Assertive outreach teams in London: patient characteristics and outcomes. Pan-London Assertive Outreach Study, part 3

BACKGROUND

Although the model of assertive outreach has been widely adopted, it is unclear who receives assertive outreach in practice and what outcomes can be expected under routine conditions.

AIMS

To assess patient characteristics and outcome in routine assertive outreach services in the UK.

METHOD

Patients (n=580) were sampled from 24 assertive outreach teams in London. Outcomes--days spent in hospital and compulsory hospitalisation--were assessed over a 9-month follow-up.

RESULTS

The 6-month prevalence rate of substance misuse was 29%, and 35% of patients had been physically violent in the past 2 years. During follow-up, 39% were hospitalised and 25% compulsorily admitted. Outcome varied significantly between team types. These differences did not hold true when baseline differences in patient characteristics were controlled for.

CONCLUSIONS

Routine assertive outreach serves a wide range of patients with significant rates of substance misuse and violent behaviour. Over a 9-month period an average of 25% of assertive outreach patients can be expected to be hospitalised compulsorily. Differences in outcome between team types can be explained by differences in patient characteristics.

The Medical Home Index: development and validation of a new practice-level measure of implementation of the Medical Home model

OBJECTIVE

The Medical Home is a clinical practice concept that sets new standards for pediatric primary care. This study describes the development and validation of a tool to measure the Medical Home.

METHODOLOGY

The Medical Home Index (MHI) consists of 25 themes arranged among 6 domains of primary care office activity. A national panel of experts on the Medical Home reviewed a prototype of the instrument. Pediatric primary care offices completed the MHI and participated in 90-minute on-site interviews with two of the authors (J.W.M., K.S.). The study examined interrater reliability between the 2 project staff and between the practices and project staff and the internal consistency of MHI domains and themes.

RESULTS

On a 100-point scale, 43 practices demonstrated a range of MHI summary scores from 18.9 to 75.4, with a mean of 43.9. Kappa coefficients of interrater reliability between two Center for Medical Home Improvement project staff were above.50 for all 25 themes. Kappa scores comparing each staff member and the practice sites' self-assessment found 80% of the themes at.65 or better for one interviewer (J.W.M.) and 60% of the themes at.65 or better for the second interviewer (K.S.). Intraclass correlation coefficients between the summary scores of the interviewers were.98 and between the scores of the two interviewers and the scores of the practices was.97. The internal consistency reliability standardized alpha coefficients across the 6 domains of the MHI ranged from.81 to.91, and the overall standardized alpha coefficient was.96.

CONCLUSIONS

In the sample of practices studied, the MHI was an internally consistent instrument with acceptable reliability and validity for pediatric primary care practices to assess their implementation of the Medical Home concept. Further work is needed to study its correlation with other process and outcome measures and its performance in a wider range of practices.

2003 NOVA award winners

Even in tough economic times, the five recipients of this year's NOVA Award understand the value of community outreach. Improving the health and well-being of the people they serve is a cornerstone of their mission and it means going outside the walls of their institutions. They also understand that getting the most out of their ambitious community programs requires cooperation with other groups. "If you just push a little more in the face of challenging financial times, through collaboration, everyone benefits," says Gregory Wozniak, president and CEO of NOVA winner St. Mary Medical Center, Langhorne, Pa. "That's one way to decrease costs and increase the access of health care."

Breaking through to improved community health

Michigan's nonprofit community hospitals serve the state's citizens in extraordinary ways--regardless of whether anyone pays for that service. In 2001, these community-based organizations provided $885 million in free health care to area residents who were uninsured or otherwise could not pay for it. In addition, the state's nonprofit hospitals contributed more than $276 million in services such as health education, outreach, screening, counseling and free clinics. The total worth of these traditional and nontraditional benefits to Michigan communities in 2001 was a staggering $1.16 billion.

John C. Lincoln Health Network recognized for community service. Phoenix institution wins prestigious Foster G. Mcgaw Prize

John C. Lincoln Health Network, Phoenix, was awarded the Foster G. McGaw Prize for excellence in community service, one of the healthcare field's most prestigious honors. The network serves a broad geographic area and nearly a dozen communities. Those communities most challenged by poverty, hunger, poor housing and crime are the focus of most of the health network's efforts.

Evaluating models of community psychology: social transformation in South Africa

Tricket (1996) described community psychology in terms of contexts of diversity within a diversity of contexts. As abstract representations of reality, various community psychological models provide further diverse contexts through which to view the diversity of community psychological reality. The Zululand Community Psychology Project is a South African initiative aimed at improving community life. This includes treating the violent sequelae of the unjust Apartheid system through improving relationships among communities divided in terms of historical, colonial, racial, ethnic, political, gender, and other boundaries as well as promoting health and social change. The aim of this article is to evaluate the applicability of various models of community psychology used in this project. The initial quantitative investigation in the Zululand Community Psychology Project involved five coresearchers, who evaluated five community psychology models--the mental health, social action, organizational, ecological, and phenomenological models--in terms of their differential applicability in three partnership centers, representing health, education, and business sectors of the local community. In all three contexts, the models were rank ordered by a representative of each center, an intern community psychologist, and his supervisor in terms of the models' respective applicability to the particular partnership center concerned. Results indicated significant agreement with regard to the differential applicability of the mental health, phenomenological, and organizational models in the health, education, and business centers respectively, with the social action model being most generally applicable across all centers. This led to a further qualitative individual and focus group investigation with eight university coresearchers into the experience of social transformation with special reference to social changes needed in the South African context. These social transformation experiences and perceived changes needed are explicated. Finally, there is discussion with regard to the evaluation of various models of community psychology in international perspective.

Anatomy of a successful K-12 educational outreach program in the health sciences: eleven years experience at one medical sciences campus

The Department of Anatomy and Neurobiology, College of Medicine, University of Arkansas for Medical Sciences (UAMS) is the administrative home of a nationally recognized educational outreach program in the health sciences for K-12 teachers (includes school nurses, counselors, etc.) and students. This program is called the Partners in Health Sciences (PIHS) program. It began in the summer of 1991 and is based on an annual needs assessment of the state's teachers. PIHS is a program available to all teachers and students in the state. It has several different components: (1) a cafeteria of 21 days of mini-courses offered in the summer to meet the professional development needs of K-12 biology/health teachers and other school personnel; (2) weekly, interactive telecommunication broadcasts for students during the academic year; (3) intensive, 5-day workshops that train five selected teachers at a time (10 per year) to use an authoring software program to develop grade-appropriate interactive, computer-assisted, instructional (CAI) modules for Internet (http://k14education.uams.edu) use by teachers and students; (4) a monthly science night for students and their parents at a local science magnet high school; (5) field trips to the UAMS campus for teachers and their students; (6) community-requested presentations by program faculty; and (7) availability of earning undergraduate and graduate credit for science education majors in the College of Education, University of Arkansas at Little Rock. The data presented in this report span the period from 1991 through 2001. For all program activities, 14,084 different participants have consumed a total of 50,029 hours of education.

An initiative to improve diabetes care standards in healthcare organizations serving minorities

PURPOSE

This study was designed to assess changes of diabetes care standards in healthcare organizations that participated in 2-year initiative to improve diabetes care and expand outreach in minority communities.

METHODS

An independent sample of the medical records of adults with type 2 diabetes was randomly drawn at 3 points of time (N = 829). Rates of compliance with 20 selected measures of standards of basic diabetes care were measured and compared over time.

RESULTS

Significant improvements in compliance rates from baseline to the end point were found in 11 measures including annual hemoglobin A1C testing (65.8% to 76.3%), annual lipid profile (33.8% to 49.1%), and biannual lower extremity examination (40.0% to 56.3%).

CONCLUSIONS

Improvements in diabetes care were credited with giving providers feedback on their compliance and increasing support of patient self-care, especially through tailoring outreach and services to minorities.

AHA NOVA award winners 2002. Hospitals direct scarce resources to help their communities get healthy, fit, strong

From the farm country of northeastern Florida to inner-city Los Angeles, the five recipients of this year's AHA NOVA Award take a broad definition of public health, then collaborate with a wide spectrum of organizations to tackle community problems. They're taking on such issues as literacy, unemployment and teen-age disaffection--issues that affect the health and well-being of individuals and of their communities as a whole.

Outpatient management of DVT using low molecular weight heparin and a hospital outreach service

In recent years there have been several studies comparing the efficacy and safety of low molecular weight (LMW) and unfractionated heparin for the treatment of deep venous thrombosis (DVT), showing them in the clinical trial setting to be equal in these regards. LMWH has the advantage of once daily subcutaneous injection and daily monitoring of levels is not usually required. This has led many centres to develop outpatient treatment strategies for these patients but evidence for the safety of this approach is scarce. In 1997 we developed a hospital outreach service for the treatment of patients with DVT and, in a retrospective study, have compared the outcome in 172 patients treated at home with 172 age, sex and thrombotic risk factor matched inpatients treated at our institution with unfractionated heparin. Five patients in the home treatment group suffered a haemorrhagic event, compared with six patients in the hospital group. One patient in the home treatment group had a recurrent DVT within the first 3 months of treatment; in the hospital-treated group, six patients had recurrent DVTs and nine developed pulmonary emboli. At 3 months, there were three deaths in the home treatment group, compared with five deaths in the hospital group. There was no difference in re-admission rate at 3 months: 23 in the home treatment group, 24 in the hospital-treated group. Average length of hospital stay for the home-treatment group was 2.1 days and 12 days for the hospital group. Warfarin control was found to be significantly better in those patients treated at home, and only 18% of patients treated in hospital received heparin according to hospital guidelines. In conclusion, outpatient management of patients with DVT using LMWH is as safe as hospitalization and continuous infusion of unfractionated heparin. The complication rate was lower in the home treatment group and, in particular, the incidence of recurrent thrombosis was significantly less in the home treatment group. In addition, warfarin control was better when managed by specialist nurses. Patients expressed a preference for home treatment.

Outreach health adviser in a community clinic screening programme improves management of genital chlamydia infection

OBJECTIVE

To assess the effectiveness of an outreach health adviser on treatment, partner notification and outcome for clients diagnosed with genital chlamydia (CT) infection at a community young people's clinic.

METHODS

From August 1999 to March 2000, a genitourinary medicine (GUM) based health adviser helped to develop testing and undertook outreach management of clients aged under 26 years diagnosed with CT infection. In addition to facilitating referral to GUM, she gave antibiotic treatment based on a GUM derived patient group direction to those not wishing to travel to the GUM clinic. She also advised them on contact tracing and the need for a compliance check (CC).

RESULTS

Chlamydia positive tests with ligase chain reaction (LCR), on first void urine, were obtained for 62 (12.9%) of 481 female clients, one (5%) of 20 male clients, and nine (53%) of 17 male contacts of female positive cases. All 72 testing positive received their result and were treated. Two urine samples positive for CT showed positive LCR tests for gonorrhoea. Proportions of named contacts seen (67%) and reattendances for compliance checks (60%) were similar to those for women seen in GUM services.

CONCLUSIONS

Health adviser input with the ability to treat can be effective in reducing the growth of identified but untreated genital chlamydia infection consequent upon community based screening. Such a strategy appears comparable with, and can add to, GUM based treatment of infection. It helps to address the need for alternative management strategies in the light of the national sexual health strategy.

Preventive health services use, lifestyle health behavior risks, and self-reported health status of women in Ohio by ethnicity and completed education status

This study assessed the health status and behavior of college-educated and non-college-educated African American women and European American women in Ohio. Analyses focused on health services utilization, health status, and life style/health behaviors from the 1998 Ohio Family Health Survey. College-educated African American women used more preventive health services and had better health status than non-college-educated African American women. Even so, college-educated African American women still had higher body mass index values, lower health status, and higher percent currently smoking than college-educated European American women. We conclude that college-educated African American women may face unique barriers to implementing all types of health-promoting behaviors available consequent to their higher education. Partnerships with respected community institutions, such as churches, may help these women develop good health practices in their entire community as well as in themselves.

Outreach: targeting high-risk women through community partnerships

The need for community-based preventive intervention is driven by the ineffectiveness and the costliness of traditional approaches. We argue that community outreach efforts should be characterized by three components: 1) careful mapping of high-risk areas, 2) developing partnerships with trusted community institutions within areas of high risk, and 3) developing a portfolio of institutional partners that maximize the penetration of high-risk populations. The analysis of these high-risk contexts redirects the focus from individuals to institutional structures. Gaining a greater understanding of how impoverished women relate to formal institutions is critical to the primary goal of reducing unnecessary deaths.

Critical care outreach services and early warning scoring systems: a review of the literature

AIM

The aim of this paper is to explore the literature relating to critical care outreach services and the use of early warning scoring systems to detect developing critical illness.

BACKGROUND

Several studies have identified how suboptimal care may contribute to physiological deterioration of patients with major consequences on morbidity, mortality and requirement for intensive care. In a review of adult critical care services, the Department of Health (DOH) (England) recommended in 2000 that outreach services be established to avert admissions to Intensive Care, to enable discharges and to share critical care skills.

METHODS

A literature search was carried out of the BIOMED and NESLI databases using the key words "outreach", "early warning signs/systems" and "suboptimal care". The literature review was limited to the past 10 years, and primary research articles of particular relevance were included in the review. The literature is examined within the context of recent findings relating to the provision of suboptimal care within general wards prior to cardiac arrest and/or admission to Intensive Care Units (ICU), and subsequent government initiatives. Discussion. The discussion explores the potential contribution of critical care outreach services and early warning scoring systems to the care of patients in acute general wards, including the role that education can have in developing the knowledge base and assessment skills of ward nurses.

CONCLUSION

The paper concludes that further study is required to evaluate the effectiveness of critical care outreach services and early warning scoring systems, and that ward staff need to be educated to identify those patients at risk of developing critical illness. Finally, it is suggested that nurses' decision-making in relation to calling the outreach team requires further investigation.

User focus groups and Best Value in services for people with learning disabilities

This paper examines the problems and potentials of employing user focus groups as part of an approach to defining and reviewing Best Value in local authority and jointly commissioned services for people with learning disabilities. Drawing on experience from three local authority initiatives and wider experience with Best Value, the paper describes the development of user focus groups for helping review adult placement, outreach and day services for people with learning disabilities. The key methodological considerations for consulting with service users with learning disabilities through focus groups are identified and the interpretation of outcomes considered. The paper concludes with pointers for the effective operation of user focus groups in local authority Best Value reviews of services for people with learning disabilities, of use to practitioners, service managers and commissioners.

Community outreach rehabilitation

OBJECTIVE

to review controlled studies evaluating the effectiveness of community rehabilitation schemes developed to facilitate effective discharge from hospital. To briefly describe the community outreach rehabilitation scheme which has been developed in York, UK.

RESULTS

in the last 10 years, 9 controlled trials were identified of which 6 resulted in improved outcome. There were no overall or mixed outcome differences observed in the other 3. Cost analysis calculations were controversial. However, in 4 of the studies early structured discharge appeared to result in cost savings-mainly by reducing hospital length of stay.

CONCLUSION

though the studies were heterogeneous in design and involved different patient groups, community rehabilitation schemes appeared to be effective in facilitating earlier discharge from hospital.

Community outreach: a focus on bioethics

The author suggests that the infusion of bioethics into all aspects of the animal research community's work provides a framework for making decisions. Such deliberations, grounded in ethical theories and principles, can help to reinforce the position that both the research process and the people involved in it are morally sound. Pro-biomedical research groups around the country are therefore investing time and effort in bioethics training.

Dilemmas in the provision of own-home respite support for parents of young children with complex health care needs: evidence from an evaluation

Dilemmas in the provision of own-home respite support for parents of young children with complex health care needs: evidence from an evaluation Aims. The aim of this article is to present some of the results of a qualitative evaluation of a United Kingdom (UK) nurse-led, home-based, respite service for the families of children under the age of five with complex health care needs. Background. Advances in neonatal medical and nursing care have contributed to a growth in the number of children who survive low birth weight, birth trauma, and various congenital anomalies. Many of these children are likely to have long-term care needs which will require innovative nursing responses. Of particular importance is the need for parental respite, given the added demands of caring for very ill children at home. Methods. A parent-centred, follow-up evaluation, using in-depth qualitative interviews with parents in 18 families consecutively referred to the Children's Outreach Service between April and December 1997. Findings. This evaluation reveals the sometimes mixed reactions of parents to this innovative service, and the equivocal evidence about its role in contributing to family well-being. We discuss, from the perspective of parents using the service, some of the dilemmas and problems in the provision of home-based respite support to this client group. In particular, we explore the diverse ways in which families talk about their need for respite support and point to the need for flexibility in this kind of service provision if these support needs are to be met. Conclusion. We conclude by discussing the practice implications of our evaluation for those planning similar services.

The cost and cost-effectiveness of an enhanced intervention for people with substance abuse problems at risk for HIV

OBJECTIVE

To estimate the costs, effectiveness, and cost-effectiveness of prevention interventions for out-of-treatment substance abusers at risk for HIV. This is the first cost-effectiveness study of an AIDS intervention that focuses on drug use as an outcome.

STUDY DESIGN

We examined data from the North Carolina Cooperative Agreement site (NC CoOp). All individuals in the study were given the revised NIDA standard intervention and randomly assigned to either a longer, more personalized enhanced intervention or no additional intervention. We estimated the cost of each intervention and, using simple means analysis and multiple regression models, estimated the incremental effectiveness of the enhanced intervention relative to the standard intervention. Finally, we computed cost-effectiveness ratios for several drug use outcomes and compared them to a "back-of-the-envelope" estimate of the benefit of reducing drug use.

PRINCIPAL FINDINGS

The estimated cost of implementing the standard intervention is $187.52, and the additional cost of the enhanced intervention is $124.17. Cost-effectiveness ratios range from $35.68 to $139.52 per reduced day of drug use, which are less than an estimate of the benefit per reduced drug day.

CONCLUSIONS

The additional cost of implementing the enhanced intervention is relatively small and compares favorably to a rough estimate of the benefits of reduced days of drug use. Thus, the enhanced intervention should be considered an important additional component of an AIDS prevention strategy for out-of-treatment substance abusers.

Is untargeted outreach visiting in primary care effective? A pragmatic randomized controlled trial

BACKGROUND

There is increasing evidence that clinical guidelines can lead to improvements in clinical care. However, they are not self-implementing. Outreach visits may improve prescribing behaviour.

METHODS

Within a before-and-after pragmatic randomized controlled trial, involving all general practices in one health district, routine methods were used to distribute guidelines for management of Helicobacter pylori eradication. Intervention practices were offered a visit and the conduct of an audit by a pharmacist trained in the techniques of outreach visiting. The intervention was evaluated using level three Prescribing Analysis and Cost (PACT) data for metronidazole and omeprazole for the two 12 month periods around the introduction of the guidelines.

RESULTS

Of the 38 intervention practices 19 accepted an outreach visit and three accepted the offer of an audit. There was a significant increase in omeprazole use during the study of 0.24 [95 per cent confidence interval (CI) +0.19 to +0.29] dose units per year but no effect from the offer [-0.02 (95 per cent CI -0.12 to +0.08) dose units] or acceptance of a visit [-0.03 (95 per cent CI -0.15 to +0.08) dose units]. The results for metronidazole were similar, with an increase in use of 0.028 (95 per cent CI +0.018 to +0.038) dose units per year. The effect of the intervention was a non-significant change in prescribing of -0.005 (95 per cent CI -0.025 to +0.015) dose units. Accepting a visit had little effect on prescribing: a change of 0.003 (95 per cent CI -0.021 to +0.027) dose units.

CONCLUSIONS

The routine use of untargeted outreach visiting is probably not a worthwhile strategy.

Telemedicine in vascular surgery: does it work?

Telemedicine (TM) using closed-circuit television systems allows specialists to evaluate patients at remote sites. Because an integral part of the vascular examination involves palpation of peripheral pulses the applicability of TM for the evaluation of vascular surgery patients is open to question. This study was carried out to test the hypothesis that TM is as effective as direct patient examination for the development of a care plan in vascular patients. Sixty-four vascular evaluations were done in 32 patients. The patients presented with a variety of vascular problems and were seen in regularly scheduled rural outreach vascular clinics. Two faculty vascular surgeons evaluated each patient; one was on site and the second, using TM, remained at the medical center. Each surgeon was blinded to the other's findings. The TM physician was aided by a nonphysician assistant, who obtained blood pressures, utilized a continuous-wave Doppler probe, positioned the patient, and operated the TM equipment. The results of each surgeon's evaluations were compared. Patient and physician satisfaction with the TM evaluation was appraised by questionnaires. Eight patients were seen for initial evaluations; 24 patients were seen for follow-up visits. Patients were seen with a variety of diagnoses, including aneurysm (seven), cerebrovascular disease (five), lower extremity occlusive disease (13), multiple vascular problems (three), and other disease (four). The average duration for the TM and on-site evaluations were 20.6+/-1.4 and 19.0+/-1.3 minutes, respectively (P = not significant). Physician concordance, as determined by treatment recommendations, was the same in 29 (91%) patients. Physician confidence in the ability to obtain an accurate history via TM was rated as excellent in 97 per cent; confidence in the TM physical examination was rated as excellent in 70 per cent. All patients rated the TM evaluation as the "same as" or "better than" the on-site examination, and all indicated a preference for being seen locally using TM as opposed to traveling to a regional medical center. We conclude that the TM evaluation of vascular patients is accurate and is as effective as on-site evaluations for a variety of vascular problems. Important adjuncts to enhance the success of a TM evaluation are physician experience with the technology and the presence of a knowledgeable on-site assistant. This technology can be easily adapted to other clinical situations.