Continuity of care in mental health: understanding and measuring a complex phenomenon

Healthcare professionals' experiences and views of providing continence support and advice to people living at home with dementia: "That's a carer's job"

BACKGROUND

People living with dementia at home and their family carers often feel unsupported by healthcare professionals in managing continence problems. In turn, primary and community-based healthcare professionals have reported lacking specific knowledge on dementia-continence. This study aimed to understand more about healthcare professionals' experiences and views of supporting people living with dementia experiencing continence problems, as part of developing acceptable resources. Having a nuanced understanding of unmet need would facilitate the design of engaging resources that enable healthcare professionals to provide more effective continence support to people living with dementia at home.

METHODS

Semi-structured interviews were conducted with a range of healthcare professionals (n = 31) working in primary and community care in the South of England in 2023. Transcribed interviews were uploaded to NVivo 12, then analysed inductively and deductively using a thematic framework.

RESULTS

Continence-related conversations were avoided by many healthcare professionals due to lack of dementia-continence specific knowledge. Many considered that continence problems of people living with dementia were largely outside their remit once a physical cause had been ruled out. This contributed to a lack of priority and proactivity in raising the subject of continence in their consultations. Challenges to providing support included limited consultation time and lack of access to specialist services with availability to support individuals.

CONCLUSION

There is substantial scope to support primary and community-based healthcare professionals in their provision of continence-related support and advice to people living at home with dementia. This includes addressing knowledge deficits, enhancing confidence and instilling a sense of accomplishment.

Relational continuity may give better clinical outcomes in patients with serious mental illness - a systematic review

BACKGROUND

Continuity of care is considered important for results of treatment of serious mental illness (SMI). Yet, evidence of associations between relational continuity and different medical and social outcomes is sparse. Research approaches differ considerably regarding how to best assess continuity as well as which outcome to study. It has hitherto been difficult to evaluate the importance of relational continuity of care. The aim of this systematic review was to investigate treatment outcomes, including effects on resource use and costs associated with receiving higher relational continuity of care for patients with SMI.

METHODS

Eleven databases were searched between January 2000 and February 2021 for studies investigating associations between some measure of relational continuity and health outcomes and costs. All eligible studies were assessed for study relevance and risk of bias by at least two independent reviewers. Only studies with acceptable risk of bias were included. Due to study heterogeneity the synthesis was made narratively, without meta-analysis. The certainty of the summarized result was assessed using GRADE. Study registration number in PROSPERO: CRD42020196518.

RESULTS

We identified 8 916 unique references and included 17 studies comprising around 300 000 patients in the review. The results were described with regard to seven outcomes. The results indicated that higher relational continuity of care for patients with serious mental illness may prevent premature deaths and suicide, may lower the number of emergency department (ED) visits and may contribute to a better quality of life compared to patients receiving lower levels of relational continuity of care. The certainty of the evidence was assessed as low or very low for all outcomes. The certainty of results for the outcomes hospitalization, costs, symptoms and functioning, and adherence to drug treatment was very low with the result that no reliable conclusions could be drawn in these areas.

CONCLUSIONS

The results of this systematic review indicate that having higher relational continuity of care may have beneficial effects for patients with severe mental illness, and no results have indicated the opposite relationship. There is a need for better studies using clear and distinctive measures of exposure for relational continuity of care.

French mental health care system: Analysis of care utilisation patterns and the case for a stepped care approach

CONTEXT

In France, spending on mental health and psychiatric care, in proportion to GDP, is close to the EU average. However, there are complaints that the French system is overwhelmed and potentially underfunded.

OBJECTIVE

To describe the utilisation of psychiatric and mental health care in different settings to consider the appropriateness of care provision and resource allocation.

METHODS

For the year 2018, several national databases on the use of all type of psychiatric care provision (full and part-time hospitalisations, private and public, public ambulatory care, private office-based psychiatrists) were cross-tabulated with diagnosis categories for different age groups and illness severity in order to assess the use of resources and evaluate the appropriateness of resource allocation.

RESULTS

A sizable proportion of patients with mild and moderate mental disorders are treated in psychiatric care whilst there is insufficient continuity of care for patients with severe disorders, who are not adequately followed up after discharge from hospitals. This contributes to increase the rate of re-hospitalisations, the use of emergency departments, and longer stays in hospitals.

CONCLUSION

The several components of the French mental health care system are used inappropriately, not only in geographical terms but also in terms of service use. We argue that strengthening the access to affordable psychotherapy and the implementation of a stepped-care approach could contribute to solve this issue.

Association between continuity of care and treatment outcomes in psychiatric patients in Germany: a prospective cohort study

BACKGROUND

Continuity of care is considered an important treatment aspect of psychiatric disorders, as it often involves long-lasting or recurrent episodes with psychosocial treatment aspects. We investigated in two psychiatric hospitals in Germany whether the positive effects of relational continuity of care on symptom severity, social functioning, and quality of life, which have been demonstrated in different countries, can also be achieved in German psychiatric care.

METHODS

Prospective cohort study with a 20-months observation period comparing 158 patients with higher and 165 Patients with lower degree of continuity of care of two psychiatric hospitals. Patients were surveyed at three points in time (10 and 20 months after baseline) using validated questionnaires (CGI Clinical Global Impression rating scales, GAF Global Assessment of Functioning scale, EQ-VAS Euro Quality of Life) and patient clinical record data. Statistical analyses with analyses of variance with repeated measurements of 162 patients for the association between the patient- (EQ-VAS) or observer-rated (CGI, GAF) outcome measures and continuity of care as between-subject factor controlling for age, sex, migration background, main psychiatric diagnosis group, duration of disease, and hospital as independent variables.

RESULTS

Higher continuity of care reduced significantly the symptom severity with a medium effect size (p 0.036, eta 0.064) and increased significantly social functioning with a medium effect size (p 0.023, eta 0.076) and quality of life but not significantly and with only a small effect size (p 0.092, eta 0.022). The analyses of variance suggest a time-independent effect of continuity of care. The duration of psychiatric disease, a migration background, and the hospital affected the outcome measures independent of continuity of care.

CONCLUSION

Our results support continuity of care as a favorable clinical aspect in psychiatric patient treatment and encourage mental health care services to consider health service delivery structures that increase continuity of care in the psychiatric patient treatment course. In psychiatric health care services research patients' motives as well as methodological reasons for non-participation remain considerable potential sources for bias.

TRIAL REGISTRATION

This prospective cohort study was not registered as a clinical intervention study because no intervention was part of the study, neither on the patient level nor the system level.

The Consequences of Discontinuing a Home Care Service for Patients with Severe Mental Illness After the COVID-19 Pandemic

Continuity of care has been considered, as a key component of the treatment process, especially after discharge from the hospital. Establishing treatment continuity is critical to achieving successful treatment outcomes. Roozbeh Home Care Program was developed to ensure the continuity of care in patients with severe mental illness. This study aims to investigate the consequences of discontinuing a home care service including; relapse, readmission, service satisfaction, severity and disability, in patients with severe mental illness in Iran. Forty-three patients who received home care service for more than 6 months were included. They were assessed 3 and 6 months after receiving the service; and 12 months after the program discontinuation. There was a significant difference between the hospitalization rate during (0.42 ± 0.64) and 1 year after the program's discontinuation (0.65 ± 1.46). The majority of the caregivers (70%) were highly satisfied with the home care services. Among the patients who received the homecare services, 40.4% were highly satisfied; and 21.2% were moderately satisfied. There was no significant difference between disability (as measured by World Health Organization Disability Assessment Schedule), clinical improvement (as measured by Clinical Global Impression-Improvement Scale), or severity of illness (as measured by Clinical Global Impression Severity of the Illness Scale) during and 1 year after program's discontinuation. During the time of receiving the service, hospitalization rate was reduced. Patients and caregivers were satisfied with the service. Providing psychiatric services at home should be considered as a solution to maintain the continuity of care.

Lack of continuity of care experienced by people diagnosed with schizophrenia in South Korea

People diagnosed with schizophrenia (PDS) will find seamlessly coordinated services and care in their communities if they are delivered with a high level of continuity of care (COC). Most studies of COC were conducted in Western countries that initiated deinstitutionalisation several decades ago. Limited studies highlight experiences of COC among PDS who live in societies still heavily relying on institutionalised care, such as prolonged hospitalisation, like South Korea where PDS stay in psychiatric hospitals over 100 days on average. This qualitative study explored COC that PDS experienced in South Korea. We focused on cross-boundary COC, which refers to service coordination at a given moment, and longitudinal COC, which refers to care over a period of time. Twenty-one PDS completed in-depth interviews from June to August 2017. Fifteen participants were male (71.4%), and ages ranged from 26 to 71. We used grounded theory techniques for data analysis, including initial open coding, in vivo coding, constant comparison and axial coding. Findings include that PDS experienced poor longitudinal COC when discharge planning during hospitalisation was absent, which undermined their ability to live independently. Poor employment support effectively undermined recovery even if PDS worked hard to attain economic self-sufficiency. As for cross-boundary COC, poor communication between psychiatrists and providers offering psychiatric rehabilitation services was a barrier. PDS in general had difficulties locating needed psychiatric rehabilitation services in the community. The lack of COC appeared to arise from particular sociocultural contexts, including poor self-determination in consumer-provider relationships, families' lack of knowledge and support, and discrimination and prejudice. Despite experiences with discrimination, no participants appeared to have internalised messages that they are 'less than' those without mental illnesses. Findings highlight the significance of multi-pronged approaches to increase COC, which can effectively link PDS, families, psychiatrists and psychiatric rehabilitation service providers.

A comparative study of two Mobile Mental Health Units in different catchment rural areas in Greece

BACKGROUND

Mental healthcare service delivery in rural and remote areas in Greece is challenging due to socioeconomic and geographical reasons, and distant facilities. To address the needs of the underserved areas, the Greek state has launched a number of Mobile Mental Health Units (MMHUs).

AIM

The objective of the present study was to explore the differences among two MMHUs, one being run by a university general hospital (MMHU UHA) and the other being run by a nongovernmental organization (MMHU I-T).

METHODS

The two MMHUs deliver services in rural areas of northeast and northwest Greece, respectively. Both MMHUs use the infrastructures of the primary healthcare system and have the potential for domiciliary visits.

RESULTS

Medical and nursing staff is much more in the MMHU UHA, whereas MMHU I-T has more psychologists, social workers and health visitors. Patients attended the MMHU I-T were significantly older than the patients attended the MMHU UHA (mean age 64.5 vs. 55.3 years) and the percentage of the elderly patients in treatment with the MMHU I-T (56.5%) is significantly higher than the corresponding percentage of the MMHU UHA (20%). The proportion of patients that received home-based care by the two MMHUs was almost identical. The percentage of patients with schizophrenia spectrum disorders that attended the MMHU UHA was significantly higher. Patients with affective disorders, anxiety disorders and organic brain disorders that attended the MMHU I-T were significantly more.

CONCLUSIONS

Despite the similarities among the MMHUs in rural Greece, this study recorded some important differences. The differences in staffing may be accounted for by the availability of resources. The differences in the patients' population may be explained by the fact that the MMHU UHA was designed from its beginning to treat patients with severe mental illnesses, mainly psychoses, and it accepts loss of referrals within the general hospital's network of psychiatric services. The MMHU I-T is an independent, locally based service that may be better perceived as an expansion of the primary care system. The results of the study could inform service practice and mental health policy.

Decrease of Hospitalizations and Length of Hospital Stay in Patients with Schizophrenia Spectrum Disorders or Bipolar Disorder Treated in a Mobile Mental Health Service in Insular Greece

In recent years serious mental health issues, such as schizophrenia spectrum disorders and bipolar disorder, have been treated in the community by community-based mental health services. In the present study our goal was to estimate the modification in the number of hospitalizations and duration of admissions in either psychotic patients or patients with bipolar disorder, treated by a Mobile Mental Health Unit in the islands of Kefalonia, Zakynthos and Ithaca (MMHU-KZI). Data were collected from a total of 108 patients with schizophrenia spectrum disorders and bipolar disorder. For each patient comparison was made for the same time interval prior and after engagement to treatment with the MMHU-KZI and not for the total hospitalizations that patients had in their history. There was a statistically significant reduction (45.9%) in hospitalizations after treatment engagement with the MMHU-KZI, as the Wilcoxon signed ranks test indicated. Furthermore, a major decrease (54.5%) of hospitalization days was noted after treatment engagement with the unit. This pattern of mental health provision may be beneficial for the reduction of the number and duration of psychiatric hospitalizations. Despite the beneficial contribution of community-based mental health units, hospital based treatment should always be available, since severe relapses are better treated in inpatient setting.

Professionals' perspectives on factors within primary mental health services that can affect pathways to involuntary psychiatric admissions

Background

Reducing involuntary psychiatric admissions has been on the international human rights and health policy agenda for years. Despite the last decades’ shift towards more services for adults with severe mental illness being provided in the community, most research on how to reduce involuntary admissions has been conducted at secondary health care level. Research from the primary health care level is largely lacking. The aim of this study was to explore mental health professionals’ experiences with factors within primary mental health services that might increase the risk of involuntary psychiatric admissions of adults, and their views on how such admissions might be avoided.

Methods

Qualitative semi-structured interviews with thirty-two mental health professionals from five Norwegian municipalities. Data were analysed according to the Systematic Text Condensation method.

Results

Within primary mental health care professionals experienced that a number of factors could increase the risk of involuntary psychiatric admissions. Insufficient time and flexibility in long-term follow-up, limited resources, none or arbitrary use of crisis plans, lack of tailored housing, few employment opportunities, little diversity in activities offered, limited opportunities for voluntary admissions, inadequate collaboration between services and lack of competence were some of the factors mentioned to increase the risk of involuntary psychiatric admissions. Several suggestions on how involuntary psychiatric admissions might be avoided were put forward.

Conclusions

Mental health professionals within primary mental health care experienced that their services might play an active part in preventing the use of involuntary psychiatric admissions, suggesting potential to facilitate a reduction by intervening at this service level. Health authorities’ incentives to reduce involuntary psychiatric admissions should to a greater extent incorporate the primary health care level. Further research is needed on effective interventions and comprehensive models adapted for this care level.

Decrease of hospitalizations and length of hospital stay in patients with schizophrenia spectrum disorders treated in a community mental health service in rural Greece

BACKGROUND

The treatment of severe and chronic mental disorders, such as schizophrenia and related syndromes, is largely based on community mental health services.

AIMS

The objective of the present study was to assess hospital admissions and length of hospital stay in patients with schizophrenia and related disorders, who are engaged to treatment with a Mobile Mental Health Unit (MMHU I-T) in a defined rural catchment area in Greece.

METHOD

Data were retrieved retrospectively for 76 patients with schizophrenia and related disorders. For each patient, comparison was made for the same interval prior and after engagement to treatment with the MMHU I-T.

RESULTS

The average age of patients was 56 years and the mean illness duration was 28 years. The mean follow-up duration was 5.3 years. There was a statistically significant decrease in the annual average of the number of voluntary and involuntary hospitalizations and on days of hospital stay after treatment engagement with the MMHU I-T.

CONCLUSIONS

Treatment of schizophrenia spectrum disorders in rural residents by the MMHUs may contribute to the reduction of patients' admissions and length of hospital stay. Future research should address the cost-effectiveness of such interventions.

Factors Associated with Perceived Continuity of Care Among Patients Suffering from Mental Disorders

This cross-sectional study identified variables associated with continuity of care among 327 patients with mental disorders receiving services from a variety of professionals in different Quebec settings. Based on the Andersen's Behavioral Model, a linear regression analysis was performed. Attention deficit and mood disorders were negatively associated with continuity of care, while substance use disorders and quality of life revealed positive associations. Consulting a psychologist was linked to weaker continuity of care whereas visiting a drug rehabilitation center, social support, and satisfaction with services were positively related. Fostering social support, comprehensive and integrated care, and facilitating access to psychologists could lead to improved continuity of care.

Coordinating Mental Health Services for People with Serious Mental Illness: A Scoping Review of Transitions from Psychiatric Hospital to Community

Effective coordination as people with serious mental illness (SMI) move between care settings is essential. We aimed to review challenges to care coordination for people with SMI and identify approaches for improving it. Sixteen articles were identified. Two main challenges emerged: people with SMI facing adjustment challenges during transitions and services struggling to provide continuity of care. Effective approaches addressed coordination challenges and resulted in better improvements in service utilization, social functioning and quality of life. Future interventions may benefit from shared decision-making, support for caregivers, and addressing the challenges associated with complicated medication regimes and accessing medications.

Key dimensions of collaboration quality in mental health care service networks

Appropriate care delivery for patients with severe mental illness (SMI) requires a high level of collaboration quality between primary, mental health, and social care services. Few studies have addressed the interpersonal and inter-organizational components of collaboration within one unique study setting and it is unclear how these components contribute to overall collaboration quality. Using a comprehensive model that includes ten key indicators of collaboration in relation to both components, we evaluated how interpersonal and inter-organizational collaboration quality were associated in 19 networks that included 994 services across Belgium. Interpersonal collaboration was significantly higher than inter-organizational collaboration. Despite the internal consistency of the model, analysis showed that respondents perceived a conflict between client-centered care and leadership in the network. Our results reveal two approaches to collaborative service networks, one relying on interpersonal interactions and driven by client needs and another based on formalization and driven by governance procedures. The results reflect a lack of strategy on the part of network leaders for supporting client-centered care and hence, the persistence of the high level of fragmentation that networks were expected to address. Policy-makers should pay more attention to network formalization and governance mechanisms with a view to achieving effective client-centered outcomes.

Healthcare system performance in continuity of care for patients with severe mental illness: A comparison of five European countries

Most healthcare systems struggle to provide continuity of care for people with chronic conditions, such as patients with severe mental illness. In this study, we reviewed how system features in two national health systems (NHS) - England and Veneto (Italy) - and three regulated-market systems (RMS) - Germany, Belgium, and Poland -, were likely to affect continuing care delivery and we empirically assessed system performance. 6418 patients recruited from psychiatric hospitals were followed up one year after admission. We collected data on their use of services and contact with professionals and assessed care continuity using indicators on the gap between hospital discharge and outpatient care, access to services, number of contacts with care professionals, satisfaction with care continuity, and helping alliance. Multivariate regressions were used to control for patients' characteristics. Important differences were found between healthcare systems. NHS countries had more effective longitudinal and cross-sectional care continuity than RMS countries, though Germany had similar results to England. Relational continuity seemed less affected by organisational mechanisms. This study provides straightforward empirical indicators for assessing healthcare system performance in care continuity. Despite systems' complexity, findings suggest that stronger regulation of care provision and financing at a local level should be considered for effective care continuity.

Rising co-payments coincide with unwanted effects on continuity of healthcare for patients with schizophrenia in the Netherlands

BACKGROUND

Co-payments, used to control rising costs of healthcare, may lead to disruption of appropriate outpatient care and to increases in acute crisis treatment or hospital admission in patients with schizophrenia. An abrupt rise in co-payments in 2012 in the Netherlands offered a natural experiment to study the effects of co-payments on continuity of healthcare in schizophrenia.

METHODS

Retrospective longitudinal registry-based cohort study. Outcome measures were (i) continuity of elective (planned) psychiatric care (outpatient care and/or antipsychotic medication); (ii) acute psychiatric care (crisis treatment and hospital admission); and (iii) somatic care per quarter of the years 2009-2014.

RESULTS

10 911 patients with schizophrenia were included. During the six-year follow-up period the level of elective psychiatric outpatient care (-20%); and acute psychiatric care (-37%) decreased. Treatment restricted to antipsychotic medication (without concurrent outpatient psychiatric care) increased (67%). The use of somatic care also increased (24%). Use of acute psychiatric care was highest in quarters when only antipsychotic medication was received. The majority (59%) of patients received continuous elective psychiatric care in 2009-2014. Patients receiving continuous care needed only half the acute psychiatric care needed by patients not in continuous care. On top of these trends time series analysis (ARIMA) showed that the abrupt rise in co-payments from 2012 onwards coincided with significant increases in stand-alone treatment with antipsychotic medication and acute psychiatric care.

CONCLUSIONS

The use of psychiatric care decreased substantially among a cohort of patients with schizophrenia. The high rise in co-payments from 2012 onwards coincided with significant increases in stand-alone treatment with antipsychotic medication and acute psychiatric care.

Continuity of care and clinical outcomes in the community for people with severe mental illness

BACKGROUND

High continuity of care is prized by users of mental health services and lauded in health policy. It is especially important in long-term conditions like schizophrenia. However, it is not routinely measured, and therefore not often evaluated when service reorganisations take place. In addition, the impact of continuity of care on clinical outcomes is unclear.AimsWe set out to examine continuity of care in people with schizophrenia, and to relate this to demographic variables and clinical outcomes.

METHOD

Pseudoanonymised community data from 5552 individuals with schizophrenia presenting over 11 years were examined for changes in continuity of care using the numbers of community teams caring for them and the Modified Modified Continuity Index (MMCI). These and demographic variables were related to clinical outcomes measured with the Health of the Nation Outcome Scales (HoNOS). Data were analysed using generalised estimating equations and multivariate marginal models.

RESULTS

There was a significant decline in MMCI and significant worsening of HoNOS total scores over 11 years. Higher (worse) HoNOS scores were significantly and independently related to older age, later years and both lower MMCI and more teams caring for the individual in each year. Most HoNOS scales contributed to the higher total scores.

CONCLUSIONS

There is evidence of declining continuity of care in this 11-year study of people with schizophrenia, and of an independent effect of this on worse clinical outcomes. We suggest that this is related to reorganisation of services.Declaration of interestNone.

Invited commentary on… Continuity of care in the community for people with severe mental illness: does it matter?

In this issue, MacDonald et al have used data from the South London and Maudsley NHS Foundation Trust electronic patient record to investigate the relationship between service change, routine outcome data and 'continuity of care'. The period they have looked at was one of huge change in the configuration of services and the background to this is explored here.Declaration of interestF.H. was a clinical director of South London and Maudsley NHS Foundation Trust and its predecessor organisations from 1991 to 2010.

Typology of patients with mental health disorders and perceived continuity of care

Background: While multiple socio-demographic, clinical and service use variables have been associated with continuity of care (CoC) in patients diagnosed with mental health disorders (MHDs), little is known about how these variables may inform clinical practice and service planning.Aim: This article identified profiles of patients with MHDs to better understand their perceptions of CoC.Method: The sample for this cross-sectional study comprised 327 patients recruited by staff or self-referred from four local health networks in Quebec (Canada). Data were collected using standardized instruments, and patient medical records. A three-factor conceptual framework based on Andersen's Behavioral Model was used, integrating predisposing, needs and enabling factors.Results: Cluster analyses identified five patient profiles. Profiles that included relatively more patients with common MHDs reported less continuity than those with patients primarily affected by severe MHDs.Conclusions: Service planning and delivery should be better adapted to patient profiles in order to improve CoC, and increased access to services prioritized.

[Medical continuity in the supply psychiatry before and after implementation of the new working hours act based on the example of the psychiatric department in the Danube hospital Vienna]

A successful and sustainable treatment of psychiatric patients is based on intensive relationship work. After the introduction of the new Working Hours Act the standards of evidence-based treatment are endangered. Using the data of the official working schedule of the Psychiatric Department of the Danube hospital in Vienna, before and after the introduction of the new Working Hours Act, we demonstrate a significant decrease of the medical consistency of the patient-related doctors. New approaches must be considered in order to solve this problem of quality.

Continuity of Care among People Experiencing Homelessness and Mental Illness: Does Community Follow-up Reduce Rehospitalization?

OBJECTIVE

To examine whether timely outpatient follow-up after hospital discharge reduces the risk of subsequent rehospitalization among people experiencing homelessness and mental illness.

DATA SOURCES

Comprehensive linked administrative data including hospital admissions, laboratory services, and community medical services.

STUDY DESIGN

Participants were recruited to the Vancouver At Home study based on a-priori criteria for homelessness and mental illness (n = 497). Logistic regression analysis was used to assess the relationship between outpatient care within 7 days postdischarge and subsequent rehospitalization over a 1-year period.

DATA EXTRACTION

Data were extracted for a consenting subsample of participants (n = 433) spanning 5 years prior to study enrollment.

PRINCIPAL FINDINGS

More than half of the eligible sample (53 percent; n = 128) were rehospitalized within 1 year following an index hospital discharge. Neither outpatient medical services nor laboratory services within 7 days following discharge were associated with a significantly reduced likelihood of rehospitalization within 2 months (AOR = 1.17 [CI = 0.94, 1.46]), 6 months (AOR = 1.00 [CI = 0.82, 1.23]) or 12 months (AOR = 1.24 [CI = 1.02, 1.52]).

CONCLUSIONS

In contrast to evidence from nonhomeless samples, we found no association between timely outpatient follow-up and the likelihood of rehospitalization in our homeless, mentally ill cohort. Our findings indicate a need to address housing as an essential component of discharge planning alongside outpatient care.

Patient satisfaction with mental health services based on Andersen's Behavioral Model

OBJECTIVE

The purpose of this article was to assess the satisfaction of adult patients who received mental health services (MHS) in healthcare networks staffed by multidisciplinary professionals and offering a range of MHS, and to identify variables associated with patient satisfaction.

METHODS

This cross-sectional study included 325 patients with mental disorders (MDs) among 4 Quebec health service networks. Data were collected using 9 standardized instruments and participant medical records. A 3-factor conceptual framework (predisposing, enabling, and needs-related factors) based on Andersen's Behavioral Model was used, integrating sociodemographic, clinical, needs-related, service utilization, social support, and quality-of-life (QOL) variables. An adjusted multiple linear regression model was performed.

RESULTS

The global mean score for patient satisfaction was 4.11 (minimum: 2.0; maximum: 5.0). Among the enabling factors, continuity of care, having a case manager, and help received from services were positively associated with patient satisfaction, whereas being hospitalized was negatively associated. Among the needs-related factors, the number of needs was negatively associated with satisfaction.

CONCLUSIONS

Findings demonstrated higher levels of satisfaction among patients who received good continuity of care and well-managed, frequent services in relation to their needs. Dissatisfaction was higher for patients with serious unmet needs or those hospitalized, which underlines the importance of taking these particular variables into account in the interest of improving MHS delivery and patient recovery.

Continuity of care as experienced by mental health service users - a qualitative study

Background

People who struggle with mental health problems can provide valuable insight into understanding and improving the coordination of mental health and welfare services. The aims of the study were to explore service users’ experiences and perceptions of continuity of care within and across services relevant to personal recovery, to elicit which dimensions of continuity of care are most essential to service users, and to generate ideas for improving service users’ experiences of continuity of care.

Methods

In the context of a hermeneutic-phenomenological approach, ten service users at a community mental health centre were interviewed about their experiences of continuity of care in and across services. Eight of these were re-interviewed two years later. A collaborative research approach was adopted. Data were analysed by means of a data-driven stepwise approach in line with thematic analysis.

Results

Following the analysis five themes representing experiences of continuity of care were developed. Each theme ranged from poor to good experiences of continuity of care: Relationship – from experiencing frequent setbacks and anxiety due to breaks in relationships, to feeling safe in an ongoing personal relationship; Timeliness – from experiencing frustrating waiting times with worsening of problems, to getting help when needed; Mutuality – from having a one-sided struggle, to a situation in which both professionals and service users take initiatives; Choice – from not having the opportunity to make practical arrangements within the context of one’s everyday life, to having an array of support options to choose from; Knowledge – from feeling confused and insecure because one does not know what is happening, to feeling safe because one is informed about what is going to happen. Participants provided a range of suggestions for improving experiences of continuity of care.

Conclusions

A discrepancy between aspects of continuity that are essential for service users and their experiences of actual practice was revealed. The valid evidence generated in the present collaborative study therefore offers knowledge to policy makers, professionals and service users that may be of help in their future efforts in orienting primary care, mental health, addiction and welfare services towards recovery.

Electronic supplementary material

The online version of this article (10.1186/s12913-017-2719-9) contains supplementary material, which is available to authorized users.

Concepts, models and measurement of continuity of care in mental health services: A systematic appraisal of the literature

WHAT IS KNOWN ON THE SUBJECT?: Care continuity is considered to be a cornerstone of modern mental health care. As community mental health services have become increasingly fragmented and complex, the crucial criterion for best quality care has become the degree to which treatment delivered by separate services and professionals is continuous and well coordinated. However, clarification of the key elements of continuity has proved challenging and a consensus has not been reached. Recent research has shown significant levels of variation in the quality of care coordination across England and Wales, with potentially detrimental consequences for individuals. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: Studies on care continuity identified in this review are grouped into three categories: studies defining concepts of care continuity, studies providing models of continuity and studies describing development of questionnaires about care continuity. There are many similarities and parallels between concepts of continuity described in the studies under review. Therefore, there is potential for developing a consensus on the nature of care continuity as a multidimensional concept. The priority placed upon the patient's experience of care continuity is identified as a major focus in these studies. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: A consensus on the nature of care continuity would benefit both theory and practice in mental health nursing. It would provide a firmer foundation for new research seeking to improve continuity for people using services, and enable mental health nurses working as care coordinators to have a better understanding of the elements of their role that are most effective.

ABSTRACT

Introduction The increased complexity of community mental health services, and associated fragmentation of traditional dividing lines between services, has underscored the centrality of care continuity and coordination in modern mental health care. However, clarification of the key features of the care continuity concept has proved difficult and a consensus has not been reached. Aim/Question This review draws together and critically examines latest evidence concerning concepts, models and scales based on a multidimensional understanding of care continuity. Method Databases ASSIA, PubMed, MEDLINE and Cochrane were searched for papers dating from January 2005 to July 2016, of which 21 articles met the inclusion criteria. These were subjected to quality appraisal based on CASP and COSMIN checklists. Studies were grouped into three thematic categories describing concepts, models and scales of care continuity. Results/Discussion Synthesis indicated correspondence between independent, multidimensional models of care continuity, providing greater clarity regarding the essential features of the concept. Association, although not causation, between care continuity factors and health outcomes is supported by current evidence. Implications for practice Clarification of care continuity in mental health services may enable nurses working as care coordinators to develop a better understanding of key elements of their role, and provide guidance for future service development.

Operationalization of the Ghanaian Patients' Charter in a Peri-urban Public Hospital: Voices of Healthcare Workers and Patients

BACKGROUND

Health is a basic human right necessary for the exercise of other human rights. Every human being is, therefore, entitled to the highest possible standard of health necessary to living a life of dignity. Establishment of patients' Charter is a step towards protecting the rights and responsibilities of patients, but violation of patients' rights is common in healthcare institutions, especially in the developing world. This study which was conducted between May 2013 and May 2014, assessed the operationalization of Ghana's Patients Charter in a peri-urban public hospital.

METHODS

Qualitative data collection methods were used to collect data from 25 healthcare workers and patients who were purposively selected. The interview data were analyzed manually, using the principles of systematic text condensation.

RESULTS

The findings indicate that the healthcare staff of the Polyclinic are aware of the existence of the patients' Charter and also know some of its contents. Patients have no knowledge of the existence or the contents of the Charter. Availability of the Charter, community sensitization, monitoring and orientation of staff are factors that promote the operationalization of the Charter, while institutional implementation procedures such as lack of complaint procedures and low knowledge among patients militate against operationalization of the Charter.

CONCLUSION

Public health facilities should ensure that their patients are well-informed about their rights and responsibilities to facilitate effective implementation of the Charter. Also, patients' rights and responsibilities can be dramatized and broadcasted on television and radio in major Ghanaian languages to enhance awareness of Ghanaians on the Charter.

Individual and contextual-level factors associated with continuity of care for adults with schizophrenia

This retrospective cohort study examined rates of conformance to continuity of care treatment guidelines and factors associated with conformance for persons with schizophrenia. Subjects were 8,621 adult Ohio Medicaid recipients, aged 18-64, treated for schizophrenia in 2004. Information on individual-level (demographic and clinical characteristics) and contextual-level variables (county socio-demographic, economic, and health care resources) were abstracted from Medicaid claim files and the Area Resource File. Outcome measures captured four dimensions of continuity of care: (1) regularity of care; (2) transitions; (3) care coordination, and (4) treatment engagement. Multilevel modeling was used to assess the association between individual and contextual-level variables and the four continuity of care measures. The results indicated that conformance rates for continuity of care for adults with schizophrenia are below recommended guidelines and that variations in continuity of care are associated with both individual and contextual-level factors. Efforts to improve continuity of care should target high risk patient groups (racial/ethnic minorities, the dually diagnosed, and younger adults with early onset psychosis), as well as community-level risk factors (provider supply and geographic barriers of rural counties) that impede access to care.

Schizophrenia in the Netherlands: Continuity of Care with Better Quality of Care for Less Medical Costs

Background

Patients with schizophrenia need continuous elective medical care which includes psychiatric treatment, antipsychotic medication and somatic health care. The objective of this study is to assess whether continuous elective psychiatric is associated with less health care costs due to less inpatient treatment.

Methods

Data concerning antipsychotic medication and psychiatric and somatic health care of patients with schizophrenia in the claims data of Agis Health Insurance were collected over 2008–2011 in the Netherlands. Included were 7,392 patients under 70 years of age with schizophrenia in 2008, insured during the whole period. We assessed the relationship between continuous elective psychiatric care and the outcome measures: acute treatment events, psychiatric hospitalization, somatic care and health care costs.

Results

Continuous elective psychiatric care was accessed by 73% of the patients during the entire three year follow-up period. These patients received mostly outpatient care and accessed more somatic care, at a total cost of €36,485 in three years, than those without continuous care. In the groups accessing fewer or no years of elective care 34%-68% had inpatient care and acute treatment events, while accessing less somatic care at average total costs of medical care from €33,284 to €64,509.

Conclusions

Continuous elective mental and somatic care for 73% of the patients with schizophrenia showed better quality of care at lower costs. Providing continuous elective care to the remaining patients may improve health while reducing acute illness episodes.

Assessment of the priority target group of mental health service networks within a nation-wide reform of adult psychiatry in Belgium

BACKGROUND

Belgium is currently implementing a nation-wide reform of mental health care delivery based on service networks. These networks are supposed to strengthen the community-based supply of care, reduce the resort to hospitals, and improve the continuity of care. They are also intended to supply comprehensive care to all adult mental health users. It is unclear, however, if one single model of network can target the needs of the whole adult population with mental health problems.

METHODS

In 2011, ten networks were commissioned and assessed. Networks included a total of 635 services of different types. Services were asked to select 10 users by systematic sampling and to state whether these users were considered as a priority for care in the network. Sociodemographic, social integration level, diagnoses, and psycho-social functioning variables were also collected.

RESULTS

Two thousand four hundred ninety users were included, and 1564 were given priority for network care. Priority was higher for men than for women (69.9 % versus 56.2 %), and for non-nationals than for Belgians (72.6 % versus 61.9 %). Users were designated priority when they had poor psycho-social functioning (HoNOS > 17, OR = 3.15, p < 0.001), personality disorder or schizophrenia (OR = 1.54, p < 0.001), and a medium level of social integration (SIX = [2,3], OR = 1.57, p < 0.001). Less socially integrated patients (SIX < 1, OR = 0.53, p < 0.001) and users of community and social services were less likely to be selected.

CONCLUSION

Although the reform was intended for the whole population of adults with mental health problems, the users selected have a profile of severe mentally-ill users with social deprivation and poor social functioning. Policy may have been over-ambitious trying to address the whole population with one single type of service network. The actual selection process of users makes it less likely that the reform will achieve all its objectives.

Electronic personal health records for people with severe mental illness; a feasibility study

BACKGROUND

Electronic Patient Health Records (ePHRs) contain information created, accessed, monitored and maintained by patients. This paper describes how an ePHR called myhealthlocker™ was used by people with severe mental illness to monitor and input their own health-related outcomes, and whether they derived any benefit from it.

METHOD

Individuals using local secondary mental health services were provided with access to myhealthlocker, an ePHR which allowed them to monitor their health and input information from Patient Reported Outcome Measures (PROMs) across to their clinical record. Participants were given support to use myhealthlocker through drop-in sessions facilitated by an Occupational Therapist. Usage of the site was monitored over time. Surveys and interviews were used to investigate what participants thought about the intervention.

RESULTS

32 of 58 participants used the ePHR (where usage was defined by logging in at least twice and completing a PROM). Almost all participants who used the site had been referred from community rather than inpatient services. Of those who used the site, 26 out of 32 used it primarily or exclusively through supported drop-in sessions. Almost half of those participants who used the site had used it outside the drop-in sessions. Those who used the site found it useful (n = 32), and most said they would continue to use it (n = 27). There were no apparent differences in usage across gender, diagnosis, and length of service use history. Suggestions for improvement included a social networking component, and finding ways to engage clinicians. In particular, users valued the ability to monitor health outcomes over time.

CONCLUSIONS

People with severe mental illness were able to use an ePHR and derive benefit from monitoring and inputting PROMs. Those who use the site are more likely to have been referred from community mental health services, and then supported to access the ePHR.

Primary health care nurses' management practices of common mental health conditions in KwaZulu-Natal, South Africa

Background

Psychiatric conditions contribute to 13% of the global burden of diseases and account for one third of years lost because of disability (YLD). Despite the high prevalence of mental health problems, primary health care (PHC) services remain ineffective in managing patients with mental health conditions.

Objectives

The aim of the study was to determine the practices of PHC nurses in the management of psychiatric patients in primary health care clinics in one of the rural districts in South Africa.

Method

A survey was conducted amongst nurses working in several PHC clinics in KwaZulu-Natal (KZN) in order to determine their practices in the management of psychiatric patients. Mixed methods were used to determine the PHC nurses practices in the management of psychiatric patients.

Results

The findings revealed that in five sites (83.3%) treatments are not reviewed every six months, there were no local protocols on the administration of psychiatric emergency drugs, and none of the study sites provided psychiatric patients with education on their medication and its possible side effects.

Conclusion

Based on the results of this study it is evident that psychiatric patients at PHC clinics in the district where the study was conducted do not receive quality treatment according to institutional mental health guidelines.

Evaluation of a new person-centered integrated care model in psychiatry

The present study evaluated a new integrated treatment concept offering inpatient care, acute psychiatric day hospital and outpatient treatment by the same therapeutic team. 178 patients participated in this randomized controlled trial. Data on psychopathology, global and social functioning, patient satisfaction, continuity of care and administrative data was gathered on admission, throughout the course of treatment, upon discharge and at 1-year follow-up. In addition, the physicians in charge rated the therapeutic relationship. The data analysis consists of group-wise comparisons and regression analyses (cross-tabulations and χ(2) test statistics for categorical data and Mann-Whitney U tests for continuous data). Differences between groups over time were analyzed with a series of generalized linear mixed model. The integrated care group showed a significant reduction in psychopathological impairment (20.7%) and an improvement of psychosocial functioning (36.8%). The mean number of days before re-admission was higher in the control group when compared to the integrated care group (156.8 vs. 91.5). There was no difference in the number of re-admissions and days spent in psychiatric institutions. This new approach offers a treatment model, which facilitates continuity of care. Beside it improves psychopathological outcome measures and psychosocial functioning in patients with mental illness.

Mental health service users' experiences of mental health care: an integrative literature review

A number of studies have highlighted issues around the relationship between service users and providers. The recovery model is predominant in mental health as is the recognition of the importance of person-centred practice. The authors completed an in-depth search of the literature to answer the question: What are service users' experiences of the mental health service? Three key themes emerged: acknowledging a mental health problem and seeking help; building relationships through participation in care; and working towards continuity of care. The review adds to the current body of knowledge by providing greater detail into the importance of relationships between service users and providers and how these may impact on the delivery of care in the mental health service. The overarching theme that emerged was the importance of the relationship between the service user and provider as a basis for interaction and support. This review has specific implications for mental health nursing. Despite the recognition made in policy documents for change, issues with stigma, poor attitudes and communication persist. There is a need for a fundamental shift in the provider-service user relationship to facilitate true service-user engagement in their care. The aim of this integrative literature review was to identify mental health service users' experiences of services. The rationale for this review was based on the growing emphasis and requirements for health services to deliver care and support, which recognizes the preferences of individuals. Contemporary models of mental health care strive to promote inclusion and empowerment. This review seeks to add to our current understanding of how service users experience care and support in order to determine to what extent the principles of contemporary models of mental health care are embedded in practice. A robust search of Web of Science, the Cochrane Database, Science Direct, EBSCO host (Academic Search Complete, MEDLINE, CINAHL Plus Full-Text), PsycINFO, PsycARTICLES, Social Sciences Full Text and the United Kingdom and Ireland Reference Centre for data published between 1 January 2008 and 31 December 2012 was completed. The initial search retrieved 272 609 papers. The authors used a staged approach and the application of predetermined inclusion/exclusion criteria, thus the numbers of papers for inclusion were reduced to 34. Data extraction, quality assessment and thematic analysis were completed for the included studies. Satisfaction with the mental health service was moderately good. However, accessing services could be difficult because of a lack of knowledge and the stigma surrounding mental health. Large surveys document moderate satisfaction ratings; however, feelings of fear regarding how services function and the lack of treatment choice remain. The main finding from this review is while people may express satisfaction with mental health services, there are still issues around three main themes: acknowledging a mental health problem and seeking help; building relationship through participation and care; and working towards continuity of care. Elements of the recovery model appear to be lacking in relation to user involvement, empowerment and decision making. There is a need for a fundamental shift in the context of the provider-service user relationship to fully facilitate service users' engagement in their care.

Collaborative development of an electronic Personal Health Record for people with severe and enduring mental health problems

BACKGROUND

Previous attempts to implement electronic Personal Health Records (ePHRs) underline the importance of stakeholder involvement. We describe the development of an ePHR for people with severe and enduring mental health problems, and provide a model of involving stakeholders throughout.

METHODS

There were three stages to the development of the ePHR. These were 1) identifying and responding to user and clinical needs; 2) preliminary testing; and 3) preliminary implementation. Stakeholder involvement was pervasive in all stages. We collaborated with 133 stakeholders in the first stage, 13 in the second, and 26 in the third. On the micro-level, a service user researcher conducted much of the data collection and analysis. On the macro-level, a service user advisory group guided decisions throughout the project, and a service user was an active member of the project executive board and the implementation team.

RESULTS

Service users and clinicians preferred an interactive ePHR with features such as access to care plans and care notes, a mood tracker, patient reported outcomes feeding into the clinical record, and social networking features. Many of the above were constructed following consultation with the relevant professionals, however further consultation is required before building a social networking function or providing access to full care notes. Service users positively rated the usability of the ePHR. Drop-in sessions helped service users access technology and learn how to use the ePHR.

CONCLUSIONS

We outline four considerations for future developers of ePHRs: appeal, construction, ease of use, and implementation. Success rests on implementation in routine practice, so ePHRs must be intuitive and useful for both service users and staff. Continued involvement of end users throughout the design and testing process can help to achieve this goal.

Patient experienced continuity of care in the psychiatric healthcare system-a study including immigrants, refugees and ethnic danes

Aim: The purpose of this study was to investigate continuity of care in the psychiatric healthcare system from the perspective of patients, including vulnerable groups such as immigrants and refugees. Method: The study is based on 19 narrative interviews conducted with 15 patients with diverse migration backgrounds (immigrants, descendents, refugees, and ethnic Danes). Patients were recruited from a community psychiatric centre situated in an area with a high proportion of immigrants and refugees. Data were analysed through the lens of a theoretical framework of continuity of care in psychiatry, developed in 2004 by Joyce et al., which encompasses four domains: accessibility, individualised care, relationship base and service delivery. Results: Investigating continuity of care, we found issues of specific concern to immigrants and refugees, but also commonalities across the groups. For accessibility, areas pertinent to immigrants and refugees include lack of knowledge concerning mental illness and obligations towards children. In terms of individualised care, trauma, additional vulnerability, and taboo concerning mental illness were of specific concern. In the domain of service delivery, social services included assistance with immigration papers for immigrants and refugees. In the relationship base domain, no differences were identified. Implications for priority area: The treatment courses of patients in the psychiatric field are complex and diverse and the patient perspective of continuity of care provides important insight into the delivery of care. The study highlights the importance of person-centred care irrespective of migration background though it may be beneficial to have an awareness of areas that may be of more specific concern to immigrants and refugees. Conclusions: The study sheds light on concerns specific to immigrants and refugees in a framework of continuity of care, but also commonalities across the patient groups.

Mental health care delivery system reform in Belgium: the challenge of achieving deinstitutionalisation whilst addressing fragmentation of care at the same time

Most mental health care delivery systems in welfare states currently face two major issues: deinstitutionalisation and fragmentation of care. Belgium is in the process of reforming its mental health care delivery system with the aim of simultaneously strengthening community care and improving integration of care. The new policy model attempts to strike a balance between hospitals and community services, and is based on networks of services. We carried out a content analysis of the policy blueprint for the reform and performed an ex-ante evaluation of its plan of operation, based on the current knowledge of mental health service networks. When we examined the policy's multiple aims, intermediate goals, suggested tools, and their articulation, we found that it was unclear how the new policy could achieve its goals. Indeed, deinstitutionalisation and integration of care require different network structures, and different modes of governance. Furthermore, most of the mechanisms contained within the new policy were not sufficiently detailed. Consequently, three major threats to the effectiveness of the reform were identified. These were: issues concerning the relationship between network structure and purpose, the continued influence of hospitals despite the goal of deinstitutionalisation, and the heterogeneity in the actual implementation of the new policy.

Local psychiatric beds appear to decrease the use of involuntary admission: a case-registry study

BACKGROUND

Studies on the effect of organizational factors on the involuntary admission of psychiatric patients have been few and yielded inconclusive results. The objective was to examine the importance of type of service-system, level of care, length of inpatient stay, gender, age, and diagnosis on rates of involuntary admission, by comparing one deinstitutionalized and one locally institutionalized service-system, in a naturalistic experiment.

METHODS

5538 admissions to two specialist psychiatric service-areas in North Norway were studied, covering a four-year period (2003-2006). The importance of various predictors on involuntary admission were analyzed in a logistic regression model.

RESULTS

Involuntary admission to the services was associated with the diagnosis of psychosis, male sex, being referred to inpatient treatment, as well as type of service-system. Patients from the deinstitutionalized system were more likely to be involuntarily admitted.

CONCLUSIONS

Several factors predicted involuntary status, including male sex, the diagnosis of psychosis, and type of service-system. The results suggests that having psychiatric beds available locally may be more favourable than a traditional deinstitutionalized service system with local outpatient clinics and central mental hospitals, with respect to the use of involuntary admission.

Continuity of care for carers of people with severe mental illness: results of a longitudinal study

INTRODUCTION

Continuity of care has been demonstrated to be important for service users and carer groups have voiced major concerns over disruptions of care. We aimed to assess the experienced continuity of care in carers of patients with both psychotic and non-psychotic disorders and explore its association with carer characteristics and psychological well-being.

METHODS

Friends and relatives caring for two groups of service users in the care of community mental health teams (CMHTs), 69 with psychotic and 38 with non-psychotic disorders, were assessed annually at three and two time points, respectively. CONTINUES, a measure specifically designed to assess continuity of care for carers themselves, was utilized along with assessments of psychological well-being and caregiving.

RESULTS

One hundred and seven carers participated. They reported moderately low continuity of care. Only 22 had had a carer's assessment and just under a third recorded psychological distress on the GHQ. For those caring for people with psychotic disorders, reported continuity was higher if the carer was male, employed, lived with the user and had had a carer's assessment; for those caring for people with non-psychotic disorders, it was higher if the carer was from the service user's immediate family, lived with them and had had a carer's assessment.

CONCLUSION

The vast majority of the carers had not had a carer's assessment provided by the CMHT despite this being a clear national priority and being an intervention with obvious potential to increase carers' reported low levels of continuity of care. Improving continuity of contact with carers may have an important part to play in the overall improvement of care in this patient group and deserves greater attention.

Continuity of care for people with psychotic illness: its relationship to clinical and social functioning

BACKGROUND

The relationship between continuity of care and user characteristics or outcomes has rarely been explored. The ECHO study operationalized and tested a multi-axial definition of continuity of care, producing a seven-factor model used here.

AIMS

To assess the relationship between user characteristics and established components of continuity of care, and the impact of continuity on clinical and social functioning.

METHODS

The sample comprised 180 community mental health team users with psychotic disorders who were interviewed at three annual time-points, to assess their experiences of continuity of care and clinical and social functioning. Scores on seven continuity factors were tested for association with user-level variables.

RESULTS

Improvement in quality of life was associated with better Experience & Relationship continuity scores (better user-rated continuity and therapeutic relationship) and with lower Meeting Needs continuity factor scores. Higher Meeting Needs scores were associated with a decrease in symptoms.

CONCLUSION

Continuity is a dynamic process, influenced significantly by care structures and organizational change.

Continuity of care for people with non-psychotic disorders

BACKGROUND

Service users with non-psychotic disorders are rarely studied. How continuity of care functions for this group is unknown.

AIMS

To compare users of community mental health teams with non-psychotic disorders to those with psychotic disorders in terms of demographic and illness characteristics, continuity of care and clinical and social functioning.

METHODS

Service users with non-psychotic disorders (N = 98) were followed up for one year and compared to 180 service users with psychotic disorders. Continuity of care factors were tested for association with user, illness and service variables.

RESULTS

Service users with non-psychotic disorders experienced more care transitions, but there were no differences in team practices in relation to these two different groups.

CONCLUSION

The underlying concepts of continuity of care derived from users with psychotic disorders appear to be meaningful for users with non-psychotic disorders. Their greater likelihood of experiencing disruptive and distressing care transitions needs to be addressed.

Treatment engagement of psychotic patients with a mobile mental health unit in rural areas in Greece: a five-year study

Objectives. Treatment of psychotic disorders is impended by high rates of disengagement from mental health services and poor adherence to antipsychotic medication. This study examined the engagement rates of psychotic patients with a community mental health service during a 5-year period. Methods. The Mobile Mental Health Unit of Ioannina and Thesprotia (MMHU I-T) delivers services in remote, rural, mountainous areas using the resources of the primary care system. Clinical and demographic information for patients with a diagnosis of schizophrenia and related psychoses was obtained from the medical records of our unit. Results. A total of 74 psychotic patients initially engaged in treatment with our unit. In half of cases treatment was home-based. With the exclusion of patients who died or discharged, engagement rates were 67.2%. Statistical analysis was performed for 64 patients, and no differences were found between engaged and disengaged patients regarding clinical and demographic parameters. All engaged patients regularly refilled their antipsychotic prescriptions. Conclusion. Engagement rates in our study were comparable to previous research, involving urban settings and shorter follow-up duration. Community mental health teams may ensure treatment continuation for psychotic patients in deprived, remote areas. This is important for low-income countries, affected by economic crisis, such as Greece.

We are bitter, but we are better off: case study of the implementation of an electronic health record system into a mental health hospital in England

BACKGROUND

In contrast to the acute hospital sector, there have been relatively few implementations of integrated electronic health record (EHR) systems into specialist mental health settings. The National Programme for Information Technology (NPfIT) in England was the most expensive IT-based transformation of public services ever undertaken, which aimed amongst other things, to implement integrated EHR systems into mental health hospitals. This paper describes the arrival, the process of implementation, stakeholders' experiences and the local consequences of the implementation of an EHR system into a mental health hospital.

METHODS

Longitudinal, real-time, case study-based evaluation of the implementation and adoption of an EHR software (RiO) into an English mental health hospital known here as Beta. We conducted 48 in-depth interviews with a wide range of internal and external stakeholders, undertook 26 hours of on-site observations, and obtained 65 sets of relevant documents from various types relating to Beta. Analysis was both inductive and deductive, the latter being informed by the 'sociotechnical changing' theoretical framework.

RESULTS

Many interviewees perceived the implementation of the EHR system as challenging and cumbersome. During the early stages of the implementation, some clinicians felt that using the software was time-consuming leading to the conclusion that the EHR was not fit for purpose. Most interviewees considered the chain of deployment of the EHR-which was imposed by NPfIT-as bureaucratic and obstructive, which restricted customization and as a result limited adoption and use. The low IT literacy among users at Beta was a further barrier to the implementation of the EHR. This along with inadequate training in using the EHR software led to resistance to the significant cultural and work environment changes initiated by EHR. Despite the many challenges, Beta achieved some early positive results. These included: the ability to check progress notes and monitor staff activities; improving quality of care as a result of real-time, more accurate and shared patient records across the hospital; and potentially improving the safety of care through increasing the legibility of the clinical record.

CONCLUSIONS

Notwithstanding what was seen as a turbulent, painful and troublesome implementation of the EHR system, Beta achieved some early clinical and managerial benefits from implementing EHRs. The 'sociotechnical changing' framework helped us go beyond the dichotomy of success versus failure, when conducting the evaluation and interpreting findings. Given the scope for continued development, there are good reasons, we argue, to scale up the intake of EHR systems by mental health care settings. Software customization and appropriate support are essential to work EHR out in such organizations.

Trust, choice and power in mental health care: experiences of patients with psychosis

BACKGROUND

Trust, choice and power are critical issues in clinical practice, public policies and a post-modern understanding of mental health care. We aimed to investigate the experiences and attitudes of patients with psychosis in relation to trust, choice and power.

METHOD

We conducted 20 in-depth interviews with patients with psychotic disorders in care of NHS services. The interviews were subjected to thematic analysis.

DISCUSSION

Patients discussed aspects of their care in terms of dimensions that enhance or undermine trust, choice and power. Two interpretive themes emerged from this data. First, patients perceive the need for a shifting balance of power, according to the severity of their illness and their own experience of care, but feel that threats of coercion and neglect disable them. Second, they appreciate the expertise of clinicians, but particularly value 'the personal touch' that goes beyond this expertise, including personal disclosure about their own lives, common acts of kindness and conversation outside clinical matters. Patients view trust as a two-way process with responsibility shared between patient and clinician.

CONCLUSIONS

The active involvement of patients with psychosis in their individual care may be strengthened, particularly when they are not acutely ill and have more experience of their illness. While patients value expertise and respect in interactions with clinicians, they also appreciate a 'personal touch', which may go beyond current notions of professionalism.

Can't surf, won't surf: the digital divide in mental health

Background: New health information technology (HIT) increasingly plays a role in health care as technology becomes cheaper and more widespread. However, there is a danger that those who do not use or have access to technology will not benefit from HIT innovations, thus creating a “digital divide”.

Aims: To assess the extent to which mental health service users have access to, skills in using and appetite for various technologies.

Methods: A cross-sectional survey was used to assess technology use and access patterns of 121 people from community mental health services. Data were analysed using logistic regression.

Results: Technology use and access were very similar to that of the general population with older individuals reporting less familiarity, access and confidence across a range of technologies. Black, minority and ethnic (BME) groups were more likely to access computers outside of their own homes than white individuals. Older participants experiencing psychosis indicated a desire to increase their computer use.

Conclusions: The findings reported here contrast with recent evidence suggesting that those who do not engage with technology are “self-excluders”. Furthermore, BME groups may need extra support regarding provision of technology in order to engage with HIT.

Understanding service user-defined continuity of care and its relationship to health and social measures: a cross-sectional study

BACKGROUND

Despite the importance of continuity of care [COC] in contemporary mental health service provision, COC lacks a clearly agreed definition. Furthermore, whilst there is broad agreement that definitions should include service users' experiences, little is known about this. This paper aims to explore a new construct of service user-defined COC and its relationship to a range of health and social outcomes.

METHODS

In a cross sectional study design, 167 people who experience psychosis participated in structured interviews, including a service user-generated COC measure (CONTINU-UM) and health and social assessments. Constructs underlying CONTINU-UM were explored using factor analysis in order to understand service user-defined COC. The relationships between the total/factor CONTINU-UM scores and the health and social measures were then explored through linear regression and an examination of quartile results in order to assess whether service user-defined COC is related to outcome.

RESULTS

Service user-defined COC is underpinned by three sub-constructs: preconditions, staff-related continuity and care contacts, although internal consistency of some sub-scales was low. High COC as assessed via CONTINU-UM, including preconditions and staff-related COC, was related to having needs met and better therapeutic alliances. Preconditions for COC were additionally related to symptoms and quality of life. COC was unrelated to empowerment and care contacts unrelated to outcomes. Service users who had experienced a hospital admission experienced higher levels of COC. A minority of service users with the poorest continuity of care also had high BPRS scores and poor quality of life.

CONCLUSIONS

Service-user defined continuity of care is a measurable construct underpinned by three sub-constructs (preconditions, staff-related and care contacts). COC and its sub-constructs demonstrate a range of relationships with health and social measures. Clinicians have an important role to play in supporting service users to navigate the complexities of the mental health system. Having experienced a hospital admission does not necessarily disrupt the flow of care. Further research is needed to test whether increasing service user-defined COC can improve clinical outcomes. Using CONTINU-UM will allow researchers to assess service users' experiences of COC based on the elements that are important from their perspective.

The role of primary care in service provision for people with severe mental illness in the United Kingdom

BACKGROUND

Severe mental illness is a serious and potentially life changing set of conditions. This paper describes and analyses patient characteristics and service usage over one year of a representative cohort of people with a diagnosis of severe mental illness across England, including contacts with primary and secondary care and continuity of care.

METHODS AND FINDINGS

Data were collected from primary care patient notes (n = 1150) by trained nurses from 64 practices in England, covering all service contacts from 1(st) April 2008 to 31st March 2009. The estimated national rate of patients seen only in primary care in the period was 31.1% (95% C.I. 27.2% to 35.3%) and the rates of schizophrenia and bipolar disorder were 56.8% (95% C.I. 52.3% to 61.2%) and 37.9% (95% C.I. 33.7% to 42.2%). In total, patients had 7,961 consultations within primary care and 1,993 contacts with mental health services (20% of the total). Unemployed individuals diagnosed more recently were more likely to have contact with secondary care. Of those seen in secondary care, 61% had at most two secondary care contacts in the period. Median annual consultation rates with GPs were lower than have been reported for previous years and were only slightly above the general population. Relational continuity in primary care was poor for 21% of patients (Modified Modified Continuity Index = <0.5), and for almost a third of new referrals to mental health services the primary care record contained no information on the referral outcome.

CONCLUSIONS

Primary care is centrally involved in the care of people with serious mental illness, but primary care and cross-boundary continuity is poor for a substantial proportion. Research is needed to determine the impact of poor continuity on patient outcomes, and above all, the impact of new collaborative ways of working at the primary/secondary care interface.

The mental health system in Lombardy, Italy: access to services and patterns of care

PURPOSE

The psychiatric reform in Italy devolved to the regions the responsibility of implementing community psychiatric care. The aim of this paper is to evaluate the mental health system in Lombardy by assessing changes in accessibility and patterns of care occurred between 1999 and 2009.

METHODS

Data on mental health services were collected through the regional mental health information system and analyzed in terms of treated prevalence, treated incidence, continuity of care and packages of care.

RESULTS

Both treated incidence and treated prevalence in Lombardy increased between 1999 and 2009. There was an increasing access to psychiatric services of people with a better social integration. Incidence of schizophrenic and personality disorders decreased and that of affective and neurotic disorders increased dramatically, while increase in prevalence concerned all diagnostic groups. The percentage of patients in continuous care remained stable and was generally low. The majority of cases, even those with schizophrenia, are cared for on outpatient basis. The percentage of patients receiving integrated multiprofessional care declined. Rates of admission to inpatient services remained low and within the inpatient sector a shift from hospital towards residential care emerged, with decreasing hospital utilization and an increase in size of patient population entering community residences. Treatment gap is still a problem in schizophrenic disorders.

CONCLUSIONS

The Lombardy mental health system is strongly based on community care. However, it is reaching a turning point and it needs to be improved in some key areas: the shifting balance towards the care of common mental disorders, in the absence of resource allocations targeted to severely mentally ill, may hinder the system ability to deal with more disabled people. A focus on early intervention and an improvement of continuity of care for people with severe mental disorder, by strengthening community teams, is a priority.

Attachment to the clinical team and its association with therapeutic relationships, social networks, and clinical well-being

OBJECTIVES

To determine (1) inter-relationships between social network size and quality and therapeutic relationship ratings and (2) inter-relationships between attachment style, team attachment, therapeutic relationships, social networks, and clinical and social functioning.

DESIGN

A cross-sectional survey.

METHOD

A sample of 93 people using community mental health teams were assessed on their attachment status, social networks, relationship to the keyworker, attachment to the team, characteristics, and clinical and social functioning. Network size and the number friends and confidants were tested for associations with user- and professional-rated therapeutic relationship. Regression analysis was used to determine variables associated with team attachment.

RESULTS

There was no evidence that network size or number of confidants was associated with therapeutic relationship ratings. Therapeutic relationship was strongly associated with team attachment, but of the four attachment dimensions, only preoccupied attachment was associated with team attachment.

CONCLUSION

There is no evidence that therapeutic relationships are associated with the service user's 'affability' or predisposition to form relationships, suggesting that measures of therapeutic relationship and service attachment do measure something distinct about service users' experience of their care. Team attachment and therapeutic relationship measures seem likely to be measuring very similar constructs. It is possible that service users with more preoccupied attachment styles may find it particularly difficult to form positive attachments to services undergoing frequent change.

The effect of an inpatient transition intervention on attendance at the first appointment postdischarge from a psychiatric hospitalization

BACKGROUND

Only 42% of initial appointments following psychiatric hospitalization are kept nationally. Missed appointments increase the likelihood of rehospitalization and increase costs of outpatient care.

OBJECTIVE

This study explored the feasibility, outcomes, and cost of a transition intervention on attendance at the first postdischarge appointment.

DESIGN

A pilot study using a one-group prospective design interviewed 15 patients hospitalized with psychosis to address potential barriers to attendance at the first postdischarge appointment. Patients also identified an agenda for this appointment and received a reminder letter.

RESULTS

Twelve (92%) of 13 patients attended the postdischarge appointment compared with the previous rate of 44%. Two additional patients were unable to attend because they had been rehospitalized before the scheduled time of the first appointment.

DISCUSSION

Contact with a clinician who can bridge the gap between discharge and the first postdischarge appointment is feasible and may be helpful in increasing attendance rates.