Policy analysis on power standing systems

Certification Trend Is Growing in LTC

The Promise of Nursing Home Medical Direction: A Work in Progress

Sialorrhoea is a frequent symptom of neurological diseases (e.g. Parkinson’s disease, motor neuron disease, cerebral palsy, and stroke) and is defined as excessive saliva accumulation leading to unintentional loss of saliva from the mouth. Sialorrhoea increases the overall burden on the patient and their caregivers, the impact of which can be both physical and psychosocial. Treatments for sialorrhoea range from lifestyle and behavioural guidance, to medications, surgery or radiation. Nonpharmacological interventions include advice on posture, swallowing control, cough management, dietary changes, eating and drinking techniques, and behavioural modification; however, these conservative measures may be ineffective for people with progressive neurological conditions. The pharmacological treatment of sialorrhoea is challenging because medications licensed for this purpose are limited, but treatments can include anticholinergic drugs and botulinum toxins. Surgical treatment of sialorrhoea is typically reserved as a last resort for patients. IncobotulinumtoxinA (Xeomin®) is the first botulinum toxin type A to receive US and UK marketing authorization for the symptomatic treatment of chronic sialorrhoea due to neurological disorders in adults. In this review, we discuss and compare the frequency and method of administration, location of treatment delivery, approximate annual costs and main side effects of botulinum toxin and different anticholinergic drugs. Management of patients with chronic neurological conditions requires input from multiple specialist teams and thus a multidisciplinary team (MDT) approach is considered fundamental to ensure that care is consistent and tailored to patients’ needs. To ensure that adult patients with neurological conditions receive the best care and sialorrhoea is well managed, we suggest a potential clinical care pathway for sialorrhoea with a MDT approach, which healthcare professionals could aspire to.

Getting serious about the dirty little secrets of health care reform to guarantee true Universal Health Care for all Filipinos

Healthcare guidelines play a prominent role in the day-to-day practice of primary care providers, and health policy research leads to the formation of these guidelines. Health policy research is the multidisciplinary approach to public policy explaining the interaction between health institutions, special interests and theoretical constructs. In this article, we demonstrate how primary care providers can conduct high-impact health policy research using Eugene Bardach’s eightfold policy analysis framework in a primary care context. In a medical case, a woman with a history of total hysterectomy had scheduled a visit for a Papanicolaou (Pap) smear screening test as part of a well-woman health check-up with a family medicine resident. Conflicting recommendations on Pap smear screening after total hysterectomy sparked an investigation using the US Preventive Services Task Force criteria for conducting a health policy analysis. We illustrate broadly how clinical care dilemmas can be examined by using Bardach’s broadly applicable health policy framework in order to inform meaningful policy change. Bardach’s framework includes (1) defining the problem, (2) assembling evidence, (3) constructing alternatives, (4) selecting criteria, (5) projecting outcomes, (6) confronting trade-offs, (7) decision-making and (8) sharing the results of the process. The policy analysis demonstrated insufficient evidence to recommend Pap test screening after hysterectomy and the findings contributed to national recommendations. By following Bardach’s steps, primary care researchers have a feasible and powerful tool for conducting meaningful health policy research and analysis that can influence clinical practice.

'Self-management relates to the tasks that an individual does to live well with one or more chronic conditions. These tasks include gaining confidence to deal with medical management role management and emotional management' (Adams, Greiner, & Corrigan, 2004, p. 57, as cited in BC Ministry of Health, 2011). In most countries, provision of self-management programs (the interface between providers and clients) began with the adoption of the Chronic Disease Self-management Program (known in the UK as the Expert Patient Program, and in each Australian State with a different name), an eight week group program run by certified lay leaders. Policy makers adopted the program, usually targeting people with cardiovascular diseases, diabetes, chronic respiratory disease and asthma: conditions with high public burden and in which symptom monitoring and lifestyle management have the potential to change the course and trajectory of the condition. Evidence began to amass indicating positive impacts on quality of life, health utilisation and health outcomes. The understanding that 'one size does not fit all' led to proliferation of group programs and alternate format programs such as telephone coaching and online programs. Training programs emerged for lay leaders and health providers. More recently, it has become clear that supporting people to self-management is an ongoing process, not a one-time intervention. Health providers throughout the system are being expected to acquire self-management support competencies to work in partnership with clients and to support their active participation in care and management of their condition(s). Health-care provider education is also changing to embed these competencies in curricula (Pols et al., 2009). Today, chronic disease self-management interventions are increasingly being proposed and included in the care of people with conditions such as brain injury, stroke, mental health, HIV-Aids and cancer. With the course and trajectory of these conditions less significantly altered by lifestyle risk factor modification and/or day to day medication monitoring and management, practitioners are wise to ask whether current interventions will yield the same results. A critical look at the (i) content (ii) delivery and (iii) outcomes of self-management interventions using an occupation and client-centred lens suggests interventions for these new client groups may need to be refocused. Although confusion exists as to exactly what constitutes a self-management intervention and what self-management support competencies are, self-management viewed from a client perspective, is in fact, consistently defined across authors, settings and populations with almost all definitions directly or indirectly referring to the pivotal work of Corbin and Strauss (1988). Their qualitative studies described three forms of 'work' people undertaken when living with a chronic condition; these forms of work are now most often referred to as medical, role and emotional management. Most definitions also articulate that knowledge, skills and confidence are part of the self-management toolkit (Adams, Greiner & Corrigan, p. 57, as cited in BC Ministry of Health, 2011). Given this consensus, self-management interventions, then, are those that support individuals to develop knowledge, skills and confidence to manage some or all aspects of medical, role and/or emotional management. A critical review of self-management interventions is revealing; content of the vast majority of interventions focuses on assisting participants with medical management only (i.e. reducing lifestyle risk factors through exercise, diet, smoking cessation; self-monitoring of symptoms/medication; and/or treatment adherence). Less obvious and less numerous are interventions with content designed to assist people with role and/or emotional management; i.e. to maintain meaningful participation and occupational engagement. Outcomes measured are, not surprisingly, aligned with the content and focus on health outcomes (blood glucose levels, pain, number of asthma attacks), health utilisation (visits to emergency) and sometimes quality of life. While depression is often measured, almost never is participation in desired roles the expected or measured outcome (Augustine, Roberts & Packer, 2011). Some of the notable exceptions are interventions developed and tested by occupational therapists which focus on role and emotional management and measure participation (Ghahari & Packer, 2012; Girdler, Boldy, Dhaliwal, Crowley & Packer, 2010; Guidetti, Andersson, Andersson, Tham & Von Koch, 2010; O'Toole, Connolly & Smith, 2012). It is now clear that acquiring knowledge, skills and confidence to self-manage does not occur through education alone (Bodenheimer, Lorig, Holman & Grurnbach, 2002). Skills such as problem solving, decision making and action planning are useful tools. Features of interventions that assist people to embed these in everyday life are validation through sharing stories and experience with others, trial-and-error practice in a real life context and encouragement from knowledgeable health providers (Ghahari, Packer & Passmore, 2009). In other words, self-management is gained through conscious and planned engagement in specifically structured occupation. In summary, a client-centred and occupation-focused approach yields new insights about the services and interventions needed by people living with chronic conditions such as neurological conditions, mental health problems, cancer and HIV-Aids. Interventions and services must go beyond medical management to include a much greater focus on role and emotional management. Expected, planned and measured outcomes must move from a focus on behaviour change and health outcomes to the more distal and important measure of participation in everyday roles. Occupational therapy is beginning to make a unique and valued contribution to the research literature, chronic disease best practice and the health and wellbeing of the population. The author wishes to thank Jennifer Lochbihler, MScOT, OTReg(NS) for her assistance in preparing this editorial.

CMS Finalizes Revisions to Conditions to Participation

A potential neuroprotective role for magnesium in neurological disease has been appreciated for almost three decades, yet translation to the clinical arena has proven elusive. Accumulating experimental evidence continues to suggest that magnesium plays a critical role in a number of neurological conditions including headache, stress, alcohol/drug intoxication, acute brain injury, seizures, Parkinson's disease and Alzheimer's disease. Simple administration of a magnesium salt in these conditions has not always been therapeutically successful, with a number of studies showing poor penetration of serum magnesium across the blood brain barrier. Several studies have since demonstrated that using a carrier such as polyethylene glycol can address this, simultaneously reducing the dose of magnesium required to achieve the desired central effects while at the same time attenuating deleterious peripheral effects. Alternatively, administering a more permeable magnesium salt, such as magnesium threonate, is seen as the preferred option in more chronic neurological conditions, with positive results having been achieved in experimental models of Alzheimer's disease. Irrespective of the approach, improved central penetration of a magnesium compound that avoids peripheral side effects of high magnesium dosages is clearly a desirable outcome, and should now be investigated in animal models that accurately mimic the complex human condition.

Implementation of a medication therapy management collaborative within a pediatric health system

Background: The call for medication management programs (MMPs) is growing, as evidence of inappropriate prescribing and medication use in seniors accumulates. Seniors in social and supportive housing programs are likely at high risk of medication problems by virtue of their socioeconomic status and/or frailty. Yet there are few published reports of MMPs in such settings. Aim: To assess the need for medication management support for seniors in a supportive housing setting; to profile a pharmacist's medication management interventions; and to evaluate the costs, barriers, facilitators, and impact of a MMP. Method: Eleven seniors' apartment buildings in Peel region, served by 1 supportive housing provider, were randomized to experimental or control groups. Seniors in experimental buildings were referred to the MMP by supportive housing supervisors, health care professionals, or themselves. A pharmacist conducted in-home medication reviews. Her drug therapy assessment and recommendations were faxed to the family physician, and shared with other health care providers and caregivers as appropriate. Medication counselling and management aids were provided as needed. On average, clients received 1.7 follow-up visits or phone calls. Medication regimen complexity, adherence, and costs will be compared between groups at 3 months. Additional measures in the experimental group include number of pharmacist-identified medication problems and interventions, acceptance of prescribing recommendations, client and health care provider satisfaction, and service cost. Results: Almost 100 clients have received the service. Of the first 50 clients, 83% were female, with a mean age of 77.7 years and an average of 8 prescription drugs and 2 nonprescription medicines each. The pharmacist identified 2.5 medication problems per client and made 1.7 prescriber interventions and 1.1 client interventions. The most common medication problem (31%) was needing an additional drug and 67% of prescribing recommendations were known to be adopted or accepted. The service required 3.9 hours of pharmacist time per client. Data analysis is in progress. Implications for pharmacists: In-home medication management reviews improve seniors' drug therapy. Opportunities exist for pharmacists to provide this service in nontraditional settings, such as supportive housing or home care programs, thus increasing access and integrating primary care and community care providers in a coordinated medication support system for seniors.

Women face a higher risk of many debilitating neurological conditions including, but not limited to Alzheimer’s disease, multiple sclerosis, migraines, myasthenia gravis, Parkinson’s disease, stroke, and vascular dementia. Not only are these conditions more prevalent in women than men, but women face noteworthy differences in the risk factors, symptoms, disease progression, and experience of many neurological diseases. Since women have traditionally been underrepresented in both randomized controlled trails and neurological research, much less is known about the unique risk factors, symptomology, treatment efficacy, and healthcare costs of neurological conditions in women. This special collection aims to gather and disseminate innovative quantitative and qualitative research, critical reviews, policy analyses, and case studies exploring the identification, prevalence, treatment, cost, and experience of neurological conditions in women. By showcasing the unique symptoms, treatments, experiences, challenges, and circumstances of women with neurological conditions, this collection will contribute to a deeper awareness and understanding of these conditions while promoting strategies to improve the diagnosis, treatment, and care of women suffering from these conditions.Neurological Conditions in WomenWomen face a higher risk of many debilitating neurological conditions, including, but not limited to, Alzheimer’s disease, multiple sclerosis, migraines, myasthenia gravis, Parkinson’s disease, stroke, and vascular dementia. Not only are these conditions more prevalent in women than men, but women face noteworthy differences in the risk factors, symptoms, disease progression, and experience of many neurological diseases. Since women have traditionally been underrepresented in both randomized controlled trials and neurological research, much less is known about the unique risk factors, symptomology, treatment efficacy, and healthcare costs of neurological conditions in women. This special collection aims to gather and disseminate innovative quantitative and qualitative research, critical reviews, policy analyses, and case studies exploring the identification, prevalence, treatment, cost, and experience of neurological conditions in women. Physical and Cognitive Decline in US WomenFunctional difficulties can result in worse quality of life. However, the factors that influence functional difficulties may vary across different life stages. This study examined associations between demographic characteristics, income, health status and walking/communication difficulties using the National Health and Nutrition Examination Survey (NHANES) 2021-2023 wave among women aged 18 and above. Binary dependent variable analysis evaluated the these associations and a sensitivity analysis estimated these associations within young, middle-aged, and older adults. High income and higher education was associated with a higher likelihood of communication and walking difficulties. Additionally, racial/ethnic and age group variations in the observed relationships was observed. This study revealed significant associations between demographic characteristics and functional difficulties in women that differed between age groups. Risk and protective factors vary throughout the lifespan and understanding the variations will be important to understanding functional difficulty in women. Post-Stroke Cognitive Decline among Women in MidlifeBackground: Stroke is a significant risk factor for cognitive impairment. Women face a heightened risk due to their longer life expectancy and the greater prevalence of stroke-related disability. Objective: To compare the trajectory of cognitive decline in women with and without a stroke diagnosis and assessed demographic differences. Methods: The Study of Women’s Health Across the Nation (SWAN) interviewed women in their 40s and 50s from seven US cities approximately yearly to collect information on their physical, biological, psychological, and social health. Cognitive assessments were conducted between 2000 (wave 4) and 2008 (wave 10) that were designed to examine information processing speed, working memory, immediate memory and delayed memory. Adjusting for baseline age, race/ethnicity, income, education, marital status, comorbidities, and insurance, generalized linear mixed models (GLMM) were used to compare cognitive decline between women who had experienced a stroke and those who had not. Results: Among the 3,302 women in the sample, age was 49.52 (SD=2.64) years old at baseline and 53.74 (SD=3.94) in the final wave. In Wave 4, only 0.67% (N=22) reported having been diagnosed with a stroke, but 8.39% (N=277) had been diagnosed by Wave 10. Compared to stroke-free women, the multivariable-adjusted acute changes in cognitive performance were -0.18 information processing, -0.09 working memory, -0.15 immediate memory and - 0.17 delayed memory. Compared to White women, Black women who suffered a stroke saw multivariable-adjusted acute annual changes in information processing, working memory, immediate memory, and delayed memory of -0.08, -0.03, -0.08, and -0.09 respectively. Conclusion: These findings underscore the acute and persistent impact of stroke on multiple cognitive domains in midlife women, with a more significant decline observed among Black women. Targeted prevention and rehabilitation efforts are needed to address both the cognitive consequences of stroke and the demographic differences in post-stroke outcomes.

Medication therapy management (MTM) is a relatively new method of monitoring patient medication use and adherence. Medicare Part D has not only recognized its effectiveness and ability to enhance patient care, but has made MTM a required process for patient members with specific diseases (Doucette, McDonough, Klepser, & McCarthy, 2005). MTM provides a flamework for pharmacists and physicians to collaborate on medication administration and monitoring of medication use (Kuo, Bucldey, Fitzsimmons, & Steinbauer, 2004). Collaborative health-care models such as MTM offer promising possibilities for improved administration of services and enhanced quality of care for patients. These frameworks use the unique skills and knowledge of each specific health-care profession involved, and they offer opportunities for the field of social work. This article examines MTM within a framework of collaborative care. First, an overview of the collaborative model of health care is provided. Second, the use of MTM in monitoring medication adherence is examined. Third, the role of pharmacists in collaborative health care is evaluated. Finally, implications for the use of MTM in conjunction with services provided by the social work profession are addressed. COLLABORATIVE HEALTH CARE In the past several decades, health care has migrated from the historical use of the medical model toward a more integrative, collaborative approach. The medical model has been described as an individualistic, specific, and rational concept of health care (Engel, 1977; Weick, 1983). This approach treats the biological issues of the patient but does not address psychosocial needs (Bird & Rieker, 1999; Calnan & Johnson, 1985).This lack of attention to the person in environment does not allow health-care providers to address the impact of economic barriers to care (Hiatt et al., 2001), disruption of family homeostasis (Andrist, 1997), social and spiritual support systems (Doherty & McCubbin, 1985), and use of family and friends in the decision-making process (Webb & Koch, 1997). Collaborative care is emerging as an effective model of treatment (Gilbody, Bower, Fletcher, Richards, & Sutton, 2006), providing a framework in which to address the psychosocial needs of patients, improve health outcomes, reduce costs, and increase available resources and services to patients (Wagner, 2000). Collaborative care has been defined as a multidisciplinary team approach to delivering evidence-based care (Hedrick et al., 2003), one that provides an environment in which health-care professionals can teach one another and share resources (Sorrells-Jones & Weaver, 1999). The fields of medicine, pharmacy, social work, nursing, and pastoral care are key components to the success of collaborative teams (Cott, 1997). Research has supported the use of collaborative care in the treatment of mental disorders (Chang-Quan et al., 2009; Davies, McBride, & Sajatovic, 2008; Dewa, Hoch, Carmen, Guscott, & Anderson, 2009; Katon et al., 1999), heart disease (Brush et al., 2009; Coviello & Tadel, 2009), and diabetes (McElmurry et al., 2009; Phelps et al., 2009) and in the area of critical care (Carr, 2009). Collaborative care involving a working relationship between physicians and pharmacists has been shown to improve patient care and reduce medication errors (Kuo et al., 2004). A meta-analysis of 37 randomized studies of 12,355 patients diagnosed with depression reported that collaborative methods to improve medication adherence were more effective than standard care, improving both short- and long-term outcomes (Gilbody et al., 2006). The application of collaborative care in MTM is addressed in the next section. MEDICATION ADHERENCE AND MTM Medication Adherence To understand the impact of MTM, it is important to examine the issue of medication adherence. Medication behavior, the manner in which a patient adheres to prescribed medication use, strongly influences health outcomes, health-care use, improvements in medication knowledge, self-efficacy, and health-care costs (Chewning & Sleath, 1996; Delgado, 2000; Edworthy & Devins, 1999). …

The effectiveness of structured multidisciplinary rounding in acute care units on length of hospital stay and satisfaction of patients and staff: a systematic review protocol

Successfully Managing Attending Physicians

Background:Multidisciplinary team (MDT) meetings are considered a component of gold-standard care for patients with spondyloarthritis (SpA) and concomitant psoriasis (PsO) or inflammatory bowel disease (IBD). There are few published reports...