Literature Collection

Older adults living with frailty and multimorbidity interact with multiple care providers and health settings, resulting in fragmented care and information discontinuity. Standardized assessments potentiate integrated care by communicating consistent measures of health information between sectors and providers. We use a pragmatic case example of a theoretical medically complex older adult to illustrate use of interRAI standardized assessments throughout the health journey. The case example represents the assessment findings of a patient accessing care through primary care, the emergency department, home/community care and long-term care. A suite of assessment instruments embedded with decision support algorithms guides nursing care decisions, while a common language and standardized assessment items support effective communication and collaboration among the health team. Successful adoption of integrated and comprehensive assessment tools requires training, engagement, and time to embed processes into practice. interRAI assessments enable integration through a common language, aligning successive assessments across the care continuum.

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.

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.

OBJECTIVE: Families with young children have regular, frequent interactions with pediatric primary care across early childhood. Thus, pediatric primary care is an ideal setting to prevent mental and behavioral health disorders through supporting access to behavioral health care services. Exploring the barriers families with young children face in accessing behavioral health care services will support insights into potential strategies to improve access through primary care settings. METHODS: Semi-structured qualitative interviews were used to explore the perspectives of 27 caregivers of young children (ie, ages 0-5 years) regarding access to behavioral health care. Participants were recruited from a large pediatric clinic affiliated with a pediatric residency program serving a high proportion of Medicaid-eligible families (>85%). Deductive and inductive methods were used to develop a codebook followed by content analysis to identify and characterize access barriers. RESULTS: Qualitative content analysis revealed several interconnected barriers families face accessing behavioral health care services for their young children. Barriers were organized into the categories of logistical, financial, and psychosocial. Logistical barriers included 1) childcare, 2) time, 3) transportation, and 4) employment-related issues. Financial barriers included 1) inadequate insurance coverage, and 2) broader financial constraints. Psychosocial barriers included 1) education and understanding of behavioral health issues, 2) anxiety or shame, 3) judgment, and 4) mistrust of health care providers. CONCLUSIONS: Improving access to behavioral health care services through pediatric primary care settings will require a multifaceted approach that addresses logistical, financial, and psychosocial barriers. Solutions should consider systemic and individual factors, promote behavioral health education, and reduce stigma.

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.