Made available in DSpace on 2014-06-11T19:28:19Z (GMT). No. of bitstreams: 0 Previous issue date: 2011-03-02Bitstream added on 2014-06-13T19:36:42Z : No. of bitstreams: 1 medeiros_tm_me_botfm.pdf: 2306101 bytes, checksum: 00e3756fbf95a3db7cdad8a3aee3eea9 (MD5) / Ministério da Saúde / Ao longo da história da humanidade, a família tem-se mantido como instituição social permanente devendo ser fortalecida. Mas, para definir família, é necessário compreender uma série de fatores, contextos e realidades e para conhecer famílias, é necessário ter uma visão das relações entre familiares, vizinhos, parentes e da rede de suporte. A família tornou-se foco de pesquisa e objeto de investigações após a implantação do Programa de Saúde da Família pelo Ministério de Saúde em 1994. A enfermagem assume um importante papel em criar vínculos com a família na construção de um novo paradigma de saúde. Nesta oportunidade, priorizou-se desenvolver o estudo sobre o enfoque de risco familiar a agravos ou danos a saúde, com o objetivo de avaliar o instrumento “Critério UFES” para identificação e classificação de risco familiar no âmbito da Estratégia Saúde da Família, adaptado pela Universidade Federal do Espírito Santo, da Escala de Coelho. Os dados foram coletados após atualização dos cadastros das famílias, por meio da Ficha A1 do Sistema de Informação da Atenção Básica, complementadas pelos agentes comunitários de saúde. Os dados foram lançados em planilha Excel para processamento dos escores. E, para analisar a consistência e coerência do instrumento, foi calculado o Coeficiente α de Cronbach. As famílias foram classificadas: 20% em Risco Zero; 63% como Risco 1; 8% como Risco 2 e 7% como Risco 3. As sentinelas de risco mais frequentes foram baixas condições de saneamento e higiene, uso de drogas lícitas e ilícitas e doenças crônicas. O instrumento em foco permite classificação de risco familiar, porém apresenta alguns limites, principalmente relacionados às definições das sentinelas, sendo que na área rural o Coeficiente α de Cronbach apresentou resultados considerados de regulares a discretos; sendo necessário a sua... / Over human history, the family has been a permanent social institution that must be strengthened. But, in order to define family, it is necessary to understand a number of factors, contexts and realities. And, in order to know families, it is necessary to have a view of the relationships among relatives, neighbors and members of the support network. The family became an object of investigation after the implantation of the Family Health Program by the Health Ministry in 1994. Nursing then assumes an important role in creating bonds with the family for the construction of a new health care paradigm. In this scenario, this study aimed at investigating family risk for health aggravations and damage, with the purpose to evaluate the instrument “UFES Criterion” for family risk identification and classification in the realm of the Family Health Strategy, adapted from the Coelho Scale by Espiríto Santo Federal University. The data were collected after updating families’ records by means of SIAB Form A1, complemented by community health agents. Hence, the data were entered on an Excel sheet for score processing. In order to analyze the consistency and coherence of the instrument, Cronbach’s α Coefficient was calculated. The families were classified as: 20% under Zero Risk; 63% under Risk 1; 8% under Risk 2 and 7% under Risk 3. The most frequent risk sentinels were poor sanitation and hygiene conditions, use of licit and illicit drugs and chronic diseases. The focused instrument classifies family risk; however, it has some limits particularly in relation to the definitions of sentinels, and, in the rural area, Cronbach’s α Coefficient showed results that are considered to be regular and discreet. Well-defined criteria are necessary for its application or for inclusion of specific sentinels in the rural area

Advance care planning (ACP) is a process of discussing the patient’s wishes and preferences for future health care. ACP allows for the patient to retain their autonomy and involves informing the patient about their illness, prognosis, and their health care options. Despite the known advantages of completion of ACP forms, ACP discussions are minimal during primary care visits. The purpose of this DNP project was to identify primary care providers (PCP) beliefs and attitudes regarding barriers to addressing ACP with patients with a chronic illness in the primary care setting at one family practice clinic in Tucson, Arizona, and to determine if providing educational information will increase the PCPs intent to address ACP within clinical practice. A pre-survey, educational handout, and post-survey containing Likert-type scale questions and one ranking format question was created and sent via email to potential participants within the family practice clinic. The pre-survey requested demographic characteristics, and both the pre and post surveys assessed the PCPs beliefs and attitudes towards barriers to addressing ACP. 42 potential PCPs were asked to participate in the online surveys, eight (19%) completed the pre-survey, and four (9.5%) completed the post-survey. The data obtain from the surveys indicate lack of time, discomfort with the subject, and communication barriers as the most frequently reported perceived barriers to addressing ACP in the primary care setting. The results from this project can be used to understand PCPs beliefs and attitudes towards addressing ACP in the primary care setting and how this can affect future care of the patient when a serious illness occurs.

Background: Improving coordination of care is a major challenge for health systems internationally. Tools are required to evaluate alternative approaches to improve coordination from the patient perspective. This study aimed to develop and validate a new measure of coordination for use in a primary care setting. Methods: Four methods were used. Firstly, a concept analysis was undertaken to identify the essential attributes of coordination drawing upon literature from health and organisational studies and to establish its boundaries with related concepts such as continuity of care, integration and patient centred care. Secondly, existing measures of coordination were reviewed to assess the extent to which item content reflected the definition arising from the concept analysis and to appraise psychometric properties. Thirdly, a new instrument, the Care Coordination Questionnaire (CCQ), was developed utilising items from existing questionnaires and others developed following focus groups with 30 patients. Ten cognitive interviews were used to evaluate the items generated. Finally, the CCQ was administered in a cross sectional survey to 980 patients. Item and model analyses were performed. Test-retest reliability was evaluated through a second administration of the CCQ after two weeks. Concurrent validity was evaluated through correlation with the Client Perceptions of Coordination Questionnaire (CPCQ). Construct validity was evaluated through correlation with responses to a global coordination item and a satisfaction scale and the testing of two a prior hypotheses: i) coordination scores would decrease with increasing numbers of providers and ii) coordination scores would decrease with increasing numbers of long-term conditions. Results: The concept analysis suggested that coordination should be considered as a process for the organisation of patient care characterised by: purposeful activity, information exchange, knowledge of roles and responsibilities, and responsiveness to change. The systematic review identified 5 existing measures of coordination and a further 10 measures which incorporated a coordination subscale. Only one demonstrated conceptual coverage but had poor psychometric properties. A new instrument was therefore developed and tested as described above. 299 completed surveys were returned. Respondents were predominantly elderly and of white ethnicity; approximately half were female. Five items were deleted following item analyses. Model analysis suggested a four factor two-level model of coordination comprising of 18 items. This correlated well with the CPCQ, the global coordination item and satisfaction scale. The a priori hypotheses were upheld. Retest reliability was acceptable at the patient group level. Conclusions: The CCQ has demonstrated good psychometric characteristics in terms of item responses, reliability and construct validity. Further exploration of these properties is required in a larger, more diverse sample before it can be recommended for widespread use, but it shows potential utility in the evaluation of different approaches to coordinating care.

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End of life planning is an essential component of complete care for patients established in a primary care clinic. Family medicine clinics, where treatment begins with birth and ends with death, it is imperative for clinicians both seasoned and new have the knowledge and resources available to ensure effective discussion of this complex subject. Surveys across the country of both patients and providers show that anywhere between 5-25% of patients have an advanced directive filled out and on file. Furthermore, most patients report a preference for holding this discussion with their established primary care physician. Numerous barriers have been identified in previous surveys and studies that tend to limit this discussion in the primary care setting in the academic and private sector. By identifying these barriers and providing possible solutions, primary care providers should be able to more effectively facilitate and navigate a discussion about end of life care. We designed a quality improvement project for family medicine residents in an effort to identify location specific barriers and to provide an educational didactic session which is aimed at overcoming these barriers. A survey was designed to be filled out by participates prior to the presentation to measure baseline comfort and understanding of advanced directives. The same survey was administered after the presentation to measure the effectiveness of the presented didactic. Statistical analysis of these two surveys will be completed and reviewed. The expected outcome is that participants in the session leave with an improved comfort with the subject of advanced directives and end of life planning. Participants are expected to have increased knowledge of available resources that can be utilized during these discussions. By providing this session to both residents and supervising physicians, the hope is that an increase in documented advanced care directives will be seen at the family medicine clinic. If this session is found to be an effective tool to address the identified barriers to end of life planning, it may be suitable to extend throughout the family medicine department at East Tennessee State University. Following this didactic session, multiple residents reported utilizing resources that were presented during discussions, with patients in regards to end of life planning and advanced care directives.

Book Summary:Practice-Based Research shows mental-health practitioners how to establish viable and productive research programs in routine clinical settings. Chapters written by experts in practice-based research use real-world examples to help clinicians work through some of the most common barriers to research output in these settings, including lack of access to institutional review boards, lack of organizational support, and limited access to financial resources. Specialized chapters also provide information on research methods and step-by-step suggestions tailored to a variety of practice settings. This is an essential volume for clinicians interested in establishing successful, long-lasting practice-based research programs.

Book Summary: Practice-Based Research shows mental-health practitioners how to establish viable and productive research programs in routine clinical settings. Chapters written by experts in practice-based research use real-world examples to help clinicians work through some of the most common barriers to research output in these settings, including lack of access to institutional review boards, lack of organizational support, and limited access to financial resources. Specialized chapters also provide information on research methods and step-by-step suggestions tailored to a variety of practice settings. This is an essential volume for clinicians interested in establishing successful, long-lasting practice-based research programs.

In the past few decades, there has been a move toward integrating behavioral health and medical services. This can be particularly beneficial for rural residents, as integration can increase access to mental healthcare in areas where there are shortages of mental health providers. Southern Appalachia is characterized by isolated areas that have shortages of both mental health and medical providers. This article discusses the experiences of a clinical psychology doctoral student integrating behavioral health services in a primary care clinic within rural Southern Appalachia. The role of the behavioral health consultant is described, including representative services and development and implementation of a clinic-wide depression protocol. Additionally, barriers to integration and recommendations for future training and practice are provided.

In many healthcare systems, family physicians are the primary source of direct care for patients with mental health problems in the community, yet family physicians are not often routinely or adequately trained to conduct counseling or psychotherapy. The current study conducted a 5-weekend year-long, hands-on, interactive, intensive training of family physicians in the skills of office-based counseling/psychotherapy. Fifty-five family physicians took the course over 4 different years. Outcomes were analyzed with 3 major measures and collected at baseline, the end of the course, and 6 months later. Based on an ability to answer a skill-testing questionnaire called the Carkhuff Discrimination Skills Index, all the family physician participants significantly improved their counseling skills by the end of the course and about half continued to improve 6 months later. Participants showed significant improvement in their confidence counseling individuals, couples, and families. Participants also indicated they significantly increased the time they spent in counseling individual patients as a result of the course. Implications for future research on primary care training programs in psychological therapy are discussed.

In recent decades, there has been an increased focus on the idealization of thinness and the pressure and expectancy to be thin, which contributes to a rising number of individuals that experience severe body dissatisfaction and body distortion, and in turn, eating disorders. Eating disorders are one of the most common chronic conditions within the youth population, approximately 13% of the adolescent youth population will suffer from at least one eating disorder by age 20, and a majority of those affected will be female. Rural health care providers encounter many health care disadvantages when detecting and treating eating disorders including physical location and distance to nearest healthcare or specialty service, ethnicity, and socioeconomic status. These disadvantages are often responsible for the inability of providers to prevent, screen for, identify, and treat eating disorders. The focus of this practice improvement project (PIP) was to determine how primary care providers in a rural clinic perceived the implementation of the Screening for Disordered Eating (SDE) in adolescent females ages 11-19. During implementation, the providers were also to identify and refer those scoring 2 or greater to a counselor, mental health specialist, and/or eating disorder specialist. Implementation began with an educational meeting explaining eating disorders and their prevalence, as well as the introduction and explanation of the SDE tool. A survey was then completed by the providers to assess the relevance of the information provided to their practice. During the implementation period, providers were to screen all adolescent females ages 11-19 using the SDE tool and refer those scoring 2 or greater. Participating providers then completed a post-implementation survey assessing their perceptions on the ease, accuracy, and applicability of the SDE tool. Overall, based on the post-implementation, providers believe screening for eating disorders is important and the SDE tool is easy and applicable to their practice. Screening for Disordered Eating completion rates (14.1%) and referral rates (17.4%) of those scoring 2 or greater were lower than expected. The prevalence of eating disorders continues to rise and continued use of the SDE tool in the primary care setting is strongly recommended.