Integrating primary care and behavioral health with four special populations: Children with special needs, people with serious mental illness, refugees, and deaf people

Special patient populations can present unique opportunities and challenges to integrating primary care and behavioral health services. This article focuses on four special populations: children with special needs, persons with severe and persistent mental illness, refugees, and deaf people who communicate via sign language. The current state of primary care and behavioral health collaboration regarding each of these four populations is examined via Doherty, McDaniel, and Baird's (1996) five-level collaboration model. The section on children with special needs offers contrasting case studies that highlight the consequences of effective versus ineffective service integration. The challenges and potential benefits of service integration for the severely mentally ill are examined via description of PRICARe (Promoting Resources for Integrated Care and Recovery), a model program in Colorado. The discussion regarding a refugee population focuses on service integration needs and emerging collaborative models as well as ways in which refugee mental health research can be improved. The section on deaf individuals examines how sign language users are typically marginalized in health care settings and offers suggestions for improving the health care experiences and outcomes of deaf persons. A well-integrated model program for deaf persons in Austria is described. All four of these special populations will benefit from further integration of primary care and mental health services.

Simultaneous Bilateral Anterior Approach Total Hip Arthroplasty

Simultaneous bilateral total hip arthroplasty (THA) has been performed successfully, with good outcomes and low complication rates reported. Most published studies on the topic used anterolateral or posterior surgical approaches. The anterior approach is performed under live fluoroscopy with the patient supine, obviating the need for patient repositioning during bilateral surgery. The authors report their experience with simultaneous bilateral anterior approach total hip arthroplasty. The authors retrospectively reviewed data for 75 patients (150 hips). Mean follow-up was 26 months (range, 5-60 months). Mean patient age was 59 years and the majority were American Society of Anesthesiology class 2 (range, 1-3). Mean total surgical time was 144 minutes (72 minutes per hip). Mean blood loss was 565 mL. Mean hospital length of stay was 2.75 days (range, 1-4 days). Ninety-six percent of patients were able to ambulate on postoperative day 1. Sixty-eight percent of patients were discharged to home. Mean Harris Hip Score improved from 50 to 97. All patients noted a return to preoperative level of activity or higher. Complications included 1 atraumatic minimally displaced trochanteric fracture occurring 2 weeks postoperatively, 1 pulmonary embolism on postoperative day 3 treated without sequelae, 1 episode of postoperative atrial fibrillation, and 4 minor local wound complications. No readmission, infection, nerve palsy, dislocation, reoperation, or death occurred. Anterior approach THA has the advantage of a single supine position for bilateral simultaneous surgery and the current study supports its use in appropriate patients.

Considerations for the Perioperative Care of Elderly and Frail Patients

The number of elderly patients undergoing anesthesia is increasing. At the same time aging is associated with decreased functional reserve of all major organ systems and an increase in comorbid conditions, requiring a comprehensive perioperative evaluation to minimize morbidity and mortality. The preoperative assessment should focus on the risk/benefit analysis vis-à-vis the proposed intervention, allowing the practitioner to adapt surgical and anesthetic care, as well optimize health and functional status. In addition to the usual evaluation for cardiac and pulmonary risk, the preoperative assessment in the older patient should also address the risk of postoperative cognitive dysfunction and delirium. 'Do-not-resuscitate' orders must be clarified with the patients or substitute decision maker. Studies have not been able to clearly show the superiority of one anesthetic approach for the geriatric patient, although there are probably advantages to using regional anesthetic techniques. Overall the patient's preoperative functional status along with the proposed intervention is the primary determinants of the patient's long term functional outcome and wellbeing. The elderly patient may be at his most vulnerable during the postoperative phase, and a relatively high frequency of adverse events in the elderly, including respiratory insufficiency, myocardial and cerebrovascular ischemia, renal failure, infectious complications as well as delirium and postoperative cognitive dysfunction have been observed. Perioperative interventions should target modifiable risk factors and the avoidance of even minor complications with an ultimate goal of improving long-term outcome.

Marantic endocarditis presenting with multifocal neurological symptoms

Non-bacterial thrombotic endocarditis (NBTE), also known as marantic endocarditis, has been reported to occur in 0.3-9.3% of the adult population at autopsy. NBTE associated with malignancy is an underrecognised cause of thromboembolic disorders. The clinical spectrum encountered and investigation results can be non-specific, often mimicking other acute conditions such as infective endocarditis. We describe the case of a 34-year-old woman with non-localising and multifocal neurological symptoms, who was subsequently diagnosed with NBTE secondary to a resectable primary lung adenocarcinoma.

Prevalence of Dirofilaria immitis (Nematoda: Filarioidea) in mosquitoes from northeast Arkansas, the United States

A mosquito survey was conducted to identify which species of mosquitoes carry Dirofilaria immitis (Leidy) (Nematoda: Filarioidea), dog heartworm, in northeast Arkansas. Using polymerase chain reaction, mosquitoes were analyzed for D. immitis, Dirofilaria repens Railliet & Henry, and Acanthocheilonema dracunculoides Cobbold. Mosquitoes were collected from April to October 2009 using black light ultraviolet traps baited with dry ice. Sixteen mosquito species were identified. D. immitis was identified in nine mosquito species, which included Aedes vexans (Meigen), Anopheles quadrimaculatus Say, Anopheles punctipennis (Say), Culex pipiens quinquefasciatus Say, Culex erraticus (Dyer & Knab), Culiseta inornata (Williston), Psorophora columbiae (Dyer & Knab), Psorophora ferox (Humboldt), and Psorophora howardii Coquillett. No D. repens or A. dracunculoides DNA was amplified. Of the 1,212 mosquito pools tested, 7.3% were positive for D. immitis. Frequency of D. immitis infections from six collection sites ranged from 2.1 to 19.4%. Ae. vexans and An. quadrimaculatus were the two most abundant species, composing 58.7 and 23.7% of the total mosquitoes collected, with 9.6 and 6.9% of pools positive for D. immitis, respectively. To investigate localized vector infection rates of D. immitis, mosquitoes were collected from inside the kennel of a heartworm-positive dog. Of the 114 mosquitoes collected, 84 (73.7%) were positive for D. immitis. The frequency of D. immitis-infected mosquitoes collected near a heartworm-positive dog was considerably higher than in the original six collection sites, suggesting a single heartworm-positive dog potentially increases infection pressure on susceptible animals sharing mosquito exposure.

Commentary: What are the benefits of training deaf and hard-of-hearing doctors?

Deaf and hard-of-hearing (DHoH) individuals are underrepresented among physicians and physicians-in-training, yet this group is frequently overlooked in the diversity efforts of many medical training programs. The inclusion of DHoH individuals, with their diverse backgrounds, experiences, and struggles, contributes to medical education and health care systems in a variety of ways, including (1) a richer medical education experience for students and faculty resulting in greater disability awareness and knowledge about how to interact with and care for DHoH individuals and their families, (2) the provision of empathetic care desired by many patients and their families, including individuals who have a disability or chronic condition, and (3) the promotion of a more supportive and accessible professional environment for physicians, including older physicians in practice and as educators, who are experiencing age-associated decreased hearing acuity or other acquired disabilities.Today, many qualified DHoH individuals face barriers to pursuing medical careers even while physicians who become DHoH can continue to practice medicine. These barriers still exist two decades after the implementation of the Americans with Disabilities Act of 1990 and despite technological advancements and changing attitudes. In light of the findings by Moreland and colleagues, the authors of this commentary discuss reasons to include DHoH individuals in the physician workforce, explain why this group remains underrepresented among physicians, and suggest ways that medical schools and training programs can ensure fair application processes and inclusive educational opportunities for work with DHoH students who are interested in health care careers.

Hearing loss and older adults' perceptions of access to care

We investigated whether hard-of-hearing older adults were more likely to report difficulties and delays in accessing care and decreased satisfaction with healthcare access than those without hearing loss. The Wisconsin Longitudinal Study (2003-2006 wave, N = 6,524) surveyed respondents regarding hearing, difficulties/delays in accessing care, satisfaction with healthcare access, socio-demographics, chronic conditions, self-rated health, depression, and length of relationship with provider/site. We used multivariate regression to compare access difficulties/delays and satisfaction by respondents' hearing status (hard-of-hearing or not). Hard-of-hearing individuals comprised 18% of the sample. Compared to those not hard-of-hearing, hard-of-hearing individuals were significantly more likely to be older, male and separated/divorced. They had a higher mean number of chronic conditions, including atherosclerotic vascular disease, diabetes and depression. After adjustment for potential confounders, hard-of-hearing individuals were more likely to report difficulties in accessing healthcare (Odds Ratio 1.85; 95% Confidence Interval 1.19-2.88). Satisfaction with healthcare access was similar in both groups. Our findings suggest healthcare access difficulties will be heightened for more of the population because of the increasing prevalence of hearing loss. The prevalence of hearing loss in this data is low and our findings from a telephone survey likely underestimate the magnitude of access difficulties experienced by hard-of-hearing older adults. Further research which incorporates accessible surveys is needed. In the meantime, clinicians should pay particular attention to assessing barriers in healthcare access for hard-of-hearing individuals. Resources should be made available to proactively address these issues for those who are hard-of-hearing and to educate providers about the specific needs of this population.

Using graded motor imagery for complex regional pain syndrome in clinical practice: failure to improve pain

BACKGROUND

There is good evidence from studies conducted in a single-centre research setting for the efficacy of graded motor imagery (GMI) treatment, a complex physiotherapy intervention, to reduce pain in long-standing complex regional pain syndrome (CRPS). However, whether GMI is effective in clinical practice is not established.

AIM

To establish whether GMI is effective in clinical practice.

METHODS

We undertook a prospective audit of GMI treatment at two UK centres with a special interest in the management of patients with CRPS. All patients received GMI, in conjunction with a range of other 'best practice' physical and psychological interventions.

RESULTS

The patients' average pain intensities did not improve with treatment [centre 1: n = 20, pre-post numeric rating scale (NRS) difference 0.6 [confidence interval (CI) -0.3 to 1.5]; centre 2: n = 12, pre-post NRS difference 0.2 (CI: -0.9 to 1.2)]. Patients at centre 1 reported significant functional improvement. Improved performance on left/right judgement replicated in both centres seen in the clinical trials.

CONCLUSIONS

The failure of our real-world implementation of GMI suggests that better understanding of both the GMI methodology and its interaction with other treatment methods is required to ensure that GMI research results can be translated into clinical practice. Our results highlight challenges with the translation of complex interventions for chronic pain conditions into clinical practice.

Community participatory research with deaf sign language users to identify health inequities

Deaf people who use American Sign Language (ASL) are medically underserved and often excluded from health research and surveillance. We used a community participatory approach to develop and administer an ASL-accessible health survey. We identified deaf community strengths (e.g., a low prevalence of current smokers) and 3 glaring health inequities: obesity, partner violence, and suicide. This collaborative work represents the first time a deaf community has used its own data to identify health priorities.

Role-reversal exercise with Deaf Strong Hospital to teach communication competency and cultural awareness

OBJECTIVE

To implement a role-reversal exercise to increase first-year pharmacy students' awareness of communication barriers in the health care setting, especially for deaf and hard-of-hearing patients.

DESIGN

Volunteers from the local deaf community conducted Deaf Strong Hospital, a role-reversal exercise in which students were the "patients." Students navigated through a reception area, encounter with a physician, and having a prescription filled at a pharmacy without receiving or using any spoken language.

ASSESSMENT

A debriefing session was held in which small groups of students had the opportunity to ask questions of a panel of deaf and hard-of-hearing volunteers. On a survey administered to assess students' learning, 97% agreed or strongly agreed that the experience would likely impact their attitudes and behavior in future interactions with patients who did not speak English.

CONCLUSIONS

The role-reversal exercise was an effective method of teaching students that the delivery of health care is dependent on adequate communication between health care providers and the patient.

Independent health care: using a board-to-ward approach to achieve improvement in infection prevention standards

The Health and Social Care Act 2008 places a legal responsibility upon healthcare organisations to provide a clean environment where infection risks are minimised. From April 2010, the regulation of both the NHS and the independent healthcare sector will, for the first time, fall under the same legislative framework. Nuffield Health (NH) is an independent healthcare provider with 30 acute hospitals. Strategic management of infection prevention is led by the NH Director for Infection Prevention. Management at the hospital level is led by the matron/Director for Infection Prevention and Control supported by trained infection prevention link practitioners (IPLPs). High-quality infection prevention across a large geographical area presents many challenges and IPLPs have been used to both monitor and improve the quality of infection prevention using national audit tools and acting as role models to influence practice. Audit results over 4 years demonstrate yearly improvements and low rates of healthcare-associated infections.