Reducing Mechanical Restraints in Acute Psychiatric Care Settings Using Rapid Response Teams

This article describes the use of rapid response teams to reduce the use of mechanical restraints (i.e., restricting a person’s movement through the use of a mechanical device such as a backboard, net, or papoose) in an acute psychiatric care setting. Rapid response teams have proven highly effective for emergent medical patients, but have not typically been used in behavioral health care settings. Utilizing a rapid cycle process improvement approach, a response team was convened following each episode of mechanical restraint in an inpatient psychiatric treatment facility. Initial results, during a 6-week rapid cycle change process, showed that mechanical restraints were reduced by 36.4% when compared with a 6-week baseline and when compared with a 1-year baseline. Changes in hospital census during the implementation process did not appear to account for the reduction in restraints. Rapid response teams and rapid cycle process improvement are discussed as useful change vehicles for behavioral health care organizations.     

Translating evidence-based depression management services to community-based primary care practices

Randomized controlled trials have demonstrated the efficacy and cost-effectiveness of using treatment models for major depression in primary care settings. Nonetheless, translating these models into enduring changes in routine primary care has proved difficult. Various health system and organizational barriers prevent the integration of these models into primary care settings. This article discusses barriers to introducing and sustaining evidence-based depression management services in community-based primary care practices and suggests organizational and financial solutions based on the Robert Wood Johnson Foundation Depression in Primary Care Program. It focuses on strategies to improve depression care in medical settings based on adaptations of the chronic care model and discusses the challenges of implementing evidence-based depression care given the structural, financial, and cultural separation between mental health and general medical care.     

Joint working in community mental health teams: implementation of an integrated care pathway

Abstract Integration of community mental health services is a key policy objective that aims to increase quality and efficiency of care. Integrated care pathways (ICPs) are a mechanism designed to formalise multi-agency working at an operational level and are currently being applied to mental health services. Evidence regarding the impact of this tool to support joint working is mixed, and there is limited evidence regarding the suitability of ICPs for complex, community-based services. The present study was set in one primary care trust (PCT) in Scotland that is currently implementing an ICP for community mental health teams (CMHTs) across the region. The aim of the study was to investigate professionals' experiences and views on the implementation of an ICP within adult CMHTs in order to generate learning points for other organisations which are considering developing and implementing such systems. The study used qualitative methods which comprised of individual interviews with three CMHT leaders and two service development managers, as well as group interviews with members of four adult CMHTs. Data was analysed using the constant comparison method. Participants reported positive views regarding joint working and the role of an ICP in theory. However, in practice, teams were not implementing the ICP. Lack of integration at higher organisational levels was found to create conflicts within the teams which became explicit in response to the ICP. Implementation was also hindered by lack of resources for ongoing support, team development and change management. In conclusion, the study suggests that operational systems such as ICPs do not address and cannot overcome wider organisational barriers to integration of mental health services. Integrated care pathways need to be developed with strategic input as well as practitioner involvement and ownership. Team development, education about integration and change management are essential if ICPs are to foster and support joint working in integrated teams.     

Risk sharing and the supply of mental health services

This paper examines the effects of risk sharing with mental health providers in a managed care context. The results show that providers that received a fixed payment per case reduced the number of outpatient visits by 20-25%, compared with providers who continued to be paid for each visit. This effect was stronger for integrated group practices and providers with more intensive utilization review protocols. In addition, evidence was found that in a setting where providers serve multiple payers, the share of their total revenue derived from risk-sharing contracts is an important determinant of the magnitude of the supply response.     

Organizational Leadership For Building Effective Health Care Teams

The movement toward accountable care organizations and patient-centered medical homes will increase with implementation of the Affordable Care Act (ACA). The ACA will therefore give further impetus to the growing importance of teams in health care. Teams typically involve 2 or more people embedded in a larger social system who differentiate their roles, share common goals, interact with each other, and perform tasks affecting others. Multiple team types fit within this definition, and they all need support from leadership to succeed. Teams have been invoked as a necessary tool to address the needs of patients with multiple chronic conditions and to address medical workforce shortages. Invoking teams, however, is much easier than making them function effectively, so we need to consider the implications of the growing emphasis on teams. Although the ACA will spur team development, organizational leadership must use what we know now to train, support, and incentivize team function. Meanwhile, we must also advance research regarding teams in health care to give those leaders more evidence to guide their work.     

Does integrated governance lead to integrated patient care? Findings from the innovation forum

Good integration of services that aim to reduce avoidable acute hospital bed use by older people requires frontline staff to be aware of service options and access them in a timely manner. In three localities where closer inter‐organisational integration was taking place, this research sought patients’ perceptions of the care received across and within organisational boundaries. Between February and July 2008, qualitative methods were used to map the care journeys of 18 patients (six from each site). Patient interviews (46) covered care received before, at the time of and following a health crisis. Additional interviews (66) were undertaken with carers and frontline staff. Grounded theory‐based approaches showed examples of well‐integrated care against a background of underuse of services for preventing health crises and a reliance on ‘traditional’ referral patterns and services at the time of a health crisis. There was scope to raise both practitioner and patient awareness of alternative care options and to expand the availability and visibility of care ‘closer to home’ services such as rapid response teams. Concerns voiced by patients centred on the adequacy of arrangements for organising ongoing care, while family members reported being excluded from discussions about care arrangements and the roles they were expected to play. The coordination of care was also affected by communication difficulties between practitioners (particularly across organisational boundaries) and a lack of compatible technologies to facilitate information sharing. Finally, closer organisational integration seemed to have limited impact on care at the patient/practitioner interface. To improve care experienced by patients, organisational integration needs to be coupled with vertical integration within organisations to ensure that strategic goals influence the actions of frontline staff. As they experience the complete care journey, feedback from patients can play an important role in the service redesign agenda.     

Working atmosphere,job satisfaction and individual characteristics of community mental health professionals in integrated care

Working requirements of community mental healthcare professionals in integrated care are complex. There is a lack of research concerning the relation of job satisfaction, working atmosphere and individual characteristics. For the current study, a survey evaluating job satisfaction and working atmosphere of mental healthcare professionals in integrated care was performed. About 321 community mental healthcare professionals were included in the survey; the response rate was 59.5%. The professional background of community mental healthcare professionals included nursing, social work and psychology. Community mental healthcare professionals reported the highest satisfaction with colleagues and the lowest satisfaction with income. Moreover, it could be shown that more responsibility, more recognition and more variety in job tasks lead to an increase of overall job satisfaction. Healthcare for mentally ill patients in the community setting is complex and requires well‐structured care with appropriate responsibilities within the team. A co‐operative relationship among colleagues as well as clearly defined responsibilities seem to be the key for the job satisfaction of community mental healthcare professionals in integrated care.     

Understanding team-based quality improvement for depression in primary care

OBJECTIVE: To assess the impacts of the characteristics of quality improvement (QI) teams and their environments on team success in designing and implementing high quality, enduring depression care improvement programs in primary care (PC) practices. STUDY SETTING/DATA SOURCES: Two nonprofit managed care organizations sponsored five QI teams tasked with improving care for depression in large PC practices. Data on characteristics of the teams and their environments is from observer process notes, national expert ratings, administrative data, and interviews. STUDY DESIGN: Comparative formative evaluation of the quality and duration of implementation of the depression improvement programs developed by Central Teams (CTs) emphasizing expert design and Local Teams (LTs) emphasizing participatory local clinician design, and of the effects of additional team and environmental factors on each type of team. Both types of teams depended upon local clinicians for implementation. PRINCIPAL FINDINGS: The CT intervention program designs were more evidence-based than those of LTs. Expert team leadership, support from local practice management, and support from local mental health specialists strongly influenced the development of successful team programs. The CTs and LTs were equally successful when these conditions could be met, but CTs were more successful than LTs in less supportive environments. CONCLUSIONS: The LT approach to QI for depression requires high local support and expertise from primary care and mental health clinicians. The CT approach is more likely to succeed than the LT approach when local practice conditions are not optimal.     

Perception and use of the results of patient satisfaction surveys by care providers in a French teaching hospital.

OBJECTIVE: . The aim of this study was to assess clinical staff's opinions on the results of in-patient satisfaction surveys and their use within the quality improvement process. SETTING: The institution is a 2200-bed teaching hospital of tertiary health care employing 8000 professionals. Patient satisfaction surveys are carried out each year using a validated questionnaire mailed to a random sample of patients. The specific results of each department are sent to the medical and paramedical managers. METHODS: We conducted a questionnaire survey on 500 care providers randomly selected in every medical and surgical department. RESULTS: A total of 261 questionnaires were returned and analysed. Overall, 94% of responders had a favourable opinion of the patient satisfaction surveys. They considered that the patient was able to judge hospital service quality, especially in its relational, organizational, and environmental dimensions. The specific results for the department were less well known than the overall hospital results (60 versus 76%). These results were formally discussed in the department according to 40% of responders; 40% declared that these data resulted in improvement actions and considered that they led to modifications in their behaviour with patients. CONCLUSIONS: Despite a declared interest in satisfaction surveys, the results remain underused by hospital staff and insufficiently discussed within teams.     

Evaluating quality of patient care communication in integrated care settings: a mixed method approach.

BACKGROUND: Owing to the involvement of multiple professionals from various institutions, integrated care settings are prone to suboptimal patient care communication. To assure continuity, communication gaps should be identified for targeted improvement initiatives. However, available assessment methods are often one-sided evaluations not appropriate for integrated care settings. OBJECTIVE: We developed an evaluation approach that takes into account the multiple communication links and evaluation perspectives inherent to these settings. In this study, we describe this approach, using the integrated care setting of Cerebral Palsy as illustration. METHODS: RESULTS: The approach follows a three-step mixed design in which the results of each step are used to mark out the subsequent step's focus. The first step patient questionnaire aims to identify quality gaps experienced by patients, comparing their expectancies and experiences with respect to patient-professional and inter-professional communication. Resulting gaps form the input of in-depth interviews with a subset of patients to evaluate underlying factors of ineffective communication. Resulting factors form the input of the final step's focus group meetings with professionals to corroborate and complete the findings. CONCLUSIONS: By combining methods, the presented approach aims to minimize limitations inherent to the application of single methods. The comprehensiveness of the approach enables its applicability in various integrated care settings. Its sequential design allows for in-depth evaluation of relevant quality gaps. Further research is needed to evaluate the approach's feasibility in practice. In our subsequent study, we present the results of the approach in the integrated care setting of children with Cerebral Palsy in three Dutch care regions.