Literature Collection

INTRODUCTION: There is an acknowledged care gap for patients with co-occurring substance use and mental ill-health. This study sought to use complexity theory to help make sense of the experiences of people who deliver or commission formal care for patients with alcohol use disorder and depression across one specific health and social care system. METHOD: Qualitative interviews with 26 health and social care professionals in the North East and North Cumbria Integrated Care System, England, were conducted. Data analysis was undertaken using reflexive thematic analysis and informed by key concepts from complexity theory. RESULTS: Three main themes were identified: (1) how the interplay between risk, stigma and resource pressures influences how care professionals interpret and apply practice guidelines; (2) how individualised and disjointed practices have structural and historical roots, in particular the impact of health service commissioning cycles; (3) ways in which practitioners have been able to adapt and engage in creative practice to temporarily plug gaps in care. CONCLUSIONS: The pressure of working with increasingly scarce resources, within a highly fragmented, shifting, and risk-averse care infrastructure, adversely affected professionals' capacity to provide consistent, patient-centered support. Innovations have emerged that address some of these barriers, but further investment is needed to better support the substance use and mental health workforce, including lived experience peer workers.

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.

OBJECTIVES: Adverse childhood experiences (ACEs) are significant contributors to the burden of disease and remain a serious concern for the health and wellbeing of children in Australia. To address ACEs, we co-designed and implemented two integrated health and social care hubs (Child and Family Hubs [CFHs]). This study explores the experiences of caregivers who received care from the CFHs, including the way they were asked about ACEs and the services offered to address identified ACEs. DESIGN: A qualitative study design was used. Using a semistructured interview guide, 29 in-depth interviews were conducted with caregivers of children who were experiencing a range of adversities, including maltreatment and household dysfunction, child neglect, parent mental illness, domestic violence, family conflict, community dysfunction, discrimination, poverty or financial hardship. A thematic analysis approach was used to analyse textual data. Triangulation of investigators and sources of data improved validation of the findings. NVivo (V.12) was used to organise, index and retrieve data. SETTINGS: This study was conducted in two Child and Family Hubs (CFHs) in Australia-IPC Health, Wyndham Vale, Melbourne, and Marrickville Health Centre, Sydney, between May and October 2023. PARTICIPANTS: Participants (n=29) were the caregivers of children living with adverse childhood experiences (ACEs). RESULTS: Four themes were identified which reflected the caregivers' experiences of being asked about adversities and how they linked to the support and services both in the CFHs and outside the CFH. These themes were as follows: (i) trusting relationships are fundamental; (ii) expectations play a role in talking about adversities; (iii) barriers to open discussion of adversities and (iv) barriers to accessing services. CONCLUSIONS: Consultations between caregivers and hub practitioners can effectively identify and address ACEs despite certain barriers. Establishing a trusting relationship where caregivers feel heard and supported is vital, highlighting the hub model's potential impact in Australia and similar contexts. Enhancing consultation duration, and service availability and accessibility may further improve caregivers' experiences in identifying and addressing adversity.

Provider groups taking on risk for the overall costs of care in accountable care organizations are developing care management programs to improve care and thereby control costs. Many such programs target “high-need, high-cost” patients: those with multiple or complex conditions, often combined with behavioral health problems or socioeconomic challenges. In this study we compared the operational approaches of 18 successful complex care management programs in order to offer guidance to providers, payers, and policymakers on best practices for complex care management. We found that effective programs customize their approach to their local contexts and caseloads; use a combination of qualitative and quantitative methods to identify patients; consider care coordination one of their key roles; focus on building trusting relationships with patients as well as their primary care providers; match team composition and interventions to patient needs; offer specialized training for team members; and use technology to bolster their efforts.