Serious Mental Illness in Primary Care: a National Physician Survey.
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ABSTRACT:
SUBMITTER: McGinty EE
PROVIDER: S-EPMC7947081 | biostudies-literature | 2021 Mar
REPOSITORIES: biostudies-literature
Publications
Serious Mental Illness in Primary Care: a National Physician Survey.
McGinty Emma E EE Stone Elizabeth M EM Daumit Gail L GL
Journal of general internal medicine 20200610 3
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Project description:ObjectivesPatients experiencing homelessness (PEH) with serious mental illness (SMI) have poor satisfaction with primary care. We assessed if primary care teams tailored for homeless patients (Homeless-Patient Aligned Care Teams (H-PACTs)) provide this population with superior experiences than mainstream primary care and explored whether integrated behavioral health and social services were associated with favorable experiences.MethodsWe surveyed VA PEH with SMI (n = 1095) to capture the valence of their primary care experiences in 4 domains (Access/Coordination, Patient-Clinician Relationships, Cooperation, and Homeless-Specific Needs). We surveyed clinicians (n = 52) from 29 H-PACTs to elucidate if their clinics had embedded mental health, addiction, social work, and/or housing services. We counted these services in each H-PACT (0-4) and classified H-PACTs as having high (3-4) versus low (0-2) service integration. We controlled for demographics, housing history, and needs in comparing H-PACT versus mainstream experiences; and experiences in high versus low integration H-PACTs.ResultsAmong respondents, 969 (91%) had complete data and 626 (62%) were in H-PACTs. After covariate adjustment, compared to mainstream respondents, H-PACT respondents were more likely (P < .01) to report favorable experiences (AORs = 1.7-2.1) and less likely to report unfavorable experiences (AORs = 0.5-0.6) in all 4 domains. Of 29 H-PACTs, 27.6% had high integration. High integration H-PACT respondents were twice as likely as low integration H-PACT respondents to report favorable access/coordination experiences (AOR = 1.7).ConclusionsHomeless-tailored clinics with highly-integrated services were associated with better care experiences among PEH with SMI. These observational data suggest that tailored primary care with integrated services may improve care perceptions among complex patients.
| S-EPMC7871055 | biostudies-literature
Project description:A largely unexplored part of the financial incentive for physicians to participate in preventive care is the degree to which they are the residual claimant from any resulting cost savings. We examine the impact of two preventive activities for people with serious mental illness (care plans and annual reviews of physical health) by English primary care practices on costs in these practices and in secondary care. Using panel two-part models to analyze patient-level data linked across primary and secondary care, we find that these preventive activities in the previous year are associated with cost reductions in the current quarter both in primary and secondary care. We estimate that there are large beneficial externalities for which the primary care physician is not the residual claimant: the cost savings in secondary care are 4.7 times larger than the cost savings in primary care. These activities are incentivized in the English National Health Service but the total financial incentives for primary care physicians to participate were considerably smaller than the total cost savings produced. This suggests that changes to the design of incentives to increase the marginal reward for conducting these preventive activities among patients with serious mental illness could have further increased welfare.
| S-EPMC10092448 | biostudies-literature
Project description:BackgroundEffective transitions of patients from Secondary Care Services (SCSs) to primary care are necessary for optimization of resources and care. Factors that enable or restrict smooth transitions of individuals with Serious Mental Illness (SMI) to primary care from SCSs have not been comprehensively synthesized.MethodsA scoping review was conducted to answer the questions (1) "What are the barriers and facilitators to discharge from SCSs to primary care for adults with SMI?" and (2) "What programs have been developed to support these transitions?".ResultsBarriers and facilitators of discharge included patient-, primary care capacity-, and transition Process/Support-related factors. Patient-related barriers and facilitators were most frequently reported. 11 discharge programs were reported across the evidence sources. The most frequently reported program components were the provision of additional mental health supports for the transition and development of care plans with relapse signatures and intervention plans.ConclusionsEstablished discharge programs should be comprehensively evaluated to determine their relative benefits. Furthermore, research should be expanded to evaluate barriers and facilitators to discharge and discharge programs in different national contexts and models of care.Trial registrationThe protocol for this scoping review is registered with the Open Science Framework ( https://doi.org/10.17605/OSF.IO/NBTMZ ).
| S-EPMC11396452 | biostudies-literature
Project description:BackgroundThere are unmet primary care needs among people with serious mental illness that might be improved with integrated care and medical care management. Many healthcare organizations have attempted to address this problem, but few interventions have been rigorously studied and found to be effective.ObjectiveStudy the implementation and effectiveness of a novel, specialized primary care medical home designed to improve the healthcare of patients with serious mental illness.Design, setting, and participantsClustered controlled trial for a median of 401 days. One Veterans Health Administration medical center was assigned to intervention and two were assigned to usual care (control). Thirty-nine clinicians and managers were included in the study, as well as 331 patients who met eligibility criteria.InterventionA specialized medical home with systematic patient engagement, proactive nurse panel management, a collaborative care psychiatrist, and a primary care physician providing care that included psychiatric treatment.Main measuresQuality of care, chronic illness care and care experience, symptoms, and quality of life.Key resultsSixty-five intervention patients (40%) moved all psychiatric care to the primary care team. No adverse events were attributable to the intervention. Compared with control, intervention patients had greater improvement over time in appropriate screening for body mass index, lipids, and glucose (χ2 = 6.9, 14.3, and 3.9; P's < .05); greater improvement in all domains of chronic illness care (activation, decision support, goal-setting, counseling, coordination) and care experience (doctor-patient interaction, shared decision-making, care coordination, access; F for each 10-24, P's < .05); and greater improvement in mental health-related quality of life (F = 3.9, P = .05) and psychotic symptoms (F = 3.9, P = .05).ConclusionA primary care medical home for serious mental illness can be feasible to implement, safe, and more effective than usual care.Trial registrationClinicalTrials.gov Identifier: NCT01668355.
| S-EPMC9550991 | biostudies-literature
Project description:ObjectiveTo estimate the effect of a nursing home's share of residents with a serious mental illness (SMI) on the quality of care.Data sourcesSecondary nursing home level data over the period 2000 through 2008 obtained from the Minimum Data Set, OSCAR, and Medicare claims.Study designWe employ an instrumental variables approach to address the potential endogeneity of the share of SMI residents in nursing homes in a model including nursing home and year fixed effects.Principal findingsAn increase in the share of SMI nursing home residents positively affected the hospitalization rate among non-SMI residents and negatively affected staffing skill mix and level. We did not observe a statistically significant effect on inspection-based health deficiencies or the hospitalization rate for SMI residents.ConclusionsAcross the majority of indicators, a greater SMI share resulted in lower nursing home quality. Given the increased prevalence of nursing home residents with SMI, policy makers and providers will need to adjust practices in the context of this new patient population. Reforms may include more stringent preadmission screening, new regulations, reimbursement changes, and increased reporting and oversight.
| S-EPMC3703484 | biostudies-literature
Project description:IntroductionPeople with serious mental illness (SMI) have poor health outcomes, in part because of inequitable access to quality health services. Primary care is well suited to coordinate and manage care for this population; however, providers may feel ill-equipped to do so and patients may not have the support and resources required to coordinate their care. We lack a strong understanding of prevention and management of chronic disease in primary care among people with SMI as well as the context-specific barriers that exist at the patient, provider and system levels. This mixed methods study will answer three research questions: (1) How do primary care services received by people living with SMI differ from those received by the general population? (2) What are the experiences of people with SMI in accessing and receiving chronic disease prevention and management in primary care? (3) What are the experiences of primary care providers in caring for individuals with SMI?Methods and analysisWe will conduct a concurrent mixed methods study in Ontario and British Columbia, Canada, including quantitative analyses of linked administrative data and in-depth qualitative interviews with people living with SMI and primary care providers. By comparing across two provinces, each with varying degrees of mental health service investment and different primary care models, results will shed light on individual and system-level factors that facilitate or impede quality preventive and chronic disease care for people with SMI in the primary care setting.Ethics and disseminationThis study was approved by the University of Ottawa Research Ethics Board and partner institutions. An integrated knowledge translation approach brings together researchers, providers, policymakers, decision-makers, patient and caregiver partners and knowledge users. Working with this team, we will develop policy-relevant recommendations for improvements to primary care systems that will better support providers and reduce health inequities.
| S-EPMC9490567 | biostudies-literature
Project description:BackgroundExperiences of homelessness and serious mental illness (SMI) negatively impact health and receipt of healthcare. Interventions that promote the use of primary care services for people with both SMI and homelessness may improve health outcomes, but this literature has not been evaluated systematically. This evidence map examines the breadth of literature to describe what intervention strategies have been studied for this population, elements of primary care integration with other services used, and the level of intervention complexity to highlight gaps for future intervention research and program development.MethodsWe followed an a priori protocol developed in collaboration with clinical stakeholders. We systematically searched the published literature to identify interventions for adults with homelessness who also had SMI. We excluded case reports, editorials, letters, and conference abstracts. Data abstraction methods followed standard practice. Data were categorized into intervention strategies and primary care integration strategies. Then we applied the Complexity Assessment Tool for Systematic Reviews (iCAT_SR) to characterize intervention complexity.ResultsTwenty-two articles met our inclusion criteria evaluating 15 unique interventions to promote engagement in primary care for adults with experiences of homelessness and SMI. Study designs varied widely from randomized controlled trials and cohort studies to single-site program evaluations. Intervention strategies varied across studies but primarily targeted patients directly (e.g., health education, evidence-based interactions such as motivational interviewing) with fewer strategies employed at the clinic (e.g., employee training, multidisciplinary teams) or system levels (e.g., data sharing). We identified elements of primary care integration, including referral strategies, co-location, and interdisciplinary care planning. Interventions displayed notable complexity around the number of intervention components, interaction between intervention components, and extent to which interventions were tailored to specific patient populations.DiscussionWe identified and categorized elements used in various combinations to address the primary care needs of individuals with experiences of homeless and SMI.
| S-EPMC9085989 | biostudies-literature
Project description:BackgroundStrategies are needed to better address the physical health needs of people with serious mental illness (SMI). Enhanced primary care for people with SMI has the potential to improve care of people with SMI, but evidence is lacking.ObjectiveTo examine the effect of a novel enhanced primary care model for people with SMI on service use and screening.DesignUsing North Carolina Medicaid claims data, we performed a retrospective cohort analysis comparing healthcare use and screening receipt of people with SMI newly receiving enhanced primary care to people with SMI newly receiving usual primary care. We used inverse probability of treatment weighting to estimate average differences in outcomes between the treatment and comparison groups adjusting for observed baseline characteristics.ParticipantsPeople with SMI newly receiving primary care in North Carolina.InterventionsEnhanced primary care that includes features tailored for individuals with SMI.Main measuresOutcome measures included outpatient visits, emergency department (ED) visits, inpatient stays and days, and recommended screenings 18 months after the initial primary care visit.Key resultsCompared to usual primary care, enhanced primary care was associated with an increase of 1.2 primary care visits (95% confidence interval [CI]: 0.31 to 2.1) in the 18 months after the initial visit and decreases of 0.33 non-psychiatric inpatient stays (CI: - 0.49 to - 0.16) and 3.0 non-psychiatric inpatient days (CI: - 5.3 to - 0.60). Enhanced primary care had no significant effect on psychiatric service and ED use. Enhanced primary care increased the probability of glucose and HIV screening, decreased the probability of lipid screening, and had no effect on hemoglobin A1c and colorectal cancer screening.ConclusionsEnhanced primary care for people with SMI can increase receipt of some preventive screening and decrease use of non-psychiatric inpatient care compared to usual primary care.
| S-EPMC8041990 | biostudies-literature
Project description:BackgroundSerious mental illness (SMI) is a set of disabling conditions associated with poor outcomes and high healthcare utilisation. However, little is known about patterns of utilisation and costs across sectors for people with SMI.ObjectiveThe aim was to develop a costing methodology and estimate annual healthcare costs for people with SMI in England across primary and secondary care settings.MethodsA retrospective observational cohort study was conducted using linked administrative records from primary care, emergency departments, inpatient admissions, and community mental health services, covering financial years 2011/12-2013/14. Costs were calculated using bottom-up costing and are expressed in 2013/14 British pounds (GBP). Determinants of annual costs by sector were estimated using generalised linear models.ResultsMean annual total healthcare costs for 13,846 adults with SMI were £4989 (median £1208), comprising 19% from primary care (£938, median £531), 34% from general hospital care (£1717, median £0), and 47% from inpatient and community-based specialist mental health services (£2334, median £0). Mean annual costs related specifically to mental health, as distinct from physical health, were £2576 (median £290). Key predictors of total cost included physical comorbidities, ethnicity, neighbourhood deprivation, SMI diagnostic subgroup, and age. Some associations varied across care context; for example, older age was associated with higher primary care and hospital costs, but lower mental healthcare costs.ConclusionsAnnual healthcare costs for people with SMI vary significantly across clinical and socioeconomic characteristics and healthcare sectors. This analysis informs policy and research, including estimation of health budgets for particular patient profiles, and economic evaluation of health services and policies.
| S-EPMC7085478 | biostudies-literature
Project description:BackgroundDespite increased focus on measuring and improving quality of serious illness care, there has been little emphasis on the primary care context or incorporation of the patient perspective.ObjectiveTo explore older patients' perspectives on the quality of serious illness care in primary care.DesignQualitative interview study.ParticipantsTwenty patients aged 60 or older who were at risk for or living with serious illness and who had participated in the clinic's quality improvement initiative.MethodsWe used a semistructured, open-ended guide focusing on how older patients perceived quality of serious illness care, particularly in primary care. We transcribed interviews verbatim and inductively identified codes. We identified emergent themes using a thematic and constant comparative method.ResultsWe identified 5 key themes: (1) the importance of patient-centered communication, (2) coordination of care, (3) the shared decision-making process, (4) clinician competence, and (5) access to care. Communication was an overarching theme that facilitated coordination of care between patients and their clinicians, empowered patients for shared decision-making, related to clinicians' perceived competence, and enabled access to primary and specialty care. Although access to care is not traditionally considered an aspect of quality, patients considered this integral to the quality of care they received. Patients perceived serious illness care as a key aspect of quality in primary care.ConclusionsEfforts to improve quality measurement and implementation of quality improvement initiatives in serious illness care should consider these aspects of care that patients deem important, particularly communication as an overarching priority.
| S-EPMC9700198 | biostudies-literature