Caregiver Integration During Discharge Planning for Older Adults to Reduce Resource Use: A Metaanalysis

Objectives To determine the effect of integrating informal caregivers into discharge planning on postdischarge cost and resource use in older adults. Design A systematic review and metaanalysis of randomized controlled trials that examine the effect of discharge planning with caregiver integration begun before discharge on healthcare cost and resource use outcomes. MEDLINE, EMBASE, and the Cochrane Library databases were searched for all English‐language articles published between 1990 and April 2016. Setting Hospital or skilled nursing facility. Participants Older adults with informal caregivers discharged to a community setting. Measurements Readmission rates, length of and time to post‐discharge rehospitalizations, costs of postdischarge care. Results Of 10,715 abstracts identified, 15 studies met the inclusion criteria. Eleven studies provided sufficient detail to calculate readmission rates for treatment and control participants. Discharge planning interventions with caregiver integration were associated with a 25% fewer readmissions at 90 days (relative risk (RR) = 0.75, 95% confidence interval (CI) = 0.62–0.91) and 24% fewer readmissions at 180 days (RR = 0.76, 95% CI = 0.64–0.90). The majority of studies reported statistically significant shorter time to readmission, shorter rehospitalization, and lower costs of postdischarge care among discharge planning interventions with caregiver integration. Conclusion For older adults discharged to a community setting, the integration of caregivers into the discharge planning process reduces the risk of hospital readmission

Barriers to health care for undocumented immigrants: A literature review

With the unprecedented international migration seen in recent years, policies that limit health care access have become prevalent. Barriers to health care for undocumented immigrants go beyond policy and range from financial limitations, to discrimination and fear of deportation. This paper is aimed at reviewing the literature on barriers to health care for undocumented immigrants and identifying strategies that have or could be used to address these barriers. To address study questions, we conducted a literature review of published articles from the last 10 years in PubMed using three main concepts: immigrants, undocumented, and access to health care. The search yielded 341 articles of which 66 met study criteria. With regard to barriers, we identified barriers in the policy arena focused on issues related to law and policy including limitations to access and type of health care. These varied widely across countries but ultimately impacted the type and amount of health care any undocumented immigrant could receive. Within the health system, barriers included bureaucratic obstacles including paperwork and registration systems. The alternative care available (safety net) was generally limited and overwhelmed. Finally, there was evidence of widespread discriminatory practices within the health care system itself. The individual level focused on the immigrant’s fear of deportation, stigma, and lack of capital (both social and financial) to obtain services. Recommendations identified in the papers reviewed included advocating for policy change to increase access to health care for undocumented immigrants, providing novel insurance options, expanding safety net services, training providers to better care for immigrant populations, and educating undocumented immigrants on navigating the system. There are numerous barriers to health care for undocumented immigrants. These vary by country and frequently change. Despite concerns that access to health care attracts immigrants, data demonstrates that people generally do not migrate to obtain health care. Solutions are needed that provide for noncitizens’ health care

Healers, Helpers and Hospitals (Volumes 1 and 2)

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Innovating to improve primary care in less developed countries:Towards a global model

One of the biggest problems in global health is the lack of well trained and supported health workers in less developed settings. In many rural areas there are no physicians, and it is important to find ways to support and empower nurses and other health workers. The Knowledge Translation Unit of the University of Cape Town Lung Institute has spent 14 years developing a series of innovative packages to support and empower nurses and other health workers. PACK (Practical Approach to Care Kit) Adult comprises policybased and evidence-informed guidelines; onsite, team and case-based training; non-physician prescribing; and a cascade system of scaling up. A series of randomised trials has shown the effectiveness of the packages, and methods are now being developed to respond cost-effectively and sustainably to global demand for implementing PACK Adult. Global health would probably benefit from less time and money spent developing new innovations and more spent on finding ways to spread those we already have

Socioeconomic predictors and consequences of depression among primary care attenders with non-communicable diseases in the Western Cape, South Africa:Cohort study within a randomised trial

Background: Socioeconomic predictors and consequences of depression and its treatment were investigated in 4393 adults with specified non-communicable diseases attending 38 public sector primary care clinics in the Eden and Overberg districts of the Western Cape, South Africa.   Methods: Participants were interviewed at baseline in 2011 and 14 months later, as part of a randomised controlled trial of a guideline-based intervention to improve diagnosis and management of chronic diseases. The 10-item Center for Epidemiologic Studies Depression Scale (CESD-10) was used to assess depression symptoms, with higher scores representing more depressed mood. Results: Higher CESD-10 scores at baseline were independently associated with being less educated (p=0.004) and having lower income (p=0.003). CESD-10 scores at follow-up were higher in participants with less education (p=0.010) or receiving welfare grants (p=0.007) independent of their baseline scores. Participants with CESD-10 scores of 10 or more at baseline (56% of all participants) had 25% higher odds of being unemployed at follow-up (p=0.016), independently of baseline CESD-10 score and treatment status. Among participants with baseline CESD-10 scores of 10 or more, antidepressant medication at baseline was independently more likely in participants who had more education (p=0.002), higher income (p<0.001), or were unemployed (p=0.001). Antidepressant medication at follow up was independently more likely in participants with higher income (p=0.023), and in clinics with better access to pharmacists (p=0.053) and off-site drug delivery (p=0.013).  Conclusions: Socioeconomic disadvantage appears to be both a cause and consequence of depression, and may also be a barrier to treatment. There are opportunities for improving the prevention, diagnosis and treatment of depression in primary care in inequitable middle income countries like South Africa.  Trial registration: The trial is registered with Current Controlled Trials (ISRCTN20283604) and the Office for Human Research Protections Database (IRB00001938, FWA00001637)

Information Practices of Disaster Response Professionals: The Preparedness Phase

Objectives: This study describes the information practices of the various professions such as emergency management, public health, health and medicine, and public safety, involved in regional disaster preparedness groups. A thorough understanding of the similarities and differences between the professions in information seeking, use, and sharing, will further the development of high-quality information sources and information-sharing channels acceptable to all professions on the team. Methods: A qualitative descriptive study was undertaken. Twelve participants in the Pennsylvania Preparedness Leadership Institute (PPLI), a multi-disciplinary training program attended by members of the Pennsylvania Regional Task Forces, were recruited interviewed. Open-ended individual interviews were conducted at PPLI trainings and in participant workplaces. Interviews focused on information practice in the workplace, including preferences for information seeking and sharing, and barriers and facilitators to information access in the workplace. Analysis used Taylor's Information Use Environments model as an organizing framework. Findings: As Taylor's model states, information practice is shaped by the educational and training requirements for entry into each profession. Factors not included by Taylor but important to this study include volunteer experience in related fields, and overlap between personal and professional information practice on the Internet. Participants report heavy use of the Internet and email, but not of Web 2.0 social media. They value face-to-face meetings for building the social networks critical to disaster response. Only public health and medical professionals use peer-reviewed literature. All would like tools to filter incoming information, and more access to the "lessons learned" reports of other agencies engaged in similar work. Conclusions: There are differences between professions in information practice, but also commonalities that can be exploited to further information use in preparedness. Librarians can make a significant contribution to preparedness efforts by incorporating these findings into the design of information services and resources for disaster professionals. Public health significance: Improving information gathering and sharing practices for all disciplines on the disaster planning team is critical to reducing the impact of man-made and natural disasters on the health of the general public

Non-communicable diseases in public sector primary care clinics in South Africa: multimorbidity, control, treatment, socioeconomic associations, and evaluation of educational outreach with a clinical management tool

This thesis uses experience gained from a large implementation trial in two rural districts of the Western Cape, South Africa, to address the needs of patients with non-communicable diseases (NCDs) and depression, and to identify solutions to those needs. The Primary Care 101 intervention supports and expands nurses' role in integrated care, in particular for NCDs. It comprises a comprehensive clinical management tool implemented in primary care services using educational outreach training. It was evaluated using a pragmatic cluster randomised controlled trial: 38 clinics in the Eden and Overberg districts of the Western Cape were randomised to receive the intervention or to continue with usual care. 4393 Patients were enrolled and four cohorts identified: hypertension, diabetes, chronic respiratory disease and depression. Patients were re-interviewed once, 14 months later. Primary outcomes for the trial were treatment intensification for the hypertension, diabetes and chronic respiratory disease cohorts, and case detection for the depression cohort. Multimorbidity, NCD care and their socioeconomic associations were assessed on the whole trial cohort (combining intervention and control arms) at baseline and follow-up. The results are presented in published papers. Baseline data revealed considerable multimorbidity and unmet treatment needs (Paper 1). Socioeconomic indicators such as education, and modifiable clinic-level factors such as adequate staffing and communitybased chronic medication collection services were associated with blood pressure control (Paper 2) and depression management (Paper 3). The intervention was shown to be feasible and safe but none of the four primary outcomes showed significant improvement (Paper 4). The thesis addresses the public health challenge of providing integrated chronic disease primary care in South Africa by: • Providing original evidence for high levels of NCD multimorbidity and unmet treatment needs. • Identifying modifiable factors that could improve care for these diseases. • Providing new evidence from South Africa to support the bidirectional relationship between poverty and depression. • Reporting evidence of the effectiveness of a novel intervention aimed at improving NCD care. The findings point to the need for improved strategies for NCD care, including equipping primary health care providers to manage the complexities of multimorbidity

The medicines regulatory system in South Africa - review and proposals for reform

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