Literature Collection

The US government funds integrated care demonstration projects to decrease health disparities for individuals with serious mental illness. Drawing on the Exploration Preparation Implementation Sustainability (EPIS) implementation framework, this case study of a community mental health clinic describes implementation barriers and sustainability challenges with grant-funded integrated care. Findings demonstrate that integrated care practices evolve during implementation and the following factors influenced sustainability: workforce rigidity, intervention clarity, policy and funding congruence between the agency and state/federal regulations, on-going support and training in practice application, and professional institutions. Implementation strategies for primary care integration within CMHCs include creating a flexible workforce, shared definition of integrated care, policy and funding congruence, and on-going support and training.

INTRODUCTION: Veteran patient partnerships in research improve patient-centred healthcare outcomes within US Department of Veterans Affairs (VA) medical centres. To achieve this, researchers must contextualize perspectives, motivations, and contributions of Veteran patients engaged in research (VPERs) as valued consultants within a complex healthcare environment. Our objective was to investigate best practices for research teams partnering with VPERs by utilizing the expertise of our research team's own VPER. The parent project of this case study, Hybrid Controlled Trial to Implement Collaborative Care in General Mental Health, was approved by the VA Boston Healthcare System Institutional Review Board and deemed research. OBJECTIVE: Provide three key recommendations when engaging military Veterans and/or VA Veteran Patients in research to facilitate sustained teamwork and integration. STUDY DESIGN AND METHODOLOGIES: This paper is structured as a qualitative descriptive data-based case study. Two team members used a semi-structured conversation guide to interview Dr. Colleen Turner, MSW, PhD, Lt. Col. (Ret., US Air Force Reserves) for one hour about her experience as a VPER on the 5-year research project. This manuscript was then written collaboratively by members of the team, with heavy influence and editing from Colleen for details and accuracy. RESULTS: Improving mental healthcare for Veterans motivated Colleen to serve as a VPER from 2015 to 2020. She used organizational and provider-level mental health expertise gained during her Air Force service, applied her graduate social work training, and offered her experience as a VA patient. A diverse background and an ability to codeswitch helped her navigate the study and enriched the team's partnership dynamics. Through a qualitative interview with Colleen about her experience as a VPER, three recommendations emerged for research teams to better situate VPERs on studies: (1) ensure initial project literacy and provide ongoing support, (2) incorporate VPER goals into project work and (3) communicate both (a) offers of reasonable compensation and professional acknowledgement and (b) visible patient-centred outcomes. CONCLUSION: This case study deepens the understanding of how to meaningfully incorporate VPERs into a partnered research study. Engagement starts early, continues throughout the study, and culminates with well-communicated outcomes as they pertain to the researchers' and VPERs' goals. These recommendations closely align with widely accepted community-engaged research practices and may guide ongoing and future studies to further improve patient engagement in research and the collaboration experiences of VPERs. PATIENT OR PUBLIC CONTRIBUTION: This manuscript focuses on Colleen's contributions to the design and conduct of a hybrid implementation/effectiveness study. Colleen also contributed to the manuscript itself. Uniquely, Dr. Turner brought her experience as a practitioner with master's and doctoral degrees in social work, as an institutional communications analyst, and as an independent author. Because of this, she was able to bring even more expertise to the project beyond just that of a patient, which is valuable in its own right. Colleen was involved in the research project from inception to conclusion, including study design, general analysis, and manuscript publication, with overall consultation throughout.

Help-seeking for depression and anxiety disorders from primary care physicians in Western countries is at three times the rate of China. Western help-seeking models for common mental disorders have limitations in the Chinese settings. This article argues that an adapted model based on Andersen's Behavioral Model of Health Services Use could be an appropriate tool to better understand patients' help-seeking behaviors and improve outcomes. We applied a narrative review approach to integrate research findings from China into Andersen's model to generate a model that fits the Chinese context. We found 39 relevant articles in PubMed, MEDLINE, and Chinese journal databases from 1999 to 2022. Findings were mapped onto predisposing, enabling, and need factors of the model. This model emphasizes that predisposing factors including demographics, social norms, and health beliefs influence help-seeking preferences. Mental health service users in China tend to be older and female. Chinese generally have high concern about psychotropic medications, and social norms that consider psychological distress a personal weakness may discourage help-seeking. However, help-seeking can be enhanced by enabling factors in the health system, including training of primary care physicians, longer consultation time, and continuity of care. Need factors for treatment increase with the severity of distress symptoms, and doctor's skills and attitudes in recognizing psychosomatic symptoms. While predisposing factors are relatively hard to change, enabling factors in the health system and need factors for treatment can be targeted by enhancing the role of family doctors and training in mental health.

BACKGROUND: Women veterans, compared to civilian women, are especially at risk of experiencing intimate partner violence (IPV), pointing to the critical need for IPV screening and intervention in the Veterans Health Administration (VHA). However, implementing paper-based IPV screening and intervention in the VHA has revealed substantial barriers, including health care providers' inadequate IPV training, competing demands, time constraints, and discomfort addressing IPV and making decisions about the appropriate type or level of intervention. OBJECTIVE: This study aimed to address IPV screening implementation barriers and hence developed and tested a novel IPV clinical decision support (CDS) tool for physicians in the Women's Health Clinic (WHC), a primary care clinic within the Veterans Affairs Palo Alto Health Care System. This tool provides intelligent, evidence-based, step-by-step guidance on how to conduct IPV screening and intervention. METHODS: Informed by existing CDS development frameworks, developing the IPV CDS tool prototype involved six steps: (1) identifying the scope of the tool, (2) identifying IPV screening and intervention content, (3) incorporating IPV-related VHA and clinic resources, (4) identifying the tool's components, (5) designing the tool, and (6) conducting initial tool revisions. We obtained preliminary physician feedback on user experience and clinical utility of the CDS tool via the System Usability Scale (SUS) and semistructured interviews with 6 WHC physicians. SUS scores were examined using descriptive statistics. Interviews were analyzed using rapid qualitative analysis to extract actionable feedback to inform design updates and improvements. RESULTS: This study includes a detailed description of the IPV CDS tool. Findings indicated that the tool was generally well received by physicians, who indicated good tool usability (SUS score: mean 77.5, SD 12.75). They found the tool clinically useful, needed in their practice, and feasible to implement in primary care. They emphasized that it increased their confidence in managing patients reporting IPV but expressed concerns regarding its length, workflow integration, flexibility, and specificity of information. Several physicians, for example, found the tool too time consuming when encountering patients at high risk; they suggested multiple uses of the tool (eg, an educational tool for less-experienced health care providers and a checklist for more-experienced health care providers) and including more detailed information (eg, a list of local shelters). CONCLUSIONS: Physician feedback on the IPV CDS tool is encouraging and will be used to improve the tool. This study offers an example of an IPV CDS tool that clinics can adapt to potentially enhance the quality and efficiency of their IPV screening and intervention process. Additional research is needed to determine the tool's clinical utility in improving IPV screening and intervention rates and patient outcomes (eg, increased patient safety, reduced IPV risk, and increased referrals to mental health treatment).