Parenteral nutrition is a therapy that supplies patients with all their nutritional requirements intravenously, thus eliminating the need for oral alimentation. The therapy was first introduced in the United States to hospitalized patients in the late 1960's. The benefit of long-term parenteral nutrition was soon recognized, and a program for ambulatory or home parenteral nutrition (HPN) was developed. In British Columbia, the first HPN patient was begun on such therapy in 1972. Since then, more than 50 British Columbians have received HPN. In March 1986, there were 24 patients on the program. The average annual cost per patient was $29,278 and the total 1986 operating budget was $702,660, not including costs for equipment or hospital training. Up to now, there has been no analytical assessment of the HPN program in B.C. This thesis describes the current home parenteral nutrition situation in B.C. and makes recommendations for its improvement. It looks at overall clinical outcomes (both physiological and psychosocial), at the results with different subgroups of the population, and at the cost of the HPN program in B.C., and also considers the potential of this therapy for children. In Chapter 2, the literature is reviewed and organized to cover a general description of HPN therapy, a summary of the results obtained from a number of academic centers, a review of HPN therapy in childhood and the psychosocial issues of concern to HPN patients. Chapter 3 provides a detailed description of the current HPN situation in B.C. The study methodology is described in Chapter 4 and the results in Chapter 5. The study is a descriptive analysis. Due to the lack of any obvious control group, a comparative evaluation per se was not possible. However, a Seattle study by Robb, reported in 1983, does allow for some comparison. The main sources of data were: 1. A Patient Questionnaire: The questionnaire was modelled on that used by the Seattle group. 23 B.C. patients, either on HPN at the time of questioning, or previously on the therapy, were surveyed. 19 (83%) responded. 2. A Health Professional Questionnaire: This questionnaire was compiled especially for and sent to all known health care workers in B.C. in the HPN field. 19 professionals, including physicians, nurses, pharmacists, dieticians, and administrators, were surveyed. 17 responded for a response rate of 89%. The patient survey provided basic demographic information, a description of HPN therapy received, as well as data on clinical outcomes, both physiological and psychosocial. Results showed that patient age, length of time on HPN, numbers of hours per week devoted to HPN, occupation and place of residence were the most important variables for predicting patient outcomes. Thus, patients that were older, had been on HPN less than one year, or spent more than 80 hours per week preparing and administering HPN solutions, had more physiological complaints and showed interference with more daily activities and personal relationships. Patients who were employed, rated the HPN experience more positively. Overall, patients found the HPN experience to be a positive one, although this was not true for a small group of patients. Data also indicated that B.C. patients achieved physiological results similar to the Seattle group, and to other centers reported in the literature, but appeared to have more interference with daily activities and personal relationships than did patients from the Seattle study. The health professional survey indicated that professionals considered the current situation in B.C. to be good with respect to patient training and the complication rate achieved. However, patient follow-up and the psychosocial support provided to patients were rated only fair to poor. These health care professionals cited problems with the program's organization, the need to standardize service to all patients, and the need to provide patients with pre-mixed solutions. In conclusion, some recommendations are made for improvement in the B.C. HPN program. / Medicine, Faculty of / Population and Public Health (SPPH), School of / Graduate

The effect of frequency of nursing home contact on family perceptions of quality care is the focus of this research. A family member characteristic, such as geographic distance from the nursing home, affects his or her frequency of contact with the nursing home. Frequency of contact, in turn, affects family perceptions of the care his or her loved one receives in the nursing home. The theoretical framework for this study is based on Allport's intergroup contact theory, which posits that when four contact conditions - institutional support, equal status, common goals, and intergroup cooperation - are present in an intergroup situation, a reduction in anxiety between groups is likely to occur. Regression analysis tested the stated hypotheses using survey data collected from 275 family members of residents in 10 Dallas-Ft. Worth area nursing homes. This study is among the first to quantify family geographic distance, finding that family geographic distance is a significant negative predictor of nursing home contact. Additionally, results build on Allport's theory by extending its' usefulness to nursing home organizations in two distinct ways. First, findings support Allport's premise that contact alone between groups - i.e., family members and nursing home staff - is insufficient for increasing or decreasing family perceptions of nursing home care. Second, three of the four contact conditions included in Allport's theory were statistically supported by the data. In sum, findings of this research provide nursing homes with an empirically tested model for improving family perceptions of quality nursing home care.

Bibliography: leaves 79-94. / The field of related foster care has to a large extent been neglected. Related foster care is regarded with considerable scepticism and ambivalence by many social workers because of a number of pitfalls which are often associated with such placements. The aim of this study is to explore the relative merits of related and unrelated foster placements, and thus to enhance knowledge in this area and so improve service delivery to foster children, their parents, by foster parents and child and family welfare agencies. A literature survey was undertaken during which it was evident that the field of related foster care has received little attention in both literature and research. The literature studies have highlighted some of the pros and cons of related and unrelated foster placements. A questionnaire was constructed and administered to a sample of related and unrelated foster parents. A descriptive analysis was made of the results with the focus being on the behaviour and academic functioning of the children. The overall findings in this study showed that children fostered by relatives seemed to be doing at least the same as, and in some aspects better than, those children fostered by recruited unrelated foster parents. Over a 11 there appeared to be some significant advantages for those children who were being fostered by relatives.

Many children are unable to remain in the care of their biological families, and often the only solution is to commit them to long-term foster-care in order to ensure their emotional, physical and social well-being. Children in long-term foster-care in South Africa are subject to impermanence in their living arrangements. Long-term foster-care, in reality, is for an unlimited time-period, during which the biological family can at any time rehabilitate itself and petition the court for the return of the child. This is further exacerbated by childcare legislation which does not provide for legal guardianship in foster-care through termination of parental rights and reconstruction services to natural parents. At present, the move in childcare practice is to institute permanency planning philosophy and tennets for children placed in foster-care in order for them to experience stability and continuity of relationships and family life. The move to implement permanency planning in foster-care is new in South Africa and is not supported through South African research and legislative procedures. There is a definite need for the development of a guideline which will exclude natural parents from resuming the care of their placed child, thereby advocating foster care as the next option of permanency for a child, given the situation where adoption is not a feasible alternative. This guideline can hopefully be utilised to gather data motivating for legal guardianship in foster care, through termination of parental rights, thereby assuring the long-term foster child of permanency in his living arrangements.

The deinstitutionalization movement has challenged administrators and professionals to develop new methods of providing services to handicapped clients who reside in geographically dispersed areas. Geographic dispersion limits the frequency of direct contact with clients and increases dependency on parents or paraprofessionals for program implementation and data collection. A difficulty is that these direct service providers' program implementation or data collection efforts may be reinforced infrequently. This problem may be especially acute when the service recipients are severely or profoundly handicapped. Such individuals have slow rates of learning thus making it difficult for the service providers to discern progress.

Background Population aging has led to an increasing number of older adults living in the community with complex care needs such as functional limitations, cognitive impairment, and multimorbidity. These individuals may need help to remain in their homes, which has created a growing demand for home care. Strategies to manage complex older adults such as home care patients safely in the community typically emphasize robust and integrated primary care. The objective of this thesis is to explore how specific measures of quality in primary care are associated with emergency department use among home care patients in Ontario. Methods I conducted four studies on varying subsets of the same population-based retrospective cohort of long-stay home care patients assessed in Ontario from 2014-2016. The first study was a descriptive examination of the entire cohort that characterized their primary care and other health system use. The second was a case-crossover study among home nursing patients examining whether access to afterhours care modifies the association between home nursing visits and same-day emergency department visits. The third study looked at physician-level provision of primary care home visits and its association with emergency department visits among home care patients with extensive functional impairments. The final study examined and compared associations between continuity of primary and specialty physician care. Results Long-stay home care patients in Ontario are high users of both primary care and the emergency department. Better access to afterhours care reduced the likelihood of an emergency department visit on the same day as a home nursing visit. Patients with extensive functional impairments whose primary care physician who provided higher levels of home visits had lower rates of emergency department use. Finally, better continuity of both primary and specialty physician care were similarly associated with lower emergency department use. Conclusion Better quality primary care integrated with other sectors of the health system is crucial to enabling home care patients to age safety in the community. Access to care is particularly important and can be improved though enhancing the availability of afterhours care and increasing the provision of home visits for those who have difficulty reaching primary care offices. Improving continuity of specialty physician care should be a health system objective alongside improving continuity of primary care. / Thesis / Doctor of Philosophy (PhD) / Older adults receiving home care are a growing population of individuals with complex care needs and high rates of emergency department use. This thesis seeks to characterize the primary care use of home care patients in Ontario and examine to what degree better quality of primary care is associated with less use of the emergency department. My findings indicate that increased access to afterhours primary care, higher levels of primary care home visits, and better continuity of both primary and specialty physician care were associated fewer emergency department visits. In conjunction with other sectors, primary care plays a central role managing older adults with complex care needs in the community. Better quality of primary care, particularly advanced access, can help keep older adults safely at home and out of hospitals as they age.

Home care has been the fastest growing sector in the U.S. healthcare system for over three decades. In 2012, there were over 4.7 million home care patients in the United States. Most of these patients were elders (4 million); and this number is expected to increase as the U.S. population continues to age. One major health concern in this elderly home care population is mental health disorders (MHDs), which have been noted with increasing rates and substantial consequences in local data. However, much of our knowledge on this topic was generated from local studies that had a number of methodological limitations. These include over reliance on local and outdated data, a lack of theoretical foundation, and a lack of statistical justification, which may well account for the high variability across findings. To date, no national investigation has been conducted on this topic, supporting the need for a large-scale study which employs recent data to better understand the prevalence, risk factors and impact of MHDs among home care elders in the U.S. This dissertation study addressed these gaps by using the de-identified national home care dataset, Outcome and Assessment Information Set (OASIS), to: 1) examine the national prevalence of MHDs and MHD-caused medical events in the U.S. elderly home care population, and 2) identify factors associated with MHDs and MHD-caused medical events in this population. The 5% random sample used in this study was consisted of 28,475 elderly home care patients: their average age was 79.41; patients were mostly female, white, Medicare beneficiaries, referred from short-stay acute hospitals, and living with others at home. Approximately 38% of this sample had MHDs, mostly depression (28.0%) and anxiety (18.9%). Compared with other patients, those with MHDs were younger, more likely to be female, smokers, frail, living alone, referred from psychiatric hospitals, cognitively or sensually impaired, in poorer general health, had a recent history of falls or multiple hospitalizations, and evidenced insufficient social support. Among patients identified with MHDs, less than one third (31.8%) received mental health services, including psychiatric nursing services (n=317) and depression interventions (n=4,459). During the 60-day home care episode, 16.95% of the sample had subsequent hospitalizations and 12.72% had subsequent emergent care events; 0.45% of these medical events were directly caused by MHDs. In addition, depression intervention was the strongest risk factor for these subsequent medical events, associated with an approximate two-fold risk for all-cause hospitalizations (HR: 1.943) and emergent care events (HR: 1.974). However, 61.61% (n=2,747) of these high-risk depression intervention recipients did not screen positive for depression at admission. Findings in this dissertation study revealed the high national prevalence of MHDs in the elderly U.S. home care population, and the strong association between these disorders and subsequent all-cause medical events. However, these MHDs were largely under-detected and under-managed in this population, highlighting the need for closer monitoring and targeted intervention through enhanced psychiatric training among front-line home care nurses. Recommendations for further work are made, including the development of an electronic algorithm of identified MHD correlates and risk factors as useful in the development of a nationwide monitoring system for geriatric MHDs in the home care setting.

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

Thesis (Ph. D.)--Oregon State University, 2007. / Printout. Includes bibliographical references (leaves 98-105). Also available on the World Wide Web.

Thesis (Ph. D.)--University of California, San Diego, 2001. / Vita. Includes bibliographical references (leaves 375-382).