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

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.

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.

<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>

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. 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. 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.

Sammanfattning Inledning: Allt mer av distriktssköterskans omvårdnadsarbete går mot att vårda människor i livets slut. Döendet för med sig existentiella tankar som kan orsaka ångest hos patienter och deras närstående. Bakgrund: Palliativ vård förebygger och lindrar lidande genom tidig upptäckt, noggrann analys och behandling av smärta och andra fysiska, psykosociala och existentiella problem. Den innefattar även stöd till närstående under och efter vårdtiden. Syftet med studien var att undersöka hur distriktssköterskor upplever ångest i livets slutskede, hos döende patienter, deras närstående och sig själva, med fokus på orsaker Metod: Studien har en kvalitativ design där fyra fokusgruppsintervjuer har genomförts med sammanlagt 20 distriktssköterskor. Kvalitativ innehållsanalys användes för att analysera datamaterialet. Resultat: Sjuksköterskorna beskrev att brist på trygghet och tillit skapade ångest för patienter och deras närstående. Känslor av otillräcklighet gav ångest hos sjuksköterskorna. Mötet med döden väckte existentiella tankar och utlöste ångest hos patienter, deras närstående och sjuksköterskorna. Kontinuitet och tillgänglighet var viktiga för att ge trygghet. Sjuksköterskorna ansåg att bästa sättet att bearbeta och hantera svåra situationer var att samtala med kollegor och stödja varandra. Konklusion: Studien visar att tid och trygghet är centralt för att lindra ångest hos patienter, närstående och distriktssköterskor i palliativ vård. Palliativ vård är utmanade, kräver mod och kreativitet. Nyckelord: Palliativ vård, hemsjukvård, distriktssköterskor, ångest / Introduction: Today, community health nurses work increasingly more with the provision of end-of-life care. Dying and the existential dimension may cause anxiety in patients and their family. Background: Palliative care prevents and relieves suffering through early detection, careful analysis and treatment of pain and other physical, psychosocial and existential problems. It also includes support for the family during and after the period of care. Aim: The purpose of this study was to examine how community health nurses experienced anxiety during the last phase of a patient’s life. The nurses' experience of anxiety in dying patients, their families and in the nurses themselves was examined with a focus on the causes and attitudes. Design and method: The study used a qualitative design where four focus group interviews were conducted with 20 community health nurses. The data was analyzed using qualitative content analysis. Results: Nurses felt that lack of safeness and confidence created anxiety in patients and their families. Feelings of inadequacy created anxiety among nurses. According to the nurses encounter with death brought on existential thoughts and created anxiety among patients, their families and the nurses themselves. Continuity and accessibility were important to provide safeness. The nurses felt that the best way to process and handle difficult situations was through discussion with colleagues and by giving each other support. Conclusion: This study shows that according to nurses’ experiences, time and safeness are central to relieve anxiety in patients, family members and community health nurses in palliative care. Palliative care is challenging, demands courage and creativity.

Syftet var att undersöka hur sjuksköterskor, inom hemsjukvården, uppfattar sin egen kompetens och sitt behov av stöd i relation till sina arbetsuppgifter. Metoden är en enkätstudie. Enkäten förmedlades via e-post. Urvalet utgjordes av 131 sjuksköterskor inom hemsjukvården i en större stad i Mellansverige, varav 15 av sjuksköterskorna deltog i studien. Resultatet visar att den egenuppfattade kompetensen hos deltagarna var hög och majoriteten av de sjuksköterskor som medverkade känner sig trygga i att arbeta självständigt och att utföra sitt uppdrag som sjuksköterska inom hemsjukvården. Stödet från sjuksköterskekollegor anses som viktigt, dock önskas mer tid eller möjlighet att diskutera patienters vårdproblem. Att ha en bra arbetsrelation med sin läkare upplevs som mycket viktigt hos deltagarna. Majoriteten önskade ett mer omfattande samarbete med läkaren. Slutsatsen är att sjuksköterskorna inom studien uppfattade sin egen kompetens som bra och samtliga känner sig bekväma med att jobba självständigt. Att ha bra arbetsrelationer med kollegor och läkare är mycket viktigt för studiedeltagarna däremot anser några deltagare att de inte alltid kan räkna med sina sjuksköterskekollegor i svåra situationer. Majoriteten av sjuksköterskorna önskade ett mer omfattande samarbete med läkaren. Urvalet i studien var litet och bortfallet var stort, därför behövs en mer omfattande studie inom området. / Aim: The purpose of this study was to describe registered nurses (RNs) perceptions of their competence within the municipal elderly care and their need of support in relation to their job assignment. Method: A questionnaire survey. The questionnaire was delivered electronically as an email. The sample consist of 131 RNs within the municipal elderly care in a large city in the middle of Sweden. 15 of the RNs engaged in the study. Results: The RNs perceive their competence as high and the majority feel secure to perform their job assignment. The support from their nurse colleagues is considered important, however more time and opportunities to discuss care issues is desirable. A good labour relation with the physician is considered important among the respondents. The majority wishes a better physician-nurse teamwork. Conclusion: The RNs perceive their competence as good and the majority feel secure to perform their job assignment independent. A good labour relation with the colleagues and physician is considered important. However some RNs doesn’t believe that they can count on their colleagues in difficult situations. The majority of the RNs desires increased teamwork with the physician. Future interventions are needed with larger sample and a lesser falling off.

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. 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? Method: A qualitative design with semistructured interviews. 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.

Infection control practices are a critical element in home-based care for people living with HIV/AIDS. It involves principles and procedures used to minimize the risk of spreading infections in home-based care. Infection control practices help to prevent morbidity, mortality rates and improve health for the volunteer caregivers and the patients. However, most previous studies on home-based care have focused on burdens of care, perceptions of rewards, quality of care and challenges faced by caregivers. Therefore, it is not clear how and to what extent infection control practices are carried out in home-based care. The purpose of this study is to explore the experiences of home-based care coordinators and volunteer caregivers regarding infection control practices in home-based care. Qualitative interviews were conducted with ten home-based care coordinators/project managers and ten focus group discussions were conducted with volunteer caregivers. An interview guide and a focus group schedule with open ended questions were used. Volunteer caregivers in home-based care organizations were faced with practical challenges regarding infection control practices that posed a threat to their work and health. The received insufficient infection control material resources such as gloves, masks and sanitizers. They also mentioned to have received poor quality gloves that easily broke, poor quality aprons that were not tight; easily blown by the wind and also thin masks that could not filter the bad odour. Other challenges that they faced included, insufficient water supply; insufficient knowledge on infection control and lack of cooperation from some patients and some family members regarding the use of protective clothing especially gloves and masks. Most volunteer caregivers were ridiculed by some family, community members and friends. Sometimes they could not access some patient due to HIV related stigma and discrimination. However, volunteers developed various strategies of dealing with these challenges such as replacing the torn gloves with plastics, carrying 2.5 litres of water, educating patients and family members about the importance of wearing gloves and practicing infection control. These findings require the government, NGOs, funders and donors to form a forum with volunteer caregivers to discuss the supply of materials. They need to establish a central administration that will be responsible for allocating adequate and quality materials for infection control practices. This central administration should also be responsible for supervising HBCOs including monitoring and evaluating infection control practices. / Thesis (M.A.)-University of KwaZulu-Natal, Durban, 2012.