Search

Background: People who experience homelessness have higher dental treatment needs compared to the general population. However, their utilization of dental services and levels of treatment completion are low. Peninsula Dental Social Enterprise, a not‐for‐profit organization in the United Kingdom, established a community dental clinic to improve access to dental care for this population. Objectives: To evaluate the impact and acceptability of the community dental service for patients and examine the barriers and enablers to using and providing the service. Methods: The evaluation included a retrospective assessment of anonymous patient data and thematic analysis of semi‐structured interviews with patients, support staff and service providers. The interviews were thematically analysed. A cost analysis of the dental service was also conducted. Results: By 18 February 2020, 89 patients had attended the clinic. These included 62 males (70%) and 27 females (30%), aged 38.43 years on average (SD ± 11.07). Of these, 42 (47%) patients have completed their treatment, 23 (26%) are in active treatment and 24 (27%) left treatment. In total, 684 appointments (541.5 hours clinical time) were given. Of these, 82% (562) of appointments were attended (452.5 hours clinical time). The 22 interviews that were conducted identified flexibility, close collaboration with support services and health‐care team attitudes as key factors influencing service utilization and continuity of care. Conclusions: This study provides details of a highly acceptable and accessible dental care model for people experiencing homelessness, with recommendations at research, practice and commissioning levels. [ABSTRACT FROM AUTHOR]

Objective: To estimate the impact of the major components of the ACA (Medicaid expansion, subsidized Marketplace plans, and insurance market reforms) on health care access and self‐assessed health during the first 2 years of the Trump administration (2017 and 2018). Data Source: The 2011‐2018 waves of the Behavioral Risk Factor Surveillance System (BRFSS), with the sample restricted to nonelderly adults. The BRFSS is a commonly used data source in the ACA literature due to its large number of questions related to access and self‐assessed health. In addition, it is large enough to precisely estimate the effects of state policy interventions, with over 300 000 observations per year. Design: We estimate difference‐in‐difference‐in‐differences (DDD) models to separately identify the effects of the private and Medicaid expansion portions of the ACA using an identification strategy initially developed in Courtemanche et al (2017). The differences come from: (a) time, (b) state Medicaid expansion status, and (c) local area pre‐2014 uninsured rates. We examine ten outcome variables, including four measures of access and six measures of self‐assessed health. We also examine differences by income and race/ethnicity. Principal Findings: Despite changes in ACA administration and the political debate surrounding the ACA during 2017 and 2018, including these fourth and fifth years of postreform data suggests continued gains in coverage. In addition, the improvements in reported excellent health that emerged with a lag after ACA implementation continued during 2017 and 2018. Conclusions: While gains in access and self‐assessed health continued in the first 2 years of the Trump administration, the ongoing debate at both the federal and state level surrounding the future of the ACA suggests the need to continue monitoring how the law impacts these and many other important outcomes over time. [ABSTRACT FROM AUTHOR]

HIV infection continues to be one of the world's greatest pandemics, affecting nearly every country on the globe. By September 2018, it is estimated that 38 million people were living with HIV, 30 million people are aware of their status, and 23 million people are taking anti‐retroviral therapy (8 million in 2010). Thus, currently 8 million people living with HIV are not aware that they are HIV‐positive and 15 million persons are not being treated. There are nearly 15 million orphans (aged 0–17). There is widespread inequality both in the prevalence of HIV infection and in the access to therapy. However, although the number of people living with HIV continues to increase, the number of new infections shows a steady decrease over the last 9 years and in 2018 was 1.7 million. Deaths from AIDS in 2018 also decreased to 750,000 from 1.2 million in 2010. The world prevalence of HIV is about 0.23% but is over 0.3% in South‐East Asia, Latin America, North America and Eastern Europe and with particularly high prevalence in the Caribbean (1.1%) and sub‐Saharan Africa (5.5%). It is approximately 0.5% in Indonesia. There were approximately 5,000 new HIV infections (adults and children) a day during 2018. About 61% were in sub‐Saharan Africa, nearly 50% were in females and 500 were in children. HIV therapy seems to have had a global impact, with AIDS‐related deaths decreasing by 33% since 2010, and new infections decreasing by 16%. Nevertheless, the majority of the world's HIV is in low and middle resource countries and social determinants are strongly related. Many people living with HIV or at risk for HIV still do not have access to prevention, care and treatment, and there is still no cure. [ABSTRACT FROM AUTHOR]

Background: Self‐harm amongst young people is an increasing problem, with looked‐after young people at higher risk. Despite this, little research exists on what young people who self‐harm find helpful. Method: One hundred and twenty‐six 11–21 year olds (53 who had experience of the care system and 73 who did not) were recruited from the community and NHS. All participants had self‐harmed in the past 6 months. Participants completed an Audio Computer‐Assisted Self‐interview (ACASI) regarding their views about the support they had received, how helpful it was, and what further help they felt they needed. Results: Looked‐after young people reported the three most helpful sources of support were Child and Adolescent Mental Health Services (CAMHS), friends and pets and the least helpful were CAMHS, Accident and Emergency (A&E) and Social services. For non‐looked‐after young people, CAMHS, counselling and Harmless (user‐led support service for self‐harm) were most helpful and CAMHS, cognitive behavioural therapy (CBT) and general practitioner (GP) were the least. Compared with the other group, more looked‐after young people had received help from A&E and CAMHS, whereas more non‐looked‐after young people had accessed GPs, parents, psychological therapies, self‐help books and websites. More looked‐after young people found support groups helpful, and more non‐looked‐after young people reported that distraction techniques, medication and their siblings were helpful. Conclusion: Young people who self‐harm have mixed views about CAMHS. Differences in the pattern of access and preferences for support between looked‐after and non‐looked‐after young people should be reflected in service availability and commissioning. Key Practitioner Message: Little is known about what young people who self‐harm find helpful, particularly for looked‐after young people.CAMHS was named amongst the most helpful and the least helpful services by both looked‐after and non‐looked‐after young people.Social services and A&E were frequently cited amongst the least helpful sources of support.Young people report finding informal support helpful, including family and friends.There appears to be a need for explorations of the reasons behind the apparent negative perception of statutory services in young people, and what is required to shift that. [ABSTRACT FROM AUTHOR]

This update presents key developments since Talmon's original (1990) publication, including an account of the three international symposia which have taken place since the last ANZJFT special edition on single session therapy in 2012, and the major compilations that followed the symposia. Underlying elements that unite different single session approaches are explored, and an attempt is made to provide a terminology that is inclusive and coherent. As reflected in the title, the term 'single session thinking' is suggested as an over‐arching term for the approach that is no longer limited to the therapy room, but reaches into many different contexts. In conclusion, possible future clinical and research developments in the field of single session thinking and practice are reflected upon, and the implications for contemporary health care delivery considered. [ABSTRACT FROM AUTHOR]

Background: Inequalities in access to renal services and acute care for rural and remote populations in Australia have been described but not quantified. Aim: To describe: the coverage of renal disease management services in rural and remote Australia; and the characteristics of patients who had an aeromedical retrieval for renal disease by Australia's Royal Flying Doctor Service (RFDS). Methods: Data from the RFDS, the Australian Bureau of Statistics, and Health Direct were used to estimate provision of renal disease management services by geographic area. RFDS patient diagnostic data were prospectively collected from 2014 to 2018. Results: Many rural and remote areas have limited access to regular renal disease management services. Most RFDS retrievals for renal disease are from regions without such services. The RFDS conducted 1636 aeromedical retrievals for renal disease, which represented 1.6% of all retrievals. Among retrieved patients, there was a higher proportion of men than women (54.6% vs 45.4%, P < 0.01), while indigenous patients (n = 546, 33.4%) were significantly younger than non‐indigenous patients (40.9 vs 58.5, P < 0.01). There were significant differences in underlying diagnoses triggering retrievals between genders, with males being more likely than females to be transferred with acute renal failure, calculus of the kidney and ureter, renal colic, obstructive uropathy, and kidney failure (all P < 0.01). Conversely, females were more likely to have chronic kidney disease, disorders of the urinary system, acute nephritic syndrome, tubulo‐interstitial nephritis, and nephrotic syndrome (all P < 0.01). Conclusion: Aeromedical retrievals for acute care were from rural areas without regular access to renal disease prevention or management services. [ABSTRACT FROM AUTHOR]

Objective: To provide new evidence on the effects of large-scale public health insurance expansions, associated with the Affordable Care Act (ACA), on the availability of specialty mental health care treatment in the United States. We measure availability with the probability that a provider accepts Medicaid.Data Source/study Setting: The National Mental Health Services Survey (N-MHSS) 2010-2018.Study Design: A quasi-experimental differences-in-differences design using observational data.Data Collection: The N-MHSS provides administrative data on the universe of specialty mental health care providers in the United States. Response rates are above 90 percent in all years. Data cover 85 019 provider/year observations.Principal Findings: ACA-Medicaid expansion increases the probability that a provider accepts Medicaid by 1.69 percentage points, 95 percent confidence interval: [0.0017,0.0321], which corresponds to an increase from 87.27 percent pre-expansion to 90.27 percent postexpansion in expansion states or a 1.94 percent increase. We observe spillovers to Medicare, although this finding is sensitive to specification.Conclusions: This study provides evidence on the impact of ACA-Medicaid expansion on accepted forms of payment for specialty mental health care treatment. Findings suggest that expansion increases availability of providers who deliver valuable care for enrollees with severe mental illness. These findings may help policy makers reflecting on the future directions of the US health care delivery system. [ABSTRACT FROM AUTHOR]

The article discusses the impact of the emergence of severe acute respiratory syndrome coronavirus 2 on medical practice in 2020. Topics mentioned include expansion in the capacity of public and private pathology services to meet the testing demand, a drop in weekly face-to-face consultations across five Australian Primary Health Networks from February to April 2020, and the cumulative COVID-19 related deaths reported to the World Health Organization from New Zealand and Australia.

The article presents the viewpoints on American Public Health Association has long recognized that access to abortion is a fundamental right and an important component of comprehensive sexual and reproductive health care. Topics include the guise of trying to protect the U.S. public during the COVID-19 pandemic, a number of states have called this right into question, and the politicians have attempted to exploit the public health crisis to further prohibit or limit access to abortion care.

Introduction: Few studies have systematically described population‐level differences comparing men and women across the continuum of routine HIV care. This study quantifies differentials in HIV care, treatment and mortality outcomes for men and women over time in South Africa. Methods: We analysed population‐wide linked anonymized data, including vital registration linkage, for the Western Cape Province, from the time of first CD4 count. Three antiretroviral therapy guideline eligibility periods were defined: 1 January 2008 to 31 July 2011 (CD4 cell count <200 cells/µL), 1 August 2011 to 31 December 2014 (<350 cells/µL), 1 January 2015 to 31 August 2016 (<500 cells/µL). We estimated care uptake based on service attendance, and modelled associations for men and women with ART initiation and overall, pre‐ART and ART mortality. Separate Cox proportional hazard models were built for each outcome and eligibility period, adjusted for tuberculosis, pregnancy, CD4 count and age. Results: Adult men made up 49% of the population and constituted 37% of those living with HIV. In 2009, 46% of men living with HIV attended health services, rising to 67% by 2015 compared to 54% and 77% of women respectively. Men contributed <35% of all CD4 cell counts over 10 years and presented with more advanced disease (39% of all first presentation CD4 cell counts from men were <200 cells/µL compared to 25% in women). ART access was lower in men compared to women (AHR 0.79 (0.77 to 0.80) summarized for Period 2) over the entire study). Mortality was greater in men irrespective of ART (AHR 1.08 (1.01 to 1.16) Period 3) and after ART start (AHR 1.15 (1.05 to 1.20) Period 3) with mortality differences decreasing over time. Conclusions: Compared to women, men presented with more advanced disease, were less likely to attend health care services annually, were less likely to initiate ART and had higher mortality overall and while receiving ART care. People living with HIV were more likely to initiate ART if they had acute reasons to access healthcare beyond HIV, such as being pregnant or being co‐infected with tuberculosis. Our findings point to missed opportunities for improving access to and outcomes from interventions for men along the entire HIV cascade. [ABSTRACT FROM AUTHOR]

While universal health coverage (UHC) has been praised as a powerful means to reduce inequalities and improve access to health globally, little has been said about how patients experience and understand its implementation locally. In this article, we explore the experiences of young Chileans with type 1 diabetes when seeking care in Santiago, within Chile's UHC program, which sought to improve people's access to health care. We argue that the implementation of UHC, within a structurally fragmented health system, did not lead to the promised equitable health care delivery. Although UHC aimed to equitably provide universal care, locally it materialized in heterogeneous configurations forcing individuals into positions of precarity and generating new inequalities. Furthermore, for the young people in the study, UHC intersected with their health insurance and socioeconomic status, impacting on the health care they could access, consequently making diabetes care and management a difficult challenge. [ABSTRACT FROM AUTHOR]

Lack of health insurance coverage is strongly associated with poor cancer outcomes in the United States. The uninsured are less likely to have access to timely and effective cancer prevention, screening, diagnosis, treatment, survivorship, and end-of-life care than their counterparts with health insurance coverage. On March 23, 2010, the Patient Protection and Affordable Care Act (ACA) was signed into law, representing the largest change to health care delivery in the United States since the introduction of the Medicare and Medicaid programs in 1965. The primary goals of the ACA are to improve health insurance coverage, the quality of care, and patient outcomes, and to maintain or lower costs by catalyzing changes in the health care delivery system. In this review, we describe the main components of the ACA, including health insurance expansions, coverage reforms, and delivery system reforms, provisions within these components, and their relevance to cancer screening and early detection, care, and outcomes. We then highlight selected, well-designed studies examining the effects of the ACA provisions on coverage, access to cancer care, and disparities throughout the cancer control continuum. Finally, we identify research gaps to inform evaluation of current and emerging health policies related to cancer outcomes. [ABSTRACT FROM AUTHOR]

Posttraumatic stress disorder (PTSD) brings with it diagnostic symptoms that can be debilitating and persist for years. Left untreated, PTSD can have far-reaching and damaging consequences for the individual, families, communities, and society at large. Although early detection and intervention are recognized as key to the effective treatment of PTSD, many individuals who suffer from PTSD do not seek essential health services. The aim of the present study was to identify the barriers and facilitators to help-seeking for individuals with PTSD, based on existing literature. A systematic review, modeled on the Joanna Briggs Institute methodology for systematic reviews, examined studies cited in PsycINFO, Medline, Embase, CINAHL, and PILOTS published from January 1980 to January 2019. Eligible studies measured barriers and facilitators to help-seeking for adults with PTSD. Two reviewers independently screened citations, and double data extraction was exercised. Of 2,391 potentially relevant citations, 21 studies, published between 1989 and 2018 and based in six countries, were included. Seventeen studies focused on military as a target population. We identified 10 principal barrier and facilitator themes: trauma-related; treatment; therapist or provider; knowledge; access; health care system; sociocultural environment; values, beliefs, and priorities; past experiences; and medical care needs and illness burden. In identifying prominent barriers and facilitators to help-seeking for individuals with PTSD, this review highlights opportunities to inform policies and programs that promote PTSD knowledge and recognition, reduce public and personal stigma, improve access and quality of care, and encourage support for patients and families living with PTSD. [ABSTRACT FROM AUTHOR]

Interpersonal relations play a critical role in both the conception and dynamics of Brazilian citizenship. Under the influence of neoliberalism, patients must build strategies to access high‐quality health care services. This study aimed to analyze the role of interpersonal relations involved in the access to and delivery of health care services in Brazil amid the influence of austerity policies and the role of nurses in enhancing citizenship through nursing care. Thirty‐one patients in a public hospital in Rio de Janeiro, Brazil, participated in qualitative interviews. A lexical analysis was conducted to analyze the interview data using Alceste® software, version 2012. The results were interpreted in light of both theoretical constructs of the Brazilian citizenship and biological subcitizenship propositions. Two lexical classes revealed contents about strategies used by patients to access high‐quality health care. In the context of budget cuts due to austerity policies, cultural aspects of Brazilian citizenship have influenced access to high‐quality health care services by creating two distinct conditions. Some patients acted as super‐citizens, while others acted as subcitizens. Nurses across the globe must spearhead the struggle for universal and equitable health care access at all levels, without losing sight of wider sociocultural aspects. [ABSTRACT FROM AUTHOR]

Objective: To examine the effect of rural hospital closures on EMS response time (minutes between dispatch notifying unit and arriving at scene); transport time (minutes between unit leaving the scene and arriving at destination); and total activation time (minutes between 9-1-1 call to responding unit returning to service), as longer EMS times are associated with worse patient outcomes.Data Sources/study Setting: We use secondary data from the National EMS Information System, Area Health Resource, and Center for Medicare & Medicaid Provider of Service files (2010-2016).Study Design: We examined the effects of rural hospital closures on EMS transport times for emergent 9-1-1 calls in rural areas using a pre-post, retrospective cohort study with the matched comparison group using difference-in-difference and quantile regression models.Principal Findings: Closures increased mean EMS transport times by 2.6 minutes (P = .09) and total activation time by 7.2 minutes (P = .02), but had no effect on mean response times. We also found closures had heterogeneous effects across the distribution of EMS times, with shorter response times, longer transport times, and median total activation times experiencing larger effects.Conclusions: Rural hospital closures increased mean transport and total activation times with varying effects across the distribution of EMS response, transport, and total times. These findings illuminate potential barriers to accessing timely emergency services due to closures. [ABSTRACT FROM AUTHOR]

Background and aims: HIV‐positive drug users' poor adherence to antiretroviral regimens can pose a significant and negative impact on individual and global health. This review aims to identify knowledge gaps and inconsistencies within the current evidence base and to measure HIV‐positive drug users' adherence rates and the factors that influence their adherence. Methods: A search of quantitative and qualitative studies in relation to HIV‐positive drug users' adherence to antiretroviral treatment was performed using five databases: Applied Social Sciences Index and Abstract (ASSIA), Cumulative Index to Nursing and Allied Health Literature (CINAHL), Medline, Embase and PsycINFO (Ovid interface). Relevant studies were retrieved based on the inclusion and exclusion criteria stated in the review. Findings were compared, contrasted and synthesized to provide a coherent account of HIV‐positive drug users' adherence rates and the factors that influence their adherence. Results: The proportion of HIV‐positive drug users who achieved ≥ 95% adherence across the studies varied widely, from 19.3 to 83.9%. Adherence rates changed over the course of HIV treatment. The factors that influenced adherence were reported as follows: stigmatization, motivation, active drug use, accessibility and conditionality of HIV and addiction care, side effects and complexity of treatment regimens, forgetfulness and non‐incorporation of dosing times into daily schedules. Conclusions: HIV‐positive drug users' medication‐taking is a dynamic social process that requires health professionals to assess adherence to HIV treatment on a regular basis. [ABSTRACT FROM AUTHOR]

Objective: Building upon earlier research, a person-centred technology-enabled solution (the InnoWell Platform) is being co-designed and implemented into regional youth primary mental health services to improve clinical safety and service quality. Design: Co-design methodologies of service pathway mapping and participatory design workshops as well as usability testing guide the development and implementation of the InnoWell Platform. Setting and participants: headspace centres on the North Coast of New South Wales and their associated communities. Main outcome measures: Participation in co-design methodologies, implementation and uptake, identification of youth mental health care needs, and service provision. Results: Nine service pathway mapping (N = 81 participants) and 10 participatory design (N = 48) workshops and usability testing sessions (N = 30) with youth, their supportive others, health professionals, service managers and administrators have been conducted. Four headspace centres have implemented the InnoWell Platform. To date, 120 youth are using the platform and 96 have completed an initial multidimensional assessment. Of these, the majority reported moderate-to-high psychological distress and a quarter reported experiencing high suicidal thoughts and behaviours with subsequent earlier provision of care. Young people have independently commenced recommended online tools and collaborated on clinical care options with their health professionals. Conclusions: Preliminary findings support co-design methodologies for the development of person-centred technology-enabled solutions embedded within youth primary mental health services in regional Australia. The findings further demonstrate that such solutions may improve clinical safety and service quality, which in turn may facilitate the delivery of the right care, first time! [ABSTRACT FROM AUTHOR]

As the need for health care services increases, some health facilities in many developing countries such as Namibia are challenged with accessing its big data. Despite the success of mobile systems, its use to access health care big data is challenging, which have impact on manageability and improvement of service delivery. The main problem is that the factors that influence interaction between mobile systems and health care big data are not empirically known within the Namibian context. The Namibian Ministry of Health (MoH) was therefore used as a case in this study. Qualitative methods and an interpretivist approach were employed, and structuration theory was used to underpin the study, which means the theory guided the analysis of the data. From the analysis, five factors were found to influence interaction in the use of mobile systems to access health care big data. On the basis of these factors, a model is proposed, which is a contribution to improving health care service delivery in the country through its practical implications: guiding interactions among health care stakeholders and developing policy for accessing patients' big data. [ABSTRACT FROM AUTHOR]

OBJECTIVES: Older patients that have aged with their doctors will likely experience their physician retiring. It is unclear if this interruption in continuity of care leaves patients at risk for adverse events or whether a new physician improves care. We sought to identify and synthesize findings from all articles examining the association between physician retirement and patient outcomes. DESIGN: Systematic review. We searched English‐language articles cataloged in Medline, Embase, Cochrane, and PsycINFO, from database inception to May 4, 2018. PARTICIPANTS: Any patient whose physician (generalist or specialist) retired. INTERVENTION: Physician retirement, defined as voluntary practice closure, death, or departure. MEASUREMENTS: Articles were categorized as anecdotes, qualitative studies, or quantitative studies. Each patient outcome was indexed under one of 11 themes (eg, adverse event, difficulty accessing care) and classified as favorable, neutral, or unfavorable. Patient outcomes included but were not limited to clinical (eg, death), resource utilization (eg, hospitalization), treatment plan adherence (eg, access to medications), and patient satisfaction (eg, expressed frustration). Two reviewers independently assessed study quality. RESULTS: Of 2099 articles screened, 17 met inclusion criteria: 12 anecdotes, 2 qualitative studies, and 3 quantitative studies. Most patient outcomes described were unfavorable. These included feelings of loss, difficulties with transition to a new provider, adverse clinical outcomes, and increased use of high‐cost services. The quality of qualitative studies was high, but that of quantitative studies was poor or moderate. CONCLUSION: Current evidence from qualitative studies suggests physician retirement affects patients unfavorably and that patients are vulnerable during this transition of care. High‐quality quantitative research is lacking to identify whether this disproportionately affects older adults and whether physician retirement has significant consequences for the broader healthcare system. J Am Geriatr Soc 68:641–649, 2020 [ABSTRACT FROM AUTHOR]

Globally, cancer is the second leading cause of death, with numbers greatly exceeding those for human immunodeficiency virus/acquired immunodeficiency syndrome, tuberculosis, and malaria combined. Limited access to timely diagnosis, to affordable, effective treatment, and to high-quality care are just some of the factors that lead to disparities in cancer survival between countries and within countries. In this article, the authors consider various factors that prevent access to cancer medicines (particularly access to essential cancer medicines). Even if an essential cancer medicine is included on a national medicines list, cost might preclude its use, it might be prescribed or used inappropriately, weak infrastructure might prevent it being accessed by those who could benefit, or quality might not be guaranteed. Potential strategies to address the access problems are discussed, including universal health coverage for essential cancer medicines, fairer methods for pricing cancer medicines, reducing development costs, optimizing regulation, and improving reliability in the global supply chain. Optimizing schedules for cancer therapy could reduce not only costs, but also adverse events, and improve access. More and better biomarkers are required to target patients who are most likely to benefit from cancer medicines. The optimum use of cancer medicines depends on the effective delivery of several services allied to oncology (including laboratory, imaging, surgery, and radiotherapy). Investment is necessary in all aspects of cancer care, from these supportive services to technologies, and the training of health care workers and other staff. [ABSTRACT FROM AUTHOR]

There is ample evidence that patient mistrust toward the American medical system is to some extent associated with communal and individual experiences of racism. For groups who have faced exploitation and discrimination at the hands of physicians, the medical profession, and medical institutions, trust is a tall order and, in many cases, would be naive. Nevertheless, trust is often regarded as a central feature of the physician‐patient relationship. In this article, I draw on empirical research, ethical theory, and clinical cases to propose one way that providers might address and, ideally, resolve mistrust when it arises in an immediate case. I describe how medical mistrust has been characterized empirically within medical and bioethics scholarship, and I provide an overview of theories of trust, arguing that they may be unable to account for the risks that providers must take in seeking to establish trust within many American medical institutions. Common assumptions in medical and bioethical scholarship on trust notwithstanding, caring and competence are not always enough to establish a trusting relationship between physician and patient. I suggest that, in an atmosphere of mistrust, comprehension of the existence and source of suspicion is essential to effective signaling of trustworthiness. [ABSTRACT FROM AUTHOR]

Rural mental health outcomes have been persistently poorer than those in larger cities suggesting that the prevailing investments to improve matters are not working. Mental health researchers and service providers from New South Wales, Victoria, Western Australia and the Australian Capital Territory met in Orange in October 2018 to explore issues pertaining to rural mental health and well‐being. The group recognised and acknowledged that rural residents experience a series of interconnected geographical, demographic, social, economic and environmental challenges which are not addressed adequately by the current mix of services. This declaration has been endorsed by those listed below and we welcome further support. We list ten interrelated problems and ten solutions. As a group, we take this declaration as an opportunity to invite discussion about how we can collectively improve the mental health of rural residents through research, service design and delivery. We invite the reader to consider endorsing this declaration. A short summary of supporting evidence is available online at https://www.crrmh.com.au/. [ABSTRACT FROM AUTHOR]

Objective: To examine allied health client, provider and community referrer perceptions of telehealth for the delivery of rural paediatric allied health services to facilitate adoption. Design: A qualitative design employed semistructured interviews with the three key stakeholder groups. Setting: Stakeholders were associated with BUSHkids (The Royal Queensland Bush Children's Health Scheme), a not‐for‐profit organisation serving children and families in Queensland, Australia. Participants: Thirty‐nine stakeholders (12 clients, 16 providers and 11 community referrers). Main outcome measures: Participants were asked about familiarity with telehealth, willingness to use telehealth and perceived barriers and facilitators to telehealth acceptability. Result: Fifty‐nine percent of participants had experienced telehealth and 77 percent were willing to use it. Participants perceived that technology problems were a barrier to telehealth, that children would not be able to concentrate on or enjoy telehealth sessions, that relationships and communication would be inferior to in‐person sessions, and that telehealth was inappropriate for disciplines employing physical touch. Participants identified access to health services as a key benefit of telehealth, said that technology problems could be worked around, and said that telehealth services could be supported with internal partners (eg, assistants) and external partners (eg, local medical centres). They also identified a variety of telehealth benefits to families (eg, convenience, privacy). Conclusion: Overall, telehealth was acceptable to stakeholders. Providers need training to facilitate child participation online and identify alternatives to physical touch. Co‐learning opportunities should be used to address low provider and referrer self‐efficacy. [ABSTRACT FROM AUTHOR]

Purpose: Critical Access Hospitals (CAHs), often the first point of access for emergency care, see few children and are challenged to remain proficient in caring for pediatric patients. Our analysis provides guidance to facilitate increasing CAHs staffs' ability to provide effective pediatric emergency care. Methods: The National Pediatric Readiness Project (NPRP) assessment of 4,146 emergency departments (EDs) was linked with the CAHs list from Centers for Medicare and Medicaid Services. Pediatric readiness was assessed using the weighted pediatric readiness score (WPRS). A WPRS of 100 indicates that the ED meets essential guidelines for pediatric readiness. Using descriptive statistics, we also compared low (fewer than 5 children a day) and medium patient volume (5‐14 children a day) EDs in 6 core areas of readiness. Findings: Eighty‐six percent (1,140) of CAHs were linked to the NPRP. In the study, 80% were low and 20% medium volume. The median WPRS was 59.0 for low and 67.3 for medium volume. While some differences were found by patient volume, overall 63% of CAHs had a pediatric emergency care coordinator, 34% had a pediatric patient care review process, 62% had interfacility transfer guidelines, and 45% weighed children only in kilograms. CAHs participating in a facility recognition program had significantly higher median WPRS scores (84.3) compared to those not participating (59.5). Conclusion: CAHs have challenges in being ready to care for children in the areas of pediatric emergency care coordinators, policies, procedures, and patient safety. Minimal cost interventions are available to increase the readiness of CAHs to care for children. [ABSTRACT FROM AUTHOR]

Background: Care pathway approaches were introduced into health care in the 1980s and have become standard international practice. They are now being introduced more specifically for health care in the criminal justice system. Care pathway delivery has the theoretical advantage of encouraging a whole-systems approach for health and social care within the criminal justice system, but how well is it supported by empirical evidence?Aims: The aim of this study is to review the nature and extent of evidence streams supporting health care delivery within interagency pathway developments since 2000.Method: We used an exploratory narrative method to review the nature and extent of evidence streams supporting health care delivery within interagency pathway developments since 2000. The available literature was reviewed using a keyword search approach with three databases: PubMed, Medline, and Google Scholar.Findings: Research in this field has covered police custody, courts, prisons, and the wider community, but there is little that follows the entire career through all these elements of offender placement. Main themes in the research to date, regardless of where the research was conducted, have been counting the disorder or the need, development and evaluation of screening tools, and evaluation of clinical intervention styles. Most evidence to date is simply observational, although the possibility of conducting randomised controlled trials of interventions within parts of the criminal justice system, especially prisons, is now well established.Conclusions: Access to health care while passing through the criminal justice system is essential because of the disproportionately high rates of mental disorder among offenders, and the concept of structured pathways to ensure this theoretically satisfying, but as yet empirically unsupported. Further, substantial cuts in services, generally following government economies, are largely unresearched. Considerable investment in new possibilities, driven by both pressure groups and government, tend to be informed by good will and theory rather than hard evidence and are often not evaluated even after introduction. This must change. [ABSTRACT FROM AUTHOR]

We explore whether a Rawlsian approach might provide a guiding philosophy for the development of a healthcare system, in particular with regard to resolving tensions between different groups within it. We argue that an approach developed from some of Rawls' principles – using his 'veil of ignorance' and both the 'difference' and 'just savings' principles which it generates – provides a compelling basis for policy making around certain areas of conflict. We ask what policies might be made if those making them did not know if one was patient, doctor, nurse or manager – in this generation or the next. We first offer a brief summary of Rawls' approach and how we intend to extrapolate from it. We examine how this adapted Rawlsian framework could be applied to specific examples of conflict within healthcare; we demonstrate how this framework can be used to develop a healthcare service which is both sustainable (in its training and treatment of staff, and in encouraging research and innovation) and open (to protect the powers and opportunities of those using the health service). We conclude that while Rawls' approach has previously been rejected as a means to address specific healthcare decisions, an adapted veil of ignorance can be a useful tool for the consideration of how a just health service should be constructed and sustained. Turning the theoretical into the practical (and combining Rawls' thought experiment with Scanlonian contractarianism), managers, doctors, patients, carers and nurses could come together and debate conflicting issues behind a hypothetical veil. [ABSTRACT FROM AUTHOR]

Background: Dietitians play an important role in the intervention and prevention of being overweight and obesity. More and more blended care interventions are being implemented. The present study aimed to evaluate the delivery by Dutch dietitians of a multicomponent, evidence‐based weight‐loss programme (SMARTsize), including counselling for relapse prevention. The aim of this qualitative study was to identify facilitators and barriers to the delivery of SMARTsize. Methods: Nine semi‐structured interviews were conducted with 10 dietitians who participated in a larger implementation study. Each interview was recorded and transcribed verbatim. Determinants of theory of implementation, including characteristics of the user, the innovation, organisational context and setting, and innovation strategy guided interviews and analysis. Data were coded and analysed using the framework approach. Results: According to dietitians, the SMARTsize intervention had a positive influence on patients. The main implementation facilitators were the availability of implementation materials, such as a manual, training in relapse prevention and social support from other dietitians. The main barriers to implementation were organisation and financial reimbursement of cooking classes, the belief that patients need more individual counselling in the starting phase, and the unsuitability for people with low levels of health literacy. Conclusions: Most dietitians considered that implementation of the SMARTsize intervention consisting of e‐health, written information and cooking classes and face‐to‐face counselling is challenging but feasible. Further development of the SMARTsize intervention and implementation tools is needed to lower experienced barriers. It is also recommended that a version of the intervention to be developed that is suitable for patients with lower levels of health literacy. [ABSTRACT FROM AUTHOR]

Policy PointsHealth care systems and policymakers in the United States increasingly use language related to social determinants of health in their strategies to improve health and control costs, but the terms used are often misunderstood, conflated, and confused.Greater clarity on key terms and the concepts underlying them could advance policies and practices related to social determinants of health—including by defining appropriate roles and limits of the health care sector in this multisector field. [ABSTRACT FROM AUTHOR]

Rational, aims, and objectives: Understanding of barriers and successes associated with the implementation of electronic patient self‐reported measures (ePSRMs) within clinical settings are limited and have not been pursued utilizing implementation science frameworks. This qualitative study is designed to assess staff perceptions of an ePSRM implementation. Methods: The study took place in an academic hospital's Consultation Liaison Psychiatry practice. Qualitative interviews were conducted with the staff and clinicians from the practice. Participants were directly involved with the implementation and use of the ePSRM system within the Psychiatry practice. Interviews were structured around the Reach, Effectiveness, Adoption, Implementation, Maintenance (RE‐AIM) framework. Results: Participants reported increased patient engagement as well as efficiency and time savings. The intervention was perceived to be more challenging for older patients. Facilitators include communicating the ePSRM to patients prior to the care visit, having enough trained staff or super‐users who can assist with technical problems, and having a shorter questionnaire. Conclusions: Overall, assessment of the ePSRM implementation was positive. Staff and clinicians indicated benefits in time, effectiveness, and improvements in patient treatment. Results indicate that defining how the system would fit within the clinical workflow was key, as was a flexible and user‐friendly technology platform. The ePSRM implementation was dependent upon clinical involvement and interest in adoption, while barriers were associated with technical challenges as well as some patient difficulties, such as cognitive impairment. The use of the RE‐AIM framework is valuable as it allows for systematic assessment of the implementation and identifies areas in that implementation has succeeded or is lacking. [ABSTRACT FROM AUTHOR]

Purpose: Health disparities among LGBTQ people have been documented across various settings and recent research has indicated that many disparities are heightened in the context of rurality. Among these disparities is the decreased rate of primary care utilization by rural LGBTQ individuals. Understanding and addressing provider knowledge and attitudes related to LGBTQ health provides a relevant avenue for addressing underutilization. Methods: The study presented was a mail‐out survey regarding rural primary care providers' knowledge and experiences regarding LGBTQ health. Publicly available records were compiled to recruit a total sample of 113 primary care providers, at a response rate of 19.8%. Findings: A majority of respondents reported experience providing care to LGBTQ patients, while only slightly over half had received LGBTQ health education. Data analyses revealed significant associations between reported experiences and patient characteristics including religion, religiousness, age, length of time practicing in current provider role, and gender identity. Provider knowledge of LGBTQ health varied greatly across the items assessed. Provider profession (physician, nurse practitioner, physician assistant) and length of current county residence were significantly predictive of LGBTQ knowledge scores. Conclusion: Results provide insight into rural health care for LGBTQ people. Preeminent findings were: (1) an existing need for LGBTQ health education, (2) variation in knowledge across content areas, and (3) association between knowledge, profession, and length of current county residence. Promotion of rural LGBTQ health may benefit by addressing identified gaps in current care. [ABSTRACT FROM AUTHOR]

Public programs such as Medicaid offer highly circumscribed access to health care for low-income patients in the United States. This article describes the work of a variety of health care staff who manage specialized cancer care for publicly insured patients who have difficulty gaining or maintaining program eligibility or for uninsured and undocumented patients who are excluded from state programs. I highlight the moral distress that occurs when clinic employees become individually responsible for reconciling policies that limit patients' access to care. I conclude that responsibility for securing access to cancer care for structurally vulnerable patients frequently falls to safety net clinics and that patients' financial constraints are visible to particular types of staff, such as non-licensed health care staff and non-physician providers, who may experience moral distress disproportionately. [ABSTRACT FROM AUTHOR]

Rationale: Since health care is facing challenges, with fewer caregivers providing care to more clients, eHealth plays a crucial role. Through eHealth, people are expected to be more involved in their own care. On the part of health care users, eHealth requires use of everyday technology such as telephones and computers, and services through the Internet which might be challenging for older adults with cognitive impairment. Aim: To investigate experiences of using eHealth in contact with health care among older adults with cognitive impairment. Method: Individual, semi‐structured interviews were conducted with nine participants, aged 65–84 years, with cognitive impairments of varying origins. A constructivist Grounded Theory approach was used. Data collection and analysis were performed simultaneously using a constant comparative method. Ethical issues: Ethical approval (Dnr: 2014/906‐32) was obtained from the regional ethical committee, Stockholm. Results: The core category, the eHealth staircase supported by habits, is presented as a model that visualises the result. The model includes three steps showing different ways of being in contact with health care through the use of technological devices and services that mirrors different levels of complexity of eHealth use as follows: (i) Analogue use, (ii) One‐way‐use and (iii) Interactive use. The participants' location on the eHealth staircase was affected by several aspects described in three categories united by habits; A stable relationship with technology: a prerequisite for use; The importance of interpersonal relationships within health care and Being supported by significant others: a prerequisite in contact with health care. Conclusions: Older adults with cognitive impairments seemed to prefer common and less complex eHealth when contacting health care. Therefore, it is necessary that health care providers offer different possibilities for patients to contact them, that is, both through the Internet and by personal telephone service. [ABSTRACT FROM AUTHOR]

The article focuses on the challenges of providing healthcare in rural, regional, and remote (RRR) areas. It addresses the issue of external validity and metropolitan bias in clinical guidelines, which may not be applicable or appropriate for RRR populations. It discusses the limitations and complexities of providing care in RRR settings, including the need to consider resource allocation and logistics in decision-making.

The article discusses sustainable development, as a concept, focuses on how to responsibly use resources in the present in such a way as not to deplete future resources. Topics include the COVID-19 pandemic has highlighting the fragility of how all health care systems have resourced across three dimensions: financial; and the health inequity between different nations has becoming increasingly apparent using unprecedented amounts of essential supplies.

Objective: The objective was to describe characteristics of civil monetary penalties levied by the Office of the Inspector General (OIG) related to violations of the Emergency Medical Treatment and Labor Act (EMTALA) involving psychiatric emergencies. Methods: Descriptions of EMTALA‐related civil monetary penalty settlements from 2002 to 2018 were obtained from the OIG. Cases related to psychiatric emergencies were identified by inclusion of key words in settlement descriptions. Characteristics of settlements involving EMTALA violations related to psychiatric emergencies including date, amount, and nature of the allegation were described and compared with settlements not involving psychiatric emergencies. Results: Of 230 civil monetary penalty settlements related to EMTALA during the study period, 44 (19%) were related to psychiatric emergencies. The average settlement for psychiatric‐related cases was $85,488, compared with $32,004 for non–psychiatric‐related cases (p < 0.001). Five (83%) of the six largest settlements during the study period were related to cases involving psychiatric emergencies. The most commonly cited deficiencies for settlements involving psychiatric patients were failure to provide appropriate medical screening examination (84%) or stabilizing treatment (68%) or arrange appropriate transfer (30%). Failure to provide stabilizing treatment was more common among cases involving psychiatric emergencies (68% vs. 51%, p = 0.041). Among psychiatric‐related settlements, 18 (41%) occurred in CMS Region IV (Southeast) and nine (20%) in Region VII (Central). Conclusions: Nearly one in five civil monetary penalty settlements related to EMTALA violations involved psychiatric emergencies. Settlements related to psychiatric emergencies were more costly and more often associated with failure to stabilize than for nonpsychiatric emergencies. Administrators should evaluate and strengthen policies and procedures related to psychiatric screening examinations, stabilizing care of psychiatric patients boarding in EDs, and transfer policies. Recent large, notable settlements related to EMTALA violations suggest that there is considerable room to improve access to and quality of care for patients with psychiatric emergencies. [ABSTRACT FROM AUTHOR]

Background: Homelessness is an increasing societal and health issue associated with high rates of substance abuse and mental health disorders. Homeless people die more often and at a younger age than others. Aim: To identify health needs and improve healthcare for homeless men. Methods: A physician‐led clinic was established on‐site at the Mission Australia Centre in Sydney, incorporating: (i) liver screening, including portable fibroscan testing, and on‐site treatment of hepatitis C; (ii) a mental health clinic, staffed by a psychiatrist; and (iii) a nurse‐led clinic to follow up medical issues and deliver vaccinations. Patient data were recorded prospectively to determine what medical problems were encountered so as to drive future healthcare planning. Results: A total of 257 men was assessed between November 2011 and December 2017. In that time, 561 men resided at the Centre. Of these 257 men who attended the clinic, 61% were <45 years old; 69% were current and 8% former smokers; 62% had a history of chronic alcoholic abuse and 66% other substance abuse; 64% had one or more of depression, anxiety, psychosis or another mental health disorder and 44% had metabolic syndrome features, 38% cardiovascular disease, 29% hepatitis C and 21% a respiratory disorder. Conclusion: The main health needs of homeless men fall into the categories of mental health; cardiovascular, respiratory and metabolic disorders and addictions and hepatitis C. Establishing on‐site clinics at homeless shelters with expertise to address these issues will likely improve the well‐being of these men, reduce hospital admissions and prolong their lives. [ABSTRACT FROM AUTHOR]

Objective: The objective was to develop an acceptable clinical decision support (CDS) system to facilitate evidence‐based sexual health care for adolescents in the emergency department (ED). Methods: In this multiphased iterative process, we engaged an expert group to synthesize evidence on a wide range of sexual health services (e.g., contraception, condoms, identification and treatment of previously diagnosed sexually transmitted infection). We created a computerized questionnaire and embedded our decision tree, utilizing patient‐entered responses to create tailored, evidence‐based recommendations, and embedded links to study‐related resources such as the emergency contraception (EC) quick guide. We utilized mixed methodology to explore perspectives of adolescents aged 14 to 19 years and clinicians at two general and two pediatric EDs after they interacted with the system. Clinicians reported usefulness (Likert scale 1 = not at all, 4 = very); adolescents reported acceptability. We used the chi‐square test to compare responses between subgroups. We collected adolescents' verbatim responses to open‐ended questions; clinicians self‐entered responses. Four authors independently generated themes from qualitative responses before compiling key findings and achieving consensus on final themes. Results: Among 57 clinicians (23 physicians, 23 nurses, 11 nurse practitioners; 54% female; 65% aged < 40 years), the mean system usefulness rating was 3.4 ± 0.7. Sex, age, clinician role, or ED type were not associated with rating the system "somewhat/very" useful. Clinicians identified barriers (e.g., time constraints) that could be overcome by implementation considerations (e.g., training) as well as benefits including improved care. For future assessments, providers preferred computer (65%) over face‐to‐face interview (26%). Among 57 adolescents (mean age = 16.2 years; 75% female; 56% sexually experienced), nearly all (95%) reported that it was "very/somewhat easy" to complete the computerized questionnaire and to understand the questions. Most adolescents understood the EC quick guide and correctly identified that ulipristal, compared to levonorgestrel, required a prescription and was more effective. For future assessments, adolescents preferred computer (69%) over face‐to‐face interviews (9%). Conclusions: We developed a sexual health CDS system that is easy to use and can facilitate evidence‐based care to reduce health outcome gaps. Evaluation of system impact on service delivery and, ultimately, health outcomes is needed. [ABSTRACT FROM AUTHOR]

Currently, in the United States and worldwide, the vast majority of children and adolescents in need of mental health services receive no treatment. Although there are many barriers, a key barrier is the dominant model of delivering psychosocial interventions. That model includes one‐to‐one, in‐person treatment, with a trained mental health professional, provided in clinical setting (e.g., clinic, private practice office, health‐care facility). That model greatly limits the scale and reach of psychosocial interventions. The article discusses many novel models of delivering interventions that permit scaling treatment to encompass children and adolescents who are not likely to receive services. Special attention is accorded the use of social media, socially assistive robots, and social networks that not only convey the ability to scale interventions but also encompass interventions that depart from the usual forms of intervention that currently dominate psychosocial treatment research. Read the Commentary on this article at doi: 10.1111/jcpp.13034 [ABSTRACT FROM AUTHOR]

Background: This study investigated the psychocultural perspectives concerning family quality of life among Brazilian families with children who have severe or profound intellectual disability. Methods: Individual in‐depth semi‐structured interviews conducted with 15 mothers, selected by convenience, were analysed using a categorical thematic analysis technique. The themes were examined to allow for an interpretative approach of the results. Results: Mothers revealed that their children with disabilities had insufficient access to services and support related to health care, transportation and recreation. Family quality of life was negatively affected by financial restrictions and social interaction difficulties. Caring for a child with disabilities seemed to be centred on the mother and religious coping appeared as a common psychological adjustment strategy. Conclusions: Improving emotional and psychological cares, as well as social and practical measures comprising income support and access to appropriate health care, were inferred to be the mothers' priorities to improve their families' quality of life. [ABSTRACT FROM AUTHOR]

Background: Hospital at home (HaH) is a model of care that provides acute‐level services in the home. HaH has been shown to improve quality and patient satisfaction, and reduce iatrogenesis and costs. Uptake of HaH in the United States has been limited, and little research exists on how to implement it successfully. Objectives: This study examined facilitators and barriers to implementation of an HaH program. Design: A HaH program that included a 30‐day transitional care bundle following the acute stay was implemented through a Centers for Medicare & Medicaid Services Innovations Award. Informants completed a priming table describing initial implementation components, their barriers, and facilitators. These were followed up with semistructured focus groups and individual interviews that were transcribed and independently coded using thematic analysis by two independent investigators. Setting: Large urban academic health system. Participants: Clinical and administrative personnel from Mount Sinai, the Visiting Nurse Service of New York, and executive leaders at partner organizations (laboratory, pharmacy, radiology, and transportation). Results: To facilitate successful development and implementation of a high‐quality HaH program, a number of barriers needed to be overcome through significant teamwork and communication internally with policymakers and external partners. Areas of paramount importance include facilitating work‐arounds to regulatory barriers and health system policies; altering an electronic health record that was not designed for HaH; developing the necessary payment and billing mechanisms; and building effective and collaborative partnerships and communication with outside vendors. Conclusion: Development of HaH programs in the United States are feasible but require strategic planning and development of strong, tightly coordinated partnerships. J Am Geriatr Soc 67:588–595, 2019. [ABSTRACT FROM AUTHOR]

The prevalence of health risk behaviours and associated poor physical health is high in people with severe mental illness. Mental health service guidelines and policies stipulate that mental health services should address physical health of people who access services. This study reports results from a large, interdisciplinary, cross‐sectional study exploring mental health clinicians' (n = 385) views of role legitimacy in physical health service provision. All disciplines reported that mental health clinicians have a role to play in addressing the physical health of consumers. Among mental health clinicians, psychiatrists and mental health nurses received higher endorsement than allied health clinicians in relation to the provision of physical health care, with primary care providers including general practitioners also ranking highly. As community mental health services routinely appoint allied health staff to case management roles, a challenge for services and a challenge for clinicians are to ensure that physical health and the effects of medication are monitored appropriately and systematically. Online and telephone support services received relatively lower endorsement. As the availability of nonface to face services increases, there is a need to explore their utility in this population and where appropriate promote their uptake. [ABSTRACT FROM AUTHOR]

Objective: To determine the relationship between health status and the magnitude of black-white and Hispanic-white disparities in the likelihood of having any office-based or hospital outpatient department visits, as well as number of visits.Data Source: 2010-2014 Medical Expenditure Panel Survey.Study Design: The probability of having a visit is modeled using a Probit model, and the number of visits using a negative binomial model. We use a nonlinear rank-and-replace method to adjust minority health status to be comparable to that of whites, and predict utilization at different levels of health by fixing an indicator of health status. We compare estimated differences in predicted utilization across racial/ethnic groups for each level of health status to map out the relationship between the racial/ethnic disparity and health status, also stratifying by health insurance coverage.Extraction Methods: We subset to nonelderly adults.Principal Findings: We find that Hispanic-white differences in the probability of having an office-based or hospital outpatient department were widest among adults in excellent health (27 percentage points, 95% CI: [23, 31]) and narrowest when reporting poor or fair health (15 p.p. [13, 17]). Black-white and Hispanic-white differences in the number of visits were wider for adults who report poor or fair health (5.3 visits [4.0, 6.6] and 5.7 [4.3, 7.0], respectively) compared to excellent health (1.7 [1.2, 2.1] and 1.5 [1.1, 2.0], respectively) among adults who are full-year privately insured.Conclusions: The magnitudes of racial/ethnic disparities vary with level of health. [ABSTRACT FROM AUTHOR]

Purpose: Worldwide, more than 214 million people have left their country of origin. This unprecedented mass migration impacts health care in host countries. This article explores and synthesizes literature on the healthcare experiences of migrants. Design: A meta‐ethnography study of qualitative studies was conducted. Methods: Eight databases (Medline, the Cumulative Index to Nursing and Allied Health Literature [CINAHL], PsycINFO, Embase, Web of Science, Migration Observatory, National Health Service Scotland Knowledge Network, and Adaptive Spectrum and Signal Alignment [ASSIA]) were searched for relevant full‐text articles in English, published between January 2006 and June 2016. Articles were screened against inclusion criteria for eligibility. Included articles were assessed for quality and analyzed using Noblit and Hare's seven‐step meta‐ethnography process. Findings: Twenty‐seven studies were included in the review. Five key contextualization dimensions were identified: personal factors, the healthcare system, accessing healthcare, the encounter, and the healthcare experience. These five areas all underlined the uniqueness of each individual migrant, emphasizing the need to treat a person rather than a population. Within a true person‐centered approach, the individual's cultural background is fundamental to effective care. Conclusions: From the findings, a model has been designed using the five dimensions and grounded in a person‐centered care approach. This may help healthcare providers to identify weak points, as well as to improve the organization and healthcare professionals' ability to provide person‐centered care to migrant patients. Clinical Relevance: The proposed model facilitates identification of points of weakness in the care of migrant patients. Employing a person‐centered care approach may contribute to improve health outcomes for migrant patients. [ABSTRACT FROM AUTHOR]

Objective: To estimate health care utilization and costs incurred by homeless Veterans relative to nonhomeless Veterans and to examine the impact of a VA homelessness program on these outcomes.Data Sources/study Setting: Combined Department of Veterans Affairs (VA) administrative and Medicare claims data.Study Design: Observational study using longitudinal data from Veterans engaged with the VA system and enrolled in Medicare. Veterans with administrative evidence of homelessness at any point during 2006-2010 were matched on period of military service to Veterans with no evidence of homelessness.Principal Findings: Experience of homelessness was associated with 1.37 (95 percent CI = 1.34-1.40) and 0.16 (95 percent CI = 0.14-0.17) more outpatient encounters per quarter in VA and non-VA settings, respectively, and 1.31 (95 percent CI = 1.30-1.32) and 0.49 (95 percent CI = 0.48-0.49) more inpatient days per quarter in VA and non-VA hospitals, respectively. These were associated with higher costs. Relative to stably housed Veterans less than 65 years of age, those enrolled in a VA homelessness program had 94.4 percent (95 percent CI = 90.7 percent-98.1 percent) more VA outpatient visits but 5.5 percent (95 percent CI = 3.0 percent-7.9 percent) fewer Medicare outpatient visits.Conclusions: Homelessness was associated with an increase in VA and Medicare utilization and cost. A VA homelessness program decreased use of Medicare outpatient services. [ABSTRACT FROM AUTHOR]

Background: Although high quality mental health care for children and youth is a goal of many health systems, little is known about the dimensions of quality mental health care from users' perspectives. We engaged young people, caregivers and service providers to share experiences, which shed light on quality dimensions for youth mental health care. Methods: Using experience‐based co‐design, we collected qualitative data from young people aged 16‐24 with a mental disorder (n = 19), identified caregivers (n = 12) and service providers (n = 14) about their experiences with respect to youth mental health services. Experience data were collected using multiple approaches including interviews, a suite of online and smartphone applications (n = 22), and a co‐design event (n = 16) and analysed to extract touch points. These touch points were used to prioritize and co‐design a user‐driven prototype of a questionnaire to provide feedback to service providers. Findings: Young people, caregiver and service provider reports of service experiences were used to identify aspects of care quality at eight mental health service contact points: Access to mental health care; Transfer to/from hospital; Intake into hospital; Services provided; Assessment and treatment; Treatment environment; and Caregiver involvement in care. In some cases, low quality care was harmful to users and their caregivers. Young people co‐designed a prototype of a user‐driven feedback questionnaire to improve quality of service experiences that was supported by service providers and caregivers at the co‐design event. Conclusion: By using EBCD to capture in‐depth data regarding experiences of young people, their caregivers and service providers, study participants have begun to establish a baseline for acceptable quality of mental health care for young people. [ABSTRACT FROM AUTHOR]

Rationale, aims, and objectives: This costing evaluation compares three service delivery models for ear, nose, and throat (ENT) surgery for remote living Indigenous children to improve their hearing outcomes, with the aim to identify the least costly model. Methods: The main outcome measure presented was the incremental cost difference between the base case (Model 1) and two alternative models (Model 2, 3). The costs in 2017 Australian dollars are assessed from two viewpoints: (1) health system perspective, and (2) patients and their families including travel out‐of‐pocket expenses, presented separately according to the funding source. Results: Findings indicate that the least costly model offered low‐risk ENT surgery from a state funded hospital in a remote setting, with high use of videoconference technology: TeleHealth (Model 3) could save $3626 to $5067 per patient, compared with patients travelling to a regional centre public hospital (Model 1). A federally funded scheme which allowed groups of patients to access a direct flight charter transfer to the private hospital in regional centre (Model 2) reduced the cost by $2178 to $2711 per patient when compared with standard care (Model 1). From a societal perspective, Model 1 required out‐of‐pocket patient expenses, with greater time away from home, and hence appears the least preferred option. Conclusions: The sensitivity analyses also demonstrate that Model 3 would be the more economical model for providing ENT surgery for remote living children. By proving an accurate assessment of the true costs of delivering these important ear and hearing health services, strategic health service planners may be better informed and sufficient budgets can be allocated to provide improved service delivery. The benefits of Model 3, over Models 1 or 2, would also incorporate improvements to patient safety as a result of reducing patient travel, which should in‐turn, reduce failure‐to‐attend rates. [ABSTRACT FROM AUTHOR]

Work on resilience in health and illness has been approached from a number of perspectives. These are the biological and psychosocial with a focus on the individual's responses to cope and adapt to changing circumstances wrought by changing physical health states. This we argue has a place but is far too narrow emphasizing the neoliberal view that the sick or imperfect individual is ultimately responsible for their own health outcomes. In this perspective, the individual's failure to cope or adapt may be seen as a personal failure to interact with the health system on offer. A broader sociological approach focuses on the overarching sociopolitical system within which health and illness occur and looks at the role of concepts such as growing social and economic inequity and the process by which neoliberalism establishes the framework of unequal opportunity and life chances. At this broader level, resilience relates to interplay between the sociopolitical and health systems and the individual. It is the role of the health system to provide opportunities, and supports and to reduce inequities to promote healthy lifestyle and beneficial coping approaches. We aim to understand and describe the mechanisms and opportunities afforded to individuals by their place in the social structure and to argue for health reform that makes a health system that assists all individuals be resilient. Longitudinal data from the Australian Epilepsy Longitudinal Survey are used to understand how income, inequity, and social isolation affect resilience over time. [ABSTRACT FROM AUTHOR]

Introduction: The receipt of remote clinical care for children via telecommunications (pediatric telemedicine) appears to improve access to and quality of care in U.S. emergency departments (EDs), but the actual prevalence and characteristics of pediatric telemedicine receipt remain unclear. We determined the prevalence and current applications of pediatric telemedicine in U.S. EDs, focusing on EDs that received telemedicine from clinicians at other facilities. Methods: We surveyed all 5,375 U.S. EDs to characterize emergency care in 2016. We then randomly surveyed 130 (39%) of the 337 EDs who reported receiving pediatric telemedicine. The second survey was administered by phone to ED directors primarily. It confirmed that the ED received pediatric telemedicine services in 2017 and asked about ED staffing and the nature, purpose, and concerns with pediatric telemedicine implementation. Results: The first survey (4,507/5,375, 84% response) showed that 337 (8%) EDs reported receiving pediatric telemedicine. Among the randomly sampled EDs completing the second survey (107/130, 82% response), 96 (90%) confirmed 2016 use and 89 (83%) confirmed 2017 use. Reasons for discontinuation included technical and scheduling concerns. Almost all who confirmed their pediatric telemedicine use in 2017 also reported 24/7 availability (98%). The most widely reported use was for patient placement and transfer coordination (80%). Many EDs (39%) reported no challenges with implementing pediatric telemedicine and described its utility. However, the most frequently reported challenges were process concerns (30%), such as concerns about slowing or interrupting providers' work flow and technological concerns (14%). Conclusion: Few EDs receive telemedicine for the delivery of pediatric emergency care nationally. Among EDs that do use telemedicine for pediatric care, many report process concerns. Addressing these barriers through focused education or interventions may support EDs in further developing and optimizing this technological adjunct to pediatric emergency care. [ABSTRACT FROM AUTHOR]

Objective: To examine the influence of dimensions of service quality on patient experience of primary care.Data Sources/study Setting: Data from the national GP Patient Survey in England 2014/15, with responses from 858,351 patients registered at 7,918 practices.Study Design: Expert panel and principal component analysis helped identify relevant dimensions of service quality. Regression was then used to examine the relationships between these dimensions and reported patient experience.Data Collection/extraction Methods: Aggregated scores for each practice were used, comprising the proportion of positive responses to each element of the study.Principal Findings: Of eight service quality dimensions identified, six have statistically significant impacts on patient experience but only two have large effects. Patient experience is highly influenced by practice responsiveness and the interactions with the physician. Other dimensions have small or even slightly negative influence. Service quality provided by nurses has negligible effect on patient experience.Conclusions: To improve patient experience in primary health care, efforts should focus on practice responsiveness and interactions with the physician. Other areas have little influence over patient experience. This suggests a gap in patients' perspectives on health care, which has policy implications for patient education. [ABSTRACT FROM AUTHOR]

In 2015, LVCT Health (a Kenyan non‐governmental organisation) conducted an exploratory study to assess the quality and comprehensiveness of services provided to child survivors of sexual violence at two public health facilities in Kenya. Both quantitative and qualitative data collection methods were used, including a retrospective review of 164 child survivor medical records, a health facility staff inventory, in‐depth interviews with 31 healthcare providers and 19 exit interviews with 14 child survivors and their caregivers. Ethical approval was obtained from two independent ethics committees. Quantitative data were analysed using SPSS version 22, while qualitative data were analysed using NVivo 10 based on a thematic coding framework. The health facility staff inventory indicated that only two out of 581 providers had undergone previous training on the management of child survivors of sexual violence. Both health facilities lacked the appropriate equipment for the collection of forensic evidence from children and private rooms in which to conduct the clinical examination. Providers cited challenges in offering psychosocial support to children. Only 27 per cent of child survivors were documented to have received trauma counselling. There is a need for health facilities to enhance their human resource and infrastructural capacity to facilitate the delivery of comprehensive care to child survivors. 'An exploratory study to assess the quality and comprehensiveness of services provided to child survivors of sexual violence... in Kenya' Key Practitioner Messages: There is a need to develop child‐specific guidelines for healthcare providers in order to ensure that child survivors of sexual violence receive good‐quality services at the facility level.Healthcare providers in public health facilities need competency‐based training to enable them to acquire knowledge and skills to identify and respond to child survivors of sexual violence, collect evidence, communicate with the children and offer counselling support to child survivors effectively.Services for child survivors should be centralised in health facilities to minimise the number of different contact points. [ABSTRACT FROM AUTHOR]