South Korea has been evaluated as having the weakest primary care system. In South Korea, the health care delivery system is concentrated too heavily in the private sector. Increased concern on keeping one’s health and reducing the burden of health care costs led community members to gather and form health care co-operatives. Currently, 19 health care co-operatives have been established through residents’ participation and even more are preparing to be incorporated. As a nonprofit organization, a health care co-operative is a voluntarily established co-operative organization that tries to solve health, medical, and life problems in communities. This report examines how these health care co-operatives work in the health care system, whether they can be effective alternatives to a future health care system in South Korea, and finally the report provides recommendations. Given the fact that the nation already has national health insurance, health care co-operatives in South Korea mainly operate several clinics by focusing more on managing chronic diseases and increasing access to care, rather than developing affordable health care insurance or lobbying in policy sectors as they do in other countries. Health care co-operatives’ motivation is to keep people healthy; hence, they put a great deal of effort into delivering primary care and helping patients deal with chronic diseases. Health care co-operatives are encouraging because of their democratic structure. Health care co-operatives emphasize the idea that the owners of the health care co-operatives are in fact the members. The overall satisfaction of users in the current health care cooperatives is moderately high. Taking the lessons from the examples of health co-operatives in other countries, health care co-operatives should be able to function as a good complementary to the health care system. / text

Background Many trials in the USA, Canada, Europe and Australia have attempted to evaluate the effectiveness of preventive in-home health assessment and home care programs for older people. Trials have differed widely in their processes, including the dependence levels of subjects, assessment components and locations (clinic/home), intensity of case management (frequency of contact, length of follow-up period, scope of interventions) and methods of case management (telephone/visits). Preventive programs use valuable health resources and, although there has been inconclusive evidence of their effectiveness, programs combining preventive in-home health assessment and home care for older people have been introduced into public policy in Australia and internationally. Ongoing research is therefore essential in order to identify the positive benefits for older people, and establish their effectiveness with regard to health resource utilisation. Purpose The purpose of the study was to maintain the health status of older people living alone in the community by implementing a preventive health assessment and follow-up home care program. Research Design An experimental group was compared with a control group using a cluster randomised controlled trial methodology. Health outcomes were measured pre and post intervention, including health perception, functional ability, psychosocial status, client satisfaction, and health resource utilisation. Population and Sample The population for this study consisted of people aged 75 years and over who lived alone in Independent Living Units within managed retirement facilities, and who were highly independent in their activities of daily living. The final sample totalled 124, comprising of an experimental group (n=61) and a control group (n=63). The sample resided in South East Queensland. Intervention The intervention for the study "A Community Preventive Health Model for over 75s Living Alone" comprised of five major elements: 1) targeting before health and/or social crisis, and while community care needs were low; 2) linking clients with a community nurse; 3) comprehensive health assessments and identification of needs; 4) introduction of basic health care and community services and referrals if required; and 5) case management by three-monthly telephone contact. Assessments and case management were carried out by experienced community care registered nurses, and case management was performed for a one year period. The control group received health assessments and phone calls similar to the experimental group for data collection purposes, and to balance the risk of a Hawthorne effect due to regular contacts with participants. However all aspects of case management were omitted from all episodes of contact with the control group. For ethical reasons control group participants were supplied with a summary of their health assessment results to share with their GP if they wished. Data Collection and Instruments Measures of health perception, functional ability and psychosocial status occurred at two points (baseline and after 12 months). Measures of health resource utilisation, mortality and client satisfaction were measured after twelve months. A combination of several widely-used, valid and reliable instruments, as well as some newly developed data collection tools, were used to measure health outcomes. Data Analysis Independent group t-tests and Chi-square tests were used to examine for baseline differences between the experimental and control groups, and also to analyse health resource utilisation data at Time 2. A series of ANCOVA tests were applied to test the remaining hypotheses, so that the effects of Time 1 scores and potential confounding variables could be incorporated into the analyses. Results The experimental group and control group were homogenous at baseline for all demographic variables and all major outcome variables. The intervention model was applied for one year, with 66% (n = 40) in the experimental group having at least one unmet need identified and appropriate interventions undertaken. Only a small proportion of interventions (16%) were recorded as not being followed through by clients, and the majority (59%) resulted in needs being met or problems resolved. Results showed no benefits were gained from the program after one year for experimental group participants for the outcomes of health perception, functional ability, psychosocial status, health resource utilisation and mortality. However, the experimental group did show a statistically significantly higher level of satisfaction with care. Conclusions Comprehensive assessments performed by Registered Nurses with expertise in gerontology resulted in the identification of previously undetected unmet needs. When comprehensive assessment was combined with low intensity case management for a one year period, higher levels of client satisfaction with care were achieved. Therefore a model involving Registered Nurses with advanced knowledge and experience in aged care, working in collaboration with General Practitioners and community service organisations, could have considerable benefits in identifying unmet needs and improving client satisfaction. However, no client benefit was detected for quality of life outcomes, nor was a reduction in health resource utilisation found. This result from an Australian cohort is consistent with findings from many other international trials (Van Haastregt et al., 2000). It is possible that methodological issues are masking the effect of the intervention. Are we measuring appropriate outcomes? Are we expecting long-term outcomes in short time frames? Are we applying the model appropriately across a diverse older population? Further research to explore these questions is recommended for the future.

Four different case management programs delivered by UnitingCare Community Options (UCCO) in the eastern suburbs of Melbourne were examined against the expectations of case management as a policy solution to a range of perceived policy problems at the micro-, meso- and macro-levels. The micro-level expectations were related to client and family experiences of the service system and outcomes. At the meso-level expectations were focused on perceived service delivery problems such as poor matching of services to the needs of ‘complex’ clients including a lack of integration, flexibility and responsiveness to clients’ needs and preferences. Perceived macro-level policy problems were concerned with a variety of issues including increasing rates of institutionalisation, increasing costs to governments, lack of economic efficiency and the desire to create market or quasi-market conditions in the community care service delivery sector. (For complete abstract open document)

Thesis (M.P.H.M.))--Mahidol University, 1988.

Despite national guidelines, the management of difficult asthma remains suboptimal, and there may be opportunities for pharmacists to improve asthma outcomes. This six-month prospective, randomised, open study investigated the effects of pharmaceutical care across primary and secondary care on difficult asthma. Fifty-two patients attending a hospital difficult asthma clinic were randomised (1:1) to receive usual medical care (UC), or pharmacist interventions (PI) comprising asthma review, education, and medicines optimisation from a hospital advanced clinical pharmacist, plus follow-up targeted Medicines Use Review (t-MUR) from community pharmacists. Forty-seven patients completed the study. More interventions were performed in the PI group at baseline (total 79 vs. 34, p<0.001), but only six patients received a t-MUR. At six-months, PI were non-inferior to UC for all outcomes. The primary outcome measure was Juniper’s Asthma Control Questionnaire score and reduced (improved) from a median (IQ) score of 2.86 (2.25, 3.25) and 3.00 (1.96, 3.71) in the PI and UC groups respectively to 2.57 (1.75, 3.67) and 2.29 (1.50, 3.50). At baseline, 58.8%, 46.9% and 17.6% of patients had optimal inhaler technique using Accuhalers, Turbohalers or pMDIs; education improved technique but this was not maintained at six-months. Adherence rates < 80% were observed in 57.5% of patients at baseline, and was improved in the PI group at six-months (10/20 PI vs. 3/21 UC had adherence rates of 80-120%, p=0.020). This study demonstrates that the management of difficult asthma by specialist pharmacists is as effective as usual medical care. Future research should investigate whether pharmacist-led follow-up produces further improvements.

Between 1980 and 2000, mortality rates of children under the age of five and maternal mortality ratios declined across sub-Saharan Africa. During the same period, Kenya's mortality rates continued to rise until 2005 when the Kenyan Ministry of Health (MOH) introduced the Kenya Essential Package for Health (KEPH) in an effort to reverse its declining health indicators. The KEPH defined six service delivery levels which included the new community level, also known as level one. The Ministry of Health's plan for delivering services at the community level, known as the Community Health Strategy (CHS), called for the creation of Community Health Workers (CHWs) which the MOH hoped would produce the expected outcomes of the CHS. CHWs would be trained volunteers that were both members of the community they would serve, and selected by their community. Their training would allow them to recognize health problems, provide basic first aid, refer patients with serious problems to health facilities, conduct surveys, maintain records, provide education, and distribute supplies. In 2010, the Division of Community Health Services released an evaluation of the relevance, efficiency, and sustainability of the community health strategy. Their results showed that CHWs could produce many of the CHS's expected outcomes. In 2013, researchers from the Boston University School of Public Health and Moi University resolved to conduct a cross-sectional study for the Kenyan Ministry of Public Health and Sanitation to assess the effectiveness of the CHWs in Kajiado County. The county faced numerous health challenges and an overburdened health system. Data collection was completed over a seven-day period in June of 2013 by fourteen teams. Data was collected from 12 communities located in the areas of Rombo, Entonet, and Central Divisions of the Loitokitok sub-county within Kajiado County in rural South Kenya. Six of the selected communities had CHWs mobilized and were the intervention communities. Six communities had no registered CHWs and served as the controls. Eligibility to participate in the study was limited to permanent members of randomly selected households that housed at least one child less than five years of age and no active CHWs. Mothers of children less than five years of age were the preferred respondents. The primary and secondary outcomes were selected to address as many of the CHS's expected outcomes as possible. In an effort to compensate for the study's cross-sectional design, results were analyzed by stratifying them by each community's proximity to a hospital, the time since the CHW's last visit, and the respondent's knowledge of their CHW's name. Data was collected from 316 households, half of which were from intervention communities, and was entered into CSPro 5.0 before being exported to EpiInfo 7.1.1 for analysis. Analysis of the results suggests that the Community Health Strategy has been largely ineffective at producing its expected outcomes in Kajiado County as communities with active community health workers typically did not fare significantly better than non-CHW communities. The CHS was not entirely unsuccessful however, as mothers in CHW communities were significantly more likely to give birth at a health facility (PR: 1.41; CI: 1.15-1.72) than in non-CHW communities. Results also indicated that a community's proximity to a hospital could be a confounder in the relationship between a community's CHW status and health outcomes. The success of CHWs may have been masked by their tendency to visit households with worse health indicators more frequently.

Magister Public Health - MPH / From 2004 the Eastern Cape Department of Health (ECDoH) started implementing the new community health worker (CHW) programme in all its clinics, but so far little is known about its implementation process, its successes and challenges. The aim of this study was to assess the implementation of the new government funded CHW programme at three clinics of the Eastern Cape Province. / South Africa

Abstract Background: Access to adequate palliative care has been identified as a challenge globally, in Canada, and in the province of Ontario. While pockets of excellence exist, there is a national call for allocation of resources and implementation of best practices to improve the care for individuals with life limiting illnesses. Furthermore, the location of care along with a desire for dying at home has shifted responsibility onto family members often without the equivalent shift in community resources to meet patient and family needs. To respond to issues of access and quality, nurse practitioners (NPs) have been increasingly added to diverse practice settings across the globe and research showing how they are contributing to diverse care settings. As a strategy to improve community palliative care locally, NPs have been added to community settings in Ontario. However, because NPs are new to palliative care settings little is known about how NPs enact their role within this unique context. NP role enactment is defined as the actual activities that NPs engage in that constitute their daily work. Aim: The purpose of this study is to better understand how NPs enact their role as consultants in a specific community palliative care setting in Ontario. Methodology and Methods: A focused ethnography was conducted in one specific geographic health administration region of Ontario between July of 2018 and October of 2020. A convenience sample was used recruiting NPs from one community palliative care consultation team. Data collection methods included observation (487.5 hrs over 89 discrete observation sessions, distributed across 7 study participants), fieldnotes and semi-structured interviews with participants (n = 7 NPs). Results: The NPs enacted their role with patients by formulating relationships, that for them, facilitated a deeper understanding of the patient and family situation, strengths, challenges and desires. Using conversations and conversational skills to have difficult and important conversations, NPs facilitated future planning for patients. Conversations also included addressing questions about MAiD, which were nuanced and often about more than MAiD, also addressing fears of suffering and uncertainty. The NPs used advanced clinical judgment and skill to diagnose and treat complex and difficult to manage symptoms and supported families to understand complicated medication regimes. Valuing their role as educators, the NPs supported their peers by offering teaching and providing clinical support in complex care scenarios. Pull together disparate and loosely connected care providers, NPs created a shared understanding of patient needs. Deficiencies in community care resourcing and organization made it difficult at times for NPs to facilitate continuity in care or to build capacity. The NPs often navigated an environment where nursing staffing was transient, inconsistent and overextended and where physicians were inconsistently available to support rapidly evolving situations. Conclusion: Findings suggest that NPs have an important role to play in supporting patients and families as well as supporting their nursing and physician colleagues. Furthermore, the broader system would benefit from embedding palliative care NPs more systematically. However, broader structural enhancements like shared communication and documentation mechanisms and adequate staffing across care settings need to be addressed to maximize the potential contributions NPs are able to offer.

Despite national guidelines, the management of difficult asthma remains suboptimal, and there may be opportunities for pharmacists to improve asthma outcomes. This six-month prospective, randomised, open study investigated the effects of pharmaceutical care across primary and secondary care on difficult asthma. Fifty-two patients attending a hospital difficult asthma clinic were randomised (1:1) to receive usual medical care (UC), or pharmacist interventions (PI) comprising asthma review, education, and medicines optimisation from a hospital advanced clinical pharmacist, plus follow-up targeted Medicines Use Review (t-MUR) from community pharmacists. Forty-seven patients completed the study. More interventions were performed in the PI group at baseline (total 79 vs. 34, p<0.001), but only six patients received a t-MUR. At six-months, PI were non-inferior to UC for all outcomes. The primary outcome measure was Juniper’s Asthma Control Questionnaire score and reduced (improved) from a median (IQ) score of 2.86 (2.25, 3.25) and 3.00 (1.96, 3.71) in the PI and UC groups respectively to 2.57 (1.75, 3.67) and 2.29 (1.50, 3.50). At baseline, 58.8%, 46.9% and 17.6% of patients had optimal inhaler technique using Accuhalers, Turbohalers or pMDIs; education improved technique but this was not maintained at six-months. Adherence rates <80% were observed in 57.5% of patients at baseline, and was improved in the PI group at six-months (10/20 PI vs. 3/21 UC had adherence rates of 80-120%, p=0.020). This study demonstrates that the management of difficult asthma by specialist pharmacists is as effective as usual medical care. Future research should investigate whether pharmacist-led follow-up produces further improvements. / The Pharmaceutical Trust for Educational and Charitable Objects (PTECO) (now known as Pharmacy Research UK).

ln 1998, the Florida state legislature mandated the privatization of child welfare services. The decision to contract child welfare services to non-profit organizations was done as an effort to attain lower costs, effectiveness, and quality in service delivery. The 1998 initiative came to be known as "Community-Based Care" and was based on the idea that local communities would have incentives to be more accountable for children than the state. The federal government requires that safety be the paramount goal for all children in the child welfare system. The purpose of this study was to assess if Community-Based Care was indeed effective in this principal objective with the use of the researcher's own developed definition of "safety" and three safety performance measures relative to her definition taken from the Florida Department of Children and Families online performance dashboard application. This research focused on the Community-Based Care initiative in district 7 (Orange, Osceola, Seminole, and Brevard counties) and drew attention to the question, are district 7 's children safer now since the privatization of child welfare services? From a public management perspective, this study showed that privatized child welfare services are both capable and incapable of keeping children safe due to various factors. The findings from this study are important as they can give national, regional, and local public managers a significant and unique view on privatized child welfare services along with associated benefits and shortcomings in ensuring children's safety.