacted at a rural Canadian FASD centre, and identified facilitators, barriers, and potential impacts of ISD at the centre. RESULTS: We describe key elements of integrated FASD programming and identify important contextual factors and themes related to ISD barriers, facilitators, and impacts: (1) connection, (2) freedom and autonomy, (3) client-centred care, (4) learning and growth, (5) and reframing expectations. CONCLUSIONS: This study may help to inform a roadmap for enhancing FASD service delivery and guiding FASD research and policy in Canada and beyond.

Family Management of Hypertension in Brazil: A Cross-Sectional Study.

In Brazil, research indicates that primary family members are the main source of support for individuals with chronic conditions such as hypertension (HTN). The burden of caregiving not only hinders effective HTN management but can also cause stress and anxiety, potentially leading to HTN in caregivers. Despite this, few studies have explored the impact of caregiving on these family members. Aims of the study were to: (1) Describe the prevalence of blood pressure (BP) control in family members of individuals with HTN; (2) identify family member perspectives on facilitators and barriers to HTN management; and (3) identify influences that help or interfere with family member functioning (levels of stress, quality of life [QOL], and caregiver burden). This descriptive, cross-sectional study included 213 family members randomly selected from 3 Family Health Strategy units. Family members were largely female (n = 143; 67.1%); the mean age was 60.1 years (SD ± 17.02) and 42.6% (n = 96) had less than a high school education. The three most important facilitators and barriers were related to medication, medical visits, healthy eating, physical activity, and stress. The mean systolic BP was 132.7 (SD ± 21.9) mmHg and a diastolic BP of 85.9 (SD ± 18.1) mmHg with 120 (56.3%) of family members classified as having normal BP. In regard to family member contributions to the self-care of the individual with HTN, family members displayed low levels of self-care maintenance (n = 148; 69.4%) and management (n = 47; 71.2%) support, while a slight majority (n = 114; 53.5%) had adequate levels of self-care confidence in supporting the individual with HTN. Family members (n = 189; 88.8%) showed moderate-to-high levels of perceived stress, but good physical (n = 189; 88.7%) and mental QOL (n = 196; 92%) and low levels of caregiver burden (n = 113; 53.1%). A variety of contextual sociocultural influences were associated with the outcomes under study. Family-based interventions are urgently needed to address the inadequate management of HTN.

"It Made Me Feel Like a Person Again": Benefits of Meals on Wheels-Based Social Connection Programs.

Social isolation and loneliness are associated with negative health outcomes, and these outcomes are exacerbated among older adults who are homebound. To address this issue, Meals on Wheels programs increasingly provide social connection services to clients in addition to home-delivered meals. This descriptive qualitative study examines the impact of three types of social connection programs on the well-being of homebound older adult clients, as well as on the volunteers and staff members who deliver the programs. Thematic analysis of semi-structured interviews conducted with 117 clients, volunteers, and staff in six Meals on Wheels social connection programs across the United States indicated that program participation was associated with substantial benefits. Benefits included the development of supportive friendships, reduced feelings of loneliness, and an improved overall sense of well-being. Insights from this study may inform the development, expansion, and sustainability of social connection programs provided by community-based organizations.

Early identification of pressure injuries in people with dark skin tones: Qualitative perspectives from community-based patients and their carers.

AIM: To examine the personal experiences and perceptions of people with dark skin tones and their carers, in relation to pressure injury. DESIGN: Qualitative study using semi-structured interviews. METHODS: Twenty-two interviews with people with dark skin tone and/or their family carers, who were known to and visited by community nurses for pressure area management or who had been identified as being at high risk for developing a pressure injury were carried out. RESULTS: Thematic analysis of the interview transcripts revealed that skin discolouration towards a darker hue than usual was the commonest symptom identified by participants as a sign of altered skin integrity and potential pressure damage. Four main overarching themes were revealed through comprehensive analysis of the transcripts: (1) indicators of pressure injury; (2) experienced symptoms of pressure damage; (3) trust in healthcare workers; and (4) improving care for populations with dark skin tones. CONCLUSION: The findings from this study clearly present how early-stage pressure damage is identified among people with dark skin tones. IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE: These findings have the potential to reduce health inequality by influencing and informing clinical policies and strategies in practice. Findings could also lead to the development of patient-informed educational strategies for nurses and health workers which will enable the early identification of pressure ulcers among people with dark skin tones. Further research is needed to better understand health disparities in relation to preventable patient safety harm. IMPACT: The findings demonstrate the importance of engaging with and listening to the stories and experiences of people living with pressure damage to help in the early recognition of pressure injuries. REPORTING METHOD: The Consolidated Criteria for Reporting Qualitative Research (COREQ) guidelines for qualitative research were followed. PATIENT OR PUBLIC CONTRIBUTION: A project steering group reviewed information sheets for participants and checked the interview questions were relevant and suitable.

Empowering a person-centered long-term care workforce.

Currently there is a crisis in the long-term care workforce, as many workers experience poor pay, a lack of training, burnout, low quality working conditions, and physical strain, which is leading to a workforce shortage. To address this, the Alzheimer's Association Dementia Care Provider Roundtable (AADCPR) convened a panel of direct care workers to discuss and provide direction on their view of the current state of the workforce. From this panel, five touchpoints for hiring and retaining direct care workers were highlighted: high quality jobs; recruitment and reputation management; onboarding; retention; and training and career advancement. In addition, the DCPR put together a set of standards to follow to meet these needs, which includes promoting staff dementia education opportunities, creating recommendations around peer mentoring programs specific to dementia care, and increasing inclusion of direct care workers in decision-making and plans of care. HIGHLIGHTS: Presents the current state of workforce in long-term care. Provides five touchpoints that long-term and home and community-based services should implement for hiring and retaining direct care workers. Recommends a set of standards to follow to meet the needs of the workforce within long-term care.

Community-based management of arterial hypertension and cardiovascular risk factors by lay village health workers for people with controlled and uncontrolled blood pressure in rural Lesotho: joint protocol for two cluster-randomized trials within the ComBaCaL cohort study (ComBaCaL aHT Twic 1 and ComBaCaL aHT TwiC 2).

BACKGROUND: Arterial hypertension (aHT) is a major cause for premature morbidity and mortality. Control rates remain poor, especially in low- and middle-income countries. Task-shifting to lay village health workers (VHWs) and the use of digital clinical decision support systems may help to overcome the current aHT care cascade gaps. However, evidence on the effectiveness of comprehensive VHW-led aHT care models, in which VHWs provide antihypertensive drug treatment and manage cardiovascular risk factors is scarce. METHODS: Using the trials within the cohort (TwiCs) design, we are assessing the effectiveness of VHW-led aHT and cardiovascular risk management in two 1:1 cluster-randomized trials nested within the Community-Based chronic disease Care Lesotho (ComBaCaL) cohort study (NCT05596773). The ComBaCaL cohort study is maintained by trained VHWs and includes the consenting inhabitants of 103 randomly selected villages in rural Lesotho. After community-based aHT screening, adult, non-pregnant ComBaCaL cohort participants with uncontrolled aHT (blood pressure (BP) ≥ 140/90 mmHg) are enrolled in the aHT TwiC 1 and those with controlled aHT (BP < 140/90 mmHg) in the aHT TwiC 2. In intervention villages, VHWs offer lifestyle counseling, basic guideline-directed antihypertensive, lipid-lowering, and antiplatelet treatment supported by a tablet-based decision support application to eligible participants. In control villages, participants are referred to a health facility for therapeutic management. The primary endpoint for both TwiCs is the proportion of participants with controlled BP levels (< 140/90 mmHg) 12 months after enrolment. We hypothesize that the intervention is superior regarding BP control rates in participants with uncontrolled BP (aHT TwiC 1) and non-inferior in participants with controlled BP at baseline (aHT TwiC 2). DISCUSSION: The TwiCs were launched on September 08, 2023. On May 20, 2024, 697 and 750 participants were enrolled in TwiC 1 and TwiC 2. To our knowledge, these TwiCs are the first trials to assess task-shifting of aHT care to VHWs at the community level, including the prescription of basic antihypertensive, lipid-lowering, and antiplatelet medication in Africa. The ComBaCaL cohort and nested TwiCs are operating within the routine VHW program and countries with similar community health worker programs may benefit from the findings. TRIAL REGISTRATION: ClinicalTrials.gov NCT05684055. Registered on January 04, 2023.

Prevalence and Correlates of Antipsychotic Medication Use in Oregon Assisted Living.

OBJECTIVE: Investigate how assisted living and residential care (AL/RC) and memory care (MC) contexts are associated with the 90-day prevalence of antipsychotic medication use (APU), considered a quality measure in long-term care. DESIGN: All licensed AL/RC settings in Oregon received an annual mailed questionnaire to provide aggregate resident demographics, health acuity, health service use, payment type, and organizational policies. Organizational measures were collected from state websites. METHODS: Random intercepts regression models were estimated to assess organizational and resident population characteristics associated with 90-day APU prevalence over 3 study waves (2017-2019). SETTING AND PARTICIPANTS: We examine 932 observations in 463 AL/RC settings from 2017 to 2019 (137 settings participated in all 3 waves, 195 in 2 waves, and 131 in 1 wave). RESULTS: The average 90-day APU prevalence in 464 Oregon AL/RC settings is 30.7%, although rates differ by MC endorsement (23.9% in AL/RC and 42.7% in MC). Nonprofit settings were associated with lower rates of APU in both AL/RC [ß = -4.4 (percentage points), 95% CI -8.4, -0.4] and MC (ß = -12.4, 95% CI -21.2, -3.6). Compared with low-Medicaid settings, settings with very high proportions of Medicaid residents were associated with higher APU prevalence, +8.9 in AL/RC (95% CI 1.7, 16.1) and +11.0 percentage points in MC (95% CI 2.3, 19.8). CONCLUSIONS AND IMPLICATIONS: APU prevalence in MC settings and with high-Medicaid populations is considerably higher than non-MC and lower-Medicaid settings. Federal policies guide APU in nursing homes but not AL/RC. No national database of AL/RC exists; thus, state-based studies can inform the discussion of state policy and practice development. Additional study is needed to contextualize the relationships between AL/RC population-level practices and characteristics and the APU prevalence to inform policy and practice development related to this measure as a quality indicator.

Countering social exclusion through inclusive homecare provision: Utilising a participatory life-course approach to influence policy.

Homecare models can be effective mechanisms in securing wellbeing and ageing-in-place goals prevalent in health policy agendas. However, the relevance and utility of these models for those living in socially and environmentally insecure conditions has rarely been considered. This is marked by an assumption of in-situ care delivery in private dwellings, and the absence of such groups from homecare development processes. This study aims to harnesses the experiences and preferences of older people in homelessness (OH), older Irish Travellers (OT), and professional stakeholders in an evidence-based co-production of policy recommendations for inclusive homecare provision. The study employed a participatory approach involving the integration of lived experience evidence in a multistakeholder co-production process. Methods comprised: five separate focus groups with OH, OT and service providers (n = 30); two consultative forums involving focus group participants together; and 49 life-course interviews with OH (n = 27) and OT (n = 22) and adults. Findings demonstrate that sizeable gaps in care remain for these groups, and that resource constraints and legislative restrictions prevail for professional stakeholders. Co-produced policy recommendations for inclusive homecare provision based on these experiences and group preferences are presented and discussed.

Does type of antiretroviral therapy pick-up point influence 12-month virologic suppression in South Africa?

We assessed the impact of community- versus clinic-based medication pick-up on rates of virologic suppression in an observational cohort of adults on ART enrolled in a decentralized antiretroviral therapy program (CCMDD) in South Africa. Participants either attended clinics where they were given the choice to pick up ART in community venues or traditional clinics, or clinics where this pathway was assigned. Among 1856 participants, 977 (53%) opted for community ART pick-up at enrollment, and 1201 (86%) were virologically suppressed at one year. Because of missing data on virologic suppression, primary results are based on a model incorporating multiple imputation. In addition to age and gender, distance from clinic and year of HIV diagnosis were included in the multivariable model. There was no difference in opting for clinic- vs. community-based pick-up with regard to achieving 12-month virologic suppression (aRR 1.02, 95% CI 0.98-1.05) in clinics offering choice. There was no impact of assigning all participants to an external pick-up point (aRR 1.00, 95% CI 0.95-1.06), but virologic suppression was reduced in the clinic that assigned participants to clinic pick-up (aRR 0.87, 95% CI 0.81-0.92). These results suggest that provision of community-based ART has not reduced continued virologic suppression in the population enrolled in the CCMDD program.

The transition towards community-based mental health care in the European Union: Current realities and prospects.

The shift of mental health care from mental institutions to community-based services has been implemented differentially throughout the EU. However, because a comprehensive overview of the current mental health provision in member states is lacking, it is challenging to compare services across nations. This study investigates the extent of implementation of community-based mental health services within the EU using data collected from the WHO Mental Health Atlas. Results show that, although great cross-country variation exists in the implementation of community-based services, mental hospitals remain the prominent model of care in most countries. A few countries endorsed a balanced care model, with the co-occurrence of community services and mental hospitals. However, missing data, low quality of data and different service definitions hamper the possibility of a thorough analysis of the status on deinstitutionalization. Although policies on the closing and downsizing of mental institutions have been endorsed by the EU, the strong presence of mental hospitals slows down the shift towards community-based mental health care. This study highlights the need for an international consensus on definitions and a harmonization of indicators on mental health services. Together with the commitment of member states to improve the quality of data reporting, leadership must emerge to ensure quality monitoring of mental health-related data, which will help advance research, policies and practices.

The implementation of person-centred plans in the community-care sector: a qualitative study of organizations in Ontario, Canada.

BACKGROUND: Person-centred planning refers to a model of care in which programs and services are developed in collaboration with persons receiving care (i.e., persons-supported) and tailored to their unique needs and goals. In recent decades, governments around the world have enacted policies requiring community-care agencies to adopt an individualized or person-centred approach to service delivery. Although regional mandates provide a framework for directing care, it is unclear how this guidance is implemented in practice given the diversity and range of organizations within the sector. This study aims to address a gap in the literature by describing how person-centred care plans are implemented in community-care organizations. METHODS: We conducted semi-structured interviews with administrators from community-care organizations in Ontario, Canada. We asked participants about their organization's approach to developing and updating person-centred care plans, including relevant supports and barriers. We analyzed the data thematically using a pragmatic, qualitative, descriptive approach. RESULTS: We interviewed administrators from 12 community-care organizations. We identified three overarching categories or processes related to organizational characteristics and person-centred planning: (1) organizational context, (2) organizational culture, and (3) the design and delivery of person-centred care plans. The context of care and the types of services offered by the organization were directly informed by the needs and characteristics of the population served. The culture of the organization (e.g., their values, attitudes and beliefs surrounding persons-supported) was a key influence in the development and implementation of person-centred care plans. Participants described the person-centred planning process as being iterative and collaborative, involving initial and continued consultations with persons-supported and their close family and friends, while also citing implementation challenges in cases where persons had difficulty communicating, and in cases where they preferred not to have a formal plan in place. CONCLUSIONS: The person-centred planning process is largely informed by organizational context and culture. There are ongoing challenges in the implementation of person-centred care plans, highlighting a gap between policy and practice and suggesting a need for comprehensive guidance and enhanced adaptability in current regulations. Policymakers, administrators, and service providers can leverage these insights to refine policies, advocating for inclusive, flexible approaches that better align with diverse community needs.

Healthcare use and costs in the last six months of life by level of care and cause of death.

BACKGROUND: Existing knowledge on healthcare use and costs in the last months of life is often limited to one patient group (i.e., cancer patients) and one level of healthcare (i.e., secondary care). Consequently, decision-makers lack knowledge in order to make informed decisions about the allocation of healthcare resources for all patients. Our aim is to elaborate the understanding of resource use and costs in the last six months of life by describing healthcare use and costs for all causes of death and by all levels of formal care. METHOD: Using five national registers, we gained access to patient-level data for all individuals who died in Norway between 2009 and 2013. We described healthcare use and costs for all levels of formal care-namely primary, secondary, and home- and community-based care -in the last six months of life, both in total and differentiated across three time periods (6-4 months, 3-2 months, and 1-month before death). Our analysis covers all causes of death categorized in ten ICD-10 categories. RESULTS: During their last six months of life, individuals used an average of healthcare resources equivalent to €46,000, ranging from €32,000 (Injuries) to €64,000 (Diseases of the nervous system and sense organs). In terms of care level, 63% of healthcare resources were used in home- and community-based care (i.e., in-home nursing, practical assistance, or nursing home care), 35% in secondary care (mostly hospital care), and 2% in primary care (i.e., general practitioners). The amount and level of care varied by cause of death and by time to death. The proportion of home- and community-based care which individuals received during their last six months of life varied from 38% for cancer patients to 92% for individuals dying with mental diseases. The shorter the time to death, the more resources were needed: nearly 40% of all end-of-life healthcare costs were expended in the last month of life across all causes of death. The composition of care also differed depending on age. Individuals aged 80 years and older used more home- and community-based care (77%) than individuals dying at younger ages (40%) and less secondary care (old: 21% versus young: 57%). CONCLUSIONS: Our analysis provides valuable evidence on how much healthcare individuals receive in their last six months of life and the associated costs, broken down by level of care and cause of death. Healthcare use and costs varied considerably by cause of death, but were generally higher the closer a person was to death. Our findings enable decision-makers to make more informed resource-allocation decisions and healthcare planners to better anticipate future healthcare needs.

Experiences of managers and staff working in community-based mental health with people ageing with severe mental health problems.

BACKGROUND: Existing research shows that older people with severe mental health problems need different forms of support in daily life and in the community to lead an active and meaningful life. A common form of support for people with severe mental health problems in Sweden is attendance at community-based day centres (DCs). However, knowledge of staff and managers' experiences of how people ageing with severe mental health problems are supported in DCs is scarce. AIM: The aim was to explore DC staff and managers' experiences of how people ageing with severe mental health problems are supported in DCs during the retirement process. METHOD/PROCEDURE: Telephone interviews were conducted with managers in 27 municipalities in southern Sweden. In addition, focus groups were held with personnel from a total of nine different DCs. The material was analysed using content analysis. RESULTS: The results showed that older people who receive support in community-based mental health care were viewed as a neglected group with complex needs, and the informants (managers and staff) had few policies to guide them when providing support. This made the informants desire more knowledge about best practices to support the target group. One theme emerged, Minding the gap between ideal and reality while working with a neglected group with complex needs, with three categories: Reasoning around unmet needs, Navigating in a muddled organisation, and Wishing for an enriched service. CONCLUSION/PRACTICAL APPLICATION: Together with previous research, the results can contribute to increase awareness about an overlooked group at risk of being neglected and the pitfalls that impact the possibility to guide this target group in their recovery journey. Further research focusing on the target group's own experience of their everyday life situations is also needed.

Acceptability and Effectiveness of a Dementia-Care Program Delivered by Community-Based Agency Staff.

BACKGROUND AND OBJECTIVES: Few proven dementia-care programs are integrated into community-based agencies. We report on the acceptability and effectiveness of an evidence-based program, Care of People in their Environment (COPE), delivered by community-based agency staff. RESEARCH DESIGN AND METHODS: Pretest/post-test design with 3 data points (baseline, 3-month program completion, 6-month follow-up). COPE was delivered by 6 occupational therapists and 4 social workers at 2 agency sites with people living with dementia and caregivers. Staff assessed the interests and abilities of people living with dementia, home safety, caregiver challenges, and readiness to learn strategies. Staff provided dementia education, stress reduction, and nonpharmacological techniques tailored to caregiver-identified challenges. Acceptability (3- and 6-months), included completed sessions, upset with and confidence managing care challenges, strategies used, and program satisfaction. Effectiveness (3- and 6-months) included people living with dementia's health events (falls, emergency room visits, hospitalizations, and 911 calls), rehospitalization risk and functional dependence; and caregiver well-being and readiness. Benefits by in-person (n = 188) versus virtual/hybrid (n = 46) delivery due to Coronavirus Disease-2019 were evaluated. RESULTS: Of 843 dyads screened, 271 (32.1%) enrolled, 246 (90.8%) completed COPE, and 234 (95.1%) completed ≥1 follow-up. Regarding acceptability, caregivers completed about 8 sessions, reported improved confidence and upset (p < .001), most implemented strategies 3-months (72.8%) and 6-months (83.5%), and expressed high program satisfaction. For effectiveness, compared to baseline, odds of people living with dementia's health events were lower including rehospitalization risk, although functional dependence increased; caregiver well-being (3-, 6-months, p < .001) and readiness (3-months, p < .01) improved. Outcomes did not differ by delivery mode. DISCUSSION AND IMPLICATIONS: Acceptability and effectiveness were strong. COPE resulted in tangible improvements for families regardless of delivery mode.

Beyond Birth Work: Addressing Social Determinants of Health With Community Perinatal Support Doulas.

Adverse maternal and infant health outcomes among African Americans are increasingly recognized as indicators of a critical public health crisis in the United States. Research has found that stress is related to structural racism and the social determinants of health (SDOH) that cause avoidable, unfair inequities in resources, education, power, and opportunities across ethnic groups. This paper describes the SDOH needs and experiences of pregnant Black women from the perspective of doulas and Birthing Beautiful Communities (BBC) clients. The design was a qualitative description, using data collected over time (2017-2018, 2020-2021, and 2023). This study took place in Cleveland and Akron, Ohio and the sample included 58 clients, 26 doulas, and 2 resource intake specialist assistants (RISAs). Qualitative data included individual client interviews, three doula focus groups, and one interview with two BBC RISAs. Three coders used content analysis to deductively identify SDOHs and calculate the number of interviews that contained information about specific SDOHs. Although the sample reported issues with all SDOH, particular ones caused a cascade of SDOH effects. Transportation issues, for example, impeded women from being able to make it to work, doctor's appointments, and to purchase essential baby items (e.g., food, infant supplies). An inability to work-whether because of transportation challenges or pregnancy-related health complications-led to unstable housing and an inability to deal with transportation challenges. Many clients mentioned that housing was a major issue, with many clients experiencing housing instability. Implications include ensuring SDOH information is collected from a trusted source who can advocate and ensure access to a wide range of local resources, ensuring policies protect pregnant women from experiencing a cascade of SDOH that may contribute to continuing health disparate infant and maternal health outcomes in African American women.

Evaluating the Implementation Fidelity of a Pilot Pragmatic Randomized Clinical Trial Comparing Daily-Delivered Meals to Mailed Frozen Meals.

In pragmatic clinical trials (PCTs), the intervention is carried out by participating sites instead of research staff. In this paper, we evaluate study sites' implementation adherence during a pilot PCT of home-delivered meals for older adults with dementia. Participants at three home-delivered meal programs were randomized to receive either (1) meals delivered daily or (2) frozen meals mailed every two weeks; participants' outcomes were tracked for six months. Using the adherence domains from the Framework for Implementation Fidelity, we identified six metrics to assess adherence, with a total possible adherence score ranging from 6 (low adherence) to 18 (high adherence); all three sites scored within the top quartile of adherence. Despite challenges to meal delivery during the COVID-19 pandemic, sites successfully implemented the intervention, justifying a follow-on PCT to test the comparative effectiveness of models of meal delivery on the time to nursing home placement for people living with dementia.