Literature Collection

BACKGROUND: 'Person-centred integrated care' (PCIC) emerged in literature, policy and practice to meet the increasing care needs of an older population living longer with increased levels of chronic illness, multimorbidity and at enhanced risk of care fragmentation. Most evaluations of PCIC have been service-centred, rather than person-centred, and there is a lack of research on the effects of integrated care on patients, especially older people. METHODS: This integrative review explored evidence regarding older people's PCIC experiences, synthesising empirical literature from five databases: Medline, PsycInfo, CINAHL, Embase and Web of Science. RESULTS: Findings included: i) definitions and components of integrated care and conceptualisations of person-centredness in the context of integrated care; ii) older people's positive PCIC experiences featured: coordination; continuity and relational care; involvement in care, including effective communication and information about care; and holistic care; iii) integrated care optimises care when successfully delivered, however, older people's experiences were mixed; and iv) barriers included a lack of integrated care frameworks developed from patients' perspectives, poor communication and information and staff shortages and turnover leading to discontinuity, limited time for meaningful interactions and follow-up care. CONCLUSION: While PCIC optimises care experiences, its evaluation is challenged by multiple conceptualisations and lack of engagement with service users.

Mental disorders are widespread, debilitating and associated with high costs. In Germany, usual care (UC) for mental disorders is afflicted by poor coordination between providers and long waiting times. Recently, the primary alternative to UC-the gatekeeping-based general practitioners (GP) program-was extended by the collaborative Psychiatry-Neurology-Psychotherapy (PNP) program, which is a selective contract designed to improve mental health care and the allocation of resources. Here, we assess the effects of the GP program and the PNP program on costs for mental health care. We analyzed claims data from 2014 to 2016 of 55,472 adults with a disorder addressed by PNP to compare costs and sick leave days between PNP, the GP program and UC. The individuals were grouped and balanced via entropy balancing to adjust for potentially confounding covariates. We employed a negative binomial model to compare sick leave days and two-part models to compare sick pay, outpatient, inpatient and medication costs over a 12-month period. The PNP program significantly reduced sick pay by 164€, compared to UC, and by 177€, compared to the GP program. Consistently, sick leave days were lower in PNP. We found lower inpatient costs in PNP than in UC (-194€) and in the GP program (-177€), but no reduction in those shares of inpatient costs that accrued in psychiatric or neurological departments. Our results suggest that integrating collaborative care elements in a gatekeeping system can favourably impact costs. In contrast, we found no evidence that the widely implemented GP program reduces costs for mental health care.

The way in which behavioral health providers (BHPs) in integrated primary care settings function and what is needed for their success has not been systematically examined. The present study used direct observation to capture integrated BHPs' clinical activities, workflows, and team interactions. Observations took place in seven integrated primary care clinics in a single health system. The model of integration combined components of the Primary Care Behavioral Health model and the Collaborative Care Model. A trained Research Service Professional (RSP) observed 13 BHPs each during one typical clinical day in an integrated primary care clinic. Data collection methods included surveys, process maps, time tracking, and field notes. We used quantitative and qualitative analysis to describe BHPs' activities. During the days observed, BHPs conducted 77 patient visits and many other activities, including supervising learners. BHPs' clinical time was divided among direct patient care (56%), administrative tasks (29%), and consultation with team members (15%). Process maps revealed similar workflows across BHPs/practices with differences in completing screening, rooming, and scheduling patients. BHPs supervising learners saw on average more patients per day than BHPs on their own (5.1 vs. 7.6). BHPs interacted with all practice team members, and most frequently with medical providers, social workers, care managers, and nurses. BHPs provide clinical care to primary care patients on a wide variety of concerns and spend time on other important team-based tasks. Recommendations for optimizing workflows, reimbursement models, and team-based care from these observations are provided.

The United States is experiencing an unprecedented opioid crisis, with a record of about 93,000 opioid-involved overdose deaths in 2020, which requires rapid and substantial scaling up of access to effective treatment for opioid use disorder. Only 18% of individuals with opioid use disorder receive evidence-based treatment, and strategies to increase access are hindered by a lack of treatment providers. Using a case study from the largest municipal hospital system in the United States, the authors describe the effects of a workforce shortage on health system responses to the opioid crisis. This national problem demands a multipronged approach, including federal programs to grow and diversify the pipeline of addiction providers, medical education initiatives, and enhanced training and mentorship to increase the capacity of allied clinicians to treat patients who have an opioid use disorder. Workforce development should be combined with structural reforms for integrating addiction treatment into mainstream medical care and with new treatment models, including telehealth, which can lower patient barriers to accessing treatment.