The effect of outreach workers' educational efforts on disadvantaged preschool children's use of preventive services. Improving access to specialist care for remote Aboriginal communities: evaluation of a specialist outreach service. Operation outreach: intensive case management for severely psychiatrically disabled adults. Effects of physician outreach programs on rural-urban differences in breast cancer management. Virtual outreach: a telemedicine pilot study using a cluster-randomized controlled design. Outreach education to improve quality of rural ICU care. Results of a randomized trial. Multicenter randomized controlled trial of an outreach nursing support program for recently discharged stroke patients. Use and impact of an automated telephone outreach system for asthma in a managed care setting. Evaluation of a mental health outreach service for homeless families.
A special program of outreach services was implemented to assist a poverty population to appropriately use health services in the Kaiser-Permanente Medical Care Program. A study was conducted to determine the effect of outreach workers' intervention on the use of preventive services by this population. Intially, families were divided into two groups, one with and one without outreach workers. Outreach workers (neighborhood health coordinators) were trained in prevention and health education. They were then assigned to specific subgroups of the poverty population to teach the importance of preventive services and to motivate persons to use these services. This paper focuses on the effect of outreach workers' services on the use of selected preventive care services (immunizations and tine test) by preschool children from poverty families. Preschool children in families with coordinator services had higher use rates for preventive care. The sub-group for which outreach workers were specially trained to focus on preventive procedures for the pre-school group had markedly higher use rates for preventive care. The findings suggest that special intervention programs, using indigenous and nonprofessional outreach workers, can increase preventive service utilization by poverty groups. To identify barriers faced by Aboriginal people from remote communities in the Northern Territory (NT) when accessing hospital-based specialist medical services, and to evaluate the impact of the Specialist Outreach Service (SOS) on these barriers.
                Combined quantitative and qualitative study.
                Remote Aboriginal communities in the "Top End" of the NT, 1993-1999 (spanning the introduction of the SOS in 1997).
                25 remote health practitioners, patients and SOS specialists.
                Numbers of consultations with specialists; average cost per consultation; perceived barriers to accessing hospital-based outpatient care; and perceived impact of specialist outreach on these barriers.
                Perceived barriers included geographic remoteness, poor doctor-patient communication, poverty, cultural differences, and the structure of the health service. Between 1993 and 1999, there were 5,184 SOS and non-SOS outreach consultations in surgical specialties. Intensive outreach practice (as in gynaecology and ophthalmology) increased total consultations by up to 441% and significantly reduced the number of transfers to hospital outpatient clinics (P< 0.001). Average cost per consultation was $277 for SOS consultations, compared with $450 at Royal Darwin Hospital and $357 at the closest regional hospital. Outreach has reduced barriers relating to distance, communication and cultural differences, and potentially bolsters existing primary healthcare services.
                When compared with hospital-based outpatient services alone, outreach is a more accessible, appropriate and efficient method of providing specialist medical services to remote Aboriginal communities in the NT. Twenty-eight severely mentally ill adults in an inner-city area of Atlanta participated in a study to determine if intensive outreach by case managers would result in decreased use of mental hospitals and improved community living. The experimental group of 14 clients received intensive support from case managers in the community who helped them anticipate and prevent crises, maintain medication schedules, and address problems in living. Fourteen clients in the control group received some of these same services but at a less intensive level and only at the offices of the case managers. Compared with control clients, experimental clients had an average of ten fewer hospital days and better adherence to medication regimens and agreed-upon service plans during the project. In 1986 to 1987, urban-rural differences in several breast cancer management practices were noted in Illinois data. Several intervention programs for physicians were initiated to improve rural patients' access to state-of-the-art breast cancer management to reduce these differences. This report compares an intensive rural oncology outreach intervention program with a lower intensity physician education program. Medical records from 1986 to 1991 were reviewed on 2,277 breast cancer patients in a 12-county study area. The care received by urban patients was compared with three groups of rural patients: those managed in rural hospitals with intensive oncology outreach programs beginning in 1988 (Rural group 1), and in those rural hospitals with less intensive interventions using an audit with feedback strategy beginning in 1989 (Rural group 2). Rural patients who traveled to one of the urban facilities also were included in the analysis because the less intensive interventions also took place in these facilities, and these patients showed unique patterns of care in the baseline analysis (Rural Group 3). The years 1986 to 1987 constituted the baseline, and 1990 to 1991 constituted the final evaluation period. Chi square and multivariate analyses were conducted to compare the effect of the two types of interventions on changing breast cancer management practices and reducing the urban-rural differences. By the final evaluation period, the high intensity intervention was not more successful in reducing or eliminating the urban-rural differences than the low intensity intervention for many practices. However, often the frequency estimates were higher in Rural Group 1, which received the high intensity intervention. The changes noted in Rural Group 3 were not always the same as in Rural Group 2, even though both received the same low intensity interventions, lending evidence to the observation that travel distance and other nonmedical factors affect the choices of management modalities for these patients. Finally, given the nonrandomized study design, other explanations for the changes could not be ruled out. A pilot study was carried out in preparation for a full-scale randomized controlled trial of teleconsultations versus routine outpatient consultation. The method of study recruited sufficient numbers of patients and avoided selection bias. Over five months, 439 referrals were received, but 297 patients were not eligible to enter the trial because they did not fall within the specialties/consultants included in it. Of the 132 referrals entering the trial, 62 were randomized to the intervention group and 70 to the control group. Consent to participate in the experimental arm of the trial was obtained for all but 13 patients. The results also suggested that patient satisfaction with teleconsultation may exceed that with conventional outpatient consultation, with a strong indication of overall time savings for patients. This study tests whether an outreach educational program tailored to institutional specific patient care practices would improve the quality of care delivered to mechanically ventilated intensive care unit (ICU) patients in rural hospitals. The study was conducted as a randomized control trial using 20 rural Iowa hospitals as the unit of analysis. Twelve randomly selected hospitals received an outreach educational program. After review of the medical records of eligible patients, a multidisciplinary team of intensive care unit specialists from an academic medical center delivered an educational program with content specific to the findings and capacity of the hospital. The outcome measures included patient care processes, patient morbidity and mortality outcomes, and resource use. Results indicated that the outreach program significantly improved many patient care processes (lab work, nursing, dietary management, ventilator management, ventilator weaning). The program marginally reduced hospital ventilator days. Both total length of stay and ICU length of stay fell markedly in the intervention group (by an average of 3.2 and 2.1 d, respectively), while the control group fell only 0.6 and 0.3 d, respectively. However, these effects did not reach statistical significance. Unfortunately, the program had no detectable effects on the clinical outcomes of mortality or nosocomial events. We conclude that an outreach program of this type can effectively improve processes of care in rural ICUs. However, improving processes of care may not always translate into improvement of specific outcomes. Many stroke patients and informal carers experience a decreased quality of life after discharge home and are dissatisfied with the care received. We assessed the effectiveness of an outreach nursing care program.
                In a multicenter trial, 536 stroke patients were randomized at discharge to standard care (n=273) or standard care plus outreach care (n=263). The outreach care consisted of 3 telephone calls and 1 home visit within 5 months after discharge by 1 of 13 stroke nurses. Patients were masked for the trial objectives. Six months after discharge, they assessed the 2 primary outcomes: quality of life (Short Form 36 [SF-36]) and dissatisfaction with care. Secondary measures of outcome were disability, handicap, depression, anxiety, and use of health care services and secondary prevention drugs. Informal carers assessed strain, and social support. Analysis was by intention to treat.
                Twelve patients died before follow-up, 38 declined outcome assessment, and 486 completed the primary outcome assessments. Outreach care patients had better scores on the SF-36 domain "Role Emotional" than controls (mean difference 7.9 [95% confidence limit, 0.1 to 15.7]). No statistically significant differences were found on the other primary outcome measures. For secondary outcomes, no statistically significant differences were found, except that intervention patients used fewer rehabilitation services (relative risk, 0.66 [0.44 to 1.00]) and had lower anxiety scores (median difference 1 [0.19 to 2.79]).
                This outreach nursing stroke care was not effective in improving quality of life and dissatisfaction with care of recently discharged patients. To test the ability of an automated telephone outreach intervention to reduce acute healthcare utilization and improve quality of life among adult asthma patients in a large managed care organization.
                Randomized clinical trial.
                Patients with persistent asthma were randomly assigned to telephone outreach (automated = 3389, live caller = 192) or usual care (n = 3367). Intervention participants received 3 outreach calls over a 10-month period. The intervention provided brief, supportive information and flagged individuals with poor asthma control for follow-up by a provider. A survey was mailed to 792 intervention participants and 236 providers after the intervention. Additional feedback was obtained as part of the final intervention contact.
                The intent-to-treat analysis found no significant differences between the intervention and usual-care groups for medication use, healthcare utilization, asthma control, or quality of life. Post hoc analyses found that, compared with the control group, individuals who actually participated in the intervention were significantly more likely to use inhaled steroids and to have had a routine medical visit for asthma during the follow-up period and less likely to use short-acting beta-agonists. They also reported higher satisfaction with their asthma care and better asthma-specific quality of life. Of surveyed providers, 59% stated the program helped them to clinically manage their asthma patients and 70% thought the program should be continued.
                This study did not find improved health outcomes in the primary analyses. The intervention was well accepted by providers, however, and the individuals who participated in the calls appeared to have benefited from them. These findings suggest that further studies of automated telephone outreach interventions seem warranted. To describe the characteristics of homeless children and families seen by the mental health outreach service (MHOS), to evaluate the impact of this service on the short term psychosocial functioning of children and parents, and to establish perceptions of, and satisfaction with, the service.
                Twenty seven children from 23 families who were in receipt of the MHOS and 27 children from 23 families residing in other hostels where no such service was available were studied. The MHOS was delivered by a clinical nurse specialist with expertise in child mental health, who offered the following interventions: assessment and brief treatment of mental health disorders in children; liaison with agencies; and training of homeless centre staff.
                Children in the experimental group had a significantly higher decrease in Strengths and Difficulties Questionnaire (SDQ) total scores. Having received the intervention was the strongest predictor of improvement in SDQ total scores. There was no significant impact on parental mental health (General Health Questionnaire) scores. Homeless families and staff expressed high satisfaction with the MHOS.
                This MHOS for homeless families is an innovative intervention which meets the complex and multiple needs of a vulnerable population unable to access mainstream mental health services. The primary objective of the service was to improve child mental health problems; however, the service developed in a responsive way by meeting social and practical needs of families in addition to its clinical role.
This review supports the hypothesis that specialist outreach can improve access, outcomes and service use, especially when delivered as part of a multifaceted intervention. The benefits of simple outreach models in urban non-disadvantaged settings seem small. There is a need for good comparative studies of outreach in rural and disadvantaged settings where outreach may confer most benefit to access and health outcomes.