Behavioural health consultants in integrated primary care teams: a model for future care

Utilization of Health Care Services and Accessibility Challenges among Adults Aged 50+ before and after Austerity Measures across 27 European Countries: Secular Trends in the SHARE Study from 2004/05 to 2019/20

This study aimed to assess and compare the utilization of preventive and other health services and the cost or availability in different regions of Europe, before and during the economic crisis. The data used in the study were obtained from Wave 8 of the Survey of Health, Ageing and Retirement in Europe (2019/2020) and Wave 1 data (2004/5), with a sample size of 46,106 individuals aged ≥50 across 27 countries, adjusted to represent a population of N = 180,886,962. Composite scores were derived for preventive health services utilization (PHSU), health care services utilization (HCSU), and lack of accessibility/availability in health care services (LAAHCS). Southern countries had lower utilization of preventive services and higher utilization of other health services compared to northern countries, with a significant lack of convergence. Moreover, the utilization of preventive health services decreased, whereas the utilization of secondary care services increased during the austerity period. Southern European countries had a significantly higher prevalence of lack of accessibility. An increase in the frequency of lack of accessibility/availability in health care services was observed from 2004/5 to 2019/20. In conclusion, our findings suggest that health inequalities increase during crisis periods. Therefore, policy interventions could prioritize accessibility and expand health coverage and prevention services.

Primary healthcare competencies needed in the management of person-centred integrated care for chronic illness and multimorbidity: Results of a scoping review

BACKGROUND

Chronic disease management is important in primary care. Disease management programmes focus primarily on the respective diseases. The occurrence of multimorbidity and social problems is addressed to a limited extent. Person-centred integrated care (PC-IC) is an alternative approach, putting the patient at the centre of care. This asks for additional competencies for healthcare professionals involved in the execution of PC-IC. In this scoping review we researched which competencies are necessary for healthcare professionals working in collaborative teams where the focus lies within the concept of PC-IC. We also explored how these competencies can be acquired.

METHODS

Six literature databases and grey literature were searched for guidelines and peer-reviewed articles on chronic illness and multimorbidity in primary care. A data synthesis was carried out resulting in an overview of the competencies that healthcare professionals need to deliver PC-IC.

RESULTS

Four guidelines and 21 studies were included and four core competencies could be derived through the synthesis: 1. interprofessional communication, 2, interprofessional collaborative teamwork, 3. leadership and 4. patient-centred communication. Included papers mostly lack a clear description of the competencies in terms of knowledge, skills and attitudes which are necessary for a PC-IC approach and on how these competencies can be acquired.

CONCLUSION

This review provides insight on competencies necessary to provide PC-IC within primary care. Research is needed in more depth on core concepts of these competencies which will then benefit educational programmes to ensure that healthcare professionals in primary care are better equipped to deliver PC-IC for patients with chronic illness and multimorbidity.

Primary care patients' experiences of video consultations for depression and anxiety: a qualitative interview study embedded in a randomized feasibility trial

BACKGROUND

Integrated mental health care models that provide rapid access to video consultations with mental health specialists for primary care patients are a promising short-term, low-threshold treatment option and may reduce waiting times for specialist care. This qualitative study, nested within a randomized feasibility trial, aimed to explore participants' views on this type of care model, its influence on the lived experience of patients, and barriers and facilitators for its delivery.

METHODS

In five primary care practices, 50 adults with depression and/or anxiety were randomly assigned to either an integrated care model (maximum of five video consultations with a mental health specialist) or usual care (primary care or another treatment option). Prior to obtaining the trial results, interviews were held with participants who had received video consultations. Interviews were transcribed and analysed thematically.

RESULTS

Twenty of the 23 patients who received video consultations participated in the interviews. Patients engaged well with the care model and reported positive effects on their most pressing needs, while denying safety concerns. Generally, they perceived the usability of video consultations as high, and temporary connectivity failures were not considered a substantial barrier. We identified two key mechanisms of impacts on the patients' lived experience: fast access to specialist mental healthcare and the emerging rapport with the specialist. In particular, patients with no prior mental healthcare experience indicated that familiarity with the primary practice and their physician as a gatekeeper were important facilitators of proactive treatment.

CONCLUSIONS

From the patients' perspective, mental health care models integrating video consultations with mental health specialists into primary care are linked to positive lived experiences. Our findings imply that primary care physicians should promote their role as gatekeepers to (1) actively engage patients, (2) apply integrated care models to provide a familiar and safe environment for conducting mental health care video consultations, and (3) be able to regularly assess whether certain patients need in-person services. Scaling up such models may be worthwhile in real-world service settings, where primary care physicians are faced with high workloads and limited specialist services.

TRIAL REGISTRATION

DRKS00015812.

Integrated primary care and social services for older adults with multimorbidity in England: a scoping review

BACKGROUND

As the prevalence of older adults with multimorbidity increases, greater integration of services is necessary to manage the physical and psycho-social needs of this cohort. This study describes and summarises current evidence, clinical provision and progress towards integrated primary care and social services for older adults with multimorbidity in England.

METHODS

A scoping review was conducted involving systematic searches of a range of electronic academic and policy databases. Articles were screened and extracted in duplicate by two independent reviewers. Data were extracted onto a charting sheet and thematic synthesis was used to summarise findings. Articles were included if published in English and related to primary care, social care and multimorbidity in older adults in England. Conceptually, the review was framed using the Rainbow Model of Integrated Care.

RESULTS

The search yielded 7656 articles of which 84 were included. Three themes were identified: (1) a focus on individual level services rather than multi-level or multi-sector integration, with an increasing emphasis on the need to consider broader determinants of population health as critical to integrated care for older adults with multimorbidity; (2) the need for policymakers to allow time for integration to embed, to enable new structures and relationships to develop and mature; and (3) the inherent tension between top-down and bottom-up driven approaches to integrated care requires a whole-systems structure, while allowing for local flexibilities.

CONCLUSIONS

There is limited evidence of multi-level and multi-sector integration of services for older adults with multimorbidity in England. The literature increasingly acknowledges wider determinants of population health that are likely to require integration beyond primary care and social services. Improving clinical care in one or two sectors may not be as effective as simultaneously improving the organisation or design across services as one single system of provision. This may take time to establish and will require local input.

The relationship between rates of hospitalization for ambulatory care sensitive conditions and local access to primary healthcare in Manitoba First Nations communities : Results from the Innovation in Community-based Primary Healthcare Supporting Transformation in the Health of First Nations in Manitoba (iPHIT) study

OBJECTIVES

The objective of this study was to assess the performance of models of primary healthcare (PHC) delivered in First Nation and adjacent communities in Manitoba, using hospitalization rates for ambulatory care sensitive conditions (ACSC) as the primary outcome.

METHODS

We used generalized estimating equation logistic regression on administrative claims data for 63 First Nations communities from Manitoba (1986-2016) comprising 140,111 people, housed at the Manitoba Centre for Health Policy. We controlled for age, sex, and socio-economic status to describe the relationship between hospitalization rates for ACSC and models of PHC in First Nation communities.

RESULTS

Hospitalization rates for acute, chronic, vaccine-preventable, and mental health-related ACSCs have decreased over time in First Nation communities, yet remain significantly higher in First Nations and remote non-First Nations communities as compared with other Manitobans. When comparing different models of care, hospitalization rates were historically higher in communities served by health centres/offices, whether or not supplemented by itinerant medical services. These rates have significantly declined over the past two decades.

CONCLUSION

Local access to a broader complement of PHC services is associated with lower rates of avoidable hospitalization in First Nation communities. The lack of these services in many First Nation communities demonstrates the failure of the current Canadian healthcare system to meet the need of First Nation peoples. Improving access to PHC in all 63 First Nation communities can be expected to result in a reduction in ACSC hospitalization rates and reduce healthcare cost.

Modeling Relationships Involving Perceived Recovery Orientation of Mental Health Teams Among Quebec Mental Health Professionals

While mental health (MH) services are expected to support client recovery, very little is known about services provided by MH teams in relation to this goal. This study explored relationships between a comprehensive collection of team effectiveness variables and the perspectives of MH professionals regarding the recovery orientation of their teams. A model developed by path analysis revealed eight team-related variables that were significantly and positively associated with recovery-oriented teams: primary care versus specialized MH services; greater proportions of clients with severe mental disorders or with suicide ideation on caseloads; knowledge sharing and knowledge production among team members; team climate; work role performance; and trust in coworkers. Results underline the importance of building knowledge and professional competence on MH teams, and the need for a positive team climate that offers flexibility and innovation for addressing the complex needs of people in MH recovery living in the community.

Part II: using an integrated case model for delivering mental health services in general practice for Pacific people

OBJECTIVE

To discuss an alternative model for delivering mental health services to Pacific people in general practice.

METHODS

Review of primary healthcare models which attempt to integrate behavioural healthcare with general practice.

RESULTS

There is some evidence that relationship-based collaborative models may improve both mental and physical health. Such a model has been implemented successfully by Alaskan Native Americans.

CONCLUSION

An integrated model of healthcare incorporating Pacific cultural values may reduce stigma and improve engagement and efficacy in delivering mental health treatment to Pacific people, their families and communities.

Explaining experiences of community-dwelling older adults with a pro-active comprehensive geriatric assessment program - a thorough evaluation by interviews

INTRODUCTION

Pro-active assessment programs are increasingly used to improve care for older adults. These programs include comprehensive geriatric tailored to individual patient preferences. Evidence for the effects of these programs on patient outcomes is nevertheless scarce or ambiguous. Explaining these dissatisfying results is difficult due to the multi-component nature of the programs. The objective of the current study was to explore and explain the experience of older adults participating in a pro-active assessment program, to help to clarify the effects.

METHODS

Semi-structured in-depth interviews were held with 25 participants of a pro-active assessment program for frail community-dwelling adults aged 65+. This study was part of an evaluation study on the effects of the program. Transcripts were analysed with thematic analysis and cross-case analysis.

RESULTS

The participants' mean age was 78.5 (SD 6.9) and 56% was female. The majority of the participants were satisfied with the program but based this on communication aspects, since only a few of them expressed real program benefits. Participant experiences could be clustered in six themes: (1) All participants expressed the need for a holistic view which was covered in the program, (2) the scope of the CGA was broader than expected or unclear, (3) the program delivered unexpected but valued help, (4) participants described a very low sense of ownership, (5) timing of the program implementation or the CGA was difficult and(6), participants and care workers had a different view on what to consider as a problem. These experiences could be explained by three program components: the degree of (the lack of) integration of the program within usual care, the pro-active screening method and the broader than expected, but appreciated multi-domain approach.

CONCLUSION

Older adults' need for a holistic view is covered by this outpatient assessment program. However, their engagement and the correct timing of the program are hampered by the pro-active recruitment and the limited integration of the program within existing care. Furthermore, satisfaction seems an insufficient guiding factor when evaluating CGA programs for older adults because it does not reflect the impact of the program.

Work-related variables associated with perceptions of recovery-oriented care among Quebec mental health professionals

BACKGROUND

Provider working conditions are important in mental health service delivery.

AIMS

To identify variables associated with perceived recovery-oriented care among mental health professionals.

METHOD

A total of 315 mental health professionals and 41 managers across four Quebec service networks completed questionnaires. Univariate and multilevel mixed-effects linear regressions for bivariate and multivariate analyses were performed using independent variables from the input-mediator-output-input model and recovery-oriented care.

RESULTS

Recovery-oriented care related to: working in primary care or out-patient mental health services, team support, team interdependence, prevalence of individuals with suicide ideation, knowledge-sharing, team reflexivity, trust, vision (a subset of team climate), belief in multidisciplinary collaboration and frequency of interaction with other organisations.

CONCLUSIONS

Optimising team processes (for example knowledge-sharing) and emergent states (for example trust) may enhance recovery-oriented care. Adequate financial and other resources, stable team composition, training on recovery best practices and use of standardised assessment tools should be promoted, while strengthening primary care and interactions with other organisations.

DECLARATION OF INTEREST

None.

Perspectives on Providing And Receiving Preventive Health Care From Primary Care Providers and Their Patients With Mental Illnesses

PURPOSE

Individuals with mental illnesses have higher morbidity rates and reduced life expectancy compared to the general population. Understanding how patients and providers perceive the need for prevention, as well as the barriers and beliefs that may contribute to insufficient care, are important for improving service delivery tailored to this population.

DESIGN

Cross-sectional; mixed methods.

SETTING

An integrated health system and a network of federally qualified health centers and safety net clinics.

PARTICIPANTS

Interviews (n = 30) and surveys (n = 249) with primary care providers. Interviews (n = 158) and surveys (n = 160) with patients diagnosed with schizophrenia, bipolar, anxiety, or major depressive disorders.

MEASURES

Semi-structured interviews and surveys.

ANALYSIS

Thematic analysis for qualitative data; frequencies for quantitative data.

RESULTS

More than half (n = 131, 53%) of clinicians believed patients with mental illnesses care less about preventive care than the general population, yet 88% (n = 139) of patients reported interest in improving health. Most providers (n = 216, 88%) lacked confidence that patients with mental illnesses would follow preventive recommendations; 82% (n = 129) of patients reported they would try to change lifestyles if their doctor recommended. Clinicians explained that their perception of patients' chaotic lives and lack of interest in preventive care contributed to their fatalistic attitudes on care delivery to this population. Clinicians and patients agreed on substantial need for additional support for behavior changes. Clinicians reported providing informational support by keeping messages simple; patients reported a desire for more detailed information on reasons to complete preventive care. Patients also detailed the need for assistive and tangible support to manage behavioral health changes.

CONCLUSIONS

Our results suggest a few clinical changes could help patients complete preventive care recommendations and improve health behaviors: improving clinician-patient collaboration on realistic goal setting, increasing visit time or utilizing behavioral health consultants that bridge primary and specialty mental health care, and increasing educational and tangible patient support services.

Two-Year Follow-Up of Fall Prediction Among Older Adults in an Independent-Living Community

Adults over the age of 70 are at risk of falls. Early detection of risk of falls can suggest early interventions. In this study, we attempted to determine valid clinical tests that can differentiate older individuals who are at risk of falling. Older adults from an independent-living community volunteered to participate in this descriptive, cohort study. They were administered the Berg Balance Scale (BBS), Zur Balance Scale (ZBS), Head Shaking Nystagmus Head Impulse Test, Dynamic Visual Acuity, and the Hallpike maneuver for evaluating benign paroxysmal positional vertigo (BPPV); a questionnaire including sociodemographics and a health characteristics survey. Multivariate analysis indicated that a ZBS score < 51, previous fall, and number of medications strongly predict falls in older adults. ZBS score, BBS score, Hallpike maneuver, number of medications, deficit of vestibular ocular reflex, along with positive ZBS score and past fall differentiate between fallers and non-fallers. ZBS <51, taking >6 medications, and history of falls were a benchmark for high-risk of falling.

Risk factors of the stigma towards psychiatric patients among primary healthcare workers in China: a county study

BACKGROUND

Attitude towards psychiatric patients among healthcare workers has an impact on quality of medical care and rehabilitation of patients. In China, primary healthcare workers play an important role in mental health care, but little is known about the attitude of them towards psychiatric patients. This study aims to examine the risk factors associated with stigma among primary healthcare workers in West China.

METHODS

This cross-sectional study randomly recruited 395 primary healthcare workers in Mianzhu County, China. Data were collected via self-reported questionnaires. Descriptive analyses, bivariate analyses, and hierarchical linear regressions were performed by SPSS 17.0 to test the factors that accounted for the variation of stigma towards psychiatric patients.

RESULTS

Several risk factors were confirmed, including the satisfaction of income, work experience in psychiatric/ psychological departments, rehabilitation of patients, contact quality, and the attitude of mass media. However, demographic factors, the rest of work-related factors, and contact frequency might not be related with primary healthcare workers' attitude towards psychiatric patients.

CONCLUSIONS

The findings suggested that the quality of contact between primary healthcare workers and psychiatric patients be enhanced in order to decrease the stigma of healthcare staff. On-the-job training and institutional medical education needs a further exploration and development.