GP Clinic: promoting access to primary health care for mental health service clients

Objective: To evaluate an innovative rural service offering comprehensive primary health care for mental health service clients. Design: A formative evaluation using mixed methods. Setting: A rural NSW community. Participants: Fifteen health care providers and 120 adult clients. Intervention: A monthly clinic held in a general practice to provide primary health care for clients of the community mental health team. Main outcome measures: Client utilisation and clinic activity data. Provider views of service effectiveness, possible improvements and sustainability. Results: The GP Clinic has operated successfully for 2.5 years without access block. Some 52% of clients had no physical illness and 82% were referred to other health and community services. In total, 40% continued to attend the clinic while 32% went on to consult a GP independently. Client access to care improved as did collaboration between the community mental health team and primary care providers. Conclusion: The GP Clinic is a straightforward and flexible service model that could be used more widely.     

Cognitive appraisals of specialty mental health services and their relation to mental health service utilization in the rural population

Abstract Purpose: Rural individuals utilize specialty mental health services (eg, psychiatrists, psychologists, counselors, and social workers) at lower rates than their urban counterparts. This study explores whether cognitive appraisals (ie, individual perceptions of need for services, outcome expectancies, and value of a positive therapeutic outcome) of help‐seeking for depression symptoms are related to the utilization of specialty mental health services in a rural sample. Methods: Demographic and environmental characteristics, cultural barriers, cognitive appraisals, and depression symptoms were assessed in one model predicting specialty mental health service utilization (MHSU) in a rural sample. Three hypotheses were proposed: (1) a higher number of environmental barriers (eg, lack of insurance or transportation) would predict lower specialty mental health service utilization; (2) an increase in cultural barriers (stigma, stoicism, and lack of anonymity) would predict lower specialty mental health utilization; and (3) higher cognitive appraisals of mental health services would predict specialty mental health care utilization beyond the predictive capacities of psychiatric symptoms, demographic variables, environmental barriers, and cultural barriers. Findings: Current depression symptoms significantly predicted lifetime specialty mental health service utilization. Hypotheses 1 and 2 were not supported: more environmental barriers predicted higher levels of specialty MHSU while cultural barriers did not predict specialty mental health service utilization. Hypothesis 3 was supported: cognitive appraisals significantly predicted specialty mental health service utilization. Conclusions: It will be important to target perceptions and attitudes about mental health services to reduce disparities in specialty MHSU for the rural population.     

Social control agents or front-line carers for people with mental health problems: police and mental health services in Sydney,Australia

The relationship between mental health services and police and people who have mental health problems, are suicidal or are drug- and/or alcohol-affected is examined in this paper. A survey of 131 police officers in Sydney, Australia, revealed that more than 10% of police time is spent dealing with people with mental health problems. Nevertheless, police felt unsupported in this role, unprepared for it and torn between the competing demands experienced in their work. A lack of confidence in dealing with suicidal people and a belief that work with mentally disturbed people does not constitute valid police work are also reported. Managing people with mental disturbance is a major concern for police. Specifically, there are difficulties relating to: inadequate training and education; deficiencies in services/resources; time and resource over-utilization; communication, liaison and feedback problems, and frustration related to accessing mental health facilities/services. It is argued that police work involving mentally disturbed people is a valid and necessary role that complements law enforcement. In order to facilitate this aspect of police work, recommendations are made regarding education and collaborative working relationships between police and mental health professionals, which, in turn, could improve the care of mentally disturbed people in the community.     

Improving transfer of mental health care for rural and remote consumers in South Australia

In Australia, it is commonplace for tertiary mental health care to be provided in large regional centres or metropolitan cities. Rural and remote consumers must be transferred long distances, and this inevitably results in difficulties with the integration of their care between primary and tertiary settings. Because of the need to address these issues, and improve the transfer process, a research project was commissioned by a national government department to be conducted in South Australia. The aim of the project was to document the experiences of mental health consumers travelling from the country to the city for acute care and to make policy recommendations to improve transitions of care. Six purposively sampled case studies were conducted collecting data through semistructured interviews with consumers, country professional and occupational groups and tertiary providers. Data were analysed to produce themes for consumers, and country and tertiary mental healthcare providers. The study found that consumers saw transfer to the city for mental health care as beneficial in spite of the challenges of being transferred over long distances, while being very unwell, and of being separated from family and friends. Country care providers noted that the disjointed nature of the mental health system caused problems with key aspects of transfer of care including transport and information flow, and achieving integration between the primary and tertiary settings. Improving transfer of care involves overcoming the systemic barriers to integration and moving to a primary care-led model of care. The distance consultation and liaison model provided by the Rural and Remote Mental Health Services, the major tertiary provider of services for country consumers, uses a primary care-led approach and was highly regarded by research participants. Extending the use of this model to other primary mental healthcare providers and tertiary facilities will improve transfer of care.     

Rural and remote mental health placements for nursing students

Clinical placements can be instrumental in encouraging nursing students to consider a future career in rural Australia. Twenty nursing students from a metropolitan university were provided with the opportunity to undertake a clinical placement in mental health in a rural or remote setting. The majority of placements were between 2 and 4 weeks in length. They took place in community health centres and rehabilitation centres in New South Wales and in hospital inpatient facilities, remote areas and community health services in the Northern Territory. On return from the placement, students completed an open-question pro forma giving their views and impressions of their experiences and contrasting this with clinical experience gained in urban settings. The content of the students' responses was analysed and presented under the following themes: scale relating to urban and rural differences in population; geographical and health facility size; staffing matters; the environment; the students' perception of the clients; and professional interaction. Additional material relating to remote area placements is presented. Questions are raised about the maintenance of students' interest and the development of rural careers.     

VA community mental health service providers' utilization of and attitudes toward telemental health care: the gatekeeper's perspective

Context: Mental health (MH) providers in community‐based outpatient clinics (CBOCs) are important stakeholders in the development of the Veterans Health Administration (VA) telemental health (TMH) system, but their perceptions of these technologies have not been systematically examined. Purpose: The purpose of this study was to investigate the attitudes of CBOC providers about TMH services, current utilization of these technologies in their clinics, and sources of knowledge regarding TMH. Method: The study employed a mixed‐methods design to examine aspects of TMH in CBOCs located in a VA network in the south‐central United States. Semistructured, on‐site group interviews conducted with 86 CBOC MH providers were followed by in‐depth phone surveys with an MH provider identified as a key informant at each of 36 CBOCs in the VA network. Findings: The utilization of TMH services varied widely between CBOCs, and the scope of services provided typically focused on delivery of medication management, with little provision of psychological services. Further, several important barriers to expanded use of TMH were identified, including limited education and training and shortage of dedicated space for TMH encounters. Conclusions: General attitudes toward TMH were positive, and most CBOC providers indicated that they would like to expand use of TMH in their clinics.     

Codesigned recommendations for increasing engagement in structured physical activity for people with serious mental health problems in Australia

People with mental health problems are at higher risk of physical health comorbidities and early mortality. A key risk factor for poor health outcomes is a lack of regular physical activity. Mental health services have typically responded by focusing on screening and promoting lifestyle programmes within secondary care mental health settings. The aim of this study was to better understand the barriers and enablers for Australian mental health consumers to participate in physical activity or exercise programmes from the perspectives of consumers and exercise practitioners. Interviews with 15 consumers experiencing serious mental health problems and five exercise practitioners were undertaken, followed by two focus groups (involving eight consumers and two exercise practitioners) to gain consensus on themes from the interviews, and codesign a set of recommendations for services to support and increase the engagement of mental health consumers in regular community‐based exercise. Barriers that impacted on engagement in physical activity included: lack of social support, insufficient knowledge and information, difficulties with work/life balance, impact of physical and mental health issues, fear and lack of confidence, and financial cost. Enablers or motivators assisting engagement in community‐based physical activity programmes included: social support, access to person‐centred individualised exercise options, connection and a sense of belonging, and access to information and education. Recommendations and a checklist were developed to assist services to increase the involvement of mental health consumers in community‐based exercise and to ensure that exercise practitioners and their employing organisations are adequately equipped to work with this population.     

Knowing is not doing: The relationship between health behaviour knowledge and actual health behaviours in people with serious mental illness

ObjectivesLow levels of physical activity and poor dietary habits are common in people with serious mental illness and contribute to the poorer overall health and early mortality observed in this population. This paper examines the relationships between health behaviour knowledge and self-reported health behaviours in people with serious mental illness.MethodsWe examined the health behaviour knowledge, level of physical activity, consumption of fruits and vegetables and attitudes towards saturated fat intake in 21 community-based mental health consumers in a regional city in Queensland, Australia. Relationships between dichotomous variables of health behaviour knowledge, physical activity levels, daily fruit and vegetable intake, and attitude towards saturated fat intake were examined using Phi coefficients and point biserial relationships respectively.ResultsThe mean score for health behaviour knowledge was 10.2 out of a possible maximum score of 14 points. No statistically significant relationships were observed between the dichotomous variables of health behaviour knowledge and level of physical activity, consumption of fruits and vegetables or attitudes towards saturated fat intake. A weak statistically significant relationship was observed between raw health knowledge score and the number of daily serves of vegetable.ConclusionsThe lack of significant relationships between health behaviour knowledge and self-reported health behaviours is supported by health behaviour theory which proposes that knowledge alone is insufficient to elicit behaviour. In this regard, people with serious mental illness may not be dissimilar to the general population.     

Associations of multiplicity of comorbid health conditions,serious mental illness,and health care costs

Using a nationally representative U.S. sample, this study analyzed the effects of serious mental illness (SMI) and comorbid medical conditions on the cost of health care. The results of path model indicated that SMI and comorbid health conditions each increased total health care costs. Additionally, individuals with SMI were likely to have more comorbid medical conditions, which in turn, increased total health care costs. Findings raise awareness of an increased risk of medical conditions among individuals with SMI and the concern of high expenditures associated with comorbid SMI and medical conditions.     

Caregiving in the shadows: National analysis of health outcomes and intensity and duration of care among those who care for people with mental illness and for people with developmental disabilities

BackgroundThe health impacts of caring for people with mental illness (MI) and developmental disabilities (DD) are not well understood.ObjectiveThe present study explored whether health outcomes differed between MI and DD caregivers, and if intensity and duration of care moderated health outcomes.MethodsNationally representative 2016 Behavioral Risk Factor Surveillance System survey data were used to explore how caring for people with MI (n = 1071) and DD (n = 888) impacted general health status and physical and mental health days, and whether intensity and duration of care moderated health outcomes. Logistic regression models and cumulative logistic regression models were used to model health outcomes.ResultsCaregivers had worse health (p = 0.0001) and more poor physical (p < 0.0001) and mental health days (p < 0.0001) than non-caregivers. Relative to DD caregivers, MI caregivers had worse health status (p = 0.02) and more poor physical (p = 0.02) and mental (p = 0.003) health days. As intensity of care increased, MI caregivers had more poor physical health days (p = 0.04) than DD caregivers and as duration of care increased, MI caregivers had worse health status (p = 0.03) than DD caregivers.ConclusionsAlthough the care provided to adults with DD was more intense and for a longer duration, MI caregivers had poorer health outcomes and were more impacted by intensity and duration of care. Implications for supporting MI and DD caregivers are discussed.     

Scoping the field: services for carers of people with mental health problems

Mental ill health is very common. Most people with mental health problems live in the community, and as many as 1.5 million people in the UK may be involved in caring for a relative or friend with a mental illness or some form of dementia. Recent legislation and policy initiatives such as the National Strategy for Carers, and the National Service Frameworks for Mental Health and Older People emphasise the importance of providing support for this particular group of carers. The present paper reports the findings of a scoping study to identify what the research tells us about the effectiveness and cost-effectiveness of interventions for the carers of people with mental health problems, and also where there are gaps in the knowledge base. Some 204 evaluation studies were included in the review, just 13 of which had an economic component. The majority of studies were conducted in the USA, and were aimed at carers of people with Alzheimer disease or other forms of dementia. Overall, there was a lack of strong evidence to support any specific interventions, although almost all studies were able to identify some positive outcomes of services provided. In contrast to the relatively narrow approach to effectiveness adopted in most of the studies reviewed, the contributors to a consultation exercise perceived this concept in a far more rounded and holistic way. For them, the process of service delivery was as important as the outcome. There was relatively little research evaluating interventions and services singled out in UK policy initiatives as potentially useful in supporting this group of carers, and further evaluation studies are needed.     

Access to health care in nursing homes: a survey in one English Health Authority

The objective of the study was to establish the arrangements for provision of general practitioner (GP), nursing advice, chiropody, physiotherapy and speech and language services to nursing homes and to establish the charging policies for those services. To this end a telephone survey of the managers of the 51 nursing homes registered with one English health authority, Merton, Sutton and Wandsworth Health Authority, was undertaken. Forty-nine homes (96%) with 1541 residents responded. Twenty per cent of homes had no regular GP visits and half the homes had no planned medication reviews. One in five homes (27% of residents) had access to all health-care services. Eight homes (10% of residents) did not have access to therapy services or nursing advice. Thirty-three homes used private or both private and NHS chiropody services and 16 homes used the NHS service only. Seventeen homes used private or both private and NHS physiotherapy services with 10 homes receiving a regular private service. Twenty homes used the NHS service and 12 homes (15% of residents) had used no physiotherapy service. None used private speech and language services. Twenty-four of the 33 homes using private chiropody charged extra for this service compared with two of 10 homes using regular private physiotherapy. The findings suggest that there are inequalities in access to health care services in nursing homes. Moreover, there has been a deterioration in access to and levels of provision of NHS nursing and physiotherapy services since the national survey undertaken by the Office Population Censuses and Surveys (OPCS) in Great Britain in the mid-1980s. The new regulatory framework for older people must include systems for monitoring the provision of health services.     

Rural mental health: neither romanticism nor despair

ABSTRACT: This paper explores the relationship between rural places and mental health. It begins with a definition of mental health and an outline of the data that have led to the current concern with promoting positive mental health. We then consider aspects of rural life and place that contribute to positive mental health or increase the likelihood of mental health problems. Issues identified include environment, place, gender identity, violence and dispossession and the influence of the effects of structural changes in rural communities. The paper concludes with a discussion of some of the determinants of resilience in rural places, including social connectedness, valuing diversity and economic participation.     

Behavioral health home impact on transitional care and readmissions among adults with serious mental illness

ObjectiveTo evaluate the impact of Maryland''s behavioral health homes (BHHs) on receipt of follow‐up care and readmissions following hospitalization among Medicaid enrollees with serious mental illness (SMI).Data SourcesMaryland Medicaid administrative claims for 12 232 individuals.Study DesignWeighted marginal structural models were estimated to account for time‐varying exposure to BHH enrollment and time‐varying confounders. These models compared changes over time in outcomes among BHH and comparison participants. Outcome measures included readmissions and follow‐up care within 7 and 30 days following hospitalization.Data Collection/Extraction MethodsEligibility criteria included continuous enrollment in Medicaid for the first two years of the study period; 21‐64 years; and use of psychiatric rehabilitation services.Principal FindingsOver three years, BHH enrollment was associated with 3.8 percentage point (95% CI: 1.5, 6.1) increased probability of having a mental health follow‐up service within 7 days of discharge from a mental illness–related hospitalization and 1.9 percentage point (95% CI: 0.0, 3.9) increased probability of having a general medical follow‐up within 7 days of discharge from a somatic hospitalization. BHHs had no effect on probability of readmission.ConclusionsBHHs may improve follow‐up care for Medicaid enrollees with SMI, but effects do not translate into reduced risk of readmission.     

Waiting time for rehabilitation services for children with physical disabilities

BACKGROUND: Early rehabilitation may minimize disability and complications. However, children often wait a long time to gain admission to rehabilitation centres. OBJECTIVES: To describe waiting times for paediatric physical and occupational therapy and to determine factors associated with these waiting times. RESEARCH DESIGN: The study was a prospective cohort design. Patients were followed from 1 January 1999 to 1 March 2000. SUBJECTS: All children with physical disabilities, aged 0-18 years, referred in 1999 from the Montreal Children's Hospital to paediatric rehabilitation centres. MEASURES: Data on date of referral, date of first appointment at the rehabilitation centre, age, gender, diagnosis, region and language were obtained from the rehabilitation transfer database. Primary family caregivers of children who were transferred to a rehabilitation facility participated in a telephone interview regarding their perceptions of the transfer process. RESULTS: There were 172 children referred to rehabilitation facilities. The mean age of the children was 2.5 years. Average waiting time was 157.4 days (SD 57.1) for occupational therapy and 129.4 days (SD 51.6) for physical therapy. Decreased waiting time was associated with living in the city as opposed to the suburbs (hazard ratio=1.77; 95% confidence interval=0.92-3.41) and inversely associated with age (hazard ratio=0.46; 95% confidence interval=0.34-0.62). Among the 41 primary family caregivers who participated in the survey, higher empowerment scores were associated with shorter waits for rehabilitation. CONCLUSION: Waiting time for rehabilitation services needs to be reduced. Empowered parents appear to manoeuvre within the system to reduce waiting times for their children.