Search

Purpose: The purpose of this article is to describe current tracheal suctioning practices of physiotherapists in the province of Ontario and to determine what factors influence these practices. Method: A cross-sectional online survey was conducted. An online survey link and quick response code were mailed to Ontario physiotherapists who were actively providing patient care and were authorized to perform tracheal suctioning as identified by the College of Physiotherapists of Ontario. Results: Ninety physiotherapists participated in the survey (23% response rate). Most (66%) suctioned in an intensive care setting, and many (41%) reported frequently using a closed endotracheal suctioning system. Hyperoxygenation was frequently performed before suctioning by 48% of participants, and only 18% frequently hyperoxygenated after suctioning. Most participants reported infrequently performing saline instillation (52%) and infrequently hyperinflating before suctioning (79%). Clean gloves were reported as the personal protective equipment most frequently worn across all suctioning approaches, and goggles and sterile gloves were least often worn while suctioning. Previous suctioning experience had the most influence on suctioning practices, and limited access to equipment had the least influence. Conclusions: Some of the tracheal suctioning practices of physiotherapists in Ontario vary from evidence-based clinical guidelines.

RATIONALE: Given that airway suctioning is a higher-risk treatment technique, it is important to assess the competence of health care professional that perform it.OBJECTIVES: The objectives of this...

Ehlers-Danlos syndrome (EDS) describes a group of heritable disorders of connective tissue comprising mutations in the genes involved in the structure and/or biosynthesis of collagen. Thirteen EDS subtypes are recognized, with a wide degree of symptom overlap among subtypes and with other connective tissue disorders. The clinical hallmarks of EDS are tissue fragility, joint hypermobility, and skin hyperextensibility. Appropriate diagnosis of EDS is important for correct multidisciplinary management and is associated with better clinical outcomes for patients.

Nursing home information technology (NH IT) adoption trends are not measured regularly. Evidence indicates digital footprints are growing, but gaps about NH IT adoption and quality impacts remain. We hypothesize as NH IT adoption grows, quality improves. This research assessed ternary (2014-2017) trends in IT and quality measures using a primary survey of U.S. NHs. Survey measures included nine dimensions/domains and total IT sophistication. Administrators completed 815 Year 1 surveys. Each year mean total IT sophistication scores in nine dimensions/domains consistently increased. Eighteen significant correlations ( r > .13, absolute value) between IT sophistication and quality measures existed. Regression shows that for every 10 units increase in administrative activity extent of IT use, a decrease of 1.3% occurs in the percentage of low-risk long-stay residents with bowel or bladder incontinence. Increases in NH IT sophistication positively impact quality. Estimating ongoing trends in NH IT sophistication provides new information that should be consistently available.

Introduction The New South Wales (NSW) health system faces challenges in the coming decades as the effects of a changing population place pressures on the delivery of health care. Integrated Care is a crucial step to delivering care that is patient-centred and of value to the population. The NSW Integrated Care Strategy was launched in 2014. Local health partnerships were supported to implement innovative, locally led models which trialled new ways of working to address the needs of communities across NSW. Detailed monitoring and evaluation informed the next steps of the strategy. Description of policy context and objective The NSW Health Strategic Framework for Integrating Care was developed in 2018. The Framework articulates a clear vision for integrating care in NSW across the life course. Principles, enablers and expected outcomes are outlined in the Framework, and these are demonstrated in two major implementation activities: scaling effective initiatives across NSW; and collaborative commissioning with providers, organisations and settings in the community. Scaling effective initiatives Six Integrated Care initiatives have been selected for scaling across NSW. Each focuses on a cohort of the community, rather than a specific disease, and aims to manage health and social needs in primary and community care where possible and appropriate. The NSW Ministry of Health provides funding to Local Health Districts (LHD) to implement scaled initiatives in partnership with primary and social care services. LHDs enrol patients on a state-wide Integrated Care Patient Flow Portal which enables continuity of care across NSW and monitoring and evaluation of the strategy with aggregated and linked data. Collaborative commissioning Collaborative commissioning promotes the development of partnerships between Primary Health Networks (supported by the Commonwealth Government) and LHDs (NSW Government). Partnerships develop care pathways for patient groups identified through a comprehensive population needs assessment. These pathways reflect the need for better coordination between primary and secondary health services, as well as other service providers that contribute to the social determinants of health. Collaborative commissioning incentivises local autonomy and accountability for delivering patient-centred, outcome-focused and value-driven care in the community. Targeted population Integrated Care in NSW focuses on improving outcomes for vulnerable people and at-risk populations across the lifecycle. Highlights Integrated Care in NSW strives for whole-of-person care where care is wrapped around the individual rather than focusing on a pathway to address a specific disease. We recognise the need to create linkages between NSW service clusters, state and federal government agencies, and non-government providers. Providing these linkages takes the burden of coordination off the patient so they have a seamless experience that meets their needs. Comments on transferability This state-wide approach to integrating care has been informed by monitoring and evaluation of previous strategies implemented in NSW. Lessons learned throughout implementation may be transferrable to other states in Australia, or similar regions internationally. Conclusion Integrated Care in NSW has evolved over time, in response to the needs of the population, new evidence and continuous monitoring and evaluation. Improved outcomes have already been demonstrated across the Quadruple Aim of healthcare delivery.

Introduction: Healthy Homes and Neighbourhoods (HHAN), an integrated care programme in the Sydney Local Health District (SLHD), seeks to address the needs of disadvantaged families through care coordination, as one of its components. This research aims to determine for whom, when and why the care coordination component of HHAN works, and establish the reported outcomes for clients, service-providers and partner organisations.Methods: Critical realist methodology was utilised to undertake a qualitative evaluation of the impact of care coordination. Purposive sampling was used to select a total of 37 participants for interview, including consumers, service-providers and key stakeholders. Thematic analysis was undertaken to derive the major modes of intervention of HHAN, and data representing these elements was coded and summarised under contexts, mechanisms and outcomes.Results: Analysis indicates that care coordination has a positive impact on clients’ sense of independence, self-awareness and outlook on life. Trust and favourable interpersonal relations were identified as major underlying mechanisms for a successful client-provider working relationship. The identified modes of intervention facilitating positive consumer outcomes included accessibility, flexibility and service navigation. Persistent siloes in health and systemic resistance to collaboration was seen to hinder effective care delivery.Conclusions: This study suggests that a care coordination model may be effective in engaging disadvantaged families in healthcare, assist them in navigating the health system and can lead to beneficial health and social outcomes. Successful implementation of care coordination requires flexible programme design and experienced and skilful clinicians to fulfil the care coordinator role. There is a need to appreciate the negative impact that the complex and siloed health system can have on disadvantaged families.

Background Healthy Homes and Neighbourhoods (HHAN) Integrated Care Initiative was established to improve the care of families with complex health and social needs who reside in Sydney Local Health District. HHAN seeks to provide long-term multi-disciplinary care coordination as well as enhance capacity building and promote integrated care. The critical realist study reported here is part of the longitudinal development and evaluation of complex integrated health and social care interventions in Sydney, Australia. Methods We describe the qualitative component of a critical realist pilot case study aimed at exploring, explaining and refining emerging HHAN programme theories in relation to care coordination. Qualitative interviews were undertaken with HHAN clients (n = 12), staff and other stakeholders (n = 21). Interviews and coding used a context (C), mechanism (M) and outcome (O) framework. Inductive, deductive, retroductive and abductive modes of reasoning were used with the CMO heuristic tool to inform the developing programme theory. Results The mechanisms underpinning effective engagement of clients by care coordinators included: building trust, leveraging other family, social and organisational relationships, meeting clients on their own terms, demonstrating staff effectiveness as quickly as possible, and client empowerment. Mechanisms for enhancing care integration included knowledge transfer activities and shared learning among collaborators, structural and cultural changes, enhancing mutual respect, co-location of multidisciplinary and/or interagency staff and cultivating faith in positive change among staff. Conclusions Use of a critical realism case study approach served to elucidate the varied influences of contexts and mechanisms on programme outcomes, to highlight what works for whom and in what context. Findings supported the initial programme theory that engagement and trust building with clients, alongside enhanced collaboration and integration of services, improved outcomes for vulnerable families with complex needs. Further research is needed to explore the cost-effectiveness of integrated care initiatives, in view of the long term nature of service provision and the risk of staff burnout.

Purpose: Although health care professional education programmes around the world are increasingly using sophisticated simulation technology, the scope of simulation use in Canadian physiotherapy programmes is currently undefined. The current study explores the definitions of simulation, its current use, and the perceived benefits and barriers in Canadian entry-to-practice physiotherapy programmes. Method: Using a qualitative, descriptive study approach, we contacted Canadian physiotherapy programmes to identify faculty members with simulation experience. Using a semi-structured interview format, we asked participants to discuss their perspectives of simulation in their physiotherapy programmes. Interviews were audio recorded, transcribed, and analyzed for themes. Results: Of 13 eligible Canadian physiotherapy programmes, participants from 8 were interviewed. The interviews revealed three major themes: (1) variability in the definition of fidelity in simulation, (2) variability in simulation use, and (3) the benefits of and barriers to the use of simulation. Conclusions: Variability in the definition of fidelity in simulation among Canadian physiotherapy programmes is consistent with the current literature, highlighting a spectrum of complexity from low fidelity to high fidelity. Physiotherapy programmes are using a variety of simulations, with the aim of creating a bridge from theoretical knowledge to clinical practice. This study describes the starting point for characterizing simulation implementation in Canadian physiotherapy programmes and reflects the diversity that exists across the country.

This article provides a summary of salient trauma findings and conveys the dearth of research pertaining specifically to the trauma of elder abuse. This material, in conjunction with information contained in other articles composing this special issue, lays the foundation for advancing a trauma-informed approach to assisting older adults who have experienced polyvictimization. Informed by the findings presented and their extensive clinical experience with victims of violence, the authors suggest steps for providing a trauma-informed and victim-centered response to older adults who have suffered polyvictimization. These steps are then illustrated with an in-depth late-life polyvictimization case analysis.

Purpose: Little is known about the role of the immune system in the earliest stages of breast carcinogenesis. We studied quantitative differences in immune cell types between breast tissues from normal donors and those from women with benign breast disease (BBD). Experimental Design: A breast tissue matched case–control study was created from donors to the Susan G. Komen for the Cure Tissue Bank (KTB) and from women diagnosed with BBD at Mayo Clinic (Rochester, MN) who either subsequently developed cancer (BBD cases) or remained cancer-free (BBD controls). Serial tissue sections underwent immunostaining and digital quantification of cell number per mm2 for CD4+ T cells, CD8+ T cells, CD20+ B cells, and CD68+ macrophages and quantification of positive pixel measure for CD11c (dendritic cells). Results: In 94 age-matched triplets, BBD lobules showed greater densities of CD8+ T cells, CD11c+ dendritic cells, CD20+ B cells, and CD68+ macrophages compared with KTB normals. Relative to BBD controls, BBD cases had lower CD20+ cell density (P = 0.04). Nearly 42% of BBD cases had no CD20+ B cells in evaluated lobules compared with 28% of BBD controls (P = 0.02). The absence of CD20+ cells versus the presence in all lobules showed an adjusted OR of 5.7 (95% confidence interval, 1.4–23.1) for subsequent breast cancer risk. Conclusions: Elevated infiltration of both innate and adaptive immune effectors in BBD tissues suggests an immunogenic microenvironment. The reduced B-cell infiltration in women with later breast cancer suggests a role for B cells in preventing disease progression and as a possible biomarker for breast cancer risk. Clin Cancer Res; 23(14); 3945–52. ©2017 AACR.

Computer models have proven to be useful tools in studying epidemic disease in human populations. Such models are being used by a broader base of researchers, and it has become more important to ensure that descriptions of model construction and data analyses are clear and communicate important features of model structure. Papers describing computer models of infectious disease often lack a clear description of how the data are aggregated and whether or not non-epidemic runs are excluded from analyses. Given that there is no concrete quantitative definition of what constitutes an epidemic within the public health literature, each modeler must decide on a strategy for identifying epidemics during simulation runs. Here, an SEIR model was used to test the effects of how varying the cutoff for considering a run an epidemic changes potential interpretations of simulation outcomes. Varying the cutoff from 0% to 15% of the model population ever infected with the illness generated significant differences in numbers of dead and timing variables. These results are important for those who use models to form public health policy, in which questions of timing or implementation of interventions might be answered using findings from computer simulation models.

An introduction (comprising background and problem statement): The Healthy Homes and Neighbourhoods (HHAN) integrated care program, which started in 2014, was developed to address the complex health and social care needs of vulnerable families, which well exceeds the capacity of the public healthcare system alone. Semi-structured, qualitative interviews took place with senior managers and executive staff from agencies which HHAN considers partners or potential partners. An agency for the purpose of this study could be within a broader organisation. The aim was to determine participant’s definition of interagency collaboration and explore enablers and barriers as viewed by them. Theory/Methods: Recruitment took place by purposive sampling. Twenty-nine invitations to participate were sent by email to participants from 11 organisations. In total, 13 interviews took place, representing 11 agencies from 6 different organisations across health and non-health in the government, non-government and charity sectors. Using a grounded theory method, questions in subsequent interviews were guided by discussions had in prior interviews though strict coherence to the methodology was not achieved nor was saturation of themes. A single coder thematic analysis of interview transcripts using NVIVO software occurred. Results: Achieving efficient, knowledgeable referrals (single client focus) between agencies was the most basic and common definition of collaboration. Collaboration was also considered to include working together on shared projects and strategic planning to advance population health initiatives. Reviewing enablers and barriers being described in the interviews, it became apparent that whether something was being characterised as an enabler or as a barrier was dependent on how the idea was being framed. Discussions: Comparative analysis to selected pre-existing literature will be presented. As well as discussion on how awareness of this literature may have influenced data collection and analysis. Conclusions (comprising key findings): A grouping system of “themes” was developed, as follows: Theme 1: Establishing and maintaining knowledgeable relationships Theme 2: Diversity of roles Theme 3: Business performance Theme 4: Clear directive and supporting infrastructure Theme 5: Organisational expectations Lessons learned: The findings from this research appear to be available in the selected pre-existing literature. This may demonstrate potential barriers exist in understanding how best to apply pre-existing knowledge. Limitations: The scope of this project was too broad to be able to achieve saturation of themes within a realistic time frame or manageable sample size. As well, a single coder reduced rigidity of the study. Suggestions for future research: Another study involves interviewing frontline staff of HHAN. Comparing the key findings of these studies may provide insight into similarities and differences these cohorts hold regarding interagency collaboration.

Background: The integration of system-wide policies and services has long provided the foundation for promoting and protecting the health, development and wellbeing of children, young people and their families. The proverb “it takes a village to raise a child” provides the underlying ethos whereby all members of society work together to raise healthy and resilient children and young people. The United Nations Convention on the Rights of Children and the Sustainable Development Goals (SDGs) provide the global platform to addressing the needs of children young people and families. Building on the SDG goal of achieving universal health coverage, WHO developed a global strategy for people centered and integrated health services, recommending that countries consciously consider the perspectives of individuals, families, and communities, and respond to their preferences and needs. Aims and Objectives: 1- Discuss definitions and scope for Integrating Health and Social Care as it applies to Children, Young People and their Families 2- DIscuss the scope and purpose of a Integrating Care for Children Youth People and Their Families ISpecial Interest Group (IC-CYF SIG) 3- Modify the Scope and Purpose Document for the Integrating Care for Children Youth People and Their Families, Special Interest Group (IC-CYF SIG) Format: Timing 60 minutes, One Speaker, Group work at tables, Feed back from tables, Discussion and Summation Target Audience: Health, education and social care practitioners and researchers who are interested in aspects of integrated health and social care as it applies to children, young people and their families. Learnings and Takeaway: The participants will learning some of the policy and academic foundations of Integrating Care for Children Youth People and Their Families, The workshop will define the scope and purpose of a SIG for Integrating Care for Children Youth People and Their Families.

Introduction: Healthy Homes and Neighbourhoods (HHAN) is a care initiative that seeks to facilitate integration of multiple agencies serving vulnerable families in Sydney Australia. As part of a broader evaluation, we examined the types and quality of interagency relationships involved in HHAN, and perceptions of advantages, disadvantages and levels of support for collaboration. Methods: A purposive sample was drawn from 29 senior managers of agencies affiliated with HHAN who provided responses on behalf of their agency. The term agency indicates work units that may be stand alone or part of a larger organisation. Responses were collected between October 2017 and February 2018 through an online survey, administered at the end of a semi-structured interview that formed part of the larger research project. Respondents reported on relationships between member agencies selecting from: “we send referrals to them”, “we receive referrals from them”, “we share information about clients”, “we work together in other ways”. The quality of each of these relationships were rated on a three-point scale: (1) somewhat trusted; (2) trusted; and, (3) highly trusted. Advantages and disadvantages were presented as statements and respondents were asked to select those that had already happened, were expected to happen, or were not expected to happen. Results: Interactions were explored between selected agencies involved in HHAN (n=20) and 26 additional agencies that were nominated as collaborative partners by respondents (N=46). The General Collaboration network (pooling all types of relationship) had a relatively low density (9.2%). Most common form of collaboration was “works with in other ways.” Most partner relationships were rated as highly trusted. Sociograms of the network will be presented. Executive support for collaboration with other services ranged from medium to very strong indicating a positive perception of top down support. Support for collaboration from staff with direct client interaction was slightly lower. “Ability to serve our clients better” was reported by all respondents as a current benefit of interagency collaboration. The benefit with the most frequent report of not being expected to happen was “acquisition of additional funding or other resources.” Respondents had more varied experience of disadvantages of collaboration. The most common disadvantages selected were: “unreliable partners”, “service and time restraints,” which had been experienced by around 50% of respondents. Discussion: Interagency collaboration clearly benefits families and increases our understanding of population needs by pooling research but there are barriers and costs involved in working together that require careful management. Limitations: Our sample was drawn from a group already working towards greater integration of services. Suggestion for future research: A greater number of respondents, including agencies from outside HHAN would enhance understanding. Conclusion: Enhanced understanding of community and population needs through research and pooling of information across the network of organisations was a clear and valued vision of most respondents. Lessons Learned: While these and other benefits to collaboration were clear, the costs were also apparent. Executive staff should use a strategic approach to collaboration, ensuring goals are articulated and aligned.

Introduction: The Healthy Homes and Neighbourhoods (HHAN) integrated care program seeks to enhance vulnerable family access to, and engagement with, health and social services. This is achieved through a care-coordination model and other integrated care activities targeted towards capacity building at the professional and organisational level. The initiative is supported by a multiagency steering committee comprised of representatives from local government and non-government agencies who are responsible for the provision of a range of health, social and education services to the community. This study, conducted early in the HHAN implementation phase, sought to build consensus from service partners and staff on what was working, not working, areas of improvement and training needs of the program to ensure effective service delivery and ultimately better outcomes for families. Methods: A three stage process was undertaken, according to a Delphi method: Stage 1: A representative from 15 HHAN-partnered organisations were interviewed and asked to comment on what was working, not working, areas for improvement and training needs. Staff involved in this project were also interviewed. Interviews were transcribed and thematically analysed. Stage 2: Participants were then asked to rank these themes in order of importance. These responses were analysed, collated and fed back to participants. Stage 3: Participants were then asked to re-rank the most commonly identifies themes in order of importance. Results: What is working: Findings suggest that service delivery is flexible and innovative and consequently allows access to a wider range of services, joint multidisciplinary assessments, ‘soft’ entry points and assertive follow-up. What is not working: Findings suggest that the shift in delivery of services has resulted in tension as organisations adapt to a new professional culture that involves novel information-sharing methods, common language and protocol development, role clarity and change sustainment. Areas for improvement: Findings reflected two major themes: 1. Strengthening adaptive processes by improving access to protocols, promoting a shared vernacular and process and recognising that change causes professional and organisation discomfort; and 2. Improving models of care by encouraging utilisation of a breadth of integrated strategies such as step-down or exit pathways for clients. Training: Findings reflected adaptive processes including additional support, training and supervision, experience in joint planning and case conferencing, and contact with other services. These processes facilitate knowledge of available resources in the health sector. Discussion: This study suggests tension and debate should be expected between and within organisations involved in attempting to integrate care. Novel processes are adopted and organisations are required to adjust to shifting workplace culture. Limitations and suggestions for further research: It is unknown if participants ranked issues based on personal rather than organisational priorities, introducing a source of reporting bias. Involvement of researchers in organisational change may assist in developing a theoretical basis of how individuals and services can be supported to integrate care.

Introduction: In March 2014, the New South Wales (NSW) Government (Australia) announced the NSW Integrated Care Strategy. In response, a family-centred, population-based, integrated care initiative for vulnerable families and their children in Sydney, Australia was developed. The initiative was called Healthy Homes and Neighbourhoods. A realist translational social epidemiology programme of research and collaborative design is at the foundation of its evaluation. Theory and Method: The UK Medical Research Council (MRC) Framework for evaluating complex health interventions was adapted. This has four components, namely 1) development, 2) feasibility/piloting, 3) evaluation and 4) implementation. We adapted the Framework to include: critical realist, theory driven, and continuous improvement approaches. The modified Framework underpins this research and evaluation protocol for Healthy Homes and Neighbourhoods. Discussion: The NSW Health Monitoring and Evaluation Framework did not make provisions for assessment of the programme layers of context, or the effect of programme mechanism at each level. We therefore developed a multilevel approach that uses mixed-method research to examine not only outcomes, but also what is working for whom and why. Published version

Testosterone has been shown to have dose-dependent effects on spatial memory in males, but the effects of aging upon this relationship remain unclear. Additionally, the mechanism by which testosterone regulates memory is unknown, but may involve changes in brain-derived neurotrophic factor (BDNF) within specific brain regions. We tested the effects of age and testosterone on spatial memory among male rats using two spatial memory tasks: an object-location memory task (OLMT) and the radial-arm maze (RAM). Castration had minimal effect on performance on the RAM, but young rats (2 months) performed significantly fewer working memory errors than aged rats (20 months), and aged rats performed significantly fewer reference memory errors. Both age and castration impaired performance on the OLMT, with only the young rats with intact gonads successfully performing the task. Subsequent experiments involved daily injections of either drug vehicle or one of four doses of testosterone propionate (0.125, 0.250, 0.500, and 1.00 mg/rat) given to castrated aged males. On the RAM, a low physiological dose (0.125 mg) and high doses (0.500-1.000 mg) of testosterone improved working memory, while an intermediate dose (0.250 mg) did not. On the OLMT, only the 0.250 mg T group showed a significant increase in exploration ratios from the exposure trials to the testing trials, indicating that this group remembered the position of the objects. Brain tissue (prefrontal cortex, hippocampus, and striatum) was collected from all subjects to assay BDNF. We found no evidence that testosterone influenced BDNF, indicating that it is unlikely that testosterone regulates spatial memory through changes in BDNF levels.

Airway suctioning is an important health care intervention that can be associated with serious adverse effects. Given the risks involved with suctioning, it is important to ensure the clinical competence of health care professionals who perform it. A scoping review was conducted to identify the nature and extent of research related to the assessment of airway-suctioning competence for health care professionals working with adults. This included an examination of the assessment context, the type of suctioning and health care professionals being assessed, and the methods used to assess competence. Four scientific electronic databases (MEDLINE, EMBASE, CINAHL, and the Cochrane Library) were searched from inception to March 9, 2018. A gray literature search was also performed. Two reviewers independently screened articles and resources for inclusion, and data were extracted using a form created by the authors. Seventy full text articles and resources were screened for eligibility, with 36 included in the review. Endotracheal suctioning was the most common type, and intensive or critical care units were the primary setting of interest (28 of 36, 78%). Competence or a component of competence for nurses, nursing students, nursing assistants, or nurse technicians was specifically addressed in 97% (35 of 36) of the included articles and resources; 4 of 36 (11%) also included physical therapists, 1 of 36 (3%) included respiratory therapists, and 1 of 36 (3%) was aimed toward all clinicians who perform suctioning. Nine (25%) used questionnaire-based assessments, 11 (31%) used checklists, audit forms, or other observational tools, and 16 (44%) used both. Directed content analysis revealed 3 major themes: consistency across overarching evaluation frameworks, inconsistency across detailed components, and inconsistency in the evaluation or reporting of assessment tool measurement properties. Additional gaps in the literature included limited consideration of health care professionals beyond nursing, limited consideration of settings beyond intensive and critical care, a lack of tools to assess nasotracheal and orotracheal suctioning, and limited detail regarding assessment tool development.

Vaccinations reduce the risk of hospitalizations and adverse health outcomes in older adult populations, which has led to initiatives such as the Healthy People 2010 goal to vaccinate 90% of all nursing home residents. The current analysis looked at the percentage of residents who received vaccinations in 15,653 nursing homes in the United States and relationships of vaccination to staffing intensity and regional location. Overall, approximately 75% of facilities reached the optimum 90% vaccination levels for long-term residents, but less than 50% reached this goal for short-term residents. Further analyses revealed a consistently lower median rate of vaccination for metropolitan areas and indicated a weak relationship between staffing levels of RNs and short-term resident vaccination. Factors influencing staffing levels, and the possible connection between vaccination and technology, are discussed, as well as suggestions for future research aimed at better understanding mechanisms involved in suboptimal influenza and pneumococcal vaccination in nursing homes. [ Journal of Gerontological Nursing, 42 (2), 38–44.]

Introduction: Sydney Local Health District undertook a collaborative planning process for vulnerable families in 2013 and 2014. In late 2014 the District successfully tendered for an integrated care initiative for vulnerable families – Healthy Homes and Neighbourhoods, which was implemented in July 2015. Practice Change Implemented: The initiative involved system redesign and commitment from health, education, social care, local government, primary-care and non-Government partners. The model included: shared intake, care-coordination, family group conferencing, wrap-around delivery models, place-based service hubs, general practice engagement and support, and population-based health improvement initiatiave. Aim and Theory of Change: The intervention aims to break intergenerational cycles of disadvantage, psychological trauma, poor parenting and poor health outcomes. A complex Theory of Change ToC was developed, that in summary, would: 1 engage, empower and support families; and 2 develop and strengthen the service system through a collaborative co-design process. Targeted Population and Stakeholders: The initiative is intended for vulnerable families with complex health and social care needs who have one or more dependent children unborn through to 17 years where their complex health needs are impacting on their capacity to parent effectively and participate in their community. The Stakeholders included: the local primary health network PHN, statutory child protection agency, housing department, schools, early childhood education and care providers, local government, and non-Government organisations working with complex families. Time Line: Implementation in July 2015, reviewed 2016 and secured recurrent funding July 2017. Highlights: The initiative has the following key features: Multiple core and non-core agencies working together over a sustained period of time i.e. 5 years with families with complex health and social needs All the needs of families are in scope for the intervention, including housing, employment, income support and legal advice Use of evidence informed integrated care methods by service partners, including family case conferencing, and “wrap around” care delivery Encouraging families to have a “health home” for all their health needs and supporting them to move from dependency to independence Supporting general practice providers to care for families that are often seen to be “too difficult” Development and implementation of shared assessment tools and referral criteria Implementation of family assessment and engagement tools that can be used over the long-term to monitor the health and wellbeing of family members Transferability: The integrated care model uses design elements that were adapted from other international projects and which can be implemented in other health and social care settings. The model may also be transferable to other vulnerable population groups including aged care. Conclusions: The development of a trusting relationship between HHAN care coordinators, service providers and their clients has been an integral component of the success of the Healthy Homes and Neighbourhoods Program. Discussion: The HHAN initiative demonstrates the benefits of integrating services with the social care, education and local government sectors to address the social determinants of health as they affect families Lessons Learned: The development of trust between agencies, clinicians and patients is essential for the development and implantation of integrated care initiatives

Introduction: The Sydney Local Health District SLHD integrated care initiative, Healthy Homes and Neighborhoods HHAN, is a comprehensive population based integrated care strategy to address the complex needs of vulnerable families. The spectrum of care required to optimise the health and social care outcomes for these families well exceeds the capacity of the public healthcare system alone. Needs such as housing, finance, and social supports often preclude these families from addressing physical and mental health issues. As part of the evaluation of HHAN, this project looks to understand the experiences of senior managers and executive staff with interagency collaboration from across the network. Theory/Methods: Recruitment took place by purposive sampling. Agencies which HHAN considers partners or potential partners were identified and an appropriate informant from within each agency selected. An agency for the purpose of this project could be within a broader organisation. The interviews focused on the participant’s individual definition of “interagency collaboration” and explored their opinions of enablers and barriers to interagency collaboration. Ideas were carried forward and explored further in subsequent interviews. To accompany the interview data, a sociogram of collaborative links was developed from an online social network analysis to provide a visual illustration of the linkages between the organisations. Results: Interviews and social network analysis data collection occurred between October 2017 and February 2018. A total of 13 semi-structured qualitative interviews took place, providing representation from six organisations. The majority of participants expressed a continuum on which they viewed interagency collaborations to be able to occur, depending on what was trying to be achieved. Achieving efficient, knowledgeable referrals with single client focus between agencies, whether government or non-government, was the most basic and common type of collaboration being aspired to. Collaboration could also include working together on shared projects and strategic planning to advance population health initiatives. The sociograms show a coherent network of collaboration with a spread of key players. Reviewing enablers and barriers, it became apparent that whether something was being characterised as an enabler or as a barrier was dependent on how the idea was being framed. As a result a thematic grouping system identifying important features of interagency collaboration is being derived, final results of which are not available at the time of this submission. Discussions: By identifying themes of identified importance to interagency collaboration from across the network, HHAN may be able to use this to optimise its ability to effectively collaborate from both a strategic and front line staff aspect. Limitations: While features of a grounded theory approach were used, strict adherence to the methodology did not take place nor did complete saturation of themes. Suggestions for Future Research: As part of the evaluation of HHAN, another project interviewing frontline staff has occurred. It may be beneficial to compare and contrast the findings from these studies, to further understand how the views of senior managers from across the network aligns with the organisational approach to interagency collaboration perceived at the client care level.

Introduction: The Healthy Homes and Neighbourhoods (HHAN) Integrated Care Program seeks to enhance vulnerable family access to and engagement with health and social services through a care coordination model. In addition to servicing families living in inner west Sydney, HHAN has also established two place-based initiatives (PBI) in areas of heightened disadvantage – one of which is located in Redfern. The Redfern PBI co-locates HHAN with housing, drug and alcohol services, financial and legal services. This integration aims to facilitate service access and provide multi-agency support for vulnerable families in the Redfern area and improve health and social outcomes for individuals and the community. This study aims to evaluate the role and impact of HHAN’s Redfern PBI and explore whether a place-based model and co-location translates into improved patient, service and community outcomes. Theory/Methods: The project utilised a critical realist methodology to undertake a qualitative evaluation of the impact of the PBI on clients, services and community health and social outcomes. Purposive sampling was used to identify 20 participants including HHAN clients, HHAN employees and stakeholders involved with the Redfern PBI. In-depth, semi-structured interviews were audio-recorded, transcribed, coded and analysed using NVivo. Results: Preliminary thematic analysis found that the PBI provided varied benefits for clients and other services. Positive outcomes for clients included better engagement with services, increased trust in health services, empowerment, improved outlook and planning for the future. Positive outcomes for services included easier referral pathways, knowledge transfer and increased integration with other services. Mechanisms by which these outcomes were achieved included proximity, flexibility, favourable interpersonal relationships and building trust by responding to need. Discussion: The HHAN place-based model has achieved early subjective successes in terms of individual client health and social outcomes and service outcomes. Whether this translates into objective health improvements and overall community benefit is yet to be determined. Conclusion (key findings): The delivery of an integrated care program via a place-based model has resulted in early positive outcomes for individual clients and other services. Lessons learned: This early qualitative evaluation provides an insight into the potential role that place-based initiatives can play in improving health and social outcomes in disadvantaged communities. Limitations: The applicability of the findings of the study in areas outside of the Redfern community is unknown, however, learnings could be applied when establishing PBI in suburbs with a similar demographic profile. Participant bias should also be considered given the most vulnerable clients or clients in crisis were unlikely to be suitable for participation. Suggestions for future research: A comprehensive evaluation of the HHAN initiative will require a mixed-methods approach. As such a quantitative review will provide further insight in regards to client outcomes and cost-benefit analysis. Additionally, given HHAN is a whole of family service, further investigation into family outcomes is required. Examining the role that a place-based initiative plays in improving overall community outcomes would also be beneficial.

Introduction: Sydney Local Health District's Healthy Homes and Neighbourhoods Integrated Care Initiative (HHAN) seeks to improve the care of families with complex needs and/or inter-generational trauma by providing long-term care coordination and promoting inter- and intra-agency integration. The disadvantage experienced by enrolled individuals is multifaceted, with issues ranging from poor financial and social capital through to adverse health and educational outcomes. This complexity demands multi-agency support but in turn leaves clients vulnerable to fragmented/poorly coordinated care. We explored barriers to attaining health and social care for vulnerable families, as perceived by clients themselves and collaborating professionals. Theory/Methods: A realist CMO (Context, Mechanisms, Outcomes) theoretical approach is being used for program evaluation. Purposive sampling was used to identify 8 clients and 16 professionals (8 healthcare workers and 8 staff from collaborating NGOs/partnering government agencies) who participated in guided interviews. Barriers to care were explored as part of the examination of underlying contexts. All interviews were audio-recorded, transcribed and coded using NVivo v11 software. Results: Both intrinsic and extrinsic barriers were identified. Intrinsic factors included: Trauma affecting families both horizontally and vertically, competing priorities, distrust of services and concerns about confidentiality. Of the extrinsic factors identified, three themes emerged: 1. Accessibility and Economic Barriers including inequitable service coverage geographically, transport issues, strict eligibility criteria, opaque referral systems, lack of financial incentives for seeing vulnerable families, and direct/indirect costs to clients. 2. Misalignment of Service Provision with Client Needs including a perception that needs were assumed not asked, unrealistic care plans given social circumstances, paucity of culturally-appropriate and trauma-informed staff training and short-termism of professionals (resulting in unstable client-service and service-service relationships). 3. Communication Issues including misunderstanding by services or clients of the role, or even existence of other services, trust/territorial issues and technological barriers (e.g. incompatible electronic referral systems). Discussions: It can be challenging for vulnerable clients to navigate health and social care systems. Professionals expressed frustration that attaining appropriate/timely referrals and client care was difficult, even when being undertaken by “high-functioning” individuals on behalf of clients. Conclusions: Families with complex needs face multiple barriers to care. The extrinsic factors identified should be amenable to cultural and structural shifts in health and social care systems. Lessons learned: Disadvantaged families are often characterised as “hard to reach” but this implies that the fault lies solely with these individuals. An examination of the underlying factors for poor engagement illustrates the need for integrated care initiatives such as HHAN, which address the social determinants of health and create enabling systems for integration/communication between professionals. Limitations: The applicability of findings within our health district to other regions is unknown. In recruiting participants for this study, the most vulnerable members of our society may still have been missed; further exploration of their views could enhance our understanding. Suggestions for future research: Integrated care initiatives are attempting to tackle some of the barriers described above. Ongoing data is required to determine which interventions are efficacious, for whom and why, so that optimal service development can be achieved.

Previous research on activational effects of testosterone on spatial memory has produced mixed results, possibly because the effects of testosterone on memory are dose-dependent effects. We tested a wide range of testosterone doses using two spatial memory tasks: a working-reference memory version of the radial-arm maze (RAM) and an object location memory task (OLMT). Adult male Sprague-Dawley rats were castrated or sham-castrated and given daily injections of drug vehicle (Oil Sham and Oil GDX) or one of four doses of testosterone propionate (0.125, 0.250, 0.500, and 1.000 mg T) beginning seven days before the first day of behavioral tests and continuing throughout testing. For the RAM, four arms of the maze were consistently baited on each day of testing. Testosterone had a significant effect on working memory on the RAM, with the Oil Sham, 0.125 mg T, and 0.500 mg T groups performing better than the Oil GDX group. In contrast, there was no significant effect of testosterone on spatial reference memory on the RAM. For the OLMT, we tested long-term memory using a 2 h inter-trial interval between first exposure to two identical objects and re-exposure after one object had been moved. Only the 0.125 and 0.500 mg T groups showed a significant increase in exploration of the moved object during the testing trials, indicating better memory than all other groups. Testosterone replacement restored spatial memory among castrated male rats on both behavioral tasks, but there was a complex dose-response relationship; therefore, the therapeutic value of testosterone is likely sensitive to dose.

Background: The integration of system-wide health and social care policies and services has long been seen as the answer to improved efficiency and outcomes for consumers of health and social care services. Recent Government reviews[1] , however, have failed to find substantial evidence that integration lead to better outcomes for patients or financial savings or reduced hospital activity. For example, there was no evidence that the widely population multidisciplinary team approach is unlikely to achieve widespread efficiencies and anticipated outcomes in constrained financial settings. Barriers identified include misaligned financial incentives, workforce challenges and reticence over information sharing. Despite these reservations optimism is widespread that integration and social care can address the challenges facing society with increasing chronic illness, mental illness, disability, homelessness, ageing and marginalised traumatised populations. The answers may not lie with large scale government policies but rather with local initiatives between primary health care, community or 3rd sector providers and hospitals. The challenge advanced by the UK Audit Office as to establish an evidence base for what works in integrating health and social care as a priority. Aims and Objectives: 1- Discuss definitions and scope for Integrating Health and Social Care 2- DIscuss the scope and purpose of an Integrating Health and Social Care Special Interest Group (IHASC SIG) 3- Modify the Scope and Purpose Document for the Integrating Health and Social Care (IHASC SIG) Format: Timing 60 minutes, One Speaker, Group work at tables, Feed back from tables, Discussion and Summation Target Audience: Health, disability, education and social care practitioners and researchers who are interested in aspects of integrated health and social care. Learnings and Takeaway: The participants will learning some of the policy and academic foundations of Integrating Health and Social Care, The workshop will define the scope and purpose of a SIG for Integrating Health and Social Care

The use of standardized language assessment tools with Australian Indigenous children has been criticized for language and cultural reasons; however, this has not been tested in an urban context. The aim of the study was to explore the language performance of a small sample of urban Aboriginal preschoolers on a standardized language tool compared with a conversational sample. Fifteen participants (drawn from a birth cohort study of over 150 Aboriginal infants born at a metropolitan hospital) completed the Clinical Evaluation of Language Fundamentals-Preschool Edition, Second Edition (CELF-P2) and generated a 30-minute conversational language sample. Descriptive data are reported, and five case studies are explored in detail to compare results of the CELF-P2 and the language sample analysis. Grammatical features of Aboriginal English are also investigated. There was a diverse range of responses to standardized assessment and language sampling, with some samples reflective of CELF-P2 results. Two or more grammatical features of Aboriginal English were identified in 13 of the language samples. The results suggest the CELF-P2 is an appropriate tool to use to assess the language development of the children in the study when used in conjunction with analysis of language samples obtained using culturally appropriate methods.

Background Optimal breastfeeding has benefits for the mother-infant dyads. This study investigated the prevalence and determinants of cessation of exclusive breastfeeding (EBF) in the early postnatal period in a culturally and linguistically diverse population in Sydney, New South Wales, Australia. Methods The study used routinely collected perinatal data on all live births in 2014 (N = 17,564) in public health facilities in two Local Health Districts in Sydney, Australia. The prevalence of mother’s breastfeeding intention, skin-to-skin contact, EBF at birth, discharge and early postnatal period (1–4 weeks postnatal) were estimated. Multivariate logistic regression models that adjusted for confounders were conducted to determine association between cessation of EBF in the early postnatal period and socio-demographic, psychosocial and health service factors. Results Most mothers intended to breastfeed (92%), practiced skin-to-skin contact (81%), exclusively breastfed at delivery (90%) and discharge (89%). However, the prevalence of EBF declined (by 27%) at the early postnatal period (62%). Younger mothers (

Breast, lung, and pancreatic cancers collectively represent one third of all diagnosed tumors and are responsible for almost 40% of overall cancer mortality. Despite improvements in current treatments, efforts to develop more specific therapeutic options are warranted. Here we identify matrix metalloproteinase 3 (MMP3) as a potential target within all three of these tumor types. MMP3 has previously been shown to induce expression of Rac1b, a tumorigenic splice isoform of Rac1. In this study we find that MMP3 and Rac1b proteins are both strongly expressed by the tumor cells of all three tumor types and that expression of MMP3 protein is prognostic of poor survival in pancreatic cancer patients. We also find that MMP3 gene expression can serve as a prognostic marker for patient survival in breast and lung cancer. These results suggest an oncogenic MMP3-Rac1b signaling axis as a driver of tumor progression in three common poor prognosis tumor types, further suggesting that new therapies to target these pathways could have substantial therapeutic benefit.

We use an agent-based computer simulation designed to model the spread of the 1918 influenza pandemic to address the question of whether, and if so, when disease-related mortality should be included in an epidemic model. Simulation outcomes from identical models that differ only in the inclusion or exclusion of disease-related mortality are compared. Results suggest that unless mortality is very high (above a case fatality rate of about 18 % for influenza), mortality has a minimal impact on simulation outcomes. High levels of mortality, however, lower the percentage infected at the epidemic peak and reduce the overall number of cases because epidemic chains are shortened overall, and so a smaller proportion of the population becomes infected. Analyses also indicate that high levels of mortality can increase the chance of oscillations in disease incidence. The decision about whether to include disease-related mortality in a model should, however, take into account the fact that diseases such as influenza, that sicken a high proportion of a population, may nonetheless lead to high numbers of deaths. These deaths can affect a real population’s perception of and response to an epidemic, even when objective measures suggest the impact of mortality on epidemic outcomes is relatively low. Thus, careful attention should be paid to the possibility of such responses when developing epidemic control strategies.

In 2015, the University of North Texas Libraries implemented an access‐based collection development policy. This new policy, coupled with the increase of interdisciplinary studies at the University, dictated the necessity for a more exhaustive evaluation of continuing resources such as databases, journals, and standing orders before they are purchased. The collection development department created a rubric of criteria to address all aspects of the evaluation. This article will provide a brief description of access‐based collection development and a detailed discussion of the rubric’s criteria and how it will be implemented.

Objective:To investigate the mechanism of propranolol on regression of infantile hemangiomas.Background:Propranolol has been found to be effective in treatment of severe hemangiomas of infancy. However, its mechanism of action is as yet unknown.Methods:Cultured proliferating and involuting hemangiom

The emotional and psychological impact of a human immunodeficiency Virus (HIV)-positive diagnosis is widely recognised. Research into the role of counselling and psychotherapy with this client group has largely focused on studies of the efficacy of cognitive-behavioural interventions. The aim of this study was to explore the process of a flexible, pluralistic approach to counselling with HIV-positive clients. Three participants were recruited from a specialist HIV service. Rich case study data were collected, using therapy transcripts and end of therapy feedback sessions with clients, and analysed using grounded theory methodology. A common element for all three clients was the importance of creating a shared understanding within the therapeutic relationship. The findings of this study are discussed in terms of the further development of pluralistic practice with this client group.

Background: We have called for the establishment of a special interest group for “Integrating Care for Children Young People and their Families. Our argument is based on the truism that “children are our future” and the observation that at the heart of achieving the Sustainable Development Goals is the Global Strategy for Women’s, Children’s and Adolescents’ Health 2016-2030. That strategy “envisages envisions a world in which every woman, child and adolescent realizes their rights to physical and mental health and well-being, has social and economic opportunities, and is able to participate fully in shaping prosperous and sustainable societies”. . The United Nations Convention on the Rights of Children and the Sustainable Development Goals SDGs provide the global platform to addressing the needs of children young people and families. Building on the SDG goal of achieving universal health coverage, WHO developed a global strategy and framework for people centered and integrated health services, recommending that countries consciously consider the perspectives of individuals, families, and communities, and respond to their preferences and needs. The framework proposed five interdependent strategies for health services to become more integrated and people-centred. empowering and engaging people and communities strengthening governance and accountability reorienting the model of care coordinating services within and across sectors creating an enabling environment. The integration of system-wide policies and services has long provided the foundation for promoting and protecting the health, development and wellbeing of children, young people and their families. The proverb “it takes a village to raise a child” provides the underlying ethos whereby all members of society work together to raise healthy and resilient children and young people. Building on the “Global Strategy for Women’s, Children’s and Adolescents’ Health 2016-2030” a draft “Nuturing Care Framework” is under development by WHO. That draft Framework contains five guiding principles. The child’s right to survive and thrive Child Rights principal Leave no child behind equity principal Family-centred care A whole-of-society approach Whole-of-government action. Based on an analysis of effective programmes the Framework proposes five action areas that “create universally enabling environments and include a focus on communities, families and children in greatest need … accompanied by strong monitoring systems and accountability mechanisms.” The five proposed action areas are: Provide leadership, create societal awareness and invest Value that families and communities are at the heart of Nurturing Care Create enabling environments through policies, information and services Monitor progress in implementation, results and impact Strengthen local evidence and innovate to support scale up. These two frameworks will be used to stimulate discussion. Aims and Objectives: To discuss service, policy and system approaches for promoting and protecting the health, development and wellbeing of children, young people and their families. Format: Network discussion among IC-CYF SIG members. Target Audience: Health, education and social care practitioners and researchers who are interested in aspects of integrated health and social care as it applies to children, young people and their families. Learnings and Take Away: Network participants will contribute to building a collaborative work programme for the IC-CYF SIG

Introduction: Healthy Homes and Neighbourhoods HHAN is an integrated care program that supports families in inner west Sydney where adults have complex health and social needs, often impacting on the parent’s ability to provide a safe and supportive environment for their children. HHAN provides care coordination and activities that promote inter- and intra-agency integration. Referral pathways from local schools are targeted in one suburb with significant family disadvantage. Practice change implemented: Following a service provider consultation with schools and other agencies to identify community barriers and enablers, the HHAN social worker established a preferred pathway relationship with target schools. This prioritised clinical pathway featured service delivery of long term care coordination, whole of family focus, flexible home and community visits, fast track Paediatric outreach clinic and consistent collaboration with the schools. Aim and theory of change: To establish new service partnerships that facilitate whole-of-family access to health and social services and result in improved outcomes for families with complex needs who are disconnected from key services. Targeted population and stakeholders: Children and families with complex health and social needs who attend either of two public primary schools in a suburb of significant family disadvantage are targeted in this initiative. Important stakeholders who need to be engaged to ensure success of the pathway include school staff, health service staff, local social service providers, and the broader community. Timeline: Stakeholder engagement commenced in October 2015 and is ongoing. The referral pathway commenced in late 2015. Highlights: This is a unique care coordination pathway linking professionals from the health, social and education sectors to provide whole-of-family care to families with complex needs. Data from Patient Reported Outcome Measures provide a baseline description of the issues that families are facing. Independentqualitative interviews conducted with referred families have shown that the intervention enabled the families to make improvements in their access to services and health and wellbeing outcomes. Trust between service providers, particularly education and healthcare providers, has developed over time. Sustainability: HHAN is a permanently funded program and the pathways established enable health and other community partners to better “join up” and access this target group. Transferability: Other community agencies are exploring similar models where education and social care services are partnered. Key lessons from the evaluation of this pathway could be applied to other models. Conclusion: Qualitative and quantitative data collected demonstrate improvements in families’ health experience, independence and quality of life following referral to HHAN care coordination via this pathway. Discussion: Establishing this pathway successfully has challenged partners to develop a new model using creative, non-standard methods of intervention. The families seen have multiple complex needs and face many barriers to care. The qualitative findings and case studies indicate the importance of integrated care initiatives such as HHAN. Lessons Learned: The establishment of this pathway has created a bridge between Health and Department of Education leaders and the broader service system to assist vulnerable families. Enabling systems now exist which encourage ongoing integration and communication between professionals.

Background: Sydney Local Health District, Australia, undertook a collaborative planning process for vulnerable families in 2013, and an interagency child health and wellbeing plan in 2014. In late 2014 the District successfully tendered for an integrated care initiative for vulnerable families – Healthy Homes and Neighbourhoods, which was implemented in July 2015. The initiative involved significant system redesign and commitment from health, education, social care, local government, and primary-care and non-Government partners. The initial model included: shared intake, care-coordination, family group conferencing, wrap-around delivery models, place-based service hubs, general practice engagement and support, and family and population-based health improvement initiatiave. A significant feature of the design is the collaborative engagement with welfare, disability, education, child protection, civil law, housing, local government and criminal justice sectors. At the level of clinical engagement and support for families all salient matters are considered in scope for the care-coordinators. Collaboration with the non-health sector is challenging for reasons that include: Differing operational policy frameworks, including: district boundaries, training, clinical tools, and performance indicators Increased commissioning and outsourcing to multiple private sector providers Privacy legislation, case-law and related sector policies and protocols Different digital technology across non-health sectors and providers. Progress toward addressing the challenges has been partially achieved at a place-based clinical level where multi-disciplinary team processes enable shared-care approaches to develop. Lessons learnt in the place-based demonstration sites are expected to be transferable. Aims and Objectives: 1- Provide an overview of the design of the Healthy Homes and Neighbourhoods Integrated Care Initative 2- Provide an update of previously presented studies 3- Describe new studies Format: Timing 90 minutes. Large group presentation format. Target Audience: Health, education and social care practitioners and researchers who are interested in the design, implementation and evaluation of integrated health and social care inititiaves for vulnerable families. Learnings and Takeaway: The participants will learn of one approach to providing integrated health and social care services for vulnerable populations Those familiar with the HHAN initiative will be brought up to date with new aspects of the initiative including school projects.

Introduction: The Sydney Local Health District (SLHD) integrated care initiative, Healthy Homes and Neighbourhoods (HHAN), provides long term care coordination to vulnerable families. The spectrum of care required to optimise the health and social care outcomes for these families well exceeds the capacity of the public healthcare system alone. The HHAN clinicians recognise that needs such as housing, finance, and social supports often preclude these families from addressing physical and mental health issues and as such, work directly with clients to coordinate holistic interagency collaboration to suit each family’s needs. As part of the evaluation of HHAN, this project looks to understand how these endeavours on the “front line” align with the strategic directions of agencies across the network. Theory/Methods: The perspectives as well as the power to influence interagency collaboration will depend in part on an individual’s formal role within an organisation. Using a semi-structured, qualitative interview approach, this aspect of the HHAN evaluation will specifically focus on senior management staff from 12 separate organisations, all of which are networked with the HHAN program in some capacity. The interviews will focus on exploring the participant’s individual definition of “interagency collaboration”, followed by exploring their opinion on context and extent of enablers and barriers to interagency collaboration. Results: Interviews are expected to commence in early September, 2017. Preliminary findings will be presented. We will compare the definitions held by senior level management staff in different organisations and focus on what they believe to be enablers and barriers to interagency collaboration. Discussions: The project will discuss how the definition of interagency collaboration manifests as/or translates to barriers or enablers to engagement and cooperation in practice. Conclusions: We believe perspectives of and definitions held by senior management staff are influenced by their position within an organisation and their formal role which in turn affects interagency collaboration on multiple levels. This study will provide further insights into this concept.

Introduction : RedLink is an interagency hub in a suburb of inner Sydney. We will describe the collaborative partnership between NSW Housing and Sydney Local Health District, and non-governmental organisations. Short description of practice change implemented : Traditionally poor communication and working in silos can act as a barrier to good care for individuals and families, especially those with complex needs. The initiative has been running since July 2015 and during this period RedLink has developed a collaborative and flexible model of service delivery that has evolved in line with clients’ own identified goals with the aim to achieve long term change. Aim and theory of change : Long term relationships are built with the community through a range of community activities and engagement strategies to improve community wellbeing. The model aims to provide a service to residents and their extended families, respect the culture of the community, and empower families to find their own solutions that work for them. Targeted population and stakeholders : Clients using the service have complex needs, including psychological trauma, mental health, substance abuse, chronic health problems, child protection and parenting issues. Service providers within Health, Housing and other NGOs are encouraged to deliver services through non-standard methods of intervention at the local level. Highlights : At RedLink, there are no wrong doors. Services collaborating in the RedLink space exercise flexibility to ensure that clients do not “fall between the cracks”. With no one service automatically assuming leadership of cases, RedLink use a unique triage system and model of service delivery. Service delivery may change over time depending on clients’ relationships with the service or changing goals. This approach has enabled the Redfern community to work alongside services, government and business to achieve long term sustainable change. Community ownership is at the centre of everything that we do, including the sustainability and governance of RedLink. Comments on sustainability : The success of this initiative has created ongoing momentum and motivation for collaborating partners to continue to deliver non-standard methods of intervention in a place-based hub. Transferability : The model at RedLink was established in conjunction with the local residents. It could be transferred to other areas and is currently being explored in another suburb in inner west Sydney. Conclusions : By allowing client control of the direction and pace of service delivery, trust is established between the community and service providers. Building trust with vulnerable community members is essential, and this has had an impact on the wider community. Extended family members are no self-referring to services, addressing the wider health and social needs of families and the community. Discussion : Building relationships and trust with vulnerable groups to address social determinants of health is crucial to encourage engagement in traditional health systems, and to address wider health needs of families and the community. Lessons learned : The need for collaborative interagency practice in partnership with the community is essential if the needs of vulnerable community members are to be addressed.

The Healthy Homes and Neighbourhoods (HHAN) Program provides long term care coordination to families with complex health and social needs, in the Sydney Local Health District (SLHD). Referral during the antenatal period is the preferred pathway, aiming to ensure complex families have support for themselves and their child, commencing in the period prior to birth. Previous geospatial mapping has identified two areas of clustered disadvantage within SLHD. Following identification of reduced attendance at one of two SLHD antenatal clinics, a HHAN care coordinator established communications with two hospitals in adjoining health districts to discover patterns of attendance for “out of area” pregnant women. Reasons for attendance at these “out of area” antenatal clinics is uncertain at this stage, but Local Government has identified gaps in public transport to the secondary SLHD hospital. Further research into cross boundary hospital attendance will be undertaken. By attending the adjacent Local Health District’s psychosocial meetings, HHAN aims to identify and engage with vulnerable women and their families, living with SLHD, but attending “out of area” health services. Engagement with adjoining health districts helps to integrate health and social care services beyond our local health district borders, which is vital for families living within previously identified areas of disadvantage. This initiative targeted pregnant women, and their families, with complex health and social needs residing in SLHD who were utilising antenatal health services outside SLHD boundaries. Engagement with health and social care providers across local health district boundaries is essential as HHAN aims to ensure vulnerable women and their families are not “falling through the cracks”. This presentation will focus on the initial collaboration between nurses/midwives and social workers, based in bordering health districts with the common aim of providing client focused support. Attendance at adjacent health district psychosocial meeting commenced in July 2017, following a period of discussion between health districts to acknowledge the identified gap in SLHD antenatal attendance and recognition of cross boundary health utilisation. Ongoing collaboration is planned to allow for seamless referral into the HHAN program and other health and social care services. Inter-Health District Care Coordination is a developing area within Australian public health. This Sydney-based, high-risk, antenatal pathway demonstrates to health care providers and their consumers that flexible support is possible across health boundaries. Interdisciplinary, cross health district collaboration is an essential current and future pathway to improve outcomes in the most vulnerable members of our population. The development of a trusting relationship between HHAN care coordinators, service providers and their clients has been an integral component of the success of the Healthy Homes and Neighbourhoods Program. This inter-health district liaison is enhancing communication and planning across health borders. Challenging and supporting health and social care partners to think and act outside their geographical boundaries is essential for ongoing change in these sectors, as we put the consumer and their complex lives at the forefront of our care. Whilst change is challenging, collaboration between health service providers is one step towards providing timely, integrated supportive care for vulnerable families.

Introduction: Healthy Homes and Neighbourhoods (HHAN) is an integrated care program that supports families in inner west Sydney where adults have complex health and social needs, often impacting on the parent’s ability to provide a safe and supportive environment for their children. HHAN provides care coordination and activities that promote inter- and intra-agency integration. Referral pathways from local schools are targeted in one suburb with significant family disadvantage. Practice change implemented: Following a service provider consultation with schools and other agencies to identify community barriers and enablers, the HHAN social worker established a preferred pathway relationship with target schools. This prioritised clinical pathway featured service delivery of long term care coordination, whole of family focus, flexible home and community visits, fast track Paediatric outreach clinic and consistent collaboration with the schools. Aim and theory of change: To establish new service partnerships that facilitate whole-of-family access to health and social services and result in improved outcomes for families with complex needs who are disconnected from key services. Targeted population and stakeholders: Children and families with complex health and social needs who attend either of two public primary schools in a suburb of significant family disadvantage are targeted in this initiative. Important stakeholders who need to be engaged to ensure success of the pathway include school staff, health service staff, local social service providers, and the broader community. Timeline: Stakeholder engagement commenced in October 2015 and is ongoing. The referral pathway commenced in late 2015. Highlights: This is a unique care coordination pathway linking professionals from the health, social and education sectors to provide whole-of-family care to families with complex needs. Data from Patient Reported Outcome Measures provide a baseline description of the issues that families are facing. Independentqualitative interviews conducted with referred families have shown that the intervention enabled the families to make improvements in their access to services and health and wellbeing outcomes. Trust between service providers, particularly education and healthcare providers, has developed over time. Sustainability: HHAN is a permanently funded program and the pathways established enable health and other community partners to better “join up” and access this target group. Transferability: Other community agencies are exploring similar models where education and social care services are partnered. Key lessons from the evaluation of this pathway could be applied to other models. Conclusion: Qualitative and quantitative data collected demonstrate improvements in families’ health experience, independence and quality of life following referral to HHAN care coordination via this pathway. Discussion: Establishing this pathway successfully has challenged partners to develop a new model using creative, non-standard methods of intervention. The families seen have multiple complex needs and face many barriers to care. The qualitative findings and case studies indicate the importance of integrated care initiatives such as HHAN. Lessons Learned: The establishment of this pathway has created a bridge between Health and Department of Education leaders and the broader service system to assist vulnerable families. Enabling systems now exist which encourage ongoing integration and communication between professionals.

Introduction: Healthy Homes and Neighbourhoods (HHAN) Integrated Care Program utilises a long-term care coordination model to enhance vulnerable family engagement with and access to appropriate health and social services. HHAN services vulnerable families across inner west Sydney, with a particular focus on two areas of clustered family disadvantage identified by a geospatial epidemiological study. Riverwood was identified as a suburb of heightened vulnerability. The study aims to identify barriers and enablers to service access and engagement in order to inform the delivery of HHAN’s Riverwood place-based initiative. Both service providers and community members were consulted in order to identify the health and social needs and current gaps in service provision in this area. The study also aims to encourage consumer participation in the health service planning process through community consultation. Theory/methods: This qualitative project will utilise informal interviews, community forums and focus groups. The first round of consultation involved informal interviews with stakeholders from which key themes and issues were identified. In the second round of consultation Riverwood community members were recruited via a variety of methods including through schools, community organisations, and letterbox drops in order to attract a varied range of participants to a community forum and follow-up focus groups. Emerging key themes and issues were identified, summarised and analysed. NVivo was used for coding and thematic analysis. Results: Preliminary results from consultation with service providers identified both intrinsic and extrinsic factors. The major extrinsic factors include issues with health district and local boundaries, unclear referral pathways, and a lack of targeted local services. Service provider consultation also suggested that intrinsic factors such as attitudes towards health and historic mistrust of services were significant barriers to accessing and engaging with health services. Discussions: The health and social service system is complex and difficult for both service providers and clients to navigate. Examining the issue of service access requires consideration of a broad range of factors including the perspective of service providers and the community and also reviewing systemic and process factors. This assessment of the service landscape will enable HHAN to establish a place-based initiative that adequately responds to community and service needs in this suburb of significant family disadvantage. Conclusions: Multiple extrinsic and intrinsic factors complicate access to and engagement in services in the Riverwood area. This highlights the need for place-based integrated care initiatives such as Healthy Homes and Neighbourhoods to target the needs of disadvantaged communities. Lessons learned: A broad framework is required to gain a comprehensive understanding of access to and engagement with services that examines the interplay of individual factors, social issues, process and systemic factors. Limitations: The transferability of these findings outside of the Riverwood context is unknown, however, learnings may assist with planning of place-based initiatives in similar areas. Suggestions for future research: Further research will focus on evaluation of the Riverwood place-based initiative in order to determine if identified needs and gaps are being adequately addressed.

Fractures resulting in impaired healing can be treated with mechanical stimulation via external fixators. To examine the effect of mechanical stimulation on fracture healing, we developed an external fixator for use in a mouse model. A 0.5 mm tibial osteotomy was stabilized with the external fixator in C57BL/6 mice. Osteotomies in the treatment group (nt = 41) were subjected to daily sessions of 150 μm of controlled displacement with the aim to create a more mineralized callus at 21 days compared with the control group (nc = 39). Qualitative assessment of the histology found no notable difference in healing patterns between groups at 7, 12, 17, and 21 days. At 21 days, micro-computed tomography (CT) analysis showed that the control group had a significantly higher bone volume (BV) fraction and trabecular number compared with treatment; however there was no significant difference in the total volume (TV) of the callus or trabecular thickness between groups. In summary, the external fixator was used with a motion application system to apply controlled displacement to a healing fracture; however, this treatment did not result in a more mineralized callus at 21 days.

Introduction: The suburb of Redfern is identified as having some of the highest rates of intergenerational family disadvantage in the Sydney district. Many families are disconnected from key services, and require multi-agency input to remain healthy and safe. Short description of practice change implemented: Health district family care coordinators are co-located in an interagency hub on a social housing estate, led by the local housing department. At this hub, staff from government and non-government organisations have partnered to provide an integrated service providing health and social support to residents with complex needs such as psychological trauma, mental health issues, substance abuse, chronic health problems, child protection and parenting issues. Aim and theory of change: By co-locating family care coordinators with partners in the community, we aim to: Bring services directly to the community. Connect care and bridge gaps for families. Provide a “Team Around the Family” model of intervention to increase a family’s capacity to independently manage their complex health and psychosocial needs. Support families to seek antenatal support earlier in pregnancy. Work in partnership with families, other services, General Practice and the community. Break down service silos. Targeted population and stakeholders: Families with children aged 0-17 years, where the parents or carers have complex health or psychosocial needs which impact on their ability to care for their children. Stakeholders include drug health services, mental health services, legal aid, financial management assistance, public housing and child and family health services. Timeline: This program commenced in July 2015 and implementation and evaluation is ongoing. Highlights: The model of care evolved in line with local family and community needs, and includes extended family members to align with the Aboriginal definition of kinship. This has empowered families to identify solutions that work for them. Trust has increased at two levels: families who have traditionally shown a mistrust of government services are now approaching staff for support; staff from different organisations are now working in partnership and share care for families. Families are now receiving the support that they require before situations turn into crises, and the adult family members’ needs are being addressed. Comments on sustainability: As this model utilises existing services, sustainability is realistic. Comments on transferability: This model could be implemented in other suburbs with high rates of family disadvantage. Elements may be adapted to suit local families and communities. Conclusions: Preliminary analysis indicates that co-location of health and social services is powerful in building trust between service providers and transferring of knowledge and skills. When a hub is located within a community, those services are able to build trust in the community, coordinate services for families and help families to achieve optimal outcomes. Discussions and Lessons Learned: Complex health and social care systems are difficult for vulnerable clients to navigate and often do not meet their needs. A family-network centred and flexible model of care-coordination is more effective. Service definitions and entry criteria may also need to be flexible to ensure that clients do not “fall between the cracks”.

True ossification within benign brain tumors is rare, and the molecular mechanism for this process is poorly understood. The authors report a case of ossified choroid plexus papilloma (CPP) and analyze it to help elucidate the underlying molecular basis of osteogenesis in benign brain tumors. A 21-year-old man presented with headache and depression that progressed over years. Computed tomography, MRI, and angiography demonstrated a large heavily calcified fourth ventricular tumor with a vascular blush and no hydrocephalus. The tumor was resected and was found to be an ossified CPP. Immunohistochemical staining for VEGF, Sox2, BMP-2, osterix, osteopontin, and osteocalcin was performed in an attempt to elucidate the mechanism of bone formation. The tumor was extensively ossified with mature bone trabeculae. Immunostaining for VEGF was positive. Additional staining showed the presence of osteocalcin in this ossified tumor but not in samples of nonossified CPPs collected from other patients. Staining for osterix and osteopontin was equivocally positive in the ossified CPP but also in the nonossified CPPs examined. The presence of osteocalcin in the ossified CPP demonstrates that there is true bone formation rather than simple calcification. Its appearance within cells around the trabeculae suggests the presence of osteoblasts. The presence of osterix suggests that a pluripotent cell, or one that is already partially differentiated, may be differentiated into an osteoblast through this pathway. This represents the first systematic immunohistochemical analysis of osteogenesis within choroid plexus tumors.

BACKGROUND The aim of this study was to compare the incidence of neuroma formation and neuropathic pain following different techniques of nerve ablation in a rat sural nerve model. METHODS Rat sural nerve was subjected to four different techniques of ablation with standardized creation of a 1-cm gap (n = 15 in each group). These included nerve avulsion, transection and burying in muscle, transection and folding of nerve, and transection alone. Animals were killed after 3 months. Explanted nerves were sectioned and stained with Masson trichrome and S-100 stain against neural tissue. The maximal neural cross-sectional area and neural-to-connective tissue ratio was quantified. Quantitative reverse-transcriptase polymerase chain reaction (n = 5) was used to analyze relative mRNA expression of ciliary neurotrophic factor and calcitonin gene-related peptide. RESULTS Neural cross-sectional area was statistically increased (p < 0.05) compared with controls in folded, muscle buried, and transected specimens but decreased in avulsed specimens. The neural-to-connective tissue ratio was statistically decreased in the avulsed group. Relative mRNA expression of ciliary neurotrophic factor was lowest in muscle buried (4 percent of control) (p < 0.05) and avulsed specimens (15 percent of control) (p < 0.05) and higher in folded (52 percent of control) and transected specimens (75 percent of control). Relative mRNA expression of calcitonin gene-related peptide was highest in folded specimens (302 percent of control) (p < 0.05). CONCLUSIONS Folding and transection lead to increased histologic evidence of neuroma formation, whereas folding leads to neuropathic pain, assayed by calcitonin gene-related peptide expression. Avulsion and muscle burying are preferable techniques for nerve ablation and inhibit nerve regeneration, evidenced by decreased ciliary neurotrophic factor expression. Avulsion offers an alternative to muscle burying when there is no muscle in the vicinity to bury the transected nerve.

Introduction: CD4+ and CD8+ T cells are important effector cells in the adaptive immune response against cancers. In premalignant proliferative breast tissues, the role of the immune system remains relatively undefined. In this study, we sought to investigate and quantify the presence of CD4 and CD8 expressing immune cells in benign breast tissues and their association with breast cancer risk. Method: Archived breast tissue samples from women with benign breast disease (BBD) or no clinical breast disease [Komen Tissue Bank (KTB)] were obtained for this age-matched case-control study. BBD samples included BBD cases (subsequently developed breast cancer) and BBD controls). Tissue sections were characterized for non-proliferative or proliferative disease and degree of lobular involution. CD4+ and CD8+ cell densities (cells/mm2) were obtained by digital image quantitation for up to 10 individual lobules per sample and a per-sample estimate of cell density was calculated as the median cell density across lobules within a sample. Statistical analysis was performed using Wilcoxon signed-rank and Kruskal-Wallis tests. Results: Among 267 women (median age 52, range 35-75) comprising 89 age-matched triplets, 2417 lobules were evaluated [783 KTB, 804 BBD case, 830 BBD control]. 1372 (57%) lobules were normal and 1045 (43%) were fibrocystic. CD4+ cells were present in 1903 (79%) lobules while CD8+ cells were present in 2214 (92%) lobules. CD4 and CD8 densities showed a moderate positive correlation (r = 0.39) with each other, but overall, lobules showed a lower density of CD4+ than CD8+ cells (mean difference -54 cells/mm2, 95% CI: -68 to -39 cells/mm2). At the per sample level (see Table), BBD controls showed significantly higher levels of both CD4+ (p=0.009) and CD8+ cells (p=0.0001) compared to KTB samples. In contrast, the BBD cases only showed elevated CD8 (p=0.007) and not CD4 (p=0.21) cell infiltrates compared to KTB samples. Comparing BBD cases to BBD controls, BBD cases showed significantly lower CD8 cell density as compared to BBD controls (p=0.002) and cases had lower CD4 cell density but the difference was not significant (p=0.07). Despite these differences in the cell densities, the ratio of CD4:CD8+ cells did not differ significantly across groups (p=0.83). The CD4:CD8+ ratio also did not differ significantly by histologic impression (p=0.74), degree of involution (p=0.27), or age (p=0.32). KTBBBD ControlsBBD CasesMedian (IQR)(n=89)(n=89)(n=89)CD4+ cells/mm240 (17-95)60 (25-124)49 (21-92)CD8+ cells/mm285 (49-131)157 (84-225)134 (80-168)Ratio (CD4:CD8)*0.45 (0.14-0.96)0.41 (0.15-0.81)0.40 (0.19-0.70)*Ratio is missing for n=7 samples (3 KTB, 2 BBD control, 2 BBD case) with undefined ratio due to zero CD8+ cells for all lobules in the sample. Conclusion: Our findings suggest that BBD is associated with increased infiltration of T cells into the breast tissue. Furthermore, these immune responses appear more robust in BBD patients at lower risk of developing breast cancer. Citation Format: Pena Jimenez A, Hoskin TL, Arshad MA, Visscher DW, Brahmbhatt RD, Miller EE, Stallings Mann ML, Carter JM, Murphy LM, Winham SJ, Radisky DC, Denison LA, Knutson KA, Degnim AC. CD4 and CD8 T cell densities are increased in benign breast disease compared to normal breast tissue. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P4-04-09.