The impact of patient-centred care on the relationship between access to care and subjective health outcomes amongst people experiencing homelessness: A mediation analysis

People experiencing homelessness (PEH) have stated that impersonal care and feelings of discrimination are barriers to accessing healthcare which is associated with poor health outcomes amongst PEH. This study examined whether patient-centred care (PCC) mediates the relationship between access to care and subjective health outcomes. Using the 2014-15 Healthcare Center Patient Survey, we identified 1873 homeless and vulnerably housed adults. Items related to the delay or inability to receive primary or mental healthcare, PCC provided by healthcare providers, general health status, and the Kessler-6 psychological distress scale were selected. Ordinary least squares analyses were used to perform mediation analysis. We found that both access to primary care and access to mental healthcare were positively associated with physical health status (β = 0.492, p < 0.001; β = 0.311, p < 0.001) and negatively associated with psychological distress (β = -2.53, p < 0.001; β = -1.85, p < 0.001). PCC partially mediated all associations, but the mediation was stronger in the relationships between access to primary care and health outcomes (ab = 0.25, 95% CI [0.002, 0.052]; ab = -0.21, 95% CI [-0.37, -0.07]) compared to mental healthcare (ab = 0.02, 95% CI [0.01, 0.04]; ab = -0.14, 95% CI [-0.25, -0.06]). The results of this study indicated access to primary and mental healthcare is important in the patient-centred health outcomes of PEH. Additionally, the partial mediation of PCC in these relationships indicated that participants' perception of collaborative, trustworthy, respectful care from healthcare providers impacted the relationship between access to healthcare and health outcomes.

Experiences of transition from children's to adult's healthcare services for young people with a neurodevelopmental condition

Previous research has highlighted a lack of continuity of care when young people with a neurodevelopmental condition make the transition from children's to adult specialist healthcare services. A lack of planning, consistency, and availability of adult services has been found to lead to; increased anxiety, poor health outcomes, reduced support and some young people not receiving healthcare. The majority of transition research has focused on what health professionals consider important in the transition process, rather than focusing on the experiences of the young people and those closest to them. Our objective was to gather evidence from young people (and their families) who had experienced transition from children's to adult specialist healthcare services through semi-structured interviews. Volunteers were recruited from two London boroughs. All young people were aged between 18 and 25 years with a neurodevelopmental condition (Attention Deficit Hyperactivity Disorder, Autism Spectrum Disorder and/or an Intellectual Disability). Overall, we interviewed six young people with support from a family member. Five further family members were interviewed on behalf of the young person. In total, ten semi-structured interviews were transcribed verbatim and analysed using Interpretative Phenomenological Analysis. Four themes emerged from the analysis: (a) Parents as advocates, (b) Availability of adult's specialist health and social care services, (c) Lack of information sharing and (d) Transition as a binary, abrupt change. Our findings suggest the transition experience could be improved by changing service specifications to incorporate assessment and handover across the age range of 16-20 years. Additionally, statutory services should understand and provide the coordination role now offered by parents in transition. We suggest future research could evaluate the feasibility of a patient-owned online information sharing tool with information about relevant services for young people and their families.

"Keeping Control": A user-led exploratory study of mental health service user experiences of targeted violence and abuse in the context of adult safeguarding in England

The situation for people with mental health problems as a group of disabled people who experience targeted violence and abuse is a complex one. Disabled people, particularly those with mental health problems, are at higher risk of targeted violence and hostility with few effective evidence-based prevention and protection strategies. Achieving effective safeguarding for adults with mental health problems is characterised by differential attitudes to and understandings of abuse by safeguarding practitioners, as well as systemic issues arising from multi-agency working. "Keeping Control" was a 16-month user-led, co-produced exploratory qualitative study into service user experiences of targeted violence and abuse that was examined in the context of Care Act 2014 adult safeguarding reforms in England. User-controlled interviews of mental health service users (N = 23) explored their experiences and concepts of targeted violence and abuse, prevention and protection. Preliminary findings from these interviews were discussed in adult safeguarding and mental health stakeholder and practitioner focus groups (N = 46). The data were also discussed via two facilitated Twitter chats (responses N = 585 and N = 139). Mental health service users' experiences and concepts of risk from others, vulnerability and neglect can be different to those of practitioners but should be central to adult safeguarding. Histories of trauma, multi-factorial abuse; living with fear and stigma as well as mental distress; the effects of "psychiatric disqualification" and individual blaming should be addressed in adult safeguarding in mental health. Fragmented responses from services can mean a person becomes "lost in the process". Staff can feel disempowered, afraid or lacking in confidence to "speak up" for individuals in complex service systems with poor communication and lines of accountability. Adult safeguarding practitioners and stakeholders need to be confident, accessible and respond quickly to service users reporting incidents of targeted violence and abuse particularly in closed environments such as wards or supported housing.

Challenges for psychosocial rehabilitation services in the Lisbon Metropolitan Area: A qualitative approach

In Portugal, a mental health reform process is in place aiming to redefine the model of service provision. In 2008, a National Mental Health Plan (NMHP) was approved to provide policy guidance over the transition period. The NMHP intended, among others, to develop community-based services, with a specific focus on rehabilitation and deinstitutionalization. This study aims to explore the perspectives of service managers of psychosocial rehabilitation services regarding the main challenges to support the community living of persons with severe mental illnesses (PWSMI) in the Lisbon Metropolitan Area (LMA). The paper also contextualises the provision of psychosocial services within the country's mental health reform process and characterises the profile of service users in socio-occupational units (SOUs) of the LMA. Semi-structured interviews were performed with all SOUs' managers of the LMA (n = 13). Information regarding service user characteristics was collected based on service records (n = 344). Interviews were analysed according to the framework methodology. The results of the interviews were triangulated using document analysis. Fieldwork took place between June and July 2016. The findings suggest that the development of the mental health reform ensured significant changes to service delivery. Community-based mental health organisations are an important actor for service provision. However, important asymmetries were identified in the provision of psychosocial care within the LMA. At the same time, family carers are perceived as responsible for ensuring a large part of the social needs of the PWSMI but there is an increasing concern with their own ageing processes. As a conclusion, it is highlighted the current inequality between services and the need to contemplate a life-course perspective that comprehends the ageing process of caregivers poses an emerging challenge for psychosocial rehabilitation. These findings are also important for other low- and middle-income countries passing through similar reforms.

Symptoms, functioning and quality of life after treatment in a residential sub-acute mental health service in Australia

The aim of this study was to assess clients' and service providers' perspectives on changes in mental health after an admission to a residential recovery-focused, sub-acute service, in Australia. Clients were either step-up clients, entering the service directly from the community, or step-down clients who were transitioning from an inpatient unit to home. During the 30-month period of data collection (August 2011 to January 2014) all clients (N = 102) were invited to participate in the longitudinal study and 41 clients consented to be involved (38% response rate). At admission and exit, participants completed the Behaviour and Symptom Identification Scale (Basis-32) and service providers completed the Life Skills Profile-16 and Health of the Nations Outcome Scales. Follow-up data 3 months after exit were available for 12 clients, including the Basis-32 and a self-report measure of quality of life (Assessment of Quality of Life 8-dimension). Both client groups reported positive improvements between admission and exit in the areas of relation to self and others, psychosis, daily living and presence of depression or anxiety symptoms. Service providers reported gains for clients in the areas of self-care, level of symptoms and presence of social problems. At 3 months, clients generally reported positive quality of life, although there was no significant change in symptoms and functioning. This study demonstrates that after an admission to a sub-acute service, step-up clients experience an improvement in their symptoms and functioning, have avoided a hospital admission and are well enough to return home. Step-down clients also experience further improvements in their symptoms and functioning, indicating that the service has assisted them in their transition to independent living after a hospital admission. Sub-acute residential units provide a continuation of care for inpatients preparing to return home, and people with a mental health problem living in the community who experience an escalation in symptoms and prefer an alternative to hospital.

Voices of care for adults with disabilities and/or mental health issues in Western Canada: what do families and agencies need from each other?

Our purpose in this paper is to report on the frustrations and unmet needs of paid, formal caregivers and unpaid, family caregivers who together provide care to adults with disabilities and/or mental health issues. We conducted eight focus group interviews between November 2010 and June 2011 in two large, urban centres and one smaller centre in Western Canada. Four of our focus groups were with family members including adults with disabilities and/or mental health issues, their parents and their siblings, and four were with representatives from agencies providing support and services to adults with disabilities and/or mental health issues and their families. Data were collected from 23 family members and 24 agency representatives who responded to questions about successes and struggles in meeting, and collaborating to meet, care needs of adults with disabilities and/or mental health issues. Each focus group session was digitally recorded and transcribed; field notes were also taken and we thematically analysed data according to family versus agency perspectives of their successes and barriers in care provision and care collaboration. We found that family members desire greater and more effective support in enriching the lives of adults with disabilities and/or mental health issues and in preparing for age-related changes. Agency representatives are keenly aware of the needs and challenges faced by families, yet grapple with being effective collaborators with families of widely varying priorities and styles of care and collaboration.