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.     

Health care service use among vulnerable adolescents

Abstract

This article describes the patterns of health care service use among a cohort of vulnerable adolescents with a history of homelessness and uses the Expanded Behavioral Model for Vulnerable Populations to examine factors associated with use of ambulatory and emergent care. We incorporated a health care interview into an existing longitudinal study of newly homeless adolescents, at their 24-month assessment (n?=?183) and assessed their sociodemographic characteristics, including living situation, health insurance rates, having a regular source of care, substance use and health care service use in the past 3 months. By the 24-month assessment, 63% of youth had returned home and 37% were currently homeless. In comparing youth who were currently homeless and those who had returned home, we found similar rates for ambulatory care use (48%) and for emergent care use (15%). The most common reason for seeking ambulatory care related to sexually transmitted disease (STD) testing/HIV testing/reproductive health for both groups. However, currently homeless youth were more likely to seek emergent care for trauma (15% vs. 4%, p?<?0.01) and for common conditions such as skin problems/respiratory infections/gastrointestinal problems/other problems (16% vs. 7%, p?<?0.05). Using multivariate logistic regression, we found older age [odds ratio (OR) 2.6, 95% confidence interval (CI) 1.0–6.5] and health insurance (OR 2.3, 95% CI 1.1–4.5) to be associated with use of ambulatory care; however, only older age (OR 2.7, 95% CI 1.0–7.0) was found to be associated with use of emergent care. Housing status, emotional distress and substance use were not found to be associated with ambulatory or emergent care use. Our findings suggest that facilitating health insurance coverage for vulnerable adolescents with a history of homelessness may lead to increased use of ambulatory care services and may consequently prevent use of emergent care services for conditions that may be treated in the ambulatory care setting.     

Immigrant Status,Mental Health Need,and Mental Health Service Utilization Among High-Risk Hispanic and Asian Pacific Islander Youth

This study examined youth mental health service (MHS) use as a function of family immigrant status and type of mental health need (internalizing vs. externalizing). A sample of Hispanic and Asian/Pacific Islander families (youth ages 11–18; N = 457) involved with public sectors of care provided reports of youth mental health need during an initial interview and MHS use was examined prospectively over 2 years. While externalizing need predicted specialty and school-based MHS use in the overall sample, family immigrant status moderated the association between youth need and specialty MHS use such that immigrant youth were more likely to receive services for externalizing need and less likely to receive services for internalizing need relative to non-immigrant youth.     

Evaluation of a community dental clinic providing care to people experiencing homelessness: A mixed methods approach

BackgroundPeople who experience homelessness have higher dental treatment needs compared to the general population. However, their utilization of dental services and levels of treatment completion are low. Peninsula Dental Social Enterprise, a not‐for‐profit organization in the United Kingdom, established a community dental clinic to improve access to dental care for this population.ObjectivesTo evaluate the impact and acceptability of the community dental service for patients and examine the barriers and enablers to using and providing the service.MethodsThe evaluation included a retrospective assessment of anonymous patient data and thematic analysis of semi‐structured interviews with patients, support staff and service providers. The interviews were thematically analysed. A cost analysis of the dental service was also conducted.ResultsBy 18 February 2020, 89 patients had attended the clinic. These included 62 males (70%) and 27 females (30%), aged 38.43 years on average (SD ± 11.07). Of these, 42 (47%) patients have completed their treatment, 23 (26%) are in active treatment and 24 (27%) left treatment. In total, 684 appointments (541.5 hours clinical time) were given. Of these, 82% (562) of appointments were attended (452.5 hours clinical time). The 22 interviews that were conducted identified flexibility, close collaboration with support services and health‐care team attitudes as key factors influencing service utilization and continuity of care.ConclusionsThis study provides details of a highly acceptable and accessible dental care model for people experiencing homelessness, with recommendations at research, practice and commissioning levels.     

NHS commissioning in probation in England – Still on a wing and a prayer

Policy reforms in England and Wales mean that all individuals released from prison will have some contact with probation services, either serving a community sentence, or being on licence post‐release. Despite often having complex health needs, including a higher prevalence of mental health problems, substance misuse problems and physical health problems than the general population, this socially excluded group of people often do not access healthcare until crisis point. This is partly due to service‐level barriers such as a lack of appropriate and accessible healthcare provision. We conducted a national survey of all Clinical Commissioning Groups (CCGs, n = 210) and Mental Health Trusts (MHTs, n = 56) in England to systematically map healthcare provision for this group. We compared findings with similar surveys conducted in 2013 and 2014. We had excellent response rates, with the data analysed here representing responses from 75% of CCGs and 52% of MHTs in England. We found that just 4.5% (n = 7) of CCG responses described commissioning a service specifically for probation service clients, and 7.6% (n = 12) described probation‐specific elements within their mainstream service provision. Responses from 19.7% of CCGs providing data (n = 31) incorrectly suggested that NHS England are responsible for commissioning healthcare for probation clients rather than CCGs. Responses from 69% (n = 20) of MHTs described providing services specifically for probation service clients, and 17.2% (n = 5) described probation‐specific elements within their mainstream service provision. This points to a need for an overarching health and justice strategy that emphasises organisational responsibilities in relation to commissioning healthcare for people in contact with probation services to ensure that there is appropriate healthcare provision for this group.     

Evaluation of trained volunteer doula services for disadvantaged women in five areas in England: women's experiences

Disadvantaged childbearing women experience barriers to accessing health and social care services and face greater risk of adverse medical, social and emotional outcomes. Support from doulas (trained lay women) has been identified as a way to improve outcomes; however, in the UK doula support is usually paid‐for privately by the individual, limiting access among disadvantaged groups. As part of an independent multi‐site evaluation of a volunteer doula service, this study examined women's experiences of one‐to‐one support from a trained volunteer doula during pregnancy, labour and the post‐natal period among women living in five low‐income communities in England. A mixed methods multi‐site evaluation was conducted with women (total n = 137) who received the service before December 2012, using a combination of questionnaires (n = 136), and individual or group interviews (n = 12). Topics explored with women included the timing and nature of support, its impact, the relationship with the doula and negative experiences. Most women valued volunteer support, describing positive impacts for emotional health and well‐being, and their relationships with their partners. Such impacts did not depend upon the volunteer's presence during labour and birth. Indeed, only half (75/137; 54.7%) had a doula attend their birth. Many experienced volunteer support as a friendship, distinct from the relationships offered by healthcare professionals and family. This led to potential feelings of loss in these often isolated women when the relationship ended. Volunteer doula support that supplements routine maternity services is potentially beneficial for disadvantaged women in the UK even when it does not involve birth support. However, the distress experienced by some women at the conclusion of their relationship with their volunteer doula may compromise the service's impact. Greater consideration is needed for managing the ending of a one‐to‐one relationship with a volunteer, particularly given the likelihood of it coinciding with a period of heightened emotional vulnerability.     

Outreach,Mental Health,and Case Management Services: Can They Help to Retain HIV-Positive and At-Risk Youth and Young Adults in Care?

Objectives: To assess the impact of outreach, mental health, and case management services on retention in primary care of HIV+ and at-risk youth and young adult clients of the Boston HAPPENS program, a comprehensive adolescent HIV prevention and care network of agencies. Methods: Providers at 8 urban sites used standard data forms at each visit to collect background and service receipt information on at-risk clients aged 12–24 years. Data were aggregated across all visits for each client to create summary variables for the number of times each client received each type of service. The retention measure was the number of days between a client's first and last visits during the 4-year data collection period. Kaplan–Meier survival curve and Cox proportional hazards regression analyses were used to assess the association between receipt of the support services of interest and the retention measure. Results: The median retention times were 21 days for male clients (range, 0–1406, N = 512), and 26 days for female clients (range, 0–1577, N = 914). Among males, 45% were retained beyond a month, 24% beyond a year, and 10% beyond 2 years. Similar proportions of females were retained beyond a month and a year, but more females were retained beyond 2 years (15%). After adjusting for other covariates, both male and female clients had significantly longer retention times if they received q2 outreach contacts, or case management at q3 visits. Among males, receipt of mental health counseling at q2 visits also increased retention times. Conclusions: These findings suggest that provision of outreach, mental health, and case management services can improve retention in care of at-risk youth and young adults.     

A paradox of need: Gaps in access to dental care among people who use drugs in Canada's publicly funded healthcare system

In Canada, publicly funded healthcare provides no-cost access to a large but not comprehensive suite of services. Dental care is largely funded by private insurance or patients, creating employment- and income-dependent gaps in care access. Difficulties accessing dental care may be amplified among vulnerable populations, including people who use drugs (PWUD), who may experience greater dental need due to side effects of substance use and health comorbidities, as well as barriers to care. Using data collected between 2014 and 2018 from two ongoing prospective cohort studies of PWUD in Vancouver, Canada, the aim of this study was to explore factors associated with dental care access. Among 1,638 participants, 246 participants (15%) reported never or only occasionally accessing adequate dental care. In generalised linear mixed-effects models, results showed significant negative associations between accessing dental care and using opioids (Adjusted Odds Ratios [AOR] = 0.73, 95% Confidence Interval [CI] = 0.58–0.91), methamphetamine (AOR = 0.75, 95% CI = 0.59–0.95) and cannabis (AOR = 0.78, 95% CI = 0.63–0.97), as well experiencing homelessness (AOR = 0.54, 95% CI = 0.42–0.70) and street-based income generation (AOR = 0.75, 95% CI = 0.59–0.94). There were significant positive associations between adequate dental care and accessing opioid agonist treatment (OAT) for opioid dependence (AOR = 1.36, 95% CI = 1.07–1.72) and receiving income assistance (AOR = 1.70, 95% CI = 1.05–2.77). These results highlight specific substance use patterns and structural exposures that may hinder dental care access, as well as how direct and indirect benefits of income assistance and OAT may improve access. These findings provide support for recent calls to expand healthcare coverage and address dental care inequities.     

Dental Care in Programs of All-Inclusive Care for the Elderly: Organizational Structures and Protocols

ObjectivesThis study uses a national model of community-based long-term services and supports, the Program of All-inclusive Care for the Elderly (PACE), to identify organizational structures and protocols that can facilitate the delivery of dental examinations.DesignWe developed an online survey instrument and conceptual model for this study representing 10 domains believed to characterize a quality PACE dental program.Setting and ParticipantsThe Qualtrics survey was distributed nationally to all 124 PACE programs in the 31 states PACE was available. Respondents in this study represented 35 programs (program response rate = 28.2%) in 23 states (state response rate = 74.2%).MethodsSelected independent variables from each of the 10 domains were tested against the reported delivery of dental examinations variable using the Kendall τ and χ². Twenty-nine programs were included in the final analysis.ResultsMost programs mandated a dental examination within 31–60 days of enrollment (63.6%). Few programs had a dental manual (15.6%) or any quality assurance for dental care (32.3%). A majority of programs (58.8%) stated that they had a protocol for enrollees to receive a cleaning every 6–12 months. Having a system for quality assurance for dental care, protocol for a cleaning every 6–12 months, mandating a comprehensive dental examination and providing preventive dental services onsite with built-in equipment, were all statistically associated with a higher reported delivery of dental examinations.Conclusion and ImplicationsOrganizations providing long-term services and supports, including PACE, can use these identified domains to develop minimal standards to ensure dental care is part of innovative models of community-based long-term services and supports. Implementing these domains can facilitate effective delivery of dental examinations that have the potential to support positive oral health and general health outcomes.     

Self‐reported health,healthcare service use and health‐related needs: A comparison of older and younger homeless people

The number of older homeless people with a limited life expectancy is increasing. European studies on their health‐related characteristics are lacking. This study compared self‐reported health, healthcare service use and health‐related needs of older and younger homeless people in the Netherlands. It is part of a cohort study that followed 513 homeless people in the four major Dutch cities for a period of 2.5 years, starting from the moment they registered at the social relief system in 2011. Using cross‐sectional data from 378 participants who completed 2.5‐year follow‐up, we analysed differences in self‐reported health, healthcare service use, and health‐related needs between homeless adults aged ≥50 years (N = 97) and <50 years (N = 281) by means of logistic regression. Results show that statistically significantly more older than younger homeless people reported cardiovascular diseases (23.7% versus 10.3%), visual problems (26.8% versus 14.6%), limited social support from family (33.0% versus 19.6%) and friends or acquaintances (27.8% versus 14.6%), and medical hospital care use in the past year (50.5% versus 34.5%). Older homeless people statistically significantly less often reported cannabis (12.4% versus 45.2%) and excessive alcohol (16.5% versus 27.0%) use in the past month and dental (20.6% versus 46.6%) and mental (16.5% versus 25.6%) healthcare use in the past year. In both age groups, few people reported unmet health‐related needs. In conclusion, compared to younger homeless adults, older homeless adults report fewer substance use problems, but a similar number of dental and mental problems, and more physical and social problems. The multiple health problems experienced by both age groups are not always expressed as needs or addressed by healthcare services. Older homeless people seem to use more medical hospital care and less non‐acute, preventive healthcare than younger homeless people. This vulnerable group might benefit from shelter‐based or community outreach programmes that proactively provide multidisciplinary healthcare services.     

Unmet health and rehabilitation needs of people with long‐term neurological conditions in Queensland,Australia

The survival and life expectancy rates of people with traumatic and degenerative neurological conditions are increasing, sometimes up to several decades. Yet compared to the general population, people with a disability continue to experience poorer health and are at greater risk of developing secondary health problems and facing barriers to services they require. These trends have significant implications for provision of health and rehabilitation services. In this study, the adequacy of health and rehabilitation services provided to people with long‐term neurological conditions and their unmet needs were explored from the perspectives of individual users, their nominated family members and key service providers. A qualitative research design with maximum variation sampling was used. Data were collected from semi‐structured interviews with 65 participants comprising 25 long‐term care service users, nominated family members or friends (n = 22) and care service providers (n = 18) in Queensland, Australia. All service users needed assistance with usual daily activities, and 22 were wheelchair dependent. The hours of funded personal care ranged from 2 to 201 hours per week. Data were analysed using framework analysis. Participants generally perceived that specialist medical and hospital services were adequate and satisfactory. They valued supportive health and rehabilitation professionals and receiving client‐centred physical rehabilitation. However, the majority of participants (n = 17) had perceived unmet needs for physical rehabilitation (n = 14), other health or rehabilitation services (n = 10) or counselling (n = 6). Community‐based physical maintenance rehabilitation was often perceived as inadequate, costly or inconveniently located. Participants highlighted the importance of personal and family counselling and information provision at time points such as diagnosis. The findings contribute to the limited international evidence on the gaps in health and rehabilitation services for people with neurological conditions receiving lifetime care services in the community. A continuum of integrated rehabilitation services to minimise avoidable impairments, optimise independence and functioning, and sustain quality of life is warranted.     

Formative research for the development of an Eye Health Strategic Planning and Evaluation Framework and a Checklist: A health systems approach

This formative research process aimed to develop an Eye Health Strategic Planning and Evaluation Framework and indicator Checklist. The research process utilized a multi‐phased multiple methods approach including literature review, initial expert review (n = 27), findings from a Cambodian Avoidable Blindness Initiative demonstration project (2009‐2012), observation and analysis of four rural sites of the Indian LV Prasad Eye Institute Pyramid Model (n = 21), and finally, a critique by Cambodian government eye health professionals/staff (n = 15), health center staff and community representatives (n = 77) and patients (n = 62). Results from three Cambodian population‐based surveys (KAP n = 599, patient follow‐up n = 354, and RAAB 4650) also informed the development of the Framework and the Checklist. The Framework domains include: situation analysis, determinants of accessibility, service delivery systems, operation systems, networks and linkages, outcomes, and impact. Domains were subdivided into 59 components. The Checklist consists of 253 indicator items. The Eye Health Strategic Planning and Evaluation Framework and the Checklist can assist policy makers, program planners, and evaluators to develop a comprehensive whole of systems approach to eye health care to improve coverage and utilization of services.     

A comparison of the home‐care and healthcare service use and costs of older Australians randomised to receive a restorative or a conventional home‐care service

Restorative home‐care services, or re‐ablement home‐care services as they are now known in the UK, aim to assist older individuals who are experiencing difficulties in everyday living to optimise their functioning and reduce their need for ongoing home care. Until recently, the effectiveness of restorative home‐care services had only been investigated in terms of singular outcomes such as length of home‐care episode, admission to hospital and quality of life. This paper reports on a more complex and perhaps more significant measure – the use and cost of the home‐care and healthcare services received over the 2‐year period following service commencement. Seven hundred and fifty older individuals referred for government‐funded home care were randomly assigned to a restorative or standard service between June 2005 and August 2007. Health and aged care service data were sourced and linked via the Western Australian Data Linkage System. Restorative clients used fewer home‐care hours (mean [SD], 117.3 [129.4] vs. 191.2 [230.4]), had lower total home‐care costs (AU$5570 vs. AU$8541) and were less likely to be approved for a higher level of aged care (N [%], 171 [55.2] vs. 249 [63.0]) during follow‐up. They were also less likely to have presented at an emergency department (OR = 0.69, 95% CI = 0.50–0.94) or have had an unplanned hospital admission [OR (95% CI), 0.69 (0.50–0.95)]. Additionally, the aggregated health and home‐care costs of the restorative clients were lower by a factor of 0.83 (95% CI 0.72–0.96) over the 2‐year follow‐up (AU$19,090 vs. AU$23,428). These results indicate that at a time when Australia is facing the challenges of population ageing and an expected increase in demand for health and aged care services, the provision of a restorative service when an older person is referred for home care is potentially a more cost‐effective option than providing conventional home care.     

Sociodemographic and substance use characteristics associated with typologies and composition of social support networks among youth experiencing homelessness in Los Angeles,USA

Youth experiencing homelessness are a vulnerable population with increased behavioural health risks. Social networks are a consistent correlate of youths’ substance use behaviours. However, less is known about the reciprocal relationships among these constructs. This study classified youth experiencing homelessness according to their social support network type (e.g. instrumental, emotional, service) and composition (e.g. family, peers, service staff) and linked their membership in these social network classes to sociodemographic and substance use characteristics. Four waves of cross‐sectional data were collected between October 2011 and June 2013 from youth experiencing homelessness, ages 14–29, at three drop‐in centres in Los Angeles, CA (N = 1,046). This study employed latent class analysis to identify subgroups of youth experiencing homelessness according to the type and composition of their social support networks. Multinomial logistic regression analyses were then conducted to identify the sociodemographic and substance use characteristics associated with social support network class membership. Five latent classes of youths’ social support networks were identified: (a) high staff emotional and service support; (b) high home‐based peer and family emotional, service and instrumental support; (c) moderate street‐ and home‐based peer emotional support; (d) low or no support and (e) high home‐based peer and family emotional and instrumental support. Multinomial logistic regression models indicated that race/ethnicity, gender, sexual orientation, literal homelessness, former foster care experience, depression, heroin and marijuana use were significant correlates of social support network class membership. Results indicate distinct classes of social support networks among youth experiencing homelessness, with certain sociodemographic and substance use characteristics implicated in youths’ social networks.     

Targeting preventive home visits to older adults in disadvantaged communities: Perspectives of professionals

This study explored the implementation of multidimensional preventive home visits targeted to older adults living in a disadvantaged community in Denmark. The intervention was adapted to include the following key components: involvement of community members in recruitment processes; a combination of individual and group-based dissemination; adaptation of materials to overcome language barriers; and diversity-sensitivity training for professionals. The study took place over 12 months between August 2016 and August 2017 and used various data sources: registry-based data, participant observations, combined with individual and focus group interviews with the target population (n = 22) and relevant health care professionals (n = 8). Here, we report on findings pertaining to implementation barriers and facilitators as seen from the perspective of professionals. Socioeconomic vulnerability was prominent, and uptake of health care services was low, indicating under-utilisation. Implementation facilitators and barriers were identified including potentials in nurturing local partnerships and proximity during recruitment; overcoming language barriers; offering diversity-sensitivity training for professionals; and a need for a more multidisciplinary, comprehensive scope of preventive visits for diverse older adults in disadvantaged communities. Thus, more focus on participatory, comprehensive and community-based health promotion are needed to ensure healthy ageing in the context of social inequality and ethnic diversity.