Descriptive and Process Evaluation of a Shared Primary Care Program
01 Jan 2007-The Internet Journal of Allied Health Sciences & Practice (Nova Southeastern University)-Vol. 5, Iss: 4, pp 10
TL;DR: An evaluation of an existing local shared care program in Hamilton, Ontario suggests that implementation and maintenance of shared care programs are possible within community practices.
Abstract: Purpose: This study involved the conduct of a descriptive and process evaluation to examine the implementation and maintenance of an existing local shared care program: The Hamilton Health Service Organization Mental Health and Nutrition Program located in the Hamilton, Ontario, Canada. The program was organized to strengthen links between mental health, nutrition, and primary care services, to improve access to mental health and nutrition care, and to realize the benefits of improved communication, collaboration and mutual support among multiple practitioners, increased continuity of care, and increased family physicians’ comfort and skill in handling more complex problems. Method: A mixed-method, multi-measures evaluation design was used. Data were gathered from the program’s central patient database and by conducting focus groups. Results: Teams of practitioners provide comprehensive primary mental health and nutrition care. Collaboration and education opportunities are extensive although time constraints are an issue. Patients with a range of problems were assessed, treated, and referred among team members. There appears to be a decreased burden on external services. Conclusions & Discussion: This evaluation suggests that implementation and maintenance of shared care programs are possible within community practices.
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TL;DR: A stepped collaborative care program for depressed primary care patients led to substantial increases in treatment effectiveness and moderate increases in costs, consistent with those of other randomized trials.
Abstract: OBJECTIVE
The authors evaluated the incremental cost-effectiveness of stepped collaborative care for patients with persistent depressive symptoms after usual primary care management.
METHOD
Primary care patients initiating antidepressant treatment completed a standardized telephone assessment 6-8 weeks after the initial prescription. Those with persistent major depression or significant subthreshold depressive symptoms were randomly assigned to continued usual care or collaborative care. The collaborative care included systematic patient education, an initial visit with a consulting psychiatrist, 2-4 months of shared care by the psychiatrist and primary care physician, and monitoring of follow-up visits and adherence to medication regimen. Clinical outcomes were assessed through blinded telephone assessments at 1, 3, and 6 months. Health services utilization and costs were assessed through health plan claims and accounting data.
RESULTS
Patients receiving collaborative care experienced a mean of 16.7 additional depression-free days over 6 months. The mean incremental cost of depression treatment in this program was $357. The additional cost was attributable to greater expenditures for antidepressant prescriptions and outpatient visits. No offsetting decrease in use of other health services was observed. The incremental cost-effectiveness was $21.44 per depression-free day.
CONCLUSIONS
A stepped collaborative care program for depressed primary care patients led to substantial increases in treatment effectiveness and moderate increases in costs. These findings are consistent with those of other randomized trials. Improving outcomes of depression treatment in primary care requires investment of additional resources, but the return on this investment is comparable to that of many other widely accepted medical interventions.
327 citations
TL;DR: The evolution of the Hamilton Family Health Team Mental Health Program is reviewed and the changes made by practices with key lessons learnt are reviewed.
Abstract: For 16 years, the Hamilton Family Health Team Mental Health Program has successfully integrated mental health counselors, addiction specialists, child mental health professionals, and psychiatrists into 81 offices of 150 family physicians in Hamilton, Ontario. Maximising the potential of a "shared care" model requires changes within the primary care setting, to support the addition of mental health and addiction professionals, active involvement of primary care staff in managing mental health problems of patients, and collaborative practice. This coordinated effort allow mental health treatment through onsite support from a mental health team and supplants the need to refer most patients to the mental health setting. This article reviews the evolution of the program and the changes made by practices with key lessons learnt.
62 citations
Cites background from "Descriptive and Process Evaluation ..."
...…HSO) Mental Health Program (HFHT-MHP) has successfully integrated mental health personnel, including psychiatric nurses, masters-level social workers, and psychiatrists into offices of family physicians in Hamilton, a community of 500 000 in Southern Ontario, Canada (Vingilis et al, 2007)....
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...SInce 1994, the Hamilton Family HealthTeam (formerly HSO) Mental Health Program (HFHT-MHP) has successfully integrated mental health personnel, including psychiatric nurses, masters-level social workers, and psychiatrists into offices of family physicians in Hamilton, a community of 500 000 in Southern Ontario, Canada (Vingilis et al, 2007)....
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TL;DR: The findings provide a framework for health planners to develop effective service linkages in primary mental health care and proposed five areas of strategy for policy makers that address organisational level support, joint clinical problem solving, local joint care guidelines, staff training and supervision and feedback.
Abstract: Background: Primary care services have not generally been effective in meeting mental health care needs. There is evidence that collaboration between primary care and specialist mental health services can improve clinical and organisational outcomes. It is not clear however what factors enable or hinder effective collaboration. The objective of this study was to examine the factors that enable effective collaboration between specialist mental health services and primary mental health care. Methods: A narrative and thematic review of English language papers published between 1998 and 2009. An expert reference group helped formulate strategies for policy makers. Studies of descriptive and qualitative design from Australia, New Zealand, UK, Europe, USA and Canada were included. Data were extracted on factors reported as enablers or barriers to development of service linkages. These were tabulated by theme at clinical and organisational levels and the inter-relationship between themes was explored. Results: A thematic analysis of 30 papers found the most frequently cited group of factors was “partnership formation”, specifically role clarity between health care workers. Other factor groups supporting clinical partnership formation were staff support, clinician attributes, clinic physical features and evaluation and feedback. At the organisational level a supportive institutional environment of leadership and change management was important. The expert reference group then proposed strategies for collaboration that would be seen as important, acceptable and feasible. Because of the variability of study types we did not exclude on quality and findings are weighted by the number of studies. Variability in local service contexts limits the generalisation of findings. Conclusion: The findings provide a framework for health planners to develop effective service linkages in primary mental health care. Our expert reference group proposed five areas of strategy for policy makers that address organisational level support, joint clinical problem solving, local joint care guidelines, staff training and supervision and feedback.
49 citations
Cites background from "Descriptive and Process Evaluation ..."
...A communication process also enabled a partnership to monitor and consider how it was operating to meet patients’ needs [13-21]....
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TL;DR: Although instabilities in the local context may have contributed to the lack of effects, wider changes in the system of care may be required to augment training and encourage reliable changes in behavior, and more specific educating models are necessary.
46 citations
Cites background from "Descriptive and Process Evaluation ..."
...Some evidence has shown that effective interaction is crucial for integrated care [27,28], although there is more limited evidence on effectiveness in improving patient outcomes [14,29]....
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TL;DR: In a partir de breve discussao desse vazio de um modelo organizativo, propomos a inducao federal de um formato de servicos especializados, partir das experiencias dos Nucleos de Apoio a Saude da Familia (NASF), cuja atuacao matricial adaptada and um prototipo otimo de organizacao do cuidado especcializado ambulatorial.
Abstract: Resumo A estruturacao da atencao especializada ambulatorial e um gargalo na construcao do Sistema Unico de Saude. A partir de breve discussao desse vazio de um modelo organizativo, propomos a inducao federal de um formato de servicos especializados a partir das experiencias dos Nucleos de Apoio a Saude da Familia (NASF), cuja atuacao matricial adaptada e um prototipo otimo de organizacao do cuidado especializado ambulatorial. Ela permite a equidade no acesso e a maxima proximidade do cuidado especializado da realidade dos usuarios, o relacionamento personalizado e a articulacao intima entre as equipes de saude da familia e os especialistas, viabilizando educacao permanente mutua, regulacao negociada e aumento da resolubilidade da atencao basica. Aspectos das experiencias municipais de Florianopolis e Curitiba sao sintetizadas como exemplos parciais da proposta. E brevemente descrita a estruturacao do cuidado em saude mental de Florianopolis, toda organizada como apoio matricial; e a mudanca de enfoque das equipes de apoio de Curitiba, que progressivamente passaram a sem empenhar, envolver e mediar a relacao entre a atencao basica e a especializada. Este formato pode ser adaptado e expandido para a maioria das especialidades medicas.
46 citations
References
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TL;DR: In recent years evaluators of educational and social programs have expanded their methodological repertoire with designs that include the use of both qualitative and quantitative methods as discussed by the authors, which can be classified into three categories: qualitative, quantitative, and qualitative.
Abstract: In recent years evaluators of educational and social programs have expanded their methodological repertoire with designs that include the use of both qualitative and quantitative methods. Such prac...
5,578 citations
TL;DR: The chronic care model is a guide to higher-quality chronic illness management within primary care and predicts that improvement in its 6 interrelated components can produce system reform in which informed, activated patients interact with prepared, proactive practice teams.
Abstract: The chronic care model is a guide to higher-quality chronic illness management within primary care. The model predicts that improvement in its 6 interrelated components—self-management support, clinical information systems, delivery system redesign, decision support, health care organization, and community resources—can produce system reform in which informed, activated patients interact with prepared, proactive practice teams. Case studies are provided describing how components of the chronic care model have been implemented in the primary care practices of 4 health care organizations.
2,909 citations
TL;DR: The challenge is to organize these components into an integrated system of chronic illness care, which can be done most efficiently and effectively in primary care practice rather than requiring specialized systems of care.
Abstract: Usual medical care often fails to meet the needs of chronically ill patients, even in managed, integrated delivery systems. The medical literature suggests strategies to improve outcomes in these patients. Effective interventions tend to fall into one of five areas: the use of evidence-based, planned care; reorganization of practice systems and provider roles; improved patient self-management support; increased access to expertise; and greater availability of clinical information. The challenge is to organize these components into an integrated system of chronic illness care. Whether this can be done most efficiently and effectively in primary care practice rather than requiring specialized systems of care remains unanswered.
2,805 citations
01 Jan 1992
TL;DR: The use of focus groups in clinical research has been explored in the context of qualitative research in primary care as mentioned in this paper, with a focus on the dance of interpretation of interpretations and the use of qualitative data.
Abstract: Introduction - Benjamin F Crabtree and William L Miller PART ONE: OVERVIEW OF QUALITATIVE RESEARCH METHODS Clinical Research - William L Miller and Benjamin F Crabtree A Multimethod Typology and Qualitative Roadmap PART TWO: DISCOVERY: DATA COLLECTION STRATEGIES Sampling in Qualitative Inquiry - Anton J Kuzel Participant Observation - Stephen P Bogdewic Key Informant Interviews - Valerie J Gilchrist and Robert L Williams Depth Interviewing - William L Miller and Benjamin F Crabtree The Use of Focus Groups in Clinical Research - Judith Belle Brown PART THREE: INTERPRETATION: STRATEGIES OF ANALYSIS The Dance of Interpretation - William L Miller and Benjamin F Crabtree A Grounded Hermeneutic Editing Approach - Richard B Addison Using Codes and Code Manuals - Benjamin F Crabtree and William L Miller A Template Organizing Style of Interpretation Immersion/Crystallization - Jeffrey Borkan Data Management and Interpretation Using Computers To Assist - Lynn M Meadows and Diane M Dodendorf PART FOUR: SPECIAL DESIGNS Narrative Approaches to Qualitative Research in Primary Care - Jessica H Muller Using Video Tapes in Qualitative Research - Virginia Elderkin-Thompson and Howard Waitzkin An Armchair Adventure in Case Study Research - Virginia A Aita and Helen E McIlvain Participatory Inquiry - Janecke Thesen and Anton J Kuzel PART FIVE: PUTTING IT ALL TOGETHER Researching Practice Settings - Benjamin F Crabtree and William L Miller A Case Study Approach Making Changes with Key Questions in Medical Practices - Kirsti Malterud Studying What Makes a Difference PART SIX: SUMMARY Standards of Qualitative Research - Richard M Frankel Qualitative Research - Lucy M Candib, Kurt C Stange and Wendy Levinson Perspectives on the Future
2,367 citations
Jürgen Unützer1, Wayne Katon2, Christopher M. Callahan3, John W Williams4, Enid M. Hunkeler5, Linda H. Harpole4, Marc Hoffing, Richard Della Penna5, Polly H. Noël6, Elizabeth H. B. Lin7, Patricia A. Areán8, Mark T. Hegel9, Lingqi Tang1, Thomas R. Belin1, Sabine M. Oishi1, Christopher Langston10 •
University of California, Los Angeles1, University of Washington2, Indiana University3, Duke University4, Kaiser Permanente5, University of Texas Health Science Center at San Antonio6, Group Health Cooperative7, University of California, San Francisco8, Dartmouth College9, John A. Hartford Foundation10
TL;DR: The IMPACT collaborative care model appears to be feasible and significantly more effective than usual care for depression in a wide range of primary care practices.
Abstract: ContextFew depressed older adults receive effective treatment in primary care
settings.ObjectiveTo determine the effectiveness of the Improving Mood–Promoting
Access to Collaborative Treatment (IMPACT) collaborative care management program
for late-life depression.DesignRandomized controlled trial with recruitment from July 1999 to August
2001.SettingEighteen primary care clinics from 8 health care organizations in 5
states.ParticipantsA total of 1801 patients aged 60 years or older with major depression
(17%), dysthymic disorder (30%), or both (53%).InterventionPatients were randomly assigned to the IMPACT intervention (n = 906)
or to usual care (n = 895). Intervention patients had access for up to 12
months to a depression care manager who was supervised by a psychiatrist and
a primary care expert and who offered education, care management, and support
of antidepressant management by the patient's primary care physician or a
brief psychotherapy for depresssion, Problem Solving Treatment in Primary
Care.Main Outcome MeasuresAssessments at baseline and at 3, 6, and 12 months for depression, depression
treatments, satisfaction with care, functional impairment, and quality of
life.ResultsAt 12 months, 45% of intervention patients had a 50% or greater reduction
in depressive symptoms from baseline compared with 19% of usual care participants
(odds ratio [OR], 3.45; 95% confidence interval [CI], 2.71-4.38; P<.001). Intervention patients also experienced greater rates of
depression treatment (OR, 2.98; 95% CI, 2.34-3.79; P<.001),
more satisfaction with depression care (OR, 3.38; 95% CI, 2.66-4.30; P<.001), lower depression severity (range, 0-4; between-group
difference, −0.4; 95% CI, −0.46 to −0.33; P<.001), less functional impairment (range, 0-10; between-group
difference, −0.91; 95% CI, −1.19 to −0.64; P<.001), and greater quality of life (range, 0-10; between-group
difference, 0.56; 95% CI, 0.32-0.79; P<.001) than
participants assigned to the usual care group.ConclusionThe IMPACT collaborative care model appears to be feasible and significantly
more effective than usual care for depression in a wide range of primary care
practices.
2,218 citations