Primary Care and Mental Health: Overview of Integrated Care Models

Primary care nurse practitioners are in a visible and critical position to screen, diagnose, and treat common mental health conditions. Integrated care models occur on a continuum from simple communication between providers to fully integrated interprofessional teams. Regardless of integration model available to the primary care nurse practitioner, mental health disorders should be appropriately identified and treated using evidence-based approaches. This clinical feature introduces the primary care nurse practitioner to various integrated care models and provides a brief overview regarding screening, diagnostic, and intervention recommendations, as well as potential future directions for education, training, and research.     

Trends in Use of Health Care Services in Swedish Primary Care District. A Ten Year Perspective

In a study that covered ten years a questionnaire about use of health care facilities was mailed each autumn to 1/60 representative samples of the population in Sollentuna, a Swedish primary care district with three health centres.

Primary care was the health care form with the greatest contact area with the population studied. However, the strengthening of district physician resources at one of the three health centres did not, in the long term, lead to more people coming into contact with this form of medical care.

It was more common for those who visited a private doctor or school/company doctor also to consult a district physician than vice versa. Similarly, hospital patients visited the health centre to a greater degree than patients of health centres visited hospitals.

The only long-term change in the flow of patients that could be registered was a reduction in the number of patients who visited hospital emergency departments.

It is concluded that the implementation of an annual survey may be considerably more helpful than more sparse investigations in distinguishing between temporary fluctuations and real changes.     

Parental Perceptions of Health Care for Children with Chronic Illness-A Population-based Study in a Swedish Primary Care District

The division of responsibilities between specialized and primary health care for children with chronic illness is unclear. The utilization and perceptions of primary and specialized care were examined by means of a questionnaire mailed to the parents of all chronically ill children and a randomly selected control group. No difference in sociodemographic variables of responders (70%) and nonresponders was found. The study comprised 98 index and 168 control children. The index children utilized both primary and specialized care more than controls. The overall satisfaction with health care was high, but primary care did not come up to the expectations of many chronically ill children's parents. Satisfaction with specialized care but not with primary care had improved during the previous 15 years. Recognition in primary care of childhood chronic illnesses and their psychosocial consequences is important. In co-operation, the two health care levels together could enable a comprehensive, well-coordinated, and continuous care for these children.     

Intensive Intervention Improves Primary Care Follow-up for Uninsured Emergency Department Patients

Objectives: To test an intervention designed to improve primary care use and decrease emergency department (ED) utilization for uninsured patients using the ED. Methods: Using a randomized design, an intensive case‐management intervention was tested with patients identified at a Level 1 urban trauma center from April 2002 through July 2002. Following assessment in the ED, six‐month follow‐up data were gathered from four primary care sites (two Federally Qualified Health Centers, two hospital outpatient clinics) and two area hospitals. Eligible participants were uninsured, were at least 18 years of age, and did not have a regular primary care provider. Of 281 patients approached, 273 (97.2%) agreed to participate. After 42 patients were eliminated following enrollment due to ineligibility, there were 121 intervention and 109 comparison subjects. Health Promotion Advocates (HPAs) in the ED gathered information from all study participants. On intervention shifts, HPAs assisted patients in choosing a primary care provider and faxed all information to a case worker at the selected site. Case managers attempted to contact patients and schedule appointments. On comparison shifts, patients received care as usual. Primary care contact in 60 days and subsequent ED visits in six months post‐ED assessment were the main outcome measures. Results: Intervention subjects were more likely to have a primary care contact (51.2% vs. 13.8%, p < 0.0001). There was no statistically significant difference between groups in either number of inpatient admissions or postintervention ED visits, although postintervention ED visits for the intervention group were less expensive. Conclusions: This project has demonstrated that it is possible to improve primary care follow‐up for uninsured ED patients.     

Population Health and Tailored Medical Care in the Home: the Roles of Home-Based Primary Care and Home-Based Palliative Care

With the growth of value-based care, payers and health systems have begun to appreciate the need to provide enhanced services to homebound adults. Recent studies have shown that home-based medical services for this high-cost, high-need population reduce costs and improve outcomes. Home-based medical care services have two flavors that are related to historical context and specialty background—home-based primary care (HBPC) and home-based palliative care (HBPalC). Although the type of services provided by HBPC and HBPalC (together termed “home-based medical care”) overlap, HBPC tends to encompass longitudinal and preventive care, while HBPalC often provides services for shorter durations focused more on distress management and goals of care clarification. Given workforce constraints and growing demand, both HBPC and HBPalC will benefit from working together within a population health framework—where HBPC provides care to all patients who have trouble accessing traditional office practices and where HBPalC offers adjunctive care to patients with high symptom burden and those who need assistance with goals clarification. Policy changes that support provision of medical care in the home, population health strategies that tailor home-based medical care to the specific needs of the patients and their caregivers, and educational initiatives to assure basic palliative care competence for all home-based medical providers will improve access and reduce illness burden to this important and underrecognized population.     

Caring for Demented Elderly in Rural Primary Health Care

In 1988, the demented in an elderly rural population (n = 851) were traced and assessed with the GBS geriatric rating scale. The aim of the study was to investigate the level of impairments of demented persons primary cared for and to relate their impairments to form of housing; to compare the distribution of care between not-demented and demented in an elderly population, and to establish the primary caregiver/patient ratio. The majority of the demented (44/50) were cared for in the studied primary health care area, despite the scarcity of staff. All received formal care. They consumed more formal care than the not-demented in the population. In relation to amount of elderly persons helped, the home-help personnel ratio was 0.30, in district care the ratio was 0.02, whereas the ratio of general practitioners was 0.002, estimated from the number of contacts and staff.     

The Organizational Climate for Nurse Practitioners Working in Primary Health Care in New Zealand: A National Survey

Little is known about the working conditions of nurse practitioners (NPs) in primary health care in New Zealand. Data were collected using an online organizational climate questionnaire from NPs and managers who employed NPs. Nearly two-thirds of all primary health care NPs in the country (n = 136) responded together with a purposive sample of 58 managers. More than 90% of respondents from both groups identified that organizations created an environment where NPs could practice independently and autonomously with collegial support. Other results signaled opportunities for improvement in local and national health policy. This study adds to international evidence on creating positive practice environments for NPs.     

Awareness of the Care Team in Electronic Health Records

OBJECTIVE: To support collaboration and clinician-targeted decision support, electronic health records (EHRs) must contain accurate information about patients' care providers. The objective of this study was to evaluate two approaches for care provider identification employed within a commercial EHR at a large academic medical center. METHODS: We performed a retrospective review of EHR data for 121 patients in two cardiology wards during a four-week period. System audit logs of chart accesses were analyzed to identify the clinicians who were likely participating in the patients' hospital care. The audit log data were compared with two functions in the EHR for documenting care team membership: 1) a vendor-supplied module called "Care Providers", and 2) a custom "Designate Provider" order that was created primarily to improve accuracy of the attending physician of record documentation. RESULTS: For patients with a 3-5 day hospital stay, an average of 30.8 clinicians accessed the electronic chart, including 10.2 nurses, 1.4 attending physicians, 2.3 residents, and 5.4 physician assistants. The Care Providers module identified 2.7 clinicians/patient (1.8 attending physicians and 0.9 nurses). The Designate Provider order identified 2.1 clinicians/patient (1.1 attending physicians, 0.2 resident physicians, and 0.8 physician assistants). Information about other members of patients' care teams (social workers, dietitians, pharmacists, etc.) was absent. CONCLUSIONS: The two methods for specifying care team information failed to identify numerous individuals involved in patients' care, suggesting that commercial EHRs may not provide adequate tools for care team designation. Improvements to EHR tools could foster greater collaboration among care teams and reduce communication-related risks to patient safety.     

Preferred Functions of Personal Health Records in Rural Primary Health Clinics in Canada: Health Care Team Perspectives

Background  Personal health records (PHR) provide opportunities for improved patient engagement, collection of patient-generated data, and overcome health-system inefficiencies. While PHR use is increasing, uptake in rural populations is lower than in urban areas. Objectives  The study aimed to identify priorities for PHR functionality and gain insights into meaning, value, and use of patient-generated data for rural primary care providers. Methods  We performed PHR preimplementation focus groups with rural providers and their health care teams from five primary care clinics in a sparsely populated mountainous region of British Columbia, Canada to obtain their understanding of PHR functionality, needs, and perceived challenges. Results  Eight general practitioners (GP), five medical office assistants, two nurse practitioners (NP), and two registered nurses (14 females and 3 males) participated in focus groups held at their respective clinics. Providers (GPs, NPs, and RNs) had been practicing for a median of 9.5 (range = 1–38) years and had used an electronic medical record for 7.0 (1–20) years. Participants expressed interest in incorporating functionality around two-way communication and appointment scheduling, previsit data gathering, patient and provider data sharing, virtual care including visits using videoconferencing tools, and postvisit sharing of educational materials. Three further themes emerged from the focus groups: (1) the context in which the providers'' practice matters, (2) the need for providing patients and providers with choice (e.g., which data to share, who gets to initiate/respond in communications, and processes around virtual care visits), and (3) perceived risks of system use (e.g., increased complexity for older patients and workload barriers for the health care team). Conclusion  Rural primary care teams perceived PHR opportunities for increased patient engagement and access to patient-generated data, while worries about changes in workflow were the biggest perceived risk. Recommendations for PHR adoption in a rural primary health network include setting provider-patient expectations about response times, ability to share notes selectively, and automatically augmented note-taking from virtual-care visits.     

The Impact of Checking the Health of Adults with Intellectual Disabilities on Primary Care Consultation Rates,Health Promotion and Contact with Specialists

Background Studies have found that health checking in primary care led to the identification of previously unrecognized morbidity among adults with intellectual disabilities. The aim here was to evaluate whether health checking stimulated increased consultation with the general practitioner or another member of the primary care team, increased health promotion actions undertaken outside the health check or increased contact with specialists. Method Data on the above three categories of activity were abstracted from the medical records of 77 adult participants with intellectual disabilities for eight 6‐month periods before and seven 6 month periods after they had undergone a health check. Comparisons of access to care before and after the health check were made using non‐parametric statistics. Results On average, participants had 5.4 and 1.8 primary care and specialist consultations per year respectively. There were no significant differences in either rate before and after the health check. The frequency of health promotion actions increased significantly after the health check from a mean of 1.2 to 2.2/year. Conclusions Comparison of the primary care and specialist consultations rates of people with intellectual disabilities with those for the general population might suggest that the former have greater access to these services. However, comparison to the general practitioner consultation rates of patients with other chronic conditions would seem to indicate that contact with primary care may not be commensurate with need. Attention to health promotion is inadequate. Further research is required to substantiate whether health checking increases health promotion and how increased health promotion activity would affect the health of this population.     

Problem of Objective Performance Assessment of Primary Health Care Physicians

Training programmes for primary health care physicians often lack methods for valid and reliable performance assessment of the trainees. A set of rating scales has been developed with the aim of increasing the objectivity of measurement of practical skills required for the management of cardiac failure. To prove the validity of the content and structure, as well as the inter-observer reliability, the scales were tested by the method of “competent judges” with the use of video-recorded clinical simulation. Calculated Kendall's coefficient of concordance W was at the minimum acceptable level of 0.5. The results reveal considerable differences among examiners (competent judges) regarding internal criteria of acceptable level of performance, and they point out the need for further search for more objective methods of performance assessment.     

Primary health care for Korean immigrants: sustaining a culturally sensitive model

This report describes a 4-year long bilingual interdisciplinary primary health care project that was designed to make culturally sensitive services available to underserved Korean immigrants in Chicago. It also describes some of the particular needs of this population and the strategies that the project staff adopted to identify and address the population's mental health needs. The project reflected the successful collaborative efforts of four participating principals: the Korean community, the University of Illinois at Chicago College of Nursing, the Chicago Department of Public Health, and the W. K. Kellogg Foundation. The model of service demonstrated in the project paired a bilingual advanced practice nurse, a certified family nurse practitioner, with a bilingual community advocate to conduct a program emphasizing community outreach and health promotion and prevention. A bilingual physician provided consultation for the nurse and attended to patients in need of medical care. Patients were referred to bilingual community social service agencies for assistance with a variety of other problems. A central goal of the project was for the services developed during its course to be assimilated into the regular programming of the Chicago Department of Public Health, a goal that was achieved. Finally, some of the challenges of introducing role change into an organization are discussed.     

General Practitioners: Allies or Enemies of Primary Health Care

In this paper the thesis is advanced that the general practitioners can either be a powerful ally or a major roadblock in the development of primary health care in the spirit of the Alma-Ata Declaration. The role they will play depends on their interpretation of, and attitudes towards, the concept. In the first part of the paper, four common interpretations of primary health care (primary health care as a set of activities; as a level of care; as a strategy; and as a philosophy) are described. The second part identifies common misconceptions — traps into which the general practitioners may fall when taking their stand on primary health care. In the third part, a blueprint for transforming the current systems of primary medical care systems into primary health care systems is outlined. The final section suggests some concrete actions to be taken by the general practitioners in implementing this blueprint.     

Helping Primary Care Patients Heal Holistically via Trauma-Informed Care

Nurse practitioners regularly treat primary care patients with trauma histories. By incorporating trauma-informed care into practice, nurse practitioners can enhance the provision of clinical care and, ultimately, improve patient health outcomes. This brief report demonstrates how to actively incorporate the principles and practices of the 4R framework of trauma-informed care into primary care to realize the prevalence of trauma, recognize patients’ trauma signs and symptoms, and respond to patients in a manner that resists retraumatization. Through early identification of trauma symptoms and referral to appropriate follow-up treatment, nurse practitioners can significantly improve the life course of their trauma survivor patients.     

Use of Primary Health Care in Spili,Crete, and in Dalby,Sweden

A computerized medical record system was introduced in Greek primary health care (PHC) in the village of Spili in Crete. The present study was carried out to study similarities and differences in the pattern of PHC use in Dalby Health Centre, Sweden (DHC), and Spili Health Centre, Greece (SHC).

In both Dalby and Spili more than half the population contacted their respective health centre during 1989. Patients contacted DHC more often than SHC, 3.33 vs 2.30 times. Relatively more females than males used the health services in Dalby (64% vs 50%), but not in Spili (57% vs 55%). More visits were made by appointment at DHC than SHC (36.0% vs 12.6%).

There were great similarities in the two areas in the ten most common diagnoses, analysed in four age-groups. In both areas, acute upper respiratory infections dominated in the youngest age-groups, and hypertension and diabetes in those aged 45 years and above.     

Case Management by Physician Assistants and Primary Care Physicians vs Emergency Physicians

Objectives : To determine whether physician assistants' (PAs') and primary care physicians' (PCPs') case management for 5 common primary care medical problems is similar to that of emergency physicians (EPs).
Methods : An anonymous survey was used to compare PAs, PCPs, and EPs regarding intended diagnostic and treatment options for hypothetical cases of asthma, pharyngitis, cystitis, back strain, and febrile child. Published national practice guidelines were used as a comparison criterion standard where available. The participants stated that they treated all of the patients and responded to all of the cases to be included in the survey. The responses of the PA and PCP groups were compared with those of the EP group, and financial charges for care by each group were analyzed.
Results : The EPs tended to follow treatment guidelines closer than did other primary care specialists. The management of PCPs and PAs differed from that of EPs, as follows:

Conclusion : The EPs more closely followed clinical guidelines than did the PAs and PCPs for these standardized clinical scenarios. Although the relationship of such theoretical practice to actual practice remains unknown, use of these clinical scenarios may identify intended practice patterns warranting attention.