Ten years of integrated care for mental disorders in the Netherlands

A multilevel study of patient-centered care perceptions in mental health teams

Background

The successful combination of interprofessional collaboration in multidisciplinary teams with patient-centered care is necessary when it comes to delivering complex mental health services. Yet collaboration is challenging and patient-centered care is intricate to manage. This study examines correlates of patient-centered care such as team adaptivity and proactivity, collaboration, belief in interprofessional collaboration and informational role self-efficacy in multidisciplinary mental health teams.

Method

A cross-sectional multilevel survey design was used, based on self-administered bilingual validated questionnaires. Participants (N=314) were mental health professionals and managers working in public primary care or specialized mental health services, in inpatient or outpatient settings.

Results

This study showed that belief in interprofessional collaboration’s relationship with patient-centered perceptions is increased in teams with high collaboration. Collaboration is also found as a mediator, representing a process by which team adaptive and proactive behaviors are transformed into positive patient-centered perceptions.

Conclusions

Our results were in line with recent studies on team processes establishing that collaboration is a key component in multilevel examinations of predictors of patient-centered care. In terms of practice, our study showed that multidisciplinary teams should know that working hard on collaboration is an answer to the complexity of patient-centered care. Collaboration is related to the teams’ ability to respond to its challenges. It is also related to individuals’ beliefs central to the delivery of interprofessional care.

Who needs collaborative care treatment? A qualitative study exploring attitudes towards and experiences with mental healthcare among general practitioners and care managers

Background

Collaborative care treatment is widely recognized as an effective approach to improve the quality of mental healthcare through enhanced and structured collaboration between general practice and specialized psychiatry. However, studies indicate that the complexity of collaborative care treatment interventions challenge the implementation in real-life general practice settings. Four Danish Collaborative Care Models were launched in 2014 for patients with mild/moderate anxiety and depression. These involved collaboration between general practitioners, care managers and consultant psychiatrists.

Taking a multi-practice bottom-up approach, this paper aims to explore the perceived barriers and enablers related to collaborative care for patients with mental health problems and to investigate the actual experiences with a Danish collaborative care model in a single-case study in order to identify enablers and barriers for successful implementation.

Methods

Combining interviews and observations of usual treatment practices, we conducted a multi-practice study among general practitioners who were not involved in the Danish collaborative care models to explore their perspectives on existing mental health treatment and to investigate (from a bottom-up approach) their perceptions of and need for collaborative care in mental health treatment. Additionally, by combining observations and qualitative interviews, we followed the implementation of a Danish collaborative care model in a single-case study to convey identified barriers and enablers of the collaborative care model.

Results

Experienced and perceived enablers of the Danish collaborative care model mainly consisted of a need for new treatment options to deal with mild/moderate anxiety and depression. The model was considered to meet the need for a free fast track to high-quality treatment. Experienced barriers included: poor adaptation of the model to the working conditions and needs in daily general practice, time consumption, unsustainable logistical set-up and unclear care manager role. General practitioners in the multi-practice study considered access to treatment and not collaboration with specialised psychiatry to be essential for this group of patients.

Conclusions

The study calls for increased attention to implementation processes and better adaptation of collaborative care models to the clinical reality of general practice. Future interventions should address the treatment needs of specific patient populations and should involve relevant stakeholders in the design and implementation processes.

Electronic supplementary material

The online version of this article (10.1186/s12875-018-0764-z) contains supplementary material, which is available to authorized users.

Comparative Effect of Collaborative Care, Pain Medication, and Duloxetine in the Treatment of Major Depressive Disorder and Comorbid (Sub)Chronic Pain: Results of an Exploratory Randomized, Placebo-Controlled, Multicenter Trial (CC:PAINDIP)

OBJECTIVE

Evidence exists for the efficacy of collaborative care (CC) for major depressive disorder (MDD), for the efficacy of the consequent use of pain medication against pain, and for the efficacy of duloxetine against both MDD and neuropathic pain. Their relative effectiveness in comorbid MDD and pain has never been established so far. This study explores the effectiveness of CC with pain medication and duloxetine, and CC with pain medication and placebo, compared with duloxetine alone, on depressive and pain symptoms. This study was prematurely terminated because of massive reorganizations and reimbursement changes in mental health care in the Netherlands during the study period and is therefore of exploratory nature.

METHODS

Three-armed, randomized, multicenter, placebo-controlled trial at three specialized mental health outpatient clinics with patients who screened positive for MDD. Interventions lasted 12 weeks. Pain medication was administered according to an algorithm that avoids opiate prescription as much as possible, where paracetamol, COX inhibitors, and pregabalin are offered as steps before opiates are considered. Patients who did not show up for three or more sessions were registered as non-compliant. Explorative, intention-to-treat and per protocol, multilevel regression analyses were performed. The trial is listed in the trial registration (http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=1089; NTR number: NTR1089).

RESULTS

Sixty patients completed the study. Patients in all treatment groups reported significantly less depressive and pain symptoms after 12 weeks. CC with placebo condition showed the fastest decrease in depressive symptoms compared with the duloxetine alone group (b = -0.78; p = 0.01). Non-compliant patients (n = 31) did not improve over the 12-week period, in contrast to compliant patients (n = 29). Pain outcomes did not differ between the three groups.

CONCLUSION

In MDD and pain, patient's compliance and placebo effects are more important in attaining effect than choice of one of the treatments. Active pain management with COX inhibitors and pregabalin as alternatives to tramadol or other opiates might provide an attractive alternative to the current WHO pain ladder as it avoids opiate prescription as much as possible. The generalizability is limited due to the small sample size. Larger studies are needed.

Relations between mental health team characteristics and work role performance

Effective mental health care requires a high performing, interprofessional team. Among 79 mental health teams in Quebec (Canada), this exploratory study aims to 1) determine the association between work role performance and a wide range of variables related to team effectiveness according to the literature, and to 2) using structural equation modelling, assess the covariance between each of these variables as well as the correlation with other exogenous variables. Work role performance was measured with an adapted version of a work role questionnaire. Various independent variables including team manager characteristics, user characteristics, team profiles, clinical activities, organizational culture, network integration strategies and frequency/satisfaction of interactions with other teams or services were analyzed under the structural equation model. The later provided a good fit with the data. Frequent use of standardized procedures and evaluation tools (e.g. screening and assessment tools for mental health disorders) and team manager seniority exerted the most direct effect on work role performance. While network integration strategies had little effect on work role performance, there was a high covariance between this variable and those directly affecting work role performance among mental health teams. The results suggest that the mental healthcare system should apply standardized procedures and evaluation tools and, to a lesser extent, clinical approaches to improve work role performance in mental health teams. Overall, a more systematic implementation of network integration strategies may contribute to improved work role performance in mental health care.

Variables Associated With Perceived Work Role Performance Among Professionals in Multidisciplinary Mental Health Teams Overall and in Primary Care and Specialized Service Teams, Respectively

This study had a dual purpose (1) to identify variables associated with perceived work role performance (WRP) among 315 mental health professionals (MHPs) in Quebec and (2) to compare variables related to WRP in MH primary care teams (PCTs) and specialized service teams (SSTs), respectively. WRP was measured using an adapted version of the work role questionnaire. Variables were organized within five areas: individual characteristics, perceived team attributes, perceived team processes, perceived team emergent states, and geographical and organizational context. Half of the WRP variables were linked to team processes. Knowledge sharing correlated with WRP in both MH PCTs and SSTs. Team attributes had more impact on MH PCTs, while team processes and team emergent states played a larger role among SSTs. The association between WRP and knowledge sharing confirms the need for a systematic training program to promote interdisciplinary collaboration. Integration strategies (e.g., service agreements) could improve collaboration between MH PCTs and SSTs and help MHPs perform more effectively within PCTs.

Towards Horizon 2020: challenges and advances for clinical mental health research - outcome of an expert survey

BACKGROUND

The size and increasing burden of disease due to mental disorders in Europe poses substantial challenges to its population and to the health policy of the European Union. This warrants a specific research agenda concerning clinical mental health research as one of the cornerstones of sustainable mental health research and health policy in Europe. The aim of this research was to identify the top priorities needed to address the main challenges in clinical research for mental disorders.

METHODS

The research was conducted as an expert survey and expert panel discussion during a scientific workshop.

RESULTS

Eighty-nine experts in clinical research and representing most European countries participated in this survey. Identified top priorities were the need for new intervention studies, understanding the diagnostic and therapeutic implications of mechanisms of disease, and research in the field of somatic-psychiatric comorbidity. The "subjectivity gap" between basic neuroscience research and clinical reality for patients with mental disorders is considered the main challenge in psychiatric research, suggesting that a shift in research paradigms is required.

CONCLUSION

Innovations in clinical mental health research should bridge the gap between mechanisms underlying novel therapeutic interventions and the patient experience of mental disorder and, if present, somatic comorbidity. Clinical mental health research is relatively underfunded and should receive specific attention in Horizon 2020 funding programs.

Incentives for telehealthcare deployment that support integrated care: a comparative analysis across eight European countries

INTRODUCTION

Health care systems are struggling to deal with the increasing demands of an older population. In an attempt to find a solution to these demands, there has been a shift towards integrated care supported by information and communication technologies. However, little is understood about the role played by incentives and reimbursement schemes in the development of integrated care and information and communication technologies uptake. The objective of this paper is to investigate this question, specifically as regards telehealthcare.

METHODS

In order to identify the deployment of telehealthcare applications and their role in supporting integrated care, a case study approach was used. A clustering exercise was carried out and eight European countries were selected for in-depth study: Denmark, Estonia, Germany, France, Italy, the Netherlands, Spain and the UK. In total, 31 telehealthcare initiatives across eight countries involving over 20,000 patients were investigated.

RESULTS

Reflecting on specific examples in each initiative, drivers promoting integrated care delivery supported by telehealthcare mainstreaming and associated incentive mechanisms were identified. Attention was also paid to other factors which acted as barriers for widespread deployment.

DISCUSSION AND CONCLUSIONS

Trends towards telehealthcare mainstreaming were found in Denmark, the UK, and in some regions of Spain, Italy and France. Mainstreaming often went hand-in-hand with progress towards integrated care delivery and payment reforms. A general trend was found towards outcomes-based payments and bundled payment schemes, which aimed to promote integrated care supported by telehealthcare deployment. Their effectiveness in achieving these goals remains to be seen. In addition, a form of outpatient diagnostic-related group reimbursement for telehealthcare services was found to have emerged in a few countries. However, it is questionable how this incentive could promote integrated care delivery on its own. This research suggests that incentives which align social, primary and hospital care are rare and there is a need to design new payment paradigms. Finally, eHealth penetration, interoperability, governance, availability of evidence and reorganisation of services represent additional factors which can act as drivers or barriers for integrated care delivery.

Exploring the role of ICT in the provision of integrated care--evidence from eight countries

This research aimed to identify the role of telehealthcare in the provision of integrated care in thirty-one experiences across eight different European countries, namely: Denmark, Estonia, Germany, France, Italy, Netherlands, Spain and the UK. Experiences were analysed from three perspectives: diffusion of innovations, governance and impact, which led to the identification of a set of drivers and barriers for widespread deployment. The analysis also found that telehealthcare developments were strongly in line with developments towards the delivery of integrated care and thus support this process. Factors which contribute to the successful delivery of integrated care, such as aligned incentives, sound governance and evidence consolidation, were identified across the most successful experiences. Although the decision to mainstream telehealthcare will remain a value judgement, the analysis of best practices across experiences allowed us to identify factors which could enable decision makers to assess both the state of maturity of the health and social care environments and their readiness to scale up.

Understanding the link between leadership style, employee satisfaction, and absenteeism: a mixed methods design study in a mental health care institution

BACKGROUND

In service oriented industries, such as the health care sector, leadership styles have been suggested to influence employee satisfaction as well as outcomes in terms of service delivery. However, how this influence comes into effect has not been widely explored. Absenteeism may be a factor in this association; however, no studies are available on this subject in the mental health care setting, although this setting has been under a lot of strain lately to provide their services at lower costs. This may have an impact on employers, employees, and the delivery of services, and absenteeism due to illness of employees tends to already be rather high in this particular industry. This study explores the association between leadership style, absenteeism, and employee satisfaction in a stressful work environment, namely a post-merger specialty mental health care institution (MHCI) in a country where MHCIs are under governmental pressure to lower their costs (The Netherlands).

METHODS

We used a mixed methods design with quantitative as well as qualitative research to explore the association between leadership style, sickness absence rates, and employee satisfaction levels in a specialty MHCI. In depth, semi-structured interviews were conducted with ten key informants and triangulated with documented research and a contrast between four departments provided by a factor analysis of the data from the employee satisfaction surveys and sickness rates. Data was analyzed thematically by means of coding and subsequent exploration of patterns. Data analysis was facilitated by qualitative analysis software.

RESULTS

Quantitative analysis revealed sickness rates of 5.7% in 2010, which is slightly higher than the 5.2% average national sickness rate in The Netherlands in 2010. A general pattern of association between low employee satisfaction, high sickness rates, and transactional leadership style in contrast to transformational leadership style was established. The association could be described best by: (1) communication between the manager and employees; (2) the application of sickness protocols by the managers; and (3) leadership style of the manager.

CONCLUSION

We conclude that the transformational leadership style is best suited for attaining employee satisfaction, for adequate handling of sickness protocols, and for lower absenteeism, in a post-merger specialty mental health setting.

Towards a better integrated stroke care: the development of integrated stroke care in the southern part of the Netherlands during the last 15 years (Special 10th Anniversary Edition paper)

Introduction

Stroke care is complex and often provided by various healthcare organisations. Integrated care solutions are needed to optimise stroke care. In this paper, we describe the development of integrated stroke care in the region of Maastricht during the last 15 years.

Description of integrated care case

Located in the south of the Netherlands, the region of Maastricht developed integrated stroke care to serve a population of about 180,000 people. Integration was needed to improve the continuity, coordination and quality of stroke care. The development of integrated care in Maastricht was a phased process. The last phase emphasized early discharge from hospital and assessing the best individual rehabilitation track in a specialized nursing home setting.

Discussion and lessons learned

The development and implementation of integrated stroke care in the region of Maastricht led to fewer days in hospital, more patients being directly admitted to the stroke unit and an earlier start of rehabilitation. The implementation of early discharge from the hospital and rehabilitation assessment in a nursing home led to some unforeseen problems and lessons learned.

Hearing voices: does it give your patient a headache? A case of auditory hallucinations as acoustic aura in migraine

OBJECTIVE

Auditory hallucinations are generally considered to be a psychotic symptom. However, they do occur without other psychotic symptoms in a substantive number of cases in the general population and can cause a lot of individual distress because of the supposed association with schizophrenia. We describe a case of nonpsychotic auditory hallucinations occurring in the context of migraine.

METHOD

Case report and literature review.

RESULTS

A 40-year-old man presented with imperative auditory hallucinations that caused depressive and anxiety symptoms. He reported migraine with visual aura as well which started at the same time as the auditory hallucinations. The auditory hallucinations occurred in the context of nocturnal migraine attacks, preceding them as aura. No psychotic disorder was present. After treatment of the migraine with propranolol 40 mg twice daily, explanation of the etiology of the hallucinations, and mirtazapine 45 mg daily, the migraine subsided and no further hallucinations occurred. The patient recovered.

DISCUSSION

Visual auras have been described in migraine and occur quite often. Auditory hallucinations as aura in migraine have been described in children without psychosis, but this is the first case describing auditory hallucinations without psychosis as aura in migraine in an adult. For description of this kind of hallucination, DSM-IV lacks an appropriate category.

CONCLUSION

Psychiatrists should consider migraine with acoustic aura as a possible etiological factor in patients without further psychotic symptoms presenting with auditory hallucinations, and they should ask for headache symptoms when they take the history. Prognosis may be favorable if the migraine is properly treated. Research is needed to explore the pathophysiological mechanism of auditory hallucinations as aura in migraine.