Home care (HC) services are crucial to the health and social wellbeing of older adults, people with disabilities, and the chronically ill. Although the HC sector is growing rapidly in the USA, there ...is high job turnover among the HC aide workforce. HC provides an important alternative to facility-based care, yet it has often been overlooked within the larger health care system: most recently, in COVID-19 pandemic planning. The objective of the study was to characterize qualitatively the impact of the COVID-19 pandemic on three key HC stakeholders: clients, aides, and agency managers.
The study included 37 phone interviews conducted during April - November 2020: HC clients (n = 9), aides (n = 16), and agency managers (n = 12). All interviews were audio recorded and transcribed verbatim. Qualitative analysis of the transcripts followed the grounded theory approach. The interview transcriptions were coded line-by-line into hierarchical themes with NVivo 12 software which allowed weighting of themes based on the number of interviews where they were coded.
Fear of infection and transmission among HC clients and aides were strong themes. Infection prevention and control became the top priority guiding day-to-day business operations at agencies; sourcing adequate personal protective equipment for staff was the most urgent task. HC aides expressed concerns for their clients who showed signs of depression, due to increased isolation during the pandemic. The disappearance of comforting touch - resulting from physical distancing practices - altered the expression of compassion in the HC aide-client care relationship.
The findings suggest that the pandemic has further increased psychosocial job demands of HC aides. Increased isolation of clients may be contributing to a wider public health problem of elder loneliness and depression. To support the HC stakeholders during the on-going COVID-19 pandemic, for future pandemic planning or other health emergencies, it is important to improve HC aide job retention. This action could also ease the serious care services shortage among the growing population of older adults.
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Background
Older persons with multimorbidity being cared for at home often have complex needs which cannot be met by one single caregiver. Interprofessional collaboration is therefore considered ...necessary if care is to be organised according to the needs of the older person. To achieve coherent health care, municipalities and county councils need to develop their collaboration.
Aim
The aim of this study was to illustrate how various professionals belonging to homemaker services, home care services in municipality and hospital‐based home care services experience collaboration in caring for older persons with multimorbidity.
Method
A hermeneutic approach was used. Eleven informants participated in the study and were individually interviewed.
Findings
The findings show that collaboration between players comprises various types of experiences which influence not only the staff who are involved in collaboration but also the outcome of the collaboration itself. The informants’ experience of collaboration was defined by distrust and trust and by insecurity and security. To focus on patients’ needs and to develop the collaboration further, it was important for informants to take the relations into account and have a reflective and questioning approach. This attitude resulted in a feeling of trust and security, and a flexible and critical approach without boundary drawings between basic and specialised care.
Conclusion and relevance of practice
Complex situations cannot be solved with simple models. Instead, a flexible approach appears necessary with focus shifting from structures to interpersonal relations and interactions. Therefore, the different professionals have to work as a transprofessional team where close interactions, flexibility and improvisation are keys to success. The transprofessional team approach is suggested to have the potential to take the competence of all staff into account when high‐quality home health care to older persons with multimorbidity is to be provided by multiple caregivers.
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Background
Removing dental plaque may play a key role maintaining oral health. There is conflicting evidence for the relative merits of manual and powered toothbrushing in achieving this. This is an ...update of a Cochrane review first published in 2003, and previously updated in 2005.
Objectives
To compare manual and powered toothbrushes in everyday use, by people of any age, in relation to the removal of plaque, the health of the gingivae, staining and calculus, dependability, adverse effects and cost.
Search methods
We searched the following electronic databases: the Cochrane Oral Health Group's Trials Register (to 23 January 2014), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2014, Issue 1), MEDLINE via OVID (1946 to 23 January 2014), EMBASE via OVID (1980 to 23 January 2014) and CINAHL via EBSCO (1980 to 23 January 2014). We searched the US National Institutes of Health Trials Register and the WHO Clinical Trials Registry Platform for ongoing trials. No restrictions were placed on the language or date of publication when searching the electronic databases.
Selection criteria
Randomised controlled trials of at least four weeks of unsupervised powered toothbrushing versus manual toothbrushing for oral health in children and adults.
Data collection and analysis
We used standard methodological procedures expected by The Cochrane Collaboration. Random‐effects models were used provided there were four or more studies included in the meta‐analysis, otherwise fixed‐effect models were used. Data were classed as short term (one to three months) and long term (greater than three months).
Main results
Fifty‐six trials met the inclusion criteria; 51 trials involving 4624 participants provided data for meta‐analysis. Five trials were at low risk of bias, five at high and 46 at unclear risk of bias.
There is moderate quality evidence that powered toothbrushes provide a statistically significant benefit compared with manual toothbrushes with regard to the reduction of plaque in both the short term (standardised mean difference (SMD) ‐0.50 (95% confidence interval (CI) ‐0.70 to ‐0.31); 40 trials, n = 2871) and long term (SMD ‐0.47 (95% CI ‐0.82 to ‐0.11; 14 trials, n = 978). These results correspond to an 11% reduction in plaque for the Quigley Hein index (Turesky) in the short term and 21% reduction long term. Both meta‐analyses showed high levels of heterogeneity (I2 = 83% and 86% respectively) that was not explained by the different powered toothbrush type subgroups.
With regard to gingivitis, there is moderate quality evidence that powered toothbrushes again provide a statistically significant benefit when compared with manual toothbrushes both in the short term (SMD ‐0.43 (95% CI ‐0.60 to ‐0.25); 44 trials, n = 3345) and long term (SMD ‐0.21 (95% CI ‐0.31 to ‐0.12); 16 trials, n = 1645). This corresponds to a 6% and 11% reduction in gingivitis for the Löe and Silness index respectively. Both meta‐analyses showed high levels of heterogeneity (I2 = 82% and 51% respectively) that was not explained by the different powered toothbrush type subgroups.
The number of trials for each type of powered toothbrush varied: side to side (10 trials), counter oscillation (five trials), rotation oscillation (27 trials), circular (two trials), ultrasonic (seven trials), ionic (four trials) and unknown (five trials). The greatest body of evidence was for rotation oscillation brushes which demonstrated a statistically significant reduction in plaque and gingivitis at both time points.
Authors' conclusions
Powered toothbrushes reduce plaque and gingivitis more than manual toothbrushing in the short and long term. The clinical importance of these findings remains unclear. Observation of methodological guidelines and greater standardisation of design would benefit both future trials and meta‐analyses.
Cost, reliability and side effects were inconsistently reported. Any reported side effects were localised and only temporary.
The study addresses staffing and workforce issues for home‐ and community‐based long‐term care in Germany. It is based on a study aimed at developing staffing recommendations for home‐care provider ...organisations. The study was commissioned within the regulation of the German long‐term care act. Following an exploratory literature search on staffing issues in home‐ and community‐based care qualitative interviews with 30 experts in home care were conducted. In addition, time needed for different interventions in homes of people in need of care (n = 129) was measured. Ethical approval for the study was obtained. The literature on the topic is limited. In Germany, no fixed staff‐to‐client ratio exists, but staffing is determined primarily by reimbursement policies, not by care recipients’ needs. The results of the interviews indicated that staffing ratios are not the main concern of home‐care providers. Experts stressed that general availability of staff with different qualification levels and the problems of existing regulation on services and their reimbursement are of higher concern. The measurement of time needed for selected interventions reveals the huge heterogeneity of home‐care service delivery and the difficulty of using a task‐based approach to determine staffing levels. Overall, the study shows that currently demand for home‐care exceeds supply. Staff shortage puts a risk to home care in Germany. Existing approaches of reimbursement‐driven determination of staffing levels have not been sufficient. A new balance between staffing, needs and reimbursement policies needs to be developed.
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Providing Support at Home for Children and Young People who have Complex Health Needs discusses elements of providing support in the home, which influence the quality of provision. This includes: the ...rationale for providing support at home, the child being central to the provision of support, taking into account the needs of the whole family, working closely with parents, working in the family home, choices and rights, supporting adolescents, team working, ethical issues, political and organisational issues. Case studies are used to illustrate the points raised.
Placement stability is an important indicator of the functioning of an out-of-home care system. Previous research suggests that frequent placement changes have a negative impact on the outcomes for ...children and young people in out-of-home care.
This paper examines the association between placement stability in out-of-home care and children's socio-emotional, cognitive and physical health outcomes.
The Pathways of Care Longitudinal Study (POCLS) is the first large-scale prospective longitudinal study of children in out-of-home care in Australia. The sample consists of any study child who participated in any of the first three waves of the POCLS interview.
Unweighted data from the first three waves of the POCLS interview and administrative data was used. A measure of placement stability was developed that accounted for both number of placements and length of time in care. Mixed effect modelling was used to examine the link between placement stability and children's developmental outcomes.
Placement stability was found to have a significant association with socio-emotional, cognitive (non-verbal) and physical health (gross and fine motor skill) development. A number of other factors were also found to be associated with positive development.
The findings support the existing evidence that placement stability is an important factor for children's development. Other factors including placement type, carer wellbeing and carer support are also important for positive development. Appropriate policy and practice intervention to support children and families to improve placement stability is fundamental to achieving positive developmental outcomes for children in out-of-home care.
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Crisis resolution and home treatment teams respond rapidly to people experiencing mental health crises and offer an alternative to hospital admission. They are an increasingly important component of ...mental health care and are adopted by many health care systems around the world. This practical and pioneering book describes the evidence for the effectiveness of such teams, the principles underpinning them, how to set up and organise them, how patients should be assessed and what types of care the teams should offer. Other topics covered include integration of crisis teams with in-patient, community residential and day care services, the service users' experiences of crisis teams, and responding to diversity in home treatment. This book is essential reading for all policy makers, service managers and mental health workers interested in establishing or operating crisis resolution and home treatment services, as well as for researchers and students seeking to understand this model.
Early discharge hospital at home Shepperd, Sasha; Gonçalves-Bradley, Daniela C; Iliffe, Steve ...
Cochrane database of systematic reviews,
06/2017, Volume:
2021, Issue:
7
Journal Article
Peer reviewed
Open access
Background
Early discharge hospital at home is a service that provides active treatment by healthcare professionals in the patient's home for a condition that otherwise would require acute hospital ...inpatient care. This is an update of a Cochrane review.
Objectives
To determine the effectiveness and cost of managing patients with early discharge hospital at home compared with inpatient hospital care.
Search methods
We searched the following databases to 9 January 2017: the Cochrane Effective Practice and Organisation of Care Group (EPOC) register, Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, CINAHL, and EconLit. We searched clinical trials registries.
Selection criteria
Randomised trials comparing early discharge hospital at home with acute hospital inpatient care for adults. We excluded obstetric, paediatric and mental health hospital at home schemes.
Data collection and analysis
We followed the standard methodological procedures expected by Cochrane and EPOC. We used the GRADE approach to assess the certainty of the body of evidence for the most important outcomes.
Main results
We included 32 trials (N = 4746), six of them new for this update, mainly conducted in high‐income countries. We judged most of the studies to have a low or unclear risk of bias. The intervention was delivered by hospital outreach services (17 trials), community‐based services (11 trials), and was co‐ordinated by a hospital‐based stroke team or physician in conjunction with community‐based services in four trials.
Studies recruiting people recovering from stroke
Early discharge hospital at home probably makes little or no difference to mortality at three to six months (risk ratio (RR) 0.92, 95% confidence interval (CI) 0.57 to 1.48, N = 1114, 11 trials, moderate‐certainty evidence) and may make little or no difference to the risk of hospital readmission (RR 1.09, 95% CI 0.71 to 1.66, N = 345, 5 trials, low‐certainty evidence). Hospital at home may lower the risk of living in institutional setting at six months (RR 0.63, 96% CI 0.40 to 0.98; N = 574, 4 trials, low‐certainty evidence) and might slightly improve patient satisfaction (N = 795, low‐certainty evidence). Hospital at home probably reduces hospital length of stay, as moderate‐certainty evidence found that people assigned to hospital at home are discharged from the intervention about seven days earlier than people receiving inpatient care (95% CI 10.19 to 3.17 days earlier, N = 528, 4 trials). It is uncertain whether hospital at home has an effect on cost (very low‐certainty evidence).
Studies recruiting people with a mix of medical conditions
Early discharge hospital at home probably makes little or no difference to mortality (RR 1.07, 95% CI 0.76 to 1.49; N = 1247, 8 trials, moderate‐certainty evidence). In people with chronic obstructive pulmonary disease (COPD) there was insufficient information to determine the effect of these two approaches on mortality (RR 0.53, 95% CI 0.25 to 1.12, N = 496, 5 trials, low‐certainty evidence). The intervention probably increases the risk of hospital readmission in a mix of medical conditions, although the results are also compatible with no difference and a relatively large increase in the risk of readmission (RR 1.25, 95% CI 0.98 to 1.58, N = 1276, 9 trials, moderate‐certainty evidence). Early discharge hospital at home may decrease the risk of readmission for people with COPD (RR 0.86, 95% CI 0.66 to 1.13, N = 496, 5 trials low‐certainty evidence). Hospital at home may lower the risk of living in an institutional setting (RR 0.69, 0.48 to 0.99; N = 484, 3 trials, low‐certainty evidence). The intervention might slightly improve patient satisfaction (N = 900, low‐certainty evidence). The effect of early discharge hospital at home on hospital length of stay for older patients with a mix of conditions ranged from a reduction of 20 days to a reduction of less than half a day (moderate‐certainty evidence, N = 767). It is uncertain whether hospital at home has an effect on cost (very low‐certainty evidence).
Studies recruiting people undergoing elective surgery
Three studies did not report higher rates of mortality with hospital at home compared with inpatient care (data not pooled, N = 856, low‐certainty evidence; mainly orthopaedic surgery). Hospital at home may lead to little or no difference in readmission to hospital for people who were mainly recovering from orthopaedic surgery (N = 1229, low‐certainty evidence). We could not establish the effects of hospital at home on the risk of living in institutional care, due to a lack of data. The intervention might slightly improve patient satisfaction (N = 1229, low‐certainty evidence). People recovering from orthopaedic surgery allocated to early discharge hospital at home were discharged from the intervention on average four days earlier than people allocated to usual inpatient care (4.44 days earlier, 95% CI 6.37 to 2.51 days earlier, , N = 411, 4 trials, moderate‐certainty evidence). It is uncertain whether hospital at home has an effect on cost (very low‐certainty evidence).
Authors' conclusions
Despite increasing interest in the potential of early discharge hospital at home services as a less expensive alternative to inpatient care, this review provides insufficient evidence of economic benefit (through a reduction in hospital length of stay) or improved health outcomes.
There is a growing recognition of multidisciplinary practices as the most rational approach to providing better and more efficient healthcare services. Pharmacists are increasingly integrated into ...primary care teams, but there is no universal approach to implementing pharmacist services across healthcare settings. In Norway, most pharmacists work in pharmacies, with very few employed outside this traditional setting. The home care workforce is primarily made up of nurses, assistant nurses, and healthcare assistants. General practitioners (GPs) are not based in the same location as home care staff. This study utilized the Normalization Process Theory (NPT) to conduct a process evaluation of the integration of pharmacists in a Norwegian home care setting. Our aim was to identify barriers and facilitators to optimal utilization of pharmacist services within a multidisciplinary team.
Semi-structured interviews (n = 9) were conducted with home care unit leaders, ward managers, registered nurses, and pharmacists in Norway, in November 2022-February 2023. Constructs from the NPT were applied to qualitative data.
Findings from this study pertain to the four constructs of the NPT. Healthcare professionals struggled to conceptualize the pharmacists' competencies and there were no collectively agreed-upon objectives of the intervention. Consequently, some participants questioned the necessity of pharmacist integration. Further, participants reported conflicting preferences regarding how to best utilize medication-optimizing services in everyday work. A lack of stakeholder empowerment was reported across all participants. Moreover, home care unit leaders and managers reported being uninformed of their roles and responsibilities related to the implementation process. However, the presence of pharmacists and their services were well received in the setting. Moreover, participants reported that pharmacists' contributions positively impacted the multidisciplinary practice.
Introducing new work methods into clinical practice is a complex task that demands expertise in implementation. Using the NTP model helped pinpoint factors that affect how pharmacists' skills are utilized in a home care setting. Insights from this study can inform the development of tailored implementation strategies to improve pharmacist integration in a multidisciplinary team.
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