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Background Free clinics are volunteer based organizations that provide health care services to low-income individuals for free or minimal cost. Communities served by a free clinic can provide ambulatory care services for uninsured individuals, reducing reliance on costly hospital admissions for ambulatory care sensitive conditions. This study examines whether free clinics in North Carolina reduce hospitalizations for ambulatory care sensitive conditions for uninsured adults. Methods The study used North Carolina hospital discharge data from 2003 to 2007, restricted to uninsured adults residing in North Carolina (N = 270,325). Prevention Quality Indicators identified hospitalizations for ambulatory care sensitive conditions. The entry of new free clinics in some counties during this time period in conjunction with county-level and year fixed effects allows the logistic regression analysis to simulate a pre/post study design. Results Discharges for ambulatory care sensitive conditions constituted 12.6% of the sample. Despite the limited coverage provided by free clinics, which serve 5.5% of the uninsured in North Carolina, uninsured adults in counties served by a free clinic had an 8.0% reduced odds of a hospitalization being for an ambulatory care sensitive condition. When the model is limited to ambulatory care sensitive conditions related to chronic conditions, the odds of a hospitalization of an uninsured adult for an ambulatory care sensitive condition in counties served by a free clinic is reduced by 9.0%. Conclusion Free clinics are effective providers of primary care services for uninsured individuals, particularly for those with chronic conditions. To enhance this impact by increasing free clinics’ reach, state and local policy makers should support and encourage development of free clinics in high need areas. Electronic supplementary material The online version of this article (10.1186/s12913-018-3082-1) contains supplementary material, which is available to authorized users.

Objective To examine the effects of campus services on the health of veterans with traumatic injuries and comorbidities as they return from military service and enter college. Design Cross-sectional Internet survey using a mixed-methods analysis approach. Setting Four-year urban research university. Participants Veterans returning from active military duty (N=127). Interventions None. Main Outcome Measures Surveys included standardized measures of health status, traumatic injuries, and functional impairment (PTSD Checklist, Civilian version; Veterans Health Administration traumatic brain injury [TBI] screen; and Veterans RAND-12 item Health Survey); use of campus services and perceived effectiveness of these services in supporting reintegration to the university; and recommendations for additional services. Results Quantitative and qualitative data revealed that student veterans experience high rates of chronic pain that interfere with their daily functioning (92.7%), symptoms of posttraumatic stress disorder (PTSD) (77.9%), symptoms of TBI (26.0%), and comorbidities as the polytrauma clinical triad (14.2%). Despite the high prevalence of pain, PTSD, and TBI, few students used disability services (5.2%), counseling services (18.8%), or student health services (36.5%). Students experienced challenges accessing needed health services when reintegrating from the military to the university, including mutable university service factors. Conclusions Findings indicate the need for campus services to address the particular needs of student veterans and the need for determining what particular services should be offered to help this population cope with injuries and succeed in college.

Gail Powell-Cope, PhD, ARNP, FAANPeter Toyinbo, PhDNitin Patel, MPHDeborah Rugs, PhDChristine Elnitsky, PhD, RNBridget Hahm, MA, MPHBryce Sutton, PhDRobert Campbell, PhDKaren Besterman-Dahan, PhDMary Matz, MSPH, CPE, CSPHPMichael Hodgson, MD, MPHOBJECTIVE: Theobjectiveofthestudywastoidentifywhichcomponentsof asystem-wide safepatienthand-ling(SPH)programreducedmusculoskeletalinjury(MSI) due to patient handling among nurses.METHODS: The3-yearlongitudinalstudyfrom2008to2011usedapretest-posttestdesign.ThestudywasconductedintheVeteransHealthAdministration,andallmedicalcentersparticipated.Theoutcomewas2011MSI incidence rates due to patient-related handlingfor nurses, expressed as injuries per 10000 full-timeemployees.RESULTS: Threeorganizationalriskfactors,beddaysof care, facility complexity level, and baseline MSIincidence rate, were significantly associated with MSIincidencerateandexplained21%ofitsvariation.FiveSPHcomponents,includingdeploymentofceilingliftsand other new technologies, peer leader effectiveness,competencyinSPHequipmentuse,facilitycoordinatorlink with safety committee, and peer leader training,uniquelyaccountedforanadditional23%ofthetotalvariation.CONCLUSIONS: Findings provide evidence to sup-port the effectiveness of a multicomponent approachto SPH programs given contextual considerations.Healthcare workers responsible for manual patienthandling,particularlynursesandnursingassistants(NAs), have among the highest rates of nonfatal occu-pational injuries requiring days away from work.

U.S. Army Combat Medic serves as both Soldier and provider of combat casualty care, often in the heat of battle and with limited resources. Yet little is known about their help-seeking behavior and perceived stigma and barriers to care. Participants were three groups of U.S. Army Combat Medics surveyed at 3- and 12-months postdeployment from assignment with line units vs. those Medics who had never deployed to combat. The primary data source was surveys of mental health service utilization, perceived stigma and barriers to care, and depression and post-traumatic stress disorder screens. Medics who received help in the past year from a mental health professional ranged from 18% to 30%, with 18% to 30% seeking mental health assistance from other sources. Previously deployed Medics were more likely to obtain assistance than those who never deployed. Those meeting a mental health screening criteria were more likely to report associated stigma and barriers to care. Findings indicate that Medics in need of assistance report greater perceived barriers to mental health care, as well as stigma from seeking treatment, and that depression may be a salient issue for Medics. The longitudinal nature of the ongoing study will help determine the actual trajectory and onset of depression and post-traumatic stress disorder.

Purpose We present five cases of adult females with major limb amputations, their concerns and preferences for services across the life span. Design A convenience sample of five veteran and nonveteran women aged 19–58 with major limb amputations participating in a regional VA Prosthetics Conference in 2010 took part in a panel interview. Findings The concerns identified by these women as high priorities included independence and participation in a full range of life activities, limitations in access, patient decision-making and body image concerns, and preferences for selected services. Maximizing function and quality of life for women amputees requires identifying patient preferences for rehabilitation and prosthetic services. Lessons learned could inform development of clinic-based rehabilitation care, prosthetic services, and studies of women with major limb amputations. Conclusions As the current conflicts in Iraq and Afghanistan wind down, the number of women veterans seeking rehabilitation and prosthetic services will increase. With this information, rehabilitation and prosthetic service providers and organizations will be uniquely positioned to provide prevention and treatment of amputations for this growing population of women veterans in national care delivery systems and in communities. Clinical Relevance An open-ended facilitated discussion among a panel of women with major limb amputations provided insights for providers and organizations with respect to needs, concerns, and preferences for rehabilitation and prosthetic services.

To identify and validate trajectories of comorbidity associated with traumatic brain injury in male and female Iraq and Afghanistan war Veterans (IAV).Derivation and validation cohorts were compiled of IAV who entered the Department of Veterans Affairs (VA) care and received 3 years of VA care between 2002-2011. Chronic disease and comorbidities associated with deployment including TBI were identified using diagnosis codes. A latent class analysis (LCA) of longitudinal comorbidity data was used to identify trajectories of comorbidity.LCA revealed five trajectories that were similar for women and men: (1) Healthy, (2) Chronic Disease, (3) Mental Health, (4) Pain and (5) Polytrauma Clinical Triad (PCT: pain, mental health and TBI). Two additional classes found in men were 6) Minor Chronic and 7) PCT with chronic disease. Among these gender-stratified trajectories, it was found that women were more likely to experience headache (Pain trajectory) and depression (Mental Health trajectory), while men were more likely to experience lower back pain (Pain trajectory) and substance use disorder (Mental Health trajectory). The probability of TBI was highest in the PCT-related trajectories, with significantly lower probabilities in other trajectories.It was found that TBI was most common in PCT-related trajectories, indicating that TBI is commonly comorbid with pain and mental health conditions for both men and women. The relatively young age of this cohort raises important questions regarding how disease burden, including the possibility of neurodegenerative sequelae, will accrue alongside normal age-related decline in individuals with TBI. Additional 'big data' methods and a longer observation period may allow the development of predictive models to identify individuals with TBI that are at-risk for adverse outcomes.

This study aimed to (1) identify the prevalence and severity of pain and psychiatric comorbidities among personnel who had been deployed during Operation Iraqi Freedom (OIF), Operation Enduring Freedom (OEF), and Operation New Dawn (OND) and (2) assess whether the Department of Veterans Affairs (VA) Polytrauma System of Care and an OIF/OEF/OND registry reflect real differences among patients. Participants (N = 359) were recruited from two VA hospitals. They completed a clinical interview, structured diagnostic interview, and self-report measures. Results indicated pain was the most common complaint, with 87 percent experiencing pain during the prior week and 56 percent reporting moderate or severe pain. Eighty percent of participants met criteria for at least one of seven assessed comorbid problems (moderate or severe pain, postconcussional disorder, posttraumatic stress disorder [PTSD], anxiety disorder, mood disorder, substance use disorder, psychosis), and 59 percent met criteria for two or more problems. PTSD and postconcussional disorder rarely occurred in the absence of pain or other comorbidities (0.3% and 0%, respectively). The Polytrauma group had more comorbid psychiatric conditions (χ(2) = 48.67, p < 0.05) and reported greater severity of symptoms (p < 0.05) than the Registry group. This study confirmed the high prevalence of pain and concurrent mental health problems among personnel returning from military deployment.

Revolutionary changes in the health care system necessitate subsequent changes in emergency medical services (EMS). The development and dissemination of the EMS Agenda for the Future focus attention on awareness and attitudes of field providers. This study attempted to measure awareness of and agreement with concepts set forth in the agenda.Through a unique cooperative partnership between state government and two health services research students, researchers were able to describe and explore the attitudes of EMS providers about the future direction of the profession. A representative sample of participants, chosen from the Commonwealth of Virginia in fall 1997, responded to a mailed researcher-developed questionnaire based on the EMS Agenda for the Future.A cover letter written by the state EMS director and the enclosure of self-addressed, stamped envelopes yielded a 47% response rate. Paramedic-level providers and paid personnel were more likely to agree with the concepts of the EMS Agenda for the Future than were other-level providers and volunteers. The attribute with which the respondents agreed most was "legislation and regulation." The respondents agreed the least with "integration of health services." Providers were most concerned with the issue of liability protection, one aspect of the "legislation and regulation" attribute. Only 10% of the respondents reported having read the agenda.EMS providers' awareness, perspectives, and attitudes are essential to the forward progression of the EMS Agenda for the Future. Successful implementation of the agenda will depend on these professionals' participation and support. Providers tended to agree most with traditional concepts discussed in the EMS Agenda for the Future. Awareness levels and attitudes toward the vision suggest implications for future education, planning, and research activities.

Risk management and quality improvement measures assume that staff recognize and report individual hospital incidents. A survey of nurses working in acute care hospitals in 15 localities across a south-eastern state was conducted to explore nurses hospital incident reporting behaviors and supervisors beliefs about and use of incident reports. Nurse managers may have reason to be concerned about this quality measure: the number of incidents documented may represent only a portion of all incidents.

Background The U.S. Department of Veterans Affairs (VA) implemented the Polytrauma System of Care to meet the health care needs of military and veterans with multiple injuries returning from combat operations in Afghanistan and Iraq. Studies are needed to systematically assess barriers to use of comprehensive and exclusive VA healthcare services from the perspective of veterans with polytrauma and with other complex health outcomes following their service in Afghanistan and Iraq. These perspectives can inform policy with regard to the optimal delivery of care to returning veterans. Methods We studied combat veterans (n = 359) from two polytrauma rehabilitation centers using structured clinical interviews and qualitative open-ended questions, augmented with data collected from electronic health records. Our outcomes included several measures of exclusive utilization of VA care with our primary exposure as reported access barriers to care. Results Nearly two thirds of the veterans reported one or more barriers to their exclusive use of VA healthcare services. These barriers predicted differences in exclusive use of VA healthcare services. Experiencing any barriers doubled the returnees’ odds of not using VA exclusively, the geographic distance to VA barrier resulted in a 7 fold increase in the returnees odds of not using VA, and reporting a wait time barrier doubled the returnee’s odds of not using VA. There were no striking differences in access barriers for veterans with polytrauma compared to other returning veterans, suggesting the barriers may be uniform barriers that predict differences in using the VA exclusively for health care. Conclusions This study provides an initial description of utilization of VA polytrauma rehabilitation and other medical care for veteran returnees from all military services who were involved in combat operations in Afghanistan or Iraq. Our findings indicate that these veterans reported important stigmatization and barriers to receiving services exclusively from the VA, including mutable health delivery system factors.

Background The prevalence of musculoskeletal injuries among nursing staff has been high due to patient handling and movement. Internationally, healthcare organizations are integrating technological equipment into patient handling and movement to improve safety. Although evidence shows that safe patient handling programs reduce work-related musculoskeletal injuries in nursing staff, it is not clear how safe these new programs are for patients. Objectives The objective of this study was to explore adverse patient events associated with safe patient handling programs and preventive approaches in US Veterans Affairs medical centers. Methods The study surveyed a convenience sample of safe patient handling program managers from 51 US Department of Veterans Affairs medical centers to collect data on skin-related and fall-related adverse patient events. Results Both skin- and fall-related adverse patient events associated with safe patient handling occurred at VA Medical centers. Skin-related events included abrasions, contusions, pressure ulcers and lacerations. Fall-related events included sprains and strains, fractures, concussions and bleeding. Program managers described contextual factors in these adverse events and ways of preventing the events. Conclusions The use of safe patient handling equipment can pose risks for patients. This study found that organizational factors, human factors and technology factors were associated with patient adverse events. The findings have implications for how nursing professionals can implement safe patient handling programs in ways that are safe for both staff and patients.

Military health care providers experience considerable stressors related to their exposure to death and traumatic injuries in others. This study used survey data from 799 active duty U.S. Army Combat Medics deployed to Operation Iraqi Freedom/Operation Enduring Freedom. Military experiences, combat exposures, and mental health care seeking of active duty Combat Medics were explored and compared across both genders. Barriers to care were also assessed. Male and female Combat Medics reported surprisingly similar experiences, exposures, and health issues. Overall, results indicate no striking differences in barriers for females compared to their male counterparts, suggesting the barriers to utilization of mental health services may be consistent across gender. Although medics endorsed barriers and stigma related to mental health counseling services, they still sought these health services. Female and male medics who endorsed barriers were more likely to report seeking services than those who did not endorse barriers. This study provides an initial description of utilization of mental health counseling services for U.S. Army Combat Medics, the majority of whom were involved in combat operations in Afghanistan or Iraq. Our findings indicate that comprehensive assessment of the military experiences and combat exposures is needed to appreciate their potential influence on military health care providers.

Military Chaplains are a critical component of behavioral health and spiritual support in combat operations. Support of combat operations has taken a toll on these caregivers. The purpose of this study was to explore the impact of deployment on the psychosocial and health characteristics and reintegration of Army National Guard (ARNG) chaplains. Seventy-four ARNG chaplains participated in an anonymous, online survey. Results were categorized into two mutually exclusive groups, combat deployed and non-combat deployed. Although both groups tended to present similar results, Combat deployed group chaplains were significantly more likely to be of higher rank, have served in a pastoral role in the ARNG longer, and present with higher scores for combat exposure, resilience, and alcohol use. Further, five and seven participants, respectively, the majority of whom were from the combat deployed group, endorsed "frequently" or "a great deal" to negative religious coping. These endorsements of abandonment may relate back to Reserve component specific deployment concerns.

Older rural residents are vulnerable in both health status and access to health services. This descriptive study was designed to assess the general health status and risk factors of older rural residents age 65 and over. Cluster analysis methods were used to group older adults into unique clusters of individuals with similar health risks. Although strategies are generally targeted at those with limitations in two or more activities of daily living, community health nurses might need to initiate interventions much earlier. Findings of this study can help community health providers, policymakers, and administrators strategically plan to meet the health care needs of various groups of at-risk older rural populations.

The Mobile Health Unit was implemented to increase access to nursing services, to improve and/or maintain functional status and health status, and to increase health promotion behaviors of rural elderly residents experiencing difficulty obtaining health care due to illness, transportation problems, or financial factors. For 222 project participants 1,773 encounters were completed, with a mean number of visits per individual of 7.9. Participants in the project demonstrated increased breast and cervical cancer screenings, increased immunization rates for influenza, pneumonia and tetanus, and decreased utilization of the emergency room. This project represents an alternative model of health care delivery in a rural area with limited resources and health care providers.