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ObjectivesFew studies have quantified the vulnerability of people experiencing homelessness and its association with emergency department (ED) reattendances. The study objectives were to identify the health and social-related vulnerability, comorbidities and reattendance to an ED within 28 days, of people experiencing homelessness and people living in stable housing.DesignProspective cohort study, 28 September 2023 to 12 October 2023.SettingMetropolitan ED in an inner-city public hospital.ParticipantsEligible participants were those who attended the ED between 8am and 5pm during the 2 week study period (2023), those aged 18 years and over and able to provide informed consent, and those deemed well enough to participate.InterventionThe homeless health access to care tool (HHACT) assesses a person’s unmet needs and quantifies their level of health and social-related vulnerability (low, moderate, high). The HHACT was applied to each participant. Routinely collected administrative data was used to identify participant demographics and ED usage on the day of study enrolment and any ED reattendance within 28 days.Main outcomes and measuresOutcome measures were the identification of participants’ level of health and social-related vulnerability and its relationship to ED reattendance.ResultsOf the 300 ED participants, 38 (12.6%) were experiencing homelessness. There was a greater than twofold increase in odds of 28-day ED reattendance for participants experiencing homelessness (OR=2.93, CI 1.29 to 6.36; p=0.008) or had moderate to high vulnerability scores (participants living in stable housing and participants homeless) (OR=2.67, CI 1.29 to 5.36; p=0.007). Compared with participants in stable housing, prevalence of comorbidities among participants experiencing homelessness was greater regarding mental health challenges (65.8% vs 21.8%); three or more physical health conditions (36.8% vs 13%) and greater alcohol and other drug use (36.8% vs 17.2%).Conclusion and relevanceThe high ED reattendance suggests that people experiencing homelessness are not being adequately screened for unmet needs on their first presentation. Comprehensive screening using the HHACT may enhance the identification of the risk of reattendance and provide opportunities to intervene through targeted responses, such as integrated care pathways. While EDs are not designed to address the multifaceted needs of people experiencing homelessness, there is an urgent need to consider how to optimise this population’s access to appropriate care.

Costello syndrome is a very rare genetic condition with a poor prognosis, caused by a mutation in the HRAS gene. We report two lethal cases diagnosed antenatally using recently introduced exome sequencing technology (R21). Without this testing, they are unlikely to have been diagnosed so promptly, which the families found very helpful in coping with their loss.

Background Homelessness is associated with significant health disparities. Conventional health services often fail to address the unique needs and lived experience of homeless individuals and fail to include participatory design when planning health services. This scoping review aimed to examine areas of patient experience that are most frequently reported by people experiencing homelessness when seeking and receiving healthcare, and to identify existing surveys used to measure patient experience for this cohort. Methods A scoping review was undertaken reported according to the PRISMA-ScR 2020 Statement. Databases were searched on 1 December 2022: MEDLINE, EMBASE, APA PsychINFO and CINAHL. Included studies focused on people experiencing homelessness, healthcare services and patient experience, primary research, published in English from 2010. Qualitative papers and findings were extracted and synthesized against a modified framework based on the National Institute for Health and Care Excellence guidelines for care for people experiencing homelessness, the Institute of Medicine Framework and Lachman’s multidimensional quality model. People with lived experience of homelessness were employed as part of the research team. Results Thirty-two studies were included. Of these, 22 were qualitative, seven quantitative and three mixed methods, from the United States of America ( n  = 17), United Kingdom ( n  = 5), Australia ( n  = 5) and Canada ( n  = 4). Health services ranged from primary healthcare to outpatient management, acute care, emergency care and hospital based healthcare. In qualitative papers, the domains of ‘accessible and timely’, ‘person-centred’, and values of ‘dignity and respect’ and ‘kindness with compassion’ were most prevalent. Among the three patient experience surveys identified, ‘accessible and timely’ and ‘person-centred’ were the most frequent domains. The least frequently highlighted domains and values were ‘equitable’ and ‘holistic’. No questions addressed the ‘safety’ domain. Conclusions The Primary Care Quality-Homeless questionnaire best reflected the priorities for healthcare provision that were highlighted in the qualitative studies of people experiencing homelessness. The most frequently cited domains and values that people experiencing homelessness expressed as important when seeking healthcare were reflected in each of the three survey tools to varying degrees. Findings suggest that the principles of ‘Kindness and compassion’ require further emphasis when seeking feedback on healthcare experiences and the domains of ‘safety’, ‘equitable’, and ‘efficiency’ are not adequately represented in existing patient experience surveys.

The objectives of this scoping review are to investigate the characteristics assessed by existing vulnerability indices and the health outcomes achieved by applying them to people experiencing homelessness. This review forms part of the development and implementation of a novel tool to prioritise people experiencing homelessness for healthcare based on their need and capacity to access healthcare. Included papers were primary research, published in the English language, participants were experiencing homelessness and aged over 18 years at the time of the study, a vulnerability index was used in the study, sample size was greater than 30, and the study had a health focus. Databases searched were MEDLINE, Embase, CINAHL, Scopus, PubMed and Web of Science, between January-April 2020. The Joanna Briggs Appraisal criteria were used to quality appraise the included studies. Results were synthesised narratively. Six papers were included, a total of 27,509 participants. The reported use of the indices varied; they included screening and profiling homeless populations, comparing homeless populations, and two studies evaluated the predictive capacity, reliability and validity of the indices. One vulnerability index focused on screening for human immunodeficiency virus, one used a 50-item index and four used a nine-item index. No direct health outcomes were reported from applying the vulnerability indices. The studies identified limitations of using vulnerability indices, including the potential bias of relying on self-reported data and two studies highlighted the need for further psychometric testing to ensure validity and reliability of the indices. The sample of included studies was small. Vulnerability indices are reportedly a useful and easily accessible method of gaining valuable data on the health status and health needs of people experiencing homelessness. The variety of characteristics included in the vulnerability indices suggests the importance of tailoring vulnerability indices to the needs of the population to which it is to be applied. Conducting appropriate psychometric testing is critical so that an index can be used to accurately inform decision making and accurately prioritise people experiencing homelessness who are most at risk of mortality and morbidity. A specific tool that prioritises people experiencing homelessness for access to health care is not yet available. The review was funded by a St Vincent's Network Inclusive Health grant.

Background Domestic violence is a public health concern of epidemic proportions in Australia. Women experiencing domestic violence struggle to access the healthcare they need, when they need it. This qualitative longitudinal study explored service users’ perspectives on the impact of a nurse-led domestic violence service on their access to healthcare. Methods Study design was guided by the five pillars of best practice from the Research Integrity Framework on Violence and Abuse and informed by social constructionism. Semi-structured interviews were conducted with women at two time points: within two months of using the service and six to 12 months later. Thematic analysis explored how women’s interactions with the clinical nurse impacted their access to healthcare and their engagement with mainstream health services. Results Fifteen women participated in first round interviews and ten in the second round. All were housed in emergency accommodation following domestic violence incidents. The clinical nurse provided a safe and flexible way for women to access immediate healthcare in a place of safety, that enabled empathy, validation and practical support to address broader health needs. Three identified themes encompassed the ways the nurse-led service impacted women’s healthcare access: living in between , partnership-based nursing care and empowering choice and staying connected . Conclusion The nurse-led service was profoundly successful in enabling women’s access to healthcare through outreach and tailored follow up care. Critical to its success was the flexibility of the nurse-led service to meet women in their place of safety and provide an immediate healthcare response. The constellation of the nurse’s specialist knowledge and skills, along with person-centred and trauma informed interpersonal skills and attributes, collectively empowered women to transition towards a state of stability in their wellbeing. Clinical trial number Not applicable.

ObjectivesTo determine the feasibility of conducting a multisite randomised controlled trial of the Healthy and HomED model of care to determine its capacity to reduce emergency department (ED) representations among people experiencing homelessness.DesignFeasibility randomised controlled trial with process evaluation.SettingSingle site public metropolitan ED.ParticipantsOur goal was to recruit 204 adults experiencing homelessness attending ED. In total, 190 participants were enrolled. The final sample comprised n=101 control and n=86 intervention.InterventionsThe Healthy and HomED model of care comprises screening for homelessness, assessing unmet needs via the Homeless Health Access to Care Tool and a Decision Assistance Guide that informs care planning. The intervention was applied by the Assessment Liaison Early Referral Team (ALERT), an ED-based multidisciplinary team specialised in supporting underserved populations.Main outcome measuresClinician acceptability of the implementation of the model of care, improved identification of homelessness and a reduction in ED representations within 28 days among people experiencing homelessness.ResultsImplementation of the Healthy and HomED model of care was feasible to the ALERT clinicians and the research team. While the Healthy and HomED did not significantly reduce representations to the ED, it improved the identification of homelessness by a third (35.3%). Qualitative findings suggest that the Homeless Health Access to Care Tool provided helpful standardisation to assessments. The Decision Assistance Guide was seldom added to the plan of care for senior clinicians but was reportedly helpful to junior clinicians with less experience in homeless healthcare.ConclusionsThe study provided assurance that running a multicentre hybrid trial to test the effectiveness and implementation of the Healthy and HomED is feasible. Process evaluation found that intervention adherence could be improved with greater contextualisation to local resources and increased engagement from ED medical and nursing teams. These factors could be addressed through the codesign of a future multisite trial.Trial registration numberANZCTR 12622001085763.

Background/Objective Initially established to improve access to healthcare, particularly for primary care, the full potential of the nurse practitioner role is yet to be realised in most countries. Despite this, most countries are working to meet an ageing population’s increasing healthcare needs and reduce healthcare costs and access disparities. Achieving these outcomes requires reform at multiple levels, including nurse practitioner practice pathways, education and regulation, and identifying the barriers and facilitators to optimising their primary care role. Methods A rapid scoping review of nurse practitioner practice pathways, education and regulation inclusive of: (1) a systematic search of Medline and CINAHL for peer-reviewed English language articles, including opinion pieces published between January 2015 and February 2022; and (2) a web-based search of nurse practitioner program entry requirements of International Nurse Regulator Collaborative country members with a protected nurse practitioner title and prescribing rights, plus the Netherlands. The individually summarised search data was integrated and synthesised using Popay’s narrative approach. Results Emerging evidence from the included nurse practitioner courses ( n  = 86) and articles ( n  = 79) suggests nurse practitioners working in primary care provide safe, effective care and improve healthcare efficiencies. However, different regulatory and educational models are required if the primary care nurse practitioner is to meet growing demand. Conclusions International variations in entry criteria, curriculum, and regulation shape the global profile of the nurse practitioner primary care workforce and their practice setting. For countries to grow their primary care nurse practitioner workforce to meet unmet needs, different entry requirements, program content and accredited post-registration transitional programs must be urgently considered.

ObjectivesIn this paper, we report the development of the Homeless Health Access to Care Tool. This tool aims to improve the gap in assessing health need and capacity to access healthcare of people experiencing homelessness. Tools exist that prioritise people experiencing homelessness for housing, but none specifically designed to prioritise for healthcare, or that are succinct enough to be easily implemented to emergency department or primary healthcare settings.Design and settingThe Homeless Health Access to Care Tool has been adapted from an existing tool, the Vulnerability Index Service Prioritisation Decision Assistance Tool through a five-step process: (1) domain identification, (2) literature review, (3) analysis of hospital admission data, (4) expert judges, and (5) Delphi study.ParticipantsThe tool was adapted and developed by homeless health clinicians, academics and people with lived experience of homelessness. The Delphi study (n=9) comprised emergency department and homeless health clinicians.ResultsConsensus was gained on all but one item, five new items were added, and wording changes were made to six items based on expert feedback. Participants perceived the tool would take between 5 to 11 min to complete, the number of items were appropriate, and the majority agreed it would facilitate the assessment of health needs and capacity to access healthcare.ConclusionRobust development of the Homeless Health Access to Care Tool through the Delphi is the first phase of its development. The Homeless Health Access to Care Tool offers an opportunity to assess both health need and capacity to access healthcare with the aim to improve access to healthcare for people experiencing homelessness. This tool will facilitate standardised data collection to inform service design and data linkage regarding access to healthcare of people experiencing homelessness. The next stages of testing include construct validity, feasibility, usability and inter-rater reliability, and pilot implementation.

Incidence of endometrial cancer (EC) is rising in the developed world. The current standard of care, hysterectomy, is often infeasible for younger patients and those with high body mass index. There are limited non-surgical treatment options and a lack of biologically relevant research models to investigate novel alternatives to surgery for EC. The aim of the present study was to develop a long-term, patient-derived explant (PDE) model of early-stage EC and demonstrate its use for investigating predictive biomarkers for a current non-surgical treatment option, the levonorgestrel intra-uterine system (LNG-IUS). Fresh tumour specimens were obtained from patients with early-stage endometrioid EC. Tumours were cut into explants, cultured on media-soaked gelatin sponges for up to 21 days and treated with LNG. Formalin-fixed, paraffin embedded (FFPE) blocks were generated for each explant after 21 days in culture. Tumour architecture and integrity were assessed by haematoxylin and eosin (H&E) and immunohistochemistry (IHC). IHC was additionally performed for the expression of five candidate biomarkers of LNG resistance. The developed ex vivo PDE model is capable of culturing explants from early-stage EC tumours long-term (21 Days). This model can complement existing models and may serve as a tool to validate results obtained in higher-throughput in vitro studies. Our study provides the foundation to validate the extent to which EC PDEs reflect patient response in future research.

The path from reference librarian or cataloger to department head to administrator is one many librarians travel, becoming organizational leaders as they do. Much has been written about how to acquire leadership skills, while mentoring programs and seminars support emerging leaders. Another kind of leadership exists alongside that first well-trodden path. Long-time reference librarians, catalogers, and others outside the ranks of more traditional leadership positions bestow on their departments a depth of experience and dedication to excellence that is needed in a stable, thriving, and successful operation. In the world of business management, these characteristics fall under the rubric of followership. Effective followers are as important to organizational success as are leaders. Business literature is replete with research and advice for leaders: how to become a leader, how to lead more effectively, servant leadership, and countless other topics.