Showing papers on "Integrated care published in 2008"

Integration of Mental Health/Substance Abuse and Primary Care

Abstract: Objectives To describe models of integrated care used in the United States, assess how integration of mental health services into primary care settings or primary health care into specialty outpatient settings impacts patient outcomes and describe barriers to sustainable programs, use of health information technology (IT), and reimbursement structures of integrated care programs within the United States. Data sources MEDLINE, CINAHL, Cochrane databases, and PsychINFO databases, the internet, and expert consultants for relevant trials and other literature that does not traditionally appear in peer reviewed journals. Review methods Randomized controlled trials and high quality quasi-experimental design studies were reviewed for integrated care model design components. For trials of mental health services in primary care settings, levels of integration codes were constructed and assigned for provider integration, integrated processes of care, and their interaction. Forest plots of patient symptom severity, treatment response, and remission were constructed to examine associations between level of integration and outcomes. Results Integrated care programs have been tested for depression, anxiety, at-risk alcohol, and ADHD in primary care settings and for alcohol disorders and persons with severe mental illness in specialty care settings. Although most interventions in either setting are effective, there is no discernible effect of integration level, processes of care, or combination, on patient outcomes for mental health services in primary care settings. Organizational and financial barriers persist to successfully implement sustainable integrated care programs. Health IT remains a mostly undocumented but promising tool. No reimbursement system has been subjected to experiment; no evidence exists as to which reimbursement system may most effectively support integrated care. Case studies will add to our understanding of their implementation and sustainability. Conclusions In general, integrated care achieved positive outcomes. However, it is not possible to distinguish the effects of increased attention to mental health problems from the effects of specific strategies, evidenced by the lack of correlation between measures of integration or a systematic approach to care processes and the various outcomes. Efforts to implement integrated care will have to address financial barriers. There is a reasonably strong body of evidence to encourage integrated care, at least for depression. Encouragement can include removing obstacles, creating incentives, or mandating integrated care. Encouragement will likely differ between fee-for-service care and managed care. However, without evidence for a clearly superior model, there is legitimate reason to worry about premature orthodoxy.

A randomized study of a multidisciplinary program to intervene on geriatric syndromes in vulnerable older people who live at home (Dutch EASYcare Study).

Abstract: Background The effectiveness of community-based geriatric intervention models for vulnerable older adults is controversial We evaluated a problem-based multidisciplinary intervention targeting vulnerable older adults at home that promised efficacy through better timing and increased commitment of patients and primary care physicians This study compared the effects of this new model to usual care Methods Primary care physicians referred older people for problems with cognition, nutrition, behavior, mood, or mobility One hundred fifty-one participants (mean age 822 years, 748% women) were included in a pseudocluster randomized trial with 6-month follow-up for the primary outcomes Eighty-five participants received the new intervention, and 66 usual care In the intervention arm, geriatric nurses visited patients at home for geriatric assessment and management in cooperation with primary care physicians and geriatricians Modified intention-to-treat analyses focused on differences between treatment arms in functional abilities (Groningen Activity Restriction Scale-3) and mental wellbeing (subscale mental health Medical Outcomes Study [MOS]-20), using a mixed linear model Results After 3 months, treatment arms showed significant differences in favor of the new intervention Functional abilities improved 22 points (95% confidence interval [CI], 03–42) and well-being 58 points (95% CI, 01–114) After 6 months, the favorable effect increased for well-being (91; 95% CI, 24–159), but the effect on functional abilities was no longer significant (16; 95% CI, � 07 to 39) Conclusions This problem-based geriatric intervention improved functional abilities and mental well-being of vulnerable older people Problem-based interventions can increase the effectiveness of primary care for this population

An Ethnographic Study of Stigma and Ageism in Residential Care or Assisted Living

Abstract: Purpose: This study explored aspects of stigmatization for older adults who live in residential care or assisted living (RC–AL) communities and what these settings have done to address stigma. Design and Methods: We used ethnography and other qualitative data-gathering and analytic techniques to gather data from 309 participants (residents, family and staff) from six RC–AL settings in Maryland. We entered the transcript data into Atlas.ti 5.0. We analyzed the data by using grounded theory techniques for emergent themes. Results: Four themes emerged that relate to stigma in RC–AL: (a) ageism in long-term care; (b) stigma as related to disease and illness; (c) sociocultural aspects of stigma; and (d) RC–AL as a stigmatizing setting. Some strategies used in RC–AL settings to combat stigma include family member advocacy on behalf of stigmatized residents, assertion of resident autonomy, and administrator awareness of potential stigmatization. Implications: Findings suggest that changes could be made to the structure as well as the process of care delivery to minimize the occurrence of stigma in RC–AL settings. Structural changes include an examination of how best, given the resident case mix, to accommodate care for persons with dementia (e.g., separate units or integrated care); processes of care include staff recognition of resident preferences and strengths, rather than their limitations.

Frameworks of Integrated Care for the Elderly: A Systematic Review

Abstract: Canadian Policy Research Networks is a not-for-profit organization. Our mission is to help make Canada a more just, prosperous and caring society. We seek to do this through excellent and timely research, effective networking and dissemination and by providing a valued neutral space within which an open dialogue among all interested parties can take place. You can obtain further information about CPRN and its work in public involvement and other policy areas at The views expressed in the report are the views of the author and do not necessarily reflect those of the Ontario Ministry of Health and Long-Term Care.

Integration of Depression and Hypertension Treatment: A Pilot, Randomized Controlled Trial

Abstract: PURPOSE We wanted to examine whether integrating depression treatment into care for hypertension improved adherence to antidepressant and antihypertensive medications, depression outcomes, and blood pressure control among older primary care patients. METHODS Older adults prescribed pharmacotherapy for depression and hypertension from physicians at a large primary care practice in West Philadelphia were randomly assigned to an integrated care intervention or usual care. Outcomes were assessed at baseline, 2, 4, and 6 weeks using the Center for Epidemiologic Studies Depression Scale (CES-D) to assess depression, an electronic monitor to measure blood pressure, and the Medication Event Monitoring System to assess adherence. RESULTS In all, 64 participants aged 50 to 80 years participated. Participants in the integrated care intervention had fewer depressive symptoms (CES-D mean scores, intervention 9.9 vs usual care 19.3; P <.01), lower systolic blood pressure (intervention 127.3 mm Hg vs usual care 141.3 mm Hg; P <.01), and lower diastolic blood pressure (intervention 75.8 mm Hg vs usual care 85.0 mm Hg; P <.01) compared with participants in the usual care group at 6 weeks. Compared with the usual care group, the proportion of participants in the intervention group who had 80% or greater adherence to an antidepressant medication (intervention 71.9% vs usual care 31.3%; P <.01) and to an antihypertensive medication (intervention 78.1% vs usual care 31.3%; P <.001) was greater at 6 weeks. CONCLUSION A pilot, randomized controlled trial integrating depression and hypertension treatment was successful in improving patient outcomes. Integrated interventions may be more feasible and effective in real-world practices, where there are competing demands for limited resources.

Evaluation of a Diabetes Management System Based on Practice Guidelines, Integrated Care, and Continuous Quality Management in a Federal State of Germany : A population-based approach to health care research

Abstract: OBJECTIVE —The aim of this study was to evaluate the Saxon Diabetes Management Program (SDMP), which is based on integrated practice guidelines, shared care, and integrated quality management. The SDMP was implemented into diabetes contracts between health insurance providers, general practitioners (GPs), and diabetes specialized practitioners (DSPs) unified in the Saxon association of Statutory Health Insurance Physicians. RESEARCH DESIGN AND METHODS —The evaluation of the SDMP in Germany represents a real-world study by using clinical data collected from participating physicians. Between 2000 and 2002 all DSPs and about 75% of the GPs in Saxony participated. Finally, 291,771 patients were included in the SDMP. Cross-sectional data were evaluated at the beginning of 2000 (group A1) and at the end of 2002 (group A2). A subcohort of 105,204 patients was followed over a period of 3 years (group B). RESULTS —The statewide implementation of the SDMP resulted in a change in therapeutic practice and in better cooperation. The median A1C at the time of referral to DSPs decreased from 8.5 to 7.5%, and so did the overall mean. At the end, 78 and 61% of group B achieved the targets for A1C and blood pressure, respectively, recommended by the guidelines compared with 69 and 50% at baseline. Patients with poorly controlled diabetes benefited the most. Preexisting regional differences were aligned. CONCLUSIONS —Integrated care disease management with practicable integrated quality management including collaboration between GPs and specialist services is a significant innovation in chronic care management and an efficient way to improve diabetes care continuously.

Orthogeriatric care for the elderly with hip fractures: where are we?

Abstract: Hip fracture (HF) is a major health care problem in the Western world, associated with significant morbidity, mortality and loss of function. Its incidence is expected to increase as the population ages. The authors discuss the role of a coordinated multidisciplinary team in the management of patients during hospital stay, at discharge and during rehabilitation. Orthogeriatric care should not just be viewed as a multidisciplinary activity, but as a radical alternative to the traditional model of care, an alternative based on all those strategies in which evidence shows an improvement in outcomes in the fractured elderly. Therefore, key points of the care are early surgery, immediate mobilization, prevention and management of delirium, pain and malnutrition, as well as an integrated and multidisciplinary approach. Comprehensive geriatric assessment is useful in identifying frail elderly and in providing information that is essential in formulating clinical recommendations and making care plans. In each hospital, the orthogeriatric unit should represent a center of excellence for treating elderly patients with major fractures. However, when an orthogeriatric project is implemented, it is essential that detailed data about the case-mix of patients, process of care and outcomes are collected, to compare the results with historical data and to be able to participate in audit processes.

Organizational culture, team climate and diabetes care in small office-based practices

Abstract: Redesigning care has been proposed as a lever for improving chronic illness care. Within primary care, diabetes care is the most widespread example of restructured integrated care. Our goal was to assess to what extent important aspects of restructured care such as multidisciplinary teamwork and different types of organizational culture are associated with high quality diabetes care in small office-based general practices. We conducted cross-sectional analyses of data from 83 health care professionals involved in diabetes care from 30 primary care practices in the Netherlands, with a total of 752 diabetes mellitus type II patients participating in an improvement study. We used self-reported measures of team climate (Team Climate Inventory) and organizational culture (Competing Values Framework), and measures of quality of diabetes care and clinical patient characteristics from medical records and self-report. We conducted multivariate analyses of the relationship between culture, climate and HbA1c, total cholesterol, systolic blood pressure and a sum score on process indicators for the quality of diabetes care, adjusting for potential patient- and practice level confounders and practice-level clustering. A strong group culture was negatively associated to the quality of diabetes care provided to patients (β = -0.04; p = 0.04), whereas a more 'balanced culture' was positively associated to diabetes care quality (β = 5.97; p = 0.03). No associations were found between organizational culture, team climate and clinical patient outcomes. Although some significant associations were found between high quality diabetes care in general practice and different organizational cultures, relations were rather marginal. Variation in clinical patient outcomes could not be attributed to organizational culture or teamwork. This study therefore contributes to the discussion about the legitimacy of the widespread idea that aspects of redesigning care such as teamwork and culture can contribute to higher quality of care. Future research should preferably combine quantitative and qualitative methods, focus on possible mediating or moderating factors and explore the use of instruments more sensitive to measure such complex constructs in small office-based practices.

The meaning of integrated care: a systems approach.

Abstract: Introduction: Organizations can be regarded as systems. The traditional model of systems views them as machines. This seems to be insufficient when it comes to understanding and organizing complex tasks. To better understand integrated care we should approach organizations as constantly changing living organisms, where many agents are interconnected in so-called Complex Adaptive Systems (CAS). Theory and discussion: The term “complex” emphasizes that the necessary competence to perform a task is not owned by any one part, but comes as a result of co-operation within the system. “Adaptive” means that system change occurs through successive adaptations. A CAS consists of several subsystems called agents, which act in dependence of one another. Examples would be the ant-hill, the human immune defence, the financial market and the surgical operating theatre team. Studying a CAS, the focus is on the interaction and communication between agents. Although these thoughts are not new, the CAS-approach has not yet been widely applied to the management of integrated care. This helps the management to understand why the traditional top down way of managing, following the machine model thinking, may meet with problems in interdependent organizations with complex tasks. Conclusion: When we perceive health and social services as CASs we should gain more insight into the processes that go on within and between organizations and how top management, for example within a hospital, in fact executes its steering function.

How has the impact of 'care pathway technologies' on service integration in stroke care been measured and what is the strength of the evidence to support their effectiveness in this respect?

Abstract: Background Across the developed world, we are witnessing an increasing emphasis on the need for more closely coordinated forms of health and social care provision. Integrated care pathways (ICPs) have emerged as a response to this aspiration and are believed by many to address the factors which contribute to service integration. ICPs map out a patient's journey, providing coordination of services for users. They aim to have: 'the right people, doing the right things, in the right order, at the right time, in the right place, with the right outcome'. The value for ICPs in supporting the delivery of care across organisational boundaries, providing greater consistency in practice, improving service continuity and increasing collaboration has been advocated by many. However, there is little evidence to support their use, and the need for systematic evaluations in order to measure their effectiveness has been widely identified. A recent Cochrane review assessed the effects of ICPs on functional outcome, process of care, quality of life and hospitalisation costs of inpatients with acute stroke, but did not specifically focus on service integration or its derivatives. To the best of our knowledge, no such systematic review of the literature exists. Objectives • To systematically review all high-quality studies which have evaluated the impact of care pathway technologies on 'service integration' and its derivatives in stroke care To examine how elements of service integration are defined in such studies To examine the type of evidence utilised to measure service integration To analyse the weight of evidence used to support claims about the effectiveness of ICPs on improving service integration To produce recommendations for ICP developers, users and evaluators. Inclusion criteria Types of participants The review focused on the care of adult patients who had suffered a stroke. It included the full spectrum of services – acute care, rehabilitation and long-term support – in hospital and community settings. Types of intervention(s)/phenomena of interest Integrated care pathways were the intervention of interest, defined for the purpose of this review as 'a multidisciplinary tool to improve the quality and efficiency of evidence based care and is used as a communication tool between professionals to manage and standardise the outcome orientated care'. Here 'multidisciplinary' is taken to refer to the involvement of two or more disciplines. Types of outcomes 'Service integration' was the outcome of interest however, this was defined and measured in the selected studies. Types of studies This review was concerned with how 'service integration' was defined in evaluations of ICPs; the type of evidence utilised in measuring the impact of the intervention and the weight of evidence to support the effectiveness of care pathway technologies on 'service integration'. Studies that made an explicit link between ICPs and service integration were included in the review. Evidence generated from randomised controlled trials, quasi-experimental, qualitative and health economics research was sought. The search was limited to publications after 1980, coinciding with the emergence of ICPs in the healthcare context. Assessment for inclusion of foreign papers was based on the English-language abstract, where available. These were included only if an English translation was available. Exclusion criteria This review excluded studies that: focused only on a single aspect of stroke care (e.g. dysphasia) evaluated ICPs as part of a wider program of service development did not make an explicit link between ICPs and service integration did not meet the definition of ICP utilised for the purposes of the review focused exclusively on the outcomes of variance analysis. Search strategy In order to avoid replication, the Joanna Briggs Institute for Evidence Based Nursing and Midwifery Database TRUNCATED AT 600 WORDS

Do case conferences between general practitioners and specialist palliative care services improve quality of life? A randomised controlled trial (ISRCTN 52269003):

Abstract: Australian palliative care is delivered by general practitioners (GPs) and specialist palliative care teams. Patient outcomes should improve if they work in formal partnership. We conducted a multi-centred randomised controlled trial of specialist- GP case conferences, with the GP participating by teleconference, or usual care and communication methods. Primary outcome measure was global Quality of Life (QoL) scores at 3 weeks from intervention. Secondary measures included subscale QoL scores and carer burden. Two a priori intention-to-treat analyses were conducted using recruitment, and time of death, as fixed time points. There was no difference between groups in the magnitude of change in global QoL measures from baseline to any time point up to 9 weeks post-case conference, or at any time before death. The case conference group showed better maintenance of some physical and mental health measures of QoL in the 35 days before death. Case conferences may improve clinical relationships and care plans at referral, which are not implemented until severe symptoms develop. Case conferences between GPs and specialist palliative care services may be warranted for palliative care patients.

Mental illness and hospitalization for ambulatory care sensitive medical conditions.

Abstract: Background:Hospitalization due to ambulatory care sensitive (ACS) medical conditions is widely used as an indicator of poor primary care access and effectiveness. It is unknown whether patients with mental disorders have higher ACS admission rate, compared with patients without mental disorders.Obje

Veterans Health Administration primary care-mental health integration initiative.

Abstract: he Veterans Health Administration has undertaken a large national initiative to integrate primary care and mental health services. A request for proposals was disseminated throughout the Veterans Affairs (VA) system inviting proposals for new programs to promote the effective treatment of common mental health and substance use disorders in the primary care environment. Both individual facilities and Veterans Integrated Service Networks (VISNs) were eligible to apply, and proposals could encompass activities at one or multiple VA facilities. Similarly, facilities within VISNs were free to use different evidence-based models for delivering integrated care. Program funding commenced during fiscal year 2007 (FY07). The overarching rationale for the initiative is to integrate care for veterans’ physical and mental health conditions, improve access and quality of care across the spectrum of illness severity, and allow treatment in mental health specialty settings to focus on persons with more severe mental illnesses. The report of the President’s New Freedom Commission on Mental Health emphasizes that mental health and physical health problems are interrelated components of overall health and are best treated in a coordinated care system. 1 That recognition also is embedded in the VA’s Mental Health Strategic Plan and its goal to “[d]evelop a collaborative care model for mental health disorders that elevates mental health care to the same level of urgency/intervention as medical health care.” 2

Do 'alternative' help-seeking strategies affect primary care service use? A survey of help-seeking for mental distress.

Abstract: Epidemiological studies suggest that only some distressed individuals seek help from primary care and that pathways to mental health care appear to be ethnically patterned. However few research studies examine how people with common mental disorder manage their mental distress, which help-seeking strategies they employ and whether these are patterned by ethnicity? This study investigates alternative help-seeking strategies in a multi-ethnic community and examines the relationship with primary care use. Participants were recruited from four GP practice registers and 14 community groups in East London. Of 268 participants, 117 had a common mental disorder according to a valid and structured interview schedule (CIS-R). Participants were of Bangladeshi, black Caribbean and White British ethnic background. For those with a common mental disorder, we examined self-reported help-seeking behaviour, perceived helpfulness of care givers, and associations with primary care service use. We found that alternative help-seeking such as talking to family about distress (OR 15.83, CI 3.9–64.5, P < .001), utilising traditional healers (OR 8.79, CI 1.98–38.93, p = .004), and severity of distress (1.11, CI 1.03–1.20, p = .006) was positively associated with primary care service use for people with a common mental disorder. Ethnic background influenced the choice of help-seeking strategies, but was less important in perceptions of their helpfulness. Primary care service use was strongly correlated with lay and community help-seeking. Alternative help-seeking was commonly employed in all ethnic groups. A large number of people believed mental distress could not be resolved or they did not know how to resolve it. The implications for health promotion and integrated care pathways are discussed.

Integrated care for co-occurring disorders: psychiatric symptoms, social functioning, and service costs at 18 months.

Abstract: Objective: Persons with severe mental illness have high rates of comorbid substance use disorders. These co-occurring disorders present a significant challenge to community mental health services, and few clinical trials are available to guide the development of effective services for this population. The study aimed to evaluate the effectiveness of a program for case managers that trained them to manage substance use disorders among persons with severe mental illness. Methods: A clusterrandomized controlled trial design was used in South London to allocate case managers either to training or to a waiting list control condition. Outcomes and service costs (health care and criminal justice) over 18 months of 127 patients treated by 40 case managers who received training were compared with those of 105 patients treated by 39 case managers in the control condition. Results: Brief Psychiatric Rating Scale scores for the intervention group indicated significant improvements in psychotic and general psychopathology symptoms. Participants in the intervention group also reported fewer needs for care at follow-up. No significant differences were found between the two groups in levels of substance use at 18 months. At follow-up both groups reported increased satisfaction with care. Service costs were also similar for the two groups. Conclusions: Compared with standard care, integrated treatment for co-occurring disorders provided by nonspecialist mental health staff produced significant improvements in symptoms and level of met needs, but not in substance use or quality of life, at no additional cost. (Psychiatric Services 59:276–282, 2008)

Office-based maintenance treatment of opioid dependence: how does it compare with traditional approaches?

Abstract: The increasing global public health burden of heroin dependence and prescription opioid dependence warrants further expansion of treatment models. The most effective intervention for opioid dependence remains maintenance with methadone, a full μ-opioid receptor agonist, or buprenorphine, a partial μ-opioid receptor agonist. A growing body of evidence supports the use of opioid receptor agonist maintenance in office-based settings. Office-based opioid treatment (OBOT) can expand treatment access in a less stigmatized environment, which enables integrated care of co-morbid conditions. The current review primarily examines OBOT in the US, although a comparison with the British and French models is provided, given that the public health impact and implementation of OBOT will likely vary between countries because of policy and logistical differences. The comparative effectiveness of maintenance treatment in office-based and traditional programme-based models of care requires further study. Clinical and practical considerations when providing treatment for opioid dependence in traditional versus office-based settings include patient selection and monitoring, health economics, management of co-morbid conditions, and access to ancillary psychosocial treatment. OBOT is not a replacement for more structured, traditional models of care, but provides an additional opportunity to help address the tremendous public health impact of opioid dependence.

A cost effectiveness study of integrated care in health services delivery: a diabetes program in Australia

Abstract: Type 2 diabetes is rapidly growing as a proportion of the disease burden in Australia as elsewhere. This study addresses the cost effectiveness of an integrated approach to assisting general practitioners (GPs) with diabetes management. This approach uses a centralized database of clinical data of an Australian Division of General Practice (a network of GPs) to co-ordinate care according to national guidelines.

The organizing vision of integrated health information systems

Abstract: The notion of ‘integration’ in the context of health information systems is ill-defi ned yet in widespread use. We identify a variety of meanings ranging from the purely technical integration of information systems to the integration of services. This ambiguity (or interpretive fl exibility), we argue, is inherent rather than accidental: it is a necessary prerequisite for mobilizing political and ideological support among stakeholders for integrated health information systems. Building on this, our aim is to trace out the career dynamics of the vision of ‘integration/ integrated’. The career dynamics is the transformation of both the imaginary and the material (technological) realizations of the unfolding implementation of the vision of integrated care. Empirically we draw on a large, ongoing project at the University Hospital of North Norway (UNN) to establish an integrated health information system.

The positive effect of integrated care on depressive symptoms in stroke survivors.

Abstract: Background: Depressive symptoms occur in approximately one-third of stroke patients. We sought to evaluate whether an integrated model of stroke care and secondary prevention reduce

Pain management: a review of organisation models with integrated processes for the management of pain in adult cancer patients.

Abstract: Aims and objectives:?This paper reports a review of the literature conducted to identify organisation models in cancer pain management that contain integrated care processes and describe their effectiveness. Background:?Pain is experienced by 30–50% of cancer patients receiving treatment and by 70–90% of those with advanced disease. Efforts to improve pain management have been made through the development and dissemination of clinical guidelines. Early improvements in pain management were focussed on just one or two single processes such as pain assessment and patient education. Little is known about organisational models with multiple integrated processes throughout the course of the disease trajectory and concerning all stages of the care process. Design:?Systematic review. Method:?The review involved a systematic search of the literature, published between 1986–2006. Subject-specific keywords used to describe patients, disease, pain management interventions and integrated care processes, relevant for this review were selected using the thesaurus of the databases. Conclusion:?Institutional models, clinical pathways and consultation services are three alternative models for the integration of care processes in cancer pain management. A clinical pathway is a comprehensive institutionalisation model, whereas a pain consultation service is a ‘stand-alone’ model that can be integrated in a clinical pathway. Positive patient and process outcomes have been described for all three models, although the level of evidence is generally low. Evaluation of the quality of pain management must involve standardised measurements of both patient and process outcomes. Relevance to clinical practice:?We recommend the development of policies for referrals to a pain consultation service. These policies can be integrated within a clinical pathway. To evaluate the effectiveness of pain management models standardised outcome measures are needed.

Gastroenterologists' attitudes and self-reported practices regarding inflammatory bowel disease.

Abstract: Background The purpose was to assess organization-, physician-, and patient-based aspects of inflammatory bowel disease (IBD) practice variation within an integrated care delivery system and the extent to which physicians are interested in adopting a chronic care model and/or nurse assistance to manage IBD patients. Methods As part of an observational cohort study to understand variation in IBD care and outcomes, we conducted semistructured, open-ended interviews with 17 gastroenterologists and 1 gastroenterology registered nurse at 6 clinics in an integrated care delivery system. Interviews were taperecorded and transcribed. We coded and analyzed transcripts using standard qualitative methods. Results Physicians reported a range of attitudes and practices regarding IBD. Analysis showed differences in 3 domains and 8 subdomains: 1) patient education and choices, including health education and patient use of complementary and alternative medicine; 2) decisions about diagnosis and treatment, including practice guidelines, conferring with colleagues, using infliximab, and medical hospitalization; and 3) organizational aspects of care, including primary care involvement with IBD and MD attitudes toward ancillary support. Conclusions Standardized algorithms on care for IBD patients do not exist, but opportunities may exist to improve IBD care by: having initial work-ups and management of patients in remission in primary care; creating and maintaining opportunities for gastroenterologists to confer with colleagues and acknowledged local experts; and having nurse coordination for medications and labs and/or some type of specialty IBD clinic for high-need patients. This research highlights the need for more directed comparative efficacy and effectiveness trials that will serve to define preferred treatment strategies.

Organizational change to transfer knowledge and improve quality and outcomes of care for patients with severe mental illness: a systematic overview of reviews.

Abstract: OBJECTIVE: To provide a comprehensive overview of the research on organizational changes aimed at improving health care for patients with severe mental illness and to learn lessons for mental health practice from the results. METHOD: We searched for systematic literature reviews published in English during 2000 to 2007 in PubMed, PsycINFO, CINAHL, EMBASE, and the Cochrane Central Register of Systematic Reviews. Three reviewers independently selected and assessed the studies' quality. Studies involving changes of who delivers health care, how care is organized, or where care is delivered were included. We categorized the studies using an existing taxonomy of 6 broad categories of strategies for organizational change. RESULTS: A total of 21 reviews were included. Among these, 17 had reasonably good methodological quality, Almost all reviews included or intended to include randomized controlled trials (RCTs), 6 reviews did not identify studies that met eligibility criteria. Multidisciplinary teams and integrated care models had been reviewed most frequently (a total of 15 reviews). In most studies, these types of changes showed better outcomes in terms of symptom severity, functioning, employment, and housing, compared with conventional services. Different results were found on cost savings. Other types of organizational changes, such as changing professional roles or introducing quality management or knowledge management, were much less frequently reviewed. Very few reviews looked at effects of organizational changes on professional performance. CONCLUSIONS: There is a fairly large body of evidence of the positive impact of multidisciplinary teams and integrated care changes on symptom severity, functioning, employment, and housing of people with severe mental illness, compared with conventional services. Other strategies, such as changes in professional roles, quality or knowledge management, have either not been the subject of systematic reviews or have not been evaluated in RCTs. There is still a lack of insight in the so-called black box of change processes and the impact of change on professional performance.

Improving integrated general medical and mental health services in community-based practices.

Abstract: The historical fragmentation of physical and mental health services has impeded efforts to improve quality and outcomes of care for persons with mental disorders. However, there is little information on effective strategies that might reduce fragmentation and improve integrated services within non-academic, community-based healthcare settings. Twenty-three practices from across the U.S. participated in a learning community meeting designed to identify barriers to integrated care and strategies for reducing such barriers. Barriers were initially identified based on a quantitative survey of organizational factors. Focus groups were used to elaborate on barriers to integrated care and to identify strategies for reducing barriers that are feasible in community-based settings. Participants identified key barriers, including administrative (e.g., lack of common medical records for mental health and general medical conditions), financial (e.g., lack of reimbursement codes to bill for mental health and general medical care in the same setting), and clinical (e.g., lack of an integrated care protocol). Top strategies recommended by participants included templates (i.e., for memoranda of understanding) to allow providers to work across practice settings, increased medical record security to enable a common medical record between mental health and general medical care, working with state Medicaid agencies to establish integrated care reimbursement codes, and guidance in establishing workflows between different providers (i.e., avoid duplication of tasks). Strategies to overcome barriers to integrated care may require cooperation across different organizational levels, including administrators, providers, and health care payers in order for integrated care to be established and sustained over time.

A stepped care programme for depression management: an uncontrolled pre-post study in primary and secondary care in The Netherlands

Abstract: Introduction: Stepped care strategies are potentially effective to organise integrated care but unknown is whether they function well in practice. This paper evaluates the implementation of a stepped care programme for depression in primary care and secondary care. Theory and methods: We developed a stepped care algorithm for diagnostics and treatment of depression, supported by a liaison-consultation function. In a 2½ year study with pre-post design in a pilot region, adherence to the protocol was assessed by interviewing 28 caregivers of 235 patients with mild, moderate, or severe major depression. Consultation and referral patterns between primary and secondary care were analysed. Results: Adherence of general practitioners and consultant caregivers to the stepped care protocol proved to be 96%. The percentage of patients referred for depression to secondary care decreased significantly from 26% to 21% (p=0.0180). In the post-period more patients received treatment in primary care and requests for consultation became more concordant with the stepped care protocol. Conclusions: Implementation of a stepped care programme is feasible in a primary and secondary care setting and is associated with less referrals. Discussion: Further research on all subsequent treatment steps in a standardised stepped care protocol is needed.

Health informatics for older people: a review of ICT facilitated integrated care for older people

Abstract: Growing demands on welfare services, arising from expanding populations of older people in many countries, has led policy makers to consider the use of information and communications technologies (ICTs) as a means to transform the cost-effective delivery of health and social care. The evidence for these claims is examined by reporting the main findings of a review of worldwide published literature documenting the adoption of health informatics applications to improve health and social care for older people. It focuses around two dimensions of the UK government's programme for ‘modernising’ public services, which emphasise the use of ICTs to facilitate the sharing of health and social services information and its potential to foster person-centred approaches to independent living. Findings suggest that there is little evidence that these dimensions have been realised in practice and the perceived incompatibility between them is more likely to produce expensive and ineffective health informatics outcomes.

The need for integrating behavioral care in a college health center.

Abstract: Objective: A trend toward the integrated care model is evident in community primary medical care settings, where behavioral services are provided alongside medical services The present study explored the potential need for implementing an integrated care model at a Midwest University Health Center by investigating whether the use of two behavioral questionnaires influenced providers' prescription of psychotropic medications and referrals for behavioral intervention Design: Participants were randomly assigned to condition The 109 participants in the experimental condition completed two behavioral questionnaires and the 91 control participants received treatment as usual Main outcome measures: The behavioral questionnaires were the mental health-oriented Patient Health Questionnaire and the college-adjustment-oriented College Health Questionnaire Postvisit, all participants rated their satisfaction with treatment; providers documented psychotropic medication prescriptions, and behavioral treatment referrals Results: The experimental condition displayed significantly higher rates of discussion of behavioral problems and prescription of psychotropic medications but not referrals for behavioral treatment Patients in the experimental condition and all providers indicated a desire to use the questionnaires in future visits Conclusion: The findings suggest that increased awareness of behavioral problems influences treatment-decision making at a university health service, and therefore this setting would be fertile ground for implementation of an integrated care model