In the United States, home health care (HHC) is the most frequently used form of post-acute care services. Majority of the HHC patients are elderly and have known activities of daily living (ADL) dependencies. The role of HHC as a post-acute care provider has been emphasized under the Affordable Care Act (ACA) as it is expected that HHC services will help patients stay in the community and reduce acute care hospitalization. Urinary tract infection (UTI) -related hospitalization is an adverse patient outcome that affects elderly patients in the HHC setting. Studies examining the ADLs of HHC patients are limited. Although dependence in ADLs is a known risk factor for hospitalization, no study has assessed the relationship between ADL dependency and UTI-related hospitalization among HHC patients. This dissertation describes the ADLs of elderly patients receiving HHC services, and examines risk of UTI-related hospitalization among this population, specifically the potential risk of ADL dependency. In Chapter One, the problems of UTI-related hospitalization and ADL dependency are introduced and their significance is described. In Chapter Two, an integrative review of the literature describing methods of assessing ADLs in skilled nursing facilities (SNF) and HHC are described. In Chapter Three, a cross-sectional study elucidating the risk factors for severe ADL dependency and predictors of ADL improvement among HHC patients is reported. In Chapter Four, the risk factors for UTI-related hospitalization among HHC patients is reported. In Chapter Five, findings of the three studies are summarized and conclusions are provided including strengths, limitations, and implications for practice and policy. Andersen’s Behavioral Model was the theoretical framework used for this study. The Andersen model posits that health care utilization is a function of patients predisposing (e.g. age, gender, race/ethnicity), enabling (e.g. living alone, insurance status, living condition, primary care giver) and need factors (e.g. ADL dependency level, comorbidity, impaired decision making). This model fits this dissertation because evidence shows that health care utilization (UTI-related hospitalizations) depends on predisposing, enabling and need factors. This was a retrospective cohort research design study based on secondary analysis of the Outcome and Assessment Information Set (OASIS) data set of 154,801 beneficiaries who received home health care services in 2013. Descriptive statistics, bivariate analysis, and multivariable logistic regression analyses were conducted to examine the effect of each individual variable on the outcomes of interest (severe ADL dependency, ADL improvement and UTI-related hospitalizations). The study population was elderly (mean age 77 years), mostly female (65%) and white (79.8%). Key findings indicated that, (a) over 60% of patients had severe ADL dependency, and impaired decision making is a strong predictor of severe ADL dependency, (b) Overall, patients experienced ADL improvement from admission to discharge. However, blacks experienced significantly less ADL improvement compared to Whites. Longer HHC length of stay was also associated with ADL improvement, and (c) For the UTI-related hospitalization outcome model, multivariable analysis showed that Medicaid insurance, severe ADL dependency and impaired decision making was associated with increased risk for UTI-related hospitalization

The place of birth for First Nations is a contested issue in Canada today. For the past 30 years, the practice of removing women from communities to birth in urban centre hospitals, called maternal evacuation, has been a part of the dialogue between First Nation organisations, the Canadian state, policy makers, and Academics. Concurrent to the practice of evacuation, there is a movement to repatriate birth to First Nations through Aboriginal midwifery. This multi-sited ethnography is based on 15 months of fieldwork in Manitoba, Canada and follows the practice of evacuation and the establishment of an Aboriginal midwifery practice in one northern First Nation community. The ethnography reveals that both evacuation and returning birth is a complex, multi-layered negotiation of risk between various actors. From women and their families, doctors and nurses, midwives and other health professionals: the management of risk is at the forefront of this discussion. This study takes into account how risk is imagined, created and targeted in the practice of maternity care for First Nations in Manitoba. The concept of risk and risk management takes on multiple forms as the practice of evacuation moves from the community to the urban centre, from federal land to provincial land, from the hospital to the board room. Through participation observation in the places of birth and interviews with the range of actors involved in maternity care for First Nations, this ethnography reveals the messiness of the concept of risk, and identifies where these actors collude and conflict on the topic of evacuation and repatriation. The study also traces how the state has co-opted the language of risk on all sides of this debate and how the bodies of the First Nations mother and midwife becomes sites in which these contestations over risk, responsibility, knowledge and safety occur.

A atenção domiciliar (AD) é uma modalidade de atenção à saúde que visa reorganizar o processo de trabalho das equipes de diferentes serviços, reduzir a demanda por atendimento hospitalar, ampliar a autonomia dos usuários e de seus familiares, além de proporcionar a integralidade da atenção. No âmbito do sistema único de saúde, a AD é operacionalizada, na atenção primária, por meio da Estratégia de Saúde da Família (ESF) e do programa Agentes Comunitários de Saúde (PACS) e pelo programa Melhor em Casa que organiza os Serviços de Atenção Domiciliar (SAD). O estudo teve como objetivo caracterizar os indivíduos assistidos pela equipe multiprofissional de atenção domiciliar (EMAD) do município de Ribeirão Preto, SP. Trata-se de um estudo epidemiológico descritivo que utilizou um formulário e o domínio motor da Medida de Independência Funcional (MIF) para obter o perfil e a incapacidade funcional, respectivamente. Participaram do estudo 58 indivíduos maiores de 18 anos, residentes na área de abrangência e cadastrados na EMAD entre o período 1 de janeiro à 12 de agosto de 2013. Para a realização da análise dos dados, utilizou-se o aplicativo Stata 9.0. Além da análise descritiva, realizou-se o teste de comparação de médias entre os grupos por meio do teste t de Student e ANOVA one way. Os indivíduos caracterizam-se pelo discreto predomínio do sexo masculino (51%), idosos (79,4%), sendo que 91,4% estão inseridos na modalidade de atenção domiciliar AD2 e 87,9% receberam a visita domiciliar do enfermeiro. Houve o predomínio do acesso à atenção domiciliar por demanda espontânea (48,2%) e 41,4% dos participantes realizavam fisioterapia, no momento da entrevista, no SUS (79,2%). Além disso, 37,6% necessitavam usar fraldas e equipamentos (91,4%), sendo este a cadeira de rodas (39,6%) e a maioria foi adquirido por meio do SUS (51%). Quanto aos diagnósticos, os mais frequentes são o acidente vascular encefálico (11%) e a doença pulmonar obstrutiva crônica (11%). Em relação aos cuidadores, 80,4% são do sexo feminino, idosos (41%), com o grau de parentesco esposa (37,6%). Entre aqueles que cuidam de indivíduos que fazem ou fizeram fisioterapia, 90% receberam orientações. No que tange à MIF, a média do domínio motor foi de 50,5 pontos. A maior categoria foi alimentação, sendo que 43,1% apresentaram independência completa, e a menor foi escadas, com 58,6% de indivíduos que necessitaram de ajuda total. O perfil dos indivíduos assistidos pela EMAD e a utilização de uma ferramenta que avalia a incapacidade funcional dos mesmos evidenciaram aspectos propositivos para potencializar o planejamento e a operacionalização da assistência e do processo de trabalho da EMAD. / Home care (AD) is a type of health care that aims to reorganize the work process of the different services teams, reduce the demand for hospital attendance, increase the autonomy of the users and of their family members, in addition to providing comprehensive care. Within the framework of the public health system, AD is operationalized, in the primary care, by means of the Family Health Strategy (ESF), of the Community Health Agents (PACS) program and by the Better Home program which organizes the Homecare Services (SAD). The study aimed at characterizing the individuals assisted by the multidisciplinary team of home care in the city of Ribeirão Preto, Brazil. This is a descriptive epidemiological study which made use of a form and of the motor domain included in the Functional Independence Measure (MIF) to get the profile and the functional disability, respectively. The study included 58 patients over 18 years old living in the area covered and enrolled in the EMAD in the period between January 1 to August 12, 2013. For carrying out the data analysis, Stata 9.0 application was used. In addition to the descriptive analysis two variables or more were compared using the t Student and ANOVA one way test. Individuals are characterized by a slight predominance of males (51%), elderly (79.4%), and 91.4% are inserted into the modality of home care AD2 and 87.9% received home visits of the nurse. There was a predominance of access to home care by spontaneous demand (48.2%) and 41.4% of the participants performed physical therapy at the time of interview, in the SUS (79.2%). Furthermore, 37.6% needed to wear diapers and equipment (91.4%), these being the wheelchair (39.6%) and most had been obtained through the SUS (51%). With regard to diagnosis, the most frequent are the stroke (11%) and the chronic obstructive pulmonary disease (11%). Regarding caregivers, 80.4% are female, elderly (41%), with the degree of relationship wife (37.6%). Among those who took care of individuals who are undergoing or underwent physical therapy, 90% received guidance. Concerning the MIF, the average of motor domain was of 50.5 points. The largest category was feeding, and 43.1% had complete independence, and the lowest was stairs, with 58.6% of individuals requiring total assistance. The profile of the individuals assisted by the EMAD and the use of a tool that evaluates their functional disability highlighted propositive aspects so as to enhance the planning and the operationalization of the assistance and of the EMAD working process.

Assembly Bill 12 was passed into law for the purpose of preparing foster youth for the transition into adulthood and provided extended support services and transitional support up to the age of 21. This qualitative study focuses on the experiences and outcome of foster youth who are participating in extended care services. Key findings were identified in the areas of education, social and emotional support, and living arrangements. These key findings provide the social workers with a better understanding of the difficulties associated with the complexity involving the transition to young adulthood. The implications of key findings have resulted in potential contributions to social work at the micro level. Suggestions include: Social worker’s increase their knowledge of the supportive resources that are appropriate for the young adult foster youth and to be well versed in the requirements of AB 12. It is further suggested, at the macro level, curriculums be developed that will connect the traditional role of social work to characteristics involving coaching and mentoring.

Thesis (M.ED (Continuing care and Training)) --University of Limpopo, 2010. / This report describes the research conducted at Phuthanang Home Based Care in Mankweng Township in the Limpopo Province of South Africa. Mankweng constitute a mixture of both formal and informal settlements, both urban and rural settlements and is situated about 32 km to the east of Polokwane which is the provincial capital for Limpopo. The aim of the research was to investigate the challenges faced by Phuthanang Home Based Care (HBC) in providing care and training in Mankweng Township. Having established the challenges faced by Phuthanang Home Based Care the researcher intended to recommend possible solutions to these problems. In an attempt to meet the above mentioned aims; the following research questions were formulated: Main question: • What are the challenges faced by Phuthanang Home Based Care in providing care and training? The following sub questions were asked derived from the main question above: • What are the aims and objectives of Phuthanang Home Based Care? • What are the existing services and training programmes offered by caregivers at Phuthanang Home Based Care? • What are the experiences of caregivers in relation to training for Home Based Care? • What is the level of community participation in Phuthanang Home Based Care activities? Chapter two outlines the theoretical framework based on relevant literature on the subject under study. I also formulated assumptions about the challenges that could be facing home based care programmes; these include issues such as lack of funds, inadequate training and stigmatisation among others. In this chapter key concepts were defined and operationalised to suit this research and to avoid ambiguity in interpretation. Chapter three outlines the research methodology. It clearly explains the research design used, data collection and data analysis. This study was purely qualitative and took the form of a single case study design. This enabled a detailed and intensive study of the case as it exists in its natural setting. Data was collected according to two streams which are fieldwork and document analysis. In fieldwork the researcher used multiple data collection techniques which include open ended interviews with the Project Coordinator, Administrator and Caregivers. The other technique used was observations. A focus group interview with the Coordinator, Administrator and four caregivers was also employed during fieldwork. A data matrix was used in the analysis of data. Chapter four constitutes the presentation and analysis of findings of the study. In this chapter; I describe the setting of the organisation in terms of location, historical background as well as its aims and services rendered. It outlines the challenges encountered by Phuthanang Home Based Care in providing care and training based on the results from document analysis, interviews, observations and focus group interview with the Caregivers’, the Administrator and the Coordinator of Phuthanang Home Based Care. The findings will suggest recommendations that will help bolster the state of care giving, training, and improve the way care is rendered to people living with HIV/AIDS and other terminal illness. Chapter five presents my conclusions by outlining the challenges faced by Phuthanang Home Based Care in providing care and training. This chapter also presents recommendations that might contribute towards finding solutions to the problems faced by Phuthanang Home Based Care. After the recommendations I presented a section on reflections of the research process. In conclusion to this chapter I recommend further research on the challenges faced by home based care organisations which have an element of training in poor communities such as townships, informal settlements and rural areas.

Thesis (M.A. (Clinical psychology)) --University of Limpopo, 2012 / A number of studies have indicated that help-seeking pathways followed by individuals suffering from mental disorders and other conditions of ill-health are not random, but are structured by a range of psychosocial and cultural factors. The quality and seriousness of the distress provide the impetus to the pathway, but its direction and duration is shaped by the convergence of psychosocial and cultural factors. This study explored the help-seeking pathways followed by patients receiving mental health care services in Polokwane-Mankweng Hospital Complex (PMHC) in Limpopo Province (South Africa). A qualitative approach was followed and participants were selected through purposive sampling. Ten participants (5 males and 5 females) who are receiving mental health care services at PMHC and were apsychotic at the time were recruited to the study. Data were collected using semi-structured interviews and analyzed using content analysis. The following psychological themes emerged from the study: participants’ subjective notions of the events or factors that could have led to their mental illness; their explanations of mental illness; the reasons for entering the mental health care system; the pathways they followed before receiving mental health services in the hospital; concurrent use of hospital mental health services and other services; their experiences of living with mental illness; and, the role of significant others in this regard. The study revealed that various agencies and providers of health care are visited by individuals suffering from mental illness and that there is also some evidence of concurrent use of these services, i.e., Western and African. The findings emphasize that help-seeking pathways are mainly determined by the perceived causes of the illness, which are derived from cultural ideologies.

Thesis Summary COMMUNITY-BASED EVIDENCE ABOUT THE HEALTH CARE SYSTEM IN RURAL VIETNAM This thesis contributes further evidence for policy-making on health care system reform in Vietnam. The author aims to provide insights into the provincial rural health system ten years after health sector reform was launched, through assessing availability of health care services, patterns of access of health care services when people are ill, and the costs of care and the performance of public and private providers. The following questions are addressed: 1. Which health care providers, i.e., public or private, are dominant in providing curative services to rural people when they are ill? 2. How much inequality exists between the poor and the non-poor in access to health care services in general, and public health care services in particular, when they are ill? Which factors explain the gap in use of services between the poor and the non-poor? 3. What policy and strategies should Vietnam consider implementing in order to reach the goals of better equity and quality of care for rural populations? These research questions were addressed using community-based survey data collected in 2001 from Hung Yen province, in which three components of the system -- user, provider, and community context -- are described and linked together in analysis. In addition, a supplementary health care provider survey collected in 1999 in three other provinces (Thai Binh, Binh Thuan, An Giang) is used to provide evidence about the availability of healthcare services in general and of private health care providers. The thesis is divided into two parts with a total of 9 chapters. Part A (chapters 1-4) provides background for the research questions raised about the commune health care system in rural Vietnam, the framework used in evaluating this health care system, and the data sources used in this thesis. Part B consists of five chapters (chapters 5-9) that presents research results on various dimensions of the rural health care system. It also provides conclusions on the health care system in rural Vietnam, and proposes policies and strategies for strengthening this system toward equity and efficiency. Chapter 1 presents the research rationale and objectives. It examine the international context of health sytem research, the Vietnamese context of health sector reform since the ?Doi Moi?, and the current trend of health sector reform, and the previous research done so far related to health system reform in Vietnam. The research questions addressed by the thesis are presented at the end of this chapter. Chapter 2 describes the historical development of rural health care system in Vietnam. It startes with an overview of social changes in the rural Vietnam including revolution and wars and both the positive and negative impacts on the health of rural populations. The evolution of the rural health care system is then outlined, from the single national provider system (public) to the reforms of 1989 where a public-private model for rural health care was introduced. Chapter 3 provides frameworks for analysis of availability, health accessibility, quality and efficiency of the rural health care system, and inequality of healthcare service utilization. It starts with a statement about the concept of health care system used in this thesis. Then five theoretical models for assessing the health care systems (health service utilization model, triangular model, model for improve quality of care, health care services as an open system, and the World Bank?s framework for assessing the performance of the health sector in serving the poor) are presented. The strategy of using these frameworks to assess the rural health system in Vietnam is explained. The link between the research questions and methodology used was described. Chapter 4 provides detailed descriptions of the two data sources and analysis strategies used to address the thesis research questions. The design and data collection methods of the health care provider surveys and household surveys in the four provinces are presented, followed by the specific strategy of using information from each database for the thesis objectives. The chapter ends with a presentation of the overall strategy of data analysis. Chapter 5 assesses availability of the commune health care system in rural areas of Vietnam with empirical data from all the four provinces. The findings show that both public and private health care providers are available in rural Vietnam, with a slight dominance of private services. There were commune health centers (CHCs) in all communes with at least one private physician in the majority of the communes. The average number of private providers ranged from 2.7 to 7.7 per 10,000 population in the four provinces. Many of them practiced without formal registration and under limited government supervision. Chapter 6 estimates perceived need of care by measuring the burden of non-fatal health problems with data from 3,498 people of 900 households randomly selected in Hung Yen province. Compared to the better off, the poor suffered significantly more long-term health ailments (an excess of 78 cases per thousand population) and more short-term morbidity (an excess of 112 cases per thousand population). The study found that the gap in household wealth index contributed approximately 55% of the explained gap in prevalence of long-term health conditions, equivalent to the gap of 60 cases per thousand population, and also 55% of the explained gap in short-term morbidity, equivalent to the gap of 38 cases per thousand population between the two groups based on the Oaxaca decomposition (D=0). Gaps in education, gender, health insurance, and occupation played a minor role in explaining the wealth-related inequalities in non-fatal health burden. Chapter 7 describes patterns of use of health care services when people are ill by type of providers, by type of illnesses, and by poverty ranking level. Findings in this chapter reveal a high level of self-medication, greater access to private than public services, and less use of public services or any health care services by the poor in comparison to the better off. Self-funded purchases of drugs for self-medication and use of private curative services were even common in those with health insurance. A single private provider contact for treatment of illness costs on average 2.6% of the total annual expenditure per capita, and self-medication with drugs purchased at private health care facilities costs 1.0% of total annual expenditure per capita, similarly these at district hospitals and commune heath centers were similar. Finally, the percentage of ill people with no access to any health care providers during their illness episode was high, regardless of their wealth or health insurance status. Chapter 8 compares the quality of private and public health services using a framework proposed by the World Bank for evaluating the quality of health care in developing countries. Results from this chapter show that technical quality of care was poorer in the private sector than among public providers while costs for patients were similar in private and public facilities, and client satisfaction was similar in public and private facilities. Chapter 9 summarizes the results from Chapters 5-8 to identify the main characteristics of the rural health system with a view to system sustainability and proposes policies and strategies for strengthening the quality of the public health care sector and improving its equity and efficiency. The main features of the current rural health care system in Vietnam identified from the community-based evidence found in this research are: (1) primary health care services are available and there is equality in physical access; (2) financial resources for the CHC system are diversified with Government resources the key contributors; (3) private health care providers for outpatient services, public providers for inpatient services; (4) quality of treatment services is below the national standard; (5) public services are available but under utilized; (6) the rural health care system is not a pro-poor system; (7) direct payment is the main component of total health care expenditure; and (8) the economic relationship of the rural health care system is a user-provider model rather than a health care triangular model. Nine recommendations to strengthen the rural health care system were then developed based on a critical view of the objectives of the Vietnam health sector reform for the period 2001-2010 supported by evidence found in this research. This chapter ends with a section to remind readers about the limitations of this study and then proposes future research with specific questions covering three main dimensions of health care system reform in Vietnam (accessibility, quality of care, and overall management). A study with a sentinel site approach to follow-up the impact of the social and health sector reform policies is also proposed to help the government make timely adjustments to their policies to protect the poor. / PhD Doctorate

<p>Purpose: Our aim is to get an insight on how home care workers experience, handle and looks upon their work. We also want to form an opinion of how home care workers experience the relationship to the clients they meet.</p><p>Questions: How does home care workers experience their daily work with their clients? Home care workers daily meet many different sorts of clients with different needs, how do they handle this? What kind of support does home care workers get in their work?</p><p>Method: A qualitative design with semistructured interviews.</p><p>Conclusion: The most central conclusion from all of our interviews were: that home care service workers has a very stressful and demanding occupation, that the work has a low status, that the personnel has a big responsibility for the wellbeing of other people and that they often find their work satisfying and fun. To have someone to talk to and exchange ideas with was also mentioned by the informants as a vital part of feeling support in their work. From the Antonovskys theory, a sense of coherence, and Goffmans views of the society, we also find that the larger part of our informants feel a high sense of coherence and that when they have to adjust to their different caretakers they play different roles.</p>

<p>The aim of the present thesis is to evaluate the effects of an Intensified Primary Health Care (IPHC) intervention on GPs' and home care nurses' possibilities to monitor and support cancer patients, and on cancer patients utilisation of medical services. A further aim is to identify determinants of cancer patients' utilisation of such services. A total of 485 patients newly diagnosed with breast, colorectal, gastric or prostate cancer were randomised to the intervention or to a control group. The follow-up period was 24 months for all patients.</p><p>Patients randomised to the IPHC were referred to the home care nurse. The home care nurse and the GP received copies of the medical record each time the patient was discharged from hospital after a period of in-patient care, or had visited a specialist out-patient clinic. In addition to this, recurrent education and supervision in cancer care were arranged.</p><p>The IPHC resulted in a marked increase of home care nurse follow-up contacts. The majority of control patients (74%) reported no such contacts, while 89% of IPHC patients reported this. High age (=80 yr) was the strongest predictor within the IPHC group for reporting a continuing home care nurse contact. Furthermore, the IPHC increased GPs' knowledge about patients' disease and treatments, and appeared to facilitate their possibilities to support the patients. The IPHC reduced the utilisation of specialist care among elderly cancer patients. The number of days of hospitalisation for older patients (=70 yr) randomised to the IPHC were 393 less than for older control patients during the 3 first months after inclusion. Regression analyses defined diagnosis, extensive treatment, comorbidity, low functional status, pain and socio-economic factors as predictors of a high utilisation of medical services.</p>

This study utilized a qualitative approach to explore how Healthy Start home visiting services affect participants' parenting and lives in general. The purpose of this study was to explore both the intended and unintended outcomes of Healthy Start, using the theory of transformative learning. This theory postulates that through education individuals examine their thoughts, beliefs, and behaviors. This self-examination results in changes in self-perception that can impact lives in many unexpected ways. Through interviews with 20 families, who had participated in Healthy Start for at least 6 months, families reported both anticipated and unanticipated changes in their lives. It was found that Healthy Start influences a variety of positive outcomes for families. Previous quantitative findings were supported. According to the parents interviewed, Healthy Start is achieving its intended outcomes and goals. Parents reported greater ability to access health care services, improvements in their home learning environment, and improved interactions with their child. Parents also indicated increased knowledge of child development and community resources. Findings also provided support for the occurrence of transformative learning. Interviewed parents indicated that their involvement with Healthy Start impacted more than just their parenting. Through a supportive relationship and goal setting, the participants were able to reach beyond basic parent education. The interviews suggest that the mechanism for transformative learning lies in the supportive, non-threatening relationship that develops between parent and home visitor. This supportive relationship, in addition to guided goals setting, enhances a parent's feelings of self-efficacy and increases their ability to make life changes and persist in the face of challenges. Parents reported improved relationships with others, increased feelings of confidence, and the ability to accomplish otherwise unattainable things. / Graduation date: 2002