Challenges faced by general practitioners and allied mental health services in providing mental health services in rural Queensland

OBJECTIVE: To examine the views of rural practitioners concerning issues and challenges in mental health service delivery and possible solutions. DESIGN: A qualitative study using individual semi-structured interviews. SETTING: Eight general practices from eight rural Queensland towns, three rural mental health services and two non-government organisations, with interviews being conducted before recent changes in government-subsidised access to allied health practitioners. PARTICIPANTS: A sample of 37 GPs, 19 Queensland Health mental health staff and 18 participants from community organisations. MAIN OUTCOME MEASURES: Analysis of qualitative themes from questions about the key mental health issues facing the town, how they might be addressed and what challenges would be faced in addressing them. RESULTS: There was substantial consensus that there are significant problems with inter-service communication and liaison, and that improved collaboration and shared care will form a critical part of any effective solution. Differences between groups reflected differing organisational contexts and priorities, and limitations to the understanding each had of the challenges that other groups were facing. CONCLUSIONS: Improvements to mental health staffing and to access to allied health might increase the ability of GPs to meet the needs of less complex patients, but specific strategies to promote better integrated services are required to address the needs of rural and regional patients with complex mental health problems. The current study provides a baseline against which effects of recent initiatives to improve mental health care can be assessed.     

Rural physical health care services for people with serious mental illness: A nursing perspective

Objective: To understand nurse perspectives on the physical health needs of their mental health clients and how well rural services are meeting their overall care needs. Design: Focus groups with semistructured format. Setting: Community mental health care in a regional and rural district of Queensland. Participants: Thirty‐eight nurses in public mental health care. Results: The major themes were (i) stigma of mental illness, (ii) barriers to accessing physical health care services, (iii) nurse adaptations under demands, and (iv) community and integration towards better overall health. Nurses integrate overall care and foster its continuity for people with physical and mental co‐morbidity and can be supported much better in sustaining this. Conclusion: Access and continuity of physical health care experienced by all Australians is exacerbated for people in rural areas. Physical health of people with serious mental illness residing in remote Australia needs to be a national health priority.     

Health Care Services for HIV-Positive Substance Abusers in a Rural Setting: An Innovative Program

ABSTRACT

Agencies that deliver health care services to HIV-positive substance abusers living in rural areas of the United States face particular treatment challenges and barriers to care. Rural consumers of HIV/AIDS health care–related services identified long travel distances to medical facilities, lack of transportation, lack of availability of HIV-specific medical personnel, a shortage of mental health and substance abuse services, community stigma, and financial problems as leading barriers to access to care. This article discusses barriers to care for rural HIV-positive substance abusers, and challenges for rural health care providers. In addition, it presents a case study of Health Services Center, a model program that has devised innovative practices in the delivery of health care services to HIV-positive substance abusers in rural northeastern Alabama.     

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.     

Nurses’ perceptions of mental healthcare in primary-care settings in Kenya

Kenya maintains an extraordinary treatment gap for mental health services because the need for and availability of mental health services are extraordinarily misaligned. One way to narrow the treatment gap is task-sharing, where specialists rationally distribute tasks across the health system, with many responsibilities falling upon frontline health workers, including nurses. Yet, little is known about how nurses perceive task-sharing mental health services. This article investigates nurses’ perceptions of mental healthcare delivery within primary-care settings in Kenya. We conducted a cross-sectional study of 60 nurses from a public urban (n?=?20), private urban (n?=?20), and public rural (n?=?20) hospitals. Nurses participated in a one-hour interview about their perceptions of mental healthcare delivery. Nurses viewed mental health services as a priority and believed integrating it into a basic package of primary care would protect it from competing health priorities, financial barriers, stigma, and social problems. Many nurses believed that integrating mental healthcare into primary care was acceptable and feasible, but low levels of knowledge of healthcare providers, especially in rural areas, and few specialists, would be barriers. These data underscore the need for task-sharing mental health services into existing primary healthcare in Kenya.     

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.     

Improving the mental health of rural New South Wales communities facing drought and other adversities

Objective: NSW has just experienced its worst drought in a century. As years passed with insufficient rain, drought‐related mental health problems became evident on farms. Our objective is to describe how, in response, the Rural Adversity Mental Health Program was introduced in 2007 to raise awareness of drought‐related mental health needs and help address these needs in rural and remote NSW. The program has since expanded to include other forms of rural adversity, including recent floods. Setting: Rural NSW. Design, participants, interventions: Designed around community development principles, health, local service networks and partner agencies collaborated to promote mental health, education and early intervention. Strategies included raising mental health literacy, organising community social events and disseminating drought‐related information. Priority areas were Aboriginal communities, older farmers, young people, women, primary health care and substance use. Results: Over 3000 people received mental health literacy training in the four years of operation from 2007 to 2010. Stakeholders collaborated to conduct hundreds of mental health‐related events attended by thousands of people. A free rural mental health support telephone line provided crisis help and referral to rural mental health‐related services. Conclusion: Drought affected mental health in rural NSW. A community development model was accepted and considered effective in helping communities build capacity and resilience in the face of chronic drought‐related hardship. Given the scale, complexity and significance of drought impacts and rural adjustment, and the threats posed by climate change, a long‐term approach to funding such programs would be appropriate.     

Improving mental health capacity in rural communities: mental health first aid delivery in drought-affected rural New South Wales

Objective: To assess the effectiveness of mental health first aid (MHFA) training in drought‐affected rural and remote Australia, as part of a strategy to improve capacity among farming communities to provide early intervention for mental health problems. Methods: Data were obtained from 99 participants recruited across 12 New South Wales towns, before and after delivery of MHFA seminars emphasising the role of front‐line workers from agricultural‐related services. Surveys assessed knowledge of, confidence in dealing with, and attitude towards people experiencing mental illness, along with the impact of training on response to mental health problems among target population of farmers and farming families. Results: Rural support workers and community volunteers attended MHFA seminars because of perceived mental health needs in the workplace. A majority of responses reflect a concern with giving appropriate advice and support well outside narrow job definitions. Participants' ability to identify high prevalence disorders and endorse evidence‐based interventions for both high and low prevalence disorders increased following MHFA training, as did their confidence in their ability to provide appropriate help. Conclusions: MHFA training can form an effective part of a strategy to improve systems of care and pathways to early intervention in rural communities by using local networks to provide mental health support.     

'Shared Care - Shared Dream': Model of shared care in rural Australia between mental health services and general practitioners

OBJECTIVE: To identify a working model between rural and remote mental health services and the local GPs in Australia. DESIGN: Postal questionnaire to assess the GPs' satisfaction level with the involvement of the mental health services in their ongoing management of mentally ill in the community. RESULT: There was a greater sense of satisfaction with the mental health services over the five years this program was implemented. CONCLUSION: This study offers a model on how a rural mental health service could enter into a shared care program with the local GP practice and achieve a greater level of satisfaction in serving the rural communities in Australia.     

General practitioners' management of patients with mental health conditions: The views of general practitioners working in rural north‐western New South Wales

Objective: To identify the needs of the region's general practitioners concerning diagnosing, treating and referring patients with mental health disorders and major barriers to the general practitioners' management of these patients. Design: Cross‐sectional survey. Subjects: All general practitioners working in rural north‐western New South Wales. Measurements: Self‐assessed levels of confidence (5‐point Likert scale) in diagnosing and treating patients with a mental health condition. Practice data relating to presentation of such patients as well as issues affecting treatment and referral. Results: The three most commonly diagnosed and treated mental health conditions are depression, anxiety and dementia. General practitioners assessed themselves as being confident in diagnosing and treating these three mental health conditions and in diagnosing and treating adults and the elderly. The only form of treatment intervention that the general practitioners self‐assessed as being confident in relates to medication. Referrals to mental health specialists were due mostly to patients needing mental health counselling, the general practitioners seeking clarification of diagnosis as well as having insufficient skills to provide the best possible care. Barriers to being able to refer relate mainly to specialist services not being available and/or accessible as well as patients being reluctant to accept such a referral. Conclusion: Our results indicate that other than for depression, anxiety and dementia, efforts to improve the general practitioners' diagnostic and treatment skills and to diagnose and treat adolescents and children are warranted. Up‐skilling the general practitioners' ability to confidently use treatment options other than medication are worth considering.     

Critical health infrastructure for refugee resettlement in rural Australia: Case study of four rural towns

Objective: To explore the reported impact of regional resettlement of refugees on rural health services, and identify critical health infrastructure for refugee resettlement. Design: Comparative case study, using interviews and situational analysis. Setting: Four rural communities in New South Wales, which had been the focus of regional resettlement of refugees since 1999. Participants: Refugees, general practitioners, practice managers and volunteer support workers in each town (n = 24). Results: The capacity of health care workers to provide comprehensive care is threatened by low numbers of practitioners, and high levels of turnover of health care staff, which results in attrition of specialised knowledge among health care workers treating refugees. Critical health infrastructure includes general practices with interest and surge capacity, subsidised dental services, mental health support services; clinical support services for rural practitioners; care coordination in the early settlement period; and a supported volunteer network. The need for intensive medical support is greatest in the early resettlement period for ‘catch‐up’ primary health care. Conclusion: The difficulties experienced by rural Australia in securing equitable access to health services are amplified for refugees. While there are economic arguments about resettlement of refugees in regional Australia, the fragility of health services in regional Australia should also be factored into considerations about which towns are best suited to regional resettlement.     

Beyond community-based diabetes management and the COAG coordinated care trial

Objective: This article describes the patient management processes developed during the Council of Australian Governments (COAG) coordinated care trial and use of health outcome measures to monitor changes in utilisation patterns and patient well‐being over time for a subgroup of 398 patients with type 2 diabetes. Design: The Eyre component of the South Australian (SA) HealthPlus coordinated care trial was a matched geographically controlled study in which the outcomes for the intervention group of 1350 patients were compared with those of a similar control group of 500 patients in another rural health region in SA. Setting: The trial was carried out on Eyre Peninsula in SA across populations in rural communities and in the main centres of Whyalla, Port Lincoln and Ceduna. Care planning was organised through general practitioner practices and services negotiated with allied health services and hospitals to meet patient needs. Subjects: The SA HealthPlus trial included 1350 patients with chronic and complex illness. A subset of this group comprising 398 patients with type 2 diabetes is described in this report. Patients recruited into the three‐year trial were care planned using a patient centred care planning model through which patient goals were generated along with medical management goals developed by clinicians and primary health care professionals. Relevant health services were scheduled in line with best practice and care plans were reviewed each year. Patient service utilisation, progress towards achieving health related goals and patient health outcomes were recorded and assessed to determine improvements in health and well‐being along with the cost and profile of the services provided. Results: Significant numbers of patients experienced improved health outcomes as a consequence of their involvement in the trial, and utilisation data showed reductions in hospital and medical expenditure for some patients. These results suggest that methods applied in the SA HealthPlus coordinated care trial have led to improvements in health outcomes for patients with diabetes and other chronic illnesses. In addition, the processes associated with the COAG trial motivated significant organisational change in the Regional Health Service as well as providing an opportunity to study the health and well‐being outcomes resulting from a major community health intervention. Conclusions: The importance of the SA HealthPlus trial has been the demonstrated link between a formal research trial and significant developments in the larger health system with the trial not only leading to improvements in clinical outcomes for patients, but also acting as a catalyst for organisational reform. We now need to look beyond the illness focus of health outcome research to develop population based health approaches to improving overall community well‐being. What is already known: Much work has been completed in recent years tracing the clinical impact of more effective management of patients with chronic illness. Evidence suggests that more structured management of patient care and better access resources and support can improve patient well‐being and reduce demand on acute care services. What is needed, however, are mechanisms for managing patients to access relevant care and to comply with best practice protocols. Lowered HbA1c readings correlate with reduced crises for diabetic patients, but how can we encourage patients to engage in practices that actually lower these levels? What this study adds: The current study, based on work carried out during the COAG coordinated care trials, suggests that a structured patient centred care planning process can improve patient knowledge of their condition and increase motivation for sustainable behaviour change in the way they manage their illness. These processes of patient engagement and symptom monitoring have led to better long‐term health and well‐being for patients with diabetes. The wider application of such processes of care management will be an important next step in improving the management of health and well‐being at larger population levels.     

Working on the interface: identifying professional responses to families with mental health and child-care needs

The gaps between mental health and child-care services constitute a recognised barrier to providing effective services to families where parents have mental health problems. Recent guidance exhorts professionals to coordinate and collaborate more consistently in this area of work. The present study aimed to identify the barriers to inter-professional collaboration through a survey of 500 health and social care professionals. The views of 11 mothers with severe mental health problems whose children had been subject to a child protection case conference were also interrogated through two sets of interviews. The study found that communication problems were identified more frequently between child care workers and adult psychiatrists than between other groups. Communication between general practitioners and child-care workers was also more likely to be described as problematic. While there was some support amongst practitioners for child-care workers to assume a coordinating or lead role in such cases, this support was not overwhelming, and reflected professional interests and alliances. The mothers themselves valued support from professionals whom they felt were 'there for them' and whom they could trust. There was evidence from the responses of child-care social workers that they lacked the capacity to fill this role in relation to parents and their statutory child-care responsibilities may make it particularly difficult for them to do so. The authors recommend that a dyad of workers from the child-care and community mental health services should share the coordinating key worker role in such cases.     

Sustainable primary health care services in rural and remote areas: innovation and evidence

Objective: To highlight how evidence from studies of innovative rural and remote models of service provision can inform global health system reform in order to develop appropriate, accessible and sustainable primary health care (PHC) services to ‘difficult‐to‐service’ communities. Methods: The paper synthesises evidence from remote and rural PHC health service innovations in Australia. Results: There is a strong history of PHC innovation in Australia. Successful health service models are ‘contextualised’ to address diverse conditions. They also require systemic solutions, which address a range of interlinked factors such as governance, leadership and management, adequate funding, infrastructure, service linkages and workforce. An effective systemic approach relies on alignment of changes at the health service level with those in the external policy environment. Ideally, every level of government or health authority needs to agree on policy and funding arrangements for optimal service development. A systematic approach in addressing these health system requirements is also important. Service providers, funders and consumers need to know what type and level of services they can reasonably expect in different community contexts, but there are gaps in agreed indicators and benchmarks for PHC services. In order to be able to comprehensively monitor and evaluate services, as well as benchmarks, we need adequate national information systems. Conclusions: Despite the gaps in our knowledge, we do have a significant amount of information about what works, where and why. At a time of global PHC reform, applying this knowledge will contribute significantly to the development of appropriate, sustainable PHC services and improving access.     

Health care services for HIV-positive substance abusers in a rural setting: an innovative program

Agencies that deliver health care services to HIV-positive substance abusers living in rural areas of the United States face particular treatment challenges and barriers to care. Rural consumers of HIV/AIDS health care-related services identified long travel distances to medical facilities, lack of transportation, lack of availability of HIV-specific medical personnel, a shortage of mental health and substance abuse services, community stigma, and financial problems as leading barriers to access to care. This article discusses barriers to care for rural HIV-positive substance abusers, and challenges for rural health care providers. In addition, it presents a case study of Health Services Center, a model program that has devised innovative practices in the delivery of health care services to HIV-positive substance abusers in rural northeastern Alabama.     

Overt and covert barriers to the integration of primary and specialist mental health care

This paper is concerned with the historical attempt over the last 20 years to improve integration between primary and specialist mental health care. Semi-structured interviews were carried out during the period December 2000-March 2001 with primary care workers, specialist medical and nursing staff, managers and other key informants in one large group model Health Maintenance Organization in the USA. Both overt (financial) and covert (attitudinal and conceptual) barriers to the integration of mental health and primary care were identified and the impact of these barriers on organizational development is discussed with reference to Activity Theory. The nature and quality of interprofessional conversation in an organization may be important mediating factors in addressing covert barriers to integration between primary and specialist mental health services. There may be insufficient actual contact between different groups of workers in primary and specialist care to enable these professionals to share ideas, challenge mutual assumptions and understand each others' viewpoints about the nature of their work, the covert barriers to integration. Workers may differ in the conceptual models of mental health care they utilize, their views about access to services, and the amount of information they require. In order to integrate services effectively, these issues will require discussion. Financial pressures in the system may lead to failure on the part of management to sanction and encourage opportunities for interprofessional conversation and the geographical distance between places of work may also limit opportunities for contact. However, an alternative explanation might be that attitudinal and other covert barriers to integration effectively prevent, in the first place, the development of such a shared space in which these covert barriers might actually be addressed.     

Forensic mental health services as a risk escalator: A case study of ideals and practice

Medium/low secure units occupy a central role in forensic mental health care, bridging high secure and community services. Although outcomes, assessed in terms of readmission and identified reoffending, have been evaluated, little research exploring processes underlying attempted rehabilitation for offenders diagnosed as having mental health problems has been undertaken. The present qualitative study built upon previous research completed in a northern England medium/low secure forensic mental health care institution for adults with learning disabilities (Heyman et al. 2002a,b). It was carried out in a medium/low secure forensic mental health care Unit located in London. In phase one, 43 staff, including general managers, doctors, nurses, psychologists and occupational therapists were interviewed about their philosophy of care, views about risk management for forensic mental health patients and perceptions of the Unit. In phase two, 10 case studies of patients were undertaken. As far as possible, patients were interviewed twice over a period of 11‐20 months, and staff were asked about their progress. Two case conferences were observed. Data were analysed using the metaphorical concept of a rehabilitative risk escalator around three themes carried forward from the previous study: organisational issues; patient active risk management; and multiprofessional collaboration.     

Conceptual and practical challenges associated with understanding patient safety within community‐based mental health services

IntroductionPatient safety problems stemming from healthcare delivery constitute a global public health concern and represent a pervasive barrier to improving care quality and clinical outcomes. However, evidence generation into safety in mental health care, particularly regarding community‐based mental health services, has long fallen behind that of physical health care, forming the focus of fewer research publications and developed largely in isolation from the wider improvement science discipline. We aimed to investigate the state of the field, along with key conceptual and empirical challenges to understanding patient safety in community‐based mental health care.MethodsA narrative review surveyed the literature to appraise the conceptual obstacles to advancing the science of patient safety in community‐based mental health services. Sources were identified through a combination of a systematic search strategy and targeted searches of theoretical and empirical evidence from the fields of mental health care, patient safety and improvement science.ResultsAmongst available evidence, challenges in defining safety in the context of community mental health care, evaluating safety in long‐term care journeys and establishing what constitutes a ‘preventable’ safety problem, were identified. A dominant risk management approach to safety in mental health care, positioning service users as the origin of risk, has seemingly prevented a focus on proactive safety promotion, considering iatrogenic harm and latent system hazards.ConclusionWe propose a wider conceptualization of safety and discuss the next steps for the integration and mobilization of disparate sources of ‘safety intelligence’, to advance how safety is conceived and addressed within community mental health care.Patient and Public ContributionThis paper was part of a larger research project aimed at understanding and improving patient safety in community‐based mental health care. Although service users, carers and healthcare professionals were not involved as part of this narrative review, the views of these stakeholder groups were central to shaping the wider research project. For a qualitative interview and focus group study conducted alongside this review, interview topic guides were informed by this narrative analysis, designed jointly and piloted with a consultation group of service users and carers with experience of community‐based mental health services for working‐age adults, who advised on key questioning priorities.     

Congestive cardiac failure: urban and rural perspectives in Victoria

Objective: Effective and timely care for congestive cardiac failure (CCF) should reduce the risks of hospitalisation. The purpose of this study is to describe variations in rates of hospital admissions for CCF in Victoria as an indicator of the adequacy of primary care services. Detailed analyses identify trends in hospitalisations, urban/rural differentials and variations by the Primary Care Partnerships (PCP). Setting: Acute care hospitals in Victoria. Design: Routine analyses of age and sex standardised admission rates of CCF in Victoria using the Victorian Admitted Episodes Dataset from 1993–1994 to 2000–2001. Subjects: All patients admitted to acute care hospitals in Victoria with the principal diagnosis of CCF between 1993–1994 and 2000–2001. Results: There were 8359 admissions for CCF in Victoria with an average of 7.37 bed days in 2000–2001. There was a significantly higher admission rate for CCF in rural areas compared to metropolitan in 2000/2001 –(2.53/1000 (2.44–2.62) and 1.80/1000 (1.75–1.85)) – respectively. Small area analyses identified 17 PCP (14 of which were rural) with significantly higher admission rate ratios of CCF compared to Victoria. Conclusion: Small area analyses of CCF have identified significant gaps in the management of CCF in the community. This may be a reflection of deficit in primary care availability, accessibility, or appropriateness. Detailed studies may be needed to determine the relative importance of these factors in Victoria for targeting specific interventions at the PCP level. What does this study add?: Congestive cardiac failure is a major public health problem. In Australia, there is a lack of studies identifying long‐term hospitalisation trends of CCF, as well as small area analyses, especially in regard to rural and urban variations. This study has identified significant variations over an eight year period in admission rates of CCF in rural and urban Victoria. Small area analyses (e.g. at the level of primary care partnerships) have identified rural communities with significantly higher admission rates of CCF compared to the Victorian average. For the first time in Australia, this study has provided a new approach for generating evidence on quality of primary care services in rural and urban areas, and offers opportunities for targeting public health and health services interventions that can decrease access barriers, improve the adequacy of primary care, and reduce demand on the hospital system in Victoria.      

Joint working in community mental health: prospects and challenges

This paper reviews the opportunities for, and the challenges facing, joint working in the provision of community mental health care. At a strategic level the organization of contemporary mental health services is marked by fragmentation, competing priorities, arbitrary divisions of responsibility, inconsistent policy, unpooled resources and unshared boundaries. At the level of localities and teams, these barriers to effective and efficient joint working reverberate within multi-disciplinary and multi-agency community mental health teams (CMHTs). To meet this challenge, CMHT operational policies need to include multiagency agreement on: professional roles and responsibilities; target client groups; eligibility criteria for access to services; client pathways to and from care; unified systems of case management; documentation and use of information technology; and management and accountability arrangements. At the level of practitioners, community mental health care is provided by professional groups who may have limited mutual understanding of differing values, education, roles and responsibilities. The prospect of overcoming these barriers in multidisciplinary CMHTs is afforded by increased opportunities for interprofessional 'seepage' and a sharing of complementary perspectives, and for joint education and training. This review suggests that policy-driven solutions to the challenges facing integrated community mental health care may be needed and concludes with an overview of the prospects for change contained in the previous UK government's Green Paper, 'Developing Partnerships in Mental Health'.