Literature Collection

Governance has been highlighted as an important building block underpinning the process of mental health integration into primary healthcare. This qualitative systematic review aims to identify the governance issues faced by countries in the Sub-Saharan Africa and South Asia Region in the implementation of integrated primary mental healthcare. PRISMA guideline was used to conduct a systematic search of relevant studies from 4 online databases that were filtered according to inclusion and exclusion criteria. Using the Critical Appraisal Skills Program (CASP) Qualitative Checklist, a quality appraisal of the selected articles was performed. By drawing upon institutional theory, data was extracted based on a pre-constructed matrix. The CERQual approach synthesized evidence and rank confidence level as low, moderate or high for 5 key findings. From 567 references identified, a total of 8 studies were included. Respondents were policymakers or implementers involved in integrated primary mental healthcare from the national, state, and district level. Overall, the main governance issues identified were a lack of leadership and mental health prioritization; inadequate financing and human resource capacity; and negative mental health perceptions/attitudes. The implication of the findings is that such issues must be addressed for long-term health system performance. This can also improve policymaking for better integration of primary mental health services into the health systems of countries in the Sub-Saharan and South Asia region.

Medical-legal partnerships (MLPs) address social determinants of health by integrating legal services into health care settings. This study examines associations between health-harming legal needs (HHLNs) and mental health quality among family medicine clinic patients screened for MLP referral. A retrospective cohort of 475 patients completed an HHLN screening instrument, including a measure of mentally unhealthy days (MUDs). Zero-inflated negative binomial models assessed associations between HHLNs and MUDs, adjusting for demographics. Patients with any HHLN had 65% lower odds of reporting zero MUDs. Worrying about housing instability was the strongest independent predictor of increased MUDs, associated with a 56% increase. Black race was associated with greater odds of reporting zero MUDs. Housing concerns are a key driver of mental health quality, highlighting the need for targeted legal interventions. Integrating MLP screening into primary care may help identify and address legal issues impacting patient mental health.

BACKGROUND: Opioid dependence carries the highest disease burden of all illicit drugs. Opioid agonist therapy (OAT) is an evidence-based medical intervention that reduces morbidity and mortality. There is limited knowledge on the health-related quality of life (HRQoL) of long-term patients in OAT. This study measures HRQoL and self-perceived health of long-term patients on OAT, compares the scores to a Norwegian reference population, and assesses changes in these scores at 1-year follow up. METHODS: We conducted a nested prospective cohort study among nine OAT outpatient clinics in Norway. 609 OAT patients were included, 245 (40%) followed-up one year later. Data on patient characteristics, HRQoL, and self-perceived health was collected. HRQoL was assessed with the EQ-5D-5L, which measures five dimensions (mobility, self-care, usual activities, pain/discomfort and anxiety/depression) on a five-point Likert scale (from "no problems" to "extreme problems"). An UK value set was applied to calculate index values (from 0 to 1) for the EQ-5D-5L and compare them to a Norwegian reference population. Self-perceived health was measured with EQ-VAS (from 0 to 100). RESULTS: Mean (standard deviation (SD)) EQ-5D-5L index value at baseline was 0.699 (0.250) and EQ-VAS 57 (22) compared to 0.848 (0.200) and 80(19) for the Norwegian reference population. There were large variations in EQ-5D-5L index values, where 43% had > 0.8 and 5% had < 0.2 at baseline. The lowest EQ-5D-5L index values were observed for female patients, age groups older than 40 years and for methadone users. At follow-up, improvements in HRQoL were observed across almost all dimensions and found significant for mobility and pain/discomfort. Mean (SD) overall index value and EQ-VAS at follow up were 0.729 (0.237) and 59 (22) respectively. CONCLUSION: The average HRQoL and self-perceived health of OAT patients is significantly lower than that of the general population, and lower than what has been found among other severe somatic and psychiatric conditions. Around 34% had very good HRQoL, higher than average Norwegian values, and around 5% had extremely poor HRQoL.

BACKGROUND: While research on health-related social needs (HRSNs) has expanded, important gaps remain in understanding associations between HRSN and healthcare cost, especially across general populations of patients with broad-ranging medical and social needs. OBJECTIVE: To examine the association between HRSN and healthcare cost in a large, diverse, insured population. DESIGN: In this cross-sectional study, we evaluated cost differences between patients with different HRSN levels using survey-weighted multivariable generalized linear models. We examined three alternate model specifications: one that included controls for basic demographics; another adding insurance type, race/ethnicity, and social isolation; and a third adding a diagnosis-based medical risk index called DxCG. Variables added in the latter models were assessed separately due to concern for over-correlations with HRSN. PARTICIPANTS: 10,226 adult survey respondents (23% response rate) from eight states and Washington, D.C. MAIN MEASURES: The primary exposure was patient-reported HRSN, based on survey questions asking about financial strain, food insecurity, housing instability, and transportation difficulties. HRSN was constructed as a three-level variable. The primary outcome was total direct healthcare cost. KEY RESULTS: "Moderate HRSN" was not significantly associated with cost in any model. In the model controlling for patient demographics, costs for patients with "Severe HRSN" were 1.27 (95%CI: 1.00-1.60) times those of patients with "No HRSN." In a model that adjusted for medical risk (DxCG), the relationship between HRSN and cost was not statistically significant. CONCLUSIONS: Relationships between HRSN and healthcare cost may vary by HRSN level. Our mixed findings highlight the complex relationship between medical and social risks, which often have bi-directional causal relationships. If measures of medical risk incidentally capture variation in social risk, then models controlling for medical risk may mask relationships between HRSN and cost. Further studies should investigate the extent to which HRSN may be related to cost, even when controlling for specific patient diagnoses.

IMPORTANCE: Health-related social needs (HRSN) influence health outcomes and health care utilization. Clinicians face challenges addressing HRSN due to limited skills, expertise, and time. Further insight is needed on how patients and clinicians navigate HRSN in clinical encounters. OBJECTIVE: This study examines outpatient primary care encounters predating widespread HRSN screening to identify how discussions on HRSN are initiated and addressed. DESIGN, SETTING, AND PARTICIPANTS: This qualitative analysis was conducted on transcripts of 97 audiotaped English-speaking patient encounters from 3 clinics in New York City within a municipal health care system from January 2011 through April 2015. Patients were eligible if they were older than 18 years, self-identified as Black or White, had a diagnosis of hypertension, and had at least one prior encounter with the participating clinician. Codes were developed from social needs domains addressed by the Accountable Health Communities HRSN Screening Tool. Codes were added for further social needs identified, whether a patient or clinician initiated the HRSN discussion, and how a social need was addressed, if at all. Encounters were analyzed between June 2023 and February 2024. MAIN OUTCOMES AND MEASURES: Characterization of the content and nature of HRSN discussions during clinical encounters within safety-net clinics. RESULTS: A total of 97 patients (55 [56.7%] women, 58 [59.8%] Black, mean [SD] age, 59.7 [10.6] years) had audiotaped encounters with 27 clinicians (18 [66.7%] women, 15 [55.6%] White, mean [SD] age, 36 [5.8] years). Physical activity (36% of encounters), financial strain (35%), mental health (34%), and substance use (28%) were the most discussed HRSN domains across the 97 encounters. Patients introduced financial strain most often (70% of the time), while clinicians led substance use (75%), physical activity (51%) and mental health (51%) discussions. Patients initiated conversations on employment (77%), food insecurity (62%), and housing instability (52%). Interventions included prescriptions, forms, counseling, and referrals. Domains frequently intervened on included health care navigation needs (85% of discussions), substance use (33%), and mental health (27%). CONCLUSIONS AND RELEVANCE: In this qualitative study of HRSN discussions in primary care encounters, clinicians were more likely to initiate discussions on substance use, physical activity, and mental health, behaviors routinely assessed in primary care, but different from topics introduced by patients. Findings underscore the need for standardized screening to improve identification of domains less frequently addressed by clinicians. Additional interventions are also needed, including clinician training for how to address HRSN in resource-constrained settings and integration of other health care team members, to enhance HRSN identification and intervention.

BACKGROUND AND OBJECTIVES: Elder abuse (EA) is common and has significant health impacts. New initiatives seek to capitalize on opportunities to respond to EA from within the healthcare system, but little is known about what clinicians may need to be successful in these efforts. Our objective was to understand perceived barriers and facilitators to managing all phases of EA within an integrated healthcare system from the perspectives of frontline clinicians from a range of different disciplines. RESEARCH DESIGN AND METHODS: Thirty-seven clinicians (10 social workers, 9 physicians, 7 psychologists, 6 nurses, and 5 advanced practice providers) from different clinical sites within 2 large Veterans Health Administration (VHA) medical centers participated in semistructured interviews. The interview guide was designed to elicit facilitators and barriers to discrete stages in the process of addressing EA, including detection, reporting, intervention, and monitoring. Transcripts were coded using deductive (based on a prespecified conceptual model) and inductive approaches and analyzed using thematic analysis. RESULTS: Most (78%) participants were women, ranging in age from 33 to 64 years, and practicing in a variety of settings (e.g., primary care and emergency department) with between 4 and 25 years of VHA experience. We identified 5 interrelated themes that cut across the different stages of EA care: situational context (theme 1), degree of trust in familial and healthcare relationships (theme 2), extent of education and skills (theme 3), and existing system infrastructure (theme 4) all contributed to clinician empowerment and motivation toward action (theme 5). DISCUSSION AND IMPLICATIONS: Efforts to enhance skills training, build trusting relationships, and improve system infrastructure could help to equip clinicians to engage in healthcare system interventions to reduce harm from EA.

Patients in Opioid Substitution Treatment (OST) have increased mortality and morbidity, with circulatory conditions suggested to be a contributing factor. Since OST patients tend to have unmet physical healthcare needs, a small-scale intervention providing on-site primary healthcare (PHC) in OST clinics was implemented in Malmö, Sweden in 2016. In this study, we assessed registered circulatory conditions and healthcare utilization in OST patients with and without use of on-site PHC. Patients from four OST clinics in Malmö, Sweden, were recruited to a survey study in 2017-2018. Medical records for the participants were retrieved for one year prior to study participation (n = 192), and examined for circulatory diagnoses, examinations and follow-ups. Patients with and without on-site PHC were compared through descriptive statistics and univariate analyses. Eighteen percent (n = 34) of the sample had 1≤ registered circulatory condition, and 6% (n = 12) attended any clinical physiology examination or follow-up, respectively. Among patients utilizing on-site PHC (n = 26), the numbers were 27% (n = 7) for circulatory diagnosis, 15% (n = 4) for examinations, and 12% (n = 3) for follow-up. OST patients seem underdiagnosed in regard to their circulatory health. On-site PHC might be a way to diagnose and treat circulatory conditions among OST patients, although further research is needed.