Literature Collection

Introduction: Psychological distress can have a significant impact on cardiovascular disease (CVD) and efforts to treat psychological distress may improve CVD risk factors. Therefore, we conducted a retrospective feasibility of implementation study to assess the utilization of short-term psychotherapy in patients engaged in a cardiovascular prevention program. Methods: Participants included patients engaged in the Women's Health or Preventive Cardiology programs from January 2019 to June 2022. Patients were referred for psychology services if deemed likely to benefit from improvements in their psychological well-being to control their CVD risk factors. Biomarkers were obtained within 6 months pre- and post-therapy. Results: More than half (52.8%) of the 36 patients referred to the program attended ≥6 psychotherapy sessions. In patients with HTN, 50% were above goal (130/80 mmHg) pre-therapy and 20.8% post-therapy. 55.5% of patients with an LDL-C ≥100 mg/dL pre-therapy achieved an LDL-C <100 mg/dL post-therapy. Among patients with a hemoglobin A1c ≥5.7% pre-therapy, 12.5% lowered their hemoglobin A1c to <5.7%. Conclusion: Our study shows the potential benefit of psychological services when delivered concurrently with preventive cardiology visits. These findings raise the possibility that expanding access to psychology services in clinical cardiology care may be a model to reduce excess cardiovascular risk factor burdens.

BACKGROUND: Evidence suggests that centralising specialist healthcare services can improve outcomes for patients but increase travel distances and times. Traditionally, people requiring specialist health care were cared for by a single specialist, with mental and physical health care delivered by separate services. Recent trends involve greater collaboration between specialists. Integrated care is the highest level of collaboration, including shared access to medical records and multidisciplinary care. OBJECTIVES: To investigate how centralisation of specialised healthcare services can be characterised. To examine the proposed integration between physical and mental health services in the care of children and young people with eating disorders and functional symptom disorders in one region of England. DESIGN: Mixed-methods study comprising: a scoping review (conducted in November 2020) of four databases to characterise centralisation of specialised healthcare services; a systematic literature review (conducted in August 2022, updated in July 2024) of three databases to evaluate integration of physical and mental health services for children and young people with eating disorders and functional symptom disorders; an interview study of parents (n = 10 participants), healthcare professionals (n = 14 participants) and a project lead (n = 1 participants) to understand perspectives on integration, which analysed data in themes organised within the Consolidated Framework for Implementation Research; and two discrete choice experiments of preferences using online surveys (n = 400 participants). RESULTS: The scoping review (n = 93 studies) found that definitions of centralisation commonly lacked detail but, where available, covered centralisation's form, objectives, mechanisms and drivers. Limited evidence suggests centralisation could be linked to better outcomes, but many important outcomes were rarely examined. The systematic review of integration found one low-quality (uncontrolled) pre-post study of eating disorders in Australia. Findings from the interviews suggest that service redesign should ensure the concept of 'integration' has shared meaning among professionals, and that agreement is reached over roles and responsibilities. From the discrete choice experiments, the main things that mattered to parents when thinking about integration were days missed from school in the case of eating disorders and time to diagnosis for functional symptom disorders. LIMITATIONS: Limited, poor-quality literature in the reviews; small numbers of interview participants; difficulties engaging parents, carers and healthcare professionals for the discrete choice experiment. CONCLUSIONS: There is a lack of evidence around integrated care for children and young people affected by eating disorders and functional symptom disorders. Implementation of integrated services needs to address concerns regarding roles, responsibilities and leadership. Future evaluations should measure impact in terms of the factors found to matter most to participants in this study. FUTURE WORK: Mixed-methods studies to evaluate integrated pathways. FUNDING: This synopsis presents independent research funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme as award number NIHR133613.; ‘Specialised healthcare services’ are teams who are expert in treating people with certain kinds of health problem. Sometimes, they are joined up into a smaller number of larger services, so that they can treat more patients with the same condition: this is called ‘centralisation’. Previous evidence suggests that centralising specialist healthcare services can improve outcomes for patients, but it can also increase travel distances and times for patients and families. We reviewed the evidence on centralisation of specialised services. The evidence was limited, but said that centralisation was linked with better care or outcomes. We also did a more focused study looking at integration between physical and mental health services for children and young people, to inform the development of a new children’s hospital. Traditionally, people requiring specialised health care were cared for by a single specialist, with mental and physical health care delivered by separate services. More recent trends involve greater collaboration between specialists. Integrated care is the highest level of collaboration, involving shared access to medical records and multidisciplinary care. We focused on two health conditions, eating disorders and functional symptom disorders (experiencing physical symptoms, for which there is no clear explanation). We looked for research to find out what is known about integrating services for these conditions and found little evidence. We also conducted interviews with healthcare professionals, and interviews and a survey of parents to find out their views. These found broad support for integrating services for children and young people affected by these conditions. There were several concerns about integration, mostly around clearly defining roles and responsibilities of staff. The main things that mattered to parents when thinking about integration were days missed from school in the case of eating disorders, and time to diagnosis in the case of functional symptom disorders.; eng

OBJECTIVES: Women experiencing homelessness (WEH) often face barriers to accessing substance use disorder (SUD) treatment. The Veterans Health Administration (VHA) has invested in primary care redesign efforts for women's health (women's primary care clinics, "PCCs") and for homelessness (homeless-tailored PCCs). There have been no comparative examinations of SUD integration in these PCCs. We aim to compare VHA SUD integration across homeless-tailored and women's PCCs, identifying areas to improve care for WEH. METHODS: A 40-question provider survey was administered online. PCC physicians, nurses, and mental health providers were randomly sampled from 57 VHAs across the United States. Likert-type items assessed active service arrangement, active communication, same-day reachability of SUD specialists, collaboration with SUD specialists, and preparedness to meet women's needs and SUD needs. Multiple-choice items assessed time to referral completion, location of routine and urgent treatment, medication, counseling, staffing, and resource needs. Ordinal logistic regressions assessed Likert-type measures. χ2 tests assessed multiple-choice items. RESULTS: Based on 114 respondents (response=23.6%), women's PCCs scored below homeless-tailored PCCs on several items: collaboration via shared patient discussions, service consults, and treatment plan coordination; women's health preparedness; SUD preparedness; urgent treatment location; and medication availability (all P values<0.05). Most providers (90% and 86%) reported access to staff with mental health or addiction expertise, but SUD treatment remained predominantly confined to specialty care rather than primary care. The most frequently endorsed resource need was on-demand access to addiction specialists. CONCLUSIONS: VHA PCCs that serve WEH report modest SUD integration; lessons from homeless-tailored PCCs could strengthen SUD practices in women's PCCs.

The changing healthcare environment and movement toward team-based care are contemporary challenges confronting health professional education. The primary care workforce must be prepared with recent national interprofessional competencies to practice and lead in this changing environment. From 2012 to 2014, the weekly Beth Israel Deaconess Crimson Care Collaborative Student-Faculty Practice collaborated with Northeastern University to develop, implement and evaluate an innovative model that incorporated interprofessional education into primary care practice with the goal of improving student understanding of, and ability to deliver quality, team-based care. In the monthly interprofessional clinic, an educational curriculum empowered students with evidence-based, team-based care principles. Integration of nursing, pharmacy, medicine, and masters of public health students and faculty into direct patient care, provided the opportunity to practice skills. The TeamSTEPPS(R) Teamwork Attitudes Questionnaire was administered pre- and post-intervention to assess its perceived impact. Seventeen students completed the post-intervention survey. Survey data indicated very positive attitudes towards team-based care at baseline. Significant improvements were reported in attitudes towards situation monitoring, limiting personal conflict, administration support and communication. However, small, but statistically significant declines were seen on one team structure and two communication items. Our program provides further evidence for the use of interprofessional training in primary care.

Amid enthusiasm about accountable care organizations (ACOs) in Medicaid, little is known about the primary care practices engaging in them. We leverage a survey of administrators within a random sample (stratified by ACO) of 225 practices joining Massachusetts Medicaid ACOs (64% response rate; 225 responses). We measure the integration of processes with distinct entities: consulting clinicians, eye specialists for diabetes care, mental/behavioral care providers, and long-term and social services agencies. Using multivariable regression, we examine organizational correlates of integration and assess integration's relationships with care quality improvement, health equity, and satisfaction with the ACO. Integration varied across practices. Clinical integration was positively associated with perceived care quality improvement; social service integration was positively associated with addressing equity; and mental/behavioral and long-term service integration were positively associated with ACO satisfaction (all p < .05). Understanding differences in integration at the practice level is vital for sharpening policy, setting expectations, and supporting improvement in Medicaid ACOs.

BACKGROUND: There is a high prevalence of health problems among single people who are homeless. Specialist primary health care services for this population have been developed in several locations across England; however, there have been very few evaluations of these services. OBJECTIVES: This study evaluated the work of different models of primary health care provision in England to determine their effectiveness in engaging people who are homeless in health care and in providing continuity of care for long-term conditions. It concerned single people (not families or couples with dependent children) staying in hostels, other temporary accommodation or on the streets. The influence on outcomes of contextual factors and mechanisms (service delivery factors), including integration with other services, were examined. Data from medical records were collated on participants' use of health care and social care services over 12 months, and costs were calculated. DESIGN AND SETTING: The evaluation involved four existing Health Service Models: (1) health centres primarily for people who are homeless (Dedicated Centres), (2) Mobile Teams providing health care in hostels and day centres, (3) Specialist GPs providing some services exclusively for patients who are homeless and (4) Usual Care GPs providing no special services for people who are homeless (as a comparison). Two Case Study Sites were recruited for each of the specialist models, and four for the Usual Care GP model. PARTICIPANTS: People who had been homeless during the previous 12 months were recruited as 'case study participants'; they were interviewed at baseline and at 4 and 8 months, and information was collected about their circumstances and their health and service use in the preceding 4 months. Overall, 363 participants were recruited; medical records were obtained for 349 participants. Interviews were conducted with 65 Case Study Site staff and sessional workers, and 81 service providers and stakeholders. RESULTS: The primary outcome was the extent of health screening for body mass index, mental health, alcohol use, tuberculosis, smoking and hepatitis A among participants, and evidence of an intervention if a problem was identified. There were no overall differences in screening between the models apart from Mobile Teams, which scored considerably lower. Dedicated Centres and Specialist GPs were more successful in providing continuity of care for participants with depression and alcohol and drug problems. Service use and costs were significantly higher for Dedicated Centre participants and lower for Usual Care GP participants. Participants and staff welcomed flexible and tailored approaches to care, and related services being available in the same building. Across all models, dental needs were unaddressed and staff reported poor availability of mental health services. LIMITATIONS: There were difficulties recruiting mainstream general practices for the Usual Care GP model. Medical records could not be accessed for 14 participants of this model. CONCLUSIONS: Participant characteristics, contextual factors and mechanisms were influential in determining outcomes. Overall, outcomes for Dedicated Centres and for one of the Specialist GP sites were relatively favourable. They had dedicated staff for patients who were homeless, 'drop-in' services, on-site mental health and substance misuse services, and worked closely with hospitals and homelessness sector services. FUNDING: This project was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (HSDR 13/156/03) and will be published in full in Health and Social Care Delivery Research; Vol. 11, No. 16. See the NIHR Journals Library website for further project information.; Health problems are common among single people who are homeless, but there is little evidence of the best ways to deliver primary health care to them. This study evaluated four types of services (models) that are in existence: (1) health centres primarily for people who are homeless (Dedicated Centres); (2) Mobile Teams that provide health care in hostels and day centres; (3) Specialist GPs that have some services exclusively for patients who are homeless; and (4) Usual Care GPs providing health care to all patients, with no special services for people who are homeless. The study concentrated on single people (not homeless families or couples with dependent children) staying in hostels, other temporary accommodation and on the streets. Overall, 363 patients at these practices who had been homeless in the previous 12 months participated, and information was collected from them over a 12-month period. We examined the extent to which screening for different health conditions was undertaken, and to which treatment and follow-up care were provided for participants with chronic respiratory problems, depression, alcohol problems and drug problems. Information was gathered from their medical records about use of health and social care services over 12 months. Overall, outcomes for Dedicated Centres and for one of the Specialist GP sites were more favourable. They had staff working specifically with patients who were homeless; provided flexible ‘drop-in’ services instead of requiring patients to book appointments; and worked closely with mental health, alcohol and drug services, and with hostels, day centres and street outreach teams. Participants were also more satisfied with the health care they received from the specialist models, and were more likely to say that they had confidence and trust in doctors and nurses at these sites. Across all models, dental needs were unaddressed and staff reported poor availability of mental health services.; eng

The incidence of mental illness continues to increase since the start of the COVID-19 pandemic (Mental Health America, 2022). Demand for mental health services has grown, and providers report being "unable to meet the demand" or having an increase in wait times for access to care (American Psychological Association, 2022, para. 1). Due to this increase in demand, more patients are seeking mental health care from their primary care providers. Over the past decade, integrative models of care have been expanding into mental health care (Lake, 2017). Integrative Nursing is a strategy for improving the quality of care provided to patients seeking care for mental health diagnoses, as well as those with a goal of increasing mental health and wellbeing. This article proposes that Integrative Nursing can serve as a framework for providing whole-person mental health care.