Literature Collection

BACKGROUND: The Veterans Health Administration (VHA) greatly expanded the proportion of health care services it purchases from community providers over the last decade, which could impact the quality of care and create care fragmentation. Continuity of care between inpatient and outpatient care delivery systems is critical for high-quality mental health care. OBJECTIVE: To compare rates of outpatient follow-up visits between VHA-purchased and VHA-delivered psychiatric hospitalizations, overall and by VHA facility. METHODS: Using VHA electronic medical records and community care claims data, we compared 7-day and 30-day outpatient follow-up rates across VHA-purchased and VHA-delivered settings. We estimated follow-up rates and comparisons overall as well as separately for 4 diagnosis groups and separately across VHA facilities. RESULTS: Our sample included 64,784 hospitalizations; more than 30% were VHA-purchased as opposed to VHA-delivered. Compared with VHA-delivered hospitalizations, follow-up rates were 30.1 (95% CI: 27.8-32.5) percentage points lower at 7 days and 22.5 (95% CI: 20.8-24.1) percentage points lower at 30 days for VHA-purchased hospitalizations. Lower follow-up rates occurred for neurocognitive disorder discharges for both VHA-purchased and delivered care. Follow-up rates at 30 days were significantly lower for VHA-purchased hospitalizations at 121 out of 128 facilities and significantly higher at no facility. CONCLUSIONS: VHA enrollees seeking mental health care and VHA program managers could benefit from data on psychiatric care quality differences between community providers and VHA providers. From a system perspective, VHA-purchased care quality reports and value-based purchasing contracts could include outpatient follow-up quality measures to incentivize higher quality care.

BACKGROUND: An academic detailing model has improved self-efficacy of memory clinic clinicians to identify and manage complex behavioral and psychological symptoms in persons with dementia (BPSD). The purpose of this report is to describe a systematic approach to adapting a clinician education program previously delivered in two primary care integrated memory clinics for improving the management of BPSD to also be deliverable outside a memory clinic setting, in generalist primary care clinics. The RE-AIM/PRISM implementation framework guided the approach. METHODS: Application of the RE-AIM/PRISM framework to the academic detailing program for BPSD was mapped. Framework-guided qualitative interviews were completed with experienced (Champion) and inexperienced (Novice) program stakeholders including questions on perceived gaps in clinical care (BPSD management) and barriers and facilitators to the educational model. Inductive and deductive qualitative thematic analytic approaches were used, the latter organized by RE-AIM domains and multi-level context. Convergence or divergence in organized themes by stakeholder experience shaped examination of fit and interactions among domains, components and strategies of the model for pre-implementation adaptations planning for non-memory clinic primary care clinicians. RESULTS: A pragmatic application of the RE-AIM/PRISM framework was completed for collecting qualitative feedback from stakeholders, identifying multi-level contextual barriers and facilitators, and planning adaptations to our clinician education program. A description of the clinician stakeholders, the approach and one example of a clinician and intervention-level theme identified across RE-AIM domains for the program, self-efficacy in the management of BPSD, and resulting planned adaptations were shared. CONCLUSIONS: We provide a novel qualitative application of the RE-AIM/PRISM framework to inform adaptations for an intervention for primary care that incorporates feedback from both current experienced and future inexperienced program stakeholders. This approach can be used to identify multi-level contextual barriers and facilitators to reach, adoption, implementation, and effectiveness of this clinician education programs approach, academic detailing, for future primary care teams.

HealthySteps is an evidence-based, prevention program for families of children ages 0 to 3 integrated into pediatric primary care. Our objective was to synthesize feedback on local implementation of an enhanced HealthySteps+ program from various stakeholder viewpoints to improve implementation. Qualitative data were gathered from HealthySteps+ team members (n = 14), current clinic staff (n = 15), and a focus group of parents serving on the program's advisory committee (n = 7). Responses indicate that the core features of the HealthySteps+ program are consultations about typical and atypical child development, facilitated connections to resources, and parent mental health support. Key challenges to implementing the program include retention of skilled staff to sustain trusting relationships with parents and other providers. Based on these findings, the HealthySteps+ implementation team has increased communication with clinic staff at daily huddles, developed orientation materials for new pediatricians, and offered families additional peer support opportunities.

Background: Shared medical appointments (SMAs) for buprenorphine prescribing are clinical encounters in which multiple patients with opioid problems receive treatment from providers in a group setting. Telehealth, the provision of clinical services remotely using telecommunications technology, is an essential modality for improving access to healthcare when combined with SMAs, especially since the COVID pandemic. Objectives: The current study specifically examined psychological components of telehealth SMAs for buprenorphine prescribing to learn about the benefits and drawbacks of this treatment model. Methods: Data was collected through qualitative interviews with patients (N=10) in a psychiatry addiction medicine clinic. Narrative synthesis using grounded theory was conducted to identify salient themes from the interviews. Results: Findings highlighted the advantages and downsides of telehealth SMA to treat addictive disorders in a digital age: (1) Shared group identity; (2) Decreased stigma around buprenorphine; (3) Benefits of telehealth; (4) Discomfort with group SMA format; (5) Strategies for managing medication side effects; and (6) Enhanced empathy for providers. Several themes corresponded to therapeutic factors identified in group therapy (i.e., installation of hope, universality, imparting information, altruism) and mechanisms theorized in previous SMA research (e.g., combating isolation, disease self-management, feeling inspired by others). Conclusion: Telehealth SMAs for buprenorphine prescribing may be a unique opportunity for patients to receive both ongoing medication management and psychosocial benefits that promote recovery and reduce stigma. The SMA group had shortcomings for some patients, including privacy concerns, fear of judgment from other patients and limited time to discuss individual concerns with providers.

BACKGROUND AND OBJECTIVES: General practice is the most common source of healthcare for people who use methamphetamine. The aim of this study was to explore primary care providers' understandings of access to and service utilisation by this group. METHOD: Semi-structured interviews were conducted with general practitioners, practice nurses and alcohol and other drug service providers from two large towns in rural Victoria. RESULTS: Participants (n = 8) reported that availability (workforce shortages, time, complex clinician-client relationships), acceptability (stigma) and appropriateness of care (skill mix, referral networks, models of care) were associated with access to care for this population. Affordability of care was not perceived to be of concern. DISCUSSION: Availability of care is not enough to ensure utilisation and improved health outcomes among consumers who use methamphetamine. Provision of services to this group and to other substance-using populations requires the right 'skill mix' across and within healthcare organisations.

This paper highlights the need for nursing-sensitive indicators tailored to children and young people with complex and integrated care needs. While nursing plays a pivotal role in influencing care quality for this population, current measures predominantly focus on adult populations, creating gaps that hinder the evaluation of nursing contributions across diverse settings such as acute, community, and home care. We examine the importance of quality care measurement for children and young people with complex and integrated care needs and highlight deficiencies in international measurement systems. The discussion highlights the multidimensional care needs of this vulnerable population and advocates for nursing-sensitive indicators that capture broader outcomes including physical health, functional outcomes, family experience, and family well-being. Also highlighted is, the weak evidence linking process indicators to improved patient outcomes, a focus on negative outcomes, such as mortality, and the lack of theoretical foundations for nursing-sensitive indicators. There is a lack of consensus on what components to measure, definitions of indicators, and appropriate methodologies for the development of nursing sensitive indicators. Donabedian's (1988) structures, processes, and outcomes framework is discussed as well as an overview of adaptations used to improve the quality of indicator sets in a variety of settings. By situating the discussion within the context of children's and young people's nursing, this paper aims to direct future research towards the development of comprehensive indicators that capture the full contribution of nursing to the care of children and young people with complex and integrated care needs. Ultimately, this paper advocates for a standardised, holistic approach to nursing-sensitive indicators for this vulnerable population to improve care quality and overall health and wellbeing for children, young people, and their families.