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Hundt NE, Plasencia M, Amspoker AB, Yusuf Z, Walder A, Nagamoto H, Kim B, Tsao CGJ, Smith TL. Evaluation of the Implementation of the FLOW Program for Increasing Access to Mental Health Care. J Behav Health Serv Res 2024; 51:325-337. [PMID: 38789862 DOI: 10.1007/s11414-024-09886-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/07/2024] [Indexed: 05/26/2024]
Abstract
The FLOW program was designed to facilitate appropriate and safe transitions of patients from specialty mental health (SMH) to primary care (PC) as a method of improving access and reducing appointment burden on veterans who have improved or remitted. In this study, the team evaluated the implementation of FLOW across nine Veterans Affairs (VA) sites using a mixed-methods evaluation in a cluster-randomized stepped wedge trial design. Outcome assessments used data from VA databases, dashboards, and semi-structured interviews and were guided by the Reach, Adoption, Effectiveness, Implementation, and Maintenance (RE-AIM) framework. Across the sites, mean level reach was 1.36% of all specialty mental health patients transitioned to primary care (standard deviation [SD] = 1.05). Mean provider adoption was 10.2% (SD = 8.3%). Approximately 75% of veterans were fully satisfied with their transition and reported shared decision-making in the decision to transition. Rates of transitions did not decrease over the 6-month maintenance period following implementation. These data suggest that FLOW can be successfully implemented and maintained, although there was wide variation in implementation across sites. Future research should examine how to support sites that struggle with implementation.
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Affiliation(s)
- Natalie E Hundt
- Michael E. DeBakey VA Medical Center, VA HSR Center of Innovations in Quality, Effectiveness, and Safety, Houston, TX, USA.
- Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, TX, USA.
- South Central Mental Illness Research, Education, and Clinical Center, VA, Houston, TX, USA.
| | - Maribel Plasencia
- Michael E. DeBakey VA Medical Center, VA HSR Center of Innovations in Quality, Effectiveness, and Safety, Houston, TX, USA
- Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, TX, USA
- South Central Mental Illness Research, Education, and Clinical Center, VA, Houston, TX, USA
| | - Amber B Amspoker
- Michael E. DeBakey VA Medical Center, VA HSR Center of Innovations in Quality, Effectiveness, and Safety, Houston, TX, USA
- South Central Mental Illness Research, Education, and Clinical Center, VA, Houston, TX, USA
- Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Zenab Yusuf
- Michael E. DeBakey VA Medical Center, VA HSR Center of Innovations in Quality, Effectiveness, and Safety, Houston, TX, USA
| | - Annette Walder
- Michael E. DeBakey VA Medical Center, VA HSR Center of Innovations in Quality, Effectiveness, and Safety, Houston, TX, USA
| | - Herbert Nagamoto
- VA Rocky Mountain Network, Denver, CO, USA
- University of Colorado School of Medicine, Denver, CO, USA
| | - Bo Kim
- VA HSR Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System, Boston, MA, 02130, USA
- Department of Psychiatry, Harvard Medical School, Boston, MA, 02115, USA
| | - Christie Ga-Jing Tsao
- Michael E. DeBakey VA Medical Center, VA HSR Center of Innovations in Quality, Effectiveness, and Safety, Houston, TX, USA
| | - Tracey L Smith
- Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, TX, USA
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Kim B, Benzer JK, Afable MK, Fletcher TL, Yusuf Z, Smith TL. Care transitions from the specialty to the primary care setting: A scoping literature review of potential barriers and facilitators with implications for mental health care. J Eval Clin Pract 2023; 29:1338-1353. [PMID: 36938857 DOI: 10.1111/jep.13832] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Accepted: 02/23/2023] [Indexed: 03/21/2023]
Abstract
BACKGROUND, AIMS AND OBJECTIVES This scoping review aimed to understand potential barriers and facilitators in transitioning patients from specialty to primary care settings, to inform the implementation of an intervention to promote active consideration of psychiatrically stable patients for transition from the specialty mental health setting back to primary care. METHODS Guided by Levac and colleagues' six-stage methodological framework for conducting scoping studies, we systematically searched electronic article databases for peer-reviewed literature from January 2000 to May 2016. We included identified articles that discuss findings related to potential barriers and facilitators in transitioning patients from specialty to primary care settings. We performed descriptive and thematic analyses of results to generate emergent codes and their categorizations. RESULTS Our database search yielded 906 unique articles, 23 of which we included in our scoping review. All but one of the included studies were conducted in North America. Identified potential barriers and facilitators spanned eight emergent themes-(i) primary care accessibility, especially in terms of timely availability of appointments, (ii) clarity in respective roles of specialty care and primary care in managing a patient, (iii) timely exchange of information, (iv) transition process management, (v) perceived ability of primary care providers to manage specialty conditions, (vi) perceived ability of patients to self-manage, (vii) leadership support and (viii) support for implementing initiatives to promote transitions. CONCLUSIONS Findings from this scoping review enable an increased understanding of current practices and considerations regarding care transitions from specialty to primary care settings. The importance of role clarification, shared clinical information systems, confidence in care competency, and adequate organizational support to promote appropriate transitions were themes most widely reported across the reviewed studies. Few studies specifically examined the transition from specialty mental health to primary care. Future studies should account for mental health-specific symptomatic patterns and recovery trajectories, such as prevalent chronicity and frequency of relapse, in planning and conducting transitions from specialty mental health back to primary care.
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Affiliation(s)
- Bo Kim
- U.S. Department of Veterans Affairs, Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System, Department of Psychiatry, Harvard Medical School, Boston, Massachusetts, USA
| | - Justin K Benzer
- U.S. Department of Veterans Affairs, Veterans Integrated Service Network 17 Center of Excellence for Research on Returning War Veterans, Central Texas Veterans Healthcare System, Department of Psychiatry and Behavioral Sciences, Dell Medical School, University of Texas at Austin, Austin, Texas, USA
| | | | - Terri L Fletcher
- U.S. Department of Veterans Affairs, South Central Mental Illness Research, Education and Clinical Center, Health Services Research & Development Center for Innovations in Quality, Effectiveness and Safety, Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, Texas, USA
| | - Zenab Yusuf
- U.S. Department of Veterans Affairs, Health Services Research & Development Center for Innovations in Quality, Effectiveness and Safety, Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, Texas, USA
| | - Tracey L Smith
- Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, Texas, USA
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Blasi PR, Mettert KD, Coleman K, Lewis C, Wagner E, Coghill MN, Dang T, Richards JE. Transitioning patients from outpatient mental health services to primary care: A rapid literature review. IMPLEMENTATION RESEARCH AND PRACTICE 2021; 2:26334895211041294. [PMID: 37089993 PMCID: PMC9981893 DOI: 10.1177/26334895211041294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background A lack of access to mental health services is a critical barrier to obtaining evidence-based care. One strategy to improve access is to transition stable patients out of mental health specialty services and into primary care, thus opening availability for new patients and those with acute mental health needs. To support these transitions, organizations might explore a range of new practices and implementation strategies. Methods We conducted a rapid literature review to summarize descriptions from the research literature about practices for transitioning stable patients from outpatient mental health services to primary care, as well as implementation strategies to enhance the adoption and sustainment of these practices. We searched PsycINFO and Cumulated Index to Nursing and Allied Health Literature (CINAHL) for articles published between January 2000 and August 2019. For articles meeting inclusion criteria, we abstracted data on study characteristics, transition practices, and implementation strategies. Results We included 11 articles representing diverse study designs, settings, and health care organizations. Across these articles, we identified six categories of commonly described transition practices, with patient engagement appearing the most frequently (10 articles), followed by shared treatment planning (eight articles), assessment of recovery and stability, care coordination, follow up and support, and medication management (seven articles each). Less frequently, articles included descriptions of implementation strategies, with five articles describing efforts to train and educate stakeholders and four articles describing the use of evaluative and iterative strategies. Conclusions We identified descriptions of several common practices to help patients transition from mental health specialty services to primary care, but there are opportunities for an increased focus on implementation strategies to enhance the adoption and sustainment of these transition practices. More research is needed to better understand the effectiveness of specific transition interventions and the feasibility of deploying these interventions in heterogeneous health care settings.
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Affiliation(s)
- Paula R. Blasi
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA
| | - Kayne D. Mettert
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA
| | - Katie Coleman
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA
| | - Cara Lewis
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA
| | - Edward Wagner
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA
| | | | - Tobias Dang
- Kaiser Permanente Washington, Renton, WA, USA
| | - Julie E. Richards
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA
- Department of Health Services, University of Washington, Seattle, WA, USA
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