Literature Collection

BACKGROUND: Australia's health care system is under pressure. Pediatric referrals to public hospital emergency and outpatient departments have increased recently, overburdening emergency services and resulting in extended waiting times for nonurgent pediatric care. Children living outside metropolitan areas are disproportionately affected. Integrated models of care with pediatricians collaborating with general practitioners (GPs) in their practices have been evaluated in the United Kingdom and Australia. Results are promising for quality of care improvement and reducing referrals to hospitals. GPs and pediatricians found the model feasible, knowledge- and confidence-boosting. In-person pediatric-GP support is resource-intensive, limiting scalability and sustainability. OBJECTIVE: The SUSTAIN trial is designed to evaluate a digitally delivered, integrated GP-pediatrician model of care. The primary objective is to determine whether the SUSTAIN model reduces GP referrals to hospital emergency departments for children <18 years. Secondary objectives include whether the model improves the delivery of guideline-concordant pediatric care by GPs, enhances GP confidence, and strengthens family trust in primary care. The trial also examines barriers and enablers to the implementation and includes a health economic evaluation comparing intervention costs with standard GP care. METHODS: SUSTAIN uses a stepped wedge cluster randomized controlled trial design to implement a GP-pediatrician integrated model of care delivered digitally. Participating GP practices across metropolitan and nonmetropolitan New South Wales are included and randomly assigned a start time. The intervention consists of 12 months' access to the shared GP-pediatrician consulting sessions with patients younger than 18 years conducted by telehealth, virtual pediatrician-led case discussions, phone/email pediatrician support, and complimentary access to the internationally renowned Sydney Child Health Program learning platform. GP and family surveys are collected at baseline and in the final month of intervention. An implementation evaluation using focus group discussions is conducted with each practice during the intervention and optional GP and family interviews at the end of the intervention. A health economic evaluation will explore the cost-effectiveness of this model of care. RESULTS: The trial is supported through a 2.5-year New South Wales Ministry of Health Translational Research Grants Scheme. Human Research Ethics Committee approval was obtained in November 2022, and practice recruitment began in March 2023. Data collection commenced for all participating practices from September 1, 2023, with anticipated completion on February 28, 2025. Data analysis will commence from March 2025, with results expected in the first quarter of 2026. CONCLUSIONS: Positive outcomes for the SUSTAIN trial, demonstrating that virtual pediatric support for GPs in both metropolitan and nonmetropolitan areas can strengthen pediatric primary care provision, have the potential to influence future health policy. This innovative approach to integrated care could be rolled out across Australia and other countries with primary care-led health care systems facing similar challenges.

BACKGROUND: Children living in regional and rural Australia have diminished health outcomes and are more likely to be developmentally vulnerable on one or more domains compared to urban peers. Despite this, children in regional and rural Australia often cannot access specialist care due to lack of availability, financial constraints, or waiting times of over 12 months. Strengthening Care for Rural Children (SC4RC) aims to evaluate an integrated general practitioner (GP)-paediatrician model of care in rural communities to enhance the quality of paediatric care by ensuring children receive timely, accessible care within their communities by reducing referrals to public and private paediatric services. METHODS: SC4RC is a stepped-wedge randomised controlled trial of 22 general practice clinics in regional and rural Victoria and New South Wales, Australia. Control data for each general practice clinic will be collected for a minimum of 1 month and each clinic will be randomly allocated a start month, with the intervention running for 11 months at each clinic. The intervention will consist of fortnightly GP-paediatrician co-consultation sessions, weekday phone and email paediatrician support for GPs, and access to a paediatric online community of practice via a Project ECHO™ series. The primary outcome is the proportion of paediatric (0 to <18 years) GP appointments that result in a referral to a paediatric service (hospital emergency departments, outpatient clinics, or private paediatricians) during the intervention period compared with the control period. Secondary outcomes include GP quality of care across 17 common childhood conditions, GP confidence in paediatric care, family confidence in GP care, and the sustainability of the SC4RC model. Integral to the project is our consumer engagement framework which will inform the translation and implementation of the project. An implementation evaluation will assess the acceptability, adaptability, and scalability of the model, whilst a health economic evaluation will measure the cost-effectiveness/benefit of the intervention. DISCUSSION: This protocol paper outlines how we will partner with primary care organisations and paediatric services to implement and evaluate SC4RC in some regional and rural communities in Victoria and NSW. TRIAL REGISTRATION: Australia New Zealand Clinical Trials Registry ACTRN12623000550606. Registered on 23 May 2023.

BACKGROUND: Individuals experiencing serious mental illness (SMI) have higher rates of comorbid physical health conditions, poorer associated health outcomes, and die on average 10-20 years earlier than the general population. They encounter multiple barriers to accessing appropriate physical health care in many countries, including Canada, where policies and practices to promote integrated care delivery to this population remain scant. This qualitative study aimed to explore health provider perspectives and experiences with integrated physical and mental health care within mental health settings in Canada, in efforts to address the health needs of this population. METHODS: This qualitative descriptive study involved conducting individual semi-structured interviews with 13 health administrators and four focus groups with 15 clinicians between July 2023 and April 2024. The data analysis team, inclusive of individuals with SMI, used thematic analysis to identify overarching themes that capture participants' perspectives on and experiences with delivering integrated physical and mental health care within mental health settings in Canada, including their clinical practices and organizational contexts. RESULTS: We identified four themes in participant narratives: (1) the need for integrated care delivery within mental health settings; (2) organizational readiness for integrated care; (3) moving integration forward: addressing challenges; and (4) leveraging opportunities to advance integrated care. Both participant groups highlighted challenges with fragmented healthcare services, emphasized the urgent need for policies, practices and guidelines that support person-centered, comprehensive care within mental health settings, and called for engaging people with living/lived experience and family members in service redesign. CONCLUSION: Findings underscore the importance of accelerating efforts to promote integrated health care delivery for adults with SMI within mental health settings, and of implementing policies that address health disparities for this population in the Canadian context. CLINICAL TRIAL NUMBER: Not Applicable.

Individuals living with serious mental illness (SMI) face significant barriers to accessing appropriate physical health care, poorer associated health outcomes and premature mortality compared to the general population. This scoping review examines service delivery models and clinical practices supporting the integration of physical health care for adults with SMI within mental health settings, and their outcomes. Searches of four academic databases yielded 65 academic articles. Most integrated service delivery models were implemented in community mental health settings in the United States and incorporated elements of Wagner's Chronic Care Model, emphasizing delivery-system redesign, patient self-management support and use of clinical information systems. In most outcome studies, integrated care models were associated with improvements in primary care access and preventative screening rates, while other physical health indicators and emergency and inpatient service use demonstrated promising but mixed results. Implementation challenges of integrated service delivery models included securing financial resources and maintaining effective use of clinical information systems, among others. Successful implementation was facilitated by effective teamwork, care coordination, and administrative and leadership support. Study findings highlight the complexity of integrating physical health care in mental health settings, and the longer timeframes needed to observe changes in some outcomes. The review further underscores the need for ongoing efforts to advance integrated care delivery in mental health settings and the importance of longitudinal data collection to fully assess and optimize the implementation and outcomes of these interventions. Systematic Review Registration: https://doi.org/10.17605/OSF.IO/3T9VK.

BACKGROUND: Individuals with serious mental illness (SMI) have higher rates of comorbid physical health conditions, poorer associated health outcomes, and die on average 10-20 years earlier than the general population. This qualitative study aimed to explore the perspectives and experiences of adults living with SMI and family members with accessing physical healthcare within primary and mental health settings in Canada. METHODS: We conducted a qualitative descriptive study using semi-structured interviews with 20 adults living with SMI and five focus groups with 18 family members between July 2023 and April 2024. After coding by two authors, thematic analysis was completed with the support of a data analysis team to identify overarching themes capturing participant experiences with accessing physical healthcare, care needs and preferences. RESULTS: Four main themes emerged from participant narratives: (1) The centrality of mental health problems in the lives of people with SMI; (2) Challenges in accessing physical healthcare; (3) The role of families in supporting access to care; (4) Perceived health priorities and preferences. There was a high degree of congruence between the perspectives of individuals living with SMI and family members. Both participant groups described challenges accessing primary care settings, fragmented health services, and a desire for person-centred, whole-person health within mental health settings, with family member support where available. CONCLUSIONS: Findings from this study highlight the need for advancing the integration of physical healthcare within mental health settings for adults living with SMI, who are less likely to engage with community-based primary care services. Enhanced access to physical healthcare could leverage multidisciplinary resources in these settings and partnerships with families. These findings can inform efforts to provide whole-person healthcare for individuals experiencing SMI. PATIENT OR PUBLIC CONTRIBUTION: The study team collaborated closely with community organizations and individuals with lived experience at every stage of this research. This included contributions to the funding proposal, the study protocol, participant recruitment, study materials, data analysis and preparing the manuscript. Individuals with lived experience and family members actively participated in management and project meetings for the duration of the study.

OBJECTIVE/BACKGROUND: Although perinatal substance use disorders (PSUDs) are increasingly prevalent among pregnant and postpartum (PPP) individuals, there is limited understanding of physicians’ perspectives on training needs and gaps in PSUD treatment. To reduce the negative impact of SUD on PPPs, identifying critical areas of intervention related to education and awareness for screening and treating PSUDs is critical. This study explored reproductive healthcare professionals’ (RHPs) perspectives on the necessary training to improve care for PPPs with PSUDs. METHODS: This study is an analysis of a cross-sectional survey of RHPs (n = 117). Inductive thematic analysis was conducted on free-text survey responses to identify RHP perspectives on training needs and strategies for improving care for PPP with SUD. Analyses were performed using Atlas.ti V 24.1. RESULTS: Participants were mostly White (77.8%) and female (93.2%) and included a broad sample of RHPs across multiple disciplines. Three primary themes were generated: (1) improving equitable access to evidence-based training, (2) prioritization of an integrated care network, and (3) addressing stigma in how care is delivered. DISCUSSION: The themes elicited from provider responses offer a framework for understanding opportunities to enhance care for PSUDs. Providers emphasized the need for more equitable access to evidence-based training to better equip clinicians to deliver high-quality care. They also described the importance of strengthening integrated care networks through collaboration among multidisciplinary professionals to improve care coordination and patient experiences. Addressing stigma in care delivery was identified as essential for fostering a more supportive treatment environment. These insights reflect provider perspectives and perceived priorities for system-level improvement rather than evaluated outcomes of specific interventions. Future research should examine the effectiveness of existing training and care models and identify strategies to enhance their accessibility and impact.

BACKGROUND: Rural and underserved communities face persistent shortages of Family Nurse Practitioners (FNPs), limiting access to high-quality care. Academic-Practice Partnerships (APPs) offer a strategy to build workforce readiness. PURPOSE: This study evaluated the effects of an enhanced APP model on FNP learners' practice confidence and employment outcomes in underserved settings. METHODS: Using a longitudinal, repeated-measures design, 33 FNP learners completed assessments at baseline, program completion, and 1-year post-graduation. Surveys measured confidence across 6 domains. RESULTS: Practice confidence significantly increased across all domains post-program (P < .001), with sustained gains at one year. Behavioral health and pharmacology showed initial surges followed by slight declines. One year after graduation, 63.6% remained at APP partner sites and 48.5% worked in rural areas. CONCLUSIONS: Enhanced APP models effectively build and sustain FNP practice confidence and retention in high-need settings, though continued post-graduation support is warranted.