Literature Collection

OBJECTIVE: Feasibility evaluation of Nutri, a clinical decision support software for brief diet counseling by primary care providers (PCPs). DESIGN: Cluster-randomized controlled trial. SETTING: Primary care practices in a large network of federally qualified health centers. PARTICIPANTS: Sixteen PCPs block randomized to Nutri (n = 8) or control (n =8) and 30 of their adult diabetes/prediabetes patients (Nutri, n = 17; control, n=13). INTERVENTION(S): After patients completed the automated self-administered 24-hour dietary assessment tool, Nutri synthesized diet data to prioritize dietary problems and guide PCPs through collaborative diet goal setting during a regularly scheduled appointment. Control PCPs provided usual care. MAIN OUTCOME MEASURE(S): Completion rates (trial feasibility); Nutri usage, usability (intervention feasibility); patient-reported goal setting, self-efficacy, diet quality; PCP-reported diet counseling self-efficacy, attitudes, and competence. ANALYSIS: Summary of trial and intervention feasibility; intent-to-treat comparisons with Bayesian mixed effects models (patient outcomes accounting for PCP-level clustering), ordinary least squares regression (PCP outcomes). RESULTS: All PCPs and patients matriculated into the trial were followed through posttest. Nutri PCPs used Nutri in all study appointments; 81% of Nutri patients reported goal setting, and 57% initiated their goal. PCP-reported diet counseling self-efficacy and competence improved. CONCLUSIONS AND IMPLICATIONS: Nutri was useful to PCPs for collaborative diet goal setting with the potential to improve diabetes management in safety-net clinics.

The co-occurrence of substance use (SUD) and mental disorders is increasing in the US. Integrating mental health services into SUD treatment facilities improves treatment retention and success, but access to integrated services is lagging behind growing demand. The purpose of this study was to map the locations of SUD treatment facilities that offer integrated mental health services and identify community characteristics associated with whether a treatment facility offers more comprehensive integrated services. We used the Mental health and Addiction Treatment Tracking Repository to identify the location and characteristics of licensed outpatient SUD treatment facilities in the US (2022; N = 8,858). Our focal predictors included the percentage of a census block group that was White, Black, and Hispanic. We used multilevel multiple logistic regression to model whether a facility offered integrated mental health (y/n), adjusted for relevant facility-, county-, and state-level covariates, and defined state as a random effect. The majority of integrated facilities were located in the eastern US, with notable concentrations around large metropolitan areas of Minneapolis, MN, Chicago, IL, Atlanta, GA, and New York, NY. For every 10-percentage point increase in a census block group's Black and Hispanic population, there was a 5% and 7% decrease in the odds of offering integrated services, respectively (aOR(Black) = 0.95, 95% CI = 0.91-0.99, p = 0.04; aOR(Hispanic) = 0.93, 95% CI = 0.90-0.96, p < 0.0001). We frame our findings around social conditions as fundamental drivers of disease and healthcare access and acknowledge the country's historical disinvestment in nonwhite and rural communities. Racially targeted programs are needed to effectively address growing racial and ethnic inequities in SUD and mental healthcare.

Locating specialized mental healthcare services in the neighborhood of people with severe mental illnesses (SMI) has been suggested as a way of improving treatment outcomes by increasing patient engagement and integration with the local care landscape. The current mixed methods study aimed to examine patient experience and treatment outcomes in three Flexible Assertive Community Treatment (FACT) teams that relocated to the neighborhood they served, compared to seven teams that continued to provide FACT as usual from a central office. Routine Outcome Measurement (ROM) and care use data were analyzed to compare change in treatment outcomes for patients in place-based FACT (n = 255) and FACT as usual (n = 833). Additionally, retrospective in-depth interviews were conducted with twenty patients about their experience with place-based FACT. Quantitative analysis showed mental health admission days decreased more in place-based than FACT as usual, although this difference was small. Both groups showed improved quality of life, psychosocial functioning, and symptomatic remission rates, and decreased unmet and overall needs for care. There was no change over time in met needs for care, employment, and daily activities. Qualitative analysis showed that patients experienced place-based FACT as more accessible, a better safety net, a more personal approach, better integrated with other forms of care, involving their social network, and embedded in their neighborhood and daily environment. This study showed that location and integration matter to patients, and the long term impact of place-based FACT on treatment outcomes should be explored.

BACKGROUND: Patients with opioid use disorder (OUD) often have complex health care needs. Methadone is one of the medications for opioid use disorder (MOUD) used in the management of OUDs. Highly restrictive methadone treatment-which requires patient compliance with many rules of care-often results in low retention, especially if there is inadequate support from healthcare providers (HCPs). Nevertheless, HCPs should strive to offer patient-centred care (PCC) as it is deemed the gold standard to care. Such an approach can encourage patients to be actively involved in their care, ultimately increasing retention and yielding positive treatment outcomes. METHODS: In this secondary analysis, we aimed to explore how HCPs were applying the principles of PCC when caring for patients with OUD in a highly restrictive, biomedical and paternalistic setting. We applied Mead and Bower's PCC framework in the secondary analysis of 40 in-depth, semi-structured interviews with both HCPs and patients. RESULTS: We present how PCC's concepts of; (a) biopsychosocial perspective; (b) patient as a person; (c) sharing power and responsibility; (d) therapeutic alliance and (e) doctor as a person-are applied in a methadone treatment program. We identified both opportunities and barriers to providing PCC in these settings. CONCLUSION: In a highly restrictive methadone treatment program, full implementation of PCC is not possible. However, implementation of some aspects of PCC are possible to improve patient empowerment and engagement with care, possibly leading to increase in retention and better treatment outcomes.