Outcomes of a Partnered Facilitation Strategy to Implement Primary Care–Mental Health

BACKGROUND

Implementing new programs and practices is challenging, even when they are mandated. Implementation Facilitation (IF) strategies that focus on partnering with sites show promise for addressing these challenges.

OBJECTIVE

Our aim was to evaluate the effectiveness of an external/internal IF strategy within the context of a Department of Veterans Affairs (VA) mandate of Primary Care–Mental Health Integration (PC-MHI).

DESIGN

This was a quasi-experimental, Hybrid Type III study. Generalized estimating equations assessed differences across sites.

PARTICIPANTS

Patients and providers at seven VA primary care clinics receiving the IF intervention and national support and seven matched comparison clinics receiving national support only participated in the study.

INTERVENTION

We used a highly partnered IF strategy incorporating evidence-based implementation interventions.

MAIN MEASURES

We evaluated the IF strategy using VA administrative data and RE-AIM framework measures for two 6-month periods.

KEY RESULTS

Evaluation of RE-AIM measures from the first 6-month period indicated that PC patients at IF clinics had nine times the odds (OR=8.93, p<0.001) of also being seen in PC-MHI (Reach) compared to patients at non-IF clinics. PC providers at IF clinics had seven times the odds (OR=7.12, p<0.001). Compared to PC patients at non-IF sites, patients at IF clinics did not have lower odds (OR=1.34, p=0.232) of being referred for first-time mental health specialty clinic visits (Effectiveness), or higher odds (OR=1.90, p=0.350) of receiving same-day access (Implementation). Assessment of program sustainability (Maintenance) was conducted by repeating this analysis for a second 6-month time period. Maintenance analyses results were similar to the earlier period.

CONCLUSION

The addition of a highly partnered IF strategy to national level support resulted in greater Reach and Adoption of the mandated PC-MHI initiative, thereby increasing patient access to VA mental health care.

     

Primary Care Clinicians’ Recognition and Management of Depression: A Model of Depression Care in Real-World Primary Care Practice

BACKGROUND

Depression is prevalent in primary care (PC) practices and poses a considerable public health burden in the United States. Despite nearly four decades of efforts to improve depression care quality in PC practices, a gap remains between desired treatment outcomes and the reality of how depression care is delivered.

OBJECTIVE

This article presents a real-world PC practice model of depression care, elucidating the processes and their influencing conditions.

DESIGN

Grounded theory methodology was used for the data collection and analysis to develop a depression care model. Data were collected from 70 individual interviews (60 to 70 min each), three focus group interviews (n?=?24, 2 h each), two surveys per clinician, and investigators’ field notes on practice environments. Interviews were audiotaped and transcribed for analysis. Surveys and field notes complemented interview data.

PARTICIPANTS

Seventy primary care clinicians from 52 PC offices in the Midwest: 28 general internists, 28 family physicians, and 14 nurse practitioners.

KEY RESULTS

A depression care model was developed that illustrates how real-world conditions infuse complexity into each step of the depression care process. Depression care in PC settings is mediated through clinicians’ interactions with patients, practice, and the local community. A clinician’s interactional familiarity (“familiarity capital”) was a powerful facilitator for depression care. For the recognition of depression, three previously reported processes and three conditions were confirmed. For the management of depression, 13 processes and 11 conditions were identified. Empowering the patient was a parallel process to the management of depression.

CONCLUSIONS

The clinician’s ability to develop and utilize interactional relationships and resources needed to recognize and treat a person with depression is key to depression care in primary care settings. The interactional context of depression care makes empowering the patient central to depression care delivery.     

Does Primary Care Fill the Gap in Access to Specialty Mental Health Care? A Mixed Methods Study

BackgroundBroad consensus supports the use of primary care to address unmet need for mental health treatment.ObjectiveTo better understand whether primary care filled the gap when individuals were unable to access specialty mental health care.Design2018 mixed methods study with a national US internet survey (completion rate 66%) and follow-up interviews.ParticipantsPrivately insured English-speaking adults ages 18–64 reporting serious psychological distress that used an outpatient mental health provider in the last year or attempted to use a mental health provider but did not ultimately use specialty services (N = 428). Follow-up interviews were conducted with 30 survey respondents.Main MeasuresWhether survey respondents obtained mental health care from their primary care provider (PCP), and if so, the rating of that care on a 1 to 10 scale, with ratings of 9 or 10 considered highly rated. Interviews explored patient-reported barriers and facilitators to engagement and satisfaction with care provided by PCPs.Key ResultsOf the 22% that reported they tried to but did not access specialty mental health care, 53% reported receiving mental health care from a PCP. Respondents receiving care only from their PCP were less likely to rate their PCP care highly (21% versus 48%; p = 0.01). Interviewees reported experiences with PCP-provided mental health care related to three major themes: PCP engagement, relationship with the PCP, and PCP role.ConclusionsPrimary care is partially filling the gap for mental health treatment when specialty care is not available. Patient experiences reinforce the need for screening and follow-up in primary care, clinician training, and referral to a trusted specialty consultant when needed.Supplementary InformationThe online version contains supplementary material available at 10.1007/s11606-021-07260-z.KEY WORDS: Mental health access, Primary care, Private health insurance     

The Relationship Between Type 2 Diabetic Patients’ Early Medical Care–Seeking Consistency to the Same Clinician and Health Care System and Their Clinical Outcomes

The literature has demonstrated that the continuity of diabetes care can lower medical service utilization and expenses. However, few studies have examined the effects of patients’ medical care–seeking behaviors in the early stage after the diagnosis of diabetes on their long-term prognoses.This study aimed to examine the association of medical care–seeking behavior in the first year following diabetes diagnosis on the occurrence of diabetes-related complications among patients in Taiwan. This is a retrospective data collection with follow-up analysis and a nationwide population-based dataset in Taiwan. A total of 89,428 newly diagnosed type 2 diabetes mellitus patients during the period from 2000 to 2006 were followed up until 2010. The patients’ medical care–seeking behaviors were classified as follows: high consistency to a physician, high consistency to a medical setting, medium consistency to providers, and low consistency to providers. The occurrence of diabetes-related complications and all-cause mortality were the primary outcomes of this study. Chi-square tests, ANOVAs, and Cox proportional hazard models were applied to examine the relationships between the predictors and medical outcomes.Compared to the patients with high medical care–seeking consistency to a physician, the multivariate-adjusted hazard ratios of diabetes-related complications occurrence among patients in the high consistency to a medical setting, medium consistency, and low consistency categories were 1.112 (95% CI 1.089–1.136, P < 0.001), 1.226 (95% CI 1.205–1.248, P < 0.001), and 1.536 (95% CI 1.504–1.567, P < 0.001) in outpatient visits and 1.032 (95% CI 0.992–1.074, P = 0.121), 1.056 (95% CI 1.022–1.092, P = 0.001), and 1.208 (95% CI 1.164–1.254, P < 0.001) in complication-incurred hospitalizations, respectively. The monotonic trend was sustained across different strata of age, gender, and disease complexity.The findings of this study suggest that the incentives of continuity of care and physician–patient relationship management should be reinforced during the early stage of diabetes care in future medical care systems.     

Patient–Provider Communication About Sexual Health Among Unmarried Middle-aged and Older Women

BACKGROUND  Although past studies have highlighted the importance of patient–provider communication about sexual health and intimate relationships (SHIR), much of the research has focused on young women’s or married women’s experiences when discussing SHIR with their providers. OBJECTIVE  To describe experiences of unmarried, middle-aged and older women in communicating about SHIR with their health care providers. DESIGN AND PARTICIPANTS  Qualitative interviews were conducted with 40 unmarried women aged 40–75 years. We compared the responses of 19 sexual minority (lesbian and bisexual) women and 21 heterosexual women. RESULTS  Women varied in their definitions of intimate relationships. Not all women thought providers should ask about SHIR unless questions were directly related to a health problem, and most were not satisfied with questions about SHIR on medical intake forms. However, the themes women considered to be important in communication about SHIR were remarkably consistent across subgroups (e.g. previously married or never married; sexual minority or heterosexual). Sexual minority women were more hesitant to share information about SHIR because they had had prior negative experiences when disclosing their sexual orientation or perceived that clinicians were not informed about relevant issues. CONCLUSIONS  Some women felt that providers should ask about SHIR only if questions relate to an associated health problem (e.g. sexually transmitted infection). When providers do ask questions about SHIR, they should do so in ways that can be answered by all women regardless of partnering status, and follow questions with non-judgmental discussions. Support for this research was provided by the National Cancer Institute, K07-CA87070, to Melissa A. Clark, PhD and the National Cancer Institute 2 R25 CA087972-06A2 to The Miriam Hospital.     

Yes, But It’s Somewhat Difficult-Managing End of Life Care in Primary Health Care

A qualitative study was undertaken to investigate the perceptions of General Practitioners regarding the management of older people with heart failure, particularly at the end of life. Semi-structured interviews were conducted with 30 General Practitioners in Auckland, New Zealand during 2008. Participants identified that the needs of older patients with heart failure could not be addressed in isolation from the wider issues which affect older people. This complexity influenced all components of patient need including the typical course of the disease, the provision of prognostic and end of life information, and how palliative care was provided, including referral to specialist services. Some participants also believed that older people??s palliative care management should be approached differently to that of younger people stating, for example, that they were concerned about the amount of information older people could take in. A model which takes into consideration the experiences of the older person and fits them into, not a ??dying model?? but a ??life model??, one that supports the natural transition to end of life is needed. A ??life planning model?? used early in the management of patients would be a useful way forward and one which would allow the integration of the different paradigms of cardiology, gerontology, palliative care and nursing.     

Patient–Provider and Patient–Staff Racial Concordance and Perceptions of Mistreatment in the Health Care Setting

Objectives To determine what roles patient–provider and patient–staff racial concordance play on patients’ perceptions within the health care setting. Design, Setting, Participants Data from the Commonwealth Fund 2001 Quality of Care telephone survey. Analysis focused on the subsample of 6,066 adults who live in the continental United States and who reported having a regular provider or a usual source of care (n = 4,762). Measurements and Results We analyzed patients’ responses about perceptions of disrespect, unfair treatment because of race and language, and the belief that he/she would have received better treatment if he/she belonged to a different race. We compared these perceptions of mistreatment with provider and staff racial concordance, controlling for sociodemographic variables. Contrary to our hypothesis, Hispanics were more likely to report being treated with disrespect if in a concordant relationship with their provider than if in a nonconcordant one (odds ratio [OR] 2.42, P < .01). Asians were less likely to report being treated unfairly because of race if in racially concordant relationships with providers than if in nonconcordant ones (P < .05). Hispanics were also less likely to perceive unfair treatment because of language when in concordant relationships with staff as compared to nonconcordant relationships with staff (P < .05). Conclusions Patients’ perceptions of health care relationships may partially depend on racial concordance with providers and staff. The nature of the association between racial concordance and perceived disrespect varies by racial group, indicating that other race-specific factors may also need to be examined. The topics discussed in this paper were presented as an abstract at a conference for the Society of Academic Emergency Medicine, May 2006.     

Racial and Social Disparities in Health and Health Care Delivery among Patients with Parkinson’s Disease and Related Disorders in a Multiracial Clinical Setting

There are racial and socioeconomic disparities in the care of patients with Parkinson’s disease (PD). Bellevue Hospital Center (BHC) in New York City is the oldest public hospital in the United States providing care to a multiracial, socioeconomically diverse and medically underserved population. We investigated racial and social disparities in providing care to patients with PD and related disorders at BHC compared to a NYU Langone Health, a Parkinson’s Foundation Center of Excellence. Retrospective chart review of patients with diagnosis of PD or PD-related disorders evaluated at BHC or at NYU outpatient clinics from January 2012 to August 2017. 100 patients were enrolled from each site: BHC (55% men); NYU (49% men). The majority of patients at NYU were White (77%), compared to 14% at BHC; Hispanic patients comprised the majority at BHC (56%) (p?<?0.001). BHC patients had more clinic visits per year compared to the NYU cohort (2.88 vs. 2.40, p?=?0.001). BHC patients were less likely to self-report exercise (p?=?0.047) or participation in physical therapy (p?=?0.015). There were no clinically significant differences in diagnosis type, time to diagnosis, average Hoehn & Yahr or levodopa equivalent dose. Compared to a Parkinson’s Foundation Center of Excellence, PD patients in a public hospital system are more racially diverse, are less likely to be insured, have higher rates of care utilization and are less likely to access necessary interventions such as physical therapy and exercise.

     

Correlates of Suicide Among Veterans Treated in Primary Care: Case–Control Study of a Nationally Representative Sample

BACKGROUND

Veterans receiving Veterans Affairs (VA) healthcare have increased suicide risk compared to the general population. Many patients see primary care clinicians prior to suicide. Yet little is known about the correlates of suicide among patients who receive primary care treatment prior to death.

OBJECTIVE

Our aim was to describe characteristics of veterans who received VA primary care in the 6 months prior to suicide; and to compare these to characteristics of control patients who also received VA primary care.

DESIGN

This was a retrospective case–control study.

SUBJECTS

The investigators partnered with VA operations leaders to obtain death certificate data from 11 states for veterans who died by suicide in 2009. Cases were matched 1:2 to controls based on age, sex, and clinician.

MAIN MEASURES

Demographic, diagnosis, and utilization data were obtained from VA’s Corporate Data Warehouse. Additional clinical and psychosocial context data were collected using manual medical record review. Multivariate conditional logistic regression was used to examine associations between potential predictor variables and suicide.

KEY RESULTS

Two hundred and sixty-nine veteran cases were matched to 538 controls. Average subject age was 63 years; 97 % were male. Rates of mental health conditions, functional decline, sleep disturbance, suicidal ideation, and psychosocial stressors were all significantly greater in cases compared to controls. In the final model describing men in the sample, non-white race (OR?=?0.51; 95 % CI?=?0.27–0.98) and VA service-connected disability (OR?=?0.54; 95 % CI?=?0.36–0.80) were associated with decreased odds of suicide, while anxiety disorder (OR?=?3.52; 95 % CI?=?1.79–6.92), functional decline (OR?=?2.52; 95 % CI?=?1.55–4.10), depression (OR?=?1.82; 95 % CI?=?1.07–3.10), and endorsement of suicidal ideation (OR?=?2.27; 95 % CI?=?1.07–4.83) were associated with greater odds of suicide.

CONCLUSIONS

Assessment for anxiety disorders and functional decline in addition to suicidal ideation and depression may be especially important for determining suicide risk in this population. Continued development of interventions that support identifying and addressing these conditions in primary care is indicated.

     

Stress and Health–Related Quality of Life Among HIV-Infected Persons in Hong Kong

This study examines the relationships among illness-related factors, stress, health-related quality of life (HRQOL), and psychological distress in persons infected with the human immunodeficiency virus (HIV) living in Hong Kong (N = 55). Participants completed questionnaires including a Symptom Checklist, Modified HIV Stressor Scale (HIVSS), Medical Outcomes Study Short-Form 36 (SF-36), and the Hospital Anxiety and Depression Scale (HADS). In addition, CD4 count information was obtained. Multiple regression analyses were used to model the SF-36 and HADS scores as a function of illness-related factors as well as the stress count and intensity. The number of symptoms was found to be inversely related to SF-36 general health and positively related to the HADS anxiety score. However, CD4 count did not have any significant association with any of the scales on the HRQOL or psychological distress. After controlling for the effect of symptoms, the HIVSS stress count still accounted significantly for additional variance in both HADS anxiety and depression as well as the SF-36 social functioning and role-emotional scores. The study supports the possible contribution of psychosocial factors to the HRQOL and psychological distress after controlling for illness-related factors. Results are discussed in the context of characteristic social factors and services in Hong Kong.