Literature Collection

BACKGROUND: People with severe mental illness (SMI) are at greater risk of earlier mortality due to physical health problems including cardiovascular disease (CVD). There is limited work exploring whether physical health interventions for people with SMI can be embedded and/or adopted within specific healthcare settings. This information is necessary to optimise the development of services and interventions within healthcare settings. This study explores the barriers and facilitators of implementing a nurse-delivered intervention ('PRIMROSE') designed to reduce CVD risk in people with SMI in primary care, using Normalisation Process Theory (NPT), a theory that explains the dynamics of embedding or 'normalising' a complex intervention within healthcare settings. METHODS: Semi-structured interviews were conducted between April-December 2016 with patients with SMI at risk of CVD who received the PRIMROSE intervention, and practice nurses and healthcare assistants who delivered it in primary care in England. Interviews were audio recorded, transcribed and analysed using thematic analysis. Emergent themes were then mapped on to constructs of NPT. RESULTS: Fifteen patients and 15 staff participated. The implementation of PRIMROSE was affected by the following as categorised by the NPT domains: 1) Coherence, where both staff and patients expressed an understanding of the purpose and value of the intervention, 2) Cognitive participation, including mental health stigma and staff perceptions of the compatibility of the intervention to primary care contexts, 3) Collective action, including 3.1. Interactional workability in terms of lack of patient engagement despite flexible appointment scheduling. The structured nature of the intervention and the need for additional nurse time were considered barriers, 3.2. Relational integration i.e. whereby positive relationships between staff and patients facilitated implementation, and access to 'in-house' staff support was considered important, 3.3. Skill-set workability in terms of staff skills, knowledge and training facilitated implementation, 3.4. Contextual integration regarding the accessibility of resources sometimes prevented collective action. 4) Reflexive monitoring, where the staff commonly appraised the intervention by suggesting designated timeslots and technology may improve the intervention. CONCLUSIONS: Future interventions for physical health in people with SMI could consider the following items to improve implementation: 1) training for practitioners in CVD risk prevention to increase practitioners knowledge of physical interventions 2) training in SMI to increase practitioner confidence to engage with people with SMI and reduce mental health stigma and 3) access to resources including specialist services, additional staff and time. Access to specialist behaviour change services may be beneficial for patients with specific health goals. Additional staff to support workload and share knowledge may also be valuable. More time for appointments with people with SMI may allow practitioners to better meet patient needs.

OBJECTIVES: Individuals with co-occurring opioid use disorder (OUD) and mental health disorders experience complex treatment trajectories. The collaborative care model (CoCM) is an effective approach for improving behavioral health outcomes in primary care, but has not been tested for patients with co-occurring disorders. We sought to understand patients' experiences receiving CoCM for co-occurring OUD and depression and/or PTSD. METHODS: We conducted interviews with patients (N=24) who received CoCM for co-occurring disorders as part of a randomized trial. CoCM was delivered across 18 clinics by 10 care managers who were community health workers embedded into primary care teams. Themes were identified by 2 coders using rapid content analyses. RESULTS: We identified 4 major themes. First, patients hoped CoCM would provide an opportunity to make OUD treatment possible by helping them navigate barriers. Second, patients thought that OUD and mental health disorders were connected and that treatment should be integrated. Third, patients felt that care managers improved their treatment, emphasizing how their compassionate style and commitment facilitated access to and retention in medications for OUD and mental health disorders. Finally, patients reported experiencing barriers to accessing mental health therapy, although support from care managers sometimes helped address those barriers. CONCLUSIONS: Patients expressed how care managers facilitated their positive experience with treatment and decreased access barriers common for individuals with co-occurring conditions. Our findings inform how community health workers in the role of care managers can facilitate access to and retention in care for people with co-occurring disorders.

BACKGROUND: Mental health conditions are often underdiagnosed and undertreated in primary care, particularly in underserved areas. Integrated behavioral health models can address this gap, but their reliance on mental health professionals may limit scalability. A multi-level intervention based on the chronic care model may enhance mental health care delivery in resource-limited settings. OBJECTIVE: To evaluate the effectiveness of a chronic care model-based primary care behavioral health integration program for improving the diagnosis and management of mental health conditions in a primary care setting. DESIGN: Quasi-experimental, pre-post observational study using interrupted time series analysis over a 10-year period (2010-2019). PARTICIPANTS: In total, 59,723 adult patients aged >18 who had at least two medical visits between 2010 and 2019. The patient population was 58% non-Hispanic Black, 29% non-Hispanic White, and 64% female. INTERVENTIONS: Implementation of clinical decision support systems for common mental health conditions (e.g., depression, anxiety, ADHD), self-management support, delivery system re-design within integrated behavioral health services, and health system community support with weekly behavioral health tips. MAIN MEASURES: Changes in the rate of mental health diagnoses and follow-up care (including psychiatric medications, referrals to psychiatry or behavioral medicine, and primary care visits with a mental health diagnosis). KEY RESULTS: The rate of mental health diagnoses increased by 58.8 per 1000 person-years in the first year after intervention implementation (p = 0.001). Follow-up care in primary care increased by 102.1 per 1000 person-years (p = 0.03), while psychiatry referrals decreased by 59.8 per 1000 person-years annually after the intervention (p = 0.004). CONCLUSIONS: This chronic care model-based system-level intervention was associated with significant increases in mental health diagnosis and treatment within primary care. Expanding the role of primary care in managing mental health conditions may offer a scalable solution to mental health professional shortages, especially in underserved areas.

BACKGROUND: Substance use is prevalent in Canada, yet treatment is inaccessible. The Rapid Access to Addiction Medicine (RAAM) clinic opened at the University Health Network (UHN) in January 2018 as part of a larger network of addictions clinics in Toronto, Ontario, to enable timely, low barrier access to medical treatment for substance use disorder (SUD). Patients attend on a walk-in basis without requiring an appointment or referral. We describe the RAAM clinic model, including referral patterns, patient demographics and substance use patterns. Secondary outcomes include retention in treatment and changes in both self-reported and objective substance use. METHODS: The Electronic Medical Record at the clinic was reviewed for the first 26 weeks of the clinic's operation. We identified SUD diagnoses, referral source, medications prescribed, retention in care and self-reported substance use. RESULTS: The clinic saw 64 unique patients: 66% had alcohol use disorder (AUD), 39% had opiate use disorder (OUD) and 20% had stimulant use disorder. Fifty-five percent of patients were referred from primary care providers, 30% from the emergency department and 11% from withdrawal management services. Forty-two percent remained on-going patients, 23% were discharged to other care and 34% were lost to follow-up. Gabapentin (39%), naltrexone (39%), and acamprosate (15%) were most frequently prescribed for AUD. Patients with AUD reported a significant decrease in alcohol consumption at their most recent visit. Most patients (65%) with OUD were prescribed buprenorphine, and most patients with OUD (65%) had a negative urine screen at their most recent visit. CONCLUSION: The RAAM model provides low-barrier, accessible outpatient care for patients with substance use disorder and facilitates the prescription of evidence-based pharmacotherapy for AUD and OUD. Patients referred by their primary care physician and the emergency department demonstrated a reduction in median alcohol consumption and high rates of opioid abstinence.

BACKGROUND: Various programs aimed at fostering the resilience of students have been implemented into healthcare undergraduate and postgraduate educational courses and degree programs. Which of these increase their participants' resilience under which circumstances, for whom and why remains uncertain. METHODS: A realist review of articles reporting program outcomes as measures of resilience through the use of via validated psychometric surveys was conducted to investigate which contexts favour the development of resilience of healthcare and health sciences students and which mechanisms have to be activated to achieve this outcome. RESULTS: Thirteen Context-Mechanism-Outcome Configurations were synthesised from data presented in 43 articles. These were combined with theories explaining the theoretical and psychological frameworks underpinning programs to develop a program theory of how and why resilience fostering programs work. Contexts which favour the development of resilience were the use of validated psychological frameworks as program foundation, e.g. Cognitive Behavioural Therapy, mindfulness-based training. Expert facilitation, longitudinal integration into curricula, flexible and multi-modal design and delivery, and opportunities for students to apply and practice resilience-building strategies also created favourable contexts. Meeting students' or practitioners' needs activated mechanisms of trust, engagement and recognition of a program's value and real-world benefits. An increase in resilience was achieved by students developing reflective skills, metacognitive awareness and positive habits of mind. CONCLUSION: The program theory established via a realist review provides guidance on how the individual resilience of healthcare students can be fostered throughout their undergraduate, postgraduate degrees and early practice, potentially supporting them to flourish and remain long-term in their chosen professional roles.