Enhancing primary care psychology services with assistant psychologists in Ireland: An evaluation of output, throughput and stakeholder satisfaction

Primary care mental health services need to expand to assist the increased number of people reporting mild to moderate mental health difficulties. In Ireland, the primary care mental health service has been recently enhanced through the employment of Assistant Psychologists (AP) in primary care psychology. This paper provides an early and brief evaluation of the impact of the AP-enhanced model through a tripartite approach to evaluation which utilises measures of throughput, output and stakeholder satisfaction. We use data from two sources; Health service key performance indicators, and a routinely gathered minimal dataset of client measures. Results indicate that the numbers of clients seen in the period rose by 16%, that AP-delivered treatments are beneficial for clients with mild to moderate mental health difficulties, and more than 80% of clients reported being 'totally satisfied' with the care received. The data provide early evidence that the AP model is beneficial in meeting clients' needs across a range of presentations within the service admission criteria, and that the AP-enhanced model may offer a satisfactory solution to primary care needs. However, further data collection is required, and additional stakeholder input is necessary for a complete evaluation of the assistant psychologist model in primary care.

Effect of Enhanced Primary Care for People with Serious Mental Illness on Service Use and Screening

BACKGROUND

Strategies are needed to better address the physical health needs of people with serious mental illness (SMI). Enhanced primary care for people with SMI has the potential to improve care of people with SMI, but evidence is lacking.

OBJECTIVE

To examine the effect of a novel enhanced primary care model for people with SMI on service use and screening.

DESIGN

Using North Carolina Medicaid claims data, we performed a retrospective cohort analysis comparing healthcare use and screening receipt of people with SMI newly receiving enhanced primary care to people with SMI newly receiving usual primary care. We used inverse probability of treatment weighting to estimate average differences in outcomes between the treatment and comparison groups adjusting for observed baseline characteristics.

PARTICIPANTS

People with SMI newly receiving primary care in North Carolina.

INTERVENTIONS

Enhanced primary care that includes features tailored for individuals with SMI.

MAIN MEASURES

Outcome measures included outpatient visits, emergency department (ED) visits, inpatient stays and days, and recommended screenings 18 months after the initial primary care visit.

KEY RESULTS

Compared to usual primary care, enhanced primary care was associated with an increase of 1.2 primary care visits (95% confidence interval [CI]: 0.31 to 2.1) in the 18 months after the initial visit and decreases of 0.33 non-psychiatric inpatient stays (CI: - 0.49 to - 0.16) and 3.0 non-psychiatric inpatient days (CI: - 5.3 to - 0.60). Enhanced primary care had no significant effect on psychiatric service and ED use. Enhanced primary care increased the probability of glucose and HIV screening, decreased the probability of lipid screening, and had no effect on hemoglobin A1c and colorectal cancer screening.

CONCLUSIONS

Enhanced primary care for people with SMI can increase receipt of some preventive screening and decrease use of non-psychiatric inpatient care compared to usual primary care.

The Effectiveness of Patient-Centred Medical Home-Based Models of Care versus Standard Primary Care in Chronic Disease Management: A Systematic Review and Meta-Analysis of Randomised and Non-Randomised Controlled Trials

Patient-centred care by a coordinated primary care team may be more effective than standard care in chronic disease management. We synthesised evidence to determine whether patient-centred medical home (PCMH)-based care models are more effective than standard general practitioner (GP) care in improving biomedical, hospital, and economic outcomes. MEDLINE, CINAHL, Embase, Cochrane Library, and Scopus were searched to identify randomised (RCTs) and non-randomised controlled trials that evaluated two or more principles of PCMH among primary care patients with chronic diseases. Study selection, data extraction, quality assessment using Joanna Briggs Institute (JBI) appraisal tools, and grading of evidence using Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach were conducted independently. A quantitative synthesis, where possible, was pooled using random effects models and the effect size estimates of standardised mean differences (SMDs) and odds ratios (ORs) with 95% confidence intervals were reported. Of the 13,820 citations, we identified 78 eligible RCTs and 7 quasi trials which included 60,617 patients. The findings suggested that PCMH-based care was associated with significant improvements in depression episodes (SMD -0.24; 95% CI -0.35, -0.14; I2 = 76%) and increased odds of remission (OR 1.79; 95% CI 1.46, 2.21; I2 = 0%). There were significant improvements in the health-related quality of life (SMD 0.10; 95% CI 0.04, 0.15; I2 = 51%), self-management outcomes (SMD 0.24; 95% CI 0.03, 0.44; I2 = 83%), and hospital admissions (OR 0.83; 95% CI 0.70, 0.98; I2 = 0%). In terms of biomedical outcomes, with exception to total cholesterol, PCMH-based care led to significant improvements in blood pressure, glycated haemoglobin, and low-density lipoprotein cholesterol outcomes. The incremental cost of PCMH care was identified to be small and significantly higher than standard care (SMD 0.17; 95% CI 0.08, 0.26; I2 = 82%). The quality of individual studies ranged from "fair" to "good" by meeting at least 60% of items on the quality appraisal checklist. Additionally, moderate to high heterogeneity across studies in outcomes resulted in downgrading the included studies as moderate or low grade of evidence. PCMH-based care has been found to be superior to standard GP care in chronic disease management. Results of the review have important implications that may inform patient, practice, and policy-level changes.

Cohort Profile: Effectiveness of a 12-Month Patient-Centred Medical Home Model Versus Standard Care for Chronic Disease Management among Primary Care Patients in Sydney, Australia

Evidence suggests that patient-centred medical home (PCMH) is more effective than standard general practitioner care in improving patient outcomes in primary care. This paper reports on the design, early implementation experiences, and early findings of the 12-month PCMH model called ‘WellNet’ delivered across six primary care practices in Sydney, Australia. The WellNet study sample comprises 589 consented participants in the intervention group receiving enhanced primary care in the form of patient-tailored chronic disease management plan, improved self-management support, and regular monitoring by general practitioners (GPs) and trained clinical coordinators. The comparison group consisted of 7750 patients who were matched based on age, gender, type and number of chronic diseases who received standard GP care. Data collected include sociodemographic characteristics, clinical measures, and self-reported health assessments at baseline and 12 months. Early study findings show the mean age of the study participants was 70 years with nearly even gender distribution of males (49.7%) and females (50.3%). The most prevalent chronic diseases in descending order were circulatory system disorders (69.8%), diabetes (47.4%), musculoskeletal disorders (43.5%), respiratory diseases (28.7%), mental illness (18.8%), and cancer (13.6%). To our knowledge, the WellNet study is the first study in Australia to generate evidence on the feasibility of design, recruitment, and implementation of a comprehensive PCMH model. Lessons learned from WellNet study may inform other medical home models in Australian primary care settings.

Effects of an enhanced primary care program on diabetes outcomes

OBJECTIVES

To evaluate the effectiveness of Buena Salud, a multidisciplinary enhanced primary care program for Medicaid Managed Care patients at a community health center serving a low-income Hispanic community.

STUDY DESIGN

Controlled before-and-after observational study.

METHODS

We extracted data from the electronic health record for patients aged 18 to 64 years with a) type 2 diabetes (T2D) enrolled in the Buena Salud program between August 2011 and January 2012 and b) randomly selected control patients with T2D who had been seen at the study health center during the same time frame. Outcomes included process measures (eg, number of glycosylated hemoglobin measures in a year), target lab and blood pressure values, and utilization measures (eg, emergency department visits). Demographics and other potential confounders were also extracted. We used a difference-in-differences (DID) analysis to estimate the effect of the intervention.

RESULTS

A total of 72 Buena Salud patients with T2D and 247 control patients with T2D were included in the analysis. The Buena Salud group had a greater increase in the percentage of patients with guideline-concordant measurement of microalbumin/creatinine (DID = 22.2%; P = .008), a trend toward fewer hospitalizations than controls, and a mean rise in diastolic blood pressure. We did not find differences in other outcome or utilization measures.

CONCLUSIONS

A recently implemented enhanced primary care program had minimal impact on T2D process, outcome, and utilization measures for patients in this study. However, there were some promising trends, and it is possible that the intervention may demonstrate more of an effect as the program matures.