Literature Collection

Objective: Explore general practitioners' (GPs') views on and experiences of working with care managers for patients treated for depression in primary care settings. Care managers are specially trained health care professionals, often specialist nurses, who coordinate care for patients with chronic diseases. Design: Qualitative content analysis of five focus-group discussions. Setting: Primary health care centers in the Region of Vastra Gotaland and Dalarna County, Sweden. Subjects: 29 GPs. Main outcome measures: GPs' views and experiences of care managers for patients with depression. Results: GPs expressed a broad variety of views and experiences. Care managers could ensure care quality while freeing GPs from case management by providing support for patients and security and relief for GPs and by coordinating patient care. GPs could also express concern about role overlap; specifically, that GPs are already care managers, that too many caregivers disrupt patient contact, and that the roles of care managers and psychotherapists seem to compete. GPs thought care managers should be assigned to patients who need them the most (e.g. patients with life difficulties or severe mental health problems). They also found that transition to a chronic care model required change, including alterations in the way GPs worked and changes that made depression treatment more like treatment for other chronic diseases. Conclusion: GPs have varied experiences of care managers. As a complementary part of the primary health care team, care managers can be useful for patients with depression, but team members' roles must be clear. KEY POINTS A growing number of primary health care centers are introducing care managers for patients with depression, but knowledge about GPs' experiences of this kind of collaborative care is limited. GPs find that care managers provide support for patients and security and relief for GPs. GPs are concerned about potential role overlap and desire greater latitude in deciding which patients can be assigned a care manager. GPs think depression can be treated using a chronic care model that includes care managers but that adjusting to the new way of working will take time.

IMPORTANCE: Patients prescribed long-term opioid therapy for chronic pain often experience unrelieved pain, poor quality of life, and serious adverse events. OBJECTIVE: To compare the effects of integrated pain team (IPT) vs pharmacist collaborative management (PCM) on pain and opioid dosage. DESIGN, SETTING, AND PARTICIPANTS: This study was a pragmatic multisite 12-month randomized comparative effectiveness trial with masked outcome assessment. Patients were recruited from October 2017 to March 2021; follow-up was completed June 2022. The study sites were Veterans Affairs primary care clinics. Eligible patients had moderate to severe chronic pain despite long-term opioid therapy (≥20 mg/d for at least 3 months). INTERVENTIONS: IPT involved interdisciplinary pain care planning, visits throughout 12 months with medical and mental health clinicians, and emphasis on nondrug therapies and motivational interviewing. PCM was a collaborative care intervention involving visits throughout 12 months with a clinical pharmacist care manager who conducted structured monitoring and medication optimization. Both interventions provided individualized pain care and opioid tapering recommendations to patients. MAIN OUTCOMES AND MEASURES: The primary outcome was pain response (≥30% decrease in Brief Pain Inventory total score) at 12 months. The main secondary outcome was 50% or greater reduction in opioid daily dosage at 12 months. RESULTS: A total of 820 patients were randomized to IPT (n = 411) or PCM (n = 409). Participants' mean (SD) age was 62.2 (10.6) years, and 709 (86.5%) were male. A pain response was achieved in 58/350 patients in the IPT group (16.4%) vs 54/362 patients in the PCM group (14.9%) (odds ratio, 1.11 [95% CI, 0.74-1.67]; P = .61). A 50% opioid dose reduction was achieved in 102/403 patients in the IPT group (25.3%) vs 98/399 patients in the PCM group (24.6%) (odds ratio, 1.03 [95% CI, 0.75-1.42]; P = .85). Over 12 months, the mean (SD) Brief Pain Inventory total score improved from 6.7 (1.5) points to 6.1 (1.8) points (P < .001) in IPT and from 6.6 (1.6) points to 6.0 (1.9) points (P < .001) in PCM (between-group P = .82). Over 12 months, mean (SD) opioid daily dosage decreased from 80.8 (74.2) mg/d to 54.2 (65.0) mg/d in IPT (P < .001) and from 74.5 (56.9) mg/d to 52.8 (51.9) mg/d (P < .001) in PCM (between-group P = .22). CONCLUSIONS AND RELEVANCE: Outcomes in this randomized clinical trial did not differ between groups; both had small improvements in pain and substantial reductions in opioid dosage. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT03026790.

Down syndrome is the most commonly diagnosed chromosomal abnormality, occurring in 1 in 640 live births in the United States each year. Prenatally, cell-free DNA screening or integrated screening (combined first and second trimester screening) for aneuploidy is highly sensitive for identifying Down syndrome. The diagnosis should be confirmed at birth with fluorescence in situ hybridization followed by chromosomal karyotyping. Children with Down syndrome have varied degrees of intellectual disability and more health complications than typical children. Newborns with Down syndrome require a cardiac evaluation including echocardiography. Children with Down syndrome should have annual vision and hearing screenings, and laboratory tests for subclinical thyroid disease and hematologic disorders. Clinicians should provide unbiased and comprehensive culturally sensitive information regarding available services and support for children with Down syndrome and caregivers. Enrollment in comprehensive early intervention programs (eg, speech, visual, physical and occupational therapy, and child psychology) enhances development.

BACKGROUND: Clinical pharmacist practitioners (CPPs) play an increasingly important role in interdisciplinary care for patients with substance use disorders (SUDs). However, CPPs' scope of practice varies substantially across clinics and settings. OBJECTIVES: We sought to describe CPP practices and activities within an interdisciplinary, team-based primary care clinic dedicated to treat Veterans with histories of substance use disorders, experience of homelessness, high medical complexity, and other vulnerabilities. METHODS: We conducted a retrospective cohort study of CPP activities using Department of Veterans Affairs (VA) administrative data in 2019. RESULTS: CPPs provided care for 228 patients, including 766 in-clinic visits, 341 telephone visits, and 626 chart reviews, with an average of 2.5 hours spent per patient per year. Patients seen by CPPs frequently experience mental health conditions and SUDs, including depression (66%), post-traumatic stress disorder (52%), opioid use disorder (OUD) (45%), and alcohol use disorder (44%). CPPs managed buprenorphine medications for OUD or chronic pain in 76 patients (33%). Most CPP interventions (3330 total) were for SUDs (33%), mental health conditions (24%), and pain management (24%), with SUD interventions including medication initiation, dose changes, discontinuations and monitoring. As part of opioid risk mitigation efforts, CPPs queried the state's prescription drug monitoring program 769 times and ordered 59 naloxone kits and 661 lab panels for empaneled patients. CONCLUSION: CPPs managed a high volume of vulnerable patients and provided complex care within an interdisciplinary primary care team. Similar CPP roles could be implemented in other primary care settings to increase access to SUD treatment.

BACKGROUND: Clinical pharmacist practitioners (CPPs) play an increasingly important role in interdisciplinary care for patients with substance use disorders (SUDs). However, CPPs' scope of practice varies substantially across clinics and settings. OBJECTIVES: We sought to describe CPP practices and activities within an interdisciplinary, team-based primary care clinic dedicated to treat Veterans with histories of substance use disorders, experience of homelessness, high medical complexity, and other vulnerabilities. METHODS: We conducted a retrospective cohort study of CPP activities using Department of Veterans Affairs (VA) administrative data in 2019. RESULTS: CPPs provided care for 228 patients, including 766 in-clinic visits, 341 telephone visits, and 626 chart reviews, with an average of 2.5 hours spent per patient per year. Patients seen by CPPs frequently experience mental health conditions and SUDs, including depression (66%), post-traumatic stress disorder (52%), opioid use disorder (OUD) (45%), and alcohol use disorder (44%). CPPs managed buprenorphine medications for OUD or chronic pain in 76 patients (33%). Most CPP interventions (3330 total) were for SUDs (33%), mental health conditions (24%), and pain management (24%), with SUD interventions including medication initiation, dose changes, discontinuations and monitoring. As part of opioid risk mitigation efforts, CPPs queried the state's prescription drug monitoring program 769 times and ordered 59 naloxone kits and 661 lab panels for empaneled patients. CONCLUSION: CPPs managed a high volume of vulnerable patients and provided complex care within an interdisciplinary primary care team. Similar CPP roles could be implemented in other primary care settings to increase access to SUD treatment.

BACKGROUND, AIMS AND OBJECTIVES: This scoping review aimed to understand potential barriers and facilitators in transitioning patients from specialty to primary care settings, to inform the implementation of an intervention to promote active consideration of psychiatrically stable patients for transition from the specialty mental health setting back to primary care. METHODS: Guided by Levac and colleagues' six-stage methodological framework for conducting scoping studies, we systematically searched electronic article databases for peer-reviewed literature from January 2000 to May 2016. We included identified articles that discuss findings related to potential barriers and facilitators in transitioning patients from specialty to primary care settings. We performed descriptive and thematic analyses of results to generate emergent codes and their categorizations. RESULTS: Our database search yielded 906 unique articles, 23 of which we included in our scoping review. All but one of the included studies were conducted in North America. Identified potential barriers and facilitators spanned eight emergent themes-(i) primary care accessibility, especially in terms of timely availability of appointments, (ii) clarity in respective roles of specialty care and primary care in managing a patient, (iii) timely exchange of information, (iv) transition process management, (v) perceived ability of primary care providers to manage specialty conditions, (vi) perceived ability of patients to self-manage, (vii) leadership support and (viii) support for implementing initiatives to promote transitions. CONCLUSIONS: Findings from this scoping review enable an increased understanding of current practices and considerations regarding care transitions from specialty to primary care settings. The importance of role clarification, shared clinical information systems, confidence in care competency, and adequate organizational support to promote appropriate transitions were themes most widely reported across the reviewed studies. Few studies specifically examined the transition from specialty mental health to primary care. Future studies should account for mental health-specific symptomatic patterns and recovery trajectories, such as prevalent chronicity and frequency of relapse, in planning and conducting transitions from specialty mental health back to primary care.