1
|
Isaacs AN, Mitchell EKL. Mental health integrated care models in primary care and factors that contribute to their effective implementation: a scoping review. Int J Ment Health Syst 2024; 18:5. [PMID: 38331913 PMCID: PMC10854062 DOI: 10.1186/s13033-024-00625-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Accepted: 02/01/2024] [Indexed: 02/10/2024] Open
Abstract
BACKGROUND In the state of Victoria, Australia, the 111-day lockdown due to the COVID-19 pandemic exacerbated the population's prevailing state of poor mental health. Of the 87% of Australians who visit their GP annually, 71% of health problems they discussed related to psychological issues. This review had two objectives: (1) To describe models of mental health integrated care within primary care settings that demonstrated improved mental health outcomes that were transferable to Australian settings, and (2) To outline the factors that contributed to the effective implementation of these models into routine practice. METHODS A scoping review was undertaken to synthesise the evidence in order to inform practice, policymaking, and research. Data were obtained from PubMed, CINAHL and APA PsycINFO. RESULTS Key elements of effective mental health integrated care models in primary care are: Co-location of mental health and substance abuse services in the primary care setting, presence of licensed mental health clinicians, a case management approach to patient care, ongoing depression monitoring for up to 24 months and other miscellaneous elements. Key factors that contributed to the effective implementation of mental health integrated care in routine practice are the willingness to accept and promote system change, integrated physical and mental clinical records, the presence of a care manager, adequate staff training, a healthy organisational culture, regular supervision and support, a standardised workflow plan and care pathways that included clear role boundaries and the use of outcome measures. The need to develop sustainable funding mechanisms has also been emphasized. CONCLUSION Integrated mental health care models typically have a co-located mental health clinician who works closely with the GP and the rest of the primary care team. Implementing mental health integrated care models in Australia requires a 'whole of system' change. Lessons learned from the Mental Health Nurse Incentive Program could form the foundation on which this model is implemented in Australia.
Collapse
Affiliation(s)
- Anton N Isaacs
- Monash University School of Rural Health, Sargeant Street, PO Box 723, Warragul, VIC, 3820, Australia.
| | - Eleanor K L Mitchell
- Monash University School of Rural Health, Corner of Victoria Street & Day Street, PO Box 1497, Bairnsdale, VIC, 3875, Australia
| |
Collapse
|
2
|
Baskin C, Duncan F, Adams EA, Oliver EJ, Samuel G, Gnani S. How co-locating public mental health interventions in community settings impacts mental health and health inequalities: a multi-site realist evaluation. BMC Public Health 2023; 23:2445. [PMID: 38062427 PMCID: PMC10702025 DOI: 10.1186/s12889-023-17404-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Accepted: 12/04/2023] [Indexed: 12/18/2023] Open
Abstract
BACKGROUND Public mental health interventions are non-clinical services that aim to promote wellbeing and prevent mental ill health at the population level. In England, the health, social and community system is characterised by complex and fragmented inter-sectoral relationships. To overcome this, there has been an expansion in co-locating public mental health services within clinical settings, the focus of prior research. This study evaluates how co-location in community-based settings can support adult mental health and reduce health inequalities. METHODS A qualitative multi-site case study design using a realist evaluation approach was employed. Data collection took place in three phases: theory gleaning, parallel testing and refining of theories, and theory consolidation. We collected data from service users (n = 32), service providers (n = 32), funders, commissioners, and policy makers (n = 11), and members of the public (n = 10). We conducted in-depth interviews (n = 65) and four focus group discussions (n = 20) at six case study sites across England, UK, and two online multi-stakeholder workshops (n = 20). Interview guides followed realist-informed open-ended questions, adapted for each phase. The realist analysis used an iterative, inductive, and deductive data analysis approach to identify the underlying mechanisms for how community co-location affects public mental health outcomes, who this works best for, and understand the contexts in which co-location operates. RESULTS Five overarching co-location theories were elicited and supported. Co-located services: (1) improved provision of holistic and person-centred support; (2) reduced stigma by creating non-judgemental environments that were not associated with clinical or mental health services; (3) delivered services in psychologically safe environments by creating a culture of empathy, friendliness and trust where people felt they were being treated with dignity and respect; (4) helped to overcome barriers to accessibility by making service access less costly and more time efficient, and (5) enhance the sustainability of services through better pooling of resources. CONCLUSION Co-locating public mental health services within communities impacts multiple social determinants of poor mental health. It has a role in reducing mental health inequalities by helping those least likely to access services. Operating practices that engender inter-service trust and resource-sharing are likely to support sustainability.
Collapse
Affiliation(s)
- Cleo Baskin
- Department of Primary Care and Public Health, Imperial College London, St Dunstan's Road, London, W6 8RP, UK
| | - Fiona Duncan
- Population Health Sciences Institute, Newcastle University, Baddiley-Clark Building, Newcastle, NE2 4AX, UK.
| | - Emma A Adams
- Population Health Sciences Institute, Newcastle University, Baddiley-Clark Building, Newcastle, NE2 4AX, UK
| | - Emily J Oliver
- Population Health Sciences Institute, Newcastle University, Baddiley-Clark Building, Newcastle, NE2 4AX, UK
| | - Gillian Samuel
- The McPin Foundation, 7-14 Great Dover Street, London, SE1 4YR, UK
| | - Shamini Gnani
- Department of Primary Care and Public Health, Imperial College London, St Dunstan's Road, London, W6 8RP, UK
| |
Collapse
|
3
|
Aebi NJ, Baenteli I, Fink G, Meinlschmidt G, Schaefert R, Schwenkglenks M, Studer A, Trost S, Tschudin S, Wyss K. Facilitators and barriers of routine psychosocial distress assessment within a stepped and collaborative care model in a Swiss hospital setting. PLoS One 2023; 18:e0285395. [PMID: 37390066 PMCID: PMC10313032 DOI: 10.1371/journal.pone.0285395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Accepted: 04/24/2023] [Indexed: 07/02/2023] Open
Abstract
BACKGROUND Stepped and Collaborative Care Models (SCCMs) have shown potential for improving mental health care. Most SCCMs have been used in primary care settings. At the core of such models are initial psychosocial distress assessments commonly in form of patient screening. We aimed to assess the feasibility of such assessments in a general hospital setting in Switzerland. METHODS We conducted and analyzed eighteen semi-structured interviews with nurses and physicians involved in a recent introduction of a SCCM model in a hospital setting, as part of the SomPsyNet project in Basel-Stadt. Following an implementation research approach, we used the Tailored Implementation for Chronic Diseases (TICD) framework for analysis. The TICD distinguishes seven domains: guideline factors, individual healthcare professional factors, patient factors, professional interactions, incentives and resources, capacity for organizational change, and social, political, and legal factors. Domains were split into themes and subthemes, which were used for line-by-line coding. RESULTS Nurses and physicians reported factors belonging to all seven TICD domains. An appropriate integration of the psychosocial distress assessment into preexisting hospital processes and information technology systems was the most important facilitator. Subjectivity of the assessment, lack of awareness about the assessment, and time constraints, particularly among physicians, were factors undermining and limiting the implementation of the psychosocial distress assessment. CONCLUSIONS Awareness raising through regular training of new employees, feedback on performance and patient benefits, and working with champions and opinion leaders can likely support a successful implementation of routine psychosocial distress assessments. Additionally, aligning psychosocial distress assessments with workflows is essential to assure the sustainability of the procedure in a working context with commonly limited time.
Collapse
Affiliation(s)
- Nicola Julia Aebi
- Swiss Center for International Health, Swiss Tropical and Public Health Institute, Allschwil, Switzerland
- University of Basel, Basel, Switzerland
| | - Iris Baenteli
- Department of Psychosomatic Medicine, University Hospital and University of Basel, Basel, Switzerland
| | - Günther Fink
- University of Basel, Basel, Switzerland
- Epidemiology and Public Health, Swiss Tropical and Public Health Institute, Allschwil, Switzerland
| | - Gunther Meinlschmidt
- Department of Psychosomatic Medicine, University Hospital and University of Basel, Basel, Switzerland
- Division of Clinical Psychology and Cognitive Behavioural Therapy, International Psychoanalytic University Berlin, Berlin, Germany
- Division of Clinical Psychology and Epidemiology, Department of Psychology, University of Basel, Basel, Switzerland
| | - Rainer Schaefert
- Department of Psychosomatic Medicine, University Hospital and University of Basel, Basel, Switzerland
| | | | - Anja Studer
- Division of Prevention, Department of Health Canton Basel-Stadt, Basel, Switzerland
| | - Sarah Trost
- Department of Geriatric Medicine FELIX PLATTER, Basel, Switzerland
| | - Sibil Tschudin
- Department of Obstetrics and Gynecology, University Hospital and University of Basel, Basel, Switzerland
| | - Kaspar Wyss
- Swiss Center for International Health, Swiss Tropical and Public Health Institute, Allschwil, Switzerland
- University of Basel, Basel, Switzerland
| | | |
Collapse
|
4
|
Hempel S, Ganz D, Saluja S, Bolshakova M, Kim T, Turvey C, Cordasco K, Basu A, Page T, Mahmood R, Motala A, Barnard J, Wong M, Fu N, Miake-Lye IM. Care coordination across healthcare systems: development of a research agenda, implications for practice, and recommendations for policy based on a modified Delphi panel. BMJ Open 2023; 13:e060232. [PMID: 37197809 DOI: 10.1136/bmjopen-2021-060232] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/19/2023] Open
Abstract
OBJECTIVE For large, integrated healthcare delivery systems, coordinating patient care across delivery systems with providers external to the system presents challenges. We explored the domains and requirements for care coordination by professionals across healthcare systems and developed an agenda for research, practice and policy. DESIGN The modified Delphi approach convened a 2-day stakeholder panel with moderated virtual discussions, preceded and followed by online surveys. SETTING The work addresses care coordination across healthcare systems. We introduced common care scenarios and differentiated recommendations for a large (main) healthcare organisation and external healthcare professionals that contribute additional care. PARTICIPANTS The panel composition included health service providers, decision makers, patients and care community, and researchers. Discussions were informed by a rapid review of tested approaches to fostering collaboration, facilitating care coordination and improving communication across healthcare systems. OUTCOME MEASURES The study planned to formulate a research agenda, implications for practice and recommendations for policy. RESULTS For research recommendations, we found consensus for developing measures of shared care, exploring healthcare professionals' needs in different care scenarios and evaluating patient experiences. Agreed practice recommendations included educating external professionals about issues specific to the patients in the main healthcare system, educating professionals within the main healthcare system about the roles and responsibilities of all involved parties, and helping patients better understand the pros and cons of within-system and out-of-system care. Policy recommendations included supporting time for professionals with high overlap in patients to engage regularly and sustaining support for care coordination for high-need patients. CONCLUSIONS Recommendations from the stakeholder panel created an agenda to foster further research, practice and policy innovations in cross-system care coordination.
Collapse
Affiliation(s)
- Susanne Hempel
- Southern California Evidence Review Center, University of Southern California, Los Angeles, California, USA
| | - David Ganz
- Geriatrics Research, Education and Clinical Center, VA Greater Los Angeles Healthcare System, Los Angeles, California, USA
- Department of Medicine, David Geffen School of Medicine at the University of California at Los Angeles, Los Angeles, California, USA
| | - Sonali Saluja
- Gehr Family Center for Health Systems Science and Innovation, University of Southern California, Los Angeles, California, USA
| | - Maria Bolshakova
- Southern California Evidence Review Center, University of Southern California, Los Angeles, California, USA
| | - Timothy Kim
- Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Carolyn Turvey
- Center for Access and Delivery Research and Evaluation, Iowa City Veterans Affairs Healthcare System, Iowa City, Iowa, USA
- Department of Psychiatry, Roy J. and Lucille A. Carver College of Medicine at the University of Iowa, Iowa City, Iowa, USA
- Rural Health Resource Center, Iowa City Veterans Affairs Healthcare System, Iowa City, Iowa, USA
| | - Kristina Cordasco
- VA Greater Los Angeles Healthcare System, Los Angeles, California, USA
| | - Aashna Basu
- Department of Medicine, David Geffen School of Medicine at the University of California at Los Angeles, Los Angeles, California, USA
- Care in the Community Service, VA Greater Los Angeles Healthcare System, Los Angeles, California, USA
| | - Tonya Page
- Office of Community, Clinical Integration & Field Support, Veteran Affairs Central Office, Kentucky City, Kentucky, USA
| | - Reshma Mahmood
- Santa Maria and San Luis Obispo Community Outpatient Clinics, VA Greater Los Angeles Healthcare System, Los Angeles, California, USA
| | - Aneesa Motala
- Southern California Evidence Review Center, University of Southern California, Los Angeles, California, USA
| | - Jenny Barnard
- VA Greater Los Angeles Healthcare System, Los Angeles, California, USA
| | - Michelle Wong
- VA Greater Los Angeles Healthcare System, Los Angeles, California, USA
| | - Ning Fu
- Southern California Evidence Review Center, University of Southern California, Los Angeles, California, USA
- School of Public Administration and Emergency Management, Jinan University, Guangzhou, Guangdong, China
| | - Isomi M Miake-Lye
- VA West Los Angeles Evidence-based Synthesis Program, VA Greater Los Angeles Healthcare System, Los Angeles, California, USA
- Health Policy and Management, UCLA Fielding School of Public Health, Los Angeles, California, USA
| |
Collapse
|
5
|
Using Normalisation Process Theory (NPT) to develop an intervention to improve referral and uptake rates for self-management education for patients with type 2 diabetes in UK primary care. BMC Health Serv Res 2022; 22:1206. [PMID: 36167564 PMCID: PMC9513934 DOI: 10.1186/s12913-022-08553-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Accepted: 09/11/2022] [Indexed: 11/10/2022] Open
Abstract
Background Referral and uptake rates of structured self-management education (SSME) for Type 2 diabetes (T2DM) in the UK are variable and relatively low. Research has documented contributing factors at patient, practitioner and organisational levels. We report a project to develop an intervention to improve referral to and uptake of SSME, involving an integrative synthesis of existing datasets and stakeholder consultation and using Normalisation Process Theory (NPT) as a flexible framework to inform the development process. Methods A three-phase mixed-methods development process involved: (1) synthesis of existing evidence; (2) stakeholder consultation; and (3) intervention design. The first phase included a secondary analysis of data from existing studies of T2DM SSME programmes and a systematic review of the literature on application of NPT in primary care. Influences on referral and uptake of diabetes SSME were identified, along with insights into implementation processes, using NPT constructs to inform analysis. This gave rise to desirable attributes for an intervention to improve uptake of SSME. The second phase involved engaging with stakeholders to prioritise and then rank these attributes, and develop a list of associated resources needed for delivery. The third phase addressed intervention design. It involved translating the ranked attributes into essential components of a complex intervention, and then further refinement of components and associated resources. Results In phase 1, synthesised analysis of 64 transcripts and 23 articles generated a longlist of 46 attributes of an embedded SSME, mapped into four overarching domains: valued, integrated, permeable and effectively delivered. Stakeholder engagement in phase 2 progressed this to a priority ranked list of 11. In phase 3, four essential components attending to the prioritised attributes and forming the basis of the intervention were identified: 1) a clear marketing strategy for SSME; 2) a user friendly and effective referral pathway; 3) new/amended professional roles; and 4) a toolkit of resources. Conclusions NPT provides a flexible framework for synthesising evidence for the purpose of developing a complex intervention designed to increase and reduce variation in uptake to SSME programmes in primary care settings. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-022-08553-7.
Collapse
|
6
|
Gil-Girbau M, Peñarrubia-Maria MT, Carbonell-Simeón D, Rodríguez-Ferraz B, Contaldo SF, Iglesias-González M, Fernández-Vergel R, Blanco-García E, Baladon-Higuera L, Serrano-Blanco A, Rubio-Valera M. Assessment of a Primary Support Program: family physicians and mental health professionals' perspective. Fam Pract 2022; 39:920-931. [PMID: 35244164 DOI: 10.1093/fampra/cmac013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Mental health (MH) disorders are increasingly prevalent in primary care (PC) and this has generated, in recent years, the development of strategies based on the collaborative model and the stepped care model. The Primary Support Program (PSP) was implemented in the community of Catalonia (Spain) during 2006 to improve, from the first level of care, treatment of the population with mild-moderate complexity MH problems along with identification and referral of severe cases to specialized care. The aim of the present study was to identify the strengths and limitations of the PSP from the perspective of health professionals involved in the programme. METHODS An explanatory qualitative study based on Grounded Theory. We conducted group semistructured interviews with 37 family physicians and 34 MH professionals. A constant comparative method of analysis was performed. RESULTS Operation of the PSP is influenced by internal factors, such as the programme framework, MH liaison, management of service supply and demand, and the professional team involved. Additionally, external factors which had an impact were related to the patient, the professionals, the Health System, and community resources. CONCLUSIONS The operation of the PSP could benefit from a review of the programme framework and optimization of MH liaison. Improvements are also proposed for MH training in PC, intraprofessional coordination, use of community resources, and creation of efficient continuous assessment systems.
Collapse
Affiliation(s)
- Montserrat Gil-Girbau
- Teaching, Research & Innovation Unit, Parc Sanitari Sant Joan de Déu, Barcelona, Spain.,Grup de Recerca PRISMA (SGR1209), Institut de Recerca Sant Joan de Déu, Esplugues de Llobregat, Spain.,Primary Care Prevention and Health Promotion Research Network (redIAPP), Barcelona, Spain.,Grup ECONSAP, Institut Universitari d'Investigació en Atenció Primària (IDIAP Jordi Gol), Barcelona, Spain
| | - Maria-Teresa Peñarrubia-Maria
- Grup de Recerca PRISMA (SGR1209), Institut de Recerca Sant Joan de Déu, Esplugues de Llobregat, Spain.,Grup ECONSAP, Institut Universitari d'Investigació en Atenció Primària (IDIAP Jordi Gol), Barcelona, Spain.,Centre d'Atenció Primària Bartomeu Fabrés Anglada, Gavà, Spain.,Grup 58 del Instituto de Salud Carlos III, Centro de Investigación Biomédica en Red de Epidemiología y Salud Pública (CIBERESP), Madrid, Spain
| | | | | | - Salvatore-Fabrizio Contaldo
- Grup de Recerca PRISMA (SGR1209), Institut de Recerca Sant Joan de Déu, Esplugues de Llobregat, Spain.,Psychiatry Department, CSMA d'Esplugues de Llobregat, Esplugues de Llobregat, Spain
| | - Maria Iglesias-González
- Grup de Recerca PRISMA (SGR1209), Institut de Recerca Sant Joan de Déu, Esplugues de Llobregat, Spain.,Grup 58 del Instituto de Salud Carlos III, Centro de Investigación Biomédica en Red de Epidemiología y Salud Pública (CIBERESP), Madrid, Spain.,Psychiatry Service, Hospital Universitari Germans Trias i Pujol, IGTP Campus Can Ruti, Badalona, Spain
| | - Rita Fernández-Vergel
- Grup de Recerca PRISMA (SGR1209), Institut de Recerca Sant Joan de Déu, Esplugues de Llobregat, Spain.,Primary Care Prevention and Health Promotion Research Network (redIAPP), Barcelona, Spain.,Grup ECONSAP, Institut Universitari d'Investigació en Atenció Primària (IDIAP Jordi Gol), Barcelona, Spain.,Centre d'Atenció Primària Bartomeu Fabrés Anglada, Gavà, Spain
| | - Elena Blanco-García
- Grup de Recerca PRISMA (SGR1209), Institut de Recerca Sant Joan de Déu, Esplugues de Llobregat, Spain.,Grup ECONSAP, Institut Universitari d'Investigació en Atenció Primària (IDIAP Jordi Gol), Barcelona, Spain.,Centre d'Atenció Primària Bartomeu Fabrés Anglada, Gavà, Spain
| | - Luisa Baladon-Higuera
- Teaching, Research & Innovation Unit, Parc Sanitari Sant Joan de Déu, Barcelona, Spain.,Grup de Recerca PRISMA (SGR1209), Institut de Recerca Sant Joan de Déu, Esplugues de Llobregat, Spain.,Primary Care Prevention and Health Promotion Research Network (redIAPP), Barcelona, Spain.,Grup ECONSAP, Institut Universitari d'Investigació en Atenció Primària (IDIAP Jordi Gol), Barcelona, Spain.,Grup 58 del Instituto de Salud Carlos III, Centro de Investigación Biomédica en Red de Epidemiología y Salud Pública (CIBERESP), Madrid, Spain
| | - Antoni Serrano-Blanco
- Teaching, Research & Innovation Unit, Parc Sanitari Sant Joan de Déu, Barcelona, Spain.,Grup de Recerca PRISMA (SGR1209), Institut de Recerca Sant Joan de Déu, Esplugues de Llobregat, Spain.,Primary Care Prevention and Health Promotion Research Network (redIAPP), Barcelona, Spain.,Grup ECONSAP, Institut Universitari d'Investigació en Atenció Primària (IDIAP Jordi Gol), Barcelona, Spain.,Grup 58 del Instituto de Salud Carlos III, Centro de Investigación Biomédica en Red de Epidemiología y Salud Pública (CIBERESP), Madrid, Spain
| | - Maria Rubio-Valera
- Teaching, Research & Innovation Unit, Parc Sanitari Sant Joan de Déu, Barcelona, Spain.,Grup de Recerca PRISMA (SGR1209), Institut de Recerca Sant Joan de Déu, Esplugues de Llobregat, Spain.,Grup ECONSAP, Institut Universitari d'Investigació en Atenció Primària (IDIAP Jordi Gol), Barcelona, Spain.,Grup 58 del Instituto de Salud Carlos III, Centro de Investigación Biomédica en Red de Epidemiología y Salud Pública (CIBERESP), Madrid, Spain
| |
Collapse
|
7
|
Implementing collaborative care for major depression in a cancer center: An observational study using mixed-methods. Gen Hosp Psychiatry 2022; 76:3-15. [PMID: 35305403 DOI: 10.1016/j.genhosppsych.2022.03.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Revised: 02/16/2022] [Accepted: 03/03/2022] [Indexed: 11/04/2022]
Abstract
OBJECTIVES To describe the implementation of a collaborative care (CC) screening and treatment program for major depression in people with cancer, found to be effective in clinical trials, into routine outpatient care of a cancer center. METHOD A mixed-methods observational study guided by the RE-AIM implementation framework using quantitative and qualitative data collected over five years. RESULTS Program set-up took three years and required more involvement of CC experts than anticipated. Barriers to implementation were uncertainty about whether oncology or psychiatry owned the program and the hospital's organizational complexity. Selecting and training CC team members was a major task. 90% (14,412/16,074) of patients participated in depression screening and 61% (136/224) of those offered treatment attended at least one session. Depression outcomes were similar to trial benchmarks (61%; 78/127 patients had a treatment response). After two years the program obtained long-term funding. Facilitators of implementation were strong trial evidence, effective integration into cancer care and ongoing clinical and managerial support. CONCLUSION A CC program for major depression, designed for the cancer setting, can be successfully implemented into routine care, but requires time, persistence and involvement of CC experts. Once operating it can be an effective and valued component of medical care.
Collapse
|
8
|
Aragonès E, López-Cortacans G, Cardoner N, Tomé-Pires C, Porta-Casteràs D, Palao D. Barriers, facilitators, and proposals for improvement in the implementation of a collaborative care program for depression: a qualitative study of primary care physicians and nurses. BMC Health Serv Res 2022; 22:446. [PMID: 35382822 DOI: 10.1186/s12913-022-07872-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Accepted: 03/28/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Primary care plays a central role in the treatment of depression. Nonetheless, shortcomings in its management and suboptimal outcomes have been identified. Collaborative care models improve processes for the management of depressive disorders and associated outcomes. We developed a strategy to implement the INDI collaborative care program for the management of depression in primary health care centers across Catalonia. The aim of this qualitative study was to evaluate a trial implementation of the program to identify barriers, facilitators, and proposals for improvement. METHODS One year after the implementation of the INDI program in 18 public primary health care centers we performed a qualitative study in which the opinions and experiences of 23 primary care doctors and nurses from the participating centers were explored in focus groups. We performed thematic content analysis of the focus group transcripts. RESULTS The results were organized into three categories: facilitators, barriers, and proposals for improvement as perceived by the health care professionals involved. The most important facilitator identified was the perception that the INDI collaborative care program could be a useful tool for reorganizing processes and improving the management of depression in primary care, currently viewed as deficient. The main barriers identified were of an organizational nature: heavy workloads, lack of time, high staff turnover and shortages, and competing demands. Additional obstacles were inertia and resistance to change among health care professionals. Proposals for improvement included institutional buy-in to guarantee enduring support and the organizational changes needed for successful implementation. CONCLUSIONS The INDI program is perceived as a useful, viable program for improving the management of depression in primary care. Uptake by primary care centers and health care professionals, however, was poor. The identification and analysis of barriers and facilitators will help refine the strategy to achieve successful, widespread implementation. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT03285659 ; Registered 18th September, 2017.
Collapse
Affiliation(s)
- Enric Aragonès
- Primary Care Area Camp de Tarragona, Catalan Health Institute, Carrer dels Horts, 6, 43120, Constantí, Tarragona, Spain. .,Primary Care Research Institute IDIAP Jordi Gol, Barcelona, Spain.
| | - Germán López-Cortacans
- Primary Care Area Camp de Tarragona, Catalan Health Institute, Carrer dels Horts, 6, 43120, Constantí, Tarragona, Spain.,Primary Care Research Institute IDIAP Jordi Gol, Barcelona, Spain
| | - Narcís Cardoner
- Mental Health Department, University Hospital Parc Taulí, Sabadell, Spain.,Department of Psychiatry and Legal Medicine, Autonomous University of Barcelona, Barcelona, Spain.,Biomedical Research Networking Center Consortium on Mental Health (CIBERSAM), Madrid, Spain
| | - Catarina Tomé-Pires
- Psychology Research Center CIP, Autonomous University of Lisbon, Lisbon, Portugal
| | - Daniel Porta-Casteràs
- Mental Health Department, University Hospital Parc Taulí, Sabadell, Spain.,Department of Psychiatry and Legal Medicine, Autonomous University of Barcelona, Barcelona, Spain
| | - Diego Palao
- Mental Health Department, University Hospital Parc Taulí, Sabadell, Spain.,Department of Psychiatry and Legal Medicine, Autonomous University of Barcelona, Barcelona, Spain.,Biomedical Research Networking Center Consortium on Mental Health (CIBERSAM), Madrid, Spain
| | | |
Collapse
|
9
|
Foo YY, Tan K, Xin X, Lim WS, Cheng Q, Rao J, Tan NC. Institutional ethnography - a primer. Singapore Med J 2022; 62:507-512. [PMID: 35001127 DOI: 10.11622/smedj.2021199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
This review introduces a qualitative methodology called institutional ethnography (IE) to healthcare professionals interested in studying complex social healthcare systems. We provide the historical context in which IE was developed, and explain the principles and terminology in IE for the novice researcher. Through the use of worked examples, the reader will be able to appreciate how IE can be used to approach research questions in the healthcare system that other methods would be unable to answer. We show how IE and qualitative research methods maintain quality and rigour in research findings. We hope to demonstrate to healthcare professionals and researchers that healthcare systems can be analysed as social organisations, and IE may be used to identify and understand how higher-level processes and policies affect day-to-day clinical work. This understanding may allow the formulation and implementation of actionable improvements to solve problems on the ground.
Collapse
Affiliation(s)
| | - Kevin Tan
- Duke-NUS Medical School, Singapore.,Department of Neurology, National Neuroscience Institute, Singapore
| | - Xiaohui Xin
- Health Services Research Unit, Singapore General Hospital, Singapore
| | - Wee Shiong Lim
- Department of Geriatric Medicine, Institute of Geriatrics and Active Aging, Tan Tock Seng Hospital, Singapore
| | - Qianhui Cheng
- Department of Neuroradiology, National Neuroscience Institute, Singapore
| | - Jai Rao
- Duke-NUS Medical School, Singapore.,Department of Neurosurgery, National Neuroscience Institute, Singapore
| | - Nigel Ck Tan
- Duke-NUS Medical School, Singapore.,Department of Neurology, National Neuroscience Institute, Singapore
| |
Collapse
|
10
|
Shulman R, Arora R, Geist R, Ali A, Ma J, Mansfield E, Martel S, Sandercock J, Versloot J. Integrated Community Collaborative Care for Seniors with Depression/Anxiety and any Physical Illness. Can Geriatr J 2021; 24:251-257. [PMID: 34484507 PMCID: PMC8390319 DOI: 10.5770/cgj.24.473] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Background We report on the feasibility and effectiveness of an integrated community collaborative care model in improving the health of seniors with depression/anxiety symptoms and chronic physical illness. Methods This community collaborative care model integrates geriatric medicine and geriatric psychiatry with care managers (CM) providing holistic initial and follow-up assessments, who use standardized rating scales to monitor treatment and provide psychotherapy (ENGAGE). The CM presents cases in a structured case review to a geriatrician and geriatric psychiatrist. Recommendations are communicated by the CM to the patient’s primary care provider. Results 187 patients were evaluated. The average age was 80 years old. Two-thirds were experiencing moderate-to-severe depression upon entry and this proportion decreased significantly to one-third at completion. Qualitative interviews with patients, family caregivers, team members, and referring physicians indicated that the program was well-received. Patients had on average six visits with the CM without the need to have a face-to-face meeting with a specialist. Conclusion The evaluation shows that the program is feasible and effective as it was well received by patients and patient outcomes improved. Implementation in fee-for-service publicly funded health-care environments may be limited by the need for dedicated funding.
Collapse
Affiliation(s)
- Richard Shulman
- Trillium Health Partners, Mississauga, ON, Canada.,Division of Geriatric Psychiatry, Department of Psychiatry, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Reenu Arora
- Trillium Health Partners, Mississauga, ON, Canada
| | - Rose Geist
- Trillium Health Partners, Mississauga, ON, Canada.,Department of Psychiatry, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Amna Ali
- Institute for Better Health, Trillium Health Partners, Mississauga, ON, Canada
| | - Julia Ma
- Institute for Better Health, Trillium Health Partners, Mississauga, ON, Canada
| | - Elizabeth Mansfield
- Institute for Better Health, Trillium Health Partners, Mississauga, ON, Canada.,Faculty of Occupational Science and Occupational Therapy, University of Toronto, Toronto, ON, Canada
| | - Sara Martel
- Institute for Better Health, Trillium Health Partners, Mississauga, ON, Canada.,U Institute of Communication, Culture, Information, & Technology, University of Toronto, Mississauga, ON, Canada
| | - Jane Sandercock
- Institute for Better Health, Trillium Health Partners, Mississauga, ON, Canada
| | - Judith Versloot
- Institute for Better Health, Trillium Health Partners, Mississauga, ON, Canada.,Institute for Health Policy, Management, & Evaluation, University of Toronto, Toronto, ON, Canada
| |
Collapse
|
11
|
Janse van Rensburg A, Kathree T, Breuer E, Selohilwe O, Mntambo N, Petrus R, Bhana A, Lund C, Fairall L, Petersen I. Fuzzy-set qualitative comparative analysis of implementation outcomes in an integrated mental healthcare trial in South Africa. Glob Health Action 2021; 14:1940761. [PMID: 34402770 PMCID: PMC8381905 DOI: 10.1080/16549716.2021.1940761] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
Abstract
BACKGROUND Integrating mental health services into primary healthcare platforms is an established health systems strategy in low-to-middle-income countries. In South Africa, this was pursued through the Programme for Improving Mental Health Care (PRIME), a multi-country initiative that relied on task-sharing as a principle implementation strategy. Towards better describing the implementation processes, qualitative comparative analysis was adopted to explore causal pathways in the intervention. OBJECTIVE This study aimed to explore factors that could have influenced key outcomes of an integrated mental healthcare intervention in South Africa. METHODS Drawing from an embedded multiple case study design, the analysis used qualitative comparative analysis. Focusing on nine PHC clinics in the Dr Kenneth Kaunda District as cases, with depression reduction scores set as outcome measures, trial data variables were modelled in a hypothetical causal process. A fuzzy-set qualitative comparative analysis was performed by 1) developing the research questions, 2) developing the fuzzy set, 3) testing necessity and 4) testing sufficiency. These steps were undertaken collaboratively among the research team. RESULTS The data were calibrated during several meetings among team members to gain a degree of consensus. Necessity analyses suggested that none of the causal conditions exceeded the threshold of necessity and triviality, and confirmed the inclusion of relevant variables in line with the proposed models. Sufficiency analyses produced two configurations, which were subjected to standard and specific analyses. Ultimately, the results suggested that none of the causal conditions were necessary for a reduction in depression scores to occur, while programme fidelity was identified as a sufficient condition for a reduction in scores to occur. CONCLUSIONS The study highlights the importance of understanding implementation pathways to enable better integration of mental health services within primary healthcare in low-to-middle-income settings. It underlines the importance of programme fidelity in achieving the goals of implementation.
Collapse
Affiliation(s)
- André Janse van Rensburg
- Centre for Rural Health, University of KwaZulu-Natal, School of Nursing and Public Health, Durban, South Africa
| | - Tasneem Kathree
- Centre for Rural Health, University of KwaZulu-Natal, Durban, South Africa
| | - Erica Breuer
- Alan J Flisher Centre for Public Mental Health, University of Cape Town, Cape Town, South Africa
| | - One Selohilwe
- Centre for Rural Health, University of KwaZulu-Natal, Durban, South Africa
| | - Ntokozo Mntambo
- Centre for Rural Health, University of KwaZulu-Natal, Durban, South Africa
| | - Ruwayda Petrus
- Department of Psychology, University of KwaZulu-Natal, Durban, South Africa
| | - Arvin Bhana
- Centre for Rural Health, University of KwaZulu-Natal & South African Medical Research Council, Durban, South Africa
| | - Crick Lund
- Alan J Flisher Centre for Public Mental Health, University of Cape Town & Centre for Global Mental Health, King's College London, Cape Town, South Africa
| | - Lara Fairall
- Centre for Knowledge Translation, University of Cape Town, Cape Town, South Africa
| | - Inge Petersen
- Centre for Rural Health, University of KwaZulu-Natal, Durban, South Africa
| |
Collapse
|
12
|
Wagner S, Addington KS, Varming A, Hempler NF. Caught between good intentions and rigid structures: A qualitative description of professionals' experiences with health promotion in mental health services. Scand J Caring Sci 2021; 36:663-672. [PMID: 34355422 DOI: 10.1111/scs.13023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Revised: 07/07/2021] [Accepted: 07/25/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND AND AIM Compared with the general population, people with mental illness are at higher risk of developing type 2 diabetes due to poor diet, medication and inactive lifestyle. People with mental illness and members of the general population are equally interested in health behaviour change, but those with mental illness experience communication barriers with professionals. The study aimed to explore philosophies that social care and healthcare professionals apply to health promotion activities targeting people with mental illness and challenges they face in applying these philosophies across multiple settings. METHODS Qualitative interviews were conducted with 18 social and healthcare professionals in a range of settings in 2016-2019. Descriptive qualitative analysis was applied to interview data. RESULTS Interviewees faced many structural challenges in the organisation of their work, which did not coincide with their philosophy or intentions in relation to health promotion. Three philosophical categories were identified: (a) health promotion approach, (b) elements of care and (c) social relations. Many interviewees intended to apply philosophies of broadly defined health, dialogue-based health education, and incremental approaches to health behaviour change. They wanted to provide holistic and flexible care and they valued peer-to-peer activities, family and friend involvement in care and a trusting relationship between the professional and the person with mental illness. However, rigid structures determining the organisation of health promotion challenged professionals' ability to follow their philosophical intentions. CONCLUSION Interviewees aspired to a collaborative, empowering and person-centred approach, but practical and structural factors made this difficult to achieve in practice. Major changes are required at the organisational level, implemented with the active involvement of professionals and people with mental illness.
Collapse
Affiliation(s)
- Sabina Wagner
- Steno Diabetes Center Copenhagen, Health Promotion Research, Gentofte, Denmark
| | | | - Annemarie Varming
- Steno Diabetes Center Copenhagen, Health Promotion Research, Gentofte, Denmark
| | | |
Collapse
|
13
|
Ohlsen S, Sanders T, Connell J, Wood E. Integrating mental health care into home-based nursing services: A qualitative study utilising normalisation process theory. J Clin Nurs 2021; 31:1184-1201. [PMID: 34309100 DOI: 10.1111/jocn.15975] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Revised: 07/05/2021] [Accepted: 07/08/2021] [Indexed: 11/30/2022]
Abstract
AIMS AND OBJECTIVES To identify barriers and facilitators to implementing community nurses being trained as psychological wellbeing practitioners and integrating this practice into home-based primary care nursing, through key stakeholders' perceptions. BACKGROUND Current drivers in UK primary care aim to increase access to mental health services and treatment, to achieve parity of esteem between physical and mental health care for patients who are housebound. However, there remains limited evidence on how to successfully implement this. Training community nurses as psychological wellbeing practitioners to offer mental health care alongside their current home-based services is one option. DESIGN A pluralistic qualitative study. This study followed the COREQ checklist for reporting qualitative research. METHODS Twenty key stakeholders were purposively recruited and interviewed including twelve health professionals and eight patients. Semi-structured interviews were analysed using a theoretical thematic analysis informed by normalisation process theory concepts of coherence, cognitive participation, collective action and reflexive monitoring, to explore the barriers and facilitators to implementation. RESULTS Staff and patients reported high coherence and cognitive participation, valuing the integrated roles. Facilitators included the development of clearer referral pathways and increased mental health knowledge in the wider team. However, sustainability and current siloed healthcare systems were identified as barriers to implementation. CONCLUSIONS A key obstacle to long-term implementation was the practical structures and financial boundaries of siloed healthcare systems, making long-term sustainability unviable. RELEVANCE TO CLINICAL PRACTICE Community nurses with additional mental health training can integrate these skills in practice and are valued by their team and patients offering holistic care to patients within their home and informal knowledge transfer to the wider team. However, long-term sustainability is required if this is to be adopted routinely. Further evidence is needed to better understand the positive outcomes to patients and potential cost savings.
Collapse
Affiliation(s)
- Sally Ohlsen
- Health Service Research, School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Tom Sanders
- Health and Life Sciences, Northumbria University, Newcastle upon Tyne, UK
| | - Janice Connell
- Health Service Research, School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Emily Wood
- Health Service Research, School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| |
Collapse
|
14
|
Ankersen PV, Steffensen RG, Blæhr EE, Beedholm K. Bumpy road: implementing integrated psychiatric and somatic care in joint-specialty emergency departments: a mixed-method study using Normalization Process Theory. JOURNAL OF INTEGRATED CARE 2021. [DOI: 10.1108/jica-07-2020-0047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PurposeLife expectancy is 15–20 years shorter for individuals with than for people without mental illness. Assuming that undiagnosed and undertreated somatic conditions are significant causes, the Central Denmark Region set out to implement joint psychiatric and somatic emergency departments (EDs) to support integrated psychiatric/somatic care as an effort to prolong the lifetime of individuals with mental illness. Through the lens of Normalization Process Theory, the authors examine healthcare frontline staff’s perceptions of and work with the implementation of integrated psychiatric/somatic care in the first joint-specialty ED in Denmark.Design/methodology/approachA single-case mixed-methods study using Normalization Process Theory (NPT) as an analytic framework to evaluate implementation of psychiatric/somatic integrated care (IC) in a joint-specialty emergency department. Data were generated from observations, qualitative interviews and questionnaires distributed to the frontline staff.FindingsImplementation was characterized by a diffuse normalization leading to an adaption of the IC in a fuzzy alignment with existing practice. Especially, confusion among the staff regarding how somatic examination in the ED would ensure prolonged lifetime for people with mental illness was a barrier to sense-making and development of coherence among the staff. The staff questioned the accuracy of IC in the ED even though they recognized the need for better somatic care for individuals with mental illness.Practical implicationsThis study highlights that a focus on outcomes (prolonging lifetime for people with mental illness and reducing stigmatization) can be counterproductive. Replacing the outcome focus with an output focus, in terms of how to develop and implement psychiatric/somatic IC with the patient perspective at the center, would probably be more productive.Originality/valueIn 2020, the Danish Health Authorities published new whole-system recommendations for emergency medicine (EM) highlighting the need for intensifying integrated intra and interorganizational care including psychiatric/somatic IC (ref). Even though this study is not conclusive, it points to subjects that can help to identify resources needed to implement psychiatric/somatic IC and to pitfalls. The authors argue that the outcome focus, prolonging the lifetime for individuals with mental illness by identifying somatic illness, was counterproductive. In accordance with the recommendations of contemporary implementation studies, the authors recommend a shift in focus from outcome to output focus; how to develop and implement psychiatric/somatic IC.
Collapse
|
15
|
Carroll S, Moss-Morris R, Hulme K, Hudson J. Therapists' perceptions of barriers and facilitators to uptake and engagement with therapy in long-term conditions. Br J Health Psychol 2020; 26:307-324. [PMID: 33043530 DOI: 10.1111/bjhp.12475] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Revised: 07/24/2020] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Improving Access to Psychological Therapies (IAPT) services in England have established a long-term condition (LTC) pathway in recent years, meaning that LTC therapies are now delivered via varied modes and by professionals with varied experiences. To gain insight into how this new pathway is functioning in practice, this study aimed to explore therapists' perceptions of barriers and facilitators to uptake and engagement with therapy in LTCs. DESIGN A qualitative design was employed using semi-structured interviews. METHODS Fifteen therapists were recruited from IAPT and physical health care settings. Interviews were first analysed using inductive thematic analysis. A deductive approach was then taken to map themes onto Normalisation Process Theory constructs (coherence, cognitive participation, collective action, reflective monitoring) to guide steps towards improving implementation. RESULTS Four key themes highlighted patient, therapist, and service-level factors related to uptake and engagement: Working flexibly with barriers within the National Health Service context; Acceptability of 'embedded' versus 'separate' psychological care; Confidence in working with people with LTCs; and Navigating implementation of online therapies. Therapists recognized the need for tailored LTC therapies, though opinions about online therapies varied. Therapists expressed commitment to flexibly adapting their practice to suit patient needs, but felt their flexibility was limited by system and service constraints. CONCLUSION Barriers to uptake and engagement need to be addressed to optimize LTC pathways. Findings demonstrated the importance of offering flexible, tailored therapy to people with LTCs, and equipping staff and services with adequate training and resources to improve functioning of LTC pathways in practice.
Collapse
Affiliation(s)
- Susan Carroll
- Psychology Department, Institute of Psychiatry, Psychology & Neuroscience at King's College London, UK
| | - Rona Moss-Morris
- Psychology Department, Institute of Psychiatry, Psychology & Neuroscience at King's College London, UK
| | - Katrin Hulme
- Psychology Department, Institute of Psychiatry, Psychology & Neuroscience at King's College London, UK
| | - Joanna Hudson
- Psychology Department, Institute of Psychiatry, Psychology & Neuroscience at King's College London, UK
| |
Collapse
|
16
|
The Role of Collaborative Healthcare in Improving Social Sustainability: A Conceptual Framework. SUSTAINABILITY 2020. [DOI: 10.3390/su12083195] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Healthcare systems around the world face both increasing demands and inequality in service distribution. The current trend is for collaboration among healthcare actors, named as collaborative healthcare, in order to address challenges such as these to improve the social sustainability of the system. That is to provide accessible and equitable healthcare services to meet people’s health and well-being needs. Based on an integrative literature review, this study aims at crafting a conceptual framework to explore how collaborative healthcare networks contribute to social sustainability and the specific actors involved in these collaborations. It identifies relationships between different collaborative healthcare networks and social sustainability. Interprofessional networks have been the most studied in relation to social sustainability. Communication and sharing information or knowledge have been identified as used collaborative healthcare practices. This study contributes theoretically by considering a new model of the healthcare organization in which collaborative networks play a central role in improving social sustainability. In terms of practical implications, the study provides managers and policy makers with investment insights on a range of collaborative networks and practices.
Collapse
|
17
|
Huddlestone L, Turner J, Eborall H, Hudson N, Davies M, Martin G. Application of normalisation process theory in understanding implementation processes in primary care settings in the UK: a systematic review. BMC FAMILY PRACTICE 2020; 21:52. [PMID: 32178624 PMCID: PMC7075013 DOI: 10.1186/s12875-020-01107-y] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Accepted: 02/05/2020] [Indexed: 01/28/2023]
Abstract
Background Normalisation Process Theory (NPT) provides a framework to understand how interventions are implemented, embedded, and integrated in healthcare settings. Previous reviews of published literature have examined the application of NPT across international healthcare and reports its benefits. However, given the distinctive clinical function, organisational arrangements and the increasing management of people with a wide variety of conditions in primary care settings in the United Kingdom, it is important to understand how and why authors utilise and reflect on NPT in such settings to inform and evaluate implementation processes. Methods A systematic review of peer-reviewed literature using NPT in primary care settings in the United Kingdom (UK) was conducted. Eight electronic databases were searched using replicable methods to identify articles published between January 2012 and April 2018. Data were analysed using a framework approach. Results Thirty-one articles met the inclusion criteria. Researchers utilised NPT to explore the implementation of interventions, targeting a wide range of health services and conditions, within primary care settings in the UK. NPT was mostly applied qualitatively; however, a small number of researchers have moved towards mixed and quantitative methods. Some variation was observed in the use of NPT constructs and sub-constructs, and whether and how researchers undertook modification to make them more relevant to the implementation process and multiple stakeholder perspectives. Conclusion NPT provides a flexible framework for the development and evaluation of complex healthcare interventions in UK primary care settings. This review updates the literature on NPT use and indicates that its application is well suited to these environments, particularly in supporting patients with long-term conditions and co-morbidities. We recommend future research explores the receipt of interventions by multiple stakeholders and suggest that authors reflect on justifications for using NPT in their reporting.
Collapse
Affiliation(s)
- Lisa Huddlestone
- Department of Health Sciences, University of Leicester, George Davies Centre, University Road, Leicester, LE1 7RH, UK.
| | - Jessica Turner
- School of Applied Social Sciences, De Montfort University, Hawthorn Building, The Gateway, Leicester, LE1 9BH, UK
| | - Helen Eborall
- Department of Health Sciences, University of Leicester, George Davies Centre, University Road, Leicester, LE1 7RH, UK
| | - Nicky Hudson
- School of Applied Social Sciences, De Montfort University, Hawthorn Building, The Gateway, Leicester, LE1 9BH, UK
| | - Melanie Davies
- Diabetes Research Centre, Affiliated with the Department of Health Sciences, University of Leicester, Leicester General Hospital, Gwendolen Road, Leicester, LE5 4PW, UK
| | - Graham Martin
- The Healthcare Improvement Studies Institute (THIS Institute), University of Cambridge, Cambridge Biomedical Campus, Clifford Allbutt Building, Cambridge, CB2 0AH, UK
| |
Collapse
|
18
|
Coyle LA, Atkinson S. Vulnerability as practice in diagnosing multiple conditions. MEDICAL HUMANITIES 2019; 45:278-287. [PMID: 29950507 PMCID: PMC6818667 DOI: 10.1136/medhum-2017-011433] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 06/01/2018] [Indexed: 06/08/2023]
Abstract
The paper contributes to contemporary understandings of vulnerability by expanding their scope with an understanding of vulnerability as generated through institutionalised practices. The argument draws on experiential accounts of navigating the practices of diagnosis by people living with multiple conditions of ill-health and disability. Vulnerability as a concept is used widely across different domains and conveys a multitude of meanings. Contemporary biomedicine, and its associated health systems and services, understands vulnerability mostly as inherent to particular physical and mental bodily conditions that put people at risk of ill-health or emotionally fragility. This may combine with a more epidemiological understanding of vulnerability as the experience of certain population groups subject to entrenched structural inequalities. Philosophers and feminists have argued that vulnerability is a universal experience of being human while political commentators have explored its potential as a resource for resistance and action. Diagnosis within medicine and psychiatry has been the subject of extensive social analysis, critique and activism. The paper draws on first-hand experiential accounts collected through face-to-face interviews with people living with multiple conditions about their experiences of diagnosis, mostly at the primary care level. We identify five aspects to diagnostic practice that are harmful and exacerbate the experience of vulnerability: temporal sequencing; diagnostic authority; medical specialisation; strategic symptom selection; medical isolation. However, these diagnostic practices are not best understood only in terms of the power asymmetries inherent to the medical consultation, but are embedded into the very institution of diagnosis. The paper thus proposes a combined approach to vulnerability that recognises it as a universal condition of humanity but one that becomes animated or amplified for some bodies, through their own inherent incapacities or the external structures of inequality, and through the practices of medicine as situated in particular times and places.
Collapse
Affiliation(s)
| | - Sarah Atkinson
- Institute for Medical Humanities, Durham University, Durham, UK
| |
Collapse
|
19
|
Pettersson A, Modin S, Hasson H, Krakau I. Feasibility of referral to a therapist for assessment of psychiatric problems in primary care - an interview study. BMC FAMILY PRACTICE 2019; 20:117. [PMID: 31426751 PMCID: PMC6700983 DOI: 10.1186/s12875-019-1007-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Accepted: 08/08/2019] [Indexed: 11/27/2022]
Abstract
Background Depression and anxiety disorders are common in primary care. Comorbidities are frequent, and the diagnoses can be difficult. The Mini-International Neuropsychiatric Interview (MINI) can be a support in the clinical examination of patients with complex problems. However, for family practitioners (FPs), time and perceptions about structured interviews can be barriers to the MINI. An inter-professional teamwork process where FPs refer a patient to a therapist for a MINI assessment represents one way in which to address the problem. The results are fed back to the FPs for diagnosis and treatment decisions. The purposes of this study were to explore if the process was feasible for FPs, patients and therapists in Swedish primary care, and to identify factors influencing the process, using the COM-B model. Methods FPs at two primary care centers (PHCC) in Stockholm were offered the opportunity to refer patients to in-house therapists. Semi-structured interviews or focus groups were conducted with 22 patients, 17 FPs and three therapists to capture their experiences and perceptions. Inductive content analysis for each group of participants was followed by triangulation across groups. Finally, the categories obtained were fitted to the components in the COM-B. Results Therapists at both PHCCs conducted the MINI. The intended process was adopted at one PHCC. At the second PHCC, the responsibilities for the diagnosis and treatment of patients referred were transferred to the therapist. The patients were satisfied, as they appreciated multi-professional examinations. The FPs’ competence in psychiatry, actual access to therapists, beliefs that the referrals saved the FPs time and effort, and established habits influenced whether patients were referred. Existing routines and professional expectations for work content influenced the degree of cooperation between the therapists and the FPs. Conclusions An inter-professional diagnostic process where FPs refer patients to a therapist for assessment and the results are fed back to the FPs can be feasible. Feasibility depends on access to a therapist, the perceptions of roles and competences among FPs and therapists, and strategies for supporting teamwork. Electronic supplementary material The online version of this article (10.1186/s12875-019-1007-7) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Agneta Pettersson
- Procome, Medical Management Centre, Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Tomtebodavägen 18 A, SE-171 77, Stockholm, Sweden. .,Swedish Agency for Health Technology Assessment and Social Assessment, SE-102 33, Stockholm, Sweden.
| | - Sonja Modin
- Division of Family Medicine and Primary Care, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Alfred Nobels allé 23 D2, SE-141 83, Huddinge, Sweden
| | - Henna Hasson
- Procome, Medical Management Centre, Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Tomtebodavägen 18 A, SE-171 77, Stockholm, Sweden.,Centre for Epidemiology and Community Medicine, Stockholm County Council, Stockholm, Sweden
| | - Ingvar Krakau
- Department of Medicine Solna, Karolinska Institutet, Clinical Epidemiology Unit T2, Karolinska University Hospital, SE-171 76, Stockholm, Sweden
| |
Collapse
|
20
|
Abstract
Researchers continue to lament the lack of organisational focus in the sociology of health and illness. Although studies have increasingly focused on boundaries between organizations, little such research has focused on the formal boundaries within the hospital itself. Given its dramatic compartmentalisation, and continuing prevalence in health systems, the lack of organisational perspective in hospital research limits insights into the effects (as well as the construction) of the order of health work and care. With a greater emphasis on 'ordering' in the concept of negotiated order, the aim of this study is to examine the manifestation and consequences of the formal boundaries of hospital departments. Fieldwork featured 12 months of ethnography, including formal and informal observations, 80 audio-recorded, semi-structured interviews, and 56 field interviews, in the Emergency Departments (EDs) of two tertiary referral hospitals. Compared with in-patient hospital departments, the ED has limited legitimacy claims of organ-specific knowledge to transfer patients out of the ED. The manifestation of specialised knowledge hierarchies in organisational structures disadvantages patients who are older and who have chronic conditions, underpinning the argument that effects as well as the negotiation of stable organisational orders deserve increased attention in the sociology of health and illness.
Collapse
Affiliation(s)
- Peter Nugus
- Center for Medicine Education and Department of Family Medicine, McGill University, Quebec, Canada
| |
Collapse
|
21
|
Baker E, Gwernan-Jones R, Britten N, Cox M, McCabe C, Retzer A, Gill L, Plappert H, Reilly S, Pinfold V, Gask L, Byng R, Birchwood M. Refining a model of collaborative care for people with a diagnosis of bipolar, schizophrenia or other psychoses in England: a qualitative formative evaluation. BMC Psychiatry 2019; 19:7. [PMID: 30616552 PMCID: PMC6323712 DOI: 10.1186/s12888-018-1997-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Accepted: 12/20/2018] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Many people diagnosed with schizophrenia, bipolar or other psychoses in England receive the majority of their healthcare from primary care. Primary care practitioners may not be well equipped to meet their needs and there is often poor communication with secondary care. Collaborative care is a promising alternative model but has not been trialled specifically with this service user group in England. Collaborative care for other mental health conditions has not been widely implemented despite evidence of its effectiveness. We carried out a formative evaluation of the PARTNERS model of collaborative care, with the aim of establishing barriers and facilitators to delivery, identifying implementation support requirements and testing the initial programme theory. METHODS The PARTNERS intervention was delivered on a small scale in three sites. Qualitative data was collected from primary and secondary care practitioners, service users and family carers, using semi-structured interviews, session recordings and tape-assisted recall. Deductive and inductive thematic analysis was carried out; themes were compared to the programme theory and used to inform an implementation support strategy. RESULTS Key components of the intervention that were not consistently delivered as intended were: interaction with primary care teams, the use of coaching, and supervision. Barriers and facilitators identified were related to service commitment, care partner skills, supervisor understanding and service user motivation. An implementation support strategy was developed, with researcher facilitation of communication and supervision and additional training for practitioners. Some components of the intervention were not experienced as intended; this appeared to reflect difficulties with operationalising the intervention. Analysis of data relating to the intended outcomes of the intervention indicated that the mechanisms proposed in the programme theory had operated as expected. CONCLUSIONS Additional implementation support is likely to be required for the PARTNERS model to be delivered; the effectiveness of such support may be affected by practitioner and service user readiness to change. There is also a need to test the programme theory more fully. These issues will be addressed in the process evaluation of our full trial. TRIAL REGISTRATION ISRCTN95702682 , 26 October 2017.
Collapse
Affiliation(s)
- Elina Baker
- Institute of Health Research, University of Exeter Medical School, St Luke's Campus, Exeter, UK.
| | - Ruth Gwernan-Jones
- 0000 0004 1936 8024grid.8391.3Institute of Health Research, University of Exeter Medical School, St Luke’s Campus, Exeter, UK
| | - Nicky Britten
- 0000 0004 1936 8024grid.8391.3Institute of Health Research, University of Exeter Medical School, St Luke’s Campus, Exeter, UK
| | - Maria Cox
- 0000 0000 8190 6402grid.9835.7Health Research, Lancaster University, Furness Building, Lancaster, UK
| | - Catherine McCabe
- 0000 0001 2219 0747grid.11201.33Community and Primary Care Research Group, University of Plymouth, Faculty of Medicine and Dentistry, Plymouth Science Park, Plymouth, UK
| | - Ameeta Retzer
- 0000 0004 1936 7486grid.6572.6Institute of Applied Health Research, University of Birmingham, Edgbaston, Birmingham, UK
| | - Laura Gill
- 0000 0001 2219 0747grid.11201.33Community and Primary Care Research Group, University of Plymouth, Faculty of Medicine and Dentistry, Plymouth Science Park, Plymouth, UK
| | - Humera Plappert
- 0000 0004 1936 7486grid.6572.6Institute of Applied Health Research, University of Birmingham, Edgbaston, Birmingham, UK
| | - Siobhan Reilly
- 0000 0000 8190 6402grid.9835.7Health Research, Lancaster University, Furness Building, Lancaster, UK
| | - Vanessa Pinfold
- grid.490917.2The McPin Foundation, 32-36 Loman Street, London, UK
| | - Linda Gask
- 0000000121662407grid.5379.8Centre for Primary Care research, University of Manchester, Oxford Road, Williamson Building, Manchester, UK
| | - Richard Byng
- 0000 0001 2219 0747grid.11201.33Community and Primary Care Research Group, University of Plymouth, Faculty of Medicine and Dentistry, Plymouth Science Park, Plymouth, UK
| | - Max Birchwood
- 0000 0000 8809 1613grid.7372.1Warwick Medical School, University of Warwick, Coventry, UK
| |
Collapse
|
22
|
Damian AJ, Gallo JJ. Models of care for populations with chronic conditions and mental/behavioral health comorbidity. Int Rev Psychiatry 2018; 30:157-169. [PMID: 30862204 DOI: 10.1080/09540261.2019.1568233] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Recent decades have seen increased interest in the integration of mental and physical healthcare. Healthcare reform in the US has provided an opportunity for integration of evidence-based mental health programmes. Three quarters of patients with behavioural health disorders are seen in medical settings, where behavioural problems are largely unaddressed. The human and economic toll of unaddressed mental and behavioural health needs is enormous and often hidden from view, since the behavioural or mental health implications of medical conditions like heart disease and diabetes have only recently begun to be appreciated. This paper has three goals: (1) to review models of integrated services delivery, providing a framework for making sense of strategies for integration; (2) to consider some evidence for clinical outcomes when care is integrated; and (3) to highlight some factors that enhance or impede integration in practice. The review concludes with comments on where the field is going.
Collapse
Affiliation(s)
| | - Joseph J Gallo
- b Department of Mental Health , Johns Hopkins University Bloomberg School of Public Health , Baltimore , MD , USA
| |
Collapse
|
23
|
Castellani B, Griffiths F, Rajaram R, Gunn J. Exploring comorbid depression and physical health trajectories: A case-based computational modelling approach. J Eval Clin Pract 2018; 24:1293-1309. [PMID: 30277297 DOI: 10.1111/jep.13042] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2018] [Revised: 07/27/2018] [Accepted: 08/20/2018] [Indexed: 11/30/2022]
Abstract
While comorbid depression/physical health is a major clinical concern, the conventional methods of medicine make it difficult to model the complexities of this relationship. Such challenges include cataloguing multiple trends, developing multiple complex aetiological explanations, and modelling the collective large-scale dynamics of these trends. Using a case-based complexity approach, this study engaged in a richly described case study to demonstrate the utility of computational modelling for primary care research. N = 259 people were subsampled from the Diamond database, one of the largest primary care depression cohort studies worldwide. A global measure of depressive symptoms (PHQ-9) and physical health (PCS-12) were assessed at 3, 6, 9, and 12 months and then annually for a total of 7 years. Eleven trajectories and 2 large-scale collective dynamics were identified, revealing that while depression is comorbid with poor physical health, chronic illness is often low dynamic and not always linked to depression. Also, some of the cases in the unhealthy and oscillator trends remain ill without much chance of improvement. Finally, childhood abuse, partner violence, and negative life events are greater amongst unhealthy trends. Computational modelling offers a major advance for health researchers to account for the diversity of primary care patients and for developing better prognostic models for team-based interdisciplinary care.
Collapse
Affiliation(s)
- Brian Castellani
- Department of Sociology, Durham University, Durham, UK.,Department of Psychiatry, Northeastern Ohio Medical University, Rootstown, OH, USA
| | - Frances Griffiths
- Division of Health Sciences, University of Warwick, Coventry, UK.,University of the Witwatersrand, Johannesburg, South Africa
| | - Rajeev Rajaram
- Department of Mathematics, Kent State University, Kent, OH, USA
| | - Jane Gunn
- Department of General Practice, University of Melbourne, Melbourne, Australia
| |
Collapse
|
24
|
Svenningsson I, Udo C, Westman J, Nejati S, Hange D, Björkelund C, Petersson EL. Creating a safety net for patients with depression in primary care; a qualitative study of care managers' experiences. Scand J Prim Health Care 2018; 36:355-362. [PMID: 30314415 PMCID: PMC6381518 DOI: 10.1080/02813432.2018.1529018] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
OBJECTIVE The aim of this study was to explore nurses' experiences and perceptions of working as care managers at primary care centers. DESIGN Qualitative, focus group study. Systematic text condensation was used to analyze the data. SETTING Primary health care in the region of Västra Götaland and region of Dalarna in Sweden. SUBJECTS Eight nurses were trained during three days including treatment of depression and how to work as care managers. The training was followed by continuous support. MAIN OUTCOME MEASURES The nurses' experiences and perceptions of working as care managers at primary care centers. RESULTS The care managers described their role as providing additional support to the already existing care at the primary care center, working in teams with a person-centered focus, where they were given the opportunity to follow, support, and constitute a safety net for patients with depression. Further, they perceived that the care manager increased continuity and accessibility to primary care for patients with depression. CONCLUSION The nurses perceived that working as care managers enabled them to follow and support patients with depression and to maintain close contact during the illness. The care manager function helped to provide continuity in care which is a main task of primary health care. Key Points The care managers described their role as an additional support to the already existing care at the primary care center. • They emphasized that as care managers, they had a person-centered focus and constituted a safety net for patients with depression. • Their role as care managers enabled them to follow and support patients with depression over time, which made their work more meaningful. • Care managers helped to achieve continuity and accessibility to primary health care for patients with depression.
Collapse
Affiliation(s)
- Irene Svenningsson
- Department of Primary Health Care, Institute of Medicine, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden;
- Primary Health Care, Närhälsan Research and Development, Region Västra Götaland, Sweden;
- CONTACT Irene Svenningsson Department of Primary Health Care, Institute of Medicine, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, SwedenPrimary Health Care, Närhälsan Research and Development, Region Västra Götaland, Sweden
| | - Camilla Udo
- School of Education, Health and Social Studies, Dalarna University, Falun, Sweden;
- Centre for Clinical Research, Dalarna, Sweden;
| | - Jeanette Westman
- Division of Family Medicine, Department of Neurobiology, Care Sciences and Society, Karolinska Institute, Stockholm, Sweden
| | - Shabnam Nejati
- Department of Primary Health Care, Institute of Medicine, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden;
| | - Dominique Hange
- Department of Primary Health Care, Institute of Medicine, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden;
| | - Cecilia Björkelund
- Department of Primary Health Care, Institute of Medicine, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden;
| | - Eva-Lisa Petersson
- Department of Primary Health Care, Institute of Medicine, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden;
- Primary Health Care, Närhälsan Research and Development, Region Västra Götaland, Sweden;
| |
Collapse
|
25
|
Baxter S, Johnson M, Chambers D, Sutton A, Goyder E, Booth A. Understanding new models of integrated care in developed countries: a systematic review. HEALTH SERVICES AND DELIVERY RESEARCH 2018. [DOI: 10.3310/hsdr06290] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
BackgroundThe NHS has been challenged to adopt new integrated models of service delivery that are tailored to local populations. Evidence from the international literature is needed to support the development and implementation of these new models of care.ObjectivesThe study aimed to carry out a systematic review of international evidence to enhance understanding of the mechanisms whereby new models of service delivery have an impact on health-care outcomes.DesignThe study combined rigorous and systematic methods for identification of literature, together with innovative methods for synthesis and presentation of findings.SettingAny setting.ParticipantsPatients receiving a health-care service and/or staff delivering services.InterventionsChanges to service delivery that increase integration and co-ordination of health and health-related services.Main outcome measuresOutcomes related to the delivery of services, including the views and perceptions of patients/service users and staff.Study designEmpirical work of a quantitative or qualitative design.Data sourcesWe searched electronic databases (between October 2016 and March 2017) for research published from 2006 onwards in databases including MEDLINE, EMBASE, PsycINFO, Cumulative Index to Nursing and Allied Health Literature, Science Citation Index, Social Science Citation Index and The Cochrane Library. We also searched relevant websites, screened reference lists and citation searched on a previous review.Review methodsThe identified evidence was synthesised in three ways. First, data from included studies were used to develop an evidence-based logic model, and a narrative summary reports the elements of the pathway. Second, we examined the strength of evidence underpinning reported outcomes and impacts using a comparative four-item rating system. Third, we developed an applicability framework to further scrutinise and characterise the evidence.ResultsWe included 267 studies in the review. The findings detail the complex pathway from new models to impacts, with evidence regarding elements of new models of integrated care, targets for change, process change, influencing factors, service-level outcomes and system-wide impacts. A number of positive outcomes were reported in the literature, with stronger evidence of perceived increased patient satisfaction and improved quality of care and access to care. There was stronger UK-only evidence of reduced outpatient appointments and waiting times. Evidence was inconsistent regarding other outcomes and system-wide impacts such as levels of activity and costs. There was an indication that new models have particular potential with patients who have complex needs.LimitationsDefining new models of integrated care is challenging, and there is the potential that our study excluded potentially relevant literature. The review was extensive, with diverse study populations and interventions that precluded the statistical summary of effectiveness.ConclusionsThere is stronger evidence that new models of integrated care may enhance patient satisfaction and perceived quality and increase access; however, the evidence regarding other outcomes is unclear. The study recommends factors to be considered during the implementation of new models.Future workLinks between elements of new models and outcomes require further study, together with research in a wider variety of populations.Study registrationThis study is registered as PROSPERO CRD37725.FundingThe National Institute for Health Research Health Services and Delivery Research programme.
Collapse
Affiliation(s)
- Susan Baxter
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Maxine Johnson
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Duncan Chambers
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Anthea Sutton
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Elizabeth Goyder
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Andrew Booth
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| |
Collapse
|
26
|
Bosanquet K, Adamson J, Atherton K, Bailey D, Baxter C, Beresford-Dent J, Birtwistle J, Chew-Graham C, Clare E, Delgadillo J, Ekers D, Foster D, Gabe R, Gascoyne S, Haley L, Hamilton J, Hargate R, Hewitt C, Holmes J, Keding A, Lewis H, McMillan D, Meer S, Mitchell N, Nutbrown S, Overend K, Parrott S, Pervin J, Richards DA, Spilsbury K, Torgerson D, Traviss-Turner G, Trépel D, Woodhouse R, Gilbody S. CollAborative care for Screen-Positive EldeRs with major depression (CASPER plus): a multicentred randomised controlled trial of clinical effectiveness and cost-effectiveness. Health Technol Assess 2018; 21:1-252. [PMID: 29171379 DOI: 10.3310/hta21670] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Depression in older adults is common and is associated with poor quality of life, increased morbidity and early mortality, and increased health and social care use. Collaborative care, a low-intensity intervention for depression that is shown to be effective in working-age adults, has not yet been evaluated in older people with depression who are managed in UK primary care. The CollAborative care for Screen-Positive EldeRs (CASPER) plus trial fills the evidence gap identified by the most recent guidelines on depression management. OBJECTIVES To establish the clinical effectiveness and cost-effectiveness of collaborative care for older adults with major depressive disorder in primary care. DESIGN A pragmatic, multicentred, two-arm, parallel, individually randomised controlled trial with embedded qualitative study. Participants were automatically randomised by computer, by the York Trials Unit Randomisation Service, on a 1 : 1 basis using simple unstratified randomisation after informed consent and baseline measures were collected. Blinding was not possible. SETTING Sixty-nine general practices in the north of England. PARTICIPANTS A total of 485 participants aged ≥ 65 years with major depressive disorder. INTERVENTIONS A low-intensity intervention of collaborative care, including behavioural activation, delivered by a case manager for an average of six sessions over 7-8 weeks, alongside usual general practitioner (GP) care. The control arm received only usual GP care. MAIN OUTCOME MEASURES The primary outcome measure was Patient Health Questionnaire-9 items score at 4 months post randomisation. Secondary outcome measures included depression severity and caseness at 12 and 18 months, the EuroQol-5 Dimensions, Short Form questionnaire-12 items, Patient Health Questionnaire-15 items, Generalised Anxiety Disorder-7 items, Connor-Davidson Resilience Scale-2 items, a medication questionnaire, objective data and adverse events. Participants were followed up at 12 and 18 months. RESULTS In total, 485 participants were randomised (collaborative care, n = 249; usual care, n = 236), with 390 participants (80%: collaborative care, 75%; usual care, 86%) followed up at 4 months, 358 participants (74%: collaborative care, 70%; usual care, 78%) followed up at 12 months and 344 participants (71%: collaborative care, 67%; usual care, 75%) followed up at 18 months. A total of 415 participants were included in primary analysis (collaborative care, n = 198; usual care, n = 217), which revealed a statistically significant effect in favour of collaborative care at the primary end point at 4 months [8.98 vs. 10.90 score points, mean difference 1.92 score points, 95% confidence interval (CI) 0.85 to 2.99 score points; p < 0.001], equivalent to a standard effect size of 0.34. However, treatment differences were not maintained in the longer term (at 12 months: 0.19 score points, 95% CI -0.92 to 1.29 score points; p = 0.741; at 18 months: < 0.01 score points, 95% CI -1.12 to 1.12 score points; p = 0.997). The study recorded details of all serious adverse events (SAEs), which consisted of 'unscheduled hospitalisation', 'other medically important condition' and 'death'. No SAEs were related to the intervention. Collaborative care showed a small but non-significant increase in quality-adjusted life-years (QALYs) over the 18-month period, with a higher cost. Overall, the mean cost per incremental QALY for collaborative care compared with usual care was £26,016; however, for participants attending six or more sessions, collaborative care appears to represent better value for money (£9876/QALY). LIMITATIONS Study limitations are identified at different stages: design (blinding unfeasible, potential contamination), process (relatively low overall consent rate, differential attrition/retention rates) and analysis (no baseline health-care resource cost or secondary/social care data). CONCLUSION Collaborative care was effective for older people with case-level depression across a range of outcomes in the short term though the reduction in depression severity was not maintained over the longer term of 12 or 18 months. Participants who received six or more sessions of collaborative care did benefit substantially more than those who received fewer treatment sessions but this difference was not statistically significant. FUTURE WORK RECOMMENDATIONS Recommendations for future research include investigating the longer-term effect of the intervention. Depression is a recurrent disorder and it would be useful to assess its impact on relapse and the prevention of future case-level depression. TRIAL REGISTRATION Current Controlled Trials ISRCTN45842879. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 21, No. 67. See the NIHR Journals Library website for further project information.
Collapse
Affiliation(s)
| | - Joy Adamson
- Department of Health Sciences, University of York, York, UK
| | - Katie Atherton
- Leeds and York Partnership NHS Foundation Trust, Leeds, UK
| | - Della Bailey
- Department of Health Sciences, University of York, York, UK
| | | | | | | | - Carolyn Chew-Graham
- Research Institute, Primary Care and Health Sciences, Keele University, Stoke-on-Trent, UK
| | - Emily Clare
- Northumberland, Tyne and Wear NHS Foundation Trust, National Institute for Health Research Clinical Research Network (Mental Health) North East and North Cumbria, Newcastle upon Tyne, UK
| | - Jaime Delgadillo
- Department of Health Sciences, University of York, York, UK.,Primary Care Mental Health Service, Leeds Community Healthcare NHS Trust, Leeds, UK
| | - David Ekers
- Mental Health Research Group, Durham University, Durham, UK.,Research and Development Department, Tees, Esk & Wear Valleys NHS Foundation Trust, Middlesbrough, UK
| | - Deborah Foster
- Department of Health Sciences, University of York, York, UK
| | - Rhian Gabe
- Department of Health Sciences, University of York, York, UK.,Hull York Medical School, University of York, York, UK
| | | | - Lesley Haley
- Research and Development Department, Tees, Esk & Wear Valleys NHS Foundation Trust, Middlesbrough, UK
| | - Jahnese Hamilton
- Northumberland, Tyne and Wear NHS Foundation Trust, National Institute for Health Research Clinical Research Network (Mental Health) North East and North Cumbria, Newcastle upon Tyne, UK
| | | | | | - John Holmes
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Ada Keding
- Department of Health Sciences, University of York, York, UK
| | - Helen Lewis
- Department of Health Sciences, University of York, York, UK
| | - Dean McMillan
- Department of Health Sciences, University of York, York, UK.,Hull York Medical School, University of York, York, UK
| | - Shaista Meer
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | | | - Sarah Nutbrown
- Department of Health Sciences, University of York, York, UK
| | - Karen Overend
- Department of Health Sciences, University of York, York, UK
| | - Steve Parrott
- Department of Health Sciences, University of York, York, UK
| | - Jodi Pervin
- Department of Health Sciences, University of York, York, UK
| | - David A Richards
- University of Exeter Medical School, University of Exeter, Exeter, UK
| | | | | | | | - Dominic Trépel
- Department of Health Sciences, University of York, York, UK
| | | | - Simon Gilbody
- Department of Health Sciences, University of York, York, UK.,Hull York Medical School, University of York, York, UK
| |
Collapse
|
27
|
Chen S, Burström B, Sparring V, Qian D. Vertical integrated service model: an educational intervention for chronic disease management and its effects in rural China - a study protocol. BMC Health Serv Res 2018; 18:567. [PMID: 30029653 PMCID: PMC6053730 DOI: 10.1186/s12913-018-3355-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Accepted: 07/04/2018] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Chronic diseases are becoming a huge threat to the Chinese health system. Although the New Round of Medical Reform aims to improve this, the chronic disease management in rural China is still worrying as it relies highly on hospital care instead of primary care. The vertical integrated care model has proven to be effective for chronic disease patients in many high-income countries, while few studies have been conducted in China. In this project, vertical integrated care will be applied to optimize the care of patients with type 2 diabetes mellitus (T2DM) and primary hypertension in rural China, and to shift the care from hospital to primary care. METHODS An educational intervention was conducted in three pilot counties in Jiangsu province, a high-income province in southeast China. The intervention was based on the model of vertical integrated care between the three-levels of healthcare institutions. In the pilot counties, 22 townships were included (11 in the intervention and control groups, respectively). Service teams assembled by the local health bureaus implemented the intervention which provides services for both patients and healthcare professionals. Questionnaire interviews (n = 4259) and medical records were used to collect patient data (physiological measures, health-related quality of life, satisfaction with care). Data from healthcare professionals (n = 282) was gathered through questionnaires and in-depth interviews (knowledge about chronic diseases, general procedure of diagnosing and registering, chronic disease management situation, perceptions of chronic disease treatment and prevention). Baseline data were collected before the start of the intervention in Nov 2015, follow-up data in Oct-Nov 2016, and final data completed in Jul-Aug 2017. DISCUSSION The intervention has been conducted smoothly and gotten support from patients, healthcare institutions and local health authorities. The research team anticipates that the vertical integrated model will improve patients' health, satisfaction with care, and their understanding of their chronic disease. We also anticipate that healthcare professionals can acquire more information about chronic diseases and improve their strategy for providing good quality care for patients. TRIAL REGISTRATION ISRCTN13319989 Registration date: 4th April, 2017.
Collapse
Affiliation(s)
- Shaofan Chen
- Karolinska Institutet, Department of Learning, Informatics, Management and Ethics, Stockholm Centre for Healthcare Ethics, Health Outcomes and Economic Evaluation Research Group, SE-17177 Stockholm, Sweden
- Karolinska Institutet, Equity and Health Policy Research Group, Department of Public Health Services, SE-17177 Stockholm, Sweden
| | - Bo Burström
- Karolinska Institutet, Equity and Health Policy Research Group, Department of Public Health Services, SE-17177 Stockholm, Sweden
- Stockholm County Council, Centre for Epidemiology and Community Medicine, P.O. Box 45436, SE-10431 Stockholm, Sweden
- Center for Health Policy Studies, Nanjing Medical University, No. 101 Longmian Avenue, Nanjing, 211166 China
| | - Vibeke Sparring
- Karolinska Institutet, Medical Management Centre, Department of Learning, Informatics, Management and Ethics, SE-17177 Stockholm, Sweden
| | - Dongfu Qian
- School of Health Policy and Management, Nanjing Medical University, No. 101 Longmian Avenue, Nanjing, 211166 China
- Creative Health Policy Research Group, Nanjing Medical University, No. 101 Longmian Avenue, Nanjing, 211166 China
| |
Collapse
|
28
|
Taylor AK, Gilbody S, Bosanquet K, Overend K, Bailey D, Foster D, Lewis H, Chew-Graham CA. How should we implement collaborative care for older people with depression? A qualitative study using normalisation process theory within the CASPER plus trial. BMC FAMILY PRACTICE 2018; 19:116. [PMID: 30021506 PMCID: PMC6052715 DOI: 10.1186/s12875-018-0813-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/17/2018] [Accepted: 06/29/2018] [Indexed: 04/27/2023]
Abstract
Background Depression in older people may have a prevalence as high as 20%, and is associated with physical co-morbidities, loss, and loneliness. It is associated with poorer health outcomes and reduced quality of life, and is under-diagnosed and under-treated. Older people may find it difficult to speak to their GPs about low mood, and GPs may avoid identifying depression due to limited consultation time and referral options for older patients. Methods A qualitative study nested within a randomised controlled trial for older people with moderate to severe depression: the CASPER plus Trial (Care for Screen Positive Elders). We interviewed patient participants, GPs, and case managers (CM) to explore patients’ and professionals’ views on collaborative care developed for older people, and how this model could be implemented at scale. Transcripts were analysed thematically using normalization process theory. Results Thirty-three interviews were conducted. Across the three data-sets, four main themes were identified based on the main principles of the Normalization Process Theory: understanding of collaborative care, interaction between patients and professionals, liaison between GPs and case managers, and the potential for implementation. Conclusions A telephone-delivered intervention, incorporating behavioural activation, is acceptable to older people with depression, and is deliverable by case managers. The collaborative care framework makes sense to case managers and has the potential to optimize patient outcomes, but implementation requires integration in day to day general practice. Increasing GPs’ understanding of collaborative care might improve liaison and collaboration with case managers, and facilitate the intervention through better support of patients. The CASPER plus model, delivering therapy to older adults with depression by telephone, offers the potential for implementation in a resource-poor health service.
Collapse
Affiliation(s)
- Anna Kathryn Taylor
- Faculty of Health Sciences, University of Bristol, Senate House, Tyndall Avenue, Bristol, BS8 1TH, UK.
| | - Simon Gilbody
- Mental Health and Addictions Research Group (MHARG), Department of Health Sciences, University of York, York, YO10 5DD, UK
| | - Katharine Bosanquet
- Mental Health and Addictions Research Group (MHARG), Department of Health Sciences, University of York, York, YO10 5DD, UK
| | - Karen Overend
- Mental Health and Addictions Research Group (MHARG), Department of Health Sciences, University of York, York, YO10 5DD, UK
| | - Della Bailey
- Mental Health and Addictions Research Group (MHARG), Department of Health Sciences, University of York, York, YO10 5DD, UK
| | - Deborah Foster
- Mental Health and Addictions Research Group (MHARG), Department of Health Sciences, University of York, York, YO10 5DD, UK
| | - Helen Lewis
- Mental Health and Addictions Research Group (MHARG), Department of Health Sciences, University of York, York, YO10 5DD, UK
| | - Carolyn Anne Chew-Graham
- Research Institute, Primary Care and Health Sciences, Keele University, Keele, Staffordshire, ST5 5BG, UK.,West Midlands CLAHRC (Collaboration for Leadership in Applied Health Research and Care), Warwick, UK
| |
Collapse
|
29
|
Møller MCR, Mygind A, Bro F. Who needs collaborative care treatment? A qualitative study exploring attitudes towards and experiences with mental healthcare among general practitioners and care managers. BMC FAMILY PRACTICE 2018; 19:78. [PMID: 29848295 PMCID: PMC5977752 DOI: 10.1186/s12875-018-0764-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Accepted: 05/18/2018] [Indexed: 01/13/2023]
Abstract
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.
Collapse
Affiliation(s)
- Marlene Christina Rosengaard Møller
- Research Unit for General Practice & Section for General Medical Practice, Department of Public Health, Aarhus University, Bartholins Allé 2, 8000, Aarhus C, Denmark.
| | - Anna Mygind
- Research Unit for General Practice & Section for General Medical Practice, Department of Public Health, Aarhus University, Bartholins Allé 2, 8000, Aarhus C, Denmark
| | - Flemming Bro
- Research Unit for General Practice & Section for General Medical Practice, Department of Public Health, Aarhus University, Bartholins Allé 2, 8000, Aarhus C, Denmark
| |
Collapse
|
30
|
Using the Normalization Process Theory to qualitatively explore sense-making in implementation of the Enhanced Recovery After Surgery programme: "It's not rocket science". PLoS One 2018; 13:e0195890. [PMID: 29668717 PMCID: PMC5906013 DOI: 10.1371/journal.pone.0195890] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2017] [Accepted: 04/02/2018] [Indexed: 01/18/2023] Open
Abstract
INTRODUCTION The Enhanced Recovery After Surgery programme (ERAS) is an approach to the perioperative care of patients encompassing multiple interventions and involving a wide range of different actors. It can thus be defined as a complex intervention. Despite the strength of the evidence-base in its support, the implementation of ERAS has been slow. This paper specifically explores the utility of Normalization Process Theory (NPT) as a methodological framework to aid exploration of ERAS implementation, with a focus on the core NPT construct coherence. METHODS AND MATERIALS The study employed qualitative methods guided by NPT. Semi-structured interviews were conducted with twenty-six healthcare professionals working in three specialities (thoracic, colorectal, head and neck) in a UK hospital. Data were analysed using an adapted Framework Approach. RESULTS Coherence, or sense-making work, was key to successful implementation and demonstrated in the importance of participants believing in ERAS both as an individual and as a team. In order to invest in ERAS individuals needed to be able to differentiate its practices favourably with those enacted pre-implementation (differentiation). Participants also needed to understand their specific tasks and responsibilities (individual specification) and build a shared understanding (communal specification), resolving differences in planning meetings. Belief in the worth of ERAS was often aligned to evidence for its effectiveness or benefit to patients (internalization), so implementing ERAS therefore 'made sense'. Sense-making work had strong links with aspects of implementation related to other NPT constructs including resource issues such as funding for data collection and feedback (reflexive monitoring: systemization) and failure to replace key staff members (collective action: skill set workability). CONCLUSIONS NPT was found to be a valuable heuristic device to employ in the exploration of ERAS implementation processes. NPT was useful in facilitating recognition of the importance of coherence work to successful implementation. However despite participants' strong beliefs in the worth of ERAS, it was in translating these beliefs into action that barriers were encountered, highlighting the interconnectedness of NPT constructs and the complicated nature of implementing complex interventions.
Collapse
|
31
|
Pals RAS, Hempler NF. How to achieve a collaborative approach in health promotion: preferences and ideas of users of mental health services. Scand J Caring Sci 2018; 32:1188-1196. [DOI: 10.1111/scs.12564] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2017] [Accepted: 01/10/2018] [Indexed: 01/15/2023]
Affiliation(s)
| | - Nana Folmann Hempler
- Diabetes Management Research; Steno Diabetes Center Copenhagen; Gentofte Denmark
| |
Collapse
|
32
|
Pentecost C, Richards DA, Frost J. Amalgamation of Marginal Gains (AMG) as a potential system to deliver high-quality fundamental nursing care: A qualitative analysis of interviews from high-performance AMG sports and healthcare practitioners. J Clin Nurs 2018; 27:2387-2402. [DOI: 10.1111/jocn.14186] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/15/2017] [Indexed: 01/28/2023]
Affiliation(s)
- Claire Pentecost
- Institute of Health Research; University of Exeter Medical School; South Cloisters Exeter UK
| | - David A. Richards
- Institute of Health Research; University of Exeter Medical School; South Cloisters Exeter UK
| | - Julia Frost
- Institute of Health Research; University of Exeter Medical School; South Cloisters Exeter UK
| |
Collapse
|
33
|
Mitchell AJ, Hardy S, Shiers D. Parity of esteem: Addressing the inequalities between mental and physical healthcare. BJPSYCH ADVANCES 2018. [DOI: 10.1192/apt.bp.114.014266] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
SummaryParity of esteem means valuing mental health as much as physical health in order to close inequalities in mortality, morbidity or delivery of care. There is clear evidence that patients with mental illness receive inferior medical, surgical and preventive care. This further exacerbated by low help-seeking, high stigma, medication side-effects and relatively low resources in mental healthcare. As a result, patients with severe mental illness die 10–20 years prematurely and have a high rate of cardiometabolic complications and other physical illnesses. Many physical healthcare guidelines and policy recommendations address parity of esteem, but their implementation to date has been poor. All clinicians should be aware that inequalities in care are adversely influencing mental health outcomes, and managers, healthcare organisations and politicians should provide resources and education to address this gap.Learning Objectives• Understand the concept of parity of esteem• Be aware of the current inequalities in mental healthcare• Appreciate how parity of esteem may be improved
Collapse
|
34
|
Guthrie E, Afzal C, Blakeley C, Blakemore A, Byford R, Camacho E, Chan T, Chew-Graham C, Davies L, de Lusignan S, Dickens C, Drinkwater J, Dunn G, Hunter C, Joy M, Kapur N, Langer S, Lovell K, Macklin J, Mackway-Jones K, Ntais D, Salmon P, Tomenson B, Watson J. CHOICE: Choosing Health Options In Chronic Care Emergencies. PROGRAMME GRANTS FOR APPLIED RESEARCH 2017. [DOI: 10.3310/pgfar05130] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BackgroundOver 70% of the health-care budget in England is spent on the care of people with long-term conditions (LTCs), and a major cost component is unscheduled health care. Psychological morbidity is high in people with LTCs and is associated with a range of adverse outcomes, including increased mortality, poorer physical health outcomes, increased health costs and service utilisation.ObjectivesThe aim of this programme of research was to examine the relationship between psychological morbidity and use of unscheduled care in people with LTCs, and to develop a psychosocial intervention that would have the potential to reduce unscheduled care use. We focused largely on emergency hospital admissions (EHAs) and attendances at emergency departments (EDs).DesignA three-phase mixed-methods study. Research methods included systematic reviews; a longitudinal prospective cohort study in primary care to identify people with LTCs at risk of EHA or ED admission; a replication study in primary care using routinely collected data; an exploratory and feasibility cluster randomised controlled trial in primary care; and qualitative studies to identify personal reasons for the use of unscheduled care and factors in routine consultations in primary care that may influence health-care use. People with lived experience of LTCs worked closely with the research team.SettingPrimary care. Manchester and London.ParticipantsPeople aged ≥ 18 years with at least one of four common LTCs: asthma, coronary heart disease, chronic obstructive pulmonary disease (COPD) and diabetes. Participants also included health-care staff.ResultsEvidence synthesis suggested that depression, but not anxiety, is a predictor of use of unscheduled care in patients with LTCs, and low-intensity complex interventions reduce unscheduled care use in people with asthma and COPD. The results of the prospective study were that depression, not having a partner and life stressors, in addition to prior use of unscheduled care, severity of illness and multimorbidity, were independent predictors of EHA and ED admission. Approximately half of the cost of health care for people with LTCs was accounted for by use of unscheduled care. The results of the replication study, carried out in London, broadly supported our findings for risk of ED attendances, but not EHAs. This was most likely due to low rates of detection of depression in general practitioner (GP) data sets. Qualitative work showed that patients were reluctant to use unscheduled care, deciding to do so when they perceived a serious and urgent need for care, and following previous experience that unscheduled care had successfully and unquestioningly met similar needs in the past. In general, emergency and primary care doctors did not regard unscheduled care as problematic. We found there are missed opportunities to identify and discuss psychosocial issues during routine consultations in primary care due to the ‘overmechanisation’ of routine health-care reviews. The feasibility trial examined two levels of an intervention for people with COPD: we tried to improve the way in which practices manage patients with COPD and developed a targeted psychosocial treatment for patients at risk of using unscheduled care. The former had low acceptability, whereas the latter had high acceptability. Exploratory health economic analyses suggested that the practice-level intervention would be unlikely to be cost-effective, limiting the value of detailed health economic modelling.LimitationsThe findings of this programme may not apply to all people with LTCs. It was conducted in an area of high social deprivation, which may limit the generalisability to more affluent areas. The response rate to the prospective longitudinal study was low. The feasibility trial focused solely on people with COPD.ConclusionsPrior use of unscheduled care is the most powerful predictor of unscheduled care use in people with LTCs. However, psychosocial factors, particularly depression, are important additional predictors of use of unscheduled care in patients with LTCs, independent of severity and multimorbidity. Patients and health-care practitioners are unaware that psychosocial factors influence health-care use, and such factors are rarely acknowledged or addressed in consultations or discussions about use of unscheduled care. A targeted patient intervention for people with LTCs and comorbid depression has shown high levels of acceptability when delivered in a primary care context. An intervention at the level of the GP practice showed little evidence of acceptability or cost-effectiveness.Future workThe potential benefits of case-finding for depression in patients with LTCs in primary care need to be evaluated, in addition to further evaluation of the targeted patient intervention.FundingThe National Institute for Health Research Programme Grants for Applied Research programme.
Collapse
Affiliation(s)
- Elspeth Guthrie
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Cara Afzal
- Manchester Mental Health and Social Care Trust, Manchester Royal Infirmary, Manchester, UK
- Greater Manchester Academic Health Science Network (GM AHSN), Manchester, UK
| | - Claire Blakeley
- Manchester Mental Health and Social Care Trust, Manchester Royal Infirmary, Manchester, UK
- Manchester Academic Health Science Centre, Manchester, UK
| | - Amy Blakemore
- Manchester Academic Health Science Centre, Manchester, UK
- Centre for Primary Care, Institute of Population Health, University of Manchester, Manchester, UK
| | - Rachel Byford
- Department of Health Care Management and Policy, University of Surrey, Guildford, UK
| | - Elizabeth Camacho
- Manchester Academic Health Science Centre, Manchester, UK
- Centre for Health Economics, Institute for Population Health, University of Manchester, Manchester, UK
| | - Tom Chan
- Department of Health Care Management and Policy, University of Surrey, Guildford, UK
| | - Carolyn Chew-Graham
- Research Institute, Primary Care and Health Sciences, Keele University, Keele, UK
| | - Linda Davies
- Centre for Health Economics, Institute for Population Health, University of Manchester, Manchester, UK
| | - Simon de Lusignan
- Centre for Primary Care, Institute of Population Health, University of Manchester, Manchester, UK
| | - Chris Dickens
- Institute of Health Research, Medical School, University of Exeter, Exeter, UK
- Peninsula Collaboration for Leadership in Health Research and Care (PenCLAHRC), University of Exeter, Exeter, UK
| | | | - Graham Dunn
- Manchester Academic Health Science Centre, Manchester, UK
- Centre for Biostatistics, Institute of Population Health, University of Manchester, Manchester, UK
| | - Cheryl Hunter
- Health Services Research Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Mark Joy
- Faculty of Science, Engineering and Computing, Kingston University, London, UK
| | - Navneet Kapur
- Manchester Academic Health Science Centre, Manchester, UK
- Institute of Brain, Behaviour and Mental Health, University of Manchester, Manchester, UK
| | - Susanne Langer
- Department of Psychology, Manchester Metropolitan University, Manchester, UK
| | - Karina Lovell
- Manchester Academic Health Science Centre, Manchester, UK
- School of Nursing, Midwifery and Social Work, University of Manchester, Manchester, UK
| | | | - Kevin Mackway-Jones
- Manchester Academic Health Science Centre, Manchester, UK
- Central Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - Dionysios Ntais
- Manchester Academic Health Science Centre, Manchester, UK
- Centre for Health Economics, Institute for Population Health, University of Manchester, Manchester, UK
| | - Peter Salmon
- Department of Psychological Sciences, University of Liverpool, Liverpool, UK
| | - Barbara Tomenson
- Manchester Academic Health Science Centre, Manchester, UK
- Centre for Biostatistics, Institute of Population Health, University of Manchester, Manchester, UK
| | - Jennifer Watson
- Manchester Mental Health and Social Care Trust, Manchester Royal Infirmary, Manchester, UK
- Manchester Academic Health Science Centre, Manchester, UK
| |
Collapse
|
35
|
O’Reilly P, Lee SH, O’Sullivan M, Cullen W, Kennedy C, MacFarlane A. Assessing the facilitators and barriers of interdisciplinary team working in primary care using normalisation process theory: An integrative review. PLoS One 2017; 12:e0177026. [PMID: 28545038 PMCID: PMC5436644 DOI: 10.1371/journal.pone.0177026] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2016] [Accepted: 03/24/2017] [Indexed: 11/19/2022] Open
Abstract
Background Interdisciplinary team working is of paramount importance in the reform of primary care in order to provide cost-effective and comprehensive care. However, international research shows that it is not routine practice in many healthcare jurisdictions. It is imperative to understand levers and barriers to the implementation process. This review examines interdisciplinary team working in practice, in primary care, from the perspective of service providers and analyses 1 barriers and facilitators to implementation of interdisciplinary teams in primary care and 2 the main research gaps. Methods and findings An integrative review following the PRISMA guidelines was conducted. Following a search of 10 international databases, 8,827 titles were screened for relevance and 49 met the criteria. Quality of evidence was appraised using predetermined criteria. Data were analysed following the principles of framework analysis using Normalisation Process Theory (NPT), which has four constructs: sense making, enrolment, enactment, and appraisal. The literature is dominated by a focus on interdisciplinary working between physicians and nurses. There is a dearth of evidence about all NPT constructs apart from enactment. Physicians play a key role in encouraging the enrolment of others in primary care team working and in enabling effective divisions of labour in the team. The experience of interdisciplinary working emerged as a lever for its implementation, particularly where communication and respect were strong between professionals. Conclusion A key lever for interdisciplinary team working in primary care is to get professionals working together and to learn from each other in practice. However, the evidence base is limited as it does not reflect the experiences of all primary care professionals and it is primarily about the enactment of team working. We need to know much more about the experiences of the full network of primary care professionals regarding all aspects of implementation work. Systematic review registration International Prospective Register of Systematic Reviews PROSPERO 2015: CRD42015019362.
Collapse
Affiliation(s)
- Pauline O’Reilly
- Department of Nursing and Midwifery, Faculty of Education and Health Sciences, University of Limerick, Limerick, Republic of Ireland
- * E-mail:
| | - Siew Hwa Lee
- School of Nursing and Midwifery, Robert Gordon University, Aberdeen, United Kingdom
| | - Madeleine O’Sullivan
- Graduate Entry Medical School (GEMS), Faculty of Education and Health Sciences & Health Research Institute, University of Limerick, Limerick, Republic of Ireland
| | - Walter Cullen
- School of Medicine and Medical Sciences, University College Dublin, Dublin, Republic of Ireland
| | - Catriona Kennedy
- School of Nursing and Midwifery, Robert Gordon University, Aberdeen, United Kingdom
| | - Anne MacFarlane
- Graduate Entry Medical School (GEMS), Faculty of Education and Health Sciences & Health Research Institute, University of Limerick, Limerick, Republic of Ireland
| |
Collapse
|
36
|
Wood E, Ohlsen S, Ricketts T. What are the barriers and facilitators to implementing Collaborative Care for depression? A systematic review. J Affect Disord 2017; 214:26-43. [PMID: 28266319 DOI: 10.1016/j.jad.2017.02.028] [Citation(s) in RCA: 56] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2016] [Revised: 01/26/2017] [Accepted: 02/13/2017] [Indexed: 10/20/2022]
Abstract
BACKGROUND Collaborative Care is an evidence-based approach to the management of depression within primary care services recommended within NICE Guidance. However, uptake within the UK has been limited. This review aims to investigate the barriers and facilitators to implementing Collaborative Care. METHODS A systematic review of the literature was undertaken to uncover what barriers and facilitators have been reported by previous research into Collaborative Care for depression in primary care. RESULTS The review identified barriers and facilitators to successful implementation of Collaborative Care for depression in 18 studies across a range of settings. A framework analysis was applied using the Collaborative Care definition. The most commonly reported barriers related to the multi-professional approach, such as staff and organisational attitudes to integration, and poor inter-professional communication. Facilitators to successful implementation particularly focussed on improving inter-professional communication through standardised care pathways and case managers with clear role boundaries and key underpinning personal qualities. LIMITATIONS Not all papers were independent title and abstract screened by multiple reviewers thus limiting the reliability of the selected studies. There are many different frameworks for assessing the quality of qualitative research and little consensus as to which is most appropriate in what circumstances. The use of a quality threshold led to the exclusion of six papers that could have included further information on barriers and facilitators. CONCLUSIONS Although the evidence base for Collaborative Care is strong, and the population within primary care with depression is large, the preferred way to implement the approach has not been identified.
Collapse
Affiliation(s)
- Emily Wood
- School of Health and Related Research, The University of Sheffield, Regent Court, 30 Regent Street, Sheffield S1 4DA, United Kingdom.
| | - Sally Ohlsen
- School of Health and Related Research, The University of Sheffield, Regent Court, 30 Regent Street, Sheffield S1 4DA, United Kingdom
| | - Thomas Ricketts
- School of Health and Related Research, The University of Sheffield, Regent Court, 30 Regent Street, Sheffield S1 4DA, United Kingdom; Sheffield Health and Social Care NHS FT, St George's Community Health Centre, Winter Street, Sheffield S3 7ND, United Kingdom
| |
Collapse
|
37
|
Motta CCLD, Moré CLOO, Nunes CHSDS. Psychological assistance provided to patients diagnosed with depression in primary care. CIENCIA & SAUDE COLETIVA 2017; 22:911-920. [PMID: 28300998 DOI: 10.1590/1413-81232017223.27982015] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2015] [Accepted: 04/16/2016] [Indexed: 11/21/2022] Open
Abstract
The scope of this research was to understand the assistance provided by psychologists to patients diagnosed with depression in the municipal health care network. In this study, the phenomenon is examined from its broader perspective, taking the psychosocial dimensions of health into account. A group of 22 psychologists participated in this study of a qualitative nature. Data collection began with participant in-field observation of the institutional context followed by semi-structured interviews. Grounded theory methodology was used to analyze information, thereby facilitating its integration and categorization.The results revealed that in the primary care network the treatment of depression is essentially restricted to its biological aspect; the choice of individual psychotherapy as the main form of treatment refers to traditional practices of psychological care for depression; the use of institutional and community methods as part of the therapeutic approach suggests mental health interventions that address the psychosocial dimension. The findings indicate that transcending the traditional models of care for patients with depression and the construction of forms of treatment using psychosocial resources are ongoing, indicating that comprehensive care needs to be further consolidated in primary care.
Collapse
Affiliation(s)
- Cibele Cunha Lima da Motta
- Departamento de Psicologia, Universidade Federal de Santa Catarina. Campus Universitário Laboratorio de Psicologia da Saúde, Família e Comunidade/Sala 10B, Trindade. 88040-970 Florianopolis SC Brasil.
| | - Carmen Leontina Ojeda Ocampo Moré
- Departamento de Psicologia, Universidade Federal de Santa Catarina. Campus Universitário Laboratorio de Psicologia da Saúde, Família e Comunidade/Sala 10B, Trindade. 88040-970 Florianopolis SC Brasil.
| | - Carlos Henrique Sancineto da Silva Nunes
- Departamento de Psicologia, Universidade Federal de Santa Catarina. Campus Universitário Laboratorio de Psicologia da Saúde, Família e Comunidade/Sala 10B, Trindade. 88040-970 Florianopolis SC Brasil.
| |
Collapse
|
38
|
Athié K, Dowrick C, Menezes ALDA, Cruz L, Lima AC, Delgado PGG, Favoretto C, Fortes S. Anxious and depressed women's experiences of emotional suffering and help seeking in a Rio de Janeiro favela. CIENCIA & SAUDE COLETIVA 2017; 22:75-86. [PMID: 28076531 DOI: 10.1590/1413-81232017221.11732016] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2016] [Accepted: 08/12/2016] [Indexed: 12/14/2022] Open
Abstract
Taking into consideration issues such as stigma and the mental health gap, this study explores narratives of anxious and depressed women treated in a community-based primary care service in a Rio de Janeiro favela about their suffering and care. We analysed 13 in-depth interviews using questions from Kadam's study. Framework analysis studied Access, Gateway, Trust, Psychosocial Issues, and Primary Mental Health Care, as key-concepts. Vulnerability and accessibility were the theoretical references. Thematic analysis found "suffering category", highlighting family and community problems, and "help seeking category", indicating how these women have coped with their emotional problems and addressed their needs through health services, community resources and self-help. Women's language patterns indicated links between implicit social rules and constraints to talk about suffering, especially if related to local violence. High medical turnover and overload are barriers for establishing a positive relationship with family physicians and continuity of care is a facilitator that promotes trust, security and adherence. Concluding, to plan community-based primary mental health care of this population, cultural and social factors must be comprehended as well as the work health teams conditions.
Collapse
Affiliation(s)
- Karen Athié
- Laboratório Interdisciplinar de Pesquisa em Atenção Primária à Saúde, Pós-Graduação em Ciências Médicas, Universidade do Estado do Rio de Janeiro. Boulevard Vinte e Oito de Setembro 77, Vila Isabel. 20551-030 Rio de Janeiro RJ Brasil.
| | - Christopher Dowrick
- Institute of Psychology Health and Society, University of Liverpool. Liverpool Inglaterra
| | - Alice Lopes do Amaral Menezes
- Laboratório Interdisciplinar de Pesquisa em Atenção Primária à Saúde, Pós-Graduação em Ciências Médicas, Universidade do Estado do Rio de Janeiro. Boulevard Vinte e Oito de Setembro 77, Vila Isabel. 20551-030 Rio de Janeiro RJ Brasil.
| | - Luanda Cruz
- Laboratório Interdisciplinar de Pesquisa em Atenção Primária à Saúde, Pós-Graduação em Ciências Médicas, Universidade do Estado do Rio de Janeiro. Boulevard Vinte e Oito de Setembro 77, Vila Isabel. 20551-030 Rio de Janeiro RJ Brasil.
| | - Ana Cristina Lima
- Laboratório Interdisciplinar de Pesquisa em Atenção Primária à Saúde, Pós-Graduação em Ciências Médicas, Universidade do Estado do Rio de Janeiro. Boulevard Vinte e Oito de Setembro 77, Vila Isabel. 20551-030 Rio de Janeiro RJ Brasil.
| | - Pedro Gabriel Godinho Delgado
- Núcleo de Políticas Públicas em Saúde Mental (NUPPSAM), Universidade Federal do Rio de Janeiro. Rio de Janeiro RJ Brasil
| | - Cesar Favoretto
- Laboratório Interdisciplinar de Pesquisa em Atenção Primária à Saúde, Pós-Graduação em Ciências Médicas, Universidade do Estado do Rio de Janeiro. Boulevard Vinte e Oito de Setembro 77, Vila Isabel. 20551-030 Rio de Janeiro RJ Brasil.
| | - Sandra Fortes
- Laboratório Interdisciplinar de Pesquisa em Atenção Primária à Saúde, Pós-Graduação em Ciências Médicas, Universidade do Estado do Rio de Janeiro. Boulevard Vinte e Oito de Setembro 77, Vila Isabel. 20551-030 Rio de Janeiro RJ Brasil.
| |
Collapse
|
39
|
Overbeck G, Davidsen AS, Kousgaard MB. Enablers and barriers to implementing collaborative care for anxiety and depression: a systematic qualitative review. Implement Sci 2016; 11:165. [PMID: 28031028 PMCID: PMC5192575 DOI: 10.1186/s13012-016-0519-y] [Citation(s) in RCA: 79] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2016] [Accepted: 11/01/2016] [Indexed: 12/26/2022] Open
Abstract
Background Collaborative care is an increasingly popular approach for improving quality of care for people with mental health problems through an intensified and structured collaboration between primary care providers and health professionals with specialized psychiatric expertise. Trials have shown significant positive effects for patients suffering from depression, but since collaborative care is a complex intervention, it is important to understand the factors which affect its implementation. We present a qualitative systematic review of the enablers and barriers to implementing collaborative care for patients with anxiety and depression. Methods We developed a comprehensive search strategy in cooperation with a research librarian and performed a search in five databases (EMBASE, PubMed, PsycINFO, ProQuest, and CINAHL). All authors independently screened titles and abstracts and reviewed full-text articles. Studies were included if they were published in English and based on the original qualitative data on the implementation of a collaborative care intervention targeted at depression or anxiety in an adult patient population in a high-income country. Our subsequent analysis employed the normalization process theory (NPT). Results We included 17 studies in our review of which 11 were conducted in the USA, five in the UK, and one in Canada. We identified several barriers and enablers within the four major analytical dimensions of NPT. Securing buy-in among primary care providers was found to be critical but sometimes difficult. Enablers included physician champions, reimbursement for extra work, and feedback on the effectiveness of collaborative care. The social and professional skills of the care managers seemed critical for integrating collaborative care in the primary health care clinic. Day-to-day implementation was also found to be facilitated by the care managers being located in the clinic since this supports regular face-to-face interactions between physicians and care managers. Conclusions The following areas require special attention when planning collaborative care interventions: effective educational programs, especially for care managers; issues of reimbursement in relation to primary care providers; good systems for communication and monitoring; and promoting face-to-face interaction between care managers and physicians, preferably through co-location. There is a need for well-sampled, in-depth qualitative studies on the implementation of collaborative care in settings outside the USA and the UK. Electronic supplementary material The online version of this article (doi:10.1186/s13012-016-0519-y) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Gritt Overbeck
- The Research Unit for General Practice and Section of General Practice, Institute of Public Health, University of Copenhagen, København, Denmark.
| | - Annette Sofie Davidsen
- The Research Unit for General Practice and Section of General Practice, Institute of Public Health, University of Copenhagen, København, Denmark
| | - Marius Brostrøm Kousgaard
- The Research Unit for General Practice and Section of General Practice, Institute of Public Health, University of Copenhagen, København, Denmark
| |
Collapse
|
40
|
Athié K, Menezes ALDA, da Silva AM, Campos M, Delgado PG, Fortes S, Dowrick C. Perceptions of health managers and professionals about mental health and primary care integration in Rio de Janeiro: a mixed methods study. BMC Health Serv Res 2016; 16:532. [PMID: 27716299 PMCID: PMC5045579 DOI: 10.1186/s12913-016-1740-8] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2015] [Accepted: 09/06/2016] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Community-based primary mental health care is recommended in low and middle-income countries. The Brazilian Health System has been restructuring primary care by expanding its Family Health Strategy. Due to mental health problems, psychosocial vulnerability and accessibility, Matrix Support teams are being set up to broaden the professional scope of primary care. This paper aims to analyse the perceptions of health professionals and managers about the integration of primary care and mental health. METHOD In this mixed-method study 18 health managers and 24 professionals were interviewed from different primary and mental health care services in Rio de Janeiro. A semi-structured survey was conducted with 185 closed questions ranging from 1 to 5 and one open-ended question, to evaluate: access, gateway, trust, family focus, primary mental health interventions, mental health records, mental health problems, team collaboration, integration with community resources and primary mental health education. Two comparisons were made: health managers and professionals' (Mann-Whitney non-parametric test) and health managers' perceptions (Kruskall-Wallis non parametric-test) in 4 service designs (General Traditional Outpatients, Mental Health Specialised Outpatients, Psychosocial Community Centre and Family Health Strategy)(SPSS version 17.0). Qualitative data were subjected to Framework Analysis. RESULTS Firstly, health managers and professionals' perceptions converged in all components, except the health record system. Secondly, managers' perceptions in traditional services contrasted with managers' perceptions in community-based services in components such as mental health interventions and team collaboration, and converged in gateway, trust, record system and primary mental health education. Qualitative data revealed an acceptance of mental health and primary care integration, but a lack of communication between institutions. The Mixed Method demonstrated that interviewees consider mental health and primary care integration as a requirement of the system, while their perceptions and the model of work produced by the institutional culture are inextricably linked. CONCLUSION There is a gap between health managers' and professionals' understanding of community-based primary mental health care. The integration of different processes of work entails both rethinking workforce actions and institutional support to help make changes.
Collapse
Affiliation(s)
- Karen Athié
- Programa de Pós Graduação em Ciências Médicas/ Faculdade de Ciências Médicas, Universidade do Estado do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Alice Lopes do Amaral Menezes
- Laboratório Interdisciplinar em Atenção Primária à Saúde/LIPAPS/Faculdade de Ciências Médicas, Universidade do Estado do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Angela Machado da Silva
- Laboratório Interdisciplinar em Atenção Primária à Saúde/LIPAPS/Faculdade de Ciências Médicas, Universidade do Estado do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Monica Campos
- Escola Nacional de Saúde Pública, Fundação Oswaldo Cruz, Rio de Janeiro, Brazil
| | - Pedro Gabriel Delgado
- Núcleo de Pesquisas em Políticas Públicas de Saúde Mental/ Instituto de Psiquiatria da Universidade do Brasil, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Sandra Fortes
- Laboratório Interdisciplinar em Atenção Primária à Saúde/LIPAPS/Faculdade de Ciências Médicas, Universidade do Estado do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Christopher Dowrick
- Institute of Psychology Health and Society, University of Liverpool, Liverpool, UK
| |
Collapse
|
41
|
Roberge P, Hudon C, Pavilanis A, Beaulieu MC, Benoit A, Brouillet H, Boulianne I, De Pauw A, Frigon S, Gaboury I, Gaudreault M, Girard A, Giroux M, Grégoire É, Langlois L, Lemieux M, Loignon C, Vanasse A. A qualitative study of perceived needs and factors associated with the quality of care for common mental disorders in patients with chronic diseases: the perspective of primary care clinicians and patients. BMC FAMILY PRACTICE 2016; 17:134. [PMID: 27620166 PMCID: PMC5020556 DOI: 10.1186/s12875-016-0531-y] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/18/2016] [Accepted: 09/01/2016] [Indexed: 12/21/2022]
Abstract
BACKGROUND The prevalence of comorbid anxiety and depressive disorders is high among patients with chronic diseases in primary care, and is associated with increased morbidity and mortality rates. The detection and treatment of common mental disorders in patients with chronic diseases can be challenging in the primary care setting. This study aims to explore the perceived needs, barriers and facilitators for the delivery of mental health care for patients with coexisting common mental disorders and chronic diseases in primary care from the clinician and patient perspectives. METHODS In this qualitative descriptive study, we conducted semi-structured interviews with clinicians (family physician, nurse, psychologist, social worker; n = 18) and patients (n = 10) from three primary care clinics in Quebec, Canada. The themes explored included clinician factors (e.g., attitudes, perception of roles, collaboration, management of clinical priorities) and patient factors (e.g., needs, preferences, access to care, communication with health professionals) associated with the delivery of care. Qualitative data analysis was conducted based on an interactive cyclical process of data reduction, data display and conclusion drawing and verification. RESULTS Clinician interviews highlighted a number of needs, barriers and enablers in the provision of patient services, which related to inter-professional collaboration, access to psychotherapy, polypharmacy as well as communication and coordination of services within the primary care clinic and the local network. Two specific facilitators associated with optimal mental health care were the broadening of nurses' functions in mental health care and the active integration of consulting psychiatrists. Patients corroborated the issues raised by the clinicians, particularly in the domains of whole-person care, service accessibility and care management. CONCLUSIONS The results of this project will contribute to the development of quality improvement interventions to increase the uptake of organizational and clinical evidence-based practices for patients with chronic diseases and concurrent common mental disorders, in priority areas including collaborative care, access to psychotherapy and linkages with specialized mental health care.
Collapse
Affiliation(s)
- Pasquale Roberge
- Department of Family Medicine and Emergency Medicine, Université de Sherbrooke, 3001, 12th Avenue North, Sherbrooke, QC Canada
- Université de Sherbrooke - Campus de la santé, Groupe de recherche PRIMUS, 3001, 12e avenue nord, Sherbrooke, QC J1H 5N4 Canada
| | - Catherine Hudon
- Department of Family Medicine and Emergency Medicine, Université de Sherbrooke, 3001, 12th Avenue North, Sherbrooke, QC Canada
- Université de Sherbrooke - Campus de la santé, Groupe de recherche PRIMUS, 3001, 12e avenue nord, Sherbrooke, QC J1H 5N4 Canada
| | - Alan Pavilanis
- St. Mary’s Hospital Center, 3830 Lacombe Avenue, Montreal, QC Canada
| | - Marie-Claude Beaulieu
- Department of Family Medicine and Emergency Medicine, Université de Sherbrooke, 3001, 12th Avenue North, Sherbrooke, QC Canada
| | - Annie Benoit
- Department of Family Medicine and Emergency Medicine, Université de Sherbrooke, 3001, 12th Avenue North, Sherbrooke, QC Canada
| | - Hélène Brouillet
- CISSS de la Montérégie-Est, 90 Sainte-Foy Boulevard, Longueuil, QC Canada
| | - Isabelle Boulianne
- Université de Sherbrooke, UMF Chicoutimi, 305, St-Vallier, Chicoutimi, QC Canada
| | - Anna De Pauw
- St. Mary’s Hospital Center, 3830 Lacombe Avenue, Montreal, QC Canada
| | - Serge Frigon
- Department of Family Medicine and Emergency Medicine, Université de Sherbrooke, 3001, 12th Avenue North, Sherbrooke, QC Canada
| | - Isabelle Gaboury
- Department of Family Medicine and Emergency Medicine, Université de Sherbrooke, 3001, 12th Avenue North, Sherbrooke, QC Canada
- Université de Sherbrooke - Campus de la santé, Groupe de recherche PRIMUS, 3001, 12e avenue nord, Sherbrooke, QC J1H 5N4 Canada
| | - Martine Gaudreault
- Université de Sherbrooke, UMF Chicoutimi, 305, St-Vallier, Chicoutimi, QC Canada
| | - Ariane Girard
- Université du Québec à Chicoutimi, 555, Boulevard de l’Université, Chicoutimi, QC Canada
| | - Marie Giroux
- Department of Family Medicine and Emergency Medicine, Université de Sherbrooke, 3001, 12th Avenue North, Sherbrooke, QC Canada
| | - Élyse Grégoire
- Department of Family Medicine and Emergency Medicine, Université de Sherbrooke, 3001, 12th Avenue North, Sherbrooke, QC Canada
| | - Line Langlois
- Department of Family Medicine and Emergency Medicine, Université de Sherbrooke, 3001, 12th Avenue North, Sherbrooke, QC Canada
| | - Martin Lemieux
- Department of Family Medicine and Emergency Medicine, Université de Sherbrooke, 3001, 12th Avenue North, Sherbrooke, QC Canada
| | - Christine Loignon
- Department of Family Medicine and Emergency Medicine, Université de Sherbrooke, 3001, 12th Avenue North, Sherbrooke, QC Canada
| | - Alain Vanasse
- Department of Family Medicine and Emergency Medicine, Université de Sherbrooke, 3001, 12th Avenue North, Sherbrooke, QC Canada
- Université de Sherbrooke - Campus de la santé, Groupe de recherche PRIMUS, 3001, 12e avenue nord, Sherbrooke, QC J1H 5N4 Canada
| |
Collapse
|
42
|
Dale H, Lee A. Behavioural health consultants in integrated primary care teams: a model for future care. BMC FAMILY PRACTICE 2016; 17:97. [PMID: 27473414 PMCID: PMC4966805 DOI: 10.1186/s12875-016-0485-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/16/2015] [Accepted: 07/13/2016] [Indexed: 12/30/2022]
Abstract
BACKGROUND Significant challenges exist within primary care services in the United Kingdom (UK). These include meeting current demand, financial pressures, an aging population and an increase in multi-morbidity. Psychological services also struggle to meet waiting time targets and to ensure increased access to psychological therapies. Innovative ways of delivering effective primary care and psychological services are needed to improve health outcomes. In this article we argue that integrated care models that incorporate behavioural health care are part of the solution, which has seldom been argued in relation to UK primary care. Integrated care involves structural and systemic changes to the delivery of services, including the co-location of multi-disciplinary primary care teams. Evidence from models of integrated primary care in the United States of America (USA) and other higher-income countries suggest that embedding continuity of care and collaborative practice within integrated care teams can be effective in improving health outcomes. The Behavioural Health Consultant (BHC) role is integral to this, working psychologically to support the team to improve collaborative working, and supporting patients to make changes to improve their health across management of long-term conditions, prevention and mental wellbeing. Patients' needs for higher-intensity interventions to enable changes in behaviour and self-management are, therefore, more fully met within primary care. The role also increases accessibility of psychological services, delivers earlier interventions and reduces stigma, since psychological staff are seen as part of the core primary care service. Although the UK has trialled a range of approaches to integrated care, these fall short of the highest level of integration. A single short pilot of integrated care in the UK showed positive results. Larger pilots with robust evaluation, as well as research trials are required. There are clearly challenges in adopting such an approach, especially for staff who must adapt to working more collaboratively with each other and patients. Strong leadership is needed to assist in this, particularly to support organisations to adopt the shift in values and attitudes towards collaborative working. CONCLUSIONS Integrated primary care services that embed behavioural health as part of a multi-disciplinary team may be part of the solution to significant modern day health challenges. However, developing this model is unlikely to be straight-forward given current primary care structures and ways of working. The discussion, developed in this article, adds to our understanding of what the BHC role might consist off and how integrated care may be supported by such behavioural health expertise. Further work is needed to develop this model in the UK, and to evaluate its impact on health outcomes and health care utilisation, and test robustly through research trials.
Collapse
Affiliation(s)
- Hannah Dale
- NHS Fife, Department of Psychology, Lynebank Hospital, Halbeath Road, Dunfermline, KY11 4UW, UK.
- School of Medicine, Medical and Biological Sciences Building, University of St Andrews, North Haugh, St Andrews, Fife, KY16 9TF, UK.
| | - Alyssa Lee
- School of Medicine, Medical and Biological Sciences Building, University of St Andrews, North Haugh, St Andrews, Fife, KY16 9TF, UK
| |
Collapse
|
43
|
Bayliss K, Riste L, Band R, Peters S, Wearden A, Lovell K, Fisher L, Chew-Graham CA. Implementing resources to support the diagnosis and management of Chronic Fatigue Syndrome/Myalgic Encephalomyelitis (CFS/ME) in primary care: A qualitative study. BMC FAMILY PRACTICE 2016; 17:66. [PMID: 27259658 PMCID: PMC4893302 DOI: 10.1186/s12875-016-0453-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/03/2015] [Accepted: 05/09/2016] [Indexed: 11/30/2022]
Abstract
Background Previous research has highlighted that many GPs lack the confidence and knowledge to diagnose and manage people with CFS/ME. Following the development of an online training module for GPs, and an information pack and DVD for patients, this study explored the extent to which these resources can be implemented in routine primary care. Methods Semi structured qualitative interviews were completed with patients and GPs across North West England. All interviews were transcribed and analysed using open exploratory thematic coding. Following this thematic analysis, the authors conducted a further theory-driven analysis of the data guided by Normalisation Process Theory. Results When used in line with advice from the research team, the information resource and training were perceived as beneficial to both patients and GPs in the diagnosis and management of CFS/ME. However, 47 % of patients in this study did not receive the information pack from their GP. When the information pack was used, it was often incomplete, sent in the post, and GPs did not work with patients to discuss the materials. Only13 out of 21 practices completed the training module due to time pressures and the low priority placed on low prevalence, contentious, hard to manage conditions. When the module was completed, many GPs stated that it was not feasible to retain the key messages as they saw so few patients with the condition. Due to the complexity of the condition, GPs also believed that the diagnosis and management of CFS/ME should take place in a specialist care setting. Conclusion While barriers to the implementation of training and resources for CFS/ME remain, there is a need to support CFS/ME patients to access reliable, evidence based information outside primary care. Our findings suggest that future research should develop an online resource for patients to support self-management. Electronic supplementary material The online version of this article (doi:10.1186/s12875-016-0453-8) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Kerin Bayliss
- Public Programmes, Central Manchester University Hospitals NHS Foundation Trust, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK.
| | - Lisa Riste
- Centre for Primary Care, Institute of Population Health, University of Manchester, Manchester, UK
| | - Rebecca Band
- School of Psychology, University of Southampton, Southampton, UK
| | - Sarah Peters
- School of Psychological Sciences, University of Manchester, Manchester, UK
| | - Alison Wearden
- School of Psychological Sciences, University of Manchester, Manchester, UK
| | - Karina Lovell
- School of Nursing, Midwifery and Social Work, University of Manchester, Manchester, UK
| | - Louise Fisher
- National School for Primary Care Research, University of Manchester, Manchester, UK
| | - Carolyn A Chew-Graham
- Primary Care and Health Sciences and National School for Primary Care Research, Keele University, Keele, Staffordshire, UK
| |
Collapse
|
44
|
Wener P, Woodgate RL. Collaborating in the context of co-location: a grounded theory study. BMC FAMILY PRACTICE 2016; 17:30. [PMID: 26965307 PMCID: PMC4785669 DOI: 10.1186/s12875-016-0427-x] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/08/2015] [Accepted: 03/02/2016] [Indexed: 11/10/2022]
Abstract
BACKGROUND Most individuals with mental health concerns seek care from their primary care provider, who may lack comfort, knowledge, and time to provide care. Interprofessional collaboration between providers improves access to primary mental health services and increases primary care providers' comfort offering these services. Building and sustaining interprofessional relationships is foundational to collaborative practice in primary care settings. However, little is known about the relationship building process within these collaborative relationships. The purpose of this grounded theory study was to gain a theoretical understanding of the interprofessional collaborative relationship-building process to guide health care providers and leaders as they integrate mental health services into primary care settings. METHODS Forty primary and mental health care providers completed a demographic questionnaire and participated in either an individual or group interview. Interviews were audio-recorded and transcribed verbatim. Transcripts were reviewed several times and then individually coded. Codes were reviewed and similar codes were collapsed to form categories using using constant comparison. All codes and categories were discussed amongst the researchers and the final categories and core category was agreed upon using constant comparison and consensus. RESULTS A four-stage developmental interprofessional collaborative relationship-building model explained the emergent core category of Collaboration in the Context of Co-location. The four stages included 1) Looking for Help, 2) Initiating Co-location, 3) Fitting-in, and 4) Growing Reciprocity. A patient-focus and communication strategies were essential processes throughout the interprofessional collaborative relationship-building process. CONCLUSIONS Building interprofessional collaborative relationships amongst health care providers are essential to delivering mental health services in primary care settings. This developmental model describes the process of how these relationships are co-created and supported by the health care region. Furthermore, the model emphasizes that all providers must develop and sustain a patient-focus and communication strategies that are flexible. Applying this model, health care providers can guide the creation and sustainability of primary care interprofessional collaborative relationships. Moreover, this model may guide health care leaders and policy makers as they initiate interprofessional collaborative practice in other health care settings.
Collapse
Affiliation(s)
- Pamela Wener
- />Department of Occupational Therapy, College of Rehabilitation Sciences, University of Manitoba, R125-771 McDermot Ave., Winnipeg, MB R3E 0T6 Canada
| | - Roberta L. Woodgate
- />College of Nursing, University of Manitoba, 465 Helen Glass Centre, 89 Curry Place, Winnipeg, MB R3T 2N2 Canada
| |
Collapse
|
45
|
Foster M, Burridge L, Donald M, Zhang J, Jackson C. The work of local healthcare innovation: a qualitative study of GP-led integrated diabetes care in primary health care. BMC Health Serv Res 2016; 16:11. [PMID: 26769248 PMCID: PMC4712472 DOI: 10.1186/s12913-016-1270-4] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2015] [Accepted: 01/12/2016] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Service delivery innovation is at the heart of efforts to combat the growing burden of chronic disease and escalating healthcare expenditure. Small-scale, locally-led service delivery innovation is a valuable source of learning about the complexities of change and the actions of local change agents. This exploratory qualitative study captures the perspectives of clinicians and managers involved in a general practitioner-led integrated diabetes care innovation. METHODS Data on these change agents' perspectives on the local innovation and how it works in the local context were collected through focus groups and semi-structured interviews at two primary health care sites. Transcribed data were analysed thematically. Normalization Process Theory provided a framework to explore perspectives on the individual and collective work involved in putting the innovation into practice in local service delivery contexts. RESULTS Twelve primary health care clinicians, hospital-based medical specialists and practice managers participated in the study, which represented the majority involved in the innovation at the two sites. The thematic analysis highlighted three main themes of local innovation work: 1) trusting and embedding new professional relationships; 2) synchronizing services and resources; and 3) reconciling realities of innovation work. As a whole, the findings show that while locally-led service delivery innovation is designed to respond to local problems, convincing others to trust change and managing the boundary tensions is core to local work, particularly when it challenges taken-for-granted practices and relationships. Despite this, the findings also show that local innovators can and do act in both discretionary and creative ways to progress the innovation. CONCLUSIONS The use of Normalization Process Theory uncovered some critical professional, organizational and structural factors early in the progression of the innovation. The key to local service delivery innovation lies in building coalitions of trust at the point of service delivery and persuading organizational and institutional mindsets to consider the opportunities of locally-led innovation.
Collapse
Affiliation(s)
- Michele Foster
- School of Nursing, Midwifery and Social Work, The University of Queensland, St Lucia, Qld 4072 Australia
- School of Human Services and Social Work, Menzies Health Institute Queensland, Griffith University, Meadowbrook, Qld 4131 Australia
| | - Letitia Burridge
- Discipline of General Practice, School of Medicine, The University of Queensland, Level 8, Health Sciences Building, Royal Brisbane & Women’s Hospitals, Herston Road, Herston, Qld 4006 Australia
| | - Maria Donald
- Discipline of General Practice, School of Medicine, The University of Queensland, Level 8, Health Sciences Building, Royal Brisbane & Women’s Hospitals, Herston Road, Herston, Qld 4006 Australia
| | - Jianzhen Zhang
- Discipline of General Practice, School of Medicine, The University of Queensland, Level 8, Health Sciences Building, Royal Brisbane & Women’s Hospitals, Herston Road, Herston, Qld 4006 Australia
| | - Claire Jackson
- Discipline of General Practice, School of Medicine, The University of Queensland, Level 8, Health Sciences Building, Royal Brisbane & Women’s Hospitals, Herston Road, Herston, Qld 4006 Australia
| |
Collapse
|
46
|
Healey EL, Jinks C, Tan VA, Chew-Graham CA, Lawton SA, Nicholls E, Finney AG, Porcheret M, Cooper V, Lewis M, Dziedzic KS, Wathall S, Mallen CD. Improving the care of people with long-term conditions in primary care: protocol for the ENHANCE pilot trial. JOURNAL OF COMORBIDITY 2015; 5:135-149. [PMID: 29090162 PMCID: PMC5636040 DOI: 10.15256/joc.2015.5.60] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/30/2015] [Accepted: 11/25/2015] [Indexed: 02/01/2023]
Abstract
BACKGROUND Long-term conditions (LTCs) are important determinants of quality of life and healthcare expenditure worldwide. Whilst multimorbidity is increasingly the norm in primary care, clinical guidelines and the delivery of care remain focused on single diseases, resulting in poorer clinical outcomes. Osteoarthritis, and anxiety and/or depression frequently co-occur with other LTCs, yet are seldom prioritized by the patient or clinician, resulting in higher levels of disability, poorer prognosis, and increased healthcare costs. OBJECTIVE To examine the feasibility and acceptability of an integrated approach to LTC management, tackling the under-diagnosis and under-management of osteoarthritis-related pain and anxiety and/or depression in older adults with other LTCs in primary care. DESIGN The ENHANCE study is a pilot stepped-wedge cluster randomized controlled trial to test the feasibility and acceptability of a nurse-led ENAHNCE LTC review consultation for identifying, assessing, and managing joint pain, and anxiety and/or depression in patients attending LTC reviews. Specific objectives (process evaluation and research outcomes) will be achieved through a theoretically informed mixed-methods approach using participant self-reported questionnaires, a medical record review, an ENHANCE EMIS template, qualitative interviews, and audio recordings of the ENHANCE LTC review. DISCUSSION Success of the pilot trial will be measured against the level of the primary care team engagement, assessment of training delivery, and degree of patient recruitment and retention. Patient satisfaction and treatment fidelity will also be explored. ISRCTN registry number: 12154418.
Collapse
Affiliation(s)
- Emma L Healey
- Research Institute for Primary Care & Health Sciences, Keele University, Keele, Staffordshire, UK
| | - Clare Jinks
- Research Institute for Primary Care & Health Sciences, Keele University, Keele, Staffordshire, UK
| | - Valerie A Tan
- Research Institute for Primary Care & Health Sciences, Keele University, Keele, Staffordshire, UK
| | | | - Sarah A Lawton
- Research Institute for Primary Care & Health Sciences, Keele University, Keele, Staffordshire, UK
| | - Elaine Nicholls
- Research Institute for Primary Care & Health Sciences, Keele University, Keele, Staffordshire, UK
| | | | - Mark Porcheret
- Research Institute for Primary Care & Health Sciences, Keele University, Keele, Staffordshire, UK
| | - Vince Cooper
- Research Institute for Primary Care & Health Sciences, Keele University, Keele, Staffordshire, UK
| | - Martyn Lewis
- Research Institute for Primary Care & Health Sciences, Keele University, Keele, Staffordshire, UK
| | - Krysia S Dziedzic
- Research Institute for Primary Care & Health Sciences, Keele University, Keele, Staffordshire, UK
| | - Simon Wathall
- Research Institute for Primary Care & Health Sciences, Keele University, Keele, Staffordshire, UK
| | - Christian D Mallen
- Research Institute for Primary Care & Health Sciences, Keele University, Keele, Staffordshire, UK
| |
Collapse
|
47
|
Goodman D. Improving Access to Maternity Care for Women with Opioid Use Disorders: Colocation of Midwifery Services at an Addiction Treatment Program. J Midwifery Womens Health 2015; 60:706-12. [DOI: 10.1111/jmwh.12340] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
|
48
|
Morden A, Brooks L, Jinks C, Porcheret M, Ong BN, Dziedzic K. Research “push”, long term-change, and general practice. J Health Organ Manag 2015; 29:798-821. [DOI: 10.1108/jhom-07-2014-0119] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Purpose
– Intervention evaluations have not always accounted for long-term implementation of interventions. The purpose of this paper is to explore implementation of a primary care intervention during the lifespan of the trial and beyond.
Design/methodology/approach
– Eight general practices participated in the trial (four control and four intervention). In-depth interviews (with nine GPs and four practices nurses who delivered the intervention) and observation methods were employed. Thematic analysis was utilized and Normalization Process Theory (NPT) constructs were compared with emergent themes.
Findings
– Macro-level policy imperatives shaped practice priorities which resulted in the “whole system” new intervention not being perceived to be sustainable. Continued routinization of the intervention into usual care beyond the lifespan of the funded study was dependent on individualized monitoring and taking forward tacit knowledge.
Research limitations/implications
– The authors discuss the implications of these findings for sociological theories of implementation and understanding outcomes of research led complex interventions.
Originality/value
– The study describes the complex interplay between macro processes and individual situated practices and contributes to understanding if, how, and why interventions are sustained beyond initial “research push”. The value of the study lies in describing the conditions and potential consequences of long-term implementation, which might be translated to other contexts.
Collapse
|
49
|
Overend K, Bosanquet K, Bailey D, Foster D, Gascoyne S, Lewis H, Nutbrown S, Woodhouse R, Gilbody S, Chew-Graham C. Revealing hidden depression in older people: a qualitative study within a randomised controlled trial. BMC FAMILY PRACTICE 2015; 16:142. [PMID: 26481581 PMCID: PMC4617777 DOI: 10.1186/s12875-015-0362-2] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/09/2015] [Accepted: 10/07/2015] [Indexed: 11/10/2022]
Abstract
BACKGROUND The prevalence of depressive symptoms in older people may be as high as 20 %. Depression in older people is associated with loss, loneliness and physical co-morbidities; it is known to be under-diagnosed and under-treated. Older people may find it difficult to speak to their GPs about low mood, and GPs may avoid identifying depression due to limited consultation time and referral options for older patients. METHODS A nested qualitative study in a randomised controlled trial for older people with moderate to severe depression: the CASPER Plus Trial (Collaborative Care for Screen Positive Elders). We interviewed GPs, case managers (CM) and patient participants to explore perspectives and experiences of delivering and receiving a psychosocial intervention, developed specifically for older adults in primary care, within a collaborative care framework. Transcripts were analysed thematically using principles of constant comparison. RESULTS Thirty three interviews were conducted and, across the three data-sets, four main themes were identified: revealing hidden depression, reducing the 'blind spots', opportunity to talk outside the primary care consultation and 'moving on' from depression. CONCLUSIONS Depression in older people is commonly hidden, and may coexist with physical conditions that are prioritised by both patients and GPs. Being invited to participate in a trial about depression may allow older people to disclose their feelings, name the problem, and seek help. Offering older people an opportunity to talk outside the primary care consultation is valued by patients and GPs. A psychosocial intervention delivered by a case manager in the primary care setting may fill the gap in the care of older people with depression. TRIAL REGISTRATION Current Controlled Trials ISRCTN45842879 .
Collapse
Affiliation(s)
| | | | - Della Bailey
- University of York, Heslington, York, YO10 5DD, UK.
| | | | | | - Helen Lewis
- University of York, Heslington, York, YO10 5DD, UK.
| | | | | | | | - Carolyn Chew-Graham
- Research Institute, Primary Care and Health Sciences, NIHR CLAHRC West Midlands, Keele, Staffordshire, ST5 5BG, UK.
| |
Collapse
|
50
|
Sun KS, Lam TP, Lam KF, Lo TL. Managing common mental health problems: contrasting views of primary care physicians and psychiatrists. Fam Pract 2015; 32:538-44. [PMID: 26094114 DOI: 10.1093/fampra/cmv044] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Recent studies have reported a lack of collaboration and consensus between primary care physicians (PCPs) and psychiatrists. OBJECTIVE To compare the views of PCPs and psychiatrists on managing common mental health problems in primary care. METHODS Four focus group interviews were conducted to explore the in-depth opinions of PCPs and psychiatrists in Hong Kong. The acceptance towards the proposed collaborative strategies from the focus groups were investigated in a questionnaire survey with data from 516 PCPs and 83 psychiatrists working in public and private sectors. RESULTS In the focus groups, the PCPs explained that several follow-up sessions to build up trust and enable the patients to accept their mental health problems were often needed before making referrals. Although some PCPs felt capable of managing common mental health problems, they had limited choices of psychiatric drugs to prescribe. Some public PCPs experienced the benefits of collaborative care, but most private PCPs perceived limited support from psychiatrists. The survey showed that around 90% of PCPs and public psychiatrists supported setting up an agreed protocol of care, management of common mental health problems by PCPs, and discharging stabilized patients to primary care. However, only around 54-67% of private psychiatrists supported different components of these strategies. Besides, less than half of the psychiatrists agreed with setting up a support hotline for the PCPs to consult them. CONCLUSIONS The majority of PCPs and psychiatrists support management of common mental health problems in primary care, but there is significantly less support from the private psychiatrists.
Collapse
Affiliation(s)
| | | | - Kwok Fai Lam
- Department of Statistics and Actuarial Science, The University of Hong Kong, Hong Kong and
| | - Tak Lam Lo
- Department of Family Medicine and Primary Care, Kwai Chung Hospital, Hong Kong, China
| |
Collapse
|