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.     

Outcomes of referrals over a six-month period to a mental health gateway team

Mental health policy in recent years has prescribed the role, function and form for services in England. Evidence of their effectiveness post-policy implementation has been limited to date and minimal guidance has been available on how services should operate together as whole systems. This paper reports findings from a study of referrals and their outcomes in respect of specialist community mental health services following implementation of national policy and its interpretation and configuration at a local level. Findings highlight that gateway workers configured as a team operating between primary and secondary care can effectively shield community mental health teams from high numbers of referrals that they would deem inappropriate. The study also identified the triage role of this service as being crucial to the effectiveness of developing and maintaining care pathways and also in potentially supporting the mental health capability of primary care.     

Stakeholder perspectives on new ways of delivering unscheduled health care: the role of ownership and organizational identity

RATIONALE, AIMS AND OBJECTIVES: To explore stakeholder perspectives of the implementation of a new, national integrated nurse-led telephone advice and consultation service [National Health Service 24 (NHS 24)], comparing the views of stakeholders from different health care organizations. METHODS: Semi-structured interviews with 26 stakeholders including partner organizations located in primary and secondary unscheduled care settings [general practitioner (GP) out-of-hours cooperative; accident and emergency department; national ambulance service, members of NHS 24 and national policy makers. Attendance at key meetings, documentary review and email implementation diaries provided a contextual history of events with which interview data could be compared. RESULTS: The contextual history of events highlighted a fast-paced implementation process, with little time for reflection. Key areas of partner concern were increasing workload, the clinical safety of nurse triage and the lack of communication across the organizations. Concerns were most apparent within the GP out-of-hours cooperative, leading to calls for the dissolution of the partnership. Accident and emergency and ambulance service responses were more conciliatory, suggesting that such problems were to be expected within the developmental phase of a new organization. Further exploration of these responses highlighted the sense of ownership within the GP cooperative, with GPs having both financial and philosophical ownership of the cooperative. This was not apparent within the other two partner organizations, in particular the ambulance service, which operated on a regional model very similar to that of NHS 24. CONCLUSIONS: As the delivery of unscheduled primary health care crosses professional boundaries and locations, different organizations and professional groups must develop new ways of partnership working, developing trust and confidence in each other. The results of this study highlight, for the first time, the key importance of understanding the professional ownership and identity of individual organizations, in order to facilitate the most effective mechanisms to enable that partnership working.     

Primary health care practitioners' tools for mental health care

The purpose of this study was to describe and analyse the content of mental health care from the practitioner's point of view. The specific aim of this paper was to outline the types of mental health care tools and the ways in which they are used by primary health care practitioners. The data were derived from interviews with doctors and nurses (n = 29) working in primary health care in six different health care centres of the Pirkanmaa region in Finland. The data were analysed by using qualitative content analysis. The tools of mental health care used in primary health care were categorized as communicative, ideological, technical and collaborative tools. The interactive tools are either informative, supportive or contextual. The ideological tools consist of patient initiative, acceptance and permissiveness, honesty and genuineness, sense of security and client orientation. The technical tools are actions related to the monitoring of the patient's physical health and medical treatment. The collaborative tools are consultation and family orientation. The primary health care practitioner him/herself is an important tool in mental health care. On the one hand, the practitioner can be categorized as a meta-tool who has control over the other tools. On the other hand, the practitioner him/herself is a tool in the sense that s/he uses his/her personality in the professional context. The professional skills and attitudes of the practitioner have a significant influence on the type of caring the client receives. Compared with previous studies, the present informants from primary health care seemed to use notably versatile tools in mental health work. This observation is important for the implementation and development of mental health practices and education.     

Training for transformation: reorientating primary health care nurses for the provision of mental health care in South Africa

Using programme research, this paper reports on the evaluation of a programme designed to orientate primary health care nurses towards the provision of a comprehensive approach to care. In addition to training in psychiatric care, this was deemed necessary in order to facilitate comprehensive integrated primary mental health care in South Africa. Nurse-patient consultations were evaluated on indicators of comprehensive care before and after the programme. Interviews were also conducted with the participants individually and in a group. The results indicate that there are several factors which mediate the provision of comprehensive care by primary health care nurses. These include individual factors as well as contextual factors, inter alia, the structure and organization of the health care system, which historically has been organized to promote biomedical care. Furthermore, biomedicine has dominated training models in South Africa, instilling in nurses a biomedical approach to patient care.     

Community health care nursing in Rajasthan. A registered nurse's perspective

This study focused on the great shortage of registered nurses (RNs) in primary health care in Rajasthan, India. It dealt especially with the nurses' own opinions about working in primary health care and their reasons for not working in it. Nurses at different levels in the health care organization were interviewed. The study was based on interviews with six RNs individually, three groups of six to eight nursing students each, and three policy-making chief nurses individually. The Minister of Health in Rajasthan also participated in the study. The study showed that the reasons for the lack of RNs in community health care were as follows: a government policy decision to place less educated nurses in the communities; the great shortage of nurses in general; the system whereby a nurse is not able to choose her/his place of work; unwillingness on the part of the nurses to work in community health care because of the great security problems; lack of support from authorities and lack of equipment. In general, community health care nursing as a work area was despised by society at large in Rajasthan.     

Mental health policy and integrated care: global perspectives

Although omitted from the World Health Organization's eight Millennium Development Goals, mental illness ranks fourth of the 10 leading causes of disability in the world and is expected to approach second place by 2020. Scarce resources challenge responses to mental health needs. Effective approaches must consider existing healthcare delivery networks, nurses as care providers, as well as social, cultural, political and historical contexts. This paper reviews policy development and care approaches to address mental health needs around the world. Challenges, successes and further needs are discussed. Selected articles were reviewed to represent varied approaches to address mental health needs in countries with diverse resources and infrastructures. Integrated systems offer one model for addressing mental health needs along with physical health needs within a population. While potentially an efficient strategy, caution is advised to ensure services are integrated and not merely added on top of an already overburdened system. As the largest group of healthcare professionals worldwide, nurses play a key role in the delivery of mental health services. Nurses have an opportunity, if not a responsibility, to collaborate across borders sharing education and innovative approaches to care delivery.     

Primary health care organizations - through a conceptual and a political lens

BACKGROUND: Governments around the world are looking at means to improve health care services and health outcomes for their communities within a sustainable expenditure framework. There is a general agreement that strengthening primary health care is the way for the future. Primary health care organizations (PHCOs) are seen as a means to achieving more effective and efficient health care. RESULTS AND CONCLUSIONS: This paper proposes a complex adaptive framework for PHCOs, taking account of health and illness being subjective experiences, health care being 'whole person'-focused, and PHCOs focusing on all of a community's health determinants and community-based health care needs. Such approach would foster building healthy local communities as much as seamless integration of health services for all. However, despite the expressed intensions towards patient-centred health care reform the bureaucratic mindset of Australian health policy makers risks true reform by imposing highly structured - rather than 'simple'- policy and operational rules.     

The KwaZulu-Natal Health Promotion Model

PURPOSE: To describe a health promotion model aimed at assisting primary health care nurses to incorporate health promotion into their practice. ORGANIZING STRUCTURE: The model is based on empowering people through a systematic, planned, needs-driven curriculum with comprehensive content, using interactive teaching in small groups, and linking the groups with external resources. The process involves identifying and engaging partners, planning the project, implementing it, and then disengaging. METHODS: The implementation of this model in a province of South Africa, KwaZulu-Natal, in a collaborative project involving two universities and the state health services, changed the practice of the primary health care nurses involved. They worked with women's groups over 3 years and changed both their own perspectives and the lives of the women. CONCLUSIONS: Unless nurses have an implementation model available to them, they frequently focus only on illness needs of people and do not participate in health promotion.     

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.     

Health Policy,Health Services,and Cancer Pain Management in the New South Africa

In 1982, the World Health Organization (WHO) identified inadequate relief from cancer pain as an international health problem. WHO recommended that governments develop and implement national policies and programs for cancer pain relief. This report evaluates national health policy and the systems of health care delivery in relation to cancer pain management in the new South Africa. This field study included multiple methods of data collection: analysis of documents, field trips with participant observation in sites of care delivery, focused interviews, and in-depth interviews of key informants. The purposive sample of key informants (n = 33) represented multiple stakeholders in a variety of settings. Strengths of the developing health policy include specific recommendations related to palliative care; the shift to universal primary care; policies to support drug availability; the inclusion of morphine and codeine as essential drugs at the primary health care level; and the development of a national standard related to cancer pain management. Health services are characterized by two parallel systems of care (private and public) with numerous vestiges of the inequities of apartheid. The management of pain varies by provider and setting; major problems with access exist in the rural areas. Health services in South Africa have been plagued by inequity and inadequate resources. New health policies have set a path to ensure universal access to health care including palliative care for cancer. Their successful implementation is the next necessary step toward improving health services and alleviating the suffering of increasing numbers of individuals with cancer.     

Evidence-based practice in primary care: past, present and future

As in other health care specialities, evidence-based practice is beginning to have an impact on the philosophy and workings of primary care. Some practising clinicians, however, may wish to question its relevance to their everyday work, and whether general practitioners and other members of the primary health care team can realistically adopt a new approach to clinical decision making, at a time of such high workload and competing priorities.
Major changes have taken place during the last 20 years as a result of the National Health Service (NHS) reforms, the development of general practice and primary care research, and other health service innovations such as the introduction of new technologies, which have had an important impact on primary care. Issues such as the availability and use of different research methods, the role of experts, and the development of guidelines, audit and evaluation of care, are becoming subject to renewed scrutiny.
Within this context, this article explores the potential of an evidence-based approach in the primary care setting, and discusses possible strategies for change to assist the dissemination of research into practice and the implementation of evidence-based health care.     

Genetic education,knowledge and experiences between nurses and physicians in primary care in Brazil: A cross‐sectional study

Recent advances in genomics and related technologies have the potential to improve health care throughout the world. In this cross‐sectional study, we examine genetics education, knowledge, and genetics‐related experiences among the nurses and physicians who provide primary care in a Brazilian city. Fifty‐four healthcare professionals from family health units participated in the study (response rate: 90%). Data were collected using a structured 36‐item questionnaire divided into five axes: sociodemographic data and academic background; genetics education; genetics knowledge; genetics‐related experiences in family practice; and knowledge regarding the National Policy for Comprehensive Care in Clinical Genetics in the Unified Health System. Although most participants (85.2%) acknowledged receiving some genetic content during their undergraduate education, the majority (77.8%) advised that they did not feel prepared to deliver genomics‐based health care in primary care. The results suggest that nurses and physicians often lack the knowledge to provide genomics‐based health care in primary care. Therefore, continuing education in genetics/genomics should be provided to primary healthcare professionals in order to enhance family practice and compliance with national policies.     

Effects of an implemented care policy on patient and personnel experiences of care

Effects of an implemented care policy on patient and personnel experiences of care A care policy was implemented within health care in the county of Västerbotten, Sweden. A questionnaire was administered before and after the implementation of the care policy to assess its effects. Patients within hospital care and primary health care described their experiences in a base‐line study (n=3950) in 1994 and a follow‐up study (n=2941) in 1996. On the same occasions personnel (n=2362 and 2310, respectively) answered the same questionnaire assessing what they thought their patients experienced. No significant positive effects of the implementation were seen by the patients. Fewer patients felt that they were understood when they talked about their problems, dared to express criticism or denied they were treated nonchalantly in the follow‐up study. The experiences of the personnel were in line with those of the patients concerning nonchalant treatment in the follow‐up study. Furthermore, fewer staff members thought that their patients felt they had adequate help with hygiene whilst more thought that their patients felt they were responded to in a loving way. One interpretation of the negative outcome is that organizational changes, strained resources and cuts in staffing during the 90s may have reduced the possibility of integrating the care policy in spite of an ambitious and extensive intervention.     

Health professionals'' perspectives on service delivery in two Northern Ireland communities

This research builds on the findings of an ethnographic study of health inequalities in two small, rural communities in Northern Ireland. Through further analysis of existing data, this second study aimed to explore health professionals' perspectives on issues of service delivery relevant to government policy on primary care. Anthropological fieldwork was conducted for two consecutive 4-month periods during 1995 and 1996 in one predominantly Catholic and one predominantly Protestant town. To preserve confidentiality, the locations have been given the pseudonyms, respectively, of Ballymacross and Hunterstown. Research tools included fieldwork journals and a fieldwork diary, meetings with key informants, tape-recorded interviews, group discussions, participant observation and use of secondary material such as census data, local newspapers and community health profiles. Interviews with 15 health workers revealed that there was not a coherent approach to achieving health gain, little collaborative enterprise and minimal interaction between the different professional groups. The National Health Service (NHS)-employed primary care professionals, more than local community workers, appeared to be demoralized, exhausted and suspicious of the business-orientated health service. In this respect, the primary care-led NHS appeared not to be working. It is concluded that a shared health agenda should be developed by NHS-employed primary care professionals and local community workers to create a health-inducing environment at community level. This needs to be complemented by the establishment of formal mechanisms for inter-agency working at local, professional and government levels.     

A qualitative study of nurses' attitudes and practices regarding brief alcohol intervention in primary health care

BACKGROUND: Excessive alcohol consumption causes significant mortality, morbidity, economic and social problems in the United Kingdom (UK). Despite strong evidence for the effectiveness of brief intervention to reduce excessive drinking in primary health care, there is little indication that such intervention routinely occurs. AIMS: This study aimed to explore primary health care nurses' attitudes and practices regarding brief alcohol intervention in order to understand why it is underexploited. METHODS: The study design was qualitative, using a grounded theory approach to data collection and analysis. Semi-structured in-depth interviews were conducted with 24 nurses from practices that had previously been involved in a General Practitioner (GP) led brief alcohol intervention trial in the North-east of England. A combination of convenience and purposive sampling was used to recruit subjects and gain a broad range of perspectives on issues emerging from ongoing data-analysis until data saturation occurred. RESULTS: It was clear that although primary health care nurses have many opportunities to engage in alcohol intervention, most have received little or no preparation for this work. This has left nurses at a disadvantage as alcohol consumption is a confusing and emotive area for both health professionals and patients. An analysis of factors influencing nurse involvement in alcohol intervention outlined a requirement for clear health messages about alcohol, training in intervention skills, facilitation to enhance confidence regarding intervention and support to help deal with negative patient reactions. CONCLUSIONS: As current health policy is to encourage, sustain and extend the health promotion and public health role of primary care nurses, more attention should be given to providing them with better preparation and support to carry out such work.     

Mental health issues in primary healthcare

This article describes a project that was designed to explore mental health issues arising in primary care, as a basis for understanding primary care professionals' mental health training needs. Whilst recent UK government initiatives, such as the National Service Framework for Mental Health, have emphasized the need to enhance mental healthcare in the general population, the capacity to respond effectively is likely to be dependent upon primary care professionals acquiring the relevant skills. To achieve this, a thorough understanding of the issues inherent in dealing with mental health problems in primary care is required. Given that the mental health issues facing primary care professionals may differ from those that confront mainstream mental health professionals, logic dictates that primary care professionals may require a discrete set of skills and a special approach to mental health training. The principal aim of this project was, hence, to identify mental health issues arising in clinical practice, as a first step towards identifying primary care training needs. A series of focus groups and semi-structured interviews was used to gather information about mental health issues arising in primary care, based on the experiences of primary care professionals and users' representatives. The findings suggest that primary care professionals are confronted by a wide range of mental health issues, many of which lie outside of the scope of the current National Service Framework for Mental Health. The article discusses the implications for mental health training in primary care practice and future research.