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Background Social disparities in healthcare persist in the US despite the expansion of Medicaid under the Affordable Care Act. We investigated the causal impact of socioeconomic status on the quality of care in a setting with minimal confounding bias from race, insurance type, and access to care. Methods We designed a retrospective population-based study with a random 25% sample of adult Taiwan population enrolled in Taiwan’s National Health Insurance system from 2000 to 2016. Patient’s income levels were categorized into low-income group (<25th percentile) and high-income group (≥25th percentile). We used marginal structural modeling analysis to calculate the odds of hospital admissions for 11 ambulatory care sensitive conditions identified by the Agency for Healthcare Research and Quality and the odds of having an Elixhauser comorbidity index greater than zero for low-income patients. Results Among 2,844,334 patients, those in lower-income group had 1.28 greater odds (95% CI 1.24–1.33) of experiencing preventable hospitalizations, and 1.04 greater odds (95% CI 1.03–1.05) of having a comorbid condition in comparison to high-income group. Conclusions Income was shown to be a causal factor in a patient’s health and a determinant of the quality of care received even with equitable access to care under a universal health insurance system. Policies focusing on addressing income as an important upstream causal determinant of health to provide support to patients in lower socioeconomic status will be effective in improving health outcomes for this vulnerable social stratum.

Ties that Enable is written for students, providers, and advocates seeking to understand how best to improve mental health care – be it for themselves, their loved ones, their clients, or for the wider community. The authors integrate their knowledge of mental health care as researchers, teachers, and advocates and rely on the experiences of people living with severe mental health problems to help understand the sources of community solidarity. Communities are the primary source of social solidarity, and given the diversity of communities, solutions to the problems faced by individuals living with severe mental health problems must start with community level initiatives. “Ties that Enable” examines the role of a faith-based community group in providing a sense of place and belonging as well as reinforcing a valued social identity. The authors argue that mental health reform efforts need to move beyond a focus on individual recovery to more complex understandings of the meaning of community care. In addition, mental health care needs to move from a medical model to a social model which sees the roots of mental illness and recovery as lying in society, not the individual. It is our society’s inability to provide inclusive supportive environments which restrict the ability of individuals to recover. This book provides insights into how communities and system level reforms can promote justice and the higher ideals we aspire to as a society.

On January 29, 2001, President George W. Bush signed an executive order creating the White House Office of Faith-Based and Community Initiatives. This action marked a key step toward institutionalizing an idea that emerged in the mid-1990s under the Clinton administration--the transfer of some social programs from government control to religious organizations. However, despite an increasingly vocal, ideologically charged national debate--a debate centered on such questions as: What are these organizations doing? How well are they doing it? Should they be supported with tax dollars?--solid answers have been few.

Introduction: The topic of patient safety, which is traditionally viewed as preventing harm stemming from healthcare treatment, has been extensively researched in hospital and institutional settings. However, less attention has been given to addressing safety at home even though an increasing number of older people receive care and support at home, for example through integrated care programs. Care provided in the context of integrated programs for older people living at home differs from care in institutional settings in that it takes place in less controlled environments and often involves multiple health and social care providers as well as informal caregivers. Knowledge on safety in relation to integrated care is scarce. Therefore, this review aims to provide insight into how safety is currently being addressed in integrated care programs for older people living at home. Methods: This review adopted a multidimensionalperspective on safety, operationalised as reducing health risks by preventing predictable harm. These risks exist in various domains (e.g. patient characteristics and behaviour, patients’ physical or social environments, health and social care delivery). Papers describing integrated care programs where at least one intervention component explicitly aimed at safety were included in the review. Data were extracted on the safety components of the interventions and the domains they focused on. Results: Ten integrated care programs were included in the review. The extent to which these programs addressed safety varied. Programs addressed risks related to patient characteristics and behaviour (e.g. falls, substance abuse, medication adherence), or health and social care management (e.g. polypharmacy, care transitions). Several tools and interventions were used to promote safety, such as needs assessments, evidence based care plans, medication reviews and case management methods. There was generally less attention to risks related to patients’ physical and social environment, although one program specifically addressed home safety by providing a handyman. Discussion: The identified programstarget a variety of safety risks at different domains, and they differ in the extent to which safety is addressed from a multidimensional perspective. Currently, attention to safety is primarily focused on risks related to health care management and patient characteristics and behaviour, while risks related to people’s physical and social environments are less often addressed. Additional interventions, targeting specific safety risks, could be incorporated in integrated care programs in order to address safety more comprehensively. Conclusions and lessons learned: Only a few of the many integrated care programs for older people at home that are described in literature explicitly address safety. Within these programs, more attention is needed for the risks related to people’s physical and social environments. Limitations: Our review only included programs that explicitly addressed safety, as documented in the research literature. Therefore, we may have missed some programs that addressed safety if this was not clearly described in the literature. Suggestions for future research: Future research might focus on the effects of integrated care programs on the multiple domains of safety.

Background Children and young people’s (CYP) mental health is worsening, and an increasing number are seeking psychiatric and mental health care. Whilst many CYPs with low-to-medium levels of psychiatric distress can be treated in outpatient services, CYPs in crisis often require inpatient hospital treatment. Although necessary in many cases, inpatient care can be distressing for CYPs and their families. Amongst other things, inpatient stays often isolate CYPs from their support networks and disrupt their education. In response to such limitations, and in order to effectively support CYPs with complex mental health needs, intensive community-based treatment models, which are known in this paper as intensive community care services (ICCS), have been developed. Although ICCS have been developed in a number of settings, there is, at present, little to no consensus of what ICCS entails. Methods A group of child and adolescent mental health clinicians, researchers and academics convened in London in January 2023. They met to discuss and agree upon the minimum requirements of ICCS. The discussion was semi-structured and used the Dartmouth Assertive Community Treatment Fidelity Scale as a framework. Following the meeting, the agreed features of ICCS, as described in this paper, were written up. Results ICCS was defined as a service which provides treatment primarily outside of hospital in community settings such as the school or home. Alongside this, ICCS should provide at least some out-of-hours support, and a minimum of 90% of CYPs should be supported at least twice per week. The maximum caseload should be approximately 5 clients per full time equivalent (FTE), and the minimum number of staff for an ICCS team should be 4 FTE. The group also confirmed the importance of supporting CYPs engagement with their communities and the need to remain flexible in treatment provision. Finally, the importance of robust evaluation utilising tools including the Children’s Global Assessment Scale were agreed. Conclusions This paper presents the agreed minimum requirements of intensive community-based psychiatric care. Using the parameters laid out herein, clinicians, academics, and related colleagues working in ICCS should seek to further develop the evidence base for this treatment model.

Background: Team-based learning (TBL) was studied in several preclinical settings, but evidence for its effectiveness in community nursing education is scant. A community health care nursing course was developed, and nursing students engaged in TBL to achieve Sustainable Development Goal 3. Purpose: This study aimed to examine the effect of TBL model integration on students’ learning attitude, community understanding, and community care competence for achieving SDG 3 and determine the extent to which the TBL model altered students’ nursing competence for providing community health care. We compared the effect of TBL and traditional learning (TL) in terms of community health care knowledge objectives. Methods: TBL was employed as the teaching strategy to guide students’ discussion of community care issues, allowing them to fully utilize the knowledge acquired in their community practice. We used an unblinded crossover design, and 99 students participated in the community health nursing course. Results: The results demonstrated that TBL improved participants’ community understanding and enhanced their skills for assessing and fulfilling community needs. The experimental and control groups differed significantly in their TBL performance, learning attitude, and nursing competencies. The performance of those who engaged in TBL was higher than that of those who engaged in TL on all community issues. TBL appears to be a more effective method than TL in terms of achieving nursing students’ knowledge objectives. Conclusions: Regarding practical application, the proposed intervention enables nursing students to acquire professional knowledge related to community aging health care and nursing skills, and establish partnerships with community residents. This facilitates the achievement of the United Nations’ sustainable development goal of ensuring healthy living and promoting well-being at all ages.

Aging societies have an increased need for care services. To solve the problem of care, we suggest community care, through which medical services are provided that meet individual needs. Korea provides care services in advance of the community care project and implements quality control to improve the quality of these social services. Therefore, this study aims to compare and analyze the factors affecting user satisfaction in care services in both 2013 and 2016. We analyzed secondary data from 2013 and 2016 collected by the Social Security Information Service. These data include standardized metrics for the quality of care. Based on the evaluation indexes for care service in 2013 and 2016, we used commonly used indexes for analysis. Specifically, non-profit organizations were influenced by sales, accounting management, lifetime tenure rate, etc., while for-profit organizations were affected by number of users, contract termination, etc. In addition, on-site evaluation had a negative effect on the change rate of user satisfaction. Therefore, in order to increase satisfaction with care services, evaluation indexes by service type should be diversified and differentiated. In addition, field evaluations related to user satisfaction should be performed in order to provide care services appropriate for local characteristics.

Background The Veterans Health Administration (VA) serves Veterans in the nation’s largest integrated healthcare system. VA seeks to provide high quality of healthcare to Veterans, but due to the VA Choice and MISSION Acts, VA increasingly pays for care outside of its system in the community. This systematic review compares care provided in VA and non-VA settings, and includes published studies from 2015 to 2023, updating 2 prior systematic reviews on this topic. Methods We searched PubMed, Web of Science, and PsychINFO from 2015 to 2023 for published literature comparing VA and non-VA care, including VA-paid community care. Records were included at the abstract or full-text level if they compared VA medical care with care provided in other healthcare systems, and included clinical quality, safety, access, patient experience, efficiency (cost), or equity outcomes. Data from included studies was abstracted by two independent reviewers, with disagreements resolved by consensus. Results were synthesized narratively and via graphical evidence maps. Results Thirty-seven studies were included after screening 2415 titles. Twelve studies compared VA and VA-paid community care. Most studies assessed clinical quality and safety, and studies of access were second most common. Only six studies assessed patient experience and six assessed cost or efficiency. Clinical quality and safety of VA care was better than or equal to non-VA care in most studies. Patient experience in VA care was better than or equal to experience in non-VA care in all studies, but access and cost/efficiency outcomes were mixed. Discussion VA care is consistently as good as or better than non-VA care in terms of clinical quality and safety. Access, cost/efficiency, and patient experience between the two systems are not well studied. Further research is needed on these outcomes and on services widely used by Veterans in VA-paid community care, like physical medicine and rehabilitation.

For too long there have been heated debates between those who believe that mental health care should be largely or solely provided from hospitals and those who adhere to the view that community care should fully replace hospitals. The aim of this study was to propose a conceptual model relevant for mental health service development in low-, medium- and high-resource settings worldwide. Method We conducted a review of the relevant peer-reviewed evidence and a series of surveys including more than 170 individual experts with direct experience of mental health system change worldwide. We integrated data from these multiple sources to develop the balanced care model (BCM), framed in three sequential steps relevant to different resource settings. Low-resource settings need to focus on improving the recognition and treatment of people with mental illnesses in primary care. Medium-resource settings in addition can develop 'general adult mental health services', namely (i) out-patient clinics, (ii) community mental health teams (CMHTs), (iii) acute in-patient services, (iv) community residential care and (v) work/occupation. High-resource settings, in addition to primary care and general adult mental health services, can also provide specialized services in these same five categories. The BCM refers both to a balance between hospital and community care and to a balance between all of the service components (e.g. clinical teams) that are present in any system, whether this is in low-, medium- or high-resource settings. The BCM therefore indicates that a comprehensive mental health system includes both community- and hospital-based components of care.

Background The Maintaining Internal Systems and Strengthening Integrated Outside Networks (MISSION) Act of 2018 authorized a major expansion of purchased care in the community for Veterans experiencing access barriers in the Veterans Affairs (VA) health care system. Objective To estimate changes in primary care, mental health, and emergency/urgent care visits in the VA and community fiscal years (FY) 2018–2021 and differences between rural and urban clinics. Design A national, longitudinal study of VA clinics and outpatient utilization. Clinic-level analysis was conducted to estimate changes in number and proportion of clinic visits provided in the community associated with the MISSION Act adjusting for clinic characteristics and underlying time trends. Participants In total, 1050 VA clinics and 6.6 million Veterans assigned to primary care. Main Measures Number of primary care, mental health, and emergency/urgent care visits provided in the VA and community and the proportion provided in the community. Key Results Nationally, community primary care visits increased by 107% (50,611 to 104,923), community mental health visits increased by 167% (100,701 to 268,976), and community emergency/urgent care visits increased by 129% (142,262 to 325,407) from the first quarter of 2018 to last quarter of 2021. In adjusted analysis, after MISSION Act implementation, there was an increase in community visits as a proportion of total clinic visits for emergency/urgent care and mental health but not primary care. Rural clinics had larger increases in the proportion of community visits for primary care and emergency/urgent care than urban clinics. Conclusions After the MISSION Act, more outpatient care shifted to the community for emergency/urgent care and mental health care but not primary care. Community care utilization increased more in rural compared to urban clinics for primary care and emergency/urgent care. These findings highlight the challenges and importance of maintaining provider networks in rural areas to ensure access to care.