Nursing care left undone in psychiatric hospitals and its association with nurse staffing: A cross-sectional multi-centre study in Switzerland

INTRODUCTION

Nursing care left undone occurs when nurses omit activities because of resource shortfalls. Higher levels of nursing care left undone are associated with worse nurse staffing and organizational factors. Plentiful evidence from acute, long-term and community care supports such associations; however, mental healthcare settings are under-studied.

AIM

The aim of the study was to describe nursing care left undone's frequency in mental health inpatient settings and explore its association with nurse staffing levels.

METHOD

As part of the multi-centre cross-sectional MatchRN Psychiatry study, data were collected by questionnaire from 114 units in 13 Swiss psychiatric hospitals. Nursing care left undone was analysed describing frequencies descriptively and used linear mixed models to assess its association with staffing.

RESULTS

Data from 994 nurses were analysed. The most commonly omitted activities were evaluating nursing processes (30.5%), formulating nursing diagnoses (27.4%) and defining care objectives (22.7%). Nursing care left undone was higher in units with low staffing levels.

DISCUSSION

As in somatic care settings, in psychiatric hospitals, 'indirect' care activities are most commonly omitted.

IMPLICATIONS FOR PRACTICE

This study highlights factors affecting the frequency of nursing care left undone, including staffing levels and perceived leadership. The findings emphasize the importance of nurse managers taking action to improve work environment factors.

Evaluation of a modernized supported housing intervention for individuals who experience severe and persistent mental illness in Ontario, Canada

WHAT IS KNOWN ON THE SUBJECT

Supported housing approaches that include case management and increased opportunities for independence and personal autonomy for people who are living with severe and persistent mental illness (SPMI) have been found to help reduce hospitalizations and use of the emergency department. What is not fully clear is if these types of supported housing arrangements also influence the use of primary health care and other specialist services.

WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE

This study uncovered that individuals experiencing SPMI who lived in supported housing used more primary health care and specialist physician services, in the year following transition to this housing arrangement.

WHAT ARE THE IMPLICATIONS FOR PRACTICE

The findings of this study suggest that supported housing arrangements for people experiencing SPMI may help in improving the personalization of health services for individual residents, including increasing access to both primary health care and specialist services. This is important for nursing practice, as the findings of the study show that supported housing arrangements for people experiencing SPMI may assist in better supporting their complex health care needs.

ABSTRACT

INTRODUCTION: Supported housing for people who are living with severe and persistent mental illness (SPMI) has been found to help reduce hospitalizations and use of the emergency department. What is not fully clear is if these types of supported housing arrangements also influence the use of primary health care and other specialist services.

AIM/QUESTION

The aim of this study was to compare the use of health services use of individuals with SPMI, before and after transition to the new supported housing program.

METHOD

Using health care administrative databases, a pre-post cohort study was conducted examining the health system use of residents who transitioned from custodial to supported housing arrangements between 2017 and 2019.

RESULTS

Individuals with SPMI used more primary health care and specialist physician services after transition to the supported housing model.

DISCUSSION

The results suggest that a supported housing model may be associated with increased usage of outpatient person-centred health services in people experiencing SPMI.

IMPLICATIONS FOR PRACTICE

The findings of this study suggest that supported housing arrangements for people experiencing SPMI may help in improving the personalization of health services for individual. This is important for nursing practice, as the findings of the study show that supported housing arrangements may assist in better supporting complex health care needs of individuals.

Analysis of changes in the national mental health nursing workforce in England, 2011-2021

WHAT IS KNOWN ON THE SUBJECT?: Nurses work in mental health services around the world, constituting the largest professional group. Nurses have been identified as being potentially able to carry out a much wider range of functions than are typically allowed in practice, when provided with suitable training. There are long-term concerns regarding shortages of mental health nurses in England and many other countries. Workforce data is rarely subject to analysis in peer-reviewed journals. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: This paper provides a case study of the workforce patterns of a national mental health nurse (MHN) workforce overtime allowing comparison with other countries and specialities. MHN numbers reduced from 2011 to 2017, then increased to near the 2011 level by 2021, not meeting ambitious national plans for increasing numbers. The mental health nursing proportion of the total NHS nursing workforce decreased through this period. Advanced practice roles and skills are widely, but unevenly, distributed and are provided by a small proportion of nurses. The proportion of nurses working in community settings has increased to constitute more than half of all nurses for the first time. The ratio of support workers to nurses increased in inpatient settings and will continue to change. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Historical challenges in recruiting MHNs suggest that future plans to expand the profession are overly optimistic. To support the development of advanced practice roles and new skill sets, clearer research evidence of impact is required and clearer national guidance regarding best practice models. Good workforce data are essential to inform good workforce planning. ABSTRACT: Introduction Data regarding changes in characteristics of the MHN workforce is commonly cited in governmental publications, but is rarely analysed in peer-reviewed journals, despite ongoing concerns regarding high vacancy rates within mental health services. Aim The aim of the study was to characterize changes in the MHN workforce, implementation of new nursing roles/skills and alignment with national policy. Method Analysis of nationally published workforce data, peer-reviewed publications and governmental policy/planning documents. Results Nurse numbers declined from 2011 to 2017, subsequently returning to near 2011 levels, but remaining below national targets. Nurses in community settings increased to constitute more than half of all nurses, whilst inpatient numbers declined, although more slowly than bed numbers. The ratio between nurses and support workers changed due to more support workers in inpatient settings. New advanced skills and roles for nurses have increased, but are unevenly distributed, constituting a small proportion of the total workforce. Implications for Practice This paper provides a case study against which comparisons may be made with the nursing workforce in other countries and specialities. Even clear policy commitment to nursing growth may not deliver planned changes in numbers and introducing new roles may have uneven impact, especially in the absence of a robust evidence base.

Impact of Technology on Neonatal Intensive Care Unit Admissions and Length of Stay: A Retrospective Study

Background Neonatal intensive care units (NICU) provide essential medical care to neonates; however, they are associated with hospital-acquired infections, less maternal-newborn bonding, and high costs. Implementing strategies to lower NICU admission rates and shorten NICU length of stay (LOS) is essential. This study uses causal-inference methods to evaluate the impact of care managers using new technology to identify and risk stratify pregnancies on NICU admissions and NICU LOS. The NICU LOS will decrease as a result of the use of new technology by care managers. Study design This retrospective study utilized delivery claims data of pregnant women from the CareFirst BlueCross BlueShield Community Health Plan District of Columbia from 2013 to 2022, which includes the pre-intervention period before the use of new technology by care managers and the post-intervention period with the use of new technology by care managers. Our sample had 4,917 deliveries whose maternal comorbidities were matched with their neonate's outcomes. Methods To evaluate the impact of the technological intervention, both Generalized Linear Models (GLMs) and Bayesian Structural Time-Series (BSTS) models were used. Results Our findings from the GLM models suggest an overall average reduction in the odds of NICU admissions of 29.2% and an average decrease in NICU LOS from 7.5%-58.5%. Using BSTS models, we estimate counterfactuals for NICU admissions and NICU LOS, which suggest an average reduction in 48 NICU admissions and 528 NICU days per year. Conclusion Equipping care managers with better technological tools can lead to significant improvements in neonatal health outcomes as indicated by a reduction in NICU admissions and NICU LOS.

Barriers to healthcare and their relationship to well-being and social support for autistic adults during COVID-19

AIM

The present study aimed to investigate barriers to healthcare and their relationships to social and emotional well-being and intersectional inequalities for autistic adults during COVID-19 restrictions in the UK.

BACKGROUND

Autistic adults experience severe health inequalities and report more barriers to accessing health services compared to other both disabled and non-disabled populations. The COVID-19 pandemic has impacted many areas of society that may have increased vulnerability of autistic people to social and health inequalities, including delivery of healthcare from in-person to remote methods.

METHOD

One hundred twenty-eight autistic adults who lived in the UK took part in an online survey. Measures included the Barriers to Healthcare Checklist (Short Form) and PROMIS outcome measure bank to assess emotional well-being and social support. Participants rated their agreement with items, retrospectively considering three different points of the trajectory of COVID-19 restrictions: before COVID-19, during the first lockdown in spring 2020, and in the month prior to taking the survey during autumn 2020. They completed a follow-up survey six months later to continue to assess change as restrictions in the UK were eased.

FINDINGS

The average number of barriers to healthcare showed no significant change between all four time points. However, the nature of barriers to healthcare changed at the point of lockdown and persisted beyond the easing of COVID-19 restrictions. Barriers to healthcare were associated with some social and emotional well-being variables and demographic groups including gender, education and presence of additional disabilities. The findings may help to identify areas to target to improve access to both remote and in-person health systems for autistic people as modes of delivery continue to change over time.

Automated telephone follow-up programs after hospital discharge: Do older adults engage with these programs?

BACKGROUND

Health systems have developed automated telephone call programs to screen and triage patients' post-hospital discharge issues and concerns. The aims of our study were to determine whether and how older adults engage with automated post-hospital discharge telephone programs and to describe the prevalence of patient-reported post-discharge issues.

METHODS

We identified all telephone calls made by an urban academic medical center as part of a post-hospital discharge program between May 1, 2018 and April 30, 2019. The program used automated telephone outreach to patients or their caregivers that included 11 distinct steps 3 days post-discharge. All adults discharged home from the hospital, were included, and we categorized patients into ≤64 years, 65-84 years, and ≥85 years age groups. We then compared call reach rate, completeness of 11-step calls and patient-reported issues between age groups.

RESULTS

Eighteen thousand and seventy six patients were included. More patients 65-84 years old were reached compared to patients ≤64 years old (84.3% vs. 78.9%, AME 5.52%; 95%CI: 3.58%-7.45%). Completion rates of automated calls for those ≥85 years old were also high. Patients ≥85 years old were more likely to have questions about their follow-up plans and need assistance scheduling appointments compared to those ≤64 years old (19.0% vs. 11.9%, AME 7.0% (95%CI: 2.7%-11.3%).

CONCLUSION

Post-hospital automated telephone calls are feasible and effective at reaching older adults. Future work should focus on improving discharge communication to ensure older adults are aware of their follow-up plan and appointments.

Population screening to identify women at risk for hereditary breast cancer syndromes: The path forward or the road not taken?

Population screening of family cancer history to identify women at risk for a hereditary breast cancer syndrome is feasible and effectively identifies high risk women who are eligible for genetic counseling referral. However, uptake of counseling is low among referred women, and there is a critical need to develop multilevel interventions that promote uptake of genetic counseling in diverse groups of patients identified through population-based screening.

Demographic & clinical correlates of admission into a specialized psychiatric inpatient service for children and adolescents in Egypt: An observational retrospective study

WHAT IS KNOWN ON THE SUBJECT

Admitting children and adolescents in psychiatric inpatient units is a relatively new and still debatable practice in Egyptian society and in the entire Arab world.

WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE

Egyptian young people diagnosed with complex behavioural problems, such as in other parts of the world, desperately need and do get benefit from inpatient psychiatric service. The demographic and clinical characteristics of children in need for such service are not clearly different from those reported in other parts of the world.

WHAT ARE THE IMPLICATIONS FOR PRACTICE

More should be done to spread awareness, remove obstacles, and develop more specialized inpatient units, with trained child psychiatrists and psychiatric nurses to provide best care for children and adolescents diagnosed with severe emotional and behavioural problems in Egypt, the Arab world and other developing countries in the world.

ABSTRACT

Background To our knowledge, this is the first study that aims to investigate the demographic and clinical correlates of admission into a specialized inpatient psychiatric unit for children and adolescents in Egypt and the Arab world. Methods The files of all service users who presented for care in the outpatient service for children and adolescents in Tanta University between July 2017 and December 2019 were reviewed. Of the 1,195 files reviewed, 100 patients were admitted to the inpatient unit for 133 admission episodes with an average duration of 18.5 days per episode. Results The most common diagnosis among admitted children and adolescents was disruptive behaviour disorder. Having a diagnosis of bipolar disorder, eating disorder, or trauma-related disorders powerfully predicted admission. Both physical and sexual abuse also predicted admission, readmission and longer duration of admission. Conclusions The need for admission into specialized psychiatric inpatient units for children and adolescents is comparable to that in other parts of the world. There is an urgent necessity to develop such therapeutic units across the entire Arab world with subsequent need to establish suitable training programs for mental health workers to deal with children and adolescents diagnosed with severe psychiatric disorders in inpatient setting.

Consumer perspective from people with a diagnosis of Borderline Personality Disorder (BPD) on BPD management-How are the Australian NHMRC BPD guidelines faring in practice?

WHAT IS KNOWN ON THE SUBJECT?: Internationally, stigma towards people with mental illness has reduced due to greater understanding, education and advocacy in the community, and more focus on recovery-oriented care within practice guidelines. However, many people with a diagnosis of BPD continue to experience stigma and difficulty accessing health services. Contributing factors include lack of understanding of BPD and effective management by health professionals, stigma from the general population and within healthcare services, and financial and geographical barriers. Mental health nurses comprise a large part of the healthcare workforce responsible for the day-to-day care of people diagnosed with BPD. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE: This paper investigates how Australian consumer perspectives on BPD management have changed over time. Comments from a large survey, delivered to consumers in 2011 (N = 153) and 2017 (N = 424), were analysed for common themes. Themes were broadly related to NHMRC BPD Guidelines sections released in 2013. These data sets therefore present an opportunity to evaluate changes in consumer perspectives pre- and post-Guideline release. Although no direct causal relationship can be drawn, analysing these changes can potentially assist with understanding the impact of the Guidelines in practice. No such analysis of the Australian Guidelines has been conducted to date in the existing literature. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Many people diagnosed with BPD continue to experience stigma, barriers to treatment and difficulty accessing appropriate services. Widespread practical implementation of the Guidelines was not apparent; however, improved general awareness and understanding of BPD from consumers and health professionals were evident. Improved education and practice across each and all aspects of the Guidelines are indicated. The Guidelines need review to ensure they are in-line with current evidence-based practice, as well as effective health professional education, support and funding to embed the revised Guidelines into practice. ABSTRACT: Introduction Internationally, many individuals diagnosed with BPD continue to experience stigma within health care and are more likely to be viewed as manipulative and evoke negative responses from clinicians, compared with other mental health consumers. Aim/Question To understand Australian consumer perspectives regarding BPD management, and how these have changed between 2011 and 2017. To comment on how NHMRC BPD Guidelines, released 2013, are faring in practice. Method Individuals who identified a BPD diagnosis completed a 75-question survey, delivered online Australia-wide, in 2011 (N = 153) and 2017 (N = 424), providing comparative data sets to evaluate changes in consumer perspective on BPD management. Results Many people diagnosed with BPD experience difficulties when seeking help, stigma within health services and barriers to treatment. Improved general awareness, communication and understanding of BPD from consumers and health professionals were evident. Discussion Consumers demonstrated increased BPD-literacy and help-seeking behaviours in 2017, providing opportunity for health professionals to build stronger therapeutic relationships. Widespread practical implementation of the Guidelines does not appear to have been achieved. More health professional education, updated Guidelines, funding and strategies to embed these Guidelines into practice are needed. Implications for Practice Mental health nurses regularly provide care to people diagnosed with BPD; with practical education and support, they and other health professionals can improve their confidence in practice and provide better quality care to consumers.

Abrupt change to telephone follow-up clinics in a regional rheumatology service during COVID-19: analysis of treatment decisions

During the 2020 COVID‐19 lockdown our rheumatology service provided follow up by phone. We reviewed clinic documents to compare patients serviced, and patient assessment and treatment outcomes. More patients received care during the lockdown but patient rheumatic disease was deemed active less frequently, more patients had no change to disease‐modifying anti‐rheumatic drugs and patients were less likely to have an intervention arranged. This suggests careful patient selection and appropriate infrastructure should be part of future rheumatology telemedicine.

A Collaborative Model to Implement Flexible, Accessible and Efficient Oncogenetic Services for Hereditary Breast and Ovarian Cancer: The C-MOnGene Study

Simple Summary

We recently developed an oncogenetic model to overcome the unprecedented demand for genetic counseling and testing for hereditary breast and ovarian cancer. Quality and performance indicators showed that the implementation of this model improved access to genetic counseling and minimized delays for genetic tests for patients, who reported to be overwhelmingly satisfied with the process. However, it remains unknown whether this model is robust and sustainable or requires adjustments. In addition, whether the model could be deployed elsewhere remains also to be elucidated. The C-MOnGene study was therefore designed to gain an in-depth understanding of the context in which the model was developed and implemented, and document the lessons that can be learned to optimize oncogenetic services delivery in other settings.

Abstract

Medical genetic services are facing an unprecedented demand for counseling and testing for hereditary breast and ovarian cancer (HBOC) in a context of limited resources. To help resolve this issue, a collaborative oncogenetic model was recently developed and implemented at the CHU de Québec-Université Laval; Quebec; Canada. Here, we present the protocol of the C-MOnGene (Collaborative Model in OncoGenetics) study, funded to examine the context in which the model was implemented and document the lessons that can be learned to optimize the delivery of oncogenetic services. Within three years of implementation, the model allowed researchers to double the annual number of patients seen in genetic counseling. The average number of days between genetic counseling and disclosure of test results significantly decreased. Group counseling sessions improved participants’ understanding of breast cancer risk and increased knowledge of breast cancer and genetics and a large majority of them reported to be overwhelmingly satisfied with the process. These quality and performance indicators suggest this oncogenetic model offers a flexible, patient-centered and efficient genetic counseling and testing for HBOC. By identifying the critical facilitating factors and barriers, our study will provide an evidence base for organizations interested in transitioning to an oncogenetic model integrated into oncology care; including teams that are not specialized but are trained in genetics.

Management of Canadian Pediatric Patients With Glomerular Diseases During the COVID-19 Pandemic: Recommendations From the Canadian Association of Pediatric Nephrologists COVID-19 Rapid Response Team

Purpose

The goal of these recommendations is to provide guidance on the optimal care of children with glomerular diseases during the COVID-19 pandemic. Patients with glomerular diseases are known to be more susceptible to infection. Risk factors include decreased vaccine uptake, urinary loss of immunoglobulins, and treatment with immunosuppressive medications. The Canadian Society of Nephrology (CSN) recently published guidelines on the care of adult glomerulonephritis patients. This guideline aims to expand and adapt those recommendations for programs caring for children with glomerular diseases.

Sources of information

We used the CSN COVID-19 Rapid Response Team adult glomerulonephritis recommendations, published in the Canadian Journal of Kidney Health and Disease, as the foundation for our guidelines. We reviewed documents published by nephrology and non-nephrology societies and health care agencies focused on kidney disease and immunocompromised populations. Finally, we conducted a formal literature review of publications relevant to pediatric and adult glomerular disease, chronic kidney disease, hypertension, and immunosuppression in the context of the COVID-19 pandemic.

Methods

The leadership of the Canadian Association of Pediatric Nephrologists (CAPN), which is affiliated with the CSN, identified a team of clinicians and researchers with expertise in pediatric glomerular diseases. The aim was to adapt Canadian adult glomerulonephritis guidelines to make them applicable to children and discuss pediatric-specific considerations. The updated guidelines were peer-reviewed by senior clinicians with expertise in the care of childhood glomerular diseases.

Key findings

We identified a number of key areas of glomerular disease care likely to be affected by the COVID-19 pandemic, including (1) clinic visit scheduling, (2) visit types, (3) provision of multidisciplinary care, (4) blood work and imaging, (5) home monitoring, (6) immunosuppression, (7) other medications, (8) immunizations, (9) management of children with suspected COVID-19, (10) renal biopsy, (11) patient education and support, and (12) school and child care.

Limitations

There are minimal data regarding the characteristics and outcomes of COVID-19 in adult or pediatric glomerular disease patients, as well as the efficacy of strategies to prevent infection transmission within these populations. Therefore, the majority of these recommendations are based on expert opinion and consensus guidance. To expedite the publication of these guidelines, an internal peer-review process was conducted, which may not have been as rigorous as formal journal peer-review.

Implications

These guidelines are intended to promote optimal care delivery for children with existing or newly diagnosed glomerular diseases during the COVID-19 pandemic. The implications of modified care delivery, altered immunosuppression strategies, and limited access to existing resources remain uncertain.

Improper Communication Makes for Squat: A Qualitative Study of the Health-Care Processes Experienced By Older Adults in a Clinical Trial for Back Pain

Background:

The study focused on perceptions of older adults toward the healthcare processes they experienced during a clinical trial for back pain that involved family medicine residents and licensed chiropractors.

Methods:

Individual semi-structured interviews were conducted with 115 older adults after a 12-week, 3-arm, randomized controlled trial. Two researchers conducted thematic analysis with inductive coding using qualitative software to identify participants’ salient experiences of the doctor–patient relationship, healthcare process, and collaboration between study providers. Investigators categorized thematic codes within an existing framework of clinical excellence in primary care.

Results:

Participants emphasized provider communication and interpersonal relationships, professionalism and passion for patient care, clinical and diagnostic acumen, and skillful negotiation of the health-care system. Older adults also described the importance of interdisciplinary collaboration and their preferences for receiving hands-on treatments for musculoskeletal conditions.

Conclusion:

These older adults valued doctors who communicated clearly and spent time listening to their concerns. Many participants appreciated clinicians who supported an active role for patients in their health-care and who provided touch-based care for musculoskeletal conditions.

Essential health services delivery in Zimbabwe during the COVID-19 pandemic: perspectives and recommendations

Zimbabwe reported its first case of COVID-19 on 20 March 2020, and since then the number has increased to over 4000. To contain the spread of the causative SARS-CoV-2 and prepare the healthcare system, public health interventions, including lockdowns, were imposed on 30 March 2020. These resulted in disruptions in healthcare provision, and movement of people and supply chains. There have been resultant delays in seeking and accessing healthcare by the patients. Additionally, disruption of essential health services in the areas of maternal and child health, sexual and reproductive health services, care for chronic conditions and access to oncological and other specialist services has occurred. Thus, there may be avoidable excess morbidity and mortality from non-COVID-19 causes that is not justifiable by the current local COVID-19 burden. Measures to restore normalcy to essential health services provision as guided by the World Health Organisation and other bodies needs to be considered and implemented urgently, to avoid preventable loss of life and excess morbidity. Adequate infection prevention and control measures must be put in place to ensure continuity of essential services whilst protecting healthcare workers and patients from contracting COVID-19.

Smart Ageing: Digital Solutions for Future Care

We propose a framework for discourse on digital solutions to support consumers and carers in delivery of health care and services for aged persons, based on a major needs analysis conducted across 56 diverse business entities in Australia. The resulting framework was based on two major identified domains: "Ageing in Place" for independent living situations, and "Ageing with Care" for managed aged care facilities. The paper describes the process used and the intermediate outcomes which enabled the framework to be synthesized. It is anticipated that the framework could be used to inform future scoping studies and to enable collaborative design, implementation and delivery of appropriate smart ageing digital solutions.

The impact of ward climate on staff perceptions of barriers to research-driven service changes on mental health wards: A cross-sectional study

WHAT IS KNOWN ON THE SUBJECT?: To date, improvements on U.K. acute mental health wards have been difficult to sustain. The barriers to change may be context dependent. Mental health wards are volatile workplaces with service user violence/aggression, frequent staff and patient changes, and ongoing service improvements. The evidence suggests that burnout affects staff perceptions of barriers to change, and ward climate affects burnout. As two potentially important, independent predictors of staff perceptions of barriers to change, the impact of ward climate and burnout on how staff regard changes should be considered. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: Elements of ward climate such as high numbers of incidents and temporary staff independently worsened mental health staff perceptions of barriers to change, in addition to negative impacts from burnout and occupational status. How staff perceived ward climate was also linked their perceptions of barriers to change; however, burnout was no longer a significant consideration with these variables. Staff with low job satisfaction and high interaction anxiety also had low confidence regarding changes. Staff with low job satisfaction were also demotivated towards changes. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Ward climate is clearly an important factor in how nurses view organizational changes. In this study, nurses' perceptions of barriers to change were worse if they viewed ward climate negatively, or if temporary staff and incident numbers were high. Staff perceptions of ward climate and barriers to change should be assessed, ahead of service changes. Developing change strategies based on such information is likely to produce better implementation outcomes. Specifically, targeting staff confidence and motivation (which are barriers to change) may improve how staff regard their ward climate. Abstract Introduction To create successful change programmes for mental health wards, it is necessary to understand which aspects of ward climate prevent change. Question Does ward climate influence mental health nurse's perceptions of barriers to change? Method Random-effects models were used to test whether the following ward climate variables influenced the outcome measure "staff perceptions of barriers to change" (VOCALISE) and its subscales (powerlessness/confidence/demotivation): (a) Perceptions of ward climate (VOTE: subscales included work intensity/job satisfaction/interaction anxiety). (b) Ward climate indicators (incidents/detention under the Mental Health Act (2007)/staffing/bed pressure). As known predictors of VOCALISE, burnout (Maslach Burnout Inventory) and occupational status were included in the models. Results Perceptions of ward climate (VOTE), incidents, temporary staff, occupational status and burnout significantly and negatively affected perceptions of barriers to change (VOCALISE). Staff with low job satisfaction (VOTE) and high interaction anxiety (VOTE) also had low confidence (VOCALISE). Staff with low job satisfaction (VOTE) were also demotivated (VOCALISE). Discussion Ward climate is an important predictor of how staff regard service changes in mental health wards. Implications for practice Staff perceptions of ward climate and barriers to change should be assessed ahead of service changes to identify pressures that impede progress and lower morale.

Influences on mental health and health services accessibility in immigrant women with post-partum depression: An interpretive descriptive study

WHAT IS KNOWN ABOUT THE SUBJECT?: Immigrant women in Canada are at greater risk for post-partum depression (PPD) than native-born women. Immigrant women are less likely to have their care needs met as they face multiple barriers to care at both individual and system levels. To date, most PPD research has focused on individual barriers to care, with limited research examining organizational and system level barriers and the uniqueness of immigrant women's post-partum health experiences. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: This study provides unique insights into immigrant women's perceptions of what influences their post-partum mental health and ability to access services for PPD. Factors contributing to immigrant women's PPD included several social determinants of health, particularly a lack of social support and limited knowledge about PPD and available services. Most helpful services acknowledge women's concerns, build trust, enact cultural competence and help with system navigation. Assessment approaches and organizational wait times created barriers to accessing care. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Relationship building by providers is foundational to effective care for immigrant women with PPD. Findings highlight the need for mental health practitioners to improve cultural competence when working with diverse ethno-cultural communities and for more effective assistance with system navigation, service integration and timely, flexible and accessible services. Findings have implications for the development of healthy public policy to address perinatal mental health issues amongst immigrant women. Abstract Introduction Immigrant women in Canada are at greater risk for post-partum depression (PPD) than native-born women yet face multiple barriers to care at individual and system levels. Aim To explore factors that contribute to PPD and health service accessibility, and the role of health services in supporting immigrant women with PPD. Methods A qualitative interpretive descriptive design was used. Individual interviews were conducted with 11 immigrant women who had delivered a baby within the previous year and had experienced PPD. Inductive thematic content analysis was conducted. Results Factors contributing to immigrant women's PPD included several social health determinants. Services were most helpful and accessible when providers acknowledged women's concerns, allowed time to build trust, provided culturally competent care and helped with navigating services. Assessment approaches and organizational wait times created barriers to care. Discussion Immigrant women with PPD see relationship building by providers as foundational to providing effective support, enhancing coping and facilitating access to services. Improved communication with diverse ethno-cultural communities and assistance with system navigation, service integration and timely, accessible services are needed. Implications for Practice Findings can inform health service delivery models and the development of healthy public policy to address perinatal mental health issues amongst immigrant women.

The use of the environmental scan in health services delivery research: a scoping review protocol

INTRODUCTION

The environmental scan has been described as an important tool to inform decision-making on policy, planning and programme development in the healthcare sector. Despite the wide adoption of environmental scans, there is no consensus on a working definition within the health services delivery context and methodological guidance on the design and implementation of this approach is lacking in the literature. The objectives of this study are to map the extent, range and nature of evidence that describe the definitions, characteristics, conceptualisations, theoretical underpinnings, study limitations and other features of the environmental scan in the health services delivery literature and to propose a working definition specific to this context.

METHODS AND ANALYSIS

This protocol describes a scoping review based on the methodology outlined by Khalil and colleagues. A comprehensive search strategy was developed by experienced health science librarians in consultation with the research team. A Peer Review of Electronic Search Strategies (PRESS) was completed. Two reviewers will independently screen titles, abstracts and full-text articles and select studies meeting the inclusion criteria from seven electronic databases: Academic Search Premier, Canadian Business & Current Affairs (CBCA), CINAHL, ERIC, Embase, MEDLINE and PsycINFO. The grey literature and reference lists of included articles will also be searched. The data will be analysed and presented in tabular format, and will include a descriptive numerical summary as well as a qualitative thematic analysis.

ETHICS AND DISSEMINATION

This protocol provides an audit trail for a scoping review that will advance understanding about the environmental scan and its application in the health services delivery context. The review will propose a working definition and will inform future research to explore the development of a conceptual framework in this context. Findings will be disseminated through a peer-reviewed journal and conference presentations. The scoping review does not require ethics approval.

Follow-up Care of Living Kidney Donors in Alberta, Canada

Background

Previous guidelines recommend that living kidney donors receive lifelong annual follow-up care to assess renal health.

Objective

To determine whether these best practice recommendations are currently being followed.

Design

Retrospective cohort study using linked health care databases.

Setting

Alberta, Canada (2002-2014).

Patients

Living kidney donors.

Measurements

We determined the proportion of donors who had annual outpatient physician visits and laboratory measurements for serum creatinine and albuminuria.

Results

There were 534 living kidney donors with a median follow-up of 7 years (maximum 13 years). The median age at the time of donation was 41 years and 62% were women. Overall, 25% of donors had all 3 markers of care (physician visit, serum creatinine, albuminuria measurement) in each year of follow-up. Adherence to physician visits was higher than serum creatinine or albuminuria measurements (67% vs 31% vs 28% of donors, respectively). Donors with guideline-concordant care were more likely to be older, reside closer to the transplant center, and receive their nephrectomy in more recent years.

Limitations

Our results may not be generalizable to other countries that do not have a similar universal health care system.

Conclusions

These findings suggest significant evidence-practice gaps, in that the majority of donors saw a physician, but the minority had measurements of kidney function or albuminuria. Future interventions should target improving follow-up care for all donors.

Improving health systems performance in low- and middle-income countries: a system dynamics model of the pay-for-performance initiative in Afghanistan

System dynamics methods were used to explore effective implementation pathways for improving health systems performance through pay-for-performance (P4P) schemes. A causal loop diagram was developed to delineate primary causal relationships for service delivery within primary health facilities. A quantitative stock-and-flow model was developed next. The stock-and-flow model was then used to simulate the impact of various P4P implementation scenarios on quality and volume of services. Data from the Afghanistan national facility survey in 2012 was used to calibrate the model. The models show that P4P bonuses could increase health workers' motivation leading to higher levels of quality and volume of services. Gaming could reduce or even reverse this desired effect, leading to levels of quality and volume of services that are below baseline levels. Implementation issues, such as delays in the disbursement of P4P bonuses and low levels of P4P bonuses, also reduce the desired effect of P4P on quality and volume, but they do not cause the outputs to fall below baseline levels. Optimal effect of P4P on quality and volume of services is obtained when P4P bonuses are distributed per the health workers' contributions to the services that triggered the payments. Other distribution algorithms such as equal allocation or allocations proportionate to salaries resulted in quality and volume levels that were substantially lower, sometimes below baseline. The system dynamics models served to inform, with quantitative results, the theory of change underlying P4P intervention. Specific implementation strategies, such as prompt disbursement of adequate levels of performance bonus distributed per health workers' contribution to service, increase the likelihood of P4P success. Poorly designed P4P schemes, such as those without an optimal algorithm for distributing performance bonuses and adequate safeguards for gaming, can have a negative overall impact on health service delivery systems.

Case Mix, Patterns of Care, and Inpatient Outcomes Among Ontario Kidney Transplant Centers: A Population-Based Study

Background:

Significant variation in both patient case mix and the structure of care in kidney transplantation has been previously described in the United States.

Objective:

The objective of our study was to characterize patient case mix, patterns of care, and inpatient outcomes across 5 kidney transplant centers in the province of Ontario, Canada.

Design:

This was a retrospective population-based cohort study using health care administrative databases.

Setting:

The setting is Ontario, Canada.

Patients:

We included adult (≥18 years) transplant recipients who received a primary, solitary kidney between January 1, 2000, and December 31, 2013 (N = 5037).

Methods:

Using linked administrative health care databases, we characterized kidney transplant recipient and donor factors, center characteristics, provider characteristics, and inpatient outcomes across transplant centers in Ontario. To compare case mix–adjusted differences in length of stay across centers, multivariable Cox proportional hazards regression was used to obtain hazard ratios (HRs) for each center relative to the average across all centers. Center volume and provider characteristics were added to the models to examine whether these factors explain differences in length of stay across centers.

Results:

We noted significant differences across transplant centers in patient race, cause of end-stage renal disease, body mass index, comorbidities, time on dialysis, and donor type. Mean annual transplant center volumes during the study period ranged between 51.5 (9.3) and 101.7 (23.9) transplants/year across centers (P < .0001). Physician specialty most responsible for in-hospital transplant care varied significantly across centers with the most common combination being nephrologist and urologist. Less than 31 deaths occurred in hospital during the index transplant admission but mortality risk did not differ significantly between centers. Overall, 25.1% of recipients required dialysis in hospital post transplantation (range across centers 18.3%-33.5%, P < .0001) and 24.7% of recipients spent time in the intensive care unit (ICU; range across centers: 5.7%-58.0%, P < .0001). The proportion of participants requiring dialysis did not change with time (P = .12), whereas the proportion staying in the ICU increased steadily over time (P < .0001). The median length of stay in hospital after transplantation ranged from 7 to 9 days across centers (P < .0001) and decreased significantly over time. After adjusting for patient case mix as well as center and provider factors, HRs for length of stay censored at the time of death ranged between 0.75 (95% confidence interval [CI]: 0.69-0.82) and 1.29 (95% CI: 1.20-1.38) across centers. Center volume and provider experience were not independently associated with length of hospital stay.

Limitations:

Data were missing (0.8%-18.4%) for certain covariates of interest.

Conclusions:

This study found significant heterogeneity across kidney transplant centers in case mix, practice patterns, and inpatient outcomes. Future studies are needed to examine the influence of length of stay and practice patterns on long-term outcomes such as patient/graft survival and quality of life.

What matters in patient-centered medical home transformation: Whole system evaluation outcomes of the Brown Primary Care Transformation Initiative

Objectives:

Patient-centered medical home transformation initiatives for enhancing team-based, patient-centered primary care are widespread in the United States. However, there remain large gaps in our understanding of these efforts. This article reports findings from a contextual, whole system evaluation study of a transformation intervention at eight primary care teaching practice sites in Rhode Island. It provides a picture of system changes from the perspective of providers, staff, and patients in these practices.

Methods:

Quantitative/qualitative evaluation methods include patient, provider, and staff surveys and qualitative interviews; practice observations; and focus groups with the intervention facilitation team.

Results:

Patient satisfaction in the practices was high. Patients could describe observable elements of patient-centered medical home functioning, but they lacked explicit awareness of the patient-centered medical home model, and their activation decreased over time. Providers’ and staff’s emotional exhaustion and depersonalization increased slightly over the course of the intervention from baseline to follow-up, and personal accomplishment decreased slightly. Providers and staff expressed appreciation for the patient-centered medical home as an ideal model, variously implemented some important patient-centered medical home components, increased their understanding of patient-centered medical home as more than specific isolated parts, and recognized their evolving work roles in the medical home. However, frustration with implementation barriers and the added work burden they associated with patient-centered medical home persisted.

Conclusion:

Patient-centered medical home transformation is disruptive to practices, requiring enduring commitment of leadership and personnel at every level, yet the model continues to hold out promise for improved delivery of patient-centered primary care.

Web-Delivered Cognitive Behavioral Therapy for Distressed Cancer Patients: Randomized Controlled Trial

BACKGROUND

Web-based interventions present a potentially cost-effective approach to supporting self-management for cancer patients; however, further evidence for acceptability and effectiveness is needed.

OBJECTIVE

The goal of our research was to assess the effectiveness of an individualized Web-based cognitive behavioral therapy (CBT) intervention on improving psychological and quality of life outcomes in cancer patients with elevated psychological distress.

METHODS

A total of 163 distressed cancer patients (111 female, 68.1%) were recruited through the Queensland Cancer Registry and the Cancer Council Queensland Cancer Helpline and randomly assigned to either a Web-based tailored CBT intervention (CancerCope) (79/163) or a static patient education website (84/163). At baseline and 8-week follow-up we assessed primary outcomes of psychological and cancer-specific distress and unmet psychological supportive care needs and secondary outcomes of positive adjustment and quality of life.

RESULTS

Intention-to-treat analyses showed no evidence of a statistically significant intervention effect on primary or secondary outcomes. However, per-protocol analyses found a greater decrease for the CancerCope group in psychological distress (P=.04), cancer-specific distress (P=.02), and unmet psychological care needs (P=.03) from baseline to 8 weeks compared with the patient education group. Younger patients were more likely to complete the CancerCope intervention.

CONCLUSIONS

This online CBT intervention was associated with greater decreases in distress for those patients who more closely adhered to the program. Given the low costs and high accessibility of this intervention approach, even if only effective for subgroups of patients, the potential impact may be substantial.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry ACTRN12613001026718; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=364768&isReview=true (Archived by WebCite at http://www.webcitation.org/6uPvpcovl).

Improving the transition from pediatric to adult diabetes care: the pediatric care provider's perspective in Quebec, Canada

OBJECTIVES

The transition from pediatric to adult care is a high-risk period for the emerging adult with diabetes. We aimed to determine adequacy of pediatric transition care structures and explore the pediatric diabetes care provider's perceptions of transition care.

RESEARCH DESIGN AND METHODS

In-depth interviews with pediatric diabetes care providers from 12 diabetes centers in Quebec were conducted. We queried alignment with Got Transition's six core elements of healthcare transition, experiences, and barriers to transition care. Interview transcripts were reviewed for themes.

RESULTS

Three centers (25%) reported having any elements of formal and structured transition care preparation and planning. When referrals were within center (n=8), pediatric providers perceived that transition was smoother; information sharing relied heavily on verbal communication rather than documented medical summaries. Barriers included lack of adult providers, less flexibility in adult care scheduling, patient struggles with multiple new adult responsibilities, and insufficient understanding by adult providers of these challenges. There was a perception that the quality of pediatric care was better than adult care. Moving out of the pediatric care geographical region appeared to increase risk for poor follow-up. Patient satisfaction and regular follow-up in adult care were thought to be good measures of transition success. Programs that included overlap between pediatric and adult care were perceived as ideal.

CONCLUSIONS

Important gaps in transition care practices persist. Efforts should focus on improving education in transition practices for pediatric care providers and establishing formal transition policies and structures at the institutional level.

Military veteran cancer survivors' preferences for a program to address lifestyle change and psychosocial wellness following treatment

This study aimed to understand military veteran cancer survivors' preferences regarding the delivery of post-treatment wellness services. Thirty-three military veteran cancer survivors were interviewed about their perceptions of three models of health service delivery (home-, primary care-, and oncology-based services). Conventional qualitative content analysis revealed strengths and weaknesses of each service delivery model's content and structure (e.g., program location, inclusion of emotional support, access to clinical experts). All service delivery programs had strengths, with clinic-based programs offering the greatest breadth of services deemed important for wellness by cancer survivors.

Community pharmacies as sites of adult vaccination: A systematic review

Vaccine-preventable deaths among adults remain a major public health concern, despite continued efforts to increase vaccination rates in this population. Alternative approaches to immunization delivery may help address under-vaccination among adults. This systematic review assesses the feasibility, acceptability, and effectiveness of community pharmacies as sites for adult vaccination. We searched 5 electronic databases (PubMed, EMBASE, Scopus, Cochrane, LILACS) for studies published prior to June 2016 and identified 47 relevant articles. We found that pharmacy-based immunization services (PBIS) have been facilitated by state regulatory changes and training programs that allow pharmacists to directly provide vaccinations. These services are widely accepted by both patients and pharmacy staff, and are capable of improving access and increasing vaccination rates. However, political and organizational barriers limit the feasibility and effectiveness of vaccine delivery in pharmacies. These studies provide evidence to inform policy and organizational efforts that promote the efficacy and sustainability of PBIS.

Perspectives of HIV agencies on improving HIV prevention, treatment, and care services in the USA

HIV healthcare services in the USA are made available through a complex funding and delivery system. We present perspectives of HIV agencies on improvements that could lead to an ideal system of HIV prevention, treatment and care. We conducted semi-structured interviews with representatives from 21 HIV agencies offering diverse services in Baltimore, MD. Thematic analysis revealed six key themes: (1) Focusing on HIV prevention, (2) Establishing common entry-points for services, (3) Improving information availability, (4) Streamlining funding streams, (5) Removing competitiveness and (6) Building trust. We recommend that in addition to addressing operational issues regarding service delivery and patient care, initiatives to improve HIV service systems should address underlying social issues such as building trust.

Usability and Acceptability of the QDACT-PC, an Electronic Point-of-Care System for Standardized Quality Monitoring in Palliative Care

CONTEXT

Few resources exist to support collaborative quality monitoring in palliative care. These tools, if proven efficient through technology-enabled methods, may begin to routinize data collection on quality during usual palliative care delivery. Usability testing is a common approach to assess how easily and effectively users can interact with a newly developed tool.

OBJECTIVES

We performed usability testing of the Quality Data Collection Tool for Palliative Care (QDACT-PC) a novel, point-of-care quality monitoring tool for palliative care.

METHODS

We used a mixed methods approach to assess community palliative care clinicians' evaluations of five domains of usability. These approaches included clinician surveys after recording mock patient data to assess satisfaction; review of entered data for accuracy and time to completion; and thematic review of "think aloud" protocols to determine issues, barriers, and advantages to the electronic system.

RESULTS

We enrolled 14 palliative care clinicians for the study. Testing the electronic system vs. paper-based methods demonstrated similar error rates and time to completion. Overall, 68% of the participants believed that the electronic interface would not pose a moderate or major burden during usual clinical activities, and 65% thought it would improve the care they provided. Thematic analysis revealed significant issues with paper-based methods alongside training needs for future participants on using novel technologies that support the QDACT-PC.

CONCLUSION

The QDACT-PC is a usable electronic system for quality monitoring in palliative care. Testing reveals equivalence with paper for data collection time, but with less burden overall for electronic methods across other domains of usability.

A population-based study evaluating family physicians' HIV experience and care of people living with HIV in Ontario

PURPOSE

Greater physician experience managing human immunodeficiency virus (HIV) infection has been associated with better HIV-specific outcomes. The objective of this study was to evaluate whether the HIV experience of a family physician modifies the association between the model of care delivery and the quality of care for people living with HIV.

METHODS

We retrospectively analyzed data from a population-based observational study conducted between April 1, 2009, and March 31, 2012. A total of 13,417 patients with HIV in Ontario were stratified into 5 possible patterns or models of care. We used multivariable hierarchical logistic regression analyses, adjusted for patient characteristics and pairwise comparisons, to evaluate the modification of the association between care model and indicators of quality of care (receipt of antiretroviral therapy, cancer screening, and health care use) by level of physician HIV experience (≤5, 6-49, ≥50 patients during study period).

RESULTS

The majority of HIV-positive patients (52.8%) saw family physicians exclusively for their care. Among these patients, receipt of antiretroviral therapy was significantly lower for those receiving care from family physicians with 5 or fewer patients and 6-49 patients compared with those with 50 or more patients (mean levels of adherence [95% CIs] were 0.34 [0.30-0.39] and 0.40 [0.34-0.45], respectively, vs 0.77 [0.74-0.80]). Patients' receipt of cancer screenings and health care use were unrelated to family physician HIV experience.

CONCLUSIONS

Family physician HIV experience was strongly associated with receipt of antiretroviral therapy by HIV-positive patients, especially among those seeing only family physicians for their care. Future work must determine the best models for integrating and delivering comprehensive HIV care among diverse populations and settings.

A population-based study comparing patterns of care delivery on the quality of care for persons living with HIV in Ontario

OBJECTIVES

Physician specialty is often positively associated with disease-specific outcomes and negatively associated with primary care outcomes for people with chronic conditions. People with HIV have increasing comorbidity arising from antiretroviral therapy (ART) related longevity, making HIV a useful condition to examine shared care models. We used a previously described, theoretically developed shared care framework to assess the impact of care delivery on the quality of care provided.

DESIGN

Retrospective population-based observational study from 1 April 2009 to 31 March 2012.

PARTICIPANTS

13 480 patients with HIV and receiving publicly funded healthcare in Ontario were assigned to one of five patterns of care.

OUTCOME MEASURES

Cancer screening, ART prescribing and healthcare utilisation across models using adjusted multivariable hierarchical logistic regression analyses.

RESULTS

Models in which patients had an assigned family physician had higher odds of cancer screening than those in exclusively specialist care (colorectal cancer screening, exclusively primary care adjusted OR (AOR)=3.12, 95% CI (1.90 to 5.13), family physician-dominant co-management AOR=3.39, 95% CI (1.94 to 5.93), specialist-dominant co-management AOR=2.01, 95% CI (1.23 to 3.26)). The odds of having one emergency department visit did not differ among models, although the odds of hospitalisation and HIV-specific hospitalisation were lower among patients who saw exclusively family physicians (AOR=0.23, 95% CI (0.14 to 0.35) and AOR=0.15, 95% CI (0.12 to 0.21)). The odds of antiretroviral prescriptions were lower among models in which patients' HIV care was provided predominantly by family physicians (exclusively primary care AOR=0.15, 95% CI (0.12 to 0.21), family physician-dominant co-management AOR=0.45, 95% CI (0.32 to 0.64)).

CONCLUSIONS

How care is provided had a potentially important influence on the quality of care delivered. Our key limitation is potential confounding due to the absence of HIV stage measures.

Collegiate presence: explaining homogenous but disparate nursing relationships

This paper examines the notion of collegiate presence. Collegiate presence is defined as a mutual connection between two or more professional individuals or groups who share a common work focus and who are mindful of cultural differences. This concept emerged as a result of an ethnographic study of two groups of triage nurses; emergency department, and mental health nurses. Data analysis exposed a number of concepts and themes including collegiality and presence. These two concepts were seen to be so closely connected that the term collegiate presence was constructed. This paper explores the notion of collegiate presence and examines factors that affect this phenomenon between what are homogenous (nurses) but disparate cultural groups (emergency department nurses and mental health triage nurses) in a health-care organization. Findings indicate that culturally disparate groups are challenged to develop functional and collaborative working relationships without a deep understanding of, and appreciation for, each other's culture. Developing collegiate presence requires effective communication, social and professional conversations, and physical presence.

Evaluating a De-Centralized Regional Delivery System for Breast Cancer Screening and Patient Navigation for the Rural Underserved

Providing breast cancer screening services in rural areas is challenging due to the fractured nature of healthcare delivery systems and complex reimbursement mechanisms that create barriers to access for the under- and uninsured. Interventions that reduce structural barriers to mammography, like patient navigation programs, are effective and recommended, especially for minority and underserved women. Although the literature on rural healthcare is significant, the field lacks studies of adaptive service delivery models and rigorous evaluation of evidence-based programs that facilitate routine screening and appropriate follow-up across large geographic areas.

OBJECTIVES

To better understand how to implement a decentralized regional delivery "hub & spoke" model for rural breast cancer screening and patient navigation, we have designed a rigorous, structured, multi-level and mixed-methods evaluation based on Glasgow's RE-AIM model (Reach, Effectiveness, Adoption, Implementation, and Maintenance).

METHODS AND DESIGN

The program is comprised of three core components: 1) Outreach to underserved women by partnering with county organizations; 2) Navigation to guide patients through screening and appropriate follow-up; and 3) Centralized Reimbursement to coordinate funding for screening services through a central contract with Medicaid Breast and Cervical Cancer Services (BCCS). Using Glasgow's RE-AIM model, we will: 1) assess which counties have the resources and capacity to implement outreach and/or navigation components, 2) train partners in each county on how to implement components, and 3) monitor process and outcome measures in each county at regular intervals, providing booster training when needed.

DISCUSSION

This evaluation strategy will elucidate how the heterogeneity of rural county infrastructure impacts decentralized service delivery as a navigation program expands. In addition to increasing breast cancer screening access, our model improves and maintains time to diagnostic resolution and facilitates timely referral to local cancer treatment services. We offer this evaluation approach as an exemplar for scientific methods to evaluate the translation of evidence-based federal policy into sustainable health services delivery in a rural setting.

Characteristics of the Frontier Extended Stay Clinic: a new facility model

Purpose

In 2004, 5 remote clinics – 4 in rural frontier communities in Alaska and 1 in Washington – were funded to pilot and examine the effectiveness and appropriateness of a new facility model. Transporting patients from these locations to higher levels of care is not always possible requiring these facilities to expand their scope of services and provide care for extended periods. The Frontier Extended Stay Clinic (FESC) model is staffed and equipped to provide the combined services usually found in the separate settings of an outpatient primary-care clinic, inpatient acute care hospital and emergency room. This is a descriptive study of the characteristics of these pilot facilities and an analysis of patient utilization and outcomes.

Methods

The 5 clinics collected outcome data for 2,226 extended-stay encounters of 4 hours or longer from 15 September 2005 to 14 September 2010. Data from these extended-stay encounters were summarized, and descriptive statistics were used to describe: number and duration of encounters, when the encounters started, chief compliant, discharge diagnoses, transfer destination, Medicare and Medicaid eligibility, and type of encounter.

Findings

From 2005 to 2010, the mean duration of an extended-stay encounter was 9.1 hours. All of the clinics experienced many extended-stay encounters that were initiated or continued after normal business hours. The 5 most frequent diagnoses at discharge for extended encounters were cardiovascular, gastrointestinal, injury, substance abuse and pneumonia/bronchitis. Almost half, 47.6%, of extended-stay encounters resulted in discharge of the patient without a need for either non-urgent follow-up referral or transport. Extended-stay encounters that ended in a patient being transported to another medical facility were 43.7% of the total. More than a quarter (26.9%) of extended-stay encounters were eligible for Medicare payment.

Conclusion

While many of communities can support a facility for primary care, there is an on-going need for facilities in remote frontier areas to also provide emergent and extended-stay care. The FESC can provide access to primary, emergent and extended-stay services in these locations.

Managing acutely ill substance-abusing patients in an integrated day hospital outpatient program: medical therapies, complications, and overall treatment outcomes

BACKGROUND

Substance-abusing adults are admitted to hospitals for medical complications from their drug and alcohol use at substantially higher rates than the general public; yet, their care is often defined by against medical advice (AMA) discharges and low rates of referral to addiction treatment programs.

METHODS

We present findings from a chart review of consecutive admissions to an integrated medical-substance abuse treatment program designed for acutely ill, hospitalized substance using adults. We specifically looked at factors associated with program completion and medical complications in this cohort of at-risk adults.

RESULTS

Overall, 83 patient cases were studied. The mean age was 41.2 years; most were African American (73.5%), male (68.7%), and homeless (77.1%). Heroin (96.4%) and cocaine (88.0%), followed by alcohol (44.6%) were the most commonly used substances before admission. The most common admitting diagnoses were infectious endocarditis (43.4%), abscess or nonhealing ulcer (18.1%), and osteomyelitis (13.3%) with intravenous antibiotic (68.7%), physical therapy (48.2%), or wound care (41.0%), the most commonly prescribed care on the integrated care/day hospital unit. The mean length of stay in the day hospital was 12.4 days. Overall, 69.9% of patients successfully completed their medical therapy, and 63.9% were successfully referred to an outpatient substance abuse treatment program. Only 10.8% required an unscheduled hospital readmission and 15.7% required an after-hours emergency department visit during their stay.

CONCLUSION

Outpatient/day hospital-based integrated treatment is a viable option for medically ill substance-abusing adults who would otherwise be hospitalized and is associated with higher than expected completion rates and low rate of complications. Co-locating the unit at a hospital and integrating extensive social supports appear to be key components to this model.

Delays in initial treatment contact after first onset of a mental disorder

OBJECTIVE

To examine nationally representative patterns and predictors of delays in contacting a professional after first onset of a mental disorder.

DATA SOURCES

The National Comorbidity Survey, a nationally representative survey of 8,098 respondents aged 15-54.

STUDY DESIGN

Cross-sectional survey.

DATA COLLECTION

Assessed lifetime DSM-III-R mental disorders using a modified version of the Composite International Diagnostic Interview (CIDI). Obtained reports on age at onset of disorders and age of first treatment contact with each of six types of professionals (general medical doctors, psychiatrists, other mental health specialists, religious professionals, human services professionals, and alternative treatment professionals). Used Kaplan-Meier (KM) curves to estimate cumulative lifetime probabilities of treatment contact after first onset of a mental disorder. Used survival analysis to study the predictors of delays in making treatment contact.

PRINCIPAL FINDINGS

The vast majority (80.1 percent) of people with a lifetime DSM-III-R disorder eventually make treatment contact, although delays average more than a decade. The duration of delay is related to less serious disorders, younger age at onset, and older age at interview. There is no evidence that delay in initial contact with a health care professional is increased by earlier contact with other non-health-care professionals.

CONCLUSIONS

Within the limits of recalling lifetime events, it appears that delays in initial treatment contact are an important component of the larger problem of unmet need for mental health care. Interventions are needed to decrease these delays.