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.     

Primary mental health workers in child and adolescent mental health services

BACKGROUND: The interface between primary care and specialist services is increasingly seen as crucial in the effective management of child and adolescent mental health (CAMH) problems. In the United Kingdom, a new role of primary mental health worker (PMHW), has been established in order to achieve effective collaboration across the interface through the provision of clinical care in primary care settings and by improving the skills and confidence of primary care staff. However, little is known about the development of this innovative role in service contexts. Issues raised during the early stages of implementation may have important implications for the preparation and development of professionals who undertake the role. AIMS: The aim of this paper is to report on a study that examined key issues in implementation of the PMHW role in six health authorities in England. METHODS: Case study evaluation was conducted, using thematic analysis of 75 qualitative interviews with key stakeholders from different professions (e.g. PMHWs, general practitioners, health visitors, psychiatrists and service managers) and representing different sectors (primary care, specialist services and community child health services). FINDINGS: The study identified three models of organization (outreach, primary care-based and teams). Each was associated with different advantages and disadvantages in its effects on referral rates to specialist services and the development of effective working relationships with primary care providers. Problems associated with accommodation and effective integration of PMHWs with specialist services, and tensions caused by the two different roles that PMHWs could undertake (direct clinical care vs. consultation-liaison) were common across all sites. CONCLUSIONS: The PMHW role is an important development that may go some way towards realizing the potential of primary care services in CAMH. The implementation of new roles and models of working in primary care is complex, but may be facilitated by effective planning with primary care providers, clear goals for staff, and a long-term perspective on service development.     

GP group profiles and involvement in mental health care

Rationale and objectives Mental health is one of the leading causes of morbidity worldwide. Its impact in terms of cost and loss of productivity is considerable. Improving the efficiency of mental health care system has thus been a high priority for decision makers. In the context of current reforms that privilege the reinforcement of primary mental health care and integration of services, this article brings new lights on the role of general practitioners (GPs) in managing mental health, and shared‐care initiatives developed to deal with more complex cases. The study presents a typology of GPs providing mental health care, by identifying clusters of GP profiles associated with the management of patients with common or serious mental disorders (CMD or SMD). Methods GPs in Quebec (n = 398) were surveyed on their practice, and socio‐demographic data were collected. Results Cluster analysis generated five GP profiles, including three that were closely tied to mental health care (labelled, respectively: group practice GPs, traditional pro‐active GPs and collaborative‐minded GPs), and two not very implicated in mental health (named: diversified and low‐implicated GPs, and money‐making GPs). Conclusion The study confirmed the central role played by GPs in the treatment of patients with CMD and their relative lack of involvement in the care of patients with SMD. Study results support current efforts to strengthen collaboration among primary care providers and mental health specialists, reinforce GP training, and favour multi‐modal clinical and collaborative strategies in mental health care.     

Interprofessional education in Denmark

The objective of this research was to explore the extent of teamworking in primary health care in the UK and compare primary health care teams with other multidisciplinary teams on fundamental critieria of team functioning. A survey was conducted, using a validated questionnaire which measures four aspects of team climate: participation, shared objectives, task orientation and support for innovation. Sixty-eight primary health care teams participated in the questionnaire survey, with additional comparison data from: 24 oil company teams; 27 NHS management teams; 20 community mental health teams; 40 social services teams. The total number of respondents across three samples was 1,555. Main outcome measures were levels of team participation, support for innovation, task orientation and clarity of, and commitment to, team objectives. Primary health care teams scored significantly lower than other teams in the sample on all team functioning factors except task orientation. It is concluded that a restructuring of the organization of primary health care is required if primary health care teams are to develop clear shared objectives to facilitate the coordinated approach to the delivery of care, long urged by practitioners and policy makers.     

Community Development Specialists in Nursing for Developing Countries

Nurses in traditional roles cannot always meet the challenge of providing health care in developing communities even though community health care is similar to that of care in developed countries (Mahler, 1984). Kupina (1995) identified components of community health including "physical aspects, safety, social norms, interpersonal processes, economic factors, and cohesion of the community" (p. 188). However, developed communities emphasize individual access to health care especially for vulnerable groups (Keane & Richmond, 1993). In developing countries, such as Pakistan, people are struggling to meet basic safety and security needs amid poor sanitary conditions, malnutrition, overcrowding, and scarce primary health care (Wagner & Menke, 1992). Massive migration of populations from rural to urban areas, overwhelming poverty and crime that threatens the very existence of some neighborhoods, high incidence of tuberculosis, drug dependency, AIDS, homelessness, and high infant and maternal mortality rates are major problems (Mason et al., 1992). In cities such as Karachi, Pakistan, rural to urban migration has resulted in the establishment of numerous squatter settlements called "katchi abadis" that lack sanitation, safe drinking water, and public health services. Even if such services were provided, high illiteracy rates and a strong sense of powerlessness, especially among women, adds further challenges for health providers.     

Mental Health Nurse Incentive Program: Facilitating physical health care for people with mental illness?

People with serious mental illness have increased rates of physical ill‐health and reduced contact with primary care services. In Australia, the Mental Health Nurse Incentive Program (MHNIP) was developed to facilitate access to mental health services. However, as a primary care service, the contribution to physical health care is worthy of consideration. Thirty‐eight nurses who were part of the MHNIP participated in a national survey of nurses working in mental health about physical health care. The survey invited nurses to report their views on the physical health of consumers and the regularity of physical health care they provide. Physical health‐care provision in collaboration with general practitioners (GPs) and other health‐care professionals was reported as common. The findings suggest that the MHNIP provides integrated care, where nurses and GPs work in collaboration, allowing enough time to discuss physical health or share physical health activities. Consumers of this service appeared to have good access to physical and mental health services, and nurses had access to primary care professionals to discuss consumers’ physical health and develop their clinical skills in the physical domain. The MHNIP has an important role in addressing physical health concerns, in addition to the mental health issues of people accessing this service.     

Barriers to preventive health care for young children

PURPOSE: To review the literature on barriers to availability, access, and utilization of preventive health care for young children three to five years of age and their families and to discuss the role of nurse practitioners (NPs) in future research, education, and practice in this area. DATA SOURCES: A comprehensive literature search was conducted of online material and CINAHL and Medline (CD-ROM 1990 to present). In addition, experts in this area were asked to recommend extra reading materials. Additional references in textbooks and articles were examined. CONCLUSIONS: The literature review supports that there are major barriers to be addressed in the areas of availability, access, and utilization of preventive health care services for young children and their families. Major concerns include mandatory system for preventative health care, lack of health insurance coverage, cultural issues, and parental effects. IMPLICATIONS FOR PRACTICE: Health professionals in the community will need to work together to reevaluate current preventive health care practices for young children. Alternative methods for approaching and providing preventive health care services may become increasingly important if these services for young children are to be provided at current or increased levels.     

Primary Care for Lesbian,Gay, Bisexual,Transgender, and Queer/Questioning (LGBTQ) Patients

The lesbian, gay, bisexual, transgender, and queer/questioning (LGBTQ) community is a vulnerable populace that accounts for 4.5% of the United States population. Unfortunately, this group of individuals faces discrimination. They need access to quality, prejudice-free health care. This article initiates the discussion of how nurse practitioners, primary care, and family practice providers can provide inclusive, unbiased, quality care to this community that is evidence based. Information is provided about common barriers preventing this population from receiving equitable care. Evidence-based methods are outlined for screening this population for common health conditions, paying particular attention to an established HIV risk assessment and its application in clinical settings to identify candidates for pre-exposure prophylaxis. Finally, pharmacologic information about preexposure prophylaxis and transgender hormone therapy is presented. The information presented prepares nurse practitioners to begin caring for this population.     

Characteristics of severely mentally ill patients in and out of contact with community mental health services

Community mental health nurses have been criticized for failing to prioritize work with people with a severe or enduring mental illness, many of whom have no contact with specialist mental health services and rely entirely on their general practitioner and primary care team. It is important to ensure that those in contact with specialist services actually need this level of input but, conversely, that those in contact with only primary care receive a service that is equipped to meet their needs. This study examines the differences between these two groups of patients. A sample of 253 community-based patients with a severe or enduring mental illness was divided into those with mental health service contact and those without. Differences in the demographic characteristics of the two groups were assessed and further, more detailed, comparisons were made with a sub-sample of 49 individuals randomly drawn from this larger sample. Instruments adopted for these purposes comprised the Camberwell Assessment of Need and the Life Fulfilment Scale. It was found that patients with a psychotic disorder were more likely than those with neurosis to be in contact with mental health services and patients with schizophrenia were significantly more likely to be on the active caseload of a community mental health nurse than those from all other diagnostic groups. However, patients' levels of need, unmet need and quality of life did not differ in relation to their service contact. Whilst the study provides limited evidence that community mental health nurses are targeting people with the most serious disorders, questions remain about the large proportion not receiving specialist care. Because primary care plays a significant role in the care of severely mentally ill people living in the community, the further mental health training of general practitioners and practice nurses is becoming increasingly important.     

Weaving the seamless web of care: an analysis of parents' perceptions of their needs following discharge of their child from hospital

Changes in children's nursing services in the United Kingdom in recent years have focused on the need for adequate and efficient services to be provided in the interests of the child. Early discharge is now the norm and children are often sent home in an earlier recovery stage than adults with comparable conditions. Whilst the contributions of paediatric community nursing services have gone some way to providing specialist nursing care for children and their families in their own homes, the majority of children are discharged home without such support being available. This may place an overwhelming responsibility of caring for a recovering child onto parents. The purpose of the qualitative research reported in this paper was to identify any gaps in nursing services for acutely sick children and their families following discharge, and to suggest ways to improve integration and communication between hospital and primary care to facilitate a 'seamless web of care' for families. Families were surveyed following discharge (n=164) and interviews carried out with those experiencing problems (n=20). General practitioners were also surveyed for their opinion as key contributors of primary care. Findings revealed the isolation felt by parents following discharge, with their need for information about a child's illness and expected recovery, and for reassurance and specific advice through some means of support, which was clearly not being met. The perceived benefit of continuity of care was a common theme, with both parents and professionals acknowledging the importance of closer liaison between hospital and primary health care services. This study is valuable in providing preliminary qualitative information regarding the gaps in children's nursing services and how these can be overcome by using our present resources more imaginatively, in order to ensure the delivery of cost-effective and quality health care services in the best interests of local need.     

Progression of the mental health nurse practitioner role in Australia

The guiding principle of health care is to serve the needs of the public. Healthcare services are therefore required to be increasingly flexible and open to new approaches to meet changing demands. They must also adjust and expand as new challenges are presented. Public awareness of mental health issues and the current demands placed on health services for access to affordable and appropriate mental health care have never been so great. The introduction of nurse practitioners (NPs) in Australia is a proud and long-anticipated moment for the discipline of nursing. However, a major challenge for the introduction of NPs in Australia will be to reassure medical colleagues, allied health professionals and the public that NPs are able to deliver high-quality primary care. This paper elaborates on the progress of the mental health NP role in Australia. Attention is centred on the characteristics the mental health NP role, the maintenance of professional competency to practise at an advanced clinical level, and the prospects and potential significance of NPs for mental health nursing practice. The nurse-led clinic, implemented through the process of consultation and systematic evaluation, is identified as an avenue for the extension of mental health NP practice in the delivery of autonomous primary care.     

A review of prison health and its implications for primary care nursing in England and Wales: the research evidence

Aims and objectives. To provide a systematic overview of the policy and practice literature concerned with the primary healthcare needs of prisoners in England and Wales and to address the implications of these health needs for nurses working in prisons. Background. The recent reorganization of the prison healthcare system, which has brought prison health services in England and Wales within the National Health Service, has major implications for the role of prison nurses. Nurses in prisons are increasingly providing services to promote the health of prisoners, in addition to making assessments of health need and treating health problems. Methods. The review examined literature from 1995 to date using standard review techniques adapted to be both sensitive and inclusive and with high recall because of the unexplored nature of primary health care in prisons. Results. Findings are identified in three main areas: the general health needs of prisoners, health promotion and chronic disease management. In all these areas, the health needs of the prison population are much greater than the community as a whole, resulting in a high demand for primary care services in prison. However, the prison setting can militate against providing good primary care services in prison. Conclusions. More research has been carried out into the health needs of prisoners than into the provision of primary care nursing services in prisons. Further research is needed into primary care nursing in prison to meet the health needs of prisoners effectively. Relevance to Clinical Practice. With the reorganization of prison health services, health provision in prisons is increasingly primary care focused. This presents new challenges to nurses working in prison to provide a primary care service, which meets the identified health needs of prisoners.     

Primary care groups and trusts: a threat or an opportunity for the development of community-based nursing in England

AIMS OF THE STUDY: To examine the role of Primary Care Groups and Trusts (PCG/T) in relation to nurses working in general practice and community health services. BACKGROUND: Over the past two decades there have been rapid changes in the numbers and roles of nurses working in primary care and community based settings. The establishment of Primary Care Groups offers health care professionals, including nurses, the chance to develop local primary care services and to integrate community and primary care nursing. These developments may offer opportunities or pose threats to nursing staff. RESEARCH METHODS: Data are drawn from a longitudinal study of a randomly selected sample of Primary Care Groups in England (n = 72). In a second survey of Groups carried out in autumn/winter 2000, Primary Care Group chairs and chief officers were interviewed by telephone. RESULTS: Response rates were 97% for both chairs and chief officers (69 of each). Chairs indicated that in most areas Primary Care Groups were consulting with local nurses to develop policy. Fifty-seven (85%) reported that investment in nursing staff and nursing services was a high priority in their area. Twenty-eight (41%) indicated that nurse-led services designed to increase patient access had already been established in their area, and 20 (29%) were planning new nurse-led services. Many developments had been initiated by Primary Care Groups. Initiatives to integrate community and general practice based staff were underway in most areas. CONCLUSIONS: Primary Care Groups and Trusts are initiating changes in general practice and community based services which are likely to have long-term and important implications for nurses in terms of their roles, conditions of work and future careers. It is important that nurses are consulted and are involved in developing and implementing policy change.     

Perceived factors influencing hospital-based primary care clinic referrals to community health medical nutrition therapy: An exploratory study

Primary care clinics provide an array of diagnostic and clinical services that assist patients in preventing the onset or managing acute and chronic conditions. Some chronic conditions such as high blood pressure, high cholesterol, and type 2 diabetes require primary care professionals to seek additional medical intervention from registered dieticians. This study explored beliefs, attitudes, and practices of medical and administrative professionals in primary care clinics encountering patients who are potential candidates for ongoing nutrition education or counselling. Five focus groups with primary care providers and clinical staff (n = 24) were conducted to identify perceived intra-organisational factors influencing initiation of community health medical nutrition therapy (MNT) referrals. Lack of clarity regarding community health dieticians’ role in chronic disease management was the primary finding for the absence of MNT referrals. Insurance-imposed constraints, perceived patient readiness to change, and service inaccessibility were revealed as barriers that influence referrals to both community health and specialty care dieticians. This study underscores the importance of identifying organisational and interpersonal barriers that influence the initiation of community health MNT referrals. Understanding these barriers can create stronger interprofessional collaboration between primary care providers and community health dieticians.     

General practitioners' views of community mental health services: A survey in one London borough

Community mental health teams are increasingly focusing their activities on people with severe mental illnesses. At the same time, the overall extent of mental health need in primary care ensures general practitioners (GPs) remain key professionals in the co-ordination and provision of mental health services to a wide range of patients. This study sought to establish the views of GPs working in one London borough on community mental health services, and to establish what they believed were appropriate services for community mental health professionals to provide. A postal questionnaire sent to all 104 GPs working in the borough produced a 48% response rate. GPs believed community mental health teams were useful, and effective in dealing with patients presenting with a variety of mental health problems. Many believed that enhanced primary health care teams, adequately resourced and staffed with attached mental health professionals, could provide a wide range of mental health interventions. Dissatisfaction appeared to be related to the evolving focus of community mental health teams. Many GPs believed that they had lost a valuable service for people with less severe mental health needs.     

General practitioners' perceptions of community psychiatric nurses in primary care

The management of and responsibility for the care of people with mental health problems in the community is increasingly being assumed by general practitioners (GPs) and primary care personnel. As primary care groups (PCGs) evolve, so must their expertise in managing people with a wide range of mental health problems. It is expected that all mental health professionals will participate in this development, although it is likely that community psychiatric nurses (CPNs) will be the largest professional group involved, with a significant part to play in the shaping, management and delivery of mental health services. To date, there has been little research into how CPNs are perceived by other primary health care professionals. This study seeks to provide an insight into how GPs assess the contribution of CPNs in primary care. Overall, the results of the study suggest that GPs view CPNs favourably and consider that they have an important role to play. Greater involvement in primary care raises issues about the education and preparation of CPNs, their professional development and supervision needs.     

Managing Chronic Disease in Affordable Primary Care

National agencies are calling for quality improvement in primary care health care services and across the United States health care system. Changes would be directed toward improving quality of life for the chronically ill and decreasing their financial burden and that placed on society. Nurse practitioners, based on their expertise and preparation in patient education, are ideal health care providers to establish partnerships with motivated, informed, chronically ill patients and to promote change in health care policy, guidelines, and meeting patient educational needs. Within worksite primary care, nurse practitioners can, through the Chronic Care Model framework, provide chronic disease management and affordable health care access.     

Evaluating the clinical efficacy of a primary care-focused, nurse-led, consultation liaison model for perinatal mental health

In Australia, perinatal mental illness is common, although poorly identified and treated. Improved perinatal mental health depends on service provision models that reflect a focus on promotion, prevention, and early intervention, while facilitating improved referral pathways between primary health and specialist mental health services. In 2008, a contemporary community-based model of mental health service provision was developed as an alternative to the pre-existing hospital-based service model. The model is delivered primarily by mental health nurses using a consultation liaison framework. It provides for specialist mental health assessment and brief intervention in collaboration with the general practitioner, who remains the primary health provider. It also aims to raise community awareness and build capacity for the management of perinatal disorders in the primary care sector. Evaluation of the clinical effectiveness of the model, and the improvement in access for primary health providers and women, was conducted at 2 years from its implementation. Clinical effectiveness was evaluated by using comparative data from the Edinburgh Depression Scale and Depression Anxiety and Stress Scale, and the results demonstrated clinical efficacy. Improved attendance rates indicated that women preferred this community-based service model as an alternative to the pre-existing service model.     

Building a Child Mental Health Workforce for the 21st Century: Closing the Training Gap

Of the children and adolescents with mental health concerns who receive treatment, most do so in outpatient community mental health service sites, systems of care which have largely failed to produce significant clinical outcomes. Suggested strategies to improve care in child mental health treatment include improving families' access to services, increasing use of evidence-based practices (EBPs), and holding service sites accountable for demonstrating outcomes. Producing a workforce to implement these strategies will require cultivating providers who have developed specific competencies within a range of agencies that naturally interface with the daily lives of families and their children. The authors report on a recently developed interprofessional child community fellowship for psychiatry residents and psychiatric mental health nurse practitioners aimed at training providers to deliver child mental health services in a variety of community settings. Activities that focus the fellowship are outlined along with the development of the related competencies: EBP translation, collaboration skills, and outcome measurement. Evaluation strategies for fellows' competency development are discussed.     

HIV in Primary Care: Case Study of Common Chronic Comorbidities

This article provides information to increase the knowledge, skills, and confidence of primary care nurse practitioners managing chronic conditions for persons living with HIV (PLWH). A case study is presented, followed by discussion of common chronic disease processes related to the patient: chronic kidney disease, diabetes mellitus, hypertension, hyperlipidemia, osteoporosis, and mental health. PLWH are at increased risk for non-HIV–related comorbidities. Nurse practitioners practicing in primary care settings are ideal providers to manage chronic conditions in PLWH.