Service-Delivery Competencies in Home and Community-Based Services Needed to Achieve Person-Centered Planning and Practices: A Systematic Review

Systemic barriers hinder person-centered home and community based services (HCBS): Perspectives of service users and professionals

BACKGROUND

In response to the 2014 Final Settings Rule issued by the Centers for Medicaid and Medicare Services, home-and-community based services (HCBS) provider organizations strengthened person-centered (PC) planning for HCBS to improve participants' choice and control over their services. Despite the call for widespread adoption of PC services, systemic barriers influence service users' and professionals' experiences in receiving and delivering PC services.

OBJECTIVE

This study describes the perspectives of HCBS professionals and users on systemic barriers that affect PC HCBS delivery.

METHODS

Semi-structured interviews with 20 HCBS users and 22 HCBS professionals explored perspectives on providing and receiving PC HCBS as well as higher level systems challenges to providing PC services. Qualitative analysis focused on participants' perspectives of system-level issues.

RESULTS

Qualitative analysis generated three themes: (1) Workforce considerations; (2) Resources and service access; and (3) Infrastructure for feedback. High direct service provider turnover rates, service-eligibility determination procedures, and waitlists affected service delivery. Participants highlighted a need for increased direct service provider compensation, access to higher-quality training, improved financial resources, and effective feedback infrastructures. Waiver flexibility due to the Covid-19 public health emergency allowed expanded service access and improved quality.

CONCLUSION

Organizational and system-level issues hinder delivery of PC services. Increased flexibility and resource allocation for service provision, as demonstrated in the Covid-19 public health emergency response, should be sustained. HCBS users' suggestions for service-delivery improvements are consistent with recent state and organizational initiatives. HCBS improvements benefit from user-identified solutions in program development and implementation.

Dementia care and prevention in community settings: a built environment framework for cognitive health promotion

PURPOSE OF REVIEW

Most people with dementia live in the community. As lifespan increases, one in three persons aged 85+ are expected to live with dementia. We conduct a systematic search to identify frameworks for dementia care and prevention in community settings. This is important to ensure quality of life for people living with cognitive decline (PLCD).

RECENT FINDINGS

61 frameworks are synthesized into the dementia care and prevention in community (DCPC) framework. It highlights three levels of provision: built environment and policy supports, access and innovation, and inclusion across stages of decline. Domains of intervention include: basic needs; built environment health and accessibility; service access and use; community health infrastructure; community engagement; mental health and wellbeing; technology; end-of-life care; cultural considerations; policy, education, and resources. Personhood is not adequately represented in current built environment frameworks. This is supplemented with 14 articles on lived experiences at home and social practices that contribute to PLCD's social identity and psychological safety.

SUMMARY

Policy makers, health and built environment professionals must work together to promote "personhood in community" with PLCD. Clinicians and community staff may focus on inclusion, social identity and a sense of at-homeness as attainable outcomes despite diagnosis.

A multisite cross-sectional study of intercultural competencies in doctor of physical therapy students

BACKGROUND

Physical therapists (PTs) work in diverse communities with individuals whose identities and beliefs may differ significantly from their own. Academic institutions must include intentional curriculum aimed at graduating PTs who can skillfully navigate intercultural encounters. Being prepared to engage with difference and demonstrate skills related to intercultural competencies (ICC) will prepare entry-level PTs to provide individualized, high-quality care. Intercultural competencies are essential skills that can reduce healthcare disparities, and promote equitable and inclusive healthcare delivery. This study examined the impact of PT curricula, student demographics, and participation in intercultural learning experiences (ILEs) on students' development of ICC.

METHODS

A cross-sectional study of 8 Doctor of Physical Therapy (DPT) programs in the United States (US) compared ICC in first-year (F) and third-year students (T), and T who participated in an ILE (T + ILE) to those who did not (T-only). Subjects included 1,038 students. Outcome measures included The Inventory for Assessing the Process of Cultural Competence-among healthcare professionals-Student Version© (IAPCC-SV), and a demographic survey.

RESULTS

Independent t-tests showed that group T (mean = 64.34 ± 5.95, 95% CI: 63.78-64.90) had significantly higher IAPCC-SV total scores than group F (mean = 60.8 ± 5.54, 95% CI = 60.33-61.27, p < 0.05). Group T + ILE (mean = 65.81 ± 5.71, 95% CI = 64.91-66.71) demonstrated significantly higher IAPCC-SV total scores than group T-only (mean = 63.35 ± 5.8, 95% CI = 62.6-64.1, p = 0.039). A one-way ANOVA and post hoc comparisons showed that the 25 to 34-year age group (mean = 63.80 ± 6.04, 95% CI = 63.25-64.35, p < 0.001) and the ≥ 35-year age group (mean = 64.21 ± 5.88, 95% CI = 62.20-66.22, p < .024) had significantly higher IAPCC-SV total scores, than the 18 to 24-year age group (mean = 60.60 ± 5.41, 95% CI = 60.09-61.11). Students who identified in US census minority ethnic or racial categories (US-Mn) (mean = 63.55 ± 5.78, 95% CI = 62.75-64.35) had significantly higher IAPCC-SV total scores than students who identified in US majority ethnic or racial categories (US-Mj) (mean = 61.98 ± 5.97, 95% CI = 61.55-62.413, p = .0001).

CONCLUSIONS

Results of the study support the hypothesis that DPT programs can promote the development of intercultural skills in students. The ultimate objective of this academic preparation is to improve the student's ability to deliver equitable, person-centered healthcare upon entry into practice. Specific ICC for entry-level DPT students are not clearly defined by US physical therapy professional organizations, academic institutions, or accrediting body. Students who participated in an ILE exhibited higher levels of ICC when compared to those who did not. Findings from this study can guide curriculum development, utilization of resources, and outcomes assessment. More research is needed to examine characteristics of an ILE that could inform best practice.