Literature Collection

BACKGROUND: The Department of Veterans Affairs (VA) is the largest integrated healthcare system in the United States and serves a rapidly aging patient population. The VA's Home-Based Primary Care (HBPC) program is a home care model for older, complex, high-risk Veterans that provides comprehensive, longitudinal primary care delivered by an interdisciplinary team of VA staff, with plans for expansion by 2027. HBPC program implementation varies considerably across local sites and contexts. Accordingly, these characteristics offer a unique opportunity to investigate real-world, cross-case heterogeneity and identify crucial factors that may lead to improved patient outcomes. METHODS: Patient home time in the last 180 days of life will serve as the primary outcome measure, calculated at the patient-level as the total days not in an acute care (e.g., emergency department [ED], hospital), post-acute care (e.g., skilled nursing facility), or institutional long-term care setting (e.g., nursing home) in the 180 days prior to death. Secondary outcomes include patient satisfaction and other utilization outcomes: ED visits, hospitalizations, days in long term care, care transitions, hospice use prior to death, and site of death. Multiple datasets will be combined to obtain a comprehensive view of HBPC site characteristics. This study will use an exploratory sequential mixed methods design to describe the heterogeneity in HBPC program implementation and evaluate how contextual factors and program delivery patterns influence home time and other patient outcomes. Analyses will identify difference-making configurations of contextual, operational, cultural, and care delivery factors that distinguish high- versus low-home time sites. Analytic methods include quantitative descriptive analyses, regression analyses, in-depth qualitative case studies at 10 high and 10 low home time sites, qualitative cross-case analysis, and the application of Coincidence Analysis to identify successful HBPC program configurations. DISCUSSION: Health care systems can take advantage of real-world heterogeneity in program implementation across sites that vary in context and setting to identify the key difference-makers and use these findings to inform future program expansion. By understanding which HBPC program features lead to improved outcomes for older adults in specific contexts, the VA can learn where site variation is a positive sign of adaptation versus a sign of inefficiency and an opportunity for improvement. CLINICAL TRIAL NUMBER: Not applicable.

BACKGROUND: Like many other nations, the rates of mental illness among children and youth have risen. Youth and emerging adults (YEA) between the ages of 16 and 25, in particular, have the highest rate of mental health disorders of any age group leading clinicians and researchers to ponder new and innovative ways to treat mental ill health (1-2). Youth centred practices (YCP) have emerged as possible new approaches in youth mental health care to better treat YEA living with mental illness, but also to empower this population to take control of their wellbeing. Despite the growing use of the term 'youth-centred,' there is little consensus on what this looks like in mental health care for youth. Using research coming out of MINDS of London-Middlesex, we explore how mental health professionals, including clinicians, researchers, administrative staff, and trainees, understand the term YCP and how they implement youth-centredness in practice. METHODS: Using a Youth Participatory Action Research framework as a guide, MINDS' researchers worked alongside YEA research assistants in all phases of research. Participants were selected from a pool of known practitioners and mental health programs utilizing YCP, as identified by YEA research assistants. Qualitative focus group and interviews, developed using an appreciative inquiry approach, were conducted with 13 mental health care professionals, staff, and trainees to ascertain how they understand and practice YCP. Researchers conducted a codebook thematic analysis of the data: five themes and fourteen subthemes were identified. RESULTS: Our analysis identified five main themes: (1) Acknowledging YCP's Role in Supporting YEA Mental Health; (2) Developing Authentic and Meaningful Relationships Between YEA and Care Providers; (3) Collaboration in Care: Engaging YEA as Active Agents in their Treatment; (4) Creation and Maintenance of Accessible Service to Facilitate YEA Engagement; and (5) Moving Beyond Tacit Knowledge to YCP as a Trainable Construct. Underlying each of these key components of YCP was a thread of recognition that systems of care for YEA must be responsive to the unique needs of those the system intends to serve. This process is seen as dynamic and fluid; often representative of societal change and growth, the specific needs of YEA will remain in flux and YCP approaches require continued reflexivity. CONCLUSIONS: When YCPs are used in mental health care, YEA and their lived experiences are respected by trusted adults on their care team. At the core, YCPs are collaborative. There is a shift from the dynamic of "practitioner as expert" to one that provides YEA a sense of agency and autonomy to make informed decisions regarding their care.

INTRODUCTION: While bipolar disorder is not uncommon in primary care, collaborative care models for bipolar depression treatment are underdeveloped. Our aim was to compare initial pharmacological treatment patterns for an episode of bipolar depression in different care models, namely primary care (PC), integrated behavioral health (IBH), and mood specialty clinic (SC). METHODS: A retrospective study of adults diagnosed with bipolar disorder who received outpatient care in 2020 was completed. Depressive episodes were captured based on DSM-5 criteria, ICD codes, or de novo emergent symptom burden (PHQ-9 ≥ 10). Pharmacological strategies were classified as 1) continuation of current regimen, 2) dose increase or 3) augmentation 4) switch to monotherapy or 5) a combination of more than two different strategies. Logistic regression was applied. RESULTS: A total of 217 encounters (PC = 32, IBH = 53, SC = 132) representing 186 unique patients were identified. PC was significantly more likely to continue the current regimen, while combination strategies were significantly more likely recommended in IBH and SC. Mood stabilizers were significantly more utilized in IBH and SC. There were no significant group differences in antidepressant use. LIMITATIONS: Retrospective study design at a single site. CONCLUSIONS: This study provides evidence of delays in depression care in bipolar disorder. This is the first study to compare treatment recommendations for bipolar depression in different clinical settings. Future studies are encouraged to better understand this gap and to guide future clinical practice, regardless of care model, emphasizing the potential benefits of decision support tools and collaborative care models tailored for bipolar depression.

OBJECTIVES: Universal screening for depression during pregnancy and postpartum is recommended, yet mental health treatment and follow-up rates among screen-positive women in rural settings are low. We studied the feasibility, acceptability and effectiveness of perinatal depression treatment integrated into a rural obstetric setting. METHODS: We conducted an open treatment study of a screening and intervention program modified from the Depression Attention for Women Now (DAWN) Collaborative Care model in a rural obstetric clinic. Depression screen-positive pregnant and postpartum women received problem-solving therapy (PST) with or without antidepressants. A care manager coordinated communication between patient, obstetrician and psychiatric consultant. We measured change in the Patient Health Questionnaire 9 (PHQ-9) score. We used surveys and focus groups to measure patient and provider satisfaction and analyzed focus groups using qualitative analysis. RESULTS: The intervention was well accepted by providers and patients, based on survey and focus group data. Feasibility was also evidenced by recruitment (87.1%) and retention (92.6%) rates and depression outcomes (64% with >50% improvement in PHQ 9) which were comparable to clinical trials in similar urban populations. Conclusions for practice: DAWN Collaborative Care modified for treatment of perinatal depression in a rural obstetric setting is feasible and acceptable. Behavioral health services integrated into rural obstetric settings could improve care for perinatal depression.