What is needed to deliver collaborative care to address comorbidity more effectively for adults with a severe mental illness?

Missing link: a qualitative analysis of community-based organisations' contributions to partnered collaborative care to treat late-life depression

OBJECTIVE

Extending collaborative care, a model integrating mental health services into primary care, to include community-based organisations (CBOs) may improve older patient health outcomes by increasing access to care and addressing patients' social needs; however, little is known about how CBOs contribute to such partnered depression care. We explored how six primary care clinic and CBO partnerships came together to provide late-life depression care through the Care Partners funded in 2014.

DESIGN

43 key informant interviews and 15 focus groups were conducted with care managers, administrators and primary care providers partnering to provide late-life depression care. Data were coded and analysed iteratively using qualitative thematic analysis.

SETTING

Six primary care clinic-CBO sites across California.

PARTICIPANTS

Care managers, administrators and primary care providers participated in this study.

RESULTS

Three unique contributions of CBOs to depression care in these clinic-CBO partnerships were identified: (1) CBOs added new services that focus on social needs and enhanced depression care; (2) CBOs strengthened core aspects of collaborative care for depression; (3) CBOs provided new avenues for building connections and trust with underserved patients.

CONCLUSIONS

CBOs, when partnered with clinics, enhanced both medical and social aspects of depression treatment for older adults. CBOs are well positioned to assist primary care clinics in treating the complex health needs of older adults by providing new and strengthening existing aspects of partnered depression care while building patient trust among culturally diverse populations.

Barriers and facilitators to the participation and engagement of primary care in shared-care arrangements with community mental health services for preventive care of people with serious mental illness: a scoping review

BACKGROUND

People with serious mental illness die about 20 years earlier than the general population from preventable diseases. Shared-care arrangements between general practitioners and mental health services can improve consumers' access to preventive care, but implementing shared care is challenging. This scoping review sought to describe current evidence on the barriers and facilitators to the participation and engagement of primary care (specifically general practitioners) in shared-care arrangements with community mental health services for preventive health care of this population.

METHODS

We searched Medline, Embase, CINAHL, Scopus, APA PsychINFO and EBM Reviews from 2010 to 2022. Data was extracted against a Microsoft Excel template developed for the review. Data was synthesised through tabulation and narrative methods.

RESULTS

We identified 295 records. After eligibility screening and full-text review, seven studies were included. Facilitators of engagement included a good fit with organisation and practice and opportunities to increase collaboration, specific roles to promote communication and coordination and help patients to navigate appointments, multidisciplinary teams and teamwork, and access to shared medical/health records. Barriers included a lack of willingness and motivation on the part of providers and low levels of confidence with tasks, lack of physical structures to produce capacity, poor alignment of funding/incentives, inability to share patient information and challenges engaging people with severe mental illness in the service and with their care.

CONCLUSION

Our results were consistent with other research on shared care and suggests that the broader literature is likely to be applicable to the context of general practitioner/mental health services shared care. Specific challenges relating to this cohort present difficulties for recruitment and retention in shared care programs. Sharing "goals and knowledge, mutual respect" and engaging in "frequent, timely, accurate, problem-solving communication", supported by structures such as shared information systems are likely to engage primary care in shared care arrangements more than the traditional focus on incentives, education, and guidelines.

Current insights of community mental healthcare for people with severe mental illness: A scoping review

Background

For the last four decades, there has been a shift in mental healthcare toward more rehabilitation and following a more humanistic and comprehensive vision on recovery for persons with severe mental illness (SMI). Consequently, many community-based mental healthcare programs and services have been developed internationally. Currently, community mental healthcare is still under development, with a focus on further inclusion of persons with enduring mental health problems. In this review, we aim to provide a comprehensive overview of existing and upcoming community mental healthcare approaches to discover the current vision on the ingredients of community mental healthcare.

Methods

We conducted a scoping review by systematically searching four databases, supplemented with the results of Research Rabbit, a hand-search in reference lists and 10 volumes of two leading journals. We included studies on adults with SMI focusing on stimulating independent living, integrated care, recovery, and social inclusion published in English between January 2011 and December 2022 in peer-reviewed journals.

Results

The search resulted in 56 papers that met the inclusion criteria. Thematic analysis revealed ingredients in 12 areas: multidisciplinary teams; collaboration within and outside the organization; attention to several aspects of health; supporting full citizenship; attention to the recovery of daily life; collaboration with the social network; tailored support; well-trained staff; using digital technologies; housing and living environment; sustainable policies and funding; and reciprocity in relationships.

Conclusion

We found 12 areas of ingredients, including some innovative topics about reciprocity and sustainable policies and funding. There is much attention to individual ingredients for good community-based mental healthcare, but very little is known about their integration and implementation in contemporary, fragmented mental healthcare services. For future studies, we recommend more empirical research on community mental healthcare, as well as further investigation(s) from the social service perspective, and solid research on general terminology about SMI and outpatient support.

A protocol for a multi-site cohort study to evaluate child and adolescent mental health service transformation in England using the i-THRIVE model

The National i-THRIVE Programme seeks to evaluate the impact of the NHS England-funded whole system transformation on child and adolescent mental health services (CAMHS). This article reports on the design for a model of implementation that has been applied in CAMHS across over 70 areas in England using the 'THRIVE' needs-based principles of care. The implementation protocol in which this model, 'i-THRIVE' (implementing-THRIVE), will be used to evaluate the effectiveness of the THRIVE intervention is reported, together with the evaluation protocol for the process of implementation. To evaluate the effectiveness of i-THRIVE to improve care for children and young people's mental health, a cohort study design will be conducted. N = 10 CAMHS sites that adopt the i-THRIVE model from the start of the NHS England-funded CAMHS transformation will be compared to N = 10 'comparator sites' that choose to use different transformation approaches within the same timeframe. Sites will be matched on population size, urbanicity, funding, level of deprivation and expected prevalence of mental health care needs. To evaluate the process of implementation, a mixed-methods approach will be conducted to explore the moderating effects of context, fidelity, dose, pathway structure and reach on clinical and service level outcomes. This study addresses a unique opportunity to inform the ongoing national transformation of CAMHS with evidence about a popular new model for delivering children and young people's mental health care, as well as a new implementation approach to support whole system transformation. If the outcomes reflect benefit from i-THRIVE, this study has the potential to guide significant improvements in CAMHS by providing a more integrated, needs-led service model that increases access and involvement of patients with services and in the care they receive.

Impact of Electronic Health Records on Information Practices in Mental Health Contexts: Scoping Review

BACKGROUND

The adoption of electronic health records (EHRs) and electronic medical records (EMRs) has been slow in the mental health context, partly because of concerns regarding the collection of sensitive information, the standardization of mental health data, and the risk of negatively affecting therapeutic relationships. However, EHRs and EMRs are increasingly viewed as critical to improving information practices such as the documentation, use, and sharing of information and, more broadly, the quality of care provided.

OBJECTIVE

This paper aims to undertake a scoping review to explore the impact of EHRs on information practices in mental health contexts and also explore how sensitive information, data standardization, and therapeutic relationships are managed when using EHRs in mental health contexts.

METHODS

We considered a scoping review to be the most appropriate method for this review because of the relatively recent uptake of EHRs in mental health contexts. A comprehensive search of electronic databases was conducted with no date restrictions for articles that described the use of EHRs, EMRs, or associated systems in the mental health context. One of the authors reviewed all full texts, with 2 other authors each screening half of the full-text articles. The fourth author mediated the disagreements. Data regarding study characteristics were charted. A narrative and thematic synthesis approach was taken to analyze the included studies' results and address the research questions.

RESULTS

The final review included 40 articles. The included studies were highly heterogeneous with a variety of study designs, objectives, and settings. Several themes and subthemes were identified that explored the impact of EHRs on information practices in the mental health context. EHRs improved the amount of information documented compared with paper. However, mental health-related information was regularly missing from EHRs, especially sensitive information. EHRs introduced more standardized and formalized documentation practices that raised issues because of the focus on narrative information in the mental health context. EHRs were found to disrupt information workflows in the mental health context, especially when they did not include appropriate templates or care plans. Usability issues also contributed to workflow concerns. Managing the documentation of sensitive information in EHRs was problematic; clinicians sometimes watered down sensitive information or chose to keep it in separate records. Concerningly, the included studies rarely involved service user perspectives. Furthermore, many studies provided limited information on the functionality or technical specifications of the EHR being used.

CONCLUSIONS

We identified several areas in which work is needed to ensure that EHRs benefit clinicians and service users in the mental health context. As EHRs are increasingly considered critical for modern health systems, health care decision-makers should consider how EHRs can better reflect the complexity and sensitivity of information practices and workflows in the mental health context.

Integration of Care in Complex and Fragmented Service Systems: Experiences of Staff in Flexible Assertive Community Treatment Teams

Introduction

To provide more integrated care, several countries have implemented the Flexible Assertive Community Treatment (FACT) model. However, this model does not guarantee full integration, especially in complex and fragmented service systems like in Norway. Hence, we investigated which barriers that might reduce the potential for integrated care in the Norwegian system, as described by staff in FACT teams, and how they adjust their way of working to increase the opportunities for integration.

Methods

Online focus group interviews involving 35 staff members of five Norwegian FACT teams were conducted using a semi-structured interview guide. The material was analysed using thematic text analysis.

Results

Six themes described the barriers to integrated care in the service system: fragmentation, different legislation and digital systems, challenges in collaboration, bureaucracy and limited opening hours. Three themes described adjustments in the teams' way of working to enhance integration: working as the responsible co-ordinator, being a collaborator, and the only entry channel into the service system.

Conclusion

The FACT team staff described several barriers to integration within the system. However, they made some adjustments in their way of working that might provide opportunities for integrated care within complex and fragmented service systems.

Deployment of the consultation-liaison model in adult and child-adolescent psychiatry and its impact on improving mental health treatment

Background

Little information exists on the perceptions of psychiatrists regarding the implementation and various impacts of the consultation-liaison model. This model has been used in Quebec (Canada) through the function of specialist respondent-psychiatrists (SRP) since 2009. This study assessed the main activities, barriers or facilitators, and impact of SRP in adult and child-adolescent psychiatry on the capacity of service providers in primary care and youth centers to treat patients with mental health disorders (MHD).

Methods

Data included 126 self-administered questionnaires from SRP and semi-structured interviews from 48 SRP managers. Mixed methods were used, with qualitative findings from managers complementing the SRP survey. Comparative analyses of SRP responses in adult versus child-adolescent psychiatry were also conducted.

Results

Psychiatrists dedicated a median 24.12 h/month to the SRP function, mainly involving case discussions with primary care teams or youth centers. They were confident about the level of support they provided and satisfied with their influence in clinical decision-making, but less satisfied with the support provided by their organizations. SRP evaluated their impacts on clinical practice as moderate, particularly among general practitioners (GP). SRP working in child-adolescent psychiatry were more comfortable, motivated, and positive about their overall performance and impact than in adult psychiatry. Organizational barriers (e.g. team instability) were most prevalent, followed by system-level factors (e.g. network size and complexity, lack of resources, model inflexibility) and individual factors (e.g. GP reluctance to treat patients with MHD). Organizational facilitators included support from family medicine group directors, collaboration with university family medicine groups and coordination by liaison nurses; at the system level, pre-existing relationships and working in the same institution; while individual-level facilitators included SRP personality and strong organizational support.

Conclusion

Quebec SRP were implemented sparingly in family medicine groups and youth centers, while SRP viewed their overall impact as moderate. Results were more positive in child-adolescent psychiatry than in adult psychiatry. Increased support for the SRP function, adapting the model to GP in need of more direct support, and resolving key system issues may improve SRP effectiveness in terms of team stability, coordination among providers, access to MH services and readiness to implement innovations.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12875-021-01437-5.

Predictors of Recurrent High Emergency Department Use among Patients with Mental Disorders

Few studies have examined predictors of recurrent high ED use. This study assessed predictors of recurrent high ED use over two and three consecutive years, compared with high one-year ED use. This five-year longitudinal study is based on a cohort of 3121 patients who visited one of six Quebec (Canada) ED at least three times in 2014–2015. Multinomial logistic regression was performed. Clinical, sociodemographic and service use variables were identified based on data extracted from health administrative databases for 2012–2013 to 2014–2015. Of the 3121 high ED users, 15% (n = 468) were recurrent high ED users for a two-year period and 12% (n = 364) over three years. Patients with three consecutive years of high ED use had more personality disorders, anxiety disorders, alcohol or drug related disorders, chronic physical illnesses, suicidal behaviors and violence or social issues. More resided in areas with high social deprivation, consulted frequently with psychiatrists, had more interventions in local community health service centers, more prior hospitalizations and lower continuity of medical care. Three consecutive years of high ED use may be a benchmark for identifying high users needing better ambulatory care. As most have multiple and complex health problems, higher continuity and adequacy of medical care should be prioritized.

Flexible assertive community treatment teams can change complex and fragmented service systems: experiences of service providers

BACKGROUND

Implementing innovative health service models in existing service systems is complicated and context dependent. Flexible assertive community treatment (FACT) is a multidisciplinary service model aimed at providing integrated care for people with severe mental illness. The model was developed in the Netherlands and is now used in several countries, such as Norway. The Norwegian service system is complex and fragmented, with challenges in collaboration. Limited research has been performed on FACT teams and other new integrative health service models as part of such systems. However, such knowledge is important for future adjustments of innovation processes and service systems. Our aim was to explore how FACT teams are integrated into the existing formal public service system, how they function and affect the system, and describe some influencing factors to this. We sought to address how service providers in the existing service system experience the functioning of FACT teams in the system.

METHODS

Five focus group interviews were undertaken 3 years after the FACT teams were implemented. Forty service providers representing different services from both levels of administration (primary and specialist healthcare) from different Norwegian regions participated in this study. Team leaders of the FACT teams also participated. Service providers were recruited through purposeful sampling. Interviews were analysed using thematic text analysis.

RESULTS

The analysis revealed five main themes regarding FACT teams: (1) They form a bridge between different services; (2) They collaborate with other services; (3) They undertake responsibility and reassure other services; (4) They do not close all gaps in service systems; and (5) They are part of a service system that hampers their functioning.

CONCLUSIONS

The FACT teams in this study contributed to positive changes in the existing service system. They largely contributed to less complex and fragmented systems by forming a bridge and undertaking responsibility in the system and by collaborating with and reassuring other services; this has reduced some gaps in the system. The way FACT teams function and needs of the existing system appear to have contributed positively to these findings. However, complexity and fragmentation of the system partly hamper functioning of the FACT teams.

Barriers and Facilitators to the Implementation of the Pathways to Comorbidity Care (PCC) Training Package for the Management of Comorbid Mental Disorders in Drug and Alcohol Settings

Background: We have previously reported that the Pathways to Comorbidity Care (PCC) training program for alcohol and other drug (AOD) clinicians improved identification of comorbidity, self-efficacy, and attitudes toward screening and monitoring of comorbidity. We aimed to identify barriers and facilitators of implementation of the PCC training program in drug and alcohol settings. Methods: The PCC training program was implemented across 6 matched sites in Australia as per (1), and 20 clinicians received training. PCC training included seminar presentations, workshops conducted by local "clinical champions," individual clinical supervision, and access to an online information portal. We examined barriers and facilitators of implementation according to the Consolidated Framework for Implementation Research. Results: Barriers included inner setting (e.g., allocated time for learning) and characteristics of individuals (e.g., resistance). Facilitators included intervention characteristics (e.g., credible sources), inner setting (e.g., leadership), and outer setting domains (e.g., patient needs). Clinical champions were identified as an important component of the implementation process. Conclusions: Barriers included limited specific allocated time for learning. A credible clinical supervisor, strong leadership engagement and an active clinical champion were found to be facilitators of the PCC training program.

Unmet needs of persons with a severe and persistent mental illness and their relationship to unmet accommodation needs

This is a cross-sectional study of unmet needs of persons enrolled in Australia's Partners in Recovery (PIR) initiative. It aimed to explore the unmet needs reported by persons with a severe and persistent mental illness (SPMI) and to examine the associations between unmet accommodation needs and other unmet needs. The study was undertaken in the Gippsland region of Victoria from February to May 2015. Data were collected from the administrative database for the PIR initiative in Gippsland, which was held by the Gippsland Primary Health Network. Data on unmet needs, as measured by the Camberwell Assessment of Needs Short Appraisal Schedule, were analysed using proportions and logistic regression. Psychological distress, daytime activities, company/someone to spend time with and employment and volunteering were the most commonly reported unmet needs. Participants with unmet accommodation needs were less likely to receive information on their condition or access other services. They also had unmet needs relating to food, money, transport, childcare, looking after home, physical health, psychological distress and self-care. Supported accommodation may not be enough for persons with SPMI who have poor functioning skills and are incapable of looking after themselves. Services such as Housing First that have shown promising results need to be part of a comprehensive strategy to care for persons with severe and enduring mental illness.

Standardized drug and alcohol questions at admission to an acute adult mental health unit: clarifying the burden of dual diagnoses across a five-year period

OBJECTIVES

We aimed to report substance use across a five-year period in individuals admitted to an acute mental health unit, utilizing data from a routine clinical measure, diagnoses, and findings related to gender, ethnicity and the implementation of a new dual-diagnosis policy.

METHODS

Data was extracted from the electronic records of 2118 individuals who had consecutive admissions to the acute inpatient unit. Analysis focused on demographic and diagnosis variables and the drug and alcohol question in the Health of the Nations Outcome Scale.

RESULTS

Some 57.6% of the sample was in the at-risk drug and alcohol category. Male and indigenous inpatients were most at risk. More than 50% of patients with schizophrenia, anxiety and personality disorders were deemed at-risk. Following implementation of the dual-diagnosis policy, recorded primary and secondary substance use disorder (SUD) diagnoses significantly increased.

CONCLUSIONS

The study replicated previous findings of a high proportion of patients with co-morbid drug and alcohol use. In this sample it seems likely that the dual-diagnosis policy and related activities increased the rate of SUD diagnoses recorded, although it is likely to still be under-reported.

Promoting continuity of care for homeless adults with unmet health needs: The role of brief interventions

Promoting timely and continuous care for people experiencing homelessness has been a challenge in many jurisdictions, plagued by access barriers and service fragmentation. As part of a larger programme evaluation, this study used qualitative methods to examine the role of a brief interdisciplinary intervention in supporting continuity of care for this population in a large Canadian urban centre. The intervention provides time-limited case management, primary and psychiatric care, and peer accompaniment to homeless adults with unmet health needs discharged from hospital. Data were collected from 52 study participants between July 2013 and December 2014. Three focus groups were conducted with service providers and people with lived experience of homelessness, and 29 individual, semi-structured interviews were conducted with service users and other key informants. Transcripts were analysed using thematic analysis. Analysis was informed by existing frameworks for continuity of care, while remaining open to additional or unexpected findings. Findings suggest that brief interdisciplinary interventions can promote continuity of care by offering low-barrier access, timely and responsive service provision, including timely connection to long-term services and supports, appropriate individualised services and effective co-ordination of services. Although brief interdisciplinary interventions were perceived to promote access, timeliness and co-ordination of care for this population with complex health and social needs, gaps in the local service delivery context can present persisting barriers to care comprehensiveness and continuity.

Clozapine and concomitant medications: Assessing the completeness and accuracy of medication records for people prescribed clozapine under shared care arrangements

RATIONALE, AIM, AND OBJECTIVE

The objective of the study is to assess the completeness and accuracy of medication records held by stakeholders (secondary care, general practice, and community pharmacy) for clozapine consumers managed in a shared care programme.

METHODS

This was an exploratory, descriptive study examining secondary and primary care medication records in a large, urban, public mental health service setting in Queensland, Australia. Consumers (18-65 years old) prescribed clozapine under shared care management with capacity to consent were eligible (n = 55) to participate. Information from medication and dispensing records was used by a pharmacist to compile a best possible medication history for each consumer. Discrepancies were identified through reconciliation of stakeholder records with the history. Discrepancies were defined as an omission, addition, or administration discrepancy (difference in dose, frequency, or clozapine brand).

RESULTS

Thirty-five (63.6%) consumers consented for records to be reviewed. Overall, 32 (91.4%) consumers had at least 1 discrepancy in their records with a mean of 4.9 discrepancies per consumer. Of 172 discrepancies, 127 (73.8%) were omissions. Primarily, concomitant medicines were omitted in 19/35 (54%) of secondary care records while clozapine was omitted in 13/32 (40.6%) of community pharmacies records.

CONCLUSIONS

Discrepancies were highly prevalent in the shared care medication records of clozapine consumers of this service. Where there is incomplete and inaccurate medication information, there is a risk of suboptimal clinical decision making, increasing the likelihood of adverse drug events. This study demonstrates a need for improved documentation and timely access to accurate and complete medication records for shared care stakeholders. Expanding the pharmacist's role in this setting could improve medication accuracy in documentation and related communication.

Family inclusion in mental health services: Reality or rhetoric?

BACKGROUND

Contemporary mental health policies require family inclusion in the design, implementation and evaluation of services.

MATERIALS

This scoping review considers the factors in mental health practice which either mediate or promote family inclusion. A wide range of factors are reported to obstruct family inclusion, while a smaller number of studies report that meaningful family inclusion rests on a partnership approach which values the input of families and services users.

DISCUSSION

When it comes to family inclusion, there is a gap between policy and service delivery practice. Changes in service delivery attitudes, values and culture are necessary to meaningfully and systematically include families and service users.

Strategies to facilitate integrated care for people with alcohol and other drug problems: a systematic review

Background

There is a growing body of research highlighting the potential benefits of integrated care as a way of addressing the needs of people with alcohol and other drug (AOD) problems, given the broad range of other issues clients often experience. However, there has been little academic attention on the strategies that treatment systems, agencies and clinicians could implement to facilitate integrated care.

Methods

We synthesised the existing evidence on strategies to improve integrated care in an AOD treatment context by conducting a systematic review of the literature. We searched major academic databases for peer-reviewed articles that evaluated strategies that contribute to integrated care in an AOD context between 1990 and 2014. Over 2600 articles were identified, of which 14 met the study inclusion criteria of reporting on an empirical study to evaluate the implementation of integrated care strategies. The types of strategies utilised in included articles were then synthesised.

Results

We identified a number of interconnected strategies at the funding, organisational, service delivery and clinical levels. Ensuring that integrated care is included within service specifications of commissioning bodies and is adequately funded was found to be critical in effective integration. Cultivating positive inter-agency relationships underpinned and enabled the implementation of most strategies identified. Staff training in identifying and responding to needs beyond clinicians’ primary area of expertise was considered important at a service level. However, some studies highlight the need to move beyond discrete training events and towards longer term coaching-type activities focussed on implementation and capacity building. Sharing of client information (subject to informed consent) was critical for most integrated care strategies. Case-management was found to be a particularly good approach to responding to the needs of clients with multiple and complex needs. At the clinical level, screening in areas beyond a clinician's primary area of practice was a common strategy for facilitating referral and integrated care, as was joint care planning.

Conclusion

Despite considerable limitations and gaps in the literature in terms of the evaluation of integrated care strategies, particularly between AOD services, our review highlights several strategies that could be useful at multiple levels. Given the interconnectedness of integrated care strategies identified, implementation of multi-level strategies rather than single strategies is likely to be preferable.

Electronic supplementary material

The online version of this article (doi:10.1186/s13011-017-0104-7) contains supplementary material, which is available to authorized users.

The effect of context in rural mental health care: Understanding integrated services in a small town

Unequal health care outcomes for those with mental illness mean that access to integrated models is critical to supporting good physical and mental health care. This is especially so in rural areas where geographic and structural issues constrain the provision of health services. Guided by a conceptual framework about rural and remote health, this study draws on interviews with health providers and other staff and examines the dynamics of integrated primary and community-based specialist care for people with severe and persistent mental illnesses living in rural Australia. Findings show that the facilitation of sustainable linkages between general practice and community mental health requires the skilful exercise of power, knowledge, and resources by partners in order to address the social and structural factors that influence local health situations. These findings suggest that incremental processes of integration that are responsive to patients' and stakeholders' needs and that build on success and increased trust may be more effective than those imposed from the 'top down' that pay insufficient attention to local contexts.

Addressing the Needs of Problem Gamblers With Co-Morbid Issues: Policy and Service Delivery Approaches

Most people with gambling problems have at least one co-occurring condition and many experience multiple co-occurring conditions simultaneously. In many Western jurisdictions, a specialist service response has developed, with separate agencies and workforces established to respond to gambling problems. Despite the number of co-occurring issues that occur alongside gambling, research is limited on the prevalence of problem gambling across some service systems, such as mental health and family service sectors. However, it is reasonable to conclude that significant numbers of people with gambling problems are currently engaged in other health and welfare service sectors. Partnership work with other service sectors is therefore vital to respond to the needs of these people. In Victoria, Australia, a partnership program was established in gambling help services to improve integration and co-ordination between gambling, alcohol and drug, family support, and mental health service sectors. From the experience acquired in developing the program, we seek in this article to outline the benefits and challenges of implementing a cross-sector approach in gambling treatment service systems and to recommend effective strategies to develop a cross-sector approach, including creating an authorising environment at the government policy level.

Characteristics of individuals presenting to treatment for primary alcohol problems versus other drug problems in the Australian patient pathways study

BACKGROUND

People seeking treatment for substance use disorders often have additional health and social issues. Although individuals presenting with alcohol as the primary drug of concern (PDOC) account for nearly half of all treatment episodes to the Australian alcohol and other drug (AOD) service system, previous treatment cohort studies have focused only on the profile of Australian heroin or methamphetamine users. While studies overseas indicate that clients seeking treatment primarily for their drinking are less likely to experience social and economic marginalisation than those seeking treatment primarily for illicit or pharmaceutical drug use, very little research has directly compared individuals presenting with alcohol as the PDOC to those primarily presenting with other drugs as their PDOC.

METHODS

Seven hundred and ninety-six participants were recruited at entry to specialist AOD treatment in Victoria and Western Australia, and completed measures of demographic and social factors, substance use, quality of life, service use, and criminal justice involvement. We compared those with alcohol as their PDOC to those with other drugs as their PDOC using Pearson chi-square and Mann-Whitney U tests.

RESULTS

Rates of social disadvantage, poor quality of life, high severity of substance dependence, and past-year AOD, mental health, acute health, and social service use were high in all groups. However, participants with alcohol as the PDOC were older; more likely to have an educational qualification; less likely to report criminal justice involvement, housing/homelessness service use, tobacco smoking, or problems with multiple substances; and reported better environmental quality of life; but were more likely to have used ambulance services, than those with other drugs as their PDOC.

CONCLUSIONS

While those seeking treatment primarily for alcohol problems appear less likely to suffer some forms of social and economic disadvantage or to use multiple substances than those with a primary drug problem, they experience similarly high levels of substance dependence severity and mental health and AOD service use. These findings reinforce the need for AOD services to integrate or coordinate care with programs that address the many complexities clients frequently present with, while also acknowledging differences between those seeking treatment for alcohol versus other drug problems.

Physical health nurse consultant role to improve physical health in mental health services: A carer's perspective

The physical health of people diagnosed with a mental illness is significantly poorer in comparison with the general population. Awareness of this health disparity is increasing; however, strategies to address the problem are limited. Carers play an important role in the physical health care of people with mental illness, particularly in facilitating navigation of and advocating in the health care system. A specialist physical health nurse consultant position has been suggested as a way to address the physical health care disparity and limited research available suggests that positive outcomes are possible. In the present study, a qualitative exploratory research project was undertaken, involving in-depth interviews with people identifying as mental health carers. Two focus groups and one individual interview were conducted involving a total of 13 carers. The resulting data were analyzed thematically. Views and opinions about the proposed physical health nurse consultant (PHNC) position were sought during these interviews and are reported in this paper. Two main sub-themes were evident relating to characteristics of this role: reliability and consistency; and communication and support. Essentially carers expressed a need for support for themselves and consumers in addressing physical health concerns. Successful implementation of this position would require a consistent and reliable approach. Carers are significant stakeholders in the physical health of consumers of mental health services and their active involvement in identifying and tailoring services, including development of the physical health nurse consultant must be seen as a priority.

Physical health and mental illness: listening to the voice of carers

BACKGROUND

Shortened life expectancy of people with mental illness is now widely known and the focus of research and policy activity. To date, research has primarily reflected perspectives of health professionals with limited attention to the views and opinions of those most closely affected. The voice of carers is particularly minimal, despite policy stipulating carer participation is required for mental health services.

AIM

To present views and opinions of carers regarding physical health of the people they care for.

METHODS

Qualitative exploratory. Two focus groups and one individual interview were conducted with 13 people identifying as carers of a person with mental illness. Research was conducted in the Australian Capital Territory. Data analysis was based on the thematic framework of Braun and Clarke.

RESULTS

Two main themes were interaction between physical and mental health; and, carers' own physical and mental health. Participants described the impact of mental illness and its treatments on physical health, including their own.

CONCLUSIONS

Carers are acknowledged as crucial for the delivery of high quality mental health services. Therefore they have an important role to play in addressing the poor physical health of people with mental illness. Hearing their views and opinions is essential.

Cross-sector Service Provision in Health and Social Care: An Umbrella Review

Introduction:

Meeting the complex health needs of people often requires interaction among numerous different sectors. No one service can adequately respond to the diverse care needs of consumers. Providers working more effectively together is frequently touted as the solution. Cross-sector service provision is defined as independent, yet interconnected sectors working together to better meet the needs of consumers and improve the quality and effectiveness of service provision. Cross-sector service provision is expected, yet much remains unknown about how it is conceptualised or its impact on health status. This umbrella review aims to clarify the critical attributes that shape cross-sector service provision by presenting the current state of the literature and building on the findings of the 2004 review by Sloper.

Methods:

Literature related to cross-sector service provision is immense, which poses a challenge for decision makers wishing to make evidence-informed decisions. An umbrella review was conducted to articulate the overall state of cross-sector service provision literature and examine the evidence to allow for the discovery of consistencies and discrepancies across the published knowledge base.

Findings:

Sixteen reviews met the inclusion criteria. Seven themes emerged: Focusing on the consumer, developing a shared vision of care, leadership involvement, service provision across the boundaries, adequately resourcing the arrangement, developing novel arrangements or aligning with existing relationships, and strengthening connections between sectors. Future research from a cross-organisational, rather than individual provider, perspective is needed to better understand what shapes cross-sector service provision at the boundaries.

Conclusion:

Findings aligned closely with the work done by Sloper and raise red flags related to reinventing what is already known. Future researchers should look to explore novel areas rather than looking into areas that have been explored at length. Evaluations of out-comes related to cross-sector service provision are still needed before any claims about effectiveness can be made.

Treating substance abuse and mental health issues as 'mutually-exclusive' entities: Best practice or an outmoded approach to intervention?

Addressing the psychological distress of individuals experiencing substance use disorders has too often been relegated to the 'too hard basket', leaving those affected with little choice but to receive treatments aimed solely at addressing their drug and alcohol issues. Conversely, individuals receiving support for psychological issues are often underdiagnosed with regards to any comorbid substance misuse problems. In fact, to date, no definitive treatment model exists that gives equal focus to the treatment of both psychological well-being and substance-related addictions. This is not to suggest, however, that existing treatment programmes for substance misuse are not impacting positively on clients' mental health, rather that further research is needed in order to determine what it is that is supporting such improvements. The aim of this study, therefore, was to address this imbalance by examining the correlation between substance dependence and psychological well-being. Using a descriptive correlation design, the Severity of Dependence and Kessler 10 scales were administered to 37 inpatient and outpatient clients at a rural drug and alcohol rehabilitation service, at intake and 2 months into treatment. Data were analysed using descriptive statistics and paired-samples t-tests. Positive correlative factors of improvement between substance dependence and psychological well-being were found for both groups. In light of these findings, the authors recommend that future research be undertaken to investigate the causal factors for this correlation.

Mental illness and housing outcomes among a sample of homeless men in an Australian urban centre

OBJECTIVE

The over-representation of mental illness among homeless people across the globe is well documented. However, there is a dearth of Australian literature on the mental health needs of homeless individuals. Furthermore, longitudinal research examining the factors that contribute to better housing outcomes among this population is sparse. The aim of this research is to describe the mental illness profile of a sample of homeless men in an Australian urban centre (in Sydney) and examine the factors associated with better housing outcomes at 12-month follow-up.

METHODS

A longitudinal survey was administered to 253 homeless men who were involved in the Michael Project: a 3-year initiative which combined existing accommodation support services with assertive case management and access to coordinated additional specialist allied health and support services. A total of 107 participants were followed up 12 months later. The survey examined the demographics of the sample and lifetime mental disorder diagnoses, and also included psychological screeners for current substance use and dependence, psychological distress, psychosis, and post-traumatic stress.

RESULTS

Consistent with existing literature, the prevalence of mental illness was significantly greater amongst this sample than the general Australian population. However, mental illness presentation was not associated with housing situation at 12-month follow-up. Instead, type of support service at baseline was the best predictor of housing outcome, wherein participants who received short to medium-term accommodation and support were significantly more likely to be housed in stable, long-term housing at the 12-month follow-up than participants who received outreach or emergency accommodation support.

CONCLUSIONS

This study provides evidence to support an innovative support model for homeless people in Australia and contributes to the limited Australian research on mental illness in this population.

Intersectoral policy for severe and persistent mental illness: review of approaches in a sample of high-income countries

BACKGROUND

It is increasingly recognised that intersectoral linkages between mental health and other health and support sectors are essential for providing effective care for individuals with severe and persistent mental illness. The extent to which intersectoral collaboration and approaches to achieve it are detailed in mental health policy has not yet been systematically examined.

METHODS

Thirty-eight mental health policy documents from 22 jurisdictions in Australia, New Zealand, the United Kingdom, Ireland and Canada were identified via a web search. Information was extracted and synthesised on: the extent to which intersectoral collaboration was an objective or guiding principle of policy; the sectors acknowledged as targets for collaboration; and the characteristics of detailed intersectoral collaboration efforts.

RESULTS

Recurring themes in objectives/guiding principles included a whole of government approach, coordination and integration of services, and increased social and economic participation. All jurisdictions acknowledged the importance of intersectoral collaboration, particularly with employment, education, housing, community, criminal justice, drug and alcohol, physical health, Indigenous, disability, emergency and aged care services. However, the level of detail provided varied widely. Where detailed strategies were described, the most common linkage mechanisms were joint service planning through intersectoral coordinating committees or liaison workers, interagency agreements, staff training and joint service provision.

CONCLUSIONS

Sectors and mechanisms identified for collaboration were largely consistent across jurisdictions. Little information was provided about strategies for accountability, resourcing, monitoring and evaluation of intersectoral collaboration initiatives, highlighting an area for further improvement. Examples of collaboration detailed in the policies provide a useful resource for other countries.

Exploring the impact of common assessment instrumentation on communication and collaboration in inpatient and community-based mental health settings: a focus group study

Background

Recognition that integrated services can lead to more efficient and effective care has made the principle of integration a priority for health systems worldwide for the last decade. However, actually bringing fully integrated services to life has eluded most health care organizations. Mental health has followed the rule, rather than the exception, when it comes integrating services. The lack of effective mechanisms to evaluate the needs of persons across mental health care services has been an important barrier to communication between professionals involved in care. This study sought to understand communication among inpatient and community-based mental health staff during transfers of care, before and after implementation of compatible assessment instrumentation.

Methods

Two focus groups were held with staff from inpatient (n = 10) and community (n = 10) settings in an urban, specialized psychiatric hospital in Ontario (Canada) – prior to and one year after implementation of compatible instrumentation in the community program. Transcripts were coded and aggregated into themes.

Results

Very different views of current communication patterns during transfers of care emerged. Inpatient mental health staff described a predictable, well-known process, whereas community-based staff emphasized unpredictability. Staff also discussed issues related to trust and the circle of care. All agreed that compatible assessments in inpatient and community mental health settings would facilitate communication through use of a common assessment language. However, no change in communication patterns was reported one year post implementation of compatible instrumentation.

Conclusions

Though all participants agreed on the potential for compatible instrumentation to improve communication during transfers of care, this cannot happen overnight. A number of issues related to trust, evidence-based practice, and organizational factors act as barriers to communication. In particular, staff noted the need for the results of comprehensive mental health assessments to be transformed into meaningful, user-friendly clinical summaries to facilitate uptake of assessment information, and consequently use of a common assessment language across mental health settings.