Cost of Home-Based Couples Human Immunodeficiency Virus Counseling and Testing and Human Immunodeficiency Virus Self-Testing During Pregnancy and Postpartum in Southwestern Kenya.

OBJECTIVE: Home-based couples HIV testing and counseling and HIV self-testing (HIVST) for pregnant women can promote HIV status disclosure and male partner testing; however, cost data are lacking. We examined a home-based couples intervention (HBCI) and HIVST intervention costs per couple (unit cost) during pregnancy and postpartum in Kenya. METHODS: This randomized controlled trial is comparing HBCI and HIVST for couples among pregnant women attending antenatal care clinics in two counties in southwestern Kenya. We used micro-costing to estimate the unit cost per couple receiving the intervention as the total of direct and indirect costs for each study arm in 2019 US$. We used a one-month window to conduct a time and motion study to determine personnel effort and resources. We then compared the unit cost by arm, identified key cost drivers, and conducted sensitivity analyses for cost uncertainties. RESULTS: At base-case, the unit cost was $129.01 and $41.99, respectively, for HBCI and HIVST. Personnel comprised half of the unit cost for both arms. Staff spent more time on activities related to participant engagement in HBCI (accounting for 6.4% of the unit cost) than in HIVST (2.3%). Staff training was another key cost driver in HBCI (20.1% of the unit cost compared to 12.5% in HIVST). Sensitivity analyses revealed that the unit cost ranges were $104.64-$154.54 for HBCI and $30.49-$56.59 for HIVST. CONCLUSIONS: Our findings may guide spending decisions for future HIV prevention and treatment programs for pregnant couples in resource-limited settings such as Kenya.

Growth of Fee-for-Service Medicare Home-Based Medical Care Within Private Residences and Domiciliary Care Settings in the U.S., 2012-2019.

OBJECTIVES: Home-based medical care (HBMC) delivers physician or advanced practice provider-led medical services for patients in private residences and domiciliary settings (eg, assisted living facilities, group/boarding homes). We aimed to examine the time trends in HBMC utilization by care settings. DESIGN: Analyses of HBMC utilization at the national and state levels during the years 2012-2019. SETTING AND PARTICIPANTS: With Medicare public use files, we calculated the state-level utilization rate of HBMC among fee-for-service (FFS) Medicare beneficiaries, measured by visits per 1000 FFS enrollees, in private residences and domiciliary settings, both separately and combined. METHODS: We assessed the trend of HBMC utilization over time via linear mixed models with random intercept for state, adjusting for the following state-level markers of HBMC supply and demand: number of HBMC providers, state ranking of total assisted living and residential care capacity, and the proportion of FFS beneficiaries with dementia, dual eligibility for Medicaid, receiving home health services, and Medicare Advantage. RESULTS: Total HBMC visits in the United States increased from 3,911,778 in 2012 to 5,524,939 in 2019. The median (interquartile range) state-level HBMC utilization rate per 1000 FFS population was 67.6 (34.1-151.3) visits overall, 17.3 (7.9-41.9) visits in private residences, and 47.7 (23.1-86.6) visits in domiciliary settings. The annual percentage increase of utilization rates was significant for all care settings in crude models (3%-8%), and remained significant for overall visits and visits in domiciliary settings (2%-4%), but not in private residences. CONCLUSIONS AND IMPLICATIONS: The national-level growth in HBMC from 2012-2019 was largely driven by a growth of HBMC occurring in domiciliary settings. To meet the needs of a growing aging population, future studies should focus efforts on policy and payment issues to address inequities in access to HBMC services for homebound older adults, and examine drivers of HBMC growth at regional and local levels.

Teaming up to traverse loneliness: a co-creative journey toward a home care work model for supporting social participation among older adults.

BACKGROUND: Participatory research is particularly suitable in adressing know-do gaps in health systems. There is a disparity between what is known about the benefits of social participation and home care's responsibility to provide conditions amenable to older adults' social participation, and what is accomplished in home care practice. Home care workers are a large, low-power group, whose competences should be better harnessed. We carried out a participatory action research (PAR) project with the goal of generating an improved structure for identifying and alleviating loneliness. This article aims to explore the co-creative process of designing a work model that guides home care workers in supporting social participation among older care recipients. METHODS: Multimodal data from 16 PAR workshops with 14 home care workers were described and explored through the 'recursive PAR process' and the 'framework for occupational enablement for change in community practice". RESULTS: The PAR process is outlined through the objectives, activities, and work model, as well as enablement strategies employed throughout the PAR process; as are its opportunities, challenges and implications. The work model describes how care workers can act as discoverers of care recipients' unmet social needs, employ intentional communication, and link to relevant professions or community services to alleviate loneliness among older home care recipients. CONCLUSIONS: This research process included opportunities of collaborating with enthusiastic and competent home care workers, but also challenges of moving between theory and practice and maintaining active participation between workshops. The resulting work model is in step with the requirements of elderly care, is unique in its field and could comprise a first step toward a more systematic approach of assessing and addressing loneliness. The vivid delineation of the PAR process provided in this paper can aid other researchers in navigating participatory research in home care contexts.

Home Delivery: Transfusion Services When and Where They Are Needed.

Home blood product transfusion has been utilized around the world in various forms over the past few decades. There is current interest in decentralizing hospital care to improve patient independence and convenience, minimize cost to the health service, and to prevent nosocomial infection, especially with the recent COVID-19 pandemic. The transition to "hospital in the home" is occurring across the healthcare sector driven by aims to improve patient outcomes and patient satisfaction, capacity pressures in the acute care sector, and most recently due to concerns regarding infectious disease transmission in hospital settings. This review explores the published literature on home red cell and platelet transfusions, and where the literature is limited, also considered data from subcutaneous immunoglobulin studies. Current published experience on red cell and platelet transfusion at home has identified benefits to the patient and health service, with further studies needed to quantify improvement in quality of life and health-related outcomes. Safety concerns may be a perceived barrier to implementation of home transfusion, however current published data suggests serious adverse reactions are rare. Cost-effectiveness data for home transfusion are very limited and a key area for future research. Home transfusion has the potential to benefit from newer technologies, such as portable/remote monitoring and electronic patient identifiers.

Home medication management problems and associated factors among psychiatric patients using home care pharmacy services at government hospitals in western Malaysia.

BACKGROUND: Proper home medication management plays a role in improving medication adherence, preserving drug efficacy and ensuring safe medication practices, which is crucial to establish positive treatment outcomes. However, no published studies are available on home medication management among psychiatric patients. The study aimed to identify home medication management problems among psychiatric patients in Malaysia and to examine the associations of inappropriate medication storage and lack of a medication administration schedule with sociodemographic factors, disease insight, number of medications and type of home care pharmacy services (HCPS). METHODS: This multicentre cross-sectional study was conducted among psychiatric patients using HCPS in six government hospitals in western Malaysia. Data were extracted from the HCPS form used for each visit as per the protocol published by the Pharmaceutical Services Division, Ministry of Health Malaysia. A minimum sample size of 169 was needed. Proportional random sampling was applied. The associations of inappropriate medication storage and lack of medication administration schedule with study parameters were analysed using multiple logistic regressions. RESULTS: A total of 205 home visits were conducted with 229 home medication management problems identified; inappropriate medication storage and lack of medication administration schedule topped the list. Inappropriate medication storage was significantly associated with low income [AOR = 4.34 (95% CI 1.17:15.98), p = 0.027], alcohol consumption [AOR = 14.26 (95% CI 1.82:111.38), p = 0.011], poor insight [AOR = 2.34 (95% CI 1.08:5.06), p = 0.030] and part-time HCPS [AOR = 2.60 (95% CI 1.20:5.67), p = 0.016]. Lack of administration schedule was significantly associated with low income [AOR = 6.90 (95% CI 1.46:32.48), p = 0.014], smoking [AOR = 2.43 (95% CI 1.20:4.92), p = 0.013], poor insight [AOR = 5.32 (95% CI 2.45:11.56), p < 0.05] and part-time HCPS [AOR = 2.96 (95% CI 1.42:6.15), p = 0.004]. CONCLUSIONS: Inappropriate medication storage and a lack of a medication administration schedule are common among psychiatric patients. The study also highlighted the potential of HCPS to improve disease insight and home medication management among psychiatric patients if the service is utilized fully.

Maximum Phonation Time is a Useful Assessment for Older Adults Requiring Long-term Care/support.

OBJECTIVE: The maximum phonation time (MPT) is used to assess simple respiratory functions and can be performed anywhere without special instruments. We investigated the association between MPT and respiration, considering the future utilization of simple respiratory assessments during home-based physical therapy. METHOD: This cross-sectional study included 140 older adults enrolled in Japanese long-term care insurance (77 men, 63 women; mean age, 77.9±8.0 years). The participants performed the MPT, followed by spirometry. We analyzed the MPT of the three age groups, relative reliability of the MPT values, and the association between MPT and respiratory function. RESULTS: We found that the MPT of older men requiring long-term care or support was related to age. The intraclass correlation coefficient of MPT was >0.8 for all groups. Only forced vital capacity was associated with MPT in the partial correlation and multiple regression analyses. CONCLUSION: MPT could be an alternative assessment of respiratory function in home-based physical therapy for older adults requiring long-term care or support.

interRAI Pediatric Home Care (PEDS-HC) Assessment Tool: Evaluating Ontario Healthcare Workers' Experience.

High quality pediatric homecare requires comprehensive assessment of the needs, supports, and health care challenges of children with special healthcare needs and their families. There is no standardized homecare assessment system to evaluate children's clinical needs in the home (support services, equipment, etc.) in Ontario, Canada, which contributes to inequitable homecare service allocation. In 2017, the interRAI Pediatric Home Care assessment tool (PEDS-HC) was implemented on a pilot basis in several regions of Ontario. This qualitative descriptive study explores the experiences of homecare coordinators using the PEDS-HC, seeking to understand the utility and feasibility of this tool through focus group discussion. Four major themes were identified including: the benefits of the tool; areas for modification; challenges to use; and Clinical Assessment Protocols to develop. These themes can guide modifications to the tool to improve utility and improve pediatric home care services. The PEDS-HC is an effective tool to assess children needing homecare in a standardized and comprehensive manner. Use of the tool can improve the quality of homecare services by ensuring equity in service provision and facilitate early identification of clinical issues to prevent unexpected health deteriorations.

Barriers and facilitators to family caregiver training during home health care: A multisite qualitative analysis.

BACKGROUND: During Medicare home health care (HHC), family caregiver assistance is often integral to implementing the care plan and avoiding readmission. Family caregiver training delivered by HHC clinicians (nurses and physical therapists [PTs]) helps ensure caregivers' ability to safely assist when HHC staff are not present. Yet, family caregiver training needs often go unmet during HHC, increasing the risk of adverse patient outcomes. There is a critical knowledge gap regarding challenges HHC clinicians face in providing necessary family caregiver training. METHODS: Multisite qualitative study using semi-structured, in-depth key informant interviews with Registered Nurses (n = 11) and PTs (n = 8) employed by four HHC agencies. Participating agencies were diverse in rurality, scale, ownership, and geographic region. Key informant interviews were audio-recorded, transcribed, and analyzed using directed content analysis to identify existing facilitators and barriers to family caregiver training during HHC. RESULTS: Clinicians had an average of 9.3 years (range = 1.5-23 years) experience in HHC, an average age of 45.1 years (range = 28-63 years), and 95% were female. Clinicians identified facilitators and barriers to providing family caregiver training at the individual, interpersonal, and structural levels. The most salient factors included clinician-caregiver communication and rapport, accuracy of hospital discharge information, and access to resources such as additional visits and social work consultation. Clinicians noted the COVID-19 pandemic introduced additional challenges to providing family caregiver training, including caregivers' reduced access to hospital staff prior to discharge. CONCLUSIONS: HHC clinicians identified a range of barriers and facilitators to delivering family caregiver training during HHC; particularly highlighting the role of clinician-caregiver communication. To support caregiver training in this setting, there is a need for updated reimbursement structures supporting greater visit flexibility, improved discharge communication between hospital and HHC, and structured communication aids to facilitate caregiver engagement and assessment.

Função e atuação do serviço de atendimento domiciliar na perspectiva de profissionais da Atenção Primária à Saúde / Function and performance of the Home care service from the perspective of Primary Health Care professionals / Función y desempeño del Servicio de atención domiciliaria desde la perspectiva de los profesionales de Atención Primaria de Salud

Introdução: O Serviço de Atenção Domiciliar (SAD) é um serviço complementar aos cuidados realizados na atenção básica e urgência e visa fortalecer a integralidade da atenção à saúde, pois assume papel importante na formação de novas estratégias de cuidado na modalidade de atenção complementar e substitutiva. Objetivo: Caracterizar a função e atuação do SAD na perspectiva dos profissionais da Atenção Primária à Saúde (APS) em um município do extremo sul catarinense. Método: Trata-se de uma pesquisa de abordagem qualitativa, do tipo descritivo-exploratório, realizada com 14 profissionais que atuaram antes da implantação do SAD e continuam trabalhando em equipes de Saúde da Família do município de Araranguá/SC. O processo de análise ocorreu pela técnica de análise de conteúdo, com auxílio do software para análise de dados qualitativos Atlas.ti. Resultados: A atuação do SAD restringe-se à prestação do cuidado no domicílio; à realização de trabalho multiprofissional; a pacientes acamados como foco da assistência; à equipe de referência para prestação do cuidado. Com relação à função do SAD, ela associa-se ao apoio às equipes de Saúde da Família; ao auxílio para a efetivação da integralidade do cuidado; ao incentivo à desospitalização; à melhoria na qualidade de vida; e à ampliação do acesso ao serviço de saúde. Conclusão: A atuação do SAD representa um serviço mais próximo da população acamada e é realizado por equipe de referência multiprofissional. Sua função vincula-se à melhoria da assistência e à ampliação da garantia do direito à saúde.

Introduction: The Home Care Service (HCS) is a complementary service to the care provided in basic and basic care and aims to intensify the integrality of training, as it plays an important role in the prevention of new care in the form of complementary and substitutive care. Objective: To identify how the HCS work process occurs from the perspective of primary health care professionals in a municipality in the extreme south of Santa Catarina. Methods: This is a qualitative research, of the descriptive-exploratory type, carried out with 14 professionals who work before the implementation of HCS and continue to work in Family Health teams in the municipality. The analysis process emerged through the content analysis technique, with the help of Atlas.ti qualitative data analysis software. Results: HCS's role is restricted to providing care at home; carrying out multi-professional work; bedridden patients as the focus of care; reference team to provide care. In relation to the role of the HCS, the Family Health teams are associated with support; in helping to carry out comprehensive care; encouraging no hospitalization; improvement in quality of life; and access to health services. Conclusions: HCS's performance represents a service closer to the bedridden population, performed by a multiprofessional reference team. And its function linked the improvement of care and guarantee of the right to health.

Introducción: El Servicio de Atención Domiciliaria (SAC) es un servicio complementario a la atención prestada en la atención básica y básica y tiene como objetivo intensificar la integralidad de la formación, ya que juega un papel importante en la prevención de nuevos cuidados en forma de complementos y sustitutivos. cuidado. Objetivo: Analizar cómo ocurre el proceso de trabajo del SAC en la perspectiva de los profesionales de la atención primaria de salud en un municipio del extremo sur de Santa Catarina. Métodos: Se trata de una investigación cualitativa, de tipo descriptiva-exploratoria, realizada con 14 profesionales que actúan antes de la implantación del SAC y continúan actuando en los equipos de Salud de la Familia del municipio. El proceso de análisis surgió a través de la técnica de análisis de contenido, con la ayuda del software de análisis de datos cualitativos Atlas.ti. Resultados: El papel de SAC se restringe a brindar atención en el hogar; realización de trabajos multiprofesionales; pacientes encamados como foco de atención; equipo de referencia para brindar atención. En relación al papel de la SAC, los equipos de Salud de la Familia están asociados al apoyo; en ayudar a llevar a cabo una atención integral; alentar la no hospitalización; mejora en la calidad de vida; y el acceso a los servicios de salud. Conclusiones: La actuación de SAC representa un servicio más cercano a la población encamada, realizado por un equipo de referencia multiprofesional. Y su función vinculada a la mejora de la atención y garantía del derecho a la salud.

Impact of informal care with multiple medical devices on caregiver burden: A cross-sectional national survey in Japan.

Family caregivers provide long-term, home-based, informal medical care to patients with special healthcare needs. We examined whether informal care involving medical device use is associated with caregiver burden, considering potential risk variables as moderators. Data were collected from March to May 2019 through a Japanese public visiting care system. This system is offered to patients with severe chronic or intractable disease or impairment. After contacting government-certified offices that provide visiting care systems, the offices that agreed to participate invited dyads of patients and caregivers to complete our questionnaire. To focus on new parameters other than the caregiver factor that had been clarified previously, we aimed to analyse the data from patient-caregiver dyads. Using a questionnaire-based cross-sectional design, we asked participants about caregiver and patient characteristics, care types, and caregiver burden using the Zarit Caregiver Burden Interview. Logistic regression analyses were conducted to test the association between caregiver burden and informal medical care. Data from 371 complete patient-caregiver dyads were analysed; 49.3% showed high caregiver burden, and 40.4% were administering at least one informal medical care procedure. Univariate analyses indicated a relationship between high caregiver burden among caregivers who slept less, provided care for longer periods daily, performed medical care procedures and cohabited with patients. Importantly, logistic regression analyses indicated a significant relationship between high caregiver burden and care involving multiple medical procedures (i.e. 4-6 procedures with medical devices; adjusted odds ratio (AOR) = 2.03, 95% confidence intervals (95% CI) = [1.01, 4.09]). In propensity-matched participants (n = 314), results continued to show that multiple medical care procedures were significantly related to high caregiver burden (AOR = 2.19, 95% CI [1.14-4.22]). The effects of non-medical informal care on caregiver burden were moderate. This result suggests that more intensive interventions are required for patients with multiple medical care needs to reduce caregiver burden.

Efficacy of a short course of lung ultrasound for primary care physicians in the assessment of COVID-19-positive patients.

INTRODUCTION: Lung ultrasound (LUS) has become the first diagnostic imaging approach to assess lung involvement in COVID-19. While LUS proved to be safe, reliable, and accurate, not many primary care physicians (PCP) are capable to employ this instrument in the first evaluation of COVID-19 outpatients. The aim of this study was to determine the effectiveness of a brief training program in LUS for PCP. METHODS: Italian local authorities promoted a training program in LUS for PCP engaged in COVID-19 outpatients' evaluation. The course took place in a COVID-19 unit and included a hands-on practice on real COVID-19 patients. We conducted a qualitative and quantitative analysis of the results of the training program. RESULTS: A total of 32 PCP completed the training. About 100% of participants reported an increase in competence and confidence in the use of LUS after the training. Self-reported confidence in detecting major COVID-19 LUS abnormalities was high (B-lines 8/10, pleural abnormalities 6.5/10). B-lines were accurately identified with a reliability of 81%, with a sensitivity of 96%, and a negative predictive value of 98%. Trainees were some less accurate in detecting pleural abnormalities (reliability 63%) but with a high specificity (99%). CONCLUSIONS: This study showed that a short training program, but comprising a hands-on practice, is capable to bring even almost novices to achieve a high overall accuracy and reliability in detecting lung involvement in COVID-19. This may result in a significant improvement of the performances of PCP involved in the first evaluation of COVID-19 cases in primary care facilities.

Factors associated with caregiver distress among home care clients in New Zealand: Evidence based on data from interRAI Home Care assessment.

OBJECTIVE: To identify factors associated with caregiver distress among home care clients in New Zealand. METHODS: The cohort consisted of 105,978 community-dwelling people aged 65 years or older requiring home care services in New Zealand who had at least one informal caregiver. Bivariate and multivariable logistic regression analyses were used to identify factors associated with caregiver distress. RESULTS: Variables associated with risk of caregiver distress included Depression Rating Scale score, aggressive behaviour symptoms, primary informal caregiver relationship to patient, Cognitive Performance Scale score, Changes in Health, End-stage disease, and Signs and Symptoms Scale score, informal care time, secondary informal caregiver relationship to care recipient, activities of daily living hierarchy scale score and any hospitalisation. CONCLUSIONS: The study has identified important characteristics that are associated with caregiver stress. These results suggest that caregiver distress can be relieved by promoting protective factors and aiming to reduce risk factors among home care clients in New Zealand.

Patient cognitive impairment associated with higher home health care delivery costs.

OBJECTIVE: To assess whether home health agencies incur significantly higher care delivery costs for patients with cognitive impairment across three timeframes relevant to home health payment policy. DATA SOURCES: Linked Medicare home health claims and patient assessments, National Health and Aging Trends Study (NHATS), and home health agency cost reports for a nationally representative sample of Medicare beneficiaries receiving home health between 2011 and 2016. STUDY DESIGN: We modeled care delivery costs incurred by the home health agency as a function of patient cognitive impairment using multivariable, propensity score-adjusted, generalized linear models. DATA COLLECTION/EXTRACTION METHODS: We identified NHATS participants who experienced an index home health episode between 2011 and 2016 (n = 1214; weighted n = 5,856,333) and linked their NHATS survey data to standardized patient assessment and claims data for the episode, as well as cost report data for the home health agency that provided care. PRINCIPAL FINDINGS: Across the first 30, 60, and 120 days of caring for a patient with cognitive impairment, we estimate additional costs of care to the home health agency of $186.19 (p = 0.02), $282.46 (p = 0.01), and $740.91 (p = 0.04), respectively. CONCLUSIONS: Home health agencies incur significantly higher costs when caring for a patient with cognitive impairment. As patient cognitive function is not considered in the most recent Medicare home health reimbursement model, agencies may be disincentivized from providing care to those with cognitive impairment. Policy makers and researchers should carefully monitor home health access among Medicare beneficiaries with cognitive impairment and further investigate the inclusion of patient cognitive function in future risk adjustment models.

Immigrant Status and Unmet Home Care Needs: Results from the Canadian Community Health Survey.

This study assessed the relationship between immigration status, including recency, and unmet home care needs. Data from the 2015-2016 Canadian Community Health Survey (CCHS) was used to analyze the relationship between immigration status and unmet home care needs. Descriptive analyses and multivariable logistic regression controlling for age, sex, marital status, and education were calculated. Of the study sample of 5976 respondents, 34.5% had unmet home care needs. Prevalence of unmet needs was highest among recent immigrants (43.8%), compared with long-time immigrants (40.5%) and non-immigrants (32.7%). Adjusted odds of unmet needs was higher for both immigrant categories than non-immigrants, and stronger for long-time immigrants (OR = 1.58, 95% CI: 1.14, 2.20) than recent immigrants (OR = 1.42, 95% CI: 0.67, 3.00). The finding that immigrants are more likely to experience unmet home care needs, with a slight difference between recent and long-time immigrants, suggests home care access inequities exist between immigrants and non-immigrants, and among immigrants.

Impact of care level, setting and accommodation costs on a newly developed oral care nursing plan format for elderly patients with care needs - Results from a cross-sectional study.

OBJECTIVES: A new oral care nursing plan format for improved communication among dentists, nursing staff and caregivers has been developed in Germany. We aimed to (1) describe this plan, (2) investigate the prevalence of oral health problems among elderly patients with care needs documented by the plan, outline the recommendations in the plans and (3) investigate whether the accommodation costs or care needs of patients influenced oral care quality or the need for oral hygiene support documented within the plan. METHODS: In this cross-sectional trial, oral care nursing plans were collected from outpatient and inpatient care clinics. Items on the oral care nursing plan were divided into three areas (oral health, oral hygiene needs, and coordination needs and dental therapy) and were correlated with the care level and accommodation costs. RESULTS: Oral care nursing plans were collected from seven dentists (N = 747; 94.5% from inpatient and 5.5% from outpatient care). The plans enabled documentation of well-known oral health and hygiene problems among elderly patients. In their current form, the plans provided recommendations for obvious oral hygiene tasks such as toothbrushing or fluoridating, rather than specialized tasks such as nutritional advice or dry mouth asymptomatic therapeutic approaches. Although accommodation costs were associated with the need for oral hygiene support (not with oral care condition), the care level influenced both measures. CONCLUSIONS: The oral care nursing plan can facilitate documentation of oral health and hygiene among elderly individuals with care needs. Further clarification of the plan would help promote careful documentation by dentists.

Left behind again: Rural home health services in a Medicaid pediatric accountable care organization.

PURPOSE: To contrast trends in rural and urban pediatric home health care use among Medicaid enrollees. METHODS: Medicaid administrative claims data were used to assess differences in home health care use for child members in a large pediatric accountable care organization (ACO) in Ohio. Descriptive statistics assessed rural and urban differences in health care use over a 10-year period between 2010 and 2019. FINDINGS: Pediatric home health care use increased markedly in the low-income (CFC) and disabled (ABD) Medicaid categories. Over the past 10 years, CFC-enrolled children from urban communities have seen more home health visits, fewer emergency department (ED) visits, and more well child visits compared to rural CFC-enrolled children. Children enrolled due to disabilities in urban communities have also seen more home health visit use but fewer preventive care visits than their rural counterparts. CONCLUSIONS: Within a pediatric ACO, rural home health care use has remained relatively stagnant over a 10-year period, a stark contrast to increases in home health care use among comparable urban populations. There are likely multiple explanations for these differences, including overuse in urban communities, lack of access in rural communities, and changes to home health reimbursement. More can be done to improve rural home health access. Such improvement will likely necessitate large-scale changes to home health care delivery, workforce, and financing. Improvements should be evaluated for return-on-investment not only in terms of direct costs, that is, reduced inpatient or ED costs, but also in terms of patient and family quality-of-life or key indicators of child well-being such as educational attainment.

Competência de idosos cuidadores informais de pessoas em assistência domiciliar / Competencia de ancianos que se desempeñan como cuidadores informales de personas en cuidados domiciliarios / Competence of aged informal caregivers of people in home care

Resumo Objetivos analisar a estimativa condicional do conhecimento, adaptação e preparo nas competências de idosos que exercem o papel de cuidadores informais de pessoas dependentes de cuidado em assistência domiciliar. Método estudo transversal, realizado com idosos cuidadores informais, residentes no município de Maringá, Paraná, Brasil. A coleta de dados foi realizada entre maio e julho de 2019 com um instrumento que avalia as competências cognitivas, psicomotoras, emocionais e relacionais de cuidadores informais de pessoas dependentes de cuidado em assistência domiciliar. O instrumento é constituído por 14 itens e três construtos: conhecimento, adaptação e preparo, sendo a escala de resposta Likert de cinco pontos. Utilizou-se análise de regressão linear para tratamento das variáveis. Resultados participaram do estudo 101 idosos cuidadores informais, e as estimativas condicionais das competências cognitiva e relacional apresentaram maior correlação com adaptação e o preparo. O melhor conhecimento estima maior desenvolvimento da competência psicomotora e cognitiva nas práticas de cuidado. Conclusão e implicações para a prática os conceitos hipotéticos de conhecimento, adaptação e preparo explicam o melhor desempenho das competências cognitiva, relacional e psicomotora de idosos cuidadores informais. Este resultado possibilita o desenvolvimento de novas intervenções educativas aos idosos que desempenham o papel de cuidador informal.

Resumen Objetivos analizar la estimación condicional del conocimiento, adaptación y preparación en las habilidades de personas mayores que desempeñan el papel de cuidadores informales de personas dependientes de cuidados en el hogar. Método estudio transversal realizado con personas mayores que se desempeñan como cuidadores informales, residentes en la ciudad de Maringá, Paraná, Brasil. La recolección de datos se realizó entre mayo y julio de 2019 a través de un instrumento construido y validado que evalúa las habilidades de los cuidadores informales de personas dependientes de cuidados en el hogar. Se utilizó análisis de regresión lineal para tratar las variables. Resultados participaron del estudio 101 personas mayores, que obran como cuidadores informales y las estimaciones condicionales de las habilidades cognitivas y relacionales de las personas mayores mostraron mayor correlación con la adaptación y preparación. Un mejor conocimiento estima un mayor desarrollo de la competencia psicomotora y cognitiva de las personas mayores en las prácticas asistenciales. Conclusión e implicaciones para la práctica los conceptos hipotéticos de conocimiento, adaptación y preparación explican el mejor desempeño de las habilidades cognitivas, relacionales y psicomotoras de las personas mayores que actúan como cuidadores informales. Este resultado permite el desarrollo de nuevas intervenciones educativas para las personas mayores que desempeñan el papel de cuidadores informales.

Abstract Objectives to analyze the conditional estimate of knowledge, adaptation and preparation in the skills of aged people who play the role of informal caregivers of assistance-dependent individuals in home care. Method a cross-sectional study carried out with aged informal caregivers who live in the city of Maringá, Paraná, Brazil. Data collection was carried out between May and July 2019 through a constructed and validated instrument that assesses the skills of informal caregivers of assistance-dependent individuals in home care. Linear regression analysis was used to treat the variables. Results the study participants were 101 aged informal caregivers, in which the conditional estimates of the cognitive and relational skills of the aged person showed a greater correlation with adaptation and preparation. Better knowledge estimates greater development of the psychomotor and cognitive competence of the elderly in care practices. Conclusion and implications for the practice the hypothetical concepts of knowledge, adaptation and preparation explain the better performance of the cognitive, relational and psychomotor skills of aged informal caregivers. This result enables the development of new educational interventions for the elderly who play the role of informal caregivers.

Characterization of Home Care Services and care for children with special health care needs / Caracterización de los Servicios de Atención Domiciliar y el cuidado a los niños con necesidades especiales de salud / Caracterização dos Serviços de Atenção Domiciliar e o cuidado às crianças com necessidades especiais de saúde

ABSTRACT Objective: To characterize Home Care Services in the state of Santa Catarina, Brazil, and to know the care demands of children with special health care needs. Method: Descriptive, exploratory study with a quantitative approach. Data collection carried out through a questionnaire, via Google Forms, with professionals from seven Home Care Services, from April to July 2020. Data were organized in the software Excel and analyzed through descriptive statistics with frequency and percentage distribution. Results: Of the seven services participating in the study, in 85.7% the nurse is the teams' coordinator. Opening hours in most services are during the day, on weekdays and weekends, and all of them receive referrals from Primary Health Care teams. Regarding care demands, all children need psychomotor and social rehabilitation, 72.2% use oxygen therapy, 66.6% gastrostomy, 55.5% tracheostomy, and 50% mechanical ventilation. Conclusion: Home care presents complexities due to chronic conditions and the use of technological devices. Thus, home care teams are fundamental in the assistance and training of family members/caregivers for children home care.

RESUMEN Objetivo: Caracterizar los Servicios de Atención Domiciliar en el estado de Santa Catarina y conocer las demandas de cuidado a los niños con necesidades especiales de salud. Método: Estudio descriptivo, exploratorio, de abordaje cuantitativo. Colecta de datos realizada por medio de cuestionario, vía Google Forms, con profesionales de siete Servicios de Atención Domiciliar, de abril a julio de 2020. Los datos fueron organizados en el Programa Excel y analizados a través de estadística descriptiva con distribución de frecuencia y porcentaje. Resultados: De los siete servicios que participaron del estudio, en el 85,7% de ellos el enfermero es el coordinador de los equipos. El horario de en la mayoría de los servicios es diurno, en días útiles y fines de semana y todos son direccionados por los equipos de Atención Primaria a la Salud. En relación a las demandas de cuidados, todos los niños necesitan de rehabilitación psicomotora y social, el 72,2% utilizan oxigenoterapia, el 66,6% de gastrostomía, el 55,5% de traqueotomía y el 50% de ventilación mecánica. Conclusión: El cuidado domiciliar presenta complexidades provenientes de condiciones crónicas y uso de dispositivos tecnológicos. Así, equipos de atención domiciliar son fundamentales en la asistencia y capacitación de familiares/cuidadores para el cuidado domiciliar a los niños.

RESUMO Objetivo: Caracterizar os Serviços de Atenção Domiciliar no estado de Santa Catarina e conhecer as demandas de cuidado das crianças com necessidades especiais de saúde. Método: Estudo descritivo, exploratório, de abordagem quantitativa. Coleta de dados realizada por meio de questionário, via Google Forms, com profissionais de sete Serviços de Atenção Domiciliar, de abril a julho de 2020. Os dados foram organizados no programa Excel e analisados pela estatística descritiva com distribuição de frequência e percentual. Resultados: Dos sete serviços que participaram do estudo, em 85,7% o enfermeiro é o coordenador das equipes. O horário de funcionamento na maioria dos serviços é diurno, em dias úteis e finais de semana e todos recebem encaminhamentos de equipes da Atenção Primária à Saúde. Em relação às demandas de cuidados, todas as crianças necessitam de reabilitação psicomotora e social, 72,2% fazem uso de oxigenoterapia, 66,6% de gastrostomia, 55,5% de traqueostomia e 50% de ventilação mecânica. Conclusão: O cuidado domiciliar apresenta complexidades em decorrência de condições crônicas e uso de dispositivos tecnológicos. Assim, equipes de atenção domiciliar são fundamentais na assistência e capacitação de familiares/cuidadores para o cuidado domiciliar às crianças.

Health professionals' subjectivation towards end of life and death in home care service / Subjetivação dos profissionais de saúde no fim da vida e morte no serviço domiciliar / Subjetivación de los profesionales de la salud al final de la vida y muerte en el servicio a domicilio

ABSTRACT Objectives: to analyze the modes of subjectification of health professionals towards end of life and death in a home care service. Methods: this is qualitative research carried out in a home care service at a teaching hospital in southern Brazil, with 12 health professionals. Participant observation and semi-structured interviews were used for data collection, from April to September 2018. Data were analyzed based on Foucault's concept of power and subjectivation. Results: professionals are sensitized by moral, spiritual and palliative care discourses, as well as experiences that constitute them subjects who modify their ways of life and professional practice based on the relation with death. Final Considerations: the discursive network of palliative care is internalized by professionals, who carry out their practices with behaviors aimed at promoting "a good death".

RESUMO Objetivos: analisar os modos de subjetivação dos profissionais de saúde em relação ao fim da vida e à morte em um serviço de atenção domiciliar. Métodos: pesquisa qualitativa, realizada em um serviço de atenção domiciliar em um hospital universitário do sul do Brasil, com 12 profissionais de saúde. Para a coleta de dados, utilizou-se observação participante e entrevistas semiestruturadas, de abril a setembro de 2018. Os dados foram analisados a partir do conceito de poder e subjetivação de Foucault. Resultados: os profissionais são sensibilizados pelos discursos morais, espirituais e dos cuidados paliativos, bem como pelas experiências que os constituem sujeitos que modificam seus modos de vida e prática profissional a partir da relação com a morte. Considerações Finais: a rede discursiva dos cuidados paliativos é internalizada pelos profissionais, que realizam suas práticas com condutas voltadas à promoção de "uma boa morte".

RESUMEN Objetivos: analizar los modos de subjetivación de los profesionales de la salud hacia el final de la vida y la muerte en un servicio de atención domiciliaria. Métodos: investigación cualitativa realizada en un servicio de atención domiciliaria en un hospital escuela en el sur de Brasil, con 12 profesionales de la salud. Para la recolección de datos se utilizó la observación participante y entrevistas semiestructuradas, de abril a septiembre de 2018. Los datos fueron analizados a partir del concepto de poder y subjetivación de Foucault. Resultados: los profesionales son sensibilizados por discursos morales, espirituales y de cuidados paliativos, así como por vivencias que los constituyen sujetos que modifican sus modos de vida y ejercicio profesional a partir de la relación con la muerte. Consideraciones Finales: la red discursiva de los cuidados paliativos es interiorizada por los profesionales, que realizan sus prácticas con conductas encaminadas a promover "una buena muerte".

A Comprehensive Assessment of Informal Caregivers of Patients in a Primary Healthcare Home-Care Program.

Studies of the characteristics of informal caregivers and associated factors have focused on care-receiver disease or caregiver social and psychological traits; however, an integral description may provide better understanding of informal caregivers' problems. A multicenter cross-sectional study in primary healthcare centers was performed in Barcelona (Spain). Participants were a random sample of informal caregivers of patients in a home-care program. Primary outcomes were health-related quality of life and caregiver burden, and related factors were sociodemographic data, clinical and risk factors, social support and social characteristics, use of healthcare services, and care receivers' status. In total, 104 informal caregivers were included (mean age 68.25 years); 81.73% were female, 54.81% were retired, 58.65% had high comorbidity, and 48.08% of care receivers had severe dependence. Adjusted multivariate regression models showed health-related quality of life and the caregivers' burden were affected by comorbidity, age, time of care, and dependency of care receiver, while social support and depression also showed relative importance. Aging, chronic diseases, and comorbidity should be included when explaining informal caregivers' health status and wellbeing. The effectiveness of interventions to support informal caregivers should comprehensively evaluate caregivers when designing programs, centering interventions on informal caregivers and not care receivers' conditions.