Impact of geographical cohorting, multidisciplinary rounding and incremental case management support on hospital length of stay and readmission rates: a propensity weighted analysis.

Hospital length of stay (LOS) in the USA has been increasing since the start of the COVID-19 pandemic, with numerous negative outcomes, including decreased quality of care, worsened patient satisfaction and negative financial impacts on hospitals. While many proposed factors contributing to prolonged LOS are challenging to modify, poor coordination of care and communication among clinical teams can be improved.Geographical cohorting of provider teams, patients and other clinical staff is proposed as a solution to prolonged LOS and readmissions. However, many studies on geographical cohorting alone have shown no significant impact on LOS or readmissions. Other potential benefits of geographical cohorting include improved quality of care, learning experience, communication, teamwork and efficiency.This paper presents a retrospective study at Duke University Hospital (DUH) on the General Medicine service, deploying a bundled intervention of geographical cohorting of patients and their care teams, twice daily multidisciplinary rounds and incremental case management support. The quality improvement study found that patients in the intervention arm had 16%-17% shorter LOS than those in the control arms, and there was a reduction in 30-day hospital readmissions compared with the concurrent control arm. Moreover, there was some evidence of improved accuracy of estimated discharge dates in the intervention arm.Based on these findings, the health system at DUH recognised the value of geographical cohorting and implemented additional geographically based medicine units with multidisciplinary rounds. Future studies will confirm the sustained impact of these care transformations on hospital throughput and patient outcomes, aiming to reduce LOS and enhance the quality of care provided to patients.

Bringing Delirium to Light: Impact of CAM-ICU Tool to Improve Care Coordination.

BACKGROUND: Delirium is a serious complication in patients in the critical care unit (CCU) that may lead to prolonged hospitalization if left undetected. The CCU at our hospital does not have a framework for determining delirium that could affect patient outcomes and discharge planning. PRIMARY PRACTICE SETTING: CCU in a community hospital. METHOD: A posttest-only design was used for this study. We established a framework for the early assessment of delirium, educated and trained nurses to detect delirium, collaborated with the informatics department, intensivist, nursing, respiratory therapy and worked with case management to deploy the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU). We used a one-tailed independent t test to determine the impact of CAM-ICU on length of stay (LOS). Cross-tabulation and chi-square tests were used to examine the impact of CAM-ICU tool on home care utilization between the intervention and comparison groups. RESULTS: There was a 3.12% reduction in LOS after implementing the CAM-ICU tool. Also, a reduction in home care service utilization demonstrated statistical significance ( p = .001) between the intervention group (62.5%; n = 177) and the comparison group (37.5%; n = 106). IMPLICATIONS FOR CASE MANAGEMENT PRACTICE: Case managers are essential in improving care transitions. Case managers need to become competent in understanding the implications of the CAM-ICU tool because of their relevant role in the multidisciplinary rounds as advocates to improve care transitions across the continuum of care. Case managers need to have an understanding on how to escalate when changes in the Richmond Agitation-Sedation Scale scores occur during the multidisciplinary rounds because it can affect care coordination throughout the hospital. CONCLUSIONS: Implementing the CAM-ICU decreased LOS, and reduced health care utilization. The early identification of patients with delirium can affect the outcomes of critically ill patients and entails multidisciplinary collaboration.

Assessing the cost-effectiveness of integrated case management of Neglected Tropical Diseases in Liberia.

BACKGROUND: In 2017, Liberia became one of the first countries in the African region to develop and implement a national strategy for integrated case management of Neglected Tropical Diseases (CM-NTDs), specifically Buruli ulcer, leprosy, lymphatic filariasis morbidities, and yaws. Implementing this plan moves the NTD program from many countries' fragmented (vertical) disease management. This study explores to what extent an integrated approach offers a cost-effective investment for national health systems. METHODS: This study is a mixed-method economic evaluation that explores the cost-effectiveness of the integrated CM-NTDs approach compared to the fragmented (vertical) disease management. Primary data were collected from two integrated intervention counties and two non-intervention counties to determine the relative cost-effectiveness of the integrated program model vs. fragmented (vertical) care. Data was sourced from the NTDs program annual budgets and financial reports for integrated CM-NTDs and Mass Drug Administration (MDA) to determine cost drivers and effectiveness. RESULTS: The total cost incurred by the integrated CM-NTD approach from 2017 to 2019 was US$ 789,856.30, with the highest percentage of costs for program staffing and motivation (41.8%), followed by operating costs (24.8%). In the two counties implementing fragmented (vertical) disease management, approximately US$ 325,000 was spent on the diagnosis of 84 persons and the treatment of twenty-four persons suffering from NTDs. While 2.5 times as much was spent in integrated counties, 9-10 times more patients were diagnosed and treated. CONCLUSIONS: The cost of a patient being diagnosed under the fragmented (vertical) implementation is five times higher than integrated CM-NTDs, and providing treatment is ten times as costly. Findings indicate that the integrated CM-NTDs strategy has achieved its primary objective of improved access to NTD services. The success of implementing an integrated CM-NTDs approach in Liberia, presented in this paper, demonstrates that NTD integration is a cost-minimizing solution.

Monitoring of the Village Malaria Workers to conduct activities of Malaria Elimination Demonstration Project in Mandla, Madhya Pradesh.

BACKGROUND: The capacity of the field staff to conduct activities related to disease surveillance, case management, and vector control has been one of the key components for successfully achieving malaria elimination. India has committed to eliminate malaria by 2030, and it has placed significance on monitoring and evaluation at the district level as one of the key strategies in its national framework. To support and guide the country's malaria elimination objectives, the Malaria Elimination Demonstration Project was conducted in the tribal district of Mandla, Madhya Pradesh. Robust monitoring of human resources received special attention to help the national programme formulate a strategy to plug the gaps in its supply chain and monitoring and evaluation systems. METHODS: A monitoring tool was developed to test the capabilities of field workers to conduct activities related to malaria elimination work. Between November 2018 to February 2021, twenty-five Malaria Field Coordinators (MFCs) of the project utilized this tool everyday during the supervisory visits for their respective Village Malaria Workers (VMWs). The data was analysed and the scores were tested for variations against different blocks, educational status, duration of monitoring, and post-training scores. RESULTS: During the study period, the VMWs were monitored a total of 8974 times using the monitoring tool. Each VMW was supervised an average of 1.8 times each month. The critical monitoring indicators scored well in all seven quarters of the study as monitored by the MFCs. Monitoring by MFCs remained stable at 97.3% in all quarters. Contrary to expectations, the study observed longer diagnosis to treatment initiation time in urban areas of the district. CONCLUSION: This study demonstrated the significance of a robust monitoring tool as an instrument to determine the capacity of the field workers in conducting surveillance, case management, and vector control related work for the malaria elimination programme. Similar tools can be replicated not only for malaria elimination, but other public health interventions as well.

Health workers readiness and practice in malaria case detection and appropriate treatment: a meta-analysis and meta-regression.

BACKGROUND: Health workers (HWs) appropriate malaria case management includes early detection and prompt treatment with appropriate anti-malarial drugs. Subsequently, HWs readiness and practice are considered authentic evidence to measure the health system performance regarding malaria control programme milestones and to issue malaria elimination certification. There is no comprehensive evidence based on meta-analysis, to measure the performance of HWs in case management of malaria. This study aimed to evaluate HWs performance in early malaria case detection (testing) and the appropriate treatment. METHODS: The published literature in English was systematically searched from Medline, Scopus, Embase, and Malaria Journal up to 30th December 2020. The inclusion criteria were any studies that assessed HWs practice in early case detection by malaria testing and appropriate treatment. Eligibility assessment of records was performed independently in a blinded, standardized way by two reviewers. Pooled prevalence estimates were stratified by HWs cadre type. Meta-regression analysis was performed to explore the impact of the appropriateness of the method and risk of bias as potential sources of the heterogeneity in the presence of effective factors. RESULTS: The study pooled data of 9245 HWs obtained from 15 included studies. No study has been found in eliminating settings. The pooled estimate for appropriate malaria treatment and malaria testing were 60%; 95% CI: 53-67% and 57%; 95% CI: 49-65%, respectively. In the final multivariable meta-regression, HWs cadre and numbers, appropriateness of study methods, malaria morbidity and mortality, total admissions of malaria suspected cases, gross domestic product, availability of anti-malarial drugs, and year of the publication were explained 85 and 83% of the total variance between studies and potential sources of the heterogeneity for malaria testing and treating, respectively. CONCLUSION: HWs adherence to appropriate malaria case management guidelines were generally low while no study has been found in eliminating countries. Studies with the inappropriateness methods and risk of bias could be overestimating the actual proportion of malaria appropriate testing and treating. Strategies that focus on improving readiness and early identification of acute febrile diseases especially in the countries that progress to malaria elimination should be highly promoted.

Baseline malaria prevalence and care-seeking behaviours in rural Madagascar prior to a trial to expand malaria community case management to all ages.

BACKGROUND: Integrated community case management of malaria, pneumonia, and diarrhoea can reduce mortality in children under five years (CU5) in resource-poor countries. There is growing interest in expanding malaria community case management (mCCM) to older individuals, but limited empirical evidence exists to guide this expansion. As part of a two-year cluster-randomized trial of mCCM expansion to all ages in southeastern Madagascar, a cross-sectional survey was conducted to assess baseline malaria prevalence and healthcare-seeking behaviours. METHODS: Two enumeration areas (EAs) were randomly chosen from each catchment area of the 30 health facilities (HFs) in Farafangana district designated for the mCCM age expansion trial; 28 households were randomly selected from each EA for the survey. All household members were asked about recent illness and care-seeking, and malaria prevalence was assessed by rapid diagnostic test (RDT) among children < 15 years of age. Weighted population estimates and Rao-Scott chi-squared tests were used to examine illness, care-seeking, malaria case management, and malaria prevalence patterns. RESULTS: Illness in the two weeks prior to the survey was reported by 459 (6.7%) of 8050 respondents in 334 of 1458 households surveyed. Most individuals noting illness (375/459; 82.3%) reported fever. Of those reporting fever, 28.7% (112/375) sought care; this did not vary by participant age (p = 0.66). Most participants seeking care for fever visited public HFs (48/112, 46.8%), or community healthcare volunteers (CHVs) (40/112, 31.0%). Of those presenting with fever at HFs or to CHVs, 87.0% and 71.0%, respectively, reported being tested for malaria. RDT positivity among 3,316 tested children < 15 years was 25.4% (CI: 21.5-29.4%) and increased with age: 16.9% in CU5 versus 31.8% in 5-14-year-olds (p < 0.0001). Among RDT-positive individuals, 28.4% of CU5 and 18.5% of 5-14-year-olds reported fever in the two weeks prior to survey (p = 0.044). CONCLUSIONS: The higher prevalence of malaria among older individuals coupled with high rates of malaria testing for those who sought care at CHVs suggest that expanding mCCM to older individuals may substantially increase the number of infected individuals with improved access to care, which could have additional favorable effects on malaria transmission.

Clustering of malaria in households in the Greater Mekong Subregion: operational implications for reactive case detection.

BACKGROUND: Malaria reactive case detection is the testing and, if positive, treatment of close contacts of index cases. It is included in national malaria control programmes of countries in the Greater Mekong Subregion to accelerate malaria elimination. Yet the value of reactive case detection in the control and elimination of malaria remains controversial because of the low yield, limited evidence for impact, and high demands on resources. METHODS: Data from the epidemiological assessments of large mass drug administration (MDA) studies in Myanmar, Vietnam, Cambodia and Laos were analysed to explore malaria infection clustering in households. The proportion of malaria positive cases among contacts screened in a hypothetical reactive case detection programme was then determined. The parasite density thresholds for rapid diagnostic test (RDT) detection was assumed to be > 50/µL (50,000/mL), for dried-blood-spot (DBS) based PCR > 5/µL (5000/mL), and for ultrasensitive PCR (uPCR) with a validated limit of detection at 0.0022/µL (22/mL). RESULTS: At baseline, before MDA, 1223 Plasmodium infections were detected by uPCR in 693 households. There was clustering of Plasmodium infections. In 637 households with asymptomatic infections 44% (278/637) had more than one member with Plasmodium infections. In the 132 households with symptomatic infections, 65% (86/132) had more than one member with Plasmodium infections. At baseline 4% of households had more than one Plasmodium falciparum infection, but three months after MDA no household had more than one P. falciparum infected member. Reactive case detection using DBS PCR would have detected ten additional cases in six households, and an RDT screen would have detected five additional cases in three households among the 169 households with at least one RDT positive case. This translates to 19 and 9 additional cases identified per 1000 people screened, respectively. Overall, assuming all febrile RDT positive patients would seek treatment and provoke reactive case detection using RDTs, then 1047 of 1052 (99.5%) Plasmodium infections in these communities would have remained undetected. CONCLUSION: Reactive case detection in the Greater Mekong subregion is predicted to have a negligible impact on the malaria burden, but it has substantial costs in terms of human and financial resources.

Patient Outcomes Associated With Utilization of Education, Case Management, and Advanced Practice Pharmacy Services by American Indian and Alaska Native Peoples With Diabetes.

BACKGROUND: The burden of diabetes is exceptionally high among American Indian and Alaska Native (AI/AN) peoples. The Indian Health Service (IHS) and Tribal health programs provide education, case management, and advanced practice pharmacy (ECP) services for AI/ANs with diabetes to improve their health outcomes. OBJECTIVE: The objective of this study was to evaluate patient outcomes associated with ECP use by AI/AN adults with diabetes. RESEARCH DESIGN: This observational study included the analysis of IHS data for fiscal years (FY) 2011-2013. Using propensity score models, we assessed FY2013 patient outcomes associated with FY2012 ECP use, controlling for FY2011 baseline characteristics. SUBJECTS: AI/AN adults with diabetes who used IHS and Tribal health services (n=28,578). MEASURES: We compared health status and hospital utilization outcomes for ECP users and nonusers. RESULTS: Among adults with diabetes, ECP users, compared with nonusers, had lower odds of high systolic blood pressure [odds ratio (OR)=0.85, P<0.001] and high low-density lipoprotein cholesterol (OR=0.89, P<0.01). Among adults with diabetes absent cardiovascular disease (CVD) at baseline, 3 or more ECP visits, compared with no visits, was associated with lower odds of CVD onset (OR=0.79, P<0.05). Among adults with diabetes and CVD, any ECP use was associated with lower odds of end-stage renal disease onset (OR=0.60, P<0.05). ECP users had lower odds of 1 or more hospitalizations (OR=0.80, P<0.001). CONCLUSIONS: Findings on positive patient outcomes associated with ECP use by adults with diabetes may inform IHS and Tribal policies, funding, and enhancements to ECP services to reduce disparities between AI/ANs and other populations in diabetes-related morbidity and mortality.

Needs assessment of community health workers to enhance efficient delivery of their services for community case management of malaria in Kenya.

BACKGROUND: Malaria continues to be the leading cause of morbidity and mortality in Africa. Community Case Management of malaria (CCMm) which is undertaken by engaging Community Health Workers (CHWs) to effectively address management of malaria cases in some endemic communities was explored in this study. The aim was to assess the needs of CHWs that would help sustain and retain their services to enhance the efficient delivery of CCMm. METHODS: Using semi-structured questionnaires, data on the needs of CHWs was gathered through a qualitative study consisting of in-depth interviews and focus group discussions (FGDs) conducted among study participants in five districts in western Kenya. The study participants comprised of 100 CHWs, 100 mothers of children under five years and 25 key informants made up of public health officers and clinicians involved in the CCMm. The interviews were conducted in English and Swahili or Dholuo, the local language. The recorded audio interviews were transcribed later. The analysis was done using NVivo version 7 software and transcripts were coded after which themes related to the objectives of the study were identified. RESULTS: All the study participants recognized the need to train and update CHWs on their work as well as remunerating them for their services to enhance efficient delivery of services. The CHWs on their part perceived the provision of gloves, rapid diagnostic test kits (RDTs), lancets, cotton wool and ethanol, bins (to dispose of RDTs and lancets), together with drugs for treating clients as the essential needs to undertake CCMm in the communities. Other logistical needs and incentives mentioned by CHWs and key informants for the successful delivery of CCMm included: gumboots, raincoats, torch lights, mobile phones, means of transportation (bicycles and motorbikes), uniforms and ID cards for identification. CONCLUSIONS: CHWs would perform tasks better and their services retained for a sustainable CCMm if: properly incentivized; offered refresher trainings (and updates) on malaria; and equipped with the requisite tools identified in this study.

Examining the Ugandan health system's readiness to deliver rheumatic heart disease-related services.

BACKGROUND: In 2018, the World Health Assembly mandated Member States to take action on rheumatic heart disease (RHD), which persists in countries with weak health systems. We conducted an assessment of the current state of RHD-related healthcare in Uganda. METHODOLOGY/PRINCIPAL FINDINGS: This was a mixed-methods, deductive simultaneous design study conducted in four districts of Uganda. Using census sampling, we surveyed health facilities in each district using an RHD survey instrument that was modeled after the WHO SARA tool. We interviewed health workers with experience managing RHD, purposively sampling to ensure a range of qualification and geographic variation. Our final sample included 402 facilities and 36 health workers. We found major gaps in knowledge of clinical guidelines and availability of diagnostic tests. Antibiotics used in RHD prevention were widely available, but cardiovascular medications were scarce. Higher levels of service readiness were found among facilities in the western region (Mbarara district) and private facilities. Level III health centers were the most prepared for delivering secondary prevention. Health worker interviews revealed that limited awareness of RHD at the district level, lack of diagnostic tests and case management registries, and absence of clearly articulated RHD policies and budget prioritization were the main barriers to providing RHD-related healthcare. CONCLUSIONS/SIGNIFICANCE: Uganda's readiness to implement the World Health Assembly RHD Resolution is low. The forthcoming national RHD strategy must focus on decentralizing RHD diagnosis and prevention to the district level, emphasizing specialized training of the primary healthcare workforce and strengthening supply chains of diagnostics and essential medicines.

Case Management on the Front Lines of COVID-19: The Importance of the Individualized Care Plan Across Care Settings.

PURPOSE: Since the outbreak of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), and the disease known as COVID-19, case management has emerged as a critical intervention in the treatment of cases, particularly for patients with severe symptoms and medical complications. In addition, case managers have been on the front lines of the response across the health care spectrum to reduce risks of contagion, including among health care workers. The purpose of this article is to discuss the case management response, highlighting the importance of individual care plans to provide access to the right care and treatment at the right time to address both the consequences of the disease and patient comorbidities. PRIMARY PRACTICE SETTINGS: The COVID-19 response spans the full continuum of health and human services, including acute care, subacute care, workers' compensation (especially catastrophic case management), home health, primary care, and community-based care. IMPLICATIONS FOR CASE MANAGEMENT PRACTICE: From the earliest days of the pandemic, case managers have assumed an important role on the front lines of the medical response to COVID-19, ensuring that procedures are in place for managing a range of patients: those who were symptomatic but able to self-isolate and care for themselves at home; those who had serious symptoms and needed to be hospitalized; and those who were asymptomatic and needed to be educated about the importance of self-isolating. Across the care spectrum, individualized responses to the clinical and psychosocial needs of patients with COVID-19 in acute care, subacute care, home health, and other outpatient settings have been guided by the well-established case management process of screening, assessing, planning, implementing, following up, transitioning, and evaluating. In addition, professional case managers are guided by values such as advocacy, ensuring access to the right care and treatment at the right time; autonomy, respecting the right to self-determination; and justice, promoting fairness and equity in access to resources and treatment. The value of justice also addresses the sobering reality that people from racial and ethnic minority groups are at an increased risk of getting sick and dying from COVID-19. Going forward, case management will continue to play a major role in supporting patients with COVID-19, in both inpatient and outpatient settings, with telephonic follow-up and greater use of telehealth.

Usage of and satisfaction with Integrated Community Case Management care in western Uganda: a cross-sectional survey.

BACKGROUND: In some areas of Uganda, village health workers (VHW) deliver Integrated Community Case Management (iCCM) care, providing initial assessment of children under 5 years of age as well as protocol-based treatment of malaria, pneumonia, and diarrhoea for eligible patients. Little is known about community perspectives on or satisfaction with iCCM care. This study examines usage of and satisfaction with iCCM care as well as potential associations between these outcomes and time required to travel to the household's preferred health facility. METHODS: A cross-sectional household survey was administered in a rural subcounty in western Uganda during December 2016, using a stratified random sampling approach in villages where iCCM care was available. Households were eligible if the household contained one or more children under 5 years of age. RESULTS: A total of 271 households across 8 villages were included in the final sample. Of these, 39% reported that it took over an hour to reach their preferred health facility, and 73% reported walking to the health facility; 92% stated they had seen a VHW for iCCM care in the past, and 55% had seen a VHW in the month prior to the survey. Of respondents whose households had sought iCCM care, 60% rated their overall experience as "very good" or "excellent," 97% stated they would seek iCCM care in the future, and 92% stated they were "confident" or "very confident" in the VHW's overall abilities. Longer travel time to the household's preferred health facility did not appear to be associated with higher propensity to seek iCCM care or higher overall satisfaction with iCCM care. CONCLUSIONS: In this setting, community usage of and satisfaction with iCCM care for malaria, pneumonia, and diarrhoea appears high overall. Ease of access to facility-based care did not appear to impact the choice to access iCCM care or satisfaction with iCCM care.

Changes in care-seeking for common childhood illnesses in the context of Integrated Community Case Management (iCCM) program implementation in Benishangul Gumuz region of Ethiopia.

BACKGROUND: Integrated Community Case Management (iCCM) is a strategy for promoting access of under-served populations to lifesaving treatments through extending case management of common childhood illnesses to trained frontline health workers. In Ethiopia iCCM is provided by health extension workers (HEWs) deployed at health posts. We evaluated the association between the implementation of iCCM program in Assosa Zuria zone, Benishangul Gumuz region and changes in care-seeking for common childhood illnesses. METHODS: We conducted a pre-post study without control arm to evaluate the association of interest. The iCCM program that incorporated training, mentoring and supportive supervision of HEWs with community-based demand creation activities was implemented for two years (2017-18). Baseline, midline and endline surveys were completed approximately one year apart. Across the surveys, children aged 2-59 months (n = 1,848) who recently had cough, fever or diarrhea were included. Data were analysed using mixed-effects logistic regression model. RESULTS: Over the two-year period, care-seeking from any health facility and from health posts significantly increased by 10.7 and 17.4 percentage points (PP) from baseline levels of 64.5 and 34.1%, respectively (p<0.001). Care sought from health centres (p = 0.420) and public hospitals (p = 0.129) did not meaningfully change while proportion of caregivers who approached private (p = 0.003) and informal providers (p<0.001) declined. Caregivers who visited health posts for the treatment of diarrhea (19.2 PP, p<0.001), fever (15.5 PP, p<0.001), cough (17.8 PP, p<0.001) and cough with respiratory difficulty (17.3 PP, p = 0.038) significantly increased. After accounting for extraneous variables, we observed that care-seeking from iCCM providers was almost doubled (adjusted odds ratio = 2.32: 95% confidence interval; 1.88-2.86) over the period. CONCLUSION: iCCM implementation was associated with a meaningful shift in care-seeking to health posts.

Trends in health workers' compliance with outpatient malaria case-management guidelines across malaria epidemiological zones in Kenya, 2010-2016.

BACKGROUND: Health workers' compliance with outpatient malaria case-management guidelines has been improving, specifically regarding the universal testing of suspected cases and the use of artemisinin-based combination therapy (ACT) only for positive results (i.e., 'test and treat'). Whether the improvements in compliance with 'test and treat' guidelines are consistent across different malaria endemicity areas has not been examined. METHODS: Data from 11 national, cross-sectional, outpatient malaria case-management surveys undertaken in Kenya from 2010 to 2016 were analysed. Four primary indicators (i.e., 'test and treat') and eight secondary indicators of artemether-lumefantrine (AL) dosing, dispensing, and counselling were measured. Mixed logistic regression models were used to analyse the annual trends in compliance with the indicators across the different malaria endemicity areas (i.e., from highest to lowest risk being lake endemic, coast endemic, highland epidemic, semi-arid seasonal transmission, and low risk). RESULTS: Compliance with all four 'test and treat' indicators significantly increased in the area with the highest malaria risk (i.e., lake endemic) as follows: testing of febrile patients (OR = 1.71 annually; 95% CI = 1.51-1.93), AL treatment for test-positive patients (OR = 1.56; 95% CI = 1.26-1.92), no anti-malarial for test-negative patients (OR = 2.04; 95% CI = 1.65-2.54), and composite 'test and treat' compliance (OR = 1.80; 95% CI = 1.61-2.01). In the low risk areas, only compliance with test-negative results significantly increased (OR = 2.27; 95% CI = 1.61-3.19) while testing of febrile patients showed declining trends (OR = 0.89; 95% CI = 0.79-1.01). Administration of the first AL dose at the facility significantly increased in the areas of lake endemic (OR = 2.33; 95% CI = 1.76-3.10), coast endemic (OR = 5.02; 95% CI = 2.77-9.09) and semi-arid seasonal transmission (OR = 1.44; 95% CI = 1.02-2.04). In areas of the lowest risk of transmission and highland epidemic zone, none of the AL dosing, dispensing, and counselling tasks significantly changed over time. CONCLUSIONS: There is variability in health workers' compliance with outpatient malaria case-management guidelines across different malaria-risk areas in Kenya. Major improvements in areas of the highest risk have not been seen in low-risk areas. Interventions to improve practices should be targeted geographically.

Quantitative evaluation of an outreach case management model of care for urban Aboriginal and Torres Strait Islander adults living with complex chronic disease: a longitudinal study.

BACKGROUND: Chronic diseases are the leading contributor to the excess morbidity and mortality burden experienced by Aboriginal and Torres Strait Islander (hereafter, respectfully, Indigenous) people, compared to their non-Indigenous counterparts. The Home-based Outreach case Management of chronic disease Exploratory (HOME) Study provided person-centred, multidisciplinary care for Indigenous people with chronic disease. This model of care, aligned to Indigenous peoples' conceptions of health and wellbeing, was integrated within an urban Indigenous primary health care service. We aimed to determine the impact of this model of care on participants' health and wellbeing at 12 months. METHODS: HOME Study participants were Indigenous, regular patients of the primary health care service, with a diagnosis of at least one chronic disease, and complex health and social care needs. Data were collected directly from participants and from their medical records at baseline, and 3, 6 and 12 months thereafter. Variables included self-rated health status, depression, utilisation of health services, and key clinical outcomes. Participants' baseline characteristics were described using frequencies and percentages. Generalized estimating equation (GEE) models were employed to evaluate participant attrition and changes in outcome measures over time. RESULTS: 60 participants were enrolled into the study and 37 (62%) completed the 12-month assessment. After receiving outreach case management for 12 months, 73% of participants had good, very good or excellent self-rated health status compared with 33% at baseline (p < 0.001) and 19% of participants had depression compared with 44% at baseline (p = 0.03). Significant increases in appointments with allied health professionals (p < 0.001) and medical specialists other than general practitioners (p = 0.001) were observed at 12-months compared with baseline rates. Mean systolic blood pressure decreased over time (p = 0.02), but there were no significant changes in mean HbA1c, body mass index, or diastolic blood pressure. CONCLUSIONS: The HOME Study model of care was predicated on a holistic conception of health and aimed to address participants' health and social care needs. The positive changes in self-rated health and rates of depression evinced that this aim was met, and that participants received the necessary care to support and improve their health and wellbeing.

Implementing a Nurse Discharge Navigator: Reducing 30-Day Readmissions for Heart Failure and Sepsis Populations.

PURPOSE/OBJECTIVES: The purpose of this quality improvement project was to evaluate the impact of a nurse discharge navigator on reducing 30-day readmissions for the heart failure and sepsis populations. PRIMARY PRACTICE SETTING: The 238-bed community hospital in central Virginia is part of a health care system that encompasses 13 acute care facilities. METHODOLOGY AND SAMPLE: The aim of this project was to identify, implement, and evaluate the transition of care of high-risk readmission patients from January 2019 to April 2019. Inclusion criteria included patients who were 55 years and older, English speaking, diagnosed with heart failure and/or sepsis, discharged to home with or without home health, and/or consults received from case management and social services. Forty-one potential participants were identified with 28 consented. Readmission data were collected pre- and postintervention. The pre-/postanalysis consisted of descriptive statistics, readmission rates, and cost avoidance. RESULTS: Out of the 28 participants, 7 participants were readmitted within 30 days. The heart failure readmission rates during the project implementation were as follows: January 24.05%, February 20%, March 19.75%, and April 11.11%. After the project completion the readmission rates were 22.97% for May and 26.03% for June, respectively. The potential cost avoidance with sustained gain from the project is $405,316.00. IMPLICATIONS FOR CASE MANAGEMENT PRACTICE: This project demonstrated that a discharge navigator had an effect on 30-day readmissions for high-risk heart failure and sepsis populations, as evident by a steady decline in overall heart failure readmission rate during project implementation. The sepsis population needs further research. The discharge navigator project added to the body of knowledge for comprehensive discharge planning, coordination, and education that is needed for these types of patient populations that have a great deal of medical complexity.

Estimando el número de casos de COVID-19 a tiempo real utilizando un formulario web a través de las redes sociales: Proyecto COVID19-TRENDS / Estimation of the number of cases of COVID-19 in real time using a web form through social networks: Project COVID19-TRENDS

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Estimando el número de casos de COVID-19 mediante una herramienta web: resultados de la primera semana del proyecto «Covid-19 Trends» en Euskadi / Estimating the number of COVID-19 cases using a web-based tool: results from the first week of the 'Covid-19 Trends' project in the Basque Country

OBJETIVO: En Euskadi, dos casos de COVID-19 fueron diagnosticados el 28 de febrero de 2020. El 14 de marzo el Gobierno español estableció el estado de alarma. La única información acerca del número de casos de COVID-19 eran los confirmados por RT-PCR. Lanzamos una herramienta de vigilancia basada en la web para estimar el número mínimo de casos sintomáticos de COVID-19 y generar información útil para la toma de decisiones en salud pública. MATERIAL Y MÉTODOS: Implementamos un cuestionario web anónimo y lo difundimos a través de redes sociales. Recopilamos información epidemiológica sobre variables de «tiempo» (fecha de inicio de los síntomas), «lugar» (código postal) y «persona» (género, edad). Comparamos los casos positivos detectados mediante RT-PCR con los casos estimados según la definición de caso del Ministerio de Sanidad Consumo y Bienestar Social. Calculamos la tasa de respuesta al cuestionario y la incidencia acumulada a 14días. RESULTADOS: Entre el 19 y 26 de marzo de 2020 el cuestionario fue contestado por 128.182 personas (5,5% de la población vasca). De ellas, 27.599 cumplieron la definición de caso. Los casos estimados fueron seis veces más que los RT-PCR positivos para COVID-19. La incidencia acumulada a 14días fue de 463,3 por 100.000 habitantes, mientras que la de los casos positivos por RT-PCR fue de 139,6 por 100.000 habitantes. CONCLUSIONES: Esta herramienta mostró su utilidad para estimar el mínimo número de casos sintomáticos en Euskadi, lo cual podría apoyar acciones de salud pública

OBJECTIVE: In the Basque Country, two cases of COVID-19 were diagnosed on February 28 2020. On March 14, the Spanish Government established a state of alarm. Only cases confirmed by molecular biology (reverse-transcriptase polymerase chain reaction [RT-PCR]) were known. We launched a web-based surveillance tool to estimate the number of symptomatic cases of COVID-19 to contribute to Public Health decision-making. MATERIAL AND METHODS: We implemented an anonymous web questionnaire and disseminated it through online social media social. We collected epidemiological information about «time» (date of onset of symptoms), «place» (zip code), and «person» (gender, age). We compared cases detected by RT-PCR with the estimated cases, according to the case definition of the Ministry of Health. We calculated the questionnaire response rate and the cumulative incidence at 14days. RESULTS: Between March 19 and 26, 128,009 people answered the questionnaire (5.5% of the Basque population). Of these, 26,375 met the case definition (symptom prevalence of 21.4%). The estimated cases were almost six times more than COVID-19 positive RT-PCR. The estimated 14-day cumulative incidence was 578.3 per 100,000 population compared to RT-PCR positive cases, which was 139.6 per 100,000 population. CONCLUSIONS: This tool was useful in estimating the minimum number of symptomatic cases in the Basque Country, which could support Public Health actions

Relationship between intervention dosage and success of resource connections in a social needs intervention.

OBJECTIVES: Social needs interventions in medical settings aim to mitigate the effects of adverse social circumstances on health outcomes by connecting vulnerable patients with resources. This study examined the relationship between intervention dosage and the success of resource connections using data from a social needs intervention in multiple clinical settings across the US. STUDY DESIGN: The intervention uses a case management approach to connect patients with unmet needs to resources and services in the community. Intervention dosage was conceptualized as the number of contacts between the navigator and the patient, categorized as direct contact (phone vs. in person) and indirect contact (initiated by the navigator vs. patient). Success of the intervention was conceptualized as 'none,' 'partial,' or 'optimal' for each patient, based on the number of social needs the resource connections addressed. METHODS: Administrative data were extracted for 38,404 unique patients who screened positive for unmet resource needs between 2012 and 2017. Owing to the large sample size, statistical corrections were made to reduce type I error. RESULTS: Multinomial logistic regression analyses showed that higher intervention dosage was related to greater success of resource connections, after adjusting for the patient and site characteristics, and the number of needs (odds ratios ranged from 1.62 to 2.89). In-person contact, although received by only 25% of the patients, was associated with the highest probability of optimal success. CONCLUSIONS: This study demonstrates a feasible way to conceptualize an intervention dose for a social needs intervention that uses a case management approach and has implications for how intervention delivery may improve success of resource connections.