Implementation of Evidence-Based Practices within Treatment-As-Usual and Evidence-Based Practice Initiatives

Publicly funded initiatives are underway to improve implementation of evidence-based practices (EBP) in youth mental health services. However, we know little about the success of these initiatives or about EBP implementation independent of such initiatives. We examined EBP implementation in a treatment as usual (TAU) state and in six states with publicly funded EBP initiatives (EBPIs). In Study 1, we examined providers' use of practices derived from the evidence base (PDEB) and their predictors among 780 providers in a TAU state. In Study 2, we conducted a systematic review of implementation strategies, outcomes, and predictors of EBP use in six state funded EBPIs. Study 1 suggests TAU providers use PDEB alongside practices without consistent research support; provider racial/ethnic minority status, learning theory orientation, and manual use predict greater PDEB use. Study 2 indicates EBPIs employ multiple recommended implementation strategies with variable outcomes across studies and measurement approaches. Predictors of EBP use in EBPIs also varied, though training, setting, and youth age were consistent predictors across studies. While sample differences and inconsistent measurement across studies made direct comparisons somewhat tenuous, rates of PDEB use in the TAU sample appeared similar to those in publicly funded EBPIs. However, two states reported comparisons with TAU samples and found higher EBP implementation under EBPI. Different predictors impacted EBP use in TAU versus EBPIs. Our findings highlight the need for improved evaluation of EBPIs including clear reporting standards for outcomes and more consistent, standardized measurement of EBP use in order to better understand and improve EBPIs.

Hyperpolarization-activated channels in trigeminal ganglia innervating healthy and pulp-exposed teeth

AIM

To use immunocytochemistry for determining the expression of HCN1, HCN2 and HCN3 (three subunits of the hyperpolarization-activated cyclic nucleotide-gated current channel) in rodent trigeminal ganglia (TG) that innervate healthy teeth and determine if expression of HCN subunits is increased in TG following pulp exposure.

METHODOLOGY

Pulps were exposed in right maxillary incisors of male Sprague-Dawley rats. After fixation, TG were removed, cryostat sectioned, and immunocytochemistry was utilized to study the expression of HCN1-3 subunits. Immunoreactivity of individual neurons from the maxillary region of the TG was determined with ImageJ software. Differences in the number immunopositive neurons amongst groups were tested for statistical significance with either a Yates or Pearson's chi-square or Fisher's exact probability tests depending on neuron sample size. Differences in the intensity of immunoreactivity between groups were tested for statistical significance with a Student's t-test.

RESULTS

The majority of TG neurons were immunopositive for HCN1-3. Moreover, statistically significant increases in the number of TG neurons immunopositive for HCN1 and the intensity of HCN1-3 immunoreactivity were observed within hours of exposing the tooth pulp.

CONCLUSIONS

HCN1-3 expression, as determined by immunocytochemistry, is increased within hours after injury. Given that I(h) can facilitate neuronal excitability, results of the current study suggest that antagonists to HCN1-3 subunits could work as analgesics in the alleviation of orofacial pain.

Post-acute dispositions of older adults hospitalized for depression

This study addressed factors associated with six-month post-acute dispositions (continuous community stay, medical hospitalization, psychiatric rehospitalization, nursing home placement, death) for older adults hospitalized for depression and discharged to the community. The sample included 199 older adults; and data were collected via medical records, interviews with discharge planners, patients, and family members. Over half of the sample remained in the community throughout the observation period; 23% experienced psychiatric re-admission and 10% entered a nursing home. Several factors associated with nursing home placement were identified: less improvement in depression during the hospitalization, lower Global Assessment of Functioning (GAF) scores at discharge; and less mental health service use in the post-acute period. Those at higher risk of psychiatric re-admission had more previous psychiatric hospitalizations and were marginally more likely to be married and have lower Brief Psychiatric Rating Scale (BPRS) scores at discharge. Differentiating those at risk for nursing home placement may be easier than differentiating those at risk of psychiatric readmission.

Adequacy of home care and hospital readmission for elderly congestive heart failure patients

Readmission to acute care facilities is a frequent and costly problem among older adults with congestive heart failure (CHF). The study reported in this article tested the hypothesis that adequate home care, operationalized as patient-perceived adequacy of formal and informal assistance, is associated with lower readmission to acute care facilities. The study followed 253 elderly (age 65 and older) Medicare patients discharged to their homes after hospitalization for CHF, through structured telephone interviews at two, six, 10, and 14 weeks postdischarge. Study findings point to the importance of home care in reducing the high risk of readmission among elderly patients. The findings raise implications for practice, policy, and research.

Service use by elderly patients after psychiatric hospitalization

The extent and source of services used by older adults discharged to a community setting after a psychiatric hospitalization were examined in a prospective follow-up study. Patients were asked about service use in structured telephone interviews one month after hospital discharge. Subjects had comorbid medical conditions and high levels of functional impairment. Service use was low, highly skewed, and spread across three sectors of care-mental health specialty care (38 percent of the services), general medical care (35 percent), and social services and formal aging services (27 percent). Most service episodes were related to mental disorder.

Physical and cognitive functioning among chronically ill African-American and white elderly in home care following hospital discharge

OBJECTIVES

Although race is recognized as an important variable in health status and medical care, the conditions of African-American and white elders have not been studied sufficiently as they enter home care after hospital discharge. This study tests hypotheses that African-American elders enter home care sicker, more dependent, and cognitively impaired.

METHODS

Hypotheses were tested in two independent studies, both conducted in a Midwestern city. Study 1 compares the physical and cognitive conditions of 208 African-Americans and white elders discharged home after hospitalization for congestive heart failure. Data were obtained from medical records and from patient interviews. Study 2 compares the physical and cognitive conditions of 212 African-Americans and white elders discharged home after hospitalization for hip fracture, cerebral vascular accident, and congestive heart failure. Data were obtained from medical records and interviews with patients' discharge planners.

RESULTS

African-Americans were found to go home more sick, more dependent, and more cognitively impaired, although no race difference was found in instability at discharge.

CONCLUSIONS

These findings raise concerns about African-American elders' access to care in community settings, given their greater needs at discharge.

Racial differences in discharge planning

Given previously reported findings of racial differences in elderly people's use of posthospital care, this article focuses on discharge planning processes as explanations of differential service utilization. We studied the discharge plans for 369 African American and white elderly patients and examined options pursued for posthospital care by social workers, patients, and families for evidence of racial differences. We also looked for racial differences in ruling out nursing home care for reasons of patient and family preference. Discharge planning with African American patients and family members involved less pursuit of nursing home care and more pursuit of formal services in the home than planning with white patients and families. Implications for practice and future research are discussed.

Implementation of discharge plans for chronically ill elders discharged home

Although discharge plans are viewed as the primary means to ensure that patients' needs will be met in the posthospital environment, little is known about the implementation of arranged care. This study addressed the extent to which discharge plans for elderly patients with congestive heart failure were implemented as planned, tested the consequences of implementation problems, and identified factors associated with implementation problems. For 40 percent of patients, one or more components of the discharge plan were not implemented as planned, with discrepancies more likely among low-income patients. Implementation discrepancies had negative consequences in terms of unmet needs, deficient quantity of help, and less than adequate care. Implications for hospital discharge planners and home health care are discussed.

Post-hospital home care for African-American and white elderly

This study of 208 chronically ill African-American and white elderly entering home care after hospitalization examined race differences in informal and formal services received and adequacy of care. Controlling for marital status, interference in activities from chronic conditions, socioeconomic status, age, and gender in regression analyses, African-Americans received significantly fewer hours of formal care per week but received significantly more hours of informal care per week from the primary caregiver. However, there was a tendency for African-Americans to rate their care as less adequate. Implications of the findings for practice, policy, and research are discussed.

Pediatric discharge planning: complications, efficiency, and adequacy

The complications encountered in discharge planning in an acute care pediatric hospital were documented. The cases of 105 children hospitalized on selected units of an acute care, regional, pediatric hospital in the Midwest were studied. The most frequently encountered complications were financial, family unavailability and lack of cooperation, family inability/unwillingness to learn patient care, custody issues, unexpected medical developments, and transportation problems. Team differences in understanding the child's psychosocial situation and custody disputes were associated with delays in discharge. Private insurance, late referral, and lack of family availability were associated with the adequacy of the discharge plan, as rated by the discharge planner at discharge. Results show discharge planning to be a complex process, affected by family, resource, and team work issues.

Hip fracture

One of the major factors contributing to a deterioration in the quality of life and independence of older adults is osteoporosis and hip fracture. Recent advances in our knowledge of the causes of hip fracture are providing new and effective approaches to the prevention of this disabling condition. Because hip fracture is a leading cause of disability, significant efforts have been directed to the development of strategies for the more effective rehabilitation and treatment of the fracture patient.

The challenge of racial difference: skills for clinical practice

Just as racial injustice negatively affects the plight of minorities in society, racial tensions impede professional helping. Often, the racially dissimilar social worker and client approach each other with little understanding of each other's social realities and with unfounded assumptions. Unfortunately, professionals find it difficult to acknowledge such differences or their effect on their relationships. Yet the fruitfulness of the helping encounter often depends on the ability to develop and invest in a trusting relationship. This article identifies the societal roots of the stresses associated with cross-racial relationships. Three concerns commonly experienced by clients whose workers are racially different are identified: (1) Is the helper a person of goodwill? (2) Is the helper trained and skilled? (3) Is the help offered valid and meaningful for me and my social reality? Case vignettes are used to illustrate how each concern is typically mishandled. The importance of successfully managing each concern is stressed, and skills for successful management are illustrated.

The social-environmental context of child clients: an empirical exploration

This article examines the family and social-environmental problems reported by parents of 226 children seen at a child guidance clinic. Responses to a 21-item problem inventory revealed a relatively high frequency of family and social problems. Financial, school, employment, and housing problems were frequently reported, as were parental arguing and problems in dividing household chores. Problems varied by race and socioeconomic status. Low-income families reported more problems, both social and family, and were more likely to experience certain types of problems. White families reported a higher number of family problems and were more likely to report parent-child conflict, family violence, and health or medical problems. Regardless of income, African American families were more likely to experience problems with unsafe neighborhoods.

Classification and correlates of ethical dilemmas in hospital social work

The authors used categories based on the NASW Code of Ethics to code hospital social workers' descriptions of ethical dilemmas according to the specific principles in conflict. They also developed codes to identify discharge destination and medical care issues involved in the ethical dilemma. Most ethical dilemmas were found to involve conflicts between client self-determination and client best interest. Ethical dilemmas were more likely when patient mental status was impaired and when decision making was problematic. Ethical dilemmas were related to delayed discharge, in-hospital mortality, and less-than-adequate postdischarge care. The study enhances understanding of ethical dilemmas and advances a methodology for studying their occurrence and consequences.

Child demographics and DSM diagnosis: a multi-axis study

Using all five axes of the DSM-III, this study explored variations by gender, race age, and socioeconomic status in diagnoses given to children at an outpatient child guidance clinic. Overall, boys, minorities, and low income children were more likely to receive the more serious diagnoses on the DSM-III and to be given the diagnoses that are least likely to go into remission with the passage of time. Alternative explanations for these findings of differences are discussed, and implications for practice and research are identified.