Randomized controlled trial of a coordinated care intervention to improve risk factor control after stroke or transient ischemic attack in the safety net: Secondary stroke prevention by Uniting Community and Chronic care model teams Early to End Disparities (SUCCEED).

BackgroundRecurrent strokes are preventable through awareness and control of risk factors such as hypertension, and through lifestyle changes such as healthier diets, greater physical activity, and smoking cessation. However, vascular risk factor control is frequently poor among stroke survivors, particularly among socio-economically disadvantaged blacks, Latinos and other people of color. The Chronic Care Model (CCM) is an effective framework for multi-component interventions aimed at improving care processes and outcomes for individuals with chronic disease. In addition, community health workers (CHWs) have played an integral role in reducing health disparities; however, their effectiveness in reducing vascular risk among stroke survivors remains unknown. Our objectives are to develop, test, and assess the economic value of a CCM-based intervention using an Advanced Practice Clinician (APC)-CHW team to improve risk factor control after stroke in an under-resourced, racially/ethnically diverse population.Methods/designIn this single-blind randomized controlled trial, 516 adults (≥40 years) with an ischemic stroke, transient ischemic attack or intracerebral hemorrhage within the prior 90 days are being enrolled at five sites within the Los Angeles County safety-net setting and randomized 1:1 to intervention vs usual care. Participants are excluded if they do not speak English, Spanish, Cantonese, Mandarin, or Korean or if they are unable to consent. The intervention includes a minimum of three clinic visits in the healthcare setting, three home visits, and Chronic Disease Self-Management Program group workshops in community venues. The primary outcome is blood pressure (BP) control (systolic BP <130 mmHg) at 1 year. Secondary outcomes include: (1) mean change in systolic BP; (2) control of other vascular risk factors including lipids and hemoglobin A1c, (3) inflammation (C reactive protein [CRP]), (4) medication adherence, (5) lifestyle factors (smoking, diet, and physical activity), (6) estimated relative reduction in risk for recurrent stroke or myocardial infarction (MI), and (7) cost-effectiveness of the intervention versus usual care.DiscussionIf this multi-component interdisciplinary intervention is shown to be effective in improving risk factor control after stroke, it may serve as a model that can be used internationally to reduce race/ethnic and socioeconomic disparities in stroke in resource-constrained settings.Trial registrationClinicalTrials.gov Identifier NCT01763203

Strengthening health-related rehabilitation services at national levels.

OBJECTIVE: One of the aims of the World Health Organization\u27s Global Disability Action Plan is to strengthen rehabilitation services. Some countries have requested support to develop (scale-up) rehabilitation services. This paper describes the measures required and how (advisory) missions can support this purpose, with the aim of developing National Disability, Health and Rehabilitation Plans. RECOMMENDATIONS: It is important to clarify the involvement of governments in the mission, to define clear terms of reference, and to use a systematic pathway for situation assessment. Information must be collected regarding policies, health, disability, rehabilitation, social security systems, the need for rehabilitation, and the existing rehabilitation services and workforce. Site visits and stakeholder dialogues must be done. In order to develop a Rehabilitation Service Implementation Framework, existing rehabilitation services, workforce, and models for service implementation and development of rehabilitation professions are described. Governance, political will and a common understanding of disability and rehabilitation are crucial for implementation of the process. The recommendations of the World Report on Disability are used for reporting purposes. CONCLUSION: This concept is feasible, and leads to concrete recommendations and proposals for projects and a high level of consensus stakeholders

Healthcare PANs: Personal Area Networks for trauma care and home care

The first hour following the trauma is of crucial importance in trauma care. The sooner treatment begins, the better the ultimate outcome for the patient. Generally the initial treatment is handled by paramedical personnel arriving at the site of the accident with an ambulance. There is evidence to show that if the expertise of the on-site paramedic team can be supported by immediate and continuous access to and communication with the expert medical team at the hospital, patient outcomes can be improved. After care also influences the ultimate recovery of the patient. After-treatment follow up often occurs in-hospital in spite of the fact that care at home can offer more advantages and can accelerate recovery. Based on emerging and future wireless communication technologies, in a previous paper [1] we presented an initial vision of two future healthcare settings, supported by applications which we call Virtual Trauma Team and Virtual Homecare Team. The Virtual Trauma Team application involves high quality wireless multimedia communications between ambulance paramedics and the hospital facilitated by paramedic Body Area Networks (BANs) [2] and an ambulance-based Vehicle Area Network (VAN). The VAN supports bi-directional streaming audio and video communication between the ambulance and the hospital even when moving at speed. The clinical motivation for Virtual Trauma Team is to increase survival rates in trauma care. The Virtual Homecare Team application enables homecare coordinated by home nursing services and supported by the patient's PAN which consists of a patient BAN in combination with an ambient intelligent home environment. The homecare PAN provides intelligent monitoring and support functions and the possibility to ad hoc network to the visiting health professionals’ own BANs as well as high quality multimedia communication links to remote members of the virtual team. The motivation for Virtual Homecare Team is to improve quality of life and independence for patients by supporting care at home; the economic motivation is to replace expensive hospital-based care with homecare by virtual teams using wireless technology to support the patient and the carers. In this paper we develop the vision further and focus in particular on the concepts of personal and body area networks

Is the Health Care System Working for Adolescents? Perspectives From Providers in Boston, Denver, Houston, and San Francisco

Assesses healthcare system services for adolescents in four urban areas. Includes provider perspectives on how health insurance, managed care, and other factors facilitate or impede access. Discusses innovative programs, and offers recommendations

Gundersen Lutheran Health System: Performance Improvement Through Partnership

Highlights Fund-defined attributes of an ideal system and best practices such as using data for benchmarking, increasing transparency, and driving improvement; investing in primary care and disease management; and hiring engineers to improve operations

Description and Experience of the Clinical Testbeds

This deliverable describes the up-to-date technical environment at three clinical testbed demonstrator sites of the 6WINIT Project, including the adapted clinical applications, project components and network transition technologies in use at these sites after 18 months of the Project. It also provides an interim description of early experiences with deployment and usage of these applications, components and technologies, and their clinical service impact

Healthcare professionals' perspectives on mental health service provision : a pilot focus group study in six European countries

Background: The mental healthcare treatment gap (mhcGAP) in adult populations has been substantiated across Europe. This study formed part of MentALLY, a research project funded by the European Commission, which aimed to gather qualitative empirical evidence to support the provision of European mental healthcare that provides effective treatment to all adults who need it. Methods: Seven focus groups were conducted with 49 health professionals (HPs), including psychologists, psychiatrists, social workers, general practitioners, and psychiatric nurses who worked in health services in Belgium, Cyprus, Greece, the Netherlands, Norway and Sweden. The focus group discussions centered on the barriers and facilitators to providing quality care to people with mild, medium, and severe mental health problems. Analyses included deductively and inductively driven coding procedures. Cross-country consensus was obtained by summarizing findings in the form of a fact sheet which was shared for triangulation by all the MentALLY partners. Results: The results converged into two overarching themes: (1) Minding the treatment gap: the availability and accessibility of Mental Health Services (MHS). The mhcGAP gap identified is composed of different elements that constitute the barriers to care, including bridging divides in care provision, obstacles in facilitating access via referrals and creating a collaborative 'chain of care'. (2) Making therapeutic practice relevant by providing a broad-spectrum of integrated and comprehensive services that value person-centered care comprised of authenticity, flexibility and congruence. Conclusions: The mhcGAP is comprised of the following barriers: a lack of funding, insufficient capacity of human resources, inaccessibility to comprehensive services and a lack of availability of relevant treatments. The facilitators to the provision of MHC include using collaborative models of primary, secondary and prevention-oriented mental healthcare. Teamwork in providing care was considered to be a more effective and efficient use of resources. HPs believe that the use of e-mental health and emerging digital technologies can enhance care provision. Facilitating access to a relevant continuum of community-based care that is responsive coordinated and in line with people's needs throughout their lives is an essential aspect of optimal care provision