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Smith AM, Prom MC, Ng LC. A Qualitative Investigation of Characteristics Impacting Clinical Decision-Making in Integrated Behavioral Health Care. J Behav Health Serv Res 2024:10.1007/s11414-024-09891-6. [PMID: 38982024 DOI: 10.1007/s11414-024-09891-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/04/2024] [Indexed: 07/11/2024]
Abstract
To support implementation of integrated behavioral health care (IBHC) models in local settings, providers may benefit from clinical decision-making support. The present analysis examines perspectives on patient characteristics appropriate or inappropriate for, and currently managed within, IBHC at a large medical center to inform recommendations for provider decision-making. Twenty-four participants (n = 13 primary care providers; n = 6 behavioral health providers; n = 5 administrators) in an IBHC setting were interviewed. Thematic analysis was conducted with acceptable interrater reliability (κ = 0.75). Responses indicated behavioral health symptom and patient characteristics that impact perceptions of appropriateness for management in IBHC, with high variability between providers. Many patients with characteristics identified as inappropriate for IBHC were nonetheless currently managed in IBHC. Interactions between patient ability to engage in care and provider ability to manage patient needs guided decisions to refer a patient to IBHC or specialty care. A heuristic representing this dimensional approach to clinical decision-making is presented to suggest provider decision-making guidance informed by both patient and provider ability.
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Affiliation(s)
- Ash M Smith
- Boston Medical Center, 720 Harrison Ave, Boston, MA, 02118, USA
- Psychology Department, The Graduate Center, City University of New York, New York, NY, USA
| | - Maria C Prom
- Boston Medical Center, 720 Harrison Ave, Boston, MA, 02118, USA
- Department of Psychiatry, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Lauren C Ng
- Boston Medical Center, 720 Harrison Ave, Boston, MA, 02118, USA.
- Psychiatry Department, Boston University School of Medicine, Boston, MA, USA.
- Department of Psychology, University of California Los Angeles, Psychology Building 1285, Box 951563, Los Angeles, CA, 90095, USA.
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2
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Moon KC, Sobolev M, Grella M, Alvarado G, Sapra M, Ball T. Mobile Health Platform to Augment Behavioral Health in Primary Care: A Feasibility Study (Preprint). JMIR Form Res 2021; 6:e36021. [PMID: 35776491 PMCID: PMC9288094 DOI: 10.2196/36021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Revised: 05/16/2022] [Accepted: 05/17/2022] [Indexed: 11/25/2022] Open
Abstract
Background The collaborative care model is a well-established system of behavioral health care within primary care settings. There is potential for mobile health (mHealth) technology to augment collaborative behavioral health care in primary care settings, thereby improving scalability, efficiency, and clinical outcomes. Objective We aimed to assess the feasibility of engaging with and the preliminary clinical outcomes of an mHealth platform that was used to augment an existing collaborative care program in primary care settings. Methods We performed a longitudinal, single-arm feasibility study of an mHealth platform that was used to augment collaborative care. A total of 3 behavioral health care managers, who were responsible for coordinating disease management in 6 primary care practices, encouraged participants to use a mobile app to augment the collaborative model of behavioral health care. The mHealth platform’s functions included asynchronous chats with the behavioral health care managers, depression self-report assessments, and psychoeducational content. The primary outcome was the feasibility of engagement, which was based on the number and type of participant-generated actions that were completed in the app. The primary clinical end point was a comparison of the baseline and final assessments of the Patient Health Questionnaire-9. Results Of the 245 individuals who were referred by their primary care provider for behavioral health services, 89 (36.3%) consented to app-augmented behavioral health care. Only 12% (11/89) never engaged with the app during the study period. Across all participants, we observed a median engagement of 7 (IQR 12; mean 10.4; range 0-130) actions in the app (participants: n=78). The chat function was the most popular, followed by psychoeducational content and assessments. The subgroup analysis revealed no significant differences in app usage by age (P=.42) or sex (P=.84). The clinical improvement rate in our sample was 73% (32/44), although follow-up assessments were only available for 49% (44/89) of participants. Conclusions Our preliminary findings indicate the moderate feasibility of using mHealth technology to augment behavioral health care in primary care settings. The results of this study are applicable to improving the design and implementation of mobile apps in collaborative care.
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Affiliation(s)
| | | | | | | | | | - Trever Ball
- Northwell Health, Manhassett, NY, United States
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Howland M, Tennant M, Bowen DJ, Bauer AM, Fortney JC, Pyne JM, Shore J, Cerimele JM. Psychiatrist and Psychologist Experiences with Telehealth and Remote Collaborative Care in Primary Care: A Qualitative Study. J Rural Health 2021; 37:780-787. [PMID: 33022079 PMCID: PMC8518862 DOI: 10.1111/jrh.12523] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
PURPOSE Availability of mental health services is limited in the rural United States. Two promising models to reach patients with limited access to care are telehealth referral and collaborative care. The objective of this study was to assess telepsychiatrist- and telepsychologist-level facilitators and barriers to satisfaction with and implementation of these 2 telehealth models in rural settings. METHODS Focus groups were held in 2019 using a semistructured interview guide. Participants were off-site telepsychiatrists (N = 10) and telepsychologists (N = 4) for primary care clinics across 3 states (Washington, Michigan, and Arkansas) involved in a recent pragmatic comparative effectiveness trial. Qualitative analysis occurred inductively by 2 independent coders. FINDINGS Participants were satisfied with the models partly owing to good patient rapport and expanding access to care. Teamwork was highlighted as a facilitator in collaborative care and was often related to work with care managers. However, participants described communication with primary care providers as a challenge, especially in the telehealth referral arm. Barriers centered on variability of logistical processes (eg, symptom monitoring, scheduling, electronic medical record processes, and credentialing) among sites. Staff turnover, variable clinic investment, and inadequacy of training were possible explanations for these barriers. CONCLUSIONS Participants described high motivation to provide team-based, remote care for patients, though they experienced operational challenges. Centralized credentialing, scheduling, and record keeping are possible solutions. These findings are important because consulting psychiatrists and psychologists may play a leadership role in the dissemination of these models.
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Affiliation(s)
- Molly Howland
- Department of Psychiatry and Behavioral SciencesUniversity of Washington School of MedicineSeattleWashington
| | - McKenna Tennant
- Department of Public Health GeneticsUniversity of Washington School of Public HealthSeattleWashington
| | - Deborah J. Bowen
- Department of Bioethics and HumanitiesUniversity of WashingtonSeattleWashington
| | - Amy M. Bauer
- Department of Psychiatry and Behavioral SciencesUniversity of Washington School of MedicineSeattleWashington
| | - John C. Fortney
- Department of Psychiatry and Behavioral SciencesUniversity of Washington School of MedicineSeattleWashington
- Department of Veterans Affairs, HSR&D Center of Innovation for Veteran‐Centered and Value‐Driven CareVA Puget Sound Health Care SystemSeattleWashington
- Department of Health ServicesUniversity of Washington School of Public HealthSeattleWashington
| | - Jeffrey M. Pyne
- Department of Psychiatry and Behavioral Sciences, College of MedicineUniversity of Arkansas for Medical SciencesLittle RockArkansas
| | - Jay Shore
- Helen and Arthur E. Johnson Depression Center, Anschutz Medical Campus, Departments of Psychiatry and Family MedicineUniversity of Colorado School of MedicineAuroraColorado
- Centers for American Indian and Alaska Native Health, Colorado School of Public HealthUniversity of Colorado Anschutz Medical CampusAuroraColorado
| | - Joseph M. Cerimele
- Department of Psychiatry and Behavioral SciencesUniversity of Washington School of MedicineSeattleWashington
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Miller CJ, Griffith KN, Stolzmann K, Kim B, Connolly SL, Bauer MS. An Economic Analysis of the Implementation of Team-based Collaborative Care in Outpatient General Mental Health Clinics. Med Care 2020; 58:874-880. [PMID: 32732780 PMCID: PMC8177737 DOI: 10.1097/mlr.0000000000001372] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND Collaborative Chronic Care Models represent an evidence-based way to structure care for chronic conditions, including mental health conditions. Few studies, however, have examined the cost implications of collaborative care for mental health. OBJECTIVE We aimed to conduct an economic analysis of implementing collaborative care in 9 outpatient general mental health clinics. RESEARCH DESIGN Analyses were derived from a stepped wedge hybrid implementation-effectiveness trial. We conducted cost-minimization analyses from the health system perspective, incorporating implementation costs, outpatient costs, and inpatient costs for the year before collaborative care implementation and the implementation year. We used a difference-in-differences approach and conducted 1-way sensitivity analyses to determine the robustness of results to variations ±15% in model parameters, along with probabilistic sensitivity analysis using Monte Carlo simulation. SUBJECTS Our treatment group included 5507 patients who were initially engaged in care within 9 outpatient general mental health teams that underwent collaborative care implementation. We compared costs for this group to 45,981 control patients who received mental health treatment as usual at the same medical centers. RESULTS Collaborative care implementation cost about $40 per patient and was associated with a significant decrease in inpatient costs and a nonsignificant increase in outpatient mental health costs. This implementation was associated with $78 in cost savings per patient. Monte Carlo simulation suggested that implementation was cost saving in 78% of iterations. CONCLUSIONS Collaborative care implementation for mental health teams was associated with significant reductions in mental health hospitalizations, leading to substantial cost savings of about $1.70 for every dollar spent for implementation.
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Affiliation(s)
- Christopher J. Miller
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System
- Department of Psychiatry, Harvard Medical School
| | - Kevin N. Griffith
- Partnered Evidence-Based Policy Resource Center (PEPReC), VA Boston Healthcare System
- Department of Health Law, Policy, & Management, Boston University School of Public Health, Boston, MA
| | - Kelly Stolzmann
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System
| | - Bo Kim
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System
- Department of Psychiatry, Harvard Medical School
| | - Samantha L. Connolly
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System
- Department of Psychiatry, Harvard Medical School
| | - Mark S. Bauer
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System
- Department of Psychiatry, Harvard Medical School
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The Collaborative Chronic Care Model for Mental Health Conditions: From Evidence Synthesis to Policy Impact to Scale-up and Spread. Med Care 2020; 57 Suppl 10 Suppl 3:S221-S227. [PMID: 31517791 PMCID: PMC6749976 DOI: 10.1097/mlr.0000000000001145] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Extensive evidence indicates that Collaborative Chronic Care Models (CCMs) improve outcome in chronic medical conditions and depression treated in primary care. Beginning with an evidence synthesis which indicated that CCMs are also effective for multiple mental health conditions, we describe a multistage process that translated this knowledge into evidence-based health system change in the US Department of Veterans Affairs (VA). EVIDENCE SYNTHESIS In 2010, recognizing that there had been numerous CCM trials for a wide variety of mental health conditions, we conducted an evidence synthesis compiling randomized controlled trials of CCMs for any mental health condition. The systematic review demonstrated CCM effectiveness across mental health conditions and treatment venues. Cumulative meta-analysis and meta-regression further informed our approach to subsequent CCM implementation. POLICY IMPACT In 2015, based on the evidence synthesis, VA Office of Mental Health and Suicide Prevention (OMHSP) adopted the CCM as the model for their outpatient mental health teams. RANDOMIZED IMPLEMENTATION TRIAL In 2015-2018 we partnered with OMHSP to conduct a 9-site stepped wedge implementation trial, guided by insights from the evidence synthesis. SCALE-UP AND SPREAD In 2017 OMHSP launched an effort to scale-up and spread the CCM to additional VA medical centers. Seventeen facilitators were trained and 28 facilities engaged in facilitation. DISCUSSION Evidence synthesis provided leverage for evidence-based policy change. This formed the foundation for a health care leadership/researcher partnership, which conducted an implementation trial and subsequent scale-up and spread effort to enhance adoption of the CCM, as informed by the evidence synthesis.
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Saldana L, Bennett I, Powers D, Vredevoogd M, Grover T, Schaper H, Campbell M. Scaling Implementation of Collaborative Care for Depression: Adaptation of the Stages of Implementation Completion (SIC). ADMINISTRATION AND POLICY IN MENTAL HEALTH AND MENTAL HEALTH SERVICES RESEARCH 2020; 47:188-196. [PMID: 31197625 PMCID: PMC6908762 DOI: 10.1007/s10488-019-00944-z] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Tools to monitor implementation progress could facilitate scale-up of effective treatments. Most treatment for depression, a common and disabling condition, is provided in primary care settings. Collaborative Care Management (CoCM) is an evidence-based model for treating common mental health conditions, including depression, in this setting; yet, it is not widely implemented. The Stages of Implementation Completion (SIC) was adapted for CoCM and piloted in eight rural primary care clinics serving adults challenged by low-income status. The CoCM-SIC accurately assessed implementation effectiveness and detected site variations in performance, suggesting key implementation activities to aid future scale-ups of CoCM for diverse populations.
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Affiliation(s)
- Lisa Saldana
- Oregon Social Learning Center, 10 Shelton McMurphey Blvd, Eugene, OR, 97401, USA.
| | | | | | | | | | - Holle Schaper
- Oregon Social Learning Center, 10 Shelton McMurphey Blvd, Eugene, OR, 97401, USA
| | - Mark Campbell
- Oregon Social Learning Center, 10 Shelton McMurphey Blvd, Eugene, OR, 97401, USA
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Rimal P, Maru D, Chwastiak L, Agrawal P, Rao D, Swar S, Citrin D, Acharya B. Treatment recommendations made by a consultant psychiatrist to improve the quality of care in a collaborative mental health intervention in rural Nepal. BMC Psychiatry 2020; 20:46. [PMID: 32024490 PMCID: PMC7003398 DOI: 10.1186/s12888-020-2464-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2019] [Accepted: 01/24/2020] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND The Collaborative Care Model (CoCM) for mental healthcare, where a consulting psychiatrist supports primary care and behavioral health workers, has the potential to address the large unmet burden of mental illness worldwide. A core component of this model is that the psychiatrist reviews treatment plans for a panel of patients and provides specific clinical recommendations to improve the quality of care. Very few studies have reported data on such recommendations. This study reviews and classifies the recommendations made by consulting psychiatrists in a rural primary care clinic in Nepal. METHODS A chart review was conducted for all patients whose cases were reviewed by the treatment team from January to June 2017, after CoCM had been operational for 6 months. Free text of the recommendations were extracted and two coders analyzed the data using an inductive approach to group and categorize recommendations until the coders achieved consensus. Cumulative frequency of the recommendations are tabulated and discussed in the context of an adapted CoCM in rural Nepal. RESULTS The clinical team discussed 1174 patient encounters (1162 unique patients) during panel reviews throughout the study period. The consultant psychiatrist made 214 recommendations for 192 (16%) patients. The most common recommendations were to revisit the primary mental health diagnosis (16%, n = 34), add or increase focus on counselling and psychosocial support (9%, n = 20), increase the antidepressant dose (9%, n = 20), and discontinue inappropriate medications (6%, n = 12). CONCLUSIONS In this CoCM study, the majority of treatment plans did not require significant change. The recommendations highlight the challenge that non-specialists face in making an accurate mental health diagnosis, the relative neglect of non-pharmacological interventions, and the risk of inappropriate medications. These results can inform interventions to better support non-specialists in rural areas.
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Affiliation(s)
| | - Duncan Maru
- Nyaya Health Nepal, Kathmandu, Nepal ,0000 0001 0670 2351grid.59734.3cDepartments of Global Health System Design and Global Health, Internal Medicine, and Pediatrics, Mount Sinai School of Medicine, New York, NY USA ,0000 0001 0670 2351grid.59734.3cArnhold Institute for Global Health, Mount Sinai School of Medicine, New York, NY USA
| | - Lydia Chwastiak
- 0000000122986657grid.34477.33Department of Psychiatry & Behavioral Sciences, University of Washington, Seattle, WA USA ,0000000122986657grid.34477.33Department of Global Health, University of Washington, Seattle, WA USA ,0000000122986657grid.34477.33Northwest Mental Health Technology Transfer Center, University of Washington, Seattle, WA USA
| | | | - Deepa Rao
- 0000000122986657grid.34477.33Department of Global Health, University of Washington, Seattle, WA USA ,0000000122986657grid.34477.33Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA USA
| | - Sikhar Swar
- Nyaya Health Nepal, Kathmandu, Nepal ,0000 0004 0442 6252grid.415089.1Department of Psychiatry, Kathmandu Medical College, Duwakot, Nepal
| | - David Citrin
- Nyaya Health Nepal, Kathmandu, Nepal ,0000000122986657grid.34477.33Department of Anthropology, University of Washington, Seattle, WA USA ,0000000122986657grid.34477.33Department of Global Health, University of Washington, Seattle, WA USA ,0000000122986657grid.34477.33Henry M. Jackson School of International Studies, University of Washington, Seattle, WA USA
| | - Bibhav Acharya
- Nyaya Health Nepal, Kathmandu, Nepal ,0000 0001 2297 6811grid.266102.1Department of Psychiatry, University of California, San Francisco, CA USA
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Smith SN, Almirall D, Prenovost K, Liebrecht C, Kyle J, Eisenberg D, Bauer MS, Kilbourne AM. Change in Patient Outcomes After Augmenting a Low-level Implementation Strategy in Community Practices That Are Slow to Adopt a Collaborative Chronic Care Model: A Cluster Randomized Implementation Trial. Med Care 2019; 57:503-511. [PMID: 31135692 PMCID: PMC6684247 DOI: 10.1097/mlr.0000000000001138] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
BACKGROUND Implementation strategies are essential for promoting the uptake of evidence-based practices and for patients to receive optimal care. Yet strategies differ substantially in their intensity and feasibility. Lower-intensity strategies (eg, training and technical support) are commonly used but may be insufficient for all clinics. Limited research has examined the comparative effectiveness of augmentations to low-level implementation strategies for nonresponding clinics. OBJECTIVES To compare 2 augmentation strategies for improving uptake of an evidence-based collaborative chronic care model (CCM) on 18-month outcomes for patients with depression at community-based clinics nonresponsive to lower-level implementation support. RESEARCH DESIGN Providers initially received support using a low-level implementation strategy, Replicating Effective Programs (REP). After 6 months, nonresponsive clinics were randomized to add either external facilitation (REP+EF) or external and internal facilitation (REP+EF/IF). MEASURES The primary outcome was patient 12-item short form survey (SF-12) mental health score at month 18. Secondary outcomes were patient health questionnaire (PHQ-9) depression score at month 18 and receipt of the CCM during months 6 through 18. RESULTS Twenty-seven clinics were nonresponsive after 6 months of REP. Thirteen clinics (N=77 patients) were randomized to REP+EF and 14 (N=92) to REP+EF/IF. At 18 months, patients in the REP+EF/IF arm had worse SF-12 [diff, 8.38; 95% confidence interval (CI), 3.59-13.18] and PHQ-9 scores (diff, 1.82; 95% CI, -0.14 to 3.79), and lower odds of CCM receipt (odds ratio, 0.67; 95% CI, 0.30-1.49) than REP+EF patients. CONCLUSIONS Patients at sites receiving the more intensive REP+EF/IF saw less improvement in mood symptoms at 18 months than those receiving REP+EF and were no more likely to receive the CCM. For community-based clinics, EF augmentation may be more feasible than EF/IF for implementing CCMs.
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Affiliation(s)
- Shawna N Smith
- Department of Psychiatry, University of Michigan Medical School
- Institute for Social Research
| | - Daniel Almirall
- Institute for Social Research
- Department of Statistics, University of Michigan
| | | | - Celeste Liebrecht
- Department of Psychiatry, University of Michigan Medical School
- Quality Enhancement Research Initiative (QUERI), US Department of Veterans Affairs
| | - Julia Kyle
- Department of Psychiatry, University of Michigan Medical School
| | - Daniel Eisenberg
- Department of Health Management and Policy, School of Public Health, University of Michigan Ann Arbor, MI
| | - Mark S Bauer
- US Department of Veterans Affairs, Center for Healthcare Organization and Implementation Research, US Department of Veterans Affairs, Boston Healthcare System and Harvard Medical School, Boston, MA
| | - Amy M Kilbourne
- Department of Psychiatry, University of Michigan Medical School
- Quality Enhancement Research Initiative (QUERI), US Department of Veterans Affairs
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Thompson H, Faig W, Gupta N, Lahey R, Golden R, Pollack M, Karnik N. Collaborative Care for Depression of Adults and Adolescents: Measuring the Effectiveness of Screening and Treatment Uptake. Psychiatr Serv 2019; 70:604-607. [PMID: 31023189 PMCID: PMC6602801 DOI: 10.1176/appi.ps.201800257] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE This study analyzed effectiveness of screening, referrals, and treatment uptake of a collaborative care for depression intervention across 10 primary care clinics in Chicago. METHODS Between November 2016 and December 2017, patients (N=25,369) were screened with the Patient Health Questionnaire-2 and the Patient Health Questionnaire-9 on the basis of an eligibility algorithm. Electronic health record data were analyzed for sample characteristics, screening rates, referrals, and treatment pathways. To identify disparities, a test of proportions was conducted between eligible and screened patients as well as referred and treated patients. RESULTS Screenings, referrals, and uptake occurred proportionately across subgroups except for patients ages 12-17. Adolescent age was associated with disproportionate Patient Health Questionnaire-9 screenings and with treatment disengagement. CONCLUSIONS The intervention shows promise in expanding access to care and reducing disparities. Greater access to psychotherapies and innovative treatment modalities, particularly for adolescents, may improve overall treatment uptake.
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Affiliation(s)
- Hale Thompson
- Department of Psychiatry & Behavioral Sciences, Rush Medical College, Rush University, Chicago, IL USA
| | - Walter Faig
- Department of Psychiatry & Behavioral Sciences, Rush Medical College, Rush University, Chicago, IL USA
| | - Neha Gupta
- Department of Psychiatry & Behavioral Sciences, Rush Medical College, Rush University, Chicago, IL USA
| | - Rebecca Lahey
- Department of Social Work & Community Health, Rush University Medical Center, Chicago, IL USA
| | - Robyn Golden
- Department of Social Work & Community Health, Rush University Medical Center, Chicago, IL USA
| | - Mark Pollack
- Department of Psychiatry & Behavioral Sciences, Rush Medical College, Rush University, Chicago, IL USA
| | - Niranjan Karnik
- Department of Psychiatry & Behavioral Sciences, Rush Medical College, Rush University, Chicago, IL USA
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Bauer MS, Miller CJ, Kim B, Lew R, Stolzmann K, Sullivan J, Riendeau R, Pitcock J, Williamson A, Connolly S, Elwy AR, Weaver K. Effectiveness of Implementing a Collaborative Chronic Care Model for Clinician Teams on Patient Outcomes and Health Status in Mental Health: A Randomized Clinical Trial. JAMA Netw Open 2019; 2:e190230. [PMID: 30821830 PMCID: PMC6484628 DOI: 10.1001/jamanetworkopen.2019.0230] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
IMPORTANCE Collaborative chronic care models (CCMs) have extensive randomized clinical trial evidence for effectiveness in serious mental illnesses, but little evidence exists regarding their feasibility or effect in typical practice conditions. OBJECTIVE To determine the effectiveness of implementation facilitation in establishing the CCM in mental health teams and the impact on health outcomes of team-treated individuals. DESIGN, SETTING, AND PARTICIPANTS This quasi-experimental, randomized stepped-wedge implementation trial was conducted from February 2016 through February 2018, in partnership with the US Department of Veterans Affairs (VA) Office of Mental Health and Suicide Prevention. Nine facilities were enrolled from all VA facilities in the United States to receive CCM implementation support. All veterans (n = 5596) treated by designated outpatient general mental health teams were included for hospitalization analyses, and a randomly selected sample (n = 1050) was identified for health status interviews. Individuals with dementia were excluded. Clinicians (n = 62) at the facilities were surveyed, and site process summaries were rated for concordance with the CCM process. The CCM implementation start time was randomly assigned across 3 waves. Data analysis of this evaluable population was performed from June to September 2018. INTERVENTIONS Internal-external facilitation, combining a study-funded external facilitator and a facility-funded internal facilitator working with a designated team for 1 year. MAIN OUTCOMES AND MEASURES Facilitation was hypothesized to be associated with improvements in both implementation and intervention outcomes (hybrid type II trial). Implementation outcomes included the clinician Team Development Measure (TDM) and proportion of CCM-concordant team care processes. The study was powered for the primary health outcome, mental component score (MCS). Hospitalization rate was derived from administrative data. RESULTS The veteran population (n = 5596) included 881 women (15.7%), and the mean (SD) age was 52.2 (14.5) years. The interviewed sample (n = 1050) was similar but was oversampled for women (n = 210 [20.0%]). Facilitation was associated with improvements in TDM subscales for role clarity (53.4%-68.6%; δ = 15.3; 95% CI, 4.4-26.2; P = .01) and team primacy (50.0%-68.6%; δ = 18.6; 95% CI, 8.3-28.9; P = .001). The percentage of CCM-concordant processes achieved varied, ranging from 44% to 89%. No improvement was seen in veteran self-ratings, including the primary outcome. In post hoc analyses, MCS improved in veterans with 3 or more treated mental health diagnoses compared with others (β = 5.03; 95% CI, 2.24-7.82; P < .001). Mental health hospitalizations demonstrated a robust decrease during facilitation (β = -0.12; 95% CI, -0.16 to -0.07; P < .001); this finding withstood 4 internal validity tests. CONCLUSIONS AND RELEVANCE Implementation facilitation that engages clinicians under typical practice conditions can enhance evidence-based team processes; its effect on self-reported overall population health status was negligible, although health status improved for individuals with complex conditions and hospitalization rate declined. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02543840.
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Affiliation(s)
- Mark S. Bauer
- Center for Healthcare Organization & Implementation Research, VA Boston Healthcare System, Jamaica Plain, Massachusetts
- Department of Psychiatry, Harvard Medical School, Boston, Massachusetts
| | - Christopher J. Miller
- Center for Healthcare Organization & Implementation Research, VA Boston Healthcare System, Jamaica Plain, Massachusetts
- Department of Psychiatry, Harvard Medical School, Boston, Massachusetts
| | - Bo Kim
- Center for Healthcare Organization & Implementation Research, VA Boston Healthcare System, Jamaica Plain, Massachusetts
- Department of Psychiatry, Harvard Medical School, Boston, Massachusetts
| | - Robert Lew
- Center for Healthcare Organization & Implementation Research, VA Boston Healthcare System, Jamaica Plain, Massachusetts
- Department of Biostatistics, Boston University School of Medicine, Boston, Massachusetts
| | - Kelly Stolzmann
- Center for Healthcare Organization & Implementation Research, VA Boston Healthcare System, Jamaica Plain, Massachusetts
| | - Jennifer Sullivan
- Center for Healthcare Organization & Implementation Research, VA Boston Healthcare System, Jamaica Plain, Massachusetts
- Department of Health Policy, Law, & Management, Boston University School of Public Health, Boston, Massachusetts
| | - Rachel Riendeau
- Center for Healthcare Organization & Implementation Research, VA Boston Healthcare System, Jamaica Plain, Massachusetts
- Department of Anthropology, University of Iowa, Iowa City
| | - Jeffery Pitcock
- Behavioral Health Quality Enhancement Research Initiative Program, Central Arkansas Veterans Healthcare System, Little Rock
| | | | - Samantha Connolly
- Center for Healthcare Organization & Implementation Research, VA Boston Healthcare System, Jamaica Plain, Massachusetts
- Department of Psychiatry, Harvard Medical School, Boston, Massachusetts
| | - A. Rani Elwy
- Center for Healthcare Organization & Implementation Research, VA Boston Healthcare System, Jamaica Plain, Massachusetts
- Department of Psychiatry and Human Behavior, Warren Alpert Medical School, Brown University, Providence, Rhode Island
| | - Kendra Weaver
- US Department of Veterans Affairs (VA) Office of Mental Health and Suicide Prevention, Washington, DC
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Kampstra NA, Zipfel N, van der Nat PB, Westert GP, van der Wees PJ, Groenewoud AS. Health outcomes measurement and organizational readiness support quality improvement: a systematic review. BMC Health Serv Res 2018; 18:1005. [PMID: 30594193 PMCID: PMC6311059 DOI: 10.1186/s12913-018-3828-9] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Accepted: 12/17/2018] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND Using outcome measures to advance healthcare continues to be of widespread interest. The goal is to summarize the results of studies which use outcome measures from clinical registries to implement and monitor QI initiatives. The second objective is to identify a) facilitators and/or barriers that contribute to the realization of QI efforts, and b) how outcomes are being used as a catalyst to change outcomes over time. METHODS We searched the PubMed, EMBASE and Cochrane databases for relevant articles published between January 1995 and March 2017. We used a standardized data abstraction form. Studies were included when the following three criteria were fulfilled: 1) they relied on structural data collection, 2) when a structural and comprehensive QI intervention had been implemented and evaluated, and 3) impact on improving clinical and/or patient-reported outcomes was described. Data on QI strategies, QI initiatives and the impact on outcomes was extracted using standardized assessment tools. RESULTS We included 21 articles, of which eight showed statistically significant improvements on outcomes using data from clinical registries. Out of these eight studies, the Chronic Care Model, IT application as feedback, benchmarking and the Collaborative Care Model were used as QI methods. Encouraging trends in realizing improved outcomes through QI initiatives were observed, ranging from improving teamwork, implementation of clinical guidelines, implementation of physician alerts and development of a decision support system. Facilitators for implementing QI initiatives included a high quality database, audits, frequent reporting and feedback, patient involvement, communication, standardization, engagement, and leadership. CONCLUSION This review suggests that outcomes collected in clinical registries are supportive to realize QI initiatives. Organizational readiness and an active approach are key in achieving improved outcomes.
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Affiliation(s)
- Nynke A Kampstra
- Department of Value-Based Healthcare, St. Antonius Hospital, Nieuwegein, the Netherlands. .,Radboud Institute for Health Sciences, Scientific Center for Quality of Healthcare (IQ healthcare), Radboud university medical center, Nijmegen, the Netherlands.
| | - Nina Zipfel
- Department of Value-Based Healthcare, St. Antonius Hospital, Nieuwegein, the Netherlands.,Radboud Institute for Health Sciences, Scientific Center for Quality of Healthcare (IQ healthcare), Radboud university medical center, Nijmegen, the Netherlands
| | - Paul B van der Nat
- Department of Value-Based Healthcare, St. Antonius Hospital, Nieuwegein, the Netherlands
| | - Gert P Westert
- Radboud Institute for Health Sciences, Scientific Center for Quality of Healthcare (IQ healthcare), Radboud university medical center, Nijmegen, the Netherlands
| | - Philip J van der Wees
- Radboud Institute for Health Sciences, Scientific Center for Quality of Healthcare (IQ healthcare), Radboud university medical center, Nijmegen, the Netherlands
| | - A Stef Groenewoud
- Radboud Institute for Health Sciences, Scientific Center for Quality of Healthcare (IQ healthcare), Radboud university medical center, Nijmegen, the Netherlands
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12
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Svenningsson I, Udo C, Westman J, Nejati S, Hange D, Björkelund C, Petersson EL. Creating a safety net for patients with depression in primary care; a qualitative study of care managers' experiences. Scand J Prim Health Care 2018; 36:355-362. [PMID: 30314415 PMCID: PMC6381518 DOI: 10.1080/02813432.2018.1529018] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
OBJECTIVE The aim of this study was to explore nurses' experiences and perceptions of working as care managers at primary care centers. DESIGN Qualitative, focus group study. Systematic text condensation was used to analyze the data. SETTING Primary health care in the region of Västra Götaland and region of Dalarna in Sweden. SUBJECTS Eight nurses were trained during three days including treatment of depression and how to work as care managers. The training was followed by continuous support. MAIN OUTCOME MEASURES The nurses' experiences and perceptions of working as care managers at primary care centers. RESULTS The care managers described their role as providing additional support to the already existing care at the primary care center, working in teams with a person-centered focus, where they were given the opportunity to follow, support, and constitute a safety net for patients with depression. Further, they perceived that the care manager increased continuity and accessibility to primary care for patients with depression. CONCLUSION The nurses perceived that working as care managers enabled them to follow and support patients with depression and to maintain close contact during the illness. The care manager function helped to provide continuity in care which is a main task of primary health care. Key Points The care managers described their role as an additional support to the already existing care at the primary care center. • They emphasized that as care managers, they had a person-centered focus and constituted a safety net for patients with depression. • Their role as care managers enabled them to follow and support patients with depression over time, which made their work more meaningful. • Care managers helped to achieve continuity and accessibility to primary health care for patients with depression.
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Affiliation(s)
- Irene Svenningsson
- Department of Primary Health Care, Institute of Medicine, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden;
- Primary Health Care, Närhälsan Research and Development, Region Västra Götaland, Sweden;
- CONTACT Irene Svenningsson Department of Primary Health Care, Institute of Medicine, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, SwedenPrimary Health Care, Närhälsan Research and Development, Region Västra Götaland, Sweden
| | - Camilla Udo
- School of Education, Health and Social Studies, Dalarna University, Falun, Sweden;
- Centre for Clinical Research, Dalarna, Sweden;
| | - Jeanette Westman
- Division of Family Medicine, Department of Neurobiology, Care Sciences and Society, Karolinska Institute, Stockholm, Sweden
| | - Shabnam Nejati
- Department of Primary Health Care, Institute of Medicine, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden;
| | - Dominique Hange
- Department of Primary Health Care, Institute of Medicine, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden;
| | - Cecilia Björkelund
- Department of Primary Health Care, Institute of Medicine, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden;
| | - Eva-Lisa Petersson
- Department of Primary Health Care, Institute of Medicine, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden;
- Primary Health Care, Närhälsan Research and Development, Region Västra Götaland, Sweden;
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13
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Fortney JC, Pyne JM, Ward-Jones S, Bennett IM, Diehl J, Farris K, Cerimele JM, Curran GM. Implementation of evidence-based practices for complex mood disorders in primary care safety net clinics. FAMILIES, SYSTEMS & HEALTH : THE JOURNAL OF COLLABORATIVE FAMILY HEALTHCARE 2018; 36:267-280. [PMID: 29809039 PMCID: PMC6131024 DOI: 10.1037/fsh0000357] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
INTRODUCTION Use quality improvement methods to implement evidence-based practices for bipolar depression and treatment-resistant depression in 6 Federally Qualified Health Centers. METHOD Following qualitative needs assessments, implementation teams comprised of front-line providers, patients, and content experts identified, adapted, and adopted evidence-based practices. With external facilitation, onsite clinical champions led the deployment of the evidence-based practices. Evaluation data were collected from 104 patients with probable bipolar disorder or treatment-resistant depression via chart review and an interactive voice response telephone system. RESULTS Five practices were implemented: (a) screening for bipolar disorder, (b) telepsychiatric consultation, (c) prescribing guidelines, (d) online cognitive-behavioral therapy, and (e) online peer support. Implementation outcomes were as follows: (a) 15% of eligible patients were screened for bipolar disorder (interclinic range = 3%-70%), (b) few engaged in online psychotherapy or peer support, (c) 38% received telepsychiatric consultation (interclinic range = 0%-83%), and (d) 64% of patients with a consult were prescribed the recommended medication. Clinical outcomes were as follows: Of those screening at high risk or very high risk, 67% and 69%, respectively, were diagnosed with bipolar disorder. A third (32%) of patients were prescribed a new mood stabilizer, and 28% were prescribed a new antidepressant. Clinical response (50% reduction in depression symptoms), was observed in 21% of patients at 3-month follow-up. DISCUSSION Quality improvement processes resulted in the implementation and evaluation of 5 detection and treatment processes. Though varying by site, screening improved detection and a substantial number of patients received consultations and medication adjustments; however, symptom improvement was modest. (PsycINFO Database Record
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Affiliation(s)
- John C Fortney
- Division of Population Health, Department of Psychiatry and Behavioral Sciences, University of Washington
| | - Jeffrey M Pyne
- Division of Health Services Research, Department of Psychiatry, University of Arkansas for Medical Sciences
| | | | - Ian M Bennett
- Division of Population Health, Department of Psychiatry and Behavioral Sciences, University of Washington
| | | | | | - Joseph M Cerimele
- Division of Population Health, Department of Psychiatry and Behavioral Sciences, University of Washington
| | - Geoffrey M Curran
- Center for Implementation Research, Department of Pharmacy Practice, University of Arkansas for Medical Sciences
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14
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Belsher BE, Evatt DP, Liu X, Freed MC, Engel CC, Beech EH, Jaycox LH. Collaborative Care for Depression and Posttraumatic Stress Disorder: Evaluation of Collaborative Care Fidelity on Symptom Trajectories and Outcomes. J Gen Intern Med 2018; 33:1124-1130. [PMID: 29704183 PMCID: PMC6025672 DOI: 10.1007/s11606-018-4451-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2017] [Revised: 02/13/2018] [Accepted: 03/28/2018] [Indexed: 10/17/2022]
Abstract
BACKGROUND Despite the growing consensus that collaborative care is effective, limited research has focused on the importance of collaborative care fidelity as it relates to mental health clinical outcomes. OBJECTIVE To assess the relationship of collaborative care fidelity on symptom trajectories and clinical outcomes among military service members enrolled in a multi-site randomized controlled trial for the treatment of depression and posttraumatic stress disorder (PTSD). DESIGN Study data for our analyses came from a two-parallel arm randomized trial that evaluated the effectiveness of a centralized collaborative care model compared to the existing collaborative care model for the treatment of PTSD and depression. All patients were included in the analyses to evaluate how longitudinal trajectories of PTSD and depression scores differed across various collaborative care fidelity groupings. PARTICIPANTS A total of 666 US Military Service members screening positive for probable PTSD or depression through primary care. MAIN MEASURES Disease registry data from a web-based clinical management support tool was used to measure collaborative care fidelity for patients enrolled in the trial. Participant depression and PTSD symptoms were collected independently from research survey assessments at four time points across the 1-year trial period. Treatment utilization records were acquired from the Military Health System administrative records to determine mental health service use. KEY RESULTS Consistent and late fidelity to the collaborative care model predicted an improving symptom trajectory over the course of treatment. This effect was more pronounced for patients with depression than for patients with PTSD. CONCLUSIONS Long-term fidelity to key collaborative care elements throughout care episodes may improve depression outcomes, particularly for patients with elevated symptoms. More controlled research is needed to further understand the influence of collaborative care fidelity on clinical outcomes. TRIAL REGISTRATION Clinicaltrials.gov Identifier NCT01492348.
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Affiliation(s)
- Bradley E Belsher
- Psychological Health Center of Excellence, Defense Health Agency, Silver Spring, MD, USA. .,Uniformed Services University of the Health Sciences, Bethesda, MD, USA.
| | - Daniel P Evatt
- Psychological Health Center of Excellence, Defense Health Agency, Silver Spring, MD, USA.,Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Xian Liu
- Psychological Health Center of Excellence, Defense Health Agency, Silver Spring, MD, USA.,Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Michael C Freed
- Uniformed Services University of the Health Sciences, Bethesda, MD, USA.,Division of Services and Intervention Research, National Institute of Mental Health (NIMH), Bethesda, MD, USA
| | - Charles C Engel
- Uniformed Services University of the Health Sciences, Bethesda, MD, USA.,RAND Corporation, Arlington, VA, USA
| | - Erin H Beech
- Psychological Health Center of Excellence, Defense Health Agency, Silver Spring, MD, USA
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15
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Bruce ML, Sirey JA. Integrated Care for Depression in Older Primary Care Patients. CANADIAN JOURNAL OF PSYCHIATRY. REVUE CANADIENNE DE PSYCHIATRIE 2018; 63:439-446. [PMID: 29495883 PMCID: PMC6099772 DOI: 10.1177/0706743718760292] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
For decades, depression in older adults was overlooked and not treated. Most treatment was by primary care providers and typically poorly managed. Recent interventions that integrate mental health services into primary care have increased the number of patients who are treated for depression and the quality of that treatment. The most effective models involve systematic depression screening and monitoring, multidisciplinary teams that include primary care providers and mental health specialists, a depression care manager to work directly with patients over time and the use of guideline-based depression treatment. The article reviews the challenges and opportunities for providing high-quality depression treatment in primary care; describes the 3 major integrated care interventions, PRISM-E, IMPACT, and PROSPECT; reviews the evidence of their effectiveness, and adaptations of the model for other conditions and settings; and explores strategies to increase their scalability into real world practice.
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Affiliation(s)
- Martha L. Bruce
- Dartmouth Centers for Health and Aging, Geisel School of Medicine, Hanover, NH, USA
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16
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Souliotis K, Agapidaki E, Tzavara C, Economou M. Psychiatrists role in primary health care in Greece: findings from a quantitative study. Int J Ment Health Syst 2017; 11:65. [PMID: 29075320 PMCID: PMC5651643 DOI: 10.1186/s13033-017-0172-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2017] [Accepted: 10/10/2017] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Although the need for integration of mental health services into primary care is well established little has been done. The outbreak of the recession found the Greek mental health system in transition. As a response to the crisis, governments implemented horizontal budget cuts instead of health reforms. This resulted in an unfavorable situation for mental health which was set once again on the sidelines of the health policy agenda. Previous studies suggest that the most prevalent disorders in the years of financial crisis in Greece are depression and anxiety while a general increase of the psychiatric morbidity is observed does not follow the population' needs. METHODS The present descriptive study was carried out between March and June of 2015. A convenience sample of 174 psychiatrists and psychiatry residents who met the inclusion criteria were finally selected to participate. Data were collected by using a 40-items questionnaire consisted of three sections: (a) nine questions about demographics, (b) nine questions pertaining to general aspects of administrative regulations related to primary care, (c) 22 questions about psychiatrists attitudes and perceptions towards their role in primary care. Quantitative variables are expressed as mean values, while qualitative variables as absolute and relative frequencies. RESULTS The vast majority of participants perceives the public primary care services and mental health services in their community as inadequate and considers psychiatrists' participation in primary care as important in order to improve the detection and management rates of people demonstrating mental health symptoms. They also believe that: (a) primary care practitioners' usually fail to detect the mental health conditions of patients; (b) their participation in primary care will decrease the social stigmatization for mental health conditions; (c) patients receiving pharmaceutical treatment for mental health problems by GPs and other primary care professionals usually fail to comply. CONCLUSIONS Respondents in the present study are receptive to participate in primary care. They believe that their inclusion to primary care will result to decreased social stigmatization for mental health problems, increased patient' access and improved detection and management rates for common mental health conditions.
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Affiliation(s)
- Kyriakos Souliotis
- Faculty of Social and Political Sciences, Department of Social and Education Policy, University of Peloponnese, Damaskinou & Kolokotroni Str., 20100 Corinth, Greece
- Health Policy Institute, Athens, Greece
| | - Eirini Agapidaki
- Health Policy Institute, 36-38, Amaryssias Artemidos Str., 15124 Athens, Greece
| | - Chara Tzavara
- Health Policy Institute, 36-38, Amaryssias Artemidos Str., 15124 Athens, Greece
| | - Marina Economou
- University Mental Health Research Institute (UMHRI), Athens, Greece
- First Department of Psychiatry, Medical School, University of Athens, Eginition Hospital, Soranou Ephesiou st., 115 27 Athens, Greece
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17
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Correlates of Opioid Use in Adults With Self-Reported Drug Use Recruited From Public Safety-Net Primary Care Clinics. J Addict Med 2016; 9:417-26. [PMID: 26428361 DOI: 10.1097/adm.0000000000000151] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES The purpose of this study was to compare demographic, clinical, and survival characteristics of drug-using safety-net primary care patients who used or did not use opioids, and to examine treatment implications of our findings. METHODS The sample consisted of 868 adults who reported illicit drug use in the 90 days before study enrollment, 396 (45.6%) of whom were opioid users. RESULTS Multiple measures indicated that, as a group, opioid users were less physically and psychiatrically healthy than drug users who did not endorse using opioids, and were heavy users of medical services (eg, emergency departments, inpatient hospitals, and outpatient medical) at considerable public expense. After adjusting for age, they were 2.61 (confidence interval, 1.48-4.61) times more likely to die in the 1 to 5 years after study enrollment and more likely to die from accidental poisoning than nonopioid users. Subgroup analyses suggested patients using any nonprescribed opioids had more serious drug problems including more intravenous drug use and greater HIV risk than patients using opioids only as prescribed. CONCLUSIONS Use of opioids adds a dimension of severity over and above illicit drug use as it presents in the primary care setting. Opioid users may benefit from psychiatric and addiction care integrated into their primary care setting, naloxone overdose prevention kits, and prevention efforts such as clean needle exchanges. Addiction or primary care providers are in a key position to facilitate change among such patients, especially the third or more opioid users having a goal of abstinence from drugs.
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18
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Chen JY, Wan EY, Choi EP, Wong CK, Chan AK, Chan KH, Li PK, Lam CL. Clinical and patient-reported outcomes of Chinese patients undergoing haemodialysis in hospital or in the community: A 1-year longitudinal study. Nephrology (Carlton) 2016; 21:617-23. [PMID: 26616825 PMCID: PMC5129586 DOI: 10.1111/nep.12686] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2015] [Revised: 11/23/2015] [Accepted: 11/24/2015] [Indexed: 12/16/2022]
Abstract
AIM Little is known about the effect of haemodialysis (HD) setting on outcomes of patients with end stage renal disease (ESRD). The study aimed at comparing clinical outcomes and patient-reported outcomes (PRO) of patients on community-based (CBHD) and hospital-based haemodialysis (HBHD). METHODS A prospective cohort of Chinese ESRD patients receiving HBHD (n = 89) or CBHD (n = 117) in Hong Kong were followed up for 12 months. Subjects were assessed on clinical outcomes of dialysis adequacy (Kt/V) and blood haemoglobin and PRO of health-related quality of life (SF-12v2), general health condition (Global Rating Scale (GRS)) and confidence to cope with their illness (Patient Enablement Instrument (PEI)). Differences between groups were analyzed by independent t-tests for the SF-12v2, GRS and PEI scores. χ(2) tests were used to analyze the difference in proportion of patients reaching the targets of Kt/V and blood haemoglobin and with GRS > 0 and PEI > 0. Multiple linear and logistic regressions were performed to assess the adjusted difference-in-difference estimation. RESULTS The mean PEI and GRS scores of CBHD patients at 12 months were significantly higher than those of HBHD patients. CBHD patients had significantly greater improvement in self-efficacy and were more likely to be enabled after 12 months than the HBHD patients. CONCLUSION The study showed similar clinical outcomes and PRO between CBHD and HBHD but CBHD was more effective than HBHD in promoting patient enablement over a 12-month period. The results suggest added value for patients receiving CBHD and support the transfer of HD care from the hospital to the community.
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Affiliation(s)
- Julie Y Chen
- Department of Family Medicine and Primary Care, The University of Hong Kong, Hong Kong, Hong Kong
| | - Eric Yf Wan
- Department of Family Medicine and Primary Care, The University of Hong Kong, Hong Kong, Hong Kong
| | - Edmond Ph Choi
- School of Nursing, The University of Hong Kong, Hong Kong, Hong Kong
| | - Carlos Kh Wong
- Department of Family Medicine and Primary Care, The University of Hong Kong, Hong Kong, Hong Kong
| | - Anca Kc Chan
- Department of Family Medicine and Primary Care, The University of Hong Kong, Hong Kong, Hong Kong
| | - Karina Hy Chan
- Department of Family Medicine and Primary Care, The University of Hong Kong, Hong Kong, Hong Kong
| | - Philip Kt Li
- Department of Medicine and Therapeutics, Prince of Wales Hospital, Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - Cindy Lk Lam
- Department of Family Medicine and Primary Care, The University of Hong Kong, Hong Kong, Hong Kong
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19
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Bao Y, Druss BG, Jung HY, Chan YF, Unützer J. Unpacking Collaborative Care for Depression: Examining Two Essential Tasks for Implementation. Psychiatr Serv 2016; 67:418-24. [PMID: 26567934 PMCID: PMC5445658 DOI: 10.1176/appi.ps.201400577] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
OBJECTIVE This study examined how two key process-of-care tasks of the collaborative care model (CCM) predict patient depression outcomes. METHODS Registry data were from a large implementation of the CCM in Washington State and included 5,439 patient-episodes for patients age 18 or older with a baseline Patient Health Questionnaire-9 (PHQ-9) score of ≥10 and at least one follow-up contact with the CCM care manager within 24 weeks of initial contact. Key CCM tasks examined were at least one care manager follow-up contact within four weeks of initial contact and at least one psychiatric consultation between weeks 8 and 12 for patients not responding to treatment by week 8. Clinically significant improvement in depression symptoms was defined as achieving a PHQ-9 score of <10 or a 50% or more reduction in PHQ-9 score compared with baseline. Bivariate and multivariate (logistic and proportional hazard models) analyses were conducted to examine how fidelity with either task predicted outcomes. All analyses were conducted with the original sample and with a propensity score-matched sample. RESULTS Four-week follow-up was associated with a greater likelihood of achieving improvement in depression (odds ratio [OR]=1.63, 95% confidence interval [CI]=1.23-2.17) and a shorter time to improvement (hazard ratio=2.06, CI=1.67-2.54). Psychiatric consultation was also associated with a greater likelihood of improvement (OR=1.44, CI=1.13-1.84) but not with a shorter time to improvement. Propensity score-matched analysis yielded very similar results. CONCLUSIONS Findings support efforts to improve fidelity to the two process-of-care tasks and to include these tasks among quality measures for CCM implementation.
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Affiliation(s)
- Yuhua Bao
- Dr. Bao and Dr. Jung are with the Department of Healthcare Policy and Research, Weill Cornell Medical College, New York City (e-mail: ). Dr. Bao is also with the Department of Psychiatry, Weill Cornell Medical College. Dr. Druss is with the Rollins School of Public Health, Emory University, Atlanta, Georgia. Dr. Chan and Dr. Unützer are with the Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle
| | - Benjamin G Druss
- Dr. Bao and Dr. Jung are with the Department of Healthcare Policy and Research, Weill Cornell Medical College, New York City (e-mail: ). Dr. Bao is also with the Department of Psychiatry, Weill Cornell Medical College. Dr. Druss is with the Rollins School of Public Health, Emory University, Atlanta, Georgia. Dr. Chan and Dr. Unützer are with the Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle
| | - Hye-Young Jung
- Dr. Bao and Dr. Jung are with the Department of Healthcare Policy and Research, Weill Cornell Medical College, New York City (e-mail: ). Dr. Bao is also with the Department of Psychiatry, Weill Cornell Medical College. Dr. Druss is with the Rollins School of Public Health, Emory University, Atlanta, Georgia. Dr. Chan and Dr. Unützer are with the Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle
| | - Ya-Fen Chan
- Dr. Bao and Dr. Jung are with the Department of Healthcare Policy and Research, Weill Cornell Medical College, New York City (e-mail: ). Dr. Bao is also with the Department of Psychiatry, Weill Cornell Medical College. Dr. Druss is with the Rollins School of Public Health, Emory University, Atlanta, Georgia. Dr. Chan and Dr. Unützer are with the Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle
| | - Jürgen Unützer
- Dr. Bao and Dr. Jung are with the Department of Healthcare Policy and Research, Weill Cornell Medical College, New York City (e-mail: ). Dr. Bao is also with the Department of Psychiatry, Weill Cornell Medical College. Dr. Druss is with the Rollins School of Public Health, Emory University, Atlanta, Georgia. Dr. Chan and Dr. Unützer are with the Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle
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20
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Holden K, Akintobi T, Hopkins J, Belton A, McGregor B, Blanks S, Wrenn G. Community Engaged Leadership to Advance Health Equity and Build Healthier Communities. SOCIAL SCIENCES (BASEL, SWITZERLAND) 2016; 5:2. [PMID: 27713839 PMCID: PMC5048675 DOI: 10.3390/socsci5010002] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Health is a human right. Equity in health implies that ideally everyone should have a fair opportunity to attain their full health potential and, more pragmatically, that no one should be disadvantaged from achieving this potential. Addressing the multi-faceted health needs of ethnically and culturally diverse individuals in the United States is a complex issue that requires inventive strategies to reduce risk factors and buttress protective factors to promote greater well-being among individuals, families, and communities. With growing diversity concerning various ethnicities and nationalities; and with significant changes in the constellation of multiple of risk factors that can influence health outcomes, it is imperative that we delineate strategic efforts that encourage better access to primary care, focused community-based programs, multi-disciplinary clinical and translational research methodologies, and health policy advocacy initiatives that may improve individuals' longevity and quality of life.
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Affiliation(s)
- Kisha Holden
- Department of Psychiatry & Behavioral Science, Morehouse School of Medicine, 720 Westview Drive, Atlanta, GA 30310, USA
- Satcher Health Leadership Institute, Morehouse School of Medicine, 720 Westview Drive, Atlanta, GA 30310, USA
- Department of Community Health and Preventive Medicine, Morehouse School of Medicine, 720 Westview Drive, Atlanta, GA 30310, USA
| | - Tabia Akintobi
- Department of Community Health and Preventive Medicine, Morehouse School of Medicine, 720 Westview Drive, Atlanta, GA 30310, USA
- Prevention Research Center, Morehouse School of Medicine, 720Westview Drive, Atlanta, GA 30310, USA
| | - Jammie Hopkins
- Satcher Health Leadership Institute, Morehouse School of Medicine, 720 Westview Drive, Atlanta, GA 30310, USA
- Department of Community Health and Preventive Medicine, Morehouse School of Medicine, 720 Westview Drive, Atlanta, GA 30310, USA
| | - Allyson Belton
- Satcher Health Leadership Institute, Morehouse School of Medicine, 720 Westview Drive, Atlanta, GA 30310, USA
| | - Brian McGregor
- Department of Psychiatry & Behavioral Science, Morehouse School of Medicine, 720 Westview Drive, Atlanta, GA 30310, USA
- Satcher Health Leadership Institute, Morehouse School of Medicine, 720 Westview Drive, Atlanta, GA 30310, USA
| | - Starla Blanks
- Satcher Health Leadership Institute, Morehouse School of Medicine, 720 Westview Drive, Atlanta, GA 30310, USA
| | - Glenda Wrenn
- Department of Psychiatry & Behavioral Science, Morehouse School of Medicine, 720 Westview Drive, Atlanta, GA 30310, USA
- Satcher Health Leadership Institute, Morehouse School of Medicine, 720 Westview Drive, Atlanta, GA 30310, USA
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21
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Price-Haywood EG, Dunn-Lombard D, Harden-Barrios J, Lefante JJ. Collaborative Depression Care in a Safety Net Medical Home: Facilitators and Barriers to Quality Improvement. Popul Health Manag 2016; 19:46-55. [PMID: 26087153 PMCID: PMC4770843 DOI: 10.1089/pop.2015.0016] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Little is known about how to integrate primary care with mental/behavioral services outside of clinical trials. The authors implemented a collaborative care model (CCM) for depression in a safety net patient-centered medical home. The model focused on universal screening for symptoms, risk stratification based on symptom severity, care management for intensive follow-up, and psychiatry consultation. CCM increased rates of primary care physician encounters, timely follow-up for monitoring symptoms of depression, and documentation of treatment response. Contextual factors that facilitated or hindered practice redesign included clinic leadership, quality improvement culture, staffing, technology infrastructure, and external incentives/disincentives for organizational change.
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Affiliation(s)
- Eboni G. Price-Haywood
- Ochsner Health System, Departments of Internal Medicine and Research, New Orleans, Louisiana
- Tulane University School of Medicine, Department of Medicine, New Orleans, Louisiana
| | - Donisha Dunn-Lombard
- Tulane University School of Medicine, Department of Medicine, New Orleans, Louisiana
| | - Jewel Harden-Barrios
- Ochsner Health System, Departments of Internal Medicine and Research, New Orleans, Louisiana
| | - John J. Lefante
- Tulane University School of Public Health and Tropical Medicine, Department of Biostatistics and Bioinformatics, New Orleans, Louisiana
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Gillies D, Buykx P, Parker AG, Hetrick SE. Consultation liaison in primary care for people with mental disorders. Cochrane Database Syst Rev 2015; 2015:CD007193. [PMID: 26384252 PMCID: PMC6463953 DOI: 10.1002/14651858.cd007193.pub2] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
BACKGROUND Approximately 25% of people will be affected by a mental disorder at some stage in their life. Despite the prevalence and negative impacts of mental disorders, many people are not diagnosed or do not receive adequate treatment. Therefore primary health care has been identified as essential to improving the delivery of mental health care. Consultation liaison is a model of mental health care where the primary care provider maintains the central role in the delivery of mental health care with a mental health specialist providing consultative support. Consultation liaison has the potential to enhance the delivery of mental health care in the primary care setting and in turn improve outcomes for people with a mental disorder. OBJECTIVES To identify whether consultation liaison can have beneficial effects for people with a mental disorder by improving the ability of primary care providers to provide mental health care. SEARCH METHODS We searched the EPOC Specialised Register, Cochrane Central Register of Controlled Trials (CENTRAL), and bibliographic databases: MEDLINE, EMBASE, CINAHL and PsycINFO, in March 2014. We also searched reference lists of relevant studies and reviews to identify any potentially relevant studies. SELECTION CRITERIA We included randomised controlled trials (RCTs) which compared consultation liaison to standard care or other service models of mental health care in the primary setting. Included participants were people attending primary care practices who required mental health care or had a mental disorder, and primary care providers who had direct contact with people in need of mental health care. DATA COLLECTION AND ANALYSIS Two review authors independently screened the titles and abstracts of identified studies against the inclusion criteria and extracted details including the study design, participants and setting, intervention, outcomes and any risk of bias. We resolved any disagreements by discussion or referral to a third author. We contacted trial authors to obtain any missing information.We collected and analysed data for all follow-up periods: up to and including three months following the start of treatment; between three and 12 months; and more than 12 months following the start of therapy.We used a random-effects model to calculate the risk difference (RD) for binary data and number needed to treat for an additional beneficial outcome (NNTB), if differences between groups were significant. The mean difference (MD) or standardised mean difference (SMD) was calculated for continuous data. MAIN RESULTS There were 8203 citations identified from database searches and reference lists. We included 12 trials with 2605 consumer participants and more than 905 primary care practitioner participants. Eleven trials compared consultation liaison to standard care and one compared consultation liaison to collaborative care, with a case manager co-ordinating mental health care. People with depression were included in eight trials; and one trial each included people with a variety of disorders: depression, anxiety and somatoform disorders; medically unexplained symptoms; and drinking problems. None of the included trials reported separate data for children or older people.There was some evidence that consultation liaison improved mental health up to three months following the start of treatment (two trials, n = 445, NNTB 8, 95% CI 5 to 25) but there was no evidence of its effectiveness between three and 12 months. Consultation liaison also appeared to improve consumer satisfaction (up to three months: one trial, n = 228, NNTB 3, 95% CI 3 to 5; 3 to 12 months: two trials, n = 445, NNTB 8, 95% CI 5 to 17) and adherence (3 to 12 months: seven trials, n = 1251, NNTB 6, 95% CI 4 to 13) up to 12 months. There was also an improvement in the primary care provider outcomes of providing adequate treatment between three to 12 months (three trials, n = 797, NNTB 7, 95% CI 4 to 17) and prescribing pharmacological treatment up to 12 months (four trials, n = 796, NNTB 13, 95% CI 7 to 50). There was also some evidence that consultation liaison may not be as effective as collaborative care in regards to symptoms of mental disorder, disability, general health status, and provision of treatment.The quality of these findings were low for all outcomes however, apart from consumer adherence from three to 12 months, which was of moderate quality. Eight trials were rated a high risk of performance bias because consumer participants were likely to have known whether or not they were allocated to the intervention group and most outcomes were self reported. Bias due to attrition was rated high in eight trials and reporting bias was rated high in six. AUTHORS' CONCLUSIONS There is evidence that consultation liaison improves mental health for up to three months; and satisfaction and adherence for up to 12 months in people with mental disorders, particularly those who are depressed. Primary care providers were also more likely to provide adequate treatment and prescribe pharmacological therapy for up to 12 months. There was also some evidence that consultation liaison may not be as effective as collaborative care in terms of mental disorder symptoms, disability, general health status, and provision of treatment. However, the overall quality of trials was low particularly in regards to performance and attrition bias and may have resulted in an overestimation of effectiveness. More evidence is needed to determine the effectiveness of consultation liaison for people with mental disorders particularly for those with mental disorders other than depression.
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Affiliation(s)
- Donna Gillies
- Western Sydney Local Health District ‐ Mental HealthCumberland HospitalLocked Bag 7118ParramattaNSWAustralia2124
| | - Penny Buykx
- University of SheffieldSchool of Health and Related Research (ScHARR)Regents CourtSheffieldSouth YorkshireUKS1 4DA
- Monash University School of Rural HealthPO Box 666BendigoVictoriaAustralia3552
| | - Alexandra G Parker
- University of MelbourneOrygen Youth Health Research Centre, Centre for Youth Mental HealthLocked Bag 10, 35 Poplar RoadParkvilleMelbourneVICAustralia3054
| | - Sarah E Hetrick
- Orygen, The National Centre of Excellence in Youth Mental Health and The Centre of Youth Mental Health, University of Melbourne35 Poplar RoadParkvilleMelbourneVictoriaAustralia3054
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Krupski A, West II, Graves MC, Atkins DC, Maynard C, Bumgardner K, Donovan D, Ries R, Roy-Byrne P. Clinical Needs of Patients with Problem Drug Use. J Am Board Fam Med 2015; 28:605-16. [PMID: 26355132 PMCID: PMC4883106 DOI: 10.3122/jabfm.2015.05.150004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
INTRODUCTION Illicit drug use is a serious public health problem associated with significant co-occurring medical disorders, mental disorders, and social problems. Yet most individuals with drug use disorders have never been treated, though they often seek medical treatment in primary care. The purpose of this study was to examine the baseline characteristics of people presenting in primary care with a range of problem drug use severity to identify their clinical needs. METHODS We examined sociodemographic characteristics, medical and psychiatric comorbidities, drug use severity, social and legal problems, and service utilization for 868 patients with drug problems. These patients were recruited from primary care clinics in a medical safety net setting. Based on Drug Abuse Screening Test results, individuals were categorized as having low, intermediate, or substantial/severe drug use severity. RESULTS Patients with substantial/severe drug use severity had serious drug use (opiates, stimulants, sedatives, intravenous drugs); high levels of homelessness (50%), psychiatric comorbidity (69%), and arrests for serious crimes (24%); and frequent use of expensive emergency department and inpatient hospitals. Patients with low drug use severity were primarily users of marijuana, with little reported use of other drugs, less psychiatric comorbidity, and more stable lifestyles. Patients with intermediate drug use severity fell in between the substantial/severe and low drug use severity subgroups on most variables. CONCLUSIONS Patients with the highest drug use severity are likely to require specialized psychiatric and substance abuse care, in addition to ongoing medical care that is equipped to address the consequences of severe/substantial drug use, including intravenous drug use. Because of their milder symptoms, patients with low drug use severity may benefit from a collaborative care model that integrates psychiatric and substance abuse care in the primary care setting. Patients with intermediate drug use severity may benefit from selective application of interventions suggested for patients with the highest and lowest drug use severity. Primary care safety net clinics are in a key position to serve patients with problem drug use by developing a range of responses that are locally effective and that may also inform national efforts to establish patient-centered medical homes and to implement the Affordable Care Act.
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Affiliation(s)
- Antoinette Krupski
- From the Department of Psychiatry and Behavioral Sciences, School of Medicine, University of Washington at Harborview Medical Center, Seattle (AK, IIW, MCG, DCA, KB, DD, RR, PR-B); the Department of Health Services, University of Washington School of Public Health, Seattle (CM); and the Alcohol & Drug Abuse Institute, University of Washington, Seattle (DD).
| | - Imara I West
- From the Department of Psychiatry and Behavioral Sciences, School of Medicine, University of Washington at Harborview Medical Center, Seattle (AK, IIW, MCG, DCA, KB, DD, RR, PR-B); the Department of Health Services, University of Washington School of Public Health, Seattle (CM); and the Alcohol & Drug Abuse Institute, University of Washington, Seattle (DD)
| | - Meredith C Graves
- From the Department of Psychiatry and Behavioral Sciences, School of Medicine, University of Washington at Harborview Medical Center, Seattle (AK, IIW, MCG, DCA, KB, DD, RR, PR-B); the Department of Health Services, University of Washington School of Public Health, Seattle (CM); and the Alcohol & Drug Abuse Institute, University of Washington, Seattle (DD)
| | - David C Atkins
- From the Department of Psychiatry and Behavioral Sciences, School of Medicine, University of Washington at Harborview Medical Center, Seattle (AK, IIW, MCG, DCA, KB, DD, RR, PR-B); the Department of Health Services, University of Washington School of Public Health, Seattle (CM); and the Alcohol & Drug Abuse Institute, University of Washington, Seattle (DD)
| | - Charles Maynard
- From the Department of Psychiatry and Behavioral Sciences, School of Medicine, University of Washington at Harborview Medical Center, Seattle (AK, IIW, MCG, DCA, KB, DD, RR, PR-B); the Department of Health Services, University of Washington School of Public Health, Seattle (CM); and the Alcohol & Drug Abuse Institute, University of Washington, Seattle (DD)
| | - Kristin Bumgardner
- From the Department of Psychiatry and Behavioral Sciences, School of Medicine, University of Washington at Harborview Medical Center, Seattle (AK, IIW, MCG, DCA, KB, DD, RR, PR-B); the Department of Health Services, University of Washington School of Public Health, Seattle (CM); and the Alcohol & Drug Abuse Institute, University of Washington, Seattle (DD)
| | - Dennis Donovan
- From the Department of Psychiatry and Behavioral Sciences, School of Medicine, University of Washington at Harborview Medical Center, Seattle (AK, IIW, MCG, DCA, KB, DD, RR, PR-B); the Department of Health Services, University of Washington School of Public Health, Seattle (CM); and the Alcohol & Drug Abuse Institute, University of Washington, Seattle (DD)
| | - Richard Ries
- From the Department of Psychiatry and Behavioral Sciences, School of Medicine, University of Washington at Harborview Medical Center, Seattle (AK, IIW, MCG, DCA, KB, DD, RR, PR-B); the Department of Health Services, University of Washington School of Public Health, Seattle (CM); and the Alcohol & Drug Abuse Institute, University of Washington, Seattle (DD)
| | - Peter Roy-Byrne
- From the Department of Psychiatry and Behavioral Sciences, School of Medicine, University of Washington at Harborview Medical Center, Seattle (AK, IIW, MCG, DCA, KB, DD, RR, PR-B); the Department of Health Services, University of Washington School of Public Health, Seattle (CM); and the Alcohol & Drug Abuse Institute, University of Washington, Seattle (DD)
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Eghaneyan BH, Sanchez K, Mitschke DB. Implementation of a collaborative care model for the treatment of depression and anxiety in a community health center: results from a qualitative case study. J Multidiscip Healthc 2014; 7:503-13. [PMID: 25395860 PMCID: PMC4226460 DOI: 10.2147/jmdh.s69821] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND The collaborative care model is a systematic approach to the treatment of depression and anxiety in primary care settings that involves the integration of care managers and consultant psychiatrists, with primary care physician oversight, to more proactively manage mental disorders as chronic diseases, rather than treating acute symptoms. While collaborative care has been shown to be more effective than usual primary care in improving depression outcomes in a number of studies, less is known about the factors that support the translation of this evidence-based intervention to real-world program implementation. The purpose of this case study was to examine the implementation of a collaborative care model in a community based primary care clinic that primarily serves a low-income, uninsured Latino population, in order to better understand the interdisciplinary relationships and the specific elements that might facilitate broader implementation. METHODS An embedded single-case study design was chosen in order to thoroughly examine the components of one of several programs within a single organization. The main unit of analysis was semi-structured interviews that were conducted with seven clinical and administrative staff members. A grounded theory approach was used to analyze the interviews. Line-by-line initial coding resulted in over 150 initial codes, which were clustered together to rebuild the data into preliminary categories and then divided into four final categories, or main themes. RESULTS FOUR UNIQUE THEMES ABOUT HOW THE IMPLEMENTATION OF A COLLABORATIVE CARE MODEL WORKED IN THIS SETTING EMERGED FROM THE INTERVIEWS: organizational change, communication, processes and outcomes of the program, and barriers to implementation. Each main theme had a number of subthemes that provided a detailed description of the implementation process and how it was unique in this setting. CONCLUSION The results indicated that adequate training and preparation, acceptance and support from key personnel, communication barriers, tools for systematic follow-up and measurement, and organizational stability can significantly impact successful implementation. Further research is necessary to understand how organizational challenges may affect outcomes for patients.
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Affiliation(s)
| | - Katherine Sanchez
- School of Social Work, The University of Texas at Arlington, Arlington, TX, USA
| | - Diane B Mitschke
- School of Social Work, The University of Texas at Arlington, Arlington, TX, USA
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Holden K, McGregor B, Thandi P, Fresh E, Sheats K, Belton A, Mattox G, Satcher D. Toward culturally centered integrative care for addressing mental health disparities among ethnic minorities. Psychol Serv 2014; 11:357-68. [PMID: 25383991 PMCID: PMC4228792 DOI: 10.1037/a0038122] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Despite decades of research, recognition and treatment of mental illness and its comorbidities still remain a significant public health problem in the United States. Ethnic minorities are identified as a population that is vulnerable to mental health disparities and face unique challenges pertaining to mental health care. Psychiatric illness is associated with great physical, emotional, functional, and societal burden. The primary health care setting may be a promising venue for screening, assessment, and treatment of mental illnesses for ethnic minority populations. We propose a comprehensive, innovative, culturally centered integrated care model to address the complexities within the health care system, from the individual level, which includes provider and patient factors, to the system level, which includes practice culture and system functionality issues. Our multidisciplinary investigative team acknowledges the importance of providing culturally tailored integrative health care to holistically concentrate on physical, mental, emotional, and behavioral problems among ethnic minorities in a primary care setting. It is our intention that the proposed model will be useful for health practitioners, contribute to the reduction of mental health disparities, and promote better mental health and well-being for ethnic minority individuals, families, and communities.
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Affiliation(s)
- Kisha Holden
- Department of Psychiatry and Behavioral Sciences, Morehouse School of Medicine
| | - Brian McGregor
- Department of Psychiatry and Behavioral Sciences, Morehouse School of Medicine
| | - Poonam Thandi
- Department of Psychiatry and Behavioral Sciences, Morehouse School of Medicine
| | - Edith Fresh
- Department of Family Medicine, Morehouse School of Medicine
| | - Kameron Sheats
- Satcher Health Leadership Institute, Morehouse School of Medicine
| | - Allyson Belton
- Satcher Health Leadership Institute, Morehouse School of Medicine
| | - Gail Mattox
- Department of Psychiatry and Behavioral Sciences, Morehouse School of Medicine
| | - David Satcher
- Satcher Health Leadership Institute, Morehouse School of Medicine
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Kilbourne AM, Almirall D, Eisenberg D, Waxmonsky J, Goodrich DE, Fortney JC, Kirchner JE, Solberg LI, Main D, Bauer MS, Kyle J, Murphy SA, Nord KM, Thomas MR. Protocol: Adaptive Implementation of Effective Programs Trial (ADEPT): cluster randomized SMART trial comparing a standard versus enhanced implementation strategy to improve outcomes of a mood disorders program. Implement Sci 2014; 9:132. [PMID: 25267385 PMCID: PMC4189548 DOI: 10.1186/s13012-014-0132-x] [Citation(s) in RCA: 75] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2014] [Accepted: 09/19/2014] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND Despite the availability of psychosocial evidence-based practices (EBPs), treatment and outcomes for persons with mental disorders remain suboptimal. Replicating Effective Programs (REP), an effective implementation strategy, still resulted in less than half of sites using an EBP. The primary aim of this cluster randomized trial is to determine, among sites not initially responding to REP, the effect of adaptive implementation strategies that begin with an External Facilitator (EF) or with an External Facilitator plus an Internal Facilitator (IF) on improved EBP use and patient outcomes in 12 months. METHODS/DESIGN This study employs a sequential multiple assignment randomized trial (SMART) design to build an adaptive implementation strategy. The EBP to be implemented is life goals (LG) for patients with mood disorders across 80 community-based outpatient clinics (N = 1,600 patients) from different U.S. regions. Sites not initially responding to REP (defined as < 50% patients receiving ≥ 3 EBP sessions) will be randomized to receive additional support from an EF or both EF/IF. Additionally, sites randomized to EF and still not responsive will be randomized to continue with EF alone or to receive EF/IF. The EF provides technical expertise in adapting LG in routine practice, whereas the on-site IF has direct reporting relationships to site leadership to support LG use in routine practice. The primary outcome is mental health-related quality of life; secondary outcomes include receipt of LG sessions, mood symptoms, implementation costs, and organizational change. DISCUSSION This study design will determine whether an off-site EF alone versus the addition of an on-site IF improves EBP uptake and patient outcomes among sites that do not respond initially to REP. It will also examine the value of delaying the provision of EF/IF for sites that continue to not respond despite EF. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT02151331.
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Affiliation(s)
- Amy M Kilbourne
- />VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, 2215 Fuller Rd, Mailstop 152, Ann Arbor, 48105 MI USA
- />Department of Psychiatry, North Campus Research Complex, University of Michigan Medical School, 2800 Plymouth Rd, Bldg 16, Ann Arbor, 48109-2800 MI USA
| | - Daniel Almirall
- />Institute for Social Research, University of Michigan, 426 Thompson Street, Ann Arbor, 48104-2321 MI USA
| | - Daniel Eisenberg
- />Department of Health Management and Policy, School of Public Health, University of Michigan, 1415 Washington Heights, Ann Arbor, 48109-2029 MI USA
| | - Jeanette Waxmonsky
- />Colorado Access, 10065 E. Harvard Ave, Suite 600, Denver, 80231 CO USA
- />Department of Psychiatry, University of Colorado School of Medicine, 13199 East Montview Blvd, Mailstop F550, Suite 330, Aurora, 80045 CO USA
| | - David E Goodrich
- />VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, 2215 Fuller Rd, Mailstop 152, Ann Arbor, 48105 MI USA
- />Department of Psychiatry, North Campus Research Complex, University of Michigan Medical School, 2800 Plymouth Rd, Bldg 16, Ann Arbor, 48109-2800 MI USA
| | - John C Fortney
- />Seattle HSR&D Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, 1660 S. Columbian Way, S-152, Seattle, 98108 WA USA
| | - JoAnn E Kirchner
- />VA Mental Health Quality Enhancement Research Initiative (MH QUERI), North Little Rock, 27114 AR USA
- />Department of Psychiatry, College of Medicine, University of Arkansas for Medical Sciences, 4301 W. Markham, Little Rock, 72205 AR USA
| | - Leif I Solberg
- />HealthPartners Institute for Education and Research, 3311 E. Old Shakopee Road, Bloomington, 55425 MN USA
| | - Deborah Main
- />Department of Health and Behavioral Sciences, University of Colorado Denver, Denver, 80217 CO USA
| | - Mark S Bauer
- />VA Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System, Bldg 9, Jamaica Plain Campus, 150 South Huntington Ave (152 M), Boston, 02130 MA USA
| | - Julia Kyle
- />VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, 2215 Fuller Rd, Mailstop 152, Ann Arbor, 48105 MI USA
- />Department of Psychiatry, North Campus Research Complex, University of Michigan Medical School, 2800 Plymouth Rd, Bldg 16, Ann Arbor, 48109-2800 MI USA
| | - Susan A Murphy
- />Institute for Social Research, University of Michigan, 426 Thompson Street, Ann Arbor, 48104-2321 MI USA
| | - Kristina M Nord
- />VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, 2215 Fuller Rd, Mailstop 152, Ann Arbor, 48105 MI USA
- />Department of Psychiatry, North Campus Research Complex, University of Michigan Medical School, 2800 Plymouth Rd, Bldg 16, Ann Arbor, 48109-2800 MI USA
| | - Marshall R Thomas
- />Colorado Access, 10065 E. Harvard Ave, Suite 600, Denver, 80231 CO USA
- />Department of Psychiatry, University of Colorado School of Medicine, 13199 East Montview Blvd, Mailstop F550, Suite 330, Aurora, 80045 CO USA
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Bauer AM, Thielke SM, Katon W, Unützer J, Areán P. Aligning health information technologies with effective service delivery models to improve chronic disease care. Prev Med 2014; 66:167-72. [PMID: 24963895 PMCID: PMC4137765 DOI: 10.1016/j.ypmed.2014.06.017] [Citation(s) in RCA: 82] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2014] [Revised: 05/14/2014] [Accepted: 06/11/2014] [Indexed: 11/24/2022]
Abstract
OBJECTIVE Healthcare reforms in the United States, including the Affordable Care and HITECH Acts, and the NCQA criteria for the Patient Centered Medical Home have promoted health information technology (HIT) and the integration of general medical and mental health services. These developments, which aim to improve chronic disease care, have largely occurred in parallel, with little attention to the need for coordination. In this article, the fundamental connections between HIT and improvements in chronic disease management are explored. We use the evidence-based collaborative care model as an example, with attention to health literacy improvement for supporting patient engagement in care. METHOD A review of the literature was conducted to identify how HIT and collaborative care, an evidence-based model of chronic disease care, support each other. RESULTS Five key principles of effective collaborative care are outlined: care is patient-centered, evidence-based, measurement-based, population-based, and accountable. The potential role of HIT in implementing each principle is discussed. Key features of the mobile health paradigm are described, including how they can extend evidence-based treatment beyond traditional clinical settings. CONCLUSION HIT, and particularly mobile health, can enhance collaborative care interventions, and thus improve the health of individuals and populations when deployed in integrated delivery systems.
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Affiliation(s)
- Amy M Bauer
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA, United States.
| | - Stephen M Thielke
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA, United States
| | - Wayne Katon
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA, United States
| | - Jürgen Unützer
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA, United States
| | - Patricia Areán
- Department of Psychiatry, University of California, San Francisco, United States
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Whitebird RR, Solberg LI, Jaeckels NA, Pietruszewski PB, Hadzic S, Unützer J, Ohnsorg KA, Rossom RC, Beck A, Joslyn KE, Rubenstein LV. Effective Implementation of collaborative care for depression: what is needed? THE AMERICAN JOURNAL OF MANAGED CARE 2014; 20:699-707. [PMID: 25365745 PMCID: PMC4270471] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
OBJECTIVES To identify the care model factors that were key for successful implementation of collaborative depression care in a statewide Minnesota primary care initiative. STUDY DESIGN We used a mixed-methods design incorporating both qualitative data from clinic site visits and quantitative measures of patient activation and 6-month remission rates. METHODS Care model factors identified from the site visits were tested for association with rates of activation into the program and remission rates. RESULTS Nine factors were identified as important for successful implementation of collaborative care by the consultants who had trained and interviewed participating clinic teams, and rated according to a Likert Scale. Factors correlated with higher patient activation rates were: strong leadership support (0.63), well-defined and -implemented care manager roles (0.62), a strong primary care physician champion (0.60), and an on-site and accessible care manager (0.59). However, remission rates at 6 months were correlated with: an engaged psychiatrist (0.62), not seeing operating costs as a barrier to participation (0.56), and face-to-face communication (warm handoffs) between the care manager and primary care physician for new patients (0.54). CONCLUSIONS Care model factors most important for successful program implementation differ for patient activation into the program versus remission at 6 months. Knowing which implementation factors are most important for successful activation will be useful for those interested in adopting this evidence-based approach to improving primary care for patients with depression.
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Affiliation(s)
- Robin R Whitebird
- Health-Partners Institute for Education and Research, 8170 33rd Ave So, Mail Stop 23301A, Minneapolis, MN 55425. E-mail:
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Ashcroft R, Silveira J, Rush B, Mckenzie K. Incentives and disincentives for the treatment of depression and anxiety: a scoping review. CANADIAN JOURNAL OF PSYCHIATRY. REVUE CANADIENNE DE PSYCHIATRIE 2014; 59:385-92. [PMID: 25007422 PMCID: PMC4086319 DOI: 10.1177/070674371405900706] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/01/2013] [Accepted: 01/01/2014] [Indexed: 11/05/2022]
Abstract
OBJECTIVE There is widespread support for primary care to help address growing mental health care demands. Incentives and disincentives are widely used in the design of health care systems to help steer toward desired goals. The absence of a conceptual model to help understand the range of factors that influence the provision of primary mental health care inspired a scoping review of the literature. Understanding the incentives that promote and the disincentives that deter treatment for depression and anxiety in the primary care context will help to achieve goals of greater access to mental health care. METHOD A review of the literature was conducted to answer the question, how are incentives and disincentives conceptualized in studies investigating the treatment of common mental disorders in primary care? A comprehensive search of MEDLINE, PsycINFO, CINAHL, and Google Scholar was undertaken using Arksey and O'Malley's 5-stage methodological framework for scoping reviews. RESULTS We identified 27 studies. A range of incentives and disincentives influence the success of primary mental health care initiatives to treat depression and anxiety. Six types of incentives and disincentives can encourage or discourage treatment of depression and anxiety in primary care: attitudes and beliefs, training and core competencies, leadership, organizational, financial, and systemic. CONCLUSIONS Understanding that there are 6 different types of incentives that influence treatment for anxiety and depression in primary care may help service planners who are trying to promote improved mental health care.
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Affiliation(s)
- Rachelle Ashcroft
- Postdoctoral Fellow, Social Aetiology of Mental Illness Training Program, Centre for Addiction and Mental Health, Toronto, Ontario; Assistant Professor, School of Social Work, Renison University College, University of Waterloo, Waterloo, Ontario
| | - Jose Silveira
- Chief of Psychiatry, Medical Director, Mental Health and Addiction Program, St Joseph's Health Centre, Toronto, Ontario; Assistant Professor, Department of Psychiatry, University of Toronto, Toronto, Ontario
| | - Brian Rush
- Senior Scientist, Health Equity Research Group, Social and Epidemiological Research Department, Centre for Addiction and Mental Health, Toronto, Ontario; Professor, Department of Psychiatry, University of Toronto, Toronto, Ontario; Associate Professor, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario
| | - Kwame Mckenzie
- Medical Director of Underserved Populations Program, Centre for Addictions and Mental Health, Toronto, Ontario; Professor of Psychiatry, University of Toronto: Director of Division of Equity, Gender and Populations, Toronto, Ontario; Director of Canadian Institutes of Health Research Social Aetiology of Mental Illness Training Program, Toronto, Ontario; President, Canadian Mental Health Association Toronto, Toronto, Ontario
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Loeb D, Sieja A, Corral J, Zehnder NG, Guiton G, Nease DE. Evaluation of the role of training in the implementation of a depression screening and treatment protocol in 2 academic outpatient internal medicine clinics utilizing the electronic medical record. Am J Med Qual 2014; 30:359-66. [PMID: 24829154 DOI: 10.1177/1062860614532681] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Systematic approaches to depression identification and management are effective though not consistently implemented. The research team implemented a depression protocol, preceded by training, in 2 faculty-resident practices. Medical assistants used the Patient Health Questionnaire (PHQ)-2 for initial screening; providers performed the PHQ-9. These were documented in the electronic medical record. Logistic regression was performed to assess the association of provider type, clinic site, and training attendance with documentation of PHQ-9 after positive PHQ-2s, and with repeat PHQ-9s after positive PHQ-9s. In logistic regression analysis, training attendance was positively associated with documentation of PHQ-9 after a positive PHQ-2 (odds ratio [OR] = 2.4 [confidence interval (CI) = 1.3-4.3]) and repeated documentation of a PHQ-9 after a positive PHQ-9 (OR = 2.5 [CI = 1.1-5.3]). This study describes the successful implementation of a stepped-care approach to depression care. The positive association of training with compliance with protocol procedures indicates the importance of training in the implementation of practice change.
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Affiliation(s)
- Danielle Loeb
- University of Colorado School of Medicine, Division of General Internal Medicine, Department of Internal Medicine, Aurora, CO
| | - Amber Sieja
- University of Colorado School of Medicine, Division of General Internal Medicine, Department of Internal Medicine, Aurora, CO
| | - Janet Corral
- University of Colorado School of Medicine, Department of Internal Medicine, Aurora, CO
| | - Nichole G Zehnder
- University of Colorado School of Medicine, Division of General Internal Medicine, Department of Internal Medicine, Aurora, CO
| | - Gretchen Guiton
- University of Colorado School of Medicine, Dean's Office, Aurora, CO
| | - Donald E Nease
- University of Colorado School of Medicine, Department of Family Medicine, Aurora, CO
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Chen S, Boyle LL, Conwell Y, Chiu H, Li L, Xiao S. Dementia care in rural China. MENTAL HEALTH IN FAMILY MEDICINE 2013; 10:133-141. [PMID: 24427180 PMCID: PMC3822660] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Subscribe] [Scholar Register] [Received: 05/08/2013] [Accepted: 08/21/2013] [Indexed: 06/03/2023]
Abstract
Dementia is a major cause of disability and has immense cost implications for the individual suffering from the condition, family caregivers and society. Given the high prevalence of dementia in China with its enormous and rapidly expanding population of elderly adults, it is necessary to develop and test approaches to the care for patients with this disorder. The need is especially great in rural China where access to mental healthcare is limited, with the task made more complex by social and economic reforms over the last 30 years that have transformed the Chinese family support system, family values and health delivery systems. Evidence-based collaborative care models for dementia, depression and other chronic diseases that have been developed in some Western countries serve as a basis for discussion of innovative approaches in the management of dementia in rural China, with particular focus on its implementation in the primary care system.
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Affiliation(s)
- Shulin Chen
- Department of Psychology, Zhejiang University, Hangzhou, China
| | - Lisa L Boyle
- Department of Psychiatry, University of Rochester School of Medicine, Rochester, NY, USA
| | - Yeates Conwell
- Department of Psychiatry, University of Rochester School of Medicine, Rochester, NY, USA
| | - Helen Chiu
- Department of Psychiatry, Chinese University of Hong Kong, Hong Kong
| | - Lydia Li
- Department of Social Work, University of Michigan, Michigan, USA
| | - Shuiyuan Xiao
- Public Health School, Central South University, Changsha, China
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Tomblin Murphy G, MacKenzie A, Alder R, Cruickshank C. Evaluation of a changed model of care delivery in a Canadian province using outcome mapping. Int J Health Plann Manage 2012; 28:346-66. [PMID: 23280769 DOI: 10.1002/hpm.2157] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2012] [Revised: 11/15/2012] [Accepted: 11/20/2012] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Collaboration between the Nova Scotia Department of Health and Wellness, the province's District Health Authorities (DHAs) and the Izaak Walton Killam (IWK) Health Center led to the development and implementation of a new collaborative model of patient-centered care delivery in the province. OBJECTIVE The objective was to determine the effectiveness of the initiative in arriving at the envisioned care model by investigating its impacts (if any) on patient, system, and providers outcomes. METHODS A repeated surveys study design with mixed methods in an outcome mapping framework was used to measure process and outcome indicators for patients and families, providers, and the system. RESULTS Almost all outcomes at the patient and family, provider, and system level improved following the implementation of the model, and these effects were stronger on units where the model was more fully implemented. CONCLUSIONS The efforts of the province, DHAs and IWK to improve patient care through the new care model have been successful. This evaluation is unique in the broad range of indicators it incorporates. Comprehensive monitoring and evaluation of health system changes is critical to system effectiveness.
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Affiliation(s)
- Gail Tomblin Murphy
- Dalhousie University-WHO Collaborating Centre on Health Workforce Planning & Research, Halifax, Nova Scotia, Canada
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Abstract
Major depression is disproportionately common among elderly adults receiving home healthcare and is characterized by greater medical illness, functional impairment, and pain. Depression is persistent in this population and is associated with numerous poor outcomes such as increased risk of hospitalization, injury-producing falls, and higher health care costs. Despite the need for mental health care in these patients, significant barriers unique to the home healthcare setting contribute to under-detection and under-treatment of depression. Intervention models target the home healthcare nurse as liaison between patients and physicians, and instruct in the identification and management of depression for their patients. Successful implementation requires interventions that 'fit' how home healthcare is organized and practiced, and long distance implementation strategies are required to increase the reach of these interventions.
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Bauer AM, Azzone V, Alexander L, Goldman HH, Unützer J, Frank RG. Are patient characteristics associated with quality of depression care and outcomes in collaborative care programs for depression? Gen Hosp Psychiatry 2012; 34:1-8. [PMID: 22018769 PMCID: PMC3253908 DOI: 10.1016/j.genhosppsych.2011.08.019] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2011] [Revised: 08/23/2011] [Accepted: 08/30/2011] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To determine whether demographic or clinical characteristics of primary care patients are associated with depression treatment quality and outcomes within a collaborative care model. METHODS Collaborative depression care, based on principles from the Improving Mood-Promoting Access to Collaborative Treatment (IMPACT) trial, was implemented in six community health organizations serving disadvantaged patients. Over 3 years, 2821 patients were treated. Outcomes were receipt of quality treatment and depression improvement. RESULTS Logistic regression analyses revealed that patients who were older, more depressed or more anxious were more likely to be retained in treatment and to receive appropriate pharmacotherapy. Whereas gender and depression severity were unrelated to depression outcomes, significantly more patients who preferred Spanish (59.1%) than English (48.5%, P<.01) improved within 12 weeks in multivariate analyses. High baseline anxiety was associated with a lower probability of improvement, and older age showed a similar trend. Survival analyses demonstrated that patients who preferred Spanish or were less anxious improved significantly more rapidly than their counterparts (P<.001). CONCLUSIONS Patients with more anxiety received higher quality care but experienced worse depression outcomes than less anxious patients. Spanish language preference was strongly associated with depression improvement. This collaborative care program attained admirable outcomes among disadvantaged Spanish-speaking patients without extensive cultural tailoring of care.
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Affiliation(s)
- Amy M Bauer
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA 98195-6560, USA.
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