Literature Collection

BACKGROUND: Primary care is often the first point of contact for adults with complex mental health difficulties, yet many experience persistent barriers to accessing timely and appropriate support. Despite policy commitments to integrated and equitable care, there remains a need to better understand how individuals make sense of distress and navigate services that may struggle to meet complex needs. This study aimed to better understand the experiences of adults with complex mental health difficulties as they access primary care services. It sought to further understand how they made sense of their difficulties accessing care and their psychological distress. METHOD: This study used a qualitative design with reflexive thematic analysis. Nineteen participants with complex mental health difficulties were interviewed using a semi-structured schedule. They were recruited via their GP practices. RESULTS: Three themes were identified: participants' desire to understand why they felt the way they did, the mental health condition itself creating barriers to care, and the precarity of self-management and help. An overarching theme of "Contradictions" was evident across all three themes. "Contradictions" included professionals talking of connecting but then distancing, help being offered but never arriving, trauma being present but ignored, and diagnosis getting in the way of receiving care. CONCLUSIONS: Overall, the study provided further evidence that those with complex mental health difficulties are currently underserved in the NHS. Novel insight into their health literacy questioned the assumptions that those with complex mental health difficulties lack understanding; rather, it provides evidence that services need to collaborate effectively with service users to enable better communication.

Team-based models of care delivery are increasingly utilized to address co-occurring mental health and/or substance use conditions. However, little is known about how team-based models function among primary care teams delivering treatment for opioid use disorder (OUD). The research team conducted qualitative interviews with a sample of multidisciplinary, primary care team members delivering OUD treatment using the collaborative care model (CoCM). Providers were recruited from 13 diverse United States (U.S.) clinics participating in a multisite hybrid effectiveness-implementation trial. Interviews were audio recorded and professionally transcribed. All transcripts were double-coded using a coding schema informed by relational coordination theory. Thirty-five team members completed an interview, including 14 primary care providers (PCPs), 13 behavioral health care managers (BHCM), and eight consulting psychiatric providers (CPP). Four themes emerged: (1) team-based work increases shared knowledge about patients; (2) team members leverage one another's relationships with patients to increase treatment engagement; (3) team collaboration is enhanced when BHCMs have opportunities and space to connect informally with PCPs; and (4) increased mutual respect between team members is needed to maximize patient engagement efforts. Team-based models may enhance patient engagement in OUD care by increasing the volume of patient contacts and augmenting therapeutic alliances.

Background: In response to the opioid epidemic, addiction consultation services (ACS) increasingly provide dedicated hospital-based addiction treatment to patients with substance use disorder. We assessed hospitalist and medical staff perceptions of how the presence of 2 hospitals' ACS impacted care for hospitalized patients with opioid use disorder (OUD). We inquired about ongoing challenges in caring for this patient population.Methods: We conducted a qualitative study of hospital-based providers utilizing focus groups and key informant interviews for data collection. Transcripts were analyzed using a mixed inductive-deductive approach. Emergent themes were identified through an iterative, multidisciplinary team-based process using a directed content analysis approach.Results: Hospitalists (n = 20), nurses (n = 13), social workers (n = 11), and pharmacists (n = 18) from a university hospital and a safety-net hospital in Colorado participated in focus groups or key informant interviews. In response to the availability of an ACS, hospitalists described increased confidence using methadone and buprenorphine to treat opioid withdrawal, which they perceived as contributing to improved patient outcomes and greater job satisfaction. Participants expressed concern about inconsistent care provided to patients with OUD that varied by the admitting team's specialty and the physician's background and training. Nurses and hospitalists reported frustrations with achieving adequate pain control among patients with OUD. Last, pharmacists reported practice variations when physicians dosed buprenorphine for acute pain among patients with OUD. A lack of standardized dosing led to concerns of inadequate analgesia or return to opioid use following hospital discharge.Conclusions: An ACS reportedly supports hospitalists and medical staff to best care for hospitalized patients with OUD. Notably, care provided to patients with OUD may not be uniform depending on various physician-level factors. Future work to address the concerns reported by study participants may include education for OUD treatment, early involvement of the ACS, and incorporation of buprenorphine prescribing algorithms to standardize care.

BACKGROUND: Enhancing care integration and coordination to improve patient outcomes in opioid use disorder treatment is a growing focus in the field. Understanding of how the treatment system implements coordination and integration, particularly in the aftermath of the COVID-19 pandemic, remains limited. In this study, we explored the implementation of medications for opioid use disorder (MOUD) and the evolution of service delivery toward a more comprehensive approach. We examined providers' perspectives from high-achieving programs in Los Angeles County, the largest and most diverse U.S. county, including barriers to integrating and coordinating care and strategies for integrating MOUD service delivery. METHODS: We gathered qualitative interview data from 30 high-performing programs in Los Angeles County, each represented by a manager or supervisor. High performance was defined by empirical indicators of access, retention, and program completion. Our data collection and analysis followed the constructivist grounded theory approach, explicating the social processes used by participating managers during the pandemic and subsequent organizational shifts. This approach yielded 14 major and six minor codes. Interrater reliability tests yielded a pooled Cohen's kappa statistic of 93%. RESULTS: Expert providers exhibited a strong commitment to destigmatizing MOUD and worked to overcome obstacles in delivering care to clients by advocating its efficacy to fellow health care providers. Along with their endorsement of MOUD, they identified challenges in integrating and coordinating MOUD care. Barriers included stigma at both patient and provider levels, inadequate education about MOUD, limited access to MOUD, and the complexities of operating in a fragmented health care framework. Despite these challenges, high-performing providers used strategies to harmonize and align MOUD service delivery with health and social services. These included establishing service colocation, adopting a multidisciplinary team-based approach, forming partnerships with the community, offering telehealth services, integrating and sharing data, and embracing a harm reduction philosophy. DISCUSSION: Through the adoption of these strategies, providers enhanced care accessibility, boosted patient engagement, sustained retention in treatment, and enhanced treatment outcomes. Even among highly skilled treatment providers in Los Angeles County, barriers to integrating and coordinating care using MOUD remain intricate and multifaceted. Addressing these challenges necessitates a comprehensive strategy involving provider education and training, increased availability of MOUD, enhanced coordination and communication among health care providers, resolution of regulatory hurdles, and addressing patient hesitancy toward MOUD.

Nationwide challenges with the lack of access to mental health care for youth have prompted efforts to integrate mental health into pediatric primary care. Kansas Kids Mental Health Access Program (KSKidsMAP) was developed to promote mental health workforce development through primary-care practitioners (PCPs) by offering free access to consultations, training, and care coordination. Kansas Kids Mental Health Access Program, a federally funded pediatric mental health care access program (PMHCA), is highly interprofessional in nature, and recommendations reflect the team composition and collaboration efforts. Therefore, a mixed-methods study was conducted to assess the type of recommendations provided to PCPs who requested case consultation services. Seven themes were identified: (1) psychotherapy; (2) diagnostic evaluation; (3) community resources; (4) pharmacotherapy; (5) patient resources and toolkits; (6) education; and (7) other health recommendations. This study highlights the multifaceted approach of KSKidsMAP in addressing PCPs' pediatric mental health concerns.