Primary care after psychiatric crisis: a qualitative analysis

Follow-up After Pediatric Mental Health Emergency Visits

OBJECTIVES

To examine how outpatient mental health (MH) follow-up after a pediatric MH emergency department (ED) discharge varies by patient characteristics and to evaluate the association between timely follow-up and return encounters.

METHODS

We conducted a retrospective study of 28 551 children aged 6 to 17 years with MH ED discharges from January 2018 to June 2019, using the IBM Watson MarketScan Medicaid database. Odds of nonemergent outpatient follow-up, adjusted for sociodemographic and clinical characteristics, were estimated using logistic regression. Cox proportional hazard models were used to evaluate the association between timely follow-up and risk of return MH acute care encounters (ED visits and hospitalizations).

RESULTS

Following MH ED discharge, 31.2% and 55.8% of children had an outpatient MH visit within 7 and 30 days, respectively. The return rate was 26.5% within 6 months. Compared with children with no past-year outpatient MH visits, those with ≥14 past-year MH visits had 9.53 odds of accessing follow-up care within 30 days (95% confidence interval [CI], 8.75-10.38). Timely follow-up within 30 days was associated with a 26% decreased risk of return within 5 days of the index ED discharge (hazard ratio, 0.74; 95% CI, 0.63-0.91), followed by an increased risk of return thereafter.

CONCLUSIONS

Connection to outpatient care within 7 and 30 days of a MH ED discharge remains poor, and children without prior MH outpatient care are at highest risk for poor access to care. Interventions to link to outpatient MH care should prioritize follow-up within 5 days of an MH ED discharge.

Professionals' perceptions of the establishment of a specialized brief therapy unit in a district psychiatric centre - a qualitative study

Background

Increasing mental health problems and scarce treatment resources put pressure on mental health services to make innovations in service provision, such as developing differentiated services adapted to different needs. One innovation in differentiated service provision is brief or short-term treatment to patients with moderate mental health problems. Implementing a new unit in an organization usually faces many potential barriers and facilitators, and knowledge on how the professionals providing the services perceive the implementation of innovative approaches in mental health services is scarce. The aim of this study was therefore to explore the professionals’ perceptions of how the establishment of a specialized brief therapy unit had affected the organization, especially the everyday work in the outpatient clinics.

Methods

Eleven professionals, five men and six women, took part in individual interviews. All participants were between 40 and 60 years old and had leading or coordinating positions in the organization. Their professional backgrounds were within psychology, nursing and medicine, most of them specialists in their field. Data was analyzed according to Systematic text condensation.

Results

The professionals’ experiences represented four main themes: (1) The brief therapy unit was perceived as successful and celebrated. (2) The general outpatient clinics, on the other hand, were described as “forgotten”. (3) The establishment process had elucidated different views on treatment in the outpatient clinics - and had set off (4) a discussion regarding the criteria for prioritizing in mental health services.

Conclusion

Providing targeted treatment to patients with moderate mental health problems, while having a concurrent aim to solve broader problems in mental health services, entails a discussion regarding resource use and the appropriate level of treatment provision. Professionals should be more involved when innovative efforts are implemented, and the criteria for success must be conceptualized and evaluated. Longitudinal research on the implementation of innovative efforts in the services should include professionals’ and service users’ perspectives.

Patient-Centered Values and Experiences with Emergency Department and Mental Health Crisis Care

Little is known about what patients value in psychiatric crisis services or how they compare community-based services with those received in the emergency department. Three focus groups (n = 27) were held of participants who had received psychiatric crisis services in emergency departments or a community mental health center. Participants described care experiences and preferences. Focus groups were audio recorded, transcribed, and coded using a value-based lens. Themes included appreciation for feeling respected, basic comforts, and shared decision-making as foundations of quality care. Participants preferred the community mental health center. Research should address long-term outcomes to motivate change in psychiatric crisis care.

Patient navigators facilitating access to primary care: a scoping review

OBJECTIVE

Patient navigators are a promising mechanism to link patients with primary care. While navigators have been used in population health promotion and prevention programmes, their impact on access to primary care is not clear. The aim of this scoping review was to examine the use of patient navigators to facilitate access to primary care and how they were defined and described, their components and the extent to which they were patient centred.

SETTING AND PARTICIPANTS

We used the Arksey and O'Malley scoping review method. Searches were conducted in MEDLINE, Embase, ProQuest Medical, other key databases and grey literature for studies reported in English from January 2000 to April 2016. We defined a patient navigator as a person or process creating a connection or link between a person needing primary care and a primary care provider. Our target population was people without a regular source of, affiliation or connection with primary care. Studies were included if they reported on participants who were connected to primary care by patient navigation and attended or made an appointment with a primary care provider. Data analysis involved descriptive numerical summaries and content analysis.

RESULTS

Twenty studies were included in the final scoping review. Most studies referred to 'patient navigator' or 'navigation' as the mechanism of connection to primary care. As such, we grouped the components according to Freeman's nine-principle framework of patient navigation. Seventeen studies included elements of patient-centred care: informed and involved patient, receptive and responsive health professionals and a coordinated, supportive healthcare environment.

CONCLUSIONS

Patient navigators may assist to connect people requiring primary care to appropriate providers and extend the concept of patient-centred care across different healthcare settings. Navigation requires further study to determine impact and cost-effectiveness and explore the experience of patients and their families.

Like a hotel, but boring: users' experience with short-time community-based residential aftercare

Background

The discharge process from hospital to home for patients with severe mental illness (SMI) is often complex, and most are in need of tailored and coordinated community services at home. One solution is to discharge patients to inpatient short-stay community residential aftercare (CRA). The aim of this study was to explore how patients with SMI experience a stay in CRA established in a City in Central Norway.

Methods

A descriptive qualitative study with individual interviews and a group interview with 13 persons. The CRA aims to improve the discharge process from hospital to independent supported living by facilitating the establishment of health and social services and preparing the patients. The philosophy is to help patients use community resources by e.g. not offering any organized in-house activities. The main question in the interviews was “How have you experienced the stay at the CRA?” The interviews were analyzed with a thematic approach using systematic text condensation.

Results

The participants experienced the stay at the CRA “Like a hotel” but also boring, due to the lack of organized in-house activities. The patients generally said they were not informed about the philosophy of the CRA before the stay. The participants had to come up with activities outside the CRA and said they got active help from the staff to do so; some experienced this as positive, whereas others wanted more organized in-house activities like they were used to from mental health hospital stays. Participants described the staff in the CRA to be helpful and forthcoming, but they did not notice the staff being active in organizing the aftercare.

Conclusions

The stay at the CRA was experienced as different from other services, with more freedom and focus on self-care, and lack of in-house activities. This led to increased self-activity among the patients, but some wanted more in-house activities. To prepare the patients better for the stay at the CRA, more information about the philosophy is needed in the pre-admission process.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-017-2777-z) contains supplementary material, which is available to authorized users.

Physiotherapy Students' Attitudes toward Psychiatry and Mental Health: A Cross-Sectional Study

Purpose: A cross-sectional exploration of Notre Dame Australia physiotherapy students' attitudes toward psychiatry and mental illness, students' perceptions regarding preparation in this area for general clinical practice, and a cross-sectional investigation of current mental health-and psychiatry-related content in physiotherapy curricula across Australia and New Zealand. Methods: A questionnaire including demographic details, level of exposure to mental illness, and the Attitudes Toward Psychiatry-30 items (ATP-30) was completed by pre-clinical and clinically experienced physiotherapy students from the University of Notre Dame Australia. Students with clinical experience were asked additional questions about preparedness for practice. Staff of 10 of 17 physiotherapy programmes across Australia and New Zealand responded to an online questionnaire investigating relevant content and quantity of learning experiences in mental health. Results: Student response rate was 89%. Students generally had a positive attitude about psychiatry and mental health. Women were significantly more positive than men, and students who had completed clinical experience had a significantly more positive attitude. Physiotherapy program responses (response rate=59%) highlighted disparate approaches to psychiatry and mental health learning opportunities in terms of quantity and content. Conclusion: Entry-level physiotherapy students who have clinical experience generally have a more positive attitude toward psychiatry and people with mental illness. Given the prevalence of mental health problems and the increase in physical and mental health comorbidities, it is imperative that future clinicians have positive educational experiences in psychiatry. A coherent, integrated approach to mental illness and psychiatry is suggested for entry-level physiotherapy programmes in Australia and New Zealand.

Perceptions of crisis care in populations who self-referred to a telephone-based mental health triage service

Although psychiatric crises are very common in people with mental illness, little is known about consumer perceptions of mental health crisis care. Given the current emphasis on recovery-oriented approaches, shared decision-making, and partnering with consumers in planning and delivering care, this knowledge gap is significant. Since the late 1990s, access to Australian mental health services has been facilitated by 24/7 telephone-based mental health triage systems, which provide initial psychiatric assessment, referral, support, and advice. A significant proportion of consumers access telephone-based mental health triage services in a state of crisis, but to date, there has been no published studies that specifically report on consumer perceptions on the quality and effectiveness of the care provided by these services. This article reports on a study that investigated consumer perceptions of accessing telephone-based mental health triage services. Seventy-five mental health consumers participated in a telephone interview about their triage service use experience. An eight-item survey designed to measure the responsiveness of mental health services was used for data collection. The findings reported here focus on the qualitative data produced in the study. Consumer participants shared a range of perspectives on telephone-based mental health triage that provide invaluable insights into the needs, expectations, and service use experiences of consumers seeking assistance with a mental health problem. Consumer perceptions of crisis care have important implications for practice. Approaches and interventions identified as important to quality care can be used to inform educational and practice initiatives that promote person-centred, collaborative crisis care.

The cardiometabolic health nurse: physical health behaviour outcomes from a randomised controlled trial

To combat the increasingly poor physical health of people with serious mental illness, the position of a cardiometabolic health nurse has been proposed. We recently conducted a 26-week trial in a regional mental health service. This paper describes the background and rationale for the position, presents the outcomes on health behaviours and health behaviour knowledge and attitudes, and offers recommendations for the future direction of the role. We show that a cardiometabolic health nurse can improve the physical health behaviours in people with mental illness, however much needs to be done to further develop and implement the role.

Utilization of a cardiometabolic health nurse - a novel strategy to manage comorbid physical and mental illness

BACKGROUND

Comorbid chronic illnesses, such as cardiovascular disease, respiratory conditions, and type 2 diabetes are common among people with serious mental illness. Management of comorbid illness in the mental health setting is sometimes ad hoc and poorly delivered. Use of a cardiometabolic health nurse (CHN) is proposed as one strategy to improve the delivery of physical health care to this vulnerable population.

OBJECTIVE

To report the CHN's utilization of primary care and allied health referrals from a trial carried out in a regional community mental health service.

DESIGN

Feasibility study. Mental health consumers were referred by their case manager or mental health nurse to the CHN. The CHN coordinated the physical health care of community-based mental health consumers by identifying the need for, and providing referrals to, additional services, including primary care, allied health, and community-based services.

RESULTS

Sixty-two percent of participants referred to the CHN received referrals for primary care, allied health, and community-based services. Almost all referrals received follow-up by the CHN. Referrals were most commonly directed to a general practitioner and for nurse-delivered services.

CONCLUSION

The CHN role shows promise in coordinating the physical health of community-based mental health consumers. More studies on role integration and development of specific outcome measurement tools are needed. Journal of Comorbidity 2014;4:22-28.

Nurse views on the cardiometabolic health nurse as an approach to improving the physical health of people with serious mental illness in Australia

People with serious mental illness (SMI) die prematurely from common physical illnesses such as cardiovascular disease and diabetes. These cardiometabolic risks are preventable and manageable yet these aspects of health care have been neglected in mental health services. A potential nurse-based strategy to decisively improve cardiometabolic health of people with SMI is to introduce a cardiometabolic health nurse (CHN) into mental health services. The current study aimed to establish the views of nurses working in mental health care on the potential benefits and limits of CHN to improve physical health-care standards in Australia. All members of the Australian College of Mental Health Nurses were invited to participate in an online survey and 643 participated. Nurses generally agreed that a CHN role would provide a range of improvements to physical health care, such as increased detection, assessment on, and follow up of cardiometabolic risks, and decreased workload for other nurses. While participants were generally supportive of such a role, they felt it would not be suitable in all health-care settings in Australia.

Cardiometabolic health nursing to improve health and primary care access in community mental health consumers: protocol for a randomised controlled trial

BACKGROUND

People with a serious mental illness are at significantly greater risk of poor cardiometabolic health with recent studies showing a greater than two-fold increase in the risk of obesity, infectious diseases, diabetes and cardiovascular disease. Contributing factors to this disparity include poorer health behaviours such as suboptimal physical activity, poor diet, smoking, alcohol and illicit drug misuse. In particular, the limited access to primary health care experienced by people with a serious mental illness has been highlighted. Persons with a serious mental illness are around 30% less likely than those without serious mental illness to receive health assessments, hospital admissions or procedures for cardiovascular disease and diabetes, and are less likely to undergo cancer screening or receive vaccinations. Studies show that mental health consumers may be more likely to use mental health services rather than primary care for contact with the health care system. However mental health nurses report several barriers to their capacity to provide cardiometabolic health care crucial for the treatment of people with a serious mental illness.

OBJECTIVES

To assess the impact of a specialist Cardiometabolic Health Nurse on the physical health care of community based mental health consumers.

SETTING

Community mental health facility in a large regional centre in Central Queensland, Australia.

DESIGN/METHODS

Community based mental health consumers will be randomised to receive either usual care, or consultations with a Cardiometabolic Health Nurse. The Cardiometabolic Health Nurse will be responsible for assessing the client and coordinating cardiometabolic health care as required. Post intervention review of health records will be performed with the primary outcome measure being self-reported physical health. Secondary outcomes include the utilisation of primary care services and changes in health behaviours. We hypothesise that the Cardiometabolic Health Nurse will increase the utilisation of health care services for mental health consumers.

RESULTS

Data collection commenced in March 2013 and will conclude September 2013. Preliminary finding are expected in December 2013.

Gaps in health care for the somatic health of outpatients with severe mental illness

The physical health of outpatients with severe mental illness (SMI) can be improved by changes in the health-care system. Analysis of current practice is necessary to develop these strategies. We compared the number of somatic health problems of outpatients with SMI with the frequency of consulting a general practitioner (GP). This was a cross-sectional study based on interviews, and records from the GP and the pharmacy. We checked whether Dutch community pharmacies had complete and correct information about the patients' medication. We observed that all patients (n = 118) had somatic problems in need of clinical attention. Patients who visited their GP less than once a year (35%, n = 42), had a mean of 2.8 somatic health problems. This was less than patients who consulted their GP more than once a year (P ≤ 0.01). In 37% of cases, the pharmacy did not have adequate information on the drug use. Many patients with SMI seemed to have insufficient contact with their GP for their somatic health problems. Insufficient information about the patients' medication suggested that the pharmacist and GP should increase exchange of information. Mental health nurses can take a lead in coordinating the care to improve somatic health for their patients.

Family practice enhancements for patients with severe mental illness

Individuals with severe mental health disorders experience difficulty maneuvering the complexity encountered in primary care (PC). This study describes the impact of three components of primary care practice enhancements on: changes in missed appointments, changes in health outcomes, number of ER visits and hospitalization days, and perceptions of integrated care. Missed PC appointments: baseline to post practice enhancement changed from 42 to 11, statistically significant (p < .01). Changes in health outcomes: SF-12 scores had no significant change nor did ER utilization and hospitalization; however, outcomes are low-base rate and assessment period was short. Integration of care: liaison was most helpful in accessing and navigating PC, educating and reconciling medication lists. Behavioral health staff voiced relief regarding access and felt better informed. Strategies focusing on increasing communication, staff education, and reducing barriers to access and receipt of PC may improve integration and continuity of care.

Cloak of compassion, or evidence of elitism? An empirical analysis of white coat ceremonies

CONTEXT

White coat ceremonies (WCCs) are widely prevalent as a celebration of matriculation in medical schools. Critics have questioned whether these ceremonies can successfully combine the themes of professionalism and humanism, as well as whether the white coat is an appropriate symbol.

OBJECTIVES

This study aimed to add a process of empirical assessment to the discussion of these criticisms by analysing the content and messages communicated during these ceremonies.

METHODS

Multiple qualitative methods were used to discern the core meanings expressed in a sample of 18 ceremonies through the analysis of artefacts, words, phrases, statements and narratives. Out of a stratified random sample of 25 US schools of medicine conducting WCCs in 2009, 18 schools submitted video, audio and written materials.

RESULTS

All ceremonies followed the same general format, but varied in their content, messages and context. Ceremonies included five principal descriptions of what is symbolised by the white coat, including: commitment to humanistic professional care; a reminder of obligations and privileges; power; the student's need to 'grow', and the white coat as a mantle. Statements about obligations were made three times more frequently than statements about privileges. Key words or phrases in WCCs mapped to four domains: professionalism; morality; humanism, and spirituality. Spoken narratives focused on humility and generosity.

CONCLUSIONS

The WCCs studied did not celebrate the status of an elite class, but marked the beginning of educational, personal and professional formation processes and urged matriculants to develop into doctors 'worthy of trust'. The ceremonies centred on the persons entering the vocation, who were invited to affirm its calling and obligations by donning a symbolic garb, and to join an ancient and modern tradition of healing and immersion in their community. The schools' articulated construct of the white coat situated it as a symbol of humanism. This study's findings may clarify and guide schools' choices in designing their own WCCs.

Utilization and perceptions of primary health care services in Australian adults with mental illness

Persons accessing inpatient mental health services generally experience reduced access to and quality of primary health care. The objective of this study was to compare health service utilization and perceptions, and receipt of specified health services, in Australian adults with and without a previous mental illness diagnosis. A cross-sectional survey was administered by computer-assisted telephone interviewing in 2011; the main outcome measures were receipt of services in the previous 12 months, satisfaction with health care services, and concerns regarding health care affordability. Participants included 1275 adults residing in Queensland, Australia; 292 (23%) participants reported a diagnosis of mental illness, largely depression and/or anxiety (87%). The mental illness group had higher scores for concerns regarding health care affordability (mean ranks 778 vs. 706, respectively; z=-2.90, P=0.004) and lower scores for perceptions of health care service quality and accessibility (mean ranks 631 vs. 701, respectively; z=-2.90, P=0.004). After adjustment for increased utilization of services, the mental illness group had an increased likelihood of having received only 5 of 19 services in the past 12 months (odds ratios: 1.54-1.71). Compared to those with no mental illness, Australians with a mental illness report increased dissatisfaction with health care affordability, accessibility, and quality, and generally have similar odds of primary care services per health care utilization despite being at significantly greater risk of chronic disease.

Shared care in mental illness: A rapid review to inform implementation

BACKGROUND

While integrated primary healthcare for the management of depression has been well researched, appropriate models of primary care for people with severe and persistent psychotic disorders are poorly understood. In 2010 the NSW (Australia) Health Department commissioned a review of the evidence on "shared care" models of ambulatory mental health services. This focussed on critical factors in the implementation of these models in clinical practice, with a view to providing policy direction. The review excluded evidence about dementia, substance use and personality disorders.

METHODS

A rapid review involving a search for systematic reviews on The Cochrane Database of Systematic Reviews and Database of Abstracts of Reviews of Effects (DARE). This was followed by a search for papers published since these systematic reviews on Medline and supplemented by limited iterative searching from reference lists.

RESULTS

Shared care trials report improved mental and physical health outcomes in some clinical settings with improved social function, self management skills, service acceptability and reduced hospitalisation. Other benefits include improved access to specialist care, better engagement with and acceptability of mental health services. Limited economic evaluation shows significant set up costs, reduced patient costs and service savings often realised by other providers. Nevertheless these findings are not evident across all clinical groups. Gains require substantial cross-organisational commitment, carefully designed and consistently delivered interventions, with attention to staff selection, training and supervision. Effective models incorporated linkages across various service levels, clinical monitoring within agreed treatment protocols, improved continuity and comprehensiveness of services.

CONCLUSIONS

"Shared Care" models of mental health service delivery require attention to multiple levels (from organisational to individual clinicians), and complex service re-design. Re-evaluation of the roles of specialist mental health staff is a critical requirement. As expected, no one model of "shared" care fits diverse clinical groups. On the basis of the available evidence, we recommended a local trial that examined the process of implementation of core principles of shared care within primary care and specialist mental health clinical services.

Practice-based depression case management in primary care: a qualitative study on family doctors' perspectives

BACKGROUND

Case management provided by health care assistants (HCAs) is effective in improving primary care for depressive patients. Little is known on the implementation-related aspects of case management performed in small family practices.

OBJECTIVE

To explore family doctors' perspectives on clinical and organizational aspects of implementation of case management and perceived practice-related aspects associated with patient care after 1 year's experience of HCAs providing case management for depressive patients in their practices.

METHODS

This qualitative study was nested in a cluster-randomized trial on case management provided by practice-based HCAs for patients with major depression in Germany. We used semi-structured interview guides and performed audio-taped interviews with family doctors. Full transcription and thematic content analysis were carried out.

RESULTS

Twenty-three family doctors were interviewed. The family doctors perceived case management as beneficial to patients and reported that it improved their consultation styles and doctor-patient relationships. They implemented case management elements into their everyday day work using 'concrete', 'subsumed' or 'progressive' implementation styles.

CONCLUSIONS

Family doctors perceived practice-based case management by HCAs as beneficial for patient care. Different implementation styles may be appropriate, depending on the health care setting, and this requires further evaluation.

Effect of mental disorders on diagnosis, treatment, and survival of older adults with colon cancer

OBJECTIVES

To evaluate the extent to which preexisting mental disorders influence diagnosis, treatment, and survival in older adults with colon cancer.

DESIGN

Retrospective cohort study.

SETTING

The Surveillance, Epidemiology and End Results (SEER)-Medicare linked database.

PARTICIPANTS

Eighty thousand six hundred seventy participants, aged 67 and older with a diagnosis of colon cancer.

MEASUREMENTS

The association between the presence of a preexisting mental disorder and the stage of colon cancer at diagnosis, receipt of cancer treatment, and overall and colon cancer-specific mortality were assessed using Cox proportional hazards regression and logistic regression.

RESULTS

Participants with mental disorders were more likely to have been diagnosed with colon cancer at autopsy (4.4% vs 1.1%; P<.001) and at an unknown stage of cancer (14.6% vs 6.2%; P<.001); to have received no surgery, chemotherapy, or radiation therapy (adjusted risk ratio (ARR)=2.09, 95% confidence interval (CI)=1.86-2.35); and to have received no chemotherapy for Stage 3 cancer (ARR=1.63, 95% CI=1.49-1.79). The rate of overall mortality (hazard ratio (HR)=1.33, 95% CI=1.31-1.36) and colon cancer-specific mortality (HR=1.23, 95% CI=1.19-1.27) was substantially higher in participants with a preexisting mental disorder than in their counterparts. All of these associations were particularly pronounced in participants with psychotic disorders and those with dementia.

CONCLUSION

Public health initiatives are needed to improve colon cancer detection and treatment in older adults with mental disorders.

Effectiveness of service linkages in primary mental health care: a narrative review part 1

BACKGROUND

With the move to community care and increased involvement of generalist health care providers in mental health, the need for health service partnerships has been emphasised in mental health policy. Within existing health system structures the active strategies that facilitate effective partnership linkages are not clear. The objective of this study was to examine the evidence from peer reviewed literature regarding the effectiveness of service linkages in primary mental health care.

METHODS

A narrative and thematic review of English language papers published between 1998 and 2009. Studies of analytic, descriptive and qualitative designs from Australia, New Zealand, UK, Europe, USA and Canada were included. Data were extracted to examine what service linkages have been used in studies of collaboration in primary mental health care. Findings from the randomised trials were tabulated to show the proportion that demonstrated clinical, service delivery and economic benefits.

RESULTS

A review of 119 studies found ten linkage types. Most studies used a combination of linkage types and so the 42 RCTs were grouped into four broad linkage categories for meaningful descriptive analysis of outcomes. Studies that used multiple linkage strategies from the suite of "direct collaborative activities" plus "agreed guidelines" plus "communication systems" showed positive clinical (81%), service (78%) and economic (75%) outcomes. Most evidence of effectiveness came from studies of depression. Long term benefits were attributed to medication concordance and the use of case managers with a professional background who received expert supervision. There were fewer randomised trials related to collaborative care of people with psychosis and there were almost none related to collaboration with the wider human service sectors. Because of the variability of study types we did not exclude on quality or attempt to weight findings according to power or effect size.

CONCLUSION

There is strong evidence to support collaborative primary mental health care for people with depression when linkages involve "direct collaborative activity", plus "agreed guidelines" and "communication systems".

Inequalities in healthcare provision for people with severe mental illness

There are many factors that contribute to the poor physical health of people with severe mental illness (SMI), including lifestyle factors and medication side effects. However, there is increasing evidence that disparities in healthcare provision contribute to poor physical health outcomes. These inequalities have been attributed to a combination of factors including systemic issues, such as the separation of mental health services from other medical services, healthcare provider issues including the pervasive stigma associated with mental illness, and consequences of mental illness and side effects of its treatment. A number of solutions have been proposed. To tackle systemic barriers to healthcare provision integrated care models could be employed including co-location of physical and mental health services or the use of case managers or other staff to undertake a co-ordination or liaison role between services. The health care sector could be targeted for programmes aimed at reducing the stigma of mental illness. The cognitive deficits and other consequences of SMI could be addressed through the provision of healthcare skills training to people with SMI or by the use of peer supporters. Population health and health promotion approaches could be developed and targeted at this population, by integrating health promotion activities across domains of interest. To date there have only been small-scale trials to evaluate these ideas suggesting that a range of models may have benefit. More work is needed to build the evidence base in this area.

A randomized trial: are care navigators effective in connecting patients to primary care after psychiatric crisis?

Persons with serious mental illnesses suffer excess medical morbidity compared to the general population. This RCT aimed to determine whether navigators are effective in helping patients connect to primary care after psychiatric crisis. Adults presenting for emergency care were randomly assigned to a navigator versus usual care. Navigators facilitated access to primary care. Outcomes were connection rates to medical care and the impact of health insurance, hospitalization and mental health care on primary care attendance. After 1 year, the intervention group was statistically more likely to access care, versus controls (62.4 vs. 37.6%, P < .001). Navigators were effective in helping patients connect to primary care after a psychiatric crisis. Improved access to primary care is important given the complex chronic health problems of this vulnerable cohort.