Literature Collection

Background Complex Mental Health Difficulties (CMHD) describes long-term difficulties with emotional regulation and relationships, including personality disorders, complex trauma and dysthymia. People with CMHD often experience episodic and crisis-related care. Aim To understand how general practices can better recognise people with CMHDs and provide the best care. Design and Setting A concurrent mixed-methods study was conducted with three components: two qualitative studies and a database study. Methods PPIE People with lived experience of CMHD were consulted throughout the study. Qualitative interviews with GPs and people with CMHD were conducted and transcripts analysed using thematic analysis. Database study A retrospective case-control analysis was conducted using the Connected Bradford database. Integration of results was conducted using 'following the thread' and triangulation methods. Results GP interviews: Four overarching themes were identified: (1) The challenges of CMHD; (2) Role expectations; (3) Fragmented communication, fragmented care; (4) Treatment in the primary care context. Lived experience interviews: Four main themes were identified: (1) "How I got here"; (2) Varied care experiences; (3) Traversing mental health services; (4) "Being Seen". Database study: Approximately 3,040 (0.3% of the database population) records met our criteria for CMHD, suggesting significant under-coding. The most informative feature was the count of unique psychiatric diagnoses. Triangulation: Five meta-themes were identified (i) Complexity of mental health difficulties; (ii) Experience of trauma; (iii) Diagnosis; (iv) Specialist services; and (v) GP services. Conclusion The current organisation of care and lack of an acceptable language for CMHD means that patients' needs continue to go unrecognised and "unseen".

BACKGROUND: Community pharmacists frequently care for patients with complex medical and social needs; however, specific evidence on pharmacist perceptions of what makes a patient encounter complex has not been clearly characterized. There is a need to better understand specific factors that contribute to patient encounter complexity and demonstrate how pharmacists in community settings care for these individuals. OBJECTIVES: The objectives of this programmatic case study were to: (1) elucidate factors that contributed to patient encounter complexity as a part of a Medicaid Managed Care Organization comprehensive medication management payer program in community pharmacies and (2) curate a series of patient case vignettes that provide evidence of pharmacists care for patients with complex medical and social needs within community pharmacies. METHODS: This qualitative programmatic case study utilized data from semi-structured interviews with community pharmacists who provided comprehensive medication management services to Medicaid patients in Pennsylvania. Pharmacists described their most complex patient encounter. Interviews were transcribed and independently coded by 2 investigators. The coded texts were grouped into categories, and a cross-case inductive thematic analysis was performed to identify complexity factors. RESULTS: Thirty pharmacists provided 48 patient case vignettes and 3 complexity factors emerged: (1) care coordination; (2) behavioral health support; and (3) social determinants of health. Representative patient case vignettes were selected to illustrate these factors. CONCLUSION: Pharmacists, who participated in a community pharmacy Medicaid Managed Care Organization payer program, provided care to patients with complex health needs. In addition to medication-related problems, specific factors that increased pharmacist perception of encounter complexity were care coordination with other health care providers, behavioral health support, and addressing social determinants of health.

Pregnant and parenting women with opioid use disorder face multiple challenges to recovery. Trauma histories, poverty, stigma and discrimination, and lack of access to treatment intersect to marginalise this population. It is important that pregnant and parenting women with opioid use disorder receive comprehensive care to improve their health, the health of their child(ren), and prevent the intergenerational transmission of opioid and other substance use disorders. For nearly 50 years the Maternal Addiction Treatment, Education, and Research program has provided an evolving and expanding range of comprehensive services for treating opioid and other substance use disorders in this population. In this review the rationale for, and processes by which, key components of a comprehensive approach are discussed. These components include patient navigation for access to care, low-barrier medications for opioid use disorder, effective trauma-responsive therapy, prenatal and well-child healthcare, and other support services that make it possible for pregnant and parenting women to engage in treatment and improve the health of the entire family. Additionally, a method for supporting staff to build resilience and reduce fatigue and burnout is discussed. These components comprise an effective model of care for pregnant and parenting women with opioid and other substance use disorders.

In response to the opioid epidemic, the Centers for Disease Control and Prevention released best practice recommendations for prescribing, yet adoption of these guidelines has been fragmented and frequently met with uncertainty by both patients and providers. This study aims to describe the development and implementation of a comprehensive approach to improving opioid stewardship in a large network of primary care providers. The authors developed a 3-tier approach to opioid management: (1) establishment and implementation of best practices for prescribing opioids, (2) development of a weaning process to decrease opioid doses when the risk outweighs benefits, and (3) support for patients when opioid use disorders were identified. Across 44 primary care practices caring for >223,000 patients, the total number of patients prescribed a chronic opioid decreased from 4848 patients in 2018 to 3106 patients in 2021, a decrease of 36% (P < 0.001). The percent of patients with a controlled substance agreement increased from 13% to 83% (P < 0.001) and the percent of patients completing an annual urine drug screen increased from 17% to 53% (P < 0.001). The number of patients coprescribed benzodiazepines decreased from 1261 patients at baseline to 834 at completion. A total of 6.5% of patients were referred for additional support from a certified alcohol and substance abuse counselor embedded within the program. Overall, the comprehensive opioid management program provided the necessary structure to support opioid prescribing and resulted in improved adherence to best practices, facilitated weaning of opioids when medically appropriate, and enhanced support for patients with opioid use disorders.