An Overview of Specialist Services for Huntington's Disease in the United Kingdom.

BACKGROUND: Huntington's disease (HD) is a rare inherited neurodegenerative disorder characterized by complex evolving needs that change as the condition progresses. There is limited understanding about the organization of HD clinical services and their resourcing in the United Kingdom (UK). OBJECTIVE: To understand the organization and resourcing of specialist HD services for people with HD (PwHD) in the UKMethods:This cross-sectional study collected quantitative data via on online survey, and qualitative data via telephone semi-structured interviews. Descriptive statistics were used to describe quantitative outcomes, and qualitative results were analyzed using content analysis. RESULTS: A total of 31 specialist services for HD were identified. Of the 27 services that completed the online survey, 23 had an active multidisciplinary team of healthcare professionals (HCPs) and were led primarily by a mental health trust (26%) or tertiary referral hospital (26%). Specialist services offered outpatient clinics (96%), outreach in the community (74%), telemedicine (70%), inpatient beds (26%) and satellite clinics (26%). Many services indicated that their capacity (ability to see patients as often as needed with current resources) was difficult, with some services reporting more difficulty at the early or later stages of HD. Key resourcing gaps were identified with access to facilities, HCPs and referral networks. CONCLUSIONS: This research highlights the variation in organization and capacity within individual HD services as well as current resourcing and gaps in access that influence this capacity. Further research should be done to understand the impact of service organization and current resourcing gaps in access on the quality of care provided for PwHD in the UK.

Atenção Primária à Saúde em municípios rurais remotos brasileiros: contexto, organização e acesso à atenção integral no Sistema Único de Saúde / Primary Health Care in remote rural municipalities: context, organization, and access to integral care in the Brazilian National Health System

Resumo A despeito da diversidade socioespacial, localidades rurais remotas têm em comum pequenos povoados dispersos em um vasto território, populações isoladas e longas distâncias em relação aos centros urbanos. O objetivo do estudo é analisar as especificidades da organização e do acesso à atenção primária à saúde (APS) no Sistema Único de Saúde (SUS) em municípios rurais remotos (MRR) brasileiros. Para tanto, realizou-se um estudo de abordagem qualitativa, com base em estudo de casos múltiplos em 27 MRR. Foi feita uma análise de conteúdo temática de 211 entrevistas semiestruturadas com gestores e profissionais de saúde, e uma triangulação de informações para explorar e reconhecer as formas de organização, estratégias e desafios para o acesso à saúde. Os resultados indicam que: as características dos contextos rurais remotos condicionam a provisão da APS; há diferenças nas formas de ofertar ações de saúde e maiores falhas de cobertura assistencial nas áreas mais rarefeitas e remotas dos municípios; existem contradições entre o financiamento da APS nacional e as características dos territórios marcado por rarefação populacional e longas distâncias; e a escassez da força de trabalho é um desafio comum nos municípios estudados. É necessário, portanto, considerar as características territoriais, sociais e de acesso aos serviços de saúde para a proposição de políticas públicas que atendam às necessidades dos MRR.

Abstract Despite the socio-spatial diversity, remote rural locations have in common small villages dispersed over a vast territory, isolated populations, and long distances from urban centers. The objective of the study is to analyze the specificities of the organization and access to primary health care (PHC) in the Brazilian National Health System (SUS) in remote rural municipalities (MRR). To that end a study with a qualitative approach, based on a multiple case study in 27 MRR was carried out. Thematic content analysis of 211 semi-structured interviews with managers and health professionals and a triangulation of information to explore and recognize the forms of organization, strategies, and challenges for the access to health were performed. The results indicate that: the characteristics of remote rural contexts condition the provision of PHC; there are differences in the ways of offering health actions and greater gaps in care coverage in the most rarefied and remote areas of the municipalities; there are contradictions between national PHC funding and the characteristics of territories marked by sparcely populated areas and long distances; and the shortage of the workforce is a common challenge among the cities studied. It is, thus, necessary to consider the territorial, social, and access characteristics to health services to propose public policies that meet the needs of the MRR.

Effect of integrating maternal and child health services, nutrition and family planning services on postpartum family planning uptake at 6 months post-partum in Burkina Faso, Cote d'Ivoire and Niger: a quasi-experimental study protocol.

BACKGROUND: Although several interventions integrating maternal, neonatal, child health and nutrition with family planning have been implemented and tested, there is still limited evidence on their effectiveness to guide program efforts and policy action on health services integration. This study aims to assess the effectiveness of a service delivery model integrating maternal and child health services, nutrition and family planning services, compared with the general standard of care in Burkina Faso, Cote d'Ivoire, and Niger. METHODS: This is a quasi experimental study with one intervention group and one control group of 3 to 4 health facilities in each country. Each facility was matched to a control facility of the same level of care that had similar coverage on selected reproductive health indicators such as family planning and post-partum family planning. The study participants are pregnant women (up to 28 weeks of gestational age) coming for their first antenatal care visit. They will be followed up to 6 months after childbirth, and will be interviewed at each antenatal visit and also during visits for infant vaccines. The analyzes will be carried out by intention to treat, using generalized linear models (binomial log or log Poisson) to assess the effect of the intervention on the ratio of contraceptive use prevalence between the two groups of the study at a significance level of 5%, while taking into account the cluster effect and adjusting for potential confounding factors (socio-demographic characteristics of women unevenly distributed at inclusion). DISCUSSION: This longitudinal study, with the provision of family planning services integrated into the whole maternal care continuum, a sufficiently long observation time and repeated measurements, will make it possible to better understand the timeline and the factors influencing women's decision-making on the use of post-partum family planning services. The results will help to increase the body of knowledge regarding the impact of maternal and child health services integration on the utilization of post-partum family planning taking into account the specific context of sub-Saharan Africa French speaking countries where such information is very needed.

One strategy to improve the utilization of health services by mothers and their children is the integration of maternal and child health services. For instance, a pregnant woman coming for an antenatal care visit would also receive counseling on post-partum family planning services and maternal nutrition. Similarly, a woman coming for her infant's vaccines would be offered counseling on post-partum family planning, maternal nutrition and breastfeeding. Although several interventions have been implemented and tested, there is still limited evidence on the conditions and factors required for successful maternal and child health services integration strategies. This study aims to assess the effectiveness of an intervention integrating maternal and child health services, nutrition and family planning services. For the purpose of the evaluation, 2 distincts groups of health facilities will be selected in each country, one group of 3 or 4 health facilities where the intervention will be implemented, and another group of 3 or 4 health facilities with the general standard of care. The study participants are pregnant women (up to 28 weeks of gestational age), coming for their first antenatal care visit, who will be followed up to 6 months after childbirth.The analyzes will be carried out to assess the effect of the intervention on contraceptive use prevalence between the two groups of health facilities. This study will make it possible to better understand the timeline and the factors influencing women's decision-making on the use of post-partum family planning services.

Description of organizational and clinician characteristics of primary dementia care in Canada: a multi-method study.

BACKGROUND: Organizational and clinician characteristics are important considerations for the implementation of evidence-based recommendations into primary care practice. The introduction of Canadian dementia practice guidelines and Alzheimer strategies offers a unique context to study which of the organizational and clinician characteristics align with good quality care in primary care practices. METHODS: To evaluate the quality of dementia care, we carried out a retrospective chart review in randomly selected patients with a diagnosis of dementia and who had a visit during a 9-month period in 33 primary care practices. We collected data on indicators that were based on existing Canadian evidence-based recommendations to measure a quality of dementia care score. In addition, four questionnaires were administered: two questionnaires to evaluate the organizational characteristics of the practices (dementia-specific and general organization) and two to evaluate the clinician characteristics (one for family physicians and one for nurses). Primary care practices were stratified into tertiles based on their average quality of dementia care score (low, moderate, high). The differences between the groups organizational and clinician questionnaires scores were analyzed descriptively and visually. RESULTS: The mean overall scores for each questionnaire were higher in the high quality of dementia care group. When looking at the breakdown of the overall score into each characteristic, the high-quality group had a higher average score for the dementia-specific organizational characteristics of "access to and coordination with home and community services", "financial support", "training", "coordination and continuity within the practice", and "caregiver support and involvement". The characteristic "Leadership" showed a higher average score for the moderate and high-quality groups than the low-quality group. In both clinician questionnaires, the high group scored better in "attitudes towards the Alzheimer's plan" than the other two groups. CONCLUSIONS: These results suggest that investing in organizational characteristics specifically aimed at dementia care is a promising avenue to improve quality of dementia care in primary care. These results may be useful to enhance the implementation of evidence-based practices and improve the quality of dementia care.

Standardized care pathways for patients with suspected urinary bladder cancer: the Swedish experience.

OBJECTIVES: To compare time intervals to diagnosis and treatment, tumor characteristics, and management in patients with primary urinary bladder cancer, diagnosed before and after the implementation of a standardized care pathway (SCP) in Sweden. MATERIALS AND METHODS: Data from the Swedish National Register of Urinary Bladder Cancer was studied before (2011-2015) and after (2016-2019) SCP. Data about time from referral to transurethral resection of bladder tumor (TURBT), patients and tumor characteristics, and management were analyzed. Subgroup analyses were performed for cT1 and cT2-4 tumors. RESULTS: Out of 26,795 patients, median time to TURBT decreased from 37 to 27 days after the implementation of SCP. While the proportion of cT2-T4 tumors decreased slightly (22-21%, p < 0.001), this change was not stable over time and the proportions cN + and cM1 remained unchanged. In the subgroups with cT1 and cT2-4 tumors, the median time to TURBT decreased and the proportions of patients discussed at a multidisciplinary team conference (MDTC) increased after SCP. In neither of these subgroups was a change in the proportions of cN + and cM1 observed, while treatment according to guidelines increased after SCP in the cT1 group. CONCLUSION: After the implementation of SCP, time from referral to TURBT decreased and the proportion of patients discussed at MDTC increased, although not at the levels recommended by guidelines. Thus, our findings point to the need for measures to increase adherence to SCP recommendations and to guidelines.

A systematic review of the preventive practices for psychosocial risks in Ibero-American health centers. / Revisión sistemática de las prácticas preventivas para riesgos psicosociales en centros sanitarios iberoamericanos.

OBJECTIVE: To identify preventive practices for psychosocial risks in Ibero-American health centers, including gaps in evidence, and to synthesize effectiveness according to dimensions and level of intervention. METHODS: Design: a global evidence mapping type systematic review. Data sources: Cochrane Central Register of Controlled Trials, Health Systems Evidence, The Campbell Collaboration, PubMed, BioMed Central, CINAHL, EMBASE, Lilacs, and Health Evidence Portal. Review methods: Ad hoc descriptors were used to identify randomized controlled trials and other types of studies. The search was done between January 2003 and March 2020, limited to the English, Portuguese, and Spanish. The PRISMA-P protocol was applied to register the synthesis of the included studies. The quality of the evidence was evaluated according to the GRADE protocol and by three external evaluators. RESULTS: A total of 8959 studies were identified, and, after screening and eligibility assessment, 18 studies were included in the systematic review, involving 1777 workers from 176 health centers in Spain, Portugal, Mexico, Nicaragua, Colombia, Brazil, Peru, and Argentina. Half of the included studies are randomized controlled trials; 37.2% of the included studies were deemed of moderate quality, while 18.7% were of high quality. CONCLUSIONS: Preventive practices with strong evidence correspond to policies that improve the working conditions of night hospital work. We found low-quality evidence in six preventive dimensions for the practices based on multi-component interventions. We found evidence gaps in five domains of preventive interventions for psychosocial risks.

OBJETIVO: Identificar las prácticas preventivas para riesgos psicosociales en centros sanitarios iberoamericanos, incluyendo los vacíos de la evidencia, y sintetizar la efectividad según dimensión y nivel de intervención. MÉTODOS: Diseño: revisión sistemática de tipo global evidence mapping. Fuentes de datos: Cochrane Central Register of Controlled Trials, Health Systems Evidence, The Campbell Collaboration, PubMed, BioMed Central, CINAHL, EMBASE, Lilacs y Health Evidence Portal. Métodos de la revisión: se emplearon descriptores ad hoc para identificar ensayos controlados aleatorios y otros tipos de estudio. El período de búsqueda comprendió entre enero de 2003 y marzo de 2020, limitado a los idiomas inglés, portugués y español. Para el registro de síntesis de estudios incluidos se aplicó el protocolo PRISMA-P. La calidad de la evidencia fue evaluada según protocolo GRADE por tres evaluadores externos. RESULTADOS: Se identificaron 8959 estudios y, tras el tamizaje y análisis de elegibilidad, se admitieron 18 estudios para revisión sistemática que involucran a 1777 trabajadores de 176 centros sanitarios de España, Portugal, México, Nicaragua, Colombia, Brasil, Perú y Argentina. La mitad de los estudios incluidos son ensayos controlados aleatorios. Las frecuencias de desenlaces predominantes son de calidad moderada (37,2%), y las de alta calidad son 18,7%. CONCLUSIONES: Las prácticas preventivas con alta calidad de evidencias corresponden a las políticas para mejorar condiciones laborales del trabajo hospitalario nocturno. Prácticas basadas en intervenciones multicomponentes presentan evidencias de baja calidad en cinco dimensiones preventivas. Los vacíos de la evidencia están en seis dominios de la intervención preventiva para los riesgos psicosociales.

Group Prenatal Care in Mexico: perspectives and experiences of health personnel / Atención Prenatal en Grupo en México: perspectivas y experiencias del personal de salud

ABSTRACT OBJECTIVE: Identify barriers and facilitators to implementing the Group Prenatal Care model in Mexico (GPC) from the health care personnel's perspective. METHODS: We carried out a qualitative descriptive study in four clinics of the Ministry of Health in two states of Mexico (Morelos and Hidalgo) from June 2016 to August 2018. We conducted 11 semi-structured interviews with health care service providers, and we examined their perceptions and experiences during the implementation of the GPC model. We identified the barriers and facilitators for its adoption in two dimensions: a) structural (space, resources, health personnel, patient volume, community) and b) attitudinal (motivation, leadership, acceptability, address problems, work atmosphere and communication). RESULTS: The most relevant barriers reported at the structural level were the availability of physical space in health units and the work overload of health personnel. We identified the difficulty in adopting a less hierarchical relationship during the pregnant women's care at the attitudinal level. The main facilitator at the attitudinal level was the acceptability that providers had of the model. One specific finding for Mexico's implementation context was the resistance to change the doctor-patient relationship; it is difficult to abandon the prevailing hierarchical model and change to a more horizontal relationship with pregnant women. CONCLUSION: Analyzing the GPC model's implementation in Mexico, from the health care personnel's perspective, has revealed barriers and facilitators similar to the experiences in other contexts. Future efforts to adopt the model should focus on timely attention to identified barriers, especially those identified in the attitudinal dimension that can be modified by regular health care personnel training.

RESUMEN OBJETIVO Identificar barreras y facilitadores de la implementación del modelo de Atención Prenatal en Grupo en México (APG), desde la perspectiva del personal de salud. MÉTODOS Estudio cualitativo descriptivo en cuatro clínicas de la Secretaría de Salud en dos estados de México (Morelos e Hidalgo) de junio de 2016 a agosto de 2018. Se realizaron 11 entrevistas semi-estructuradas a prestadores de servicios de salud. Se exploraron sus percepciones y experiencias durante la implementación del modelo de APG. Se identificaron barreras y facilitadores para su adopción en dos dimensiones: a) estructurales (espacio, recursos, personal de salud, volumen de pacientes, comunidad) y b) actitudinales (motivación, liderazgo, aceptabilidad, abordaje de problemas, clima y comunicación). RESULTADOS Las barreras más relevantes reportadas en el nivel estructural fueron la disponibilidad de espacio físico en las unidades y la sobrecarga de trabajo del personal de salud. Se identificó la dificultad para adoptar una relación menos jerárquica durante la atención a las gestantes en el nivel actitudinal. El principal facilitador a nivel actitudinal fue la aceptabilidad que los prestadores tienen del modelo. Un hallazgo específico para el contexto de la implementación en México fue la resistencia al cambio en la relación médico-paciente; resulta difícil abandonar el modelo jerárquico prevaleciente y cambiar a una relación más horizontal con las gestantes. CONCLUSIONES El análisis de la implementación del modelo de APG en México, desde la perspectiva del personal de salud, ha evidenciado barreras y facilitadores similares a las experiencias en otros contextos. Esfuerzos futuros para la adopción del modelo deberán enfocarse en la atención oportuna de las barreras identificadas, sobre todo aquellas señaladas en la dimensión actitudinal que pueden ser modificadas a través de capacitaciones continuas al personal de salud.

Revisión sistemática de las prácticas preventivas para riesgos psicosociales en centros sanitarios iberoamericanos / A systematic review of the preventive practices for psychosocial risks in Ibero-American health centers

OBJETIVO: Identificar las prácticas preventivas para riesgos psicosociales en centros sanitarios iberoamericanos, incluyendo los vacíos de la evidencia, y sintetizar la efectividad según dimensión y nivel de intervención. Métodos: Diseño: revisión sistemática de tipo global evidence mapping. FUENTES DE DATOS: Cochrane Central Register of Controlled Trials, Health Systems Evidence, The Campbell Collaboration, PubMed, BioMed Central, CINAHL, EMBASE, Lilacs y Health Evidence Portal. MÉTODOS DE LA REVISIÓN: se emplearon descriptores ad hoc para identificar ensayos controlados aleatorios y otros tipos de estudio. El período de búsqueda comprendió entre enero de 2003 y marzo de 2020, limitado a los idiomas inglés, portugués y español. Para el registro de síntesis de estudios incluidos se aplicó el protocolo PRISMA-P. La calidad de la evidencia fue evaluada según protocolo GRADE por tres evaluadores externos. RESULTADOS: Se identificaron 8959 estudios y, tras el tamizaje y análisis de elegibilidad, se admitieron 18 estudios para revisión sistemática que involucran a 1777 trabajadores de 176 centros sanitarios de España, Portugal, México, Nicaragua, Colombia, Brasil, Perú y Argentina. La mitad de los estudios incluidos son ensayos controlados aleatorios. Las frecuencias de desenlaces predominantes son de calidad moderada (37,2%), y las de alta calidad son 18,7%. CONCLUSIONES: Las prácticas preventivas con alta calidad de evidencias corresponden a las políticas para mejorar condiciones laborales del trabajo hospitalario nocturno. Prácticas basadas en intervenciones multicomponentes presentan evidencias de baja calidad en cinco dimensiones preventivas. Los vacíos de la evidencia están en seis dominios de la intervención preventiva para los riesgos psicosociales.

OBJECTIVE: To identify preventive practices for psychosocial risks in Ibero-American health centers, including gaps in evidence, and to synthesize effectiveness according to dimensions and level of intervention. METHODS: Design: a global evidence mapping type systematic review. DATA SOURCES: Cochrane Central Register of Controlled Trials, Health Systems Evidence, The Campbell Collaboration, PubMed, BioMed Central, CINAHL, EMBASE, Lilacs, and Health Evidence Portal. REVIEW METHODS: Ad hoc descriptors were used to identify randomized controlled trials and other types of studies. The search was done between January 2003 and March 2020, limited to the English, Portuguese, and Spanish. The PRISMA-P protocol was applied to register the synthesis of the included studies. The quality of the evidence was evaluated according to the GRADE protocol and by three external evaluators. RESULTS: A total of 8959 studies were identified, and, after screening and eligibility assessment, 18 studies were included in the systematic review, involving 1777 workers from 176 health centers in Spain, Portugal, Mexico, Nicaragua, Colombia, Brazil, Peru, and Argentina. Half of the included studies are randomized controlled trials; 37.2% of the included studies were deemed of moderate quality, while 18.7% were of high quality. CONCLUSIONS: Preventive practices with strong evidence correspond to policies that improve the working conditions of night hospital work. We found low-quality evidence in six preventive dimensions for the practices based on multi-component interventions. We found evidence gaps in five domains of preventive interventions for psychosocial risks.

Barriers to and solutions for addressing insufficient professional interpreter use in primary healthcare.

BACKGROUND: The aim of this nationwide study was to investigate barriers to adequate professional interpreter use and to describe existing initiatives and identify key factors for successful interpreter policies in primary care, using Switzerland as a case study. METHODS: Adult and paediatric primary care providers were invited to participate in an online cross-sectional questionnaire-based study. All accredited regional interpreter agencies were contacted first by email and, in the absence of a reply, by mail and then by phone. Local as well as the national health authorities were asked about existing policies. RESULTS: 599 primary care physicians participated. Among other reasons, physicians identified cumbersome organization (58.7%), absent financial coverage (53.7%) and lack of knowledge on how to arrange interpreter interventions (44%) as main barriers. The odds of organising professional interpreters were 6.6-times higher with full financial coverage. Some agencies confirmed difficulties providing professional interpreters for certain languages at a timely manner. Degrees of coverage of professional interpreter costs (full coverage to none) and organization varied between regions resulting in different levels of unmet needs. CONCLUSIONS: Professional interpreter use can be improved through the following points: increase awareness and knowledge of primary care providers on interpreter use and organization, ensure financial coverage, as well as address organizational aspects. Examples of successful interventions exist.

Midwives' perspectives of continuity based working in the UK: A cross-sectional survey.

OBJECTIVE: UK policy is advocating continuity of midwife throughout the antenatal, intrapartum and postnatal period in order to improve outcomes. We explored the working patterns that midwives are willing and able to adopt, barriers to change, and what would help midwives to work in continuity models of care. DESIGN: A cross-sectional survey. SETTING: 27 English maternity providers in the seven geographically-based 'Early Adopter' sites, which have been chosen to fast-track national policy implementation. PARTICIPANTS: All midwives working in the 'Early Adopter' sites were eligible to take part. METHOD: Anonymous online survey disseminated by local and national leaders, and social media, in October 2017. Descriptive statistics were calculated for quantitative survey responses. Qualitative free text responses were analysed thematically. FINDINGS: 798 midwives participated (estimated response rate 20% calculated using local and national NHS workforce headcount data for participating sites). Being willing or able to work in a continuity model (caseloading and/or team) was lowest where this included intrapartum care in both hospital and home settings (35%, n = 279). Willingness to work in a continuity model of care increased as the range of intrapartum care settings covered decreased (home births only 45%, n = 359; no intrapartum care at all 54%, n = 426). A need to work on the same day each week was reported by 24% (n = 188). 31% (n = 246) were currently working 12 h shifts only, while 37% (n = 295) reported being unable to work any on-calls and/or nights. Qualitative analysis revealed multiple barriers to working in continuity models: the most prominent was caring responsibilities for children and others. Midwives suggested a range of approaches to facilitate working differently including concessions in the way midwife roles are organised, such as greater autonomy and choice in working patterns. CONCLUSIONS: Findings suggest that many midwives are not currently able or willing to work in continuity models, which includes care across antenatal, intrapartum and postnatal periods as recommended by UK policy. IMPLICATIONS FOR PRACTICE: A range of approaches to providing continuity models should be explored as the implementation of 'Better Births' takes place across England. This should include studies of the impact of the different models on women, babies and midwives, along with their practical scalability and cost.

Cuba's Strategy Toward Universal Health.

After 40 years of the Alma Ata Declaration on primary health care, the Pan American Journal of Public Health published an actualized overview of Cuban policies on health and well-being. It describes the longstanding and successful experience of this socialist country, developed in adverse and complex circumstances. The Cuban case remains one of the leading examples of a comprehensive governmental approach toward population health and well-being. The analysis underscores the essential role of continued political will toward population health.

Health promotion for the aging workforce in Poland.

OBJECTIVES: The aging of the workforce is an issue that calls for concrete measures to promote the health of older workers. This study reports on the results of the European "ProHealth65+" research project interventions conducted in Poland in relation to workplace health promotion for older workers (WHPOW) and the institutions involved in these programs. MATERIAL AND METHODS: A three-stage search of peer-reviewed and grey literature on the WHPOW in Poland. RESULTS: A total of 59 WHPOW programs were retrieved in Poland in the observation period (2000-2015). Most of these aimed at improving the Qualification and Training or at the Work Climate and attitudes toward older workers. The promotion, organization, and funding of these activities were carried out mainly by supra-national and governmental bodies, enterprises and employers, and educational and trainee institutions. CONCLUSIONS: Although there is great commitment to the medical surveillance of workers on the part of the Polish occupational health service, our search detected a relatively low number of the WHPOW initiatives. Greater efforts should be made to introduce strategies for addressing aging of the workforce. Int J Occup Med Environ Health 2018;31(6):753-761.

Identification of service improvement opportunities in an Australian community transition care program.

BACKGROUND: Transition care programs (TCPs) are designed to optimise functional recovery and independence in older adults post-hospitalisation. These programs are under high demand, and understanding inefficiencies in patient flow are a key step towards service improvement. AIMS: To identify service improvement opportunities in an Australian community TCP service. METHODS: An in-depth retrospective study of 113 community TCP clients. RESULTS: TCP occupancy was high (94%) and client functional level improved across the program. Inefficiencies experienced included: admission delays to the program; low completion rates (61%) predominantly due to re-hospitalisation; variable response times by Allied Health services (5-20 days); and discharge delays-the latter attributed to waiting for services such as Home Care Packages through Non-Government Organisations. DISCUSSION: This study identified several opportunities for service improvement in a community TCP service. Health practitioners should be regularly provided with up-to-date information on efficiency of TCP services.

Mental health in primary care: an evaluation using the Item response theory / Saúde mental na atenção básica: uma avaliação por meio da teoria da resposta ao Item

ABSTRACT OBJECTIVE To determine the items of the Brazilian National Program for Improving Access and Quality of Primary Care that better evaluate the capacity to provide mental health care. METHODS This is a cross-sectional study carried out using the Graded Response Model of the Item Response Theory using secondary data from the second cycle of the National Program for Improving Access and Quality of Primary Care, which evaluates 30,523 primary care teams in the period from 2013 to 2014 in Brazil. The internal consistency, correlation between items, and correlation between items and the total score were tested using the Cronbach's alpha, Spearman's correlation, and point biserial coefficients, respectively. The assumptions of unidimensionality and local independence of the items were tested. Word clouds were used as one way to present the results. RESULTS The items with the greatest ability to discriminate were scheduling of the agenda according to risk stratification, keeping of records of the most serious cases of users in psychological distress, and provision of group care. The items that required a higher level of mental health care in the parameter of location were the provision of any type of group care and the provision of educational and mental health promotion activities. Total Cronbach's alpha coefficient was 0.87. The items that obtained the highest correlation with total score were the recording of the most serious cases of users in psychological distress and scheduling of the agenda according to risk stratification. The final scores obtained oscillated between -2.07 (minimum) and 1.95 (maximum). CONCLUSIONS There are important aspects in the discrimination of the capacity to provide mental health care by primary health care teams: risk stratification for care management, follow-up of the most serious cases, group care, and preventive and health promotion actions.

RESUMO OBJETIVO Determinar os itens do Programa Nacional de Melhoria do Acesso e da Qualidade da Atenção Básica que melhor avaliam a capacidade de oferta de cuidados em saúde mental. MÉTODOS Estudo transversal efetuado por meio do Modelo de Resposta Gradual da Teoria da Resposta ao Item, utilizando dados secundários do segundo ciclo do Programa Nacional de Melhoria do Acesso e da Qualidade da Atenção Básica, tendo sido avaliadas 30.523 equipes de atenção básica no período de 2013 a 2014. A consistência interna, a correlação entre os itens e dos itens com o escore total foram testadas usando os coeficientes alfa de Cronbach, correlação de Spearman e ponto bisserial, respectivamente. Foram testados os pressupostos de unidimensionalidade e independência local dos itens. Utilizaram-se como uma das formas de apresentação dos resultados as nuvens de palavras. RESULTADOS Programar a agenda de acordo com a estratificação de risco, manter registro dos casos mais graves de usuários em sofrimento psíquico e ofertar algum atendimento em grupo foram os itens com maior capacidade de discriminação. Ofertar alguma modalidade de atendimento em grupo e ofertar ações educativas e de promoção de saúde mental foram os itens que requereram maior nível de oferta de cuidados em saúde mental no parâmetro de locação. O coeficiente alfa de Cronbach total foi 0,87. Realizar o registro dos casos mais graves de usuários em sofrimento psíquico e programar a agenda de acordo com a estratificação de risco foram os itens que obtiveram maior correlação com o escore total. Os escores finais obtidos oscilaram entre -2,07 (mínimo) e 1,95 (máximo). CONCLUSÕES São aspectos relevantes na discriminação da capacidade de ofertar cuidados em saúde mental pelas equipes de atenção básica: a estratificação do risco para gestão do cuidado, o acompanhamento dos casos mais graves, o atendimento em grupo e as ações preventivas e de promoção da saúde.

The three paradoxes of patient flow: an explanatory case study.

BACKGROUND: Health systems in many jurisdictions struggle to reduce Emergency Department congestion and improve patient flow across the continuum of care. Flow is often described as a systemic issue requiring a "system approach"; however, the implications of this idea remain poorly understood. Focusing on a Canadian regional health system whose flow problems have been particularly intractable, this study sought to determine what system-level flaws impede healthcare organizations from improving flow. METHODS: This study drew primarily on qualitative data from in-depth interviews with 62 senior, middle and departmental managers representing the Region, its programs and sites; quantitative analysis of key flow indicators (1999-2012) and review of ~700 documents furnished important context. Examination of the interview data revealed that the most striking feature of the dataset was contradiction; accordingly, a technique of dialectical analysis was developed to examine observed contradictions at successively deeper levels. RESULTS: Analysis uncovered three paradoxes: "Many Small Successes and One Big Failure" (initiatives improve parts of the system but fail to fix underlying system constraints); "Your Innovation Is My Aggravation" (local innovation clashes with regional integration); and most critically, "Your Order Is My Chaos" (rules that improve service organization for my patients create obstacles for yours). This last emerges when some entities (sites/hospitals) define their patients in terms of their location in the system, while others (regional programs) define them in terms of their needs/characteristics. As accountability for improving flow was distributed among groups that thus variously defined their patients, local efforts achieved little for the overall system, and often clashed with each other. These paradoxes are indicative of a fundamental antagonism between the system's parts and the whole. CONCLUSION: An accretion of flow initiatives in all parts of the system will never add up to a system approach, and may indeed perpetuate the paradoxes. What is needed is a coherent strategy of defining patient populations by needs, analyzing their entire trajectories of care, and developing consistent processes to better meet those needs.

The mental health care model in Brazil: analyses of the funding, governance processes, and mechanisms of assessment / Modelo de atenção à saúde mental do Brasil: análise do financiamento, governança e mecanismos de avaliação

ABSTRACT OBJECTIVE This study aims to analyze the current status of the mental health care model of the Brazilian Unified Health System, according to its funding, governance processes, and mechanisms of assessment. METHODS We have carried out a documentary analysis of the ordinances, technical reports, conference reports, normative resolutions, and decrees from 2009 to 2014. RESULTS This is a time of consolidation of the psychosocial model, with expansion of the health care network and inversion of the funding for community services with a strong emphasis on the area of crack cocaine and other drugs. Mental health is an underfunded area within the chronically underfunded Brazilian Unified Health System. The governance model constrains the progress of essential services, which creates the need for the incorporation of a process of regionalization of the management. The mechanisms of assessment are not incorporated into the health policy in the bureaucratic field. CONCLUSIONS There is a need to expand the global funding of the area of health, specifically mental health, which has been shown to be a successful policy. The current focus of the policy seems to be archaic in relation to the precepts of the psychosocial model. Mechanisms of assessment need to be expanded.

RESUMO OBJETIVO Analisar o estágio atual do modelo de atenção à saúde mental do Sistema Único de Saúde, segundo seu financiamento, processos de governança e mecanismos de avaliação. MÉTODOS Foi realizada uma análise documental de portarias, informes técnicos, relatórios de conferência, resoluções e decretos de 2009 a 2014. RESULTADOS Trata-se de um momento de consolidação do modelo psicossocial, com ampliação da rede assistencial, inversão de financiamento para serviços comunitários com forte ênfase na área de crack e outras drogas. A saúde mental é uma área subfinanciada dentro do subfinanciamento crônico do Sistema Único de Saúde. O modelo de governança constrange o avanço de serviços essenciais, havendo a necessidade da incorporação de um processo de regionalização da gestão. Os mecanismos avaliativos no campo burocrático se mostram pouco incorporados à política de saúde. CONCLUSÕES É necessário ampliar o financiamento global da saúde e específico da saúde mental, que vem se constituindo como uma política exitosa. O foco atual da política se mostra anacrônico aos preceitos do modelo psicossocial. Aponta-se a necessidade de ampliação de mecanismos avaliativos.

Early Intervention for Psychosis in Canada: What Is the State of Affairs?

OBJECTIVE: Early intervention services (EIS) for psychosis have been developed in several countries, including Canada. There is some agreement about the program elements considered essential for improving the long-term outcomes for patients in the early phase of psychotic disorders. In the absence of national standards, the current state of EIS for psychosis in Canada needs to be examined in relation to expert recommendations currently available. METHOD: A detailed online benchmark survey was developed and administered to 11 Canadian academic EIS programs covering administrative, clinical, education, and research domains. In addition, an electronic database and Internet search was conducted to find existing guidelines for EIS. Survey results were then compared with the existing expert recommendations. RESULTS: Most of the surveyed programs offer similar services, in line with published expert recommendations (i.e., easy and rapid access, intensive follow-up through case management with emphasis on patient engagement and continuity of care, and a range of integrated evidence-based psychosocial interventions). However, differences are observed among programs in admission and discharge criteria, services for patients at ultra high risk (UHR) for psychosis, patient to clinician ratios, accessibility of services, and existence of specific inpatient units. These seem to diverge from expert recommendations. CONCLUSIONS: Although Canadian programs are following most expert recommendations on clinical components of care, some programs lack administrative and organizational elements considered essential. Continued mentoring and networking of clinicians through organizations such as the Canadian Consortium for Early Intervention in Psychosis (CCEIP), as well as the development of a fidelity scale through further research, could possibly help programs attain and maintain the best standards of early intervention. However, simply making clinical guidelines available to care providers is not sufficient for changing practices; this will need to be accompanied by adequate funding and support from organizations and policy makers.

Assessment and management of fall risk in primary care settings.

Falls among older adults are neither purely accidental nor inevitable; research has shown that many falls are preventable. Primary care providers play a key role in preventing falls. However, fall risk assessment and management is performed infrequently in primary care settings. This article provides an overview of a clinically relevant, evidence-based approach to fall risk screening and management. It describes resources, including the STEADI (Stopping Elderly Accidents, Deaths, and Injuries) tool kit that can help providers integrate fall prevention into their practice.

The politics of patient-centred care.

BACKGROUND: Despite widespread belief in the importance of patient-centred care, it remains difficult to create a system in which all groups work together for the good of the patient. Part of the problem may be that the issue of patient-centred care itself can be used to prosecute intergroup conflict. OBJECTIVE: This qualitative study of texts examined the presence and nature of intergroup language within the discourse on patient-centred care. METHODS: A systematic SCOPUS and Google search identified 85 peer-reviewed and grey literature reports that engaged with the concept of patient-centred care. Discourse analysis, informed by the social identity approach, examined how writers defined and portrayed various groups. RESULTS: Managers, physicians and nurses all used the discourse of patient-centred care to imply that their own group was patient centred while other group(s) were not. Patient organizations tended to downplay or even deny the role of managers and providers in promoting patient centredness, and some used the concept to advocate for controversial health policies. Intergroup themes were even more obvious in the rhetoric of political groups across the ideological spectrum. In contrast to accounts that juxtaposed in-groups and out-groups, those from reportedly patient-centred organizations defined a 'mosaic' in-group that encompassed managers, providers and patients. CONCLUSION: The seemingly benign concept of patient-centred care can easily become a weapon on an intergroup battlefield. Understanding this dimension may help organizations resolve the intergroup tensions that prevent collective achievement of a patient-centred system.

Advances and challenges in oral health after a decade of the "Smiling Brazil" Program / Avanços e desafios da saúde bucal após uma década de Programa Brasil Sorridente

ABSTRACT OBJECTIVE To analyze oral health work changes in primary health care after Brazil's National Oral Health Policy Guidelines were released. METHODS A literature review was conducted on Medline, LILACS, Embase, SciELO, Biblioteca Virtual em Saúde, and The Cochrane Library databases, from 2000 to 2013, on elements to analyze work changes. The descriptors used included: primary health care, family health care, work, health care policy, oral health care services, dentistry, oral health, and Brazil. Thirty-two studies were selected and analyzed, with a predominance of qualitative studies from the Northeast region with workers, especially dentists, focusing on completeness and quality of care. RESULTS Observed advances focused on educational and permanent education actions; on welcoming, bonding, and accountability. The main challenges were related to completeness; extension and improvement of care; integrated teamwork; working conditions; planning, monitoring, and evaluation of actions; stimulating people's participation and social control; and intersectorial actions. CONCLUSIONS Despite the new regulatory environment, there are very few changes in oral health work. Professionals tend to reproduce the dominant biomedical model. Continuing efforts will be required in work management, training, and permanent education fields. Among the possibilities are the increased engagement of managers and professionals in a process to understand work dynamics and training in the perspective of building significant changes for local realities.

RESUMO OBJETIVO Analisar as mudanças no trabalho em saúde bucal na atenção primária à saúde após o lançamento das Diretrizes da Política Nacional de Saúde Bucal. MÉTODOS Foi realizada revisão da literatura nas bases de dados Medline, Lilacs, Embase, SciELO, Biblioteca Virtual em Saúde e The Cochrane Library, de 2000 a 2013, sobre elementos analisadores das mudanças no trabalho. Os descritores utilizados foram: atenção primária à saúde, saúde da família, trabalho, política de saúde, serviços de saúde bucal, odontologia, saúde bucal e Brasil. Foram selecionados e analisados 32 estudos, com predomínio de estudos qualitativos, da região Nordeste, com trabalhadores, sobretudo dentistas, e com foco na integralidade e qualificação da assistência. RESULTADOS Os avanços observados concentraram-se nas ações educativas e de educação permanente; no acolhimento, vínculo e responsabilização. Os principais desafios estiveram relacionados à: integralidade; ampliação e qualificação da assistência; trabalho integrado em equipe; condições de trabalho; planejamento, monitoramento e avaliação das ações; estímulo à participação popular e ao controle social; e ações intersetoriais. CONCLUSÕES Apesar do novo cenário normativo, as mudanças são incipientes no trabalho em saúde bucal. Os profissionais tendem a reproduzir o modelo biomédico dominante. Serão necessários esforços continuados no campo da gestão do trabalho, da formação e da educação permanente. Dentre as possibilidades, está a ampliação do engajamento dos gestores e dos profissionais num processo de compreensão da dinâmica do trabalho e da formação na perspectiva de construir mudanças significativas para as realidades locais.