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Spheres of provider accountability among general medical, mental health and substance use disorder specialists.
Source publication
Background:
Quality measures can be effective tools for improving delivery of care and patient outcomes. Co-occurring conditions (COCs), including general medical conditions and substance use disorders, are the rule rather than the exception in patients with serious mental health disorders and lead to substantial morbidity and mortality burden. CO...
Context in source publication
Context 1
... degrees of accountability for COCs Figure 1 presents a framework for clarifying degrees of account- ability for COCs between mental health, general medical and SUD providers. In developing this framework, we acknowledge that there are varying degrees of accountability. For example, to what extent are mental health providers accountable for general medical illnesses such as those derived from psychotropic medi- cations? Monitoring the effects of psychotropic drugs should be the responsibility of the psychiatrist prescribing the medication, yet managing the ongoing glucose intolerance that may stem from atypical antipsychotic use might be a more appropriate role for the patient's primary care physician (table 2). Arguably, the decision to continue use of the antipsychotic agent despite the risk of glucose intolerance should be a shared decision between the psychiatrist and primary care physician. 31 ...
Citations
... 2,3 With over 75% of adult mental disorders emerging before the age of 25 years, these disorders often have lifelong impacts even if the disorder is subthreshold or has remitted, so effective mental healthcare during this period is critical to reduce the burden for individuals, society and the health system. [4][5][6][7][8] The development and expansion of primary youth mental healthcare services in Australia has increased access to mental health services for young people. 9 Previous work has demonstrated that young people accessing these services often present with attenuated mood, anxiety and psychotic syndromes, 10 yet 14% reported a previous suicide attempt, which carries risks for worsening illness trajectories (e.g. ...
Background
Primary youth mental health services in Australia have increased access to care for young people, yet the longer-term outcomes and utilisation of other health services among these populations is unclear.
Aims
To describe the emergency department presentation patterns of a help-seeking youth mental health cohort.
Method
Data linkage was performed to extract Emergency Department Data Collection registry data (i.e. emergency department presentations, pattern of re-presentations) for a transdiagnostic cohort of 7024 youths (aged 12–30 years) who presented to mental health services. Outcome measures were pattern of presentations and reason for presentations (i.e. mental illness; suicidal behaviours and self-harm; alcohol and substance use; accident and injury; physical illness; and other).
Results
During the follow-up period, 5372 (76.5%) had at least one emergency department presentation. The presentation rate was lower for males (IRR = 0.87, 95% CI 0.86–0.89) and highest among those aged 18 to 24 (IRR = 1.117, 95% CI 1.086–1.148). Almost one-third (31.12%) had an emergency department presentation that was directly associated with mental illness or substance use, and the most common reasons for presentation were for physical illness and accident or injury. Index visits for mental illness or substance use were associated with a higher rate of re-presentation.
Conclusions
Most young people presenting to primary mental health services also utilised emergency services. The preventable and repeated nature of many presentations suggests that reducing the ongoing secondary risks of mental disorders (i.e. substance misuse, suicidality, physical illness) could substantially improve the mental and physical health outcomes of young people.
... Get out of the silo Our data demonstrate that the siloed QI capacity building investments are not leveraged to other parts of the health system. Horizontal integration of QI may better serve patients [39,40]. Siloed QI training means that many HCWs will struggle to make the leap to applications outside the case mix in which they were trained. ...
Introduction
Poor quality health care is a significant cause of preventable deaths, especially in low- and middle-income countries (LMICs). Quality improvement is multifaceted and includes strategies such as standard setting, quality assurance and clinic audits. In order to move quality improvement in health care into every day practice it is essential to fully engage the frontline where health care is delivered. The objective of this scoping review is to investigate front line health care worker line led quality improvement in Sub Saharan Africa (SSA).
Methods
We conducted a scoping review to identify, map and synthesize evidence on health care worker led quality improvement initiatives in Sub Sahara Africa using electronic databases PubMed, Cochrane, Embase, CINAHL, Scopus and Psychinfo to identify peer-reviewed literature published between January 2000 and January 2021. To identify grey literature, we used the same search terms in google search to a maximum of 10 pages or when there was no new information. All evidence was scored based on the 6 criteria described by Backhouse et al., which clearly distinguish quality improvement from clinical audit and research. Inclusion criteria were studies that involved frontline health care workers to test “change ideas” and used data systems to measure improvement in service delivery.
Results
A total of 75 records were identified and including 52 from the peer review search and 23 records from the grey literature search. Only 15 of 47 countries had publications (peer-review or grey literature) describing QI initiatives. Most quality improvement (QI) initiatives were multicomponent and included knowledge transfer, skills building, mentorship and learning visits. Most publications reported QI initiatives aimed at reproductive, maternal, neonatal and child health (n=23) and HIV (n=14) service delivery. Only 6 had experimental designs. No publications were identified prior to 2012 and a rapid escalation of published quality improvement initiatives from 2012 to 2020 was seen.
Conclusion
QI is in the very nascent stage in SSA. Most large-scale public health QI initiatives are sector specific, siloed, and donor driven. QI initiatives within sector specific programs have not moved horizontally and have had limited ability to change the broader system. Energy must be exerted to change the status quo. Making health care safer and more effective is not spontaneous.
... Conversely, the primary and geriatric care sectors are likely to have increasing contact with older PWUD, but are unaccustomed to the specific complexities of providing care for this population, including their frequent distrust of mainstream health-care settings [98], complex pain management needs [112,113] and clinical approaches to providing care in the context of ongoing drug use [18,114]. The need to bridge discipline-based 'silos' has been frequently noted in the care of PWUD, usually in relation to mental health [115,116] and infectious diseases [117]; such work is also needed here. ...
Aims:
To provide an overview of research literature on aging and older people who use illicit opioids and stimulants by documenting the conceptual frameworks used and content areas that have been investigated.
Methods:
We conducted a scoping review of literature relating to aging and older people who use illicit stimulants and opioids, defining "older" as 40 years and above. Primary studies, secondary studies, and editorials were included. Searches were conducted in PubMed and Embase in July 2020 and March 2021; the Cochrane library was searched in November 2021. Charted data included methodological details, any conceptual frameworks explicitly applied by authors, and the content areas that were the focus of the publication. We developed a hierarchy of content areas and mapped this to provide a visual guide to the research area.
Results:
Of the 164 publications included in this review, only 16 explicitly applied a conceptual framework. Seven core content areas were identified, with most publications contributing to multiple content areas: acknowledgement of drug use among older people (n = 64), health status (n = 129), health services (n = 109), drug use practices and patterns (n = 84), social environments (n = 74), the criminal legal system (n = 28), and quality of life (n = 15).
Conclusions:
The literature regarding older people who use illicit drugs remains under-theorized. Conceptual frameworks are rarely applied and few have been purposely adapted to this population. Health status and health services access and use are among the most frequently researched topics in this area.
... While youth mental health services have improved access to care (5)(6)(7)(8), many services struggle to manage high demand and have difficulty matching individuals to timely interventions due to the heterogeneity of disorders. Together these challenges perpetuate a vicious cycle between health service inefficiencies and poor treatment outcomes at high costs to the health system and society (9)(10)(11)(12). ...
Most mental disorders emerge before the age of 25 years and, if left untreated, have the potential to lead to considerable lifetime burden of disease. Many services struggle to manage high demand and have difficulty matching individuals to timely interventions due to the heterogeneity of disorders. The technological implementation of clinical staging for youth mental health may assist the early detection and treatment of mental disorders. We describe the development of a theory-based automated protocol to facilitate the initial clinical staging process, its intended use, and strategies for protocol validation and refinement. The automated clinical staging protocol leverages the clinical validation and evidence base of the staging model to improve its standardization, scalability, and utility by deploying it using Health Information Technologies (HIT). Its use has the potential to enhance clinical decision-making and transform existing care pathways, but further validation and evaluation of the tool in real-world settings is needed.
... For some, access to mental health care has improved [6][7][8][9]; however, most health systems lack effective coordination between service silos, which impacts on the delivery of holistic, timely, and quality mental health care [10,11]. Service fragmentation, delayed care, mental health treatment isolated from other physical and social needs, complicated service pathways, and inefficient resource allocation are persistent features of an underperforming service system [5,12]. ...
Background:
Prior to the COVID-19 pandemic major shortcomings in the way mental health care systems are organised was impairing the delivery of effective care. The mental health impacts of the pandemic, the recession, and resulting social dislocation will depend on the extent to which care systems will become overwhelmed and the strategic investments made across the system to effectively respond.
Objective:
This study aimed to explore the impact of strengthening the mental health system through technology-enabled care coordination on mental health and suicide outcomes.
Methods:
A system dynamics model for the regional population catchment of North Coast New South Wales was developed that incorporated defined pathways from social determinants of mental health to psychological distress, mental health care and suicidal behaviour (SB). The model reproduced historic timeseries data across a range of outcomes and was used to evaluate the relative impact of a set of scenarios on attempted suicide (self-harm hospitalisations), suicide deaths, mental health-related ED presentations and psychological distress over the period of 2021 to 2030. These scenarios include: (1) business as usual; (2) increase in service capacity growth rate by 20% (3) standard telehealth; and (4) technology-enabled care coordination. Each scenario was tested using both pre- and post-COVID-19 social and economic conditions.
Results:
Technology-enabled care coordination was forecast to deliver a reduction in self-harm hospitalisations and suicide deaths by 6·71% (95% interval, 5·63-7·8%), mental health-related ED presentations by 10·33% (95% interval, 8·58-12·1%), and the prevalence of high psychological distress by 1.76 percentage points (95% interval, 1·35-2·32 percentage points). Scenario testing demonstrated that increasing service capacity growth rate by 20% or standard telehealth had a substantially lower impact. This pattern of results was replicated under post-COVID-19 conditions with technology-enabled care coordination being the only tested scenario, which effectively reduces the negative impact of the pandemic on mental health and suicide.
Conclusions:
The use of technology-enabled care coordination is likely to improve mental health and suicide outcomes. The substantially lower effectiveness of increasing service capacity growth rate by 20% or standard telehealth reiterates that strengthening how the whole mental health system functions together will have a greater impact on outcomes than simply improving the capacity of individual components of the system. Investments into more of the same type of programs and services alone won't be enough to improve outcomes, instead new models of care and the digital infrastructure to support them are needed.
Clinicaltrial:
Na.
... For some, access to mental health care has improved [6][7][8][9]; however, most health systems lack effective coordination between service silos, which impacts on the delivery of holistic, timely, and quality mental health care [10,11]. Service fragmentation, delayed care, mental health treatment isolated from other physical and social needs, complicated service pathways, and inefficient resource allocation are persistent features of an underperforming service system [5,12]. ...
BACKGROUND
Prior to the COVID-19 pandemic, major shortcomings in the way mental health care systems were organized were impairing the delivery of effective care. The mental health impacts of the pandemic, the recession, and the resulting social dislocation will depend on the extent to which care systems will become overwhelmed and on the strategic investments made across the system to effectively respond.
OBJECTIVE
This study aimed to explore the impact of strengthening the mental health system through technology-enabled care coordination on mental health and suicide outcomes.
METHODS
A system dynamics model for the regional population catchment of North Coast New South Wales, Australia, was developed that incorporated defined pathways from social determinants of mental health to psychological distress, mental health care, and suicidal behavior. The model reproduced historic time series data across a range of outcomes and was used to evaluate the relative impact of a set of scenarios on attempted suicide (ie, self-harm hospitalizations), suicide deaths, mental health–related emergency department (ED) presentations, and psychological distress over the period from 2021 to 2030. These scenarios include (1) business as usual, (2) increase in service capacity growth rate by 20%, (3) standard telehealth, and (4) technology-enabled care coordination. Each scenario was tested using both pre– and post–COVID-19 social and economic conditions.
RESULTS
Technology-enabled care coordination was forecast to deliver a reduction in self-harm hospitalizations and suicide deaths by 6.71% (95% interval 5.63%-7.87%), mental health–related ED presentations by 10.33% (95% interval 8.58%-12.19%), and the prevalence of high psychological distress by 1.76 percentage points (95% interval 1.35-2.32 percentage points). Scenario testing demonstrated that increasing service capacity growth rate by 20% or standard telehealth had substantially lower impacts. This pattern of results was replicated under post–COVID-19 conditions with technology-enabled care coordination being the only tested scenario, which was forecast to reduce the negative impact of the pandemic on mental health and suicide.
CONCLUSIONS
The use of technology-enabled care coordination is likely to improve mental health and suicide outcomes. The substantially lower effectiveness of targeting individual components of the mental health system (ie, increasing service capacity growth rate by 20% or standard telehealth) reiterates that strengthening the whole system has the greatest impact on patient outcomes. Investments into more of the same types of programs and services alone will not be enough to improve outcomes; instead, new models of care and the digital infrastructure to support them and their integration are needed.
... Furthermore, the field has a limited ability to compare the outcomes of different initiatives and few contemporary checklists that identify elements important to collaborative care or integration (Butler et al., 2008). Kilbourne, Fullerton, Dausey, Pincus, and Hermann (2010) also observe there are no validated measures of coordination or clinical integration that can be used to assess quality of care for persons with mental and substance use disorders. ...
Objective
To perform a factor analysis of the Practice Integration Profile (PIP), a 30‐item practice‐level measure of primary care and behavioral health integration derived from the Agency for Healthcare Research and Quality's Lexicon for Behavioral Health and Primary Care Integration.
Data Sources
The PIP was completed by 735 individuals, representing 357 practices across the United States.
Study Design
The study design was a cross‐sectional survey. An exploratory factor analysis and assessment of internal consistency reliability via Cronbach's alpha were performed.
Data Collection Methods
Participant responses were collected using REDCap, a secure, web‐based data capture tool.
Principal Findings
Five of the PIP's six domains had factor loadings for most items related to each factor representing the PIP of 0.50 or greater. However, one factor had items from two PIP domains that had loadings >0.50. A five‐factor model with redistributed items resulted in improved factor loadings for all domains along with greater internal consistency reliability (>0.80).
Conclusions
Five of the PIP's six domains demonstrated excellent internal consistency for measures of health care resources. Although minor improvements to strengthen the PIP are possible, it is a valid and reliable measure of the integration of primary care and behavioral health.
... Much greater attention was paid in the literature to temporal dimensions, likely owing to the traction of Donabedian's conceptual framework for assessing quality in health care (Donabedian, 2005). A number of reports framed their evaluation of performance solely or primarily in terms of structures, processes, and outcomes (e.g., Cheng et al., 2010;Dausey et al., 2009;Grabowski et al., 2010;Kilbourne et al., 2010;Meehan et al., 2007;Roeg et al., 2005;Schaub et al., 2013). Most frameworks contained elements of all three dimensions (last column in Tables 1 and 2). ...
Objective:
The purpose of this study was to evaluate how performance is defined, conceptualized, and measured in mental health and addiction service systems around the world.
Method:
We conducted a systematic scoping review of English-language scientific and gray literature published from 2005 to 2015. Eligible documents (n = 222) described performance measurement systems and outlined the theory or empirical evidence for indicators. We used a structured approach for data extraction and descriptive and thematic analysis, supplemented with stakeholder consultation.
Results:
We identified seven themes in the literature: similarity in performance domains across frameworks; the ability of frameworks to inform care quality at client, program/facility, and system levels; the predominance of indicators of process and outcome, over structure; the lack of evidence on the links between domains and/or indicators; common, but limited, evaluation of family/caregiver involvement; equity as a cross-cutting domain of performance; and limited attention to performance measurement in peer support services.
Conclusions:
The literature on performance measurement in mental health and addictions services is vast, and a wide variety of indicators is available to those designing a measurement system. Evaluations of commonly used performance indicators have yielded mixed evidence on their ability to discriminate high- and low-performing service providers, and their sensitivity to changes in policies and practices. As performance measurement efforts grow in scope and complexity, work will be needed to ensure that indicators are fair, appropriate, and suited to support quality improvement in services of different types.
... Following on the widespread use of benchmarks for patient care quality monitoring (Kilbourne, Fullerton, Dausey, Pincus, & Hermann, 2010;Ozcan, 2014), the question arises for many stakeholders as to whether similar results could be achieved in aged care with sufficient resources and efforts put toward improving quality of life for older adults in care. ...
We aimed to develop a graphical procedure for benchmarking quality of life care results using the Long‐Term Care Quality of Life (LTC‐QoL) scale. While clinical care quality benchmarking is now well established, similar research for quality of life (QOL) aged care benchmarking has received scant attention. Data from 10 facilities utilizing the LTC‐QoL scale were analysed to establish baseline statistics for developing a graphical procedure for QOL benchmarking. Client LTC‐QoL records were tested with varimax rotation factor analysis revealing three viable benchmarking themes: B1 (Self‐efficacy), B2 (supporting relationships), and B3 (outlook on life) were selected for benchmark development utilizing Analysis of Means to generate graphical outputs using Minitab version 17.3.1. In this way, in the absence of verified industry standards, it is possible to compare organizations providing similar services using the same indicators, against group averages.
In conclusion, the benchmarking protocol produced comparative information on three benchmarks for 10 facilities. Similar analysis is feasible for a single facility over time. The results of these analyses provide evidence for on‐site discussion of quality of life care quality performance.
... Participants' widespread agreement that various stakeholders should share responsibilities and coordinate efforts echoes Canadian and international mental health policy documents (MHCC, 2012;National Treatment Strategy Working Group, 2008;WHO, 2013). However, this stands in contrast to the current silo-like organization of mental health services and professions (Hall, 2005;Kilbourne, Fullerton, Dausey, Pincus, & Hermann, 2010;Linden, 2015), wherein mental health care is delivered by multiple sectors and different service providers/professionals, often with a lack of communication or collaboration (National Treatment Strategy Working Group, 2008). ...
Varying perceptions of who should be responsible for supporting individuals with mental health problems may contribute to their needs remaining unmet. A qualitative descriptive design was used to explore these perceptions among key stakeholders. Focus groups were conducted with 13 service users, 12 family members, and 18 treatment providers from an early psychosis intervention program in Montreal, Canada. Individual interviews were conducted with six mental health policy-/decision-makers. Participants across stakeholder groups assigned a range of responsibilities to individuals with mental health problems; stakeholders in these individuals’ immediate and extended social networks (e.g. families); macro-level stakeholders with influence (e.g. government); and society as a whole. Perceived failings of the healthcare system and the need for greater sharing of roles and responsibilities also emerged as important themes. Our findings suggest that different stakeholders should collectively assume certain responsibilities and that systems-level failings may contribute to unmet needs for mental health support.
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