Whole person care: Outcomes from a 5-year care model integrating primary care into a behavioral health clinic.

INTRODUCTION: Integrated mental and physical health care has the potential to improve health outcomes. A behavioral health organization established a reverse integration program site using a co-located model to provide primary care services to patients receiving behavioral health services. We ask whether this model of co-located care was effective in improving a range of physical health outcomes for clients. This program was funded with a grant from the Substance Abuse and Mental Health Services Administration Primary and Behavioral Health Care Integration. METHOD: Patients received services in a community mental health setting that embedded primary care services. The population included adult patients with mental illness, substance use disorder (SUD), or co-occurring medical diagnoses in an urban setting. Just under half of the patients identified as non-White, and over one quarter identified as Hispanic. These characteristics demonstrate a medically complex and underserved population. This description and exploratory analysis utilized National Outcome Measures data and clinical health measures from electronic health records. We stratified data by SUD and mental illness diagnoses. We measured changes in health outcomes for this complex population of 532 patients from 2015 to 2019. RESULTS: From enrollment to last visit, patient outcomes improved for blood pressure and cholesterol. Conversely, waist circumference and breath carbon monoxide levels significantly worsened. DISCUSSION: This reverse integration co-location program demonstrates that positive health outcomes can be achieved through evidence-based care, adaptable clinic arrangements, and robust community connections and support. More work is needed to generate positive health outcomes in medically complex patients. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

"I just need to be with my family": resettlement experiences of asylum seeker and refugee survivors of torture.

A global migration of individuals fleeing persecution, violence and armed conflict reached almost 60 million world-wide in 2015. This world-wide crisis of displacement reflects people seeking safety across borders and oceans; dangerous journeys that compound the trauma endured by these women, men and children. Refugees/asylum seekers face barriers upon entry to the U.S. The Western New York Center for Survivors (WNYCST) provides care coordination/trauma-informed care to mitigate these challenges. The objective of this study was to explore the resettlement experiences of survivors of torture living in Western New York, who had received services from the WNYCST; identifying challenges, unmet needs, and services that were helpful. Secondarily, we describe the experiences of asylum seekers and legally resettled refugees, who due to their differing legal status, might be expected to have different experiences. Data were collected using semi-structured qualitative interviews. RESULTS: Three themes emerged: mental health challenges, relating to their experiences in their home country and their separation from family; unmet needs, including lack of a sense of purpose and meaning, difficulty navigating services, and missing connections to community; and coping strategies, including WNYCST assistance with connecting with sources of social support in their new community. WNYCST services were helpful, particularly the assistance and connection with care coordinators and local support groups. This care and outreach helped to mitigate feelings of separation and apartness from their home countries and families. CONCLUSIONS: Some refugees/asylum seekers continue to struggle with unmet needs, issues of loss and isolation. If care providers recognize signs of stress early, appropriate interventions can be implemented. Care connections and trauma informed treatment with an emphasis on recreating ties with communities, may be one important factor in ensuring successful integration.

Uniting Public Health and Primary Care for Healthy Communities in the COVID-19 Era and Beyond.

The Coronavirus disease 2019 (COVID-19) pandemic has laid bare the dis-integrated health care system in the United States. Decades of inattention and dwindling support for public health, coupled with declining access to primary care medical services have left many vulnerable communities without adequate COVID-19 response and recovery capacity. "Health is a Community Affair" is a 1966 effort to build and deploy local communities of solution that align public health, primary care, and community organizations to identify health care problem sheds, and activate local asset sheds. After decades of independent effort, the COVID-19 pandemic offers an opportunity to reunite and align the shared goals of public health and primary care. Imagine how different things might look if we had widely implemented the recommendations from the 1966 report? The ideas and concepts laid out in "Health is a Community Affair" still offer a COVID-19 response and recovery approach. By bringing public health and primary care together in community now, a future that includes a shared vision and combined effort may emerge.

Mental Health and Illness.

Circumstances forcing individuals and families to flee set the stage for disruptions in mental health and forge resilience. Individual characteristics and conditions premigration, perimigration, and postmigration influence health, mental health, care-seeking behavior, and stages of well-being and successful resettlement. Primary care providers have strategies to promote mental well-being, including focusing on resilience and social determinants of health. Integrated or collaborative care models are ideal for delivering optimum care for refugee and immigrant communities. Connecting primary and behavioral care promotes a team approach; provides comprehensive, whole-person care; and relies on participation of patients and families.

Barriers to the use of trained interpreters in consultations with refugees in four resettlement countries: a qualitative analysis using normalisation process theory.

BACKGROUND: Increasing numbers of primary care practitioners in refugee resettlement countries are providing care to refugees. Access to trained interpreters is a priority for these practitioners, but there are many barriers to the implementation of interpreted consultations in routine care. There is a lack of international, theoretically informed research. The purpose of this paper is to understand barriers to interpreter use in primary care consultations in four resettlement countries using Normalisation Process Theory. METHOD: We conducted a cross-sectional online survey with networks of primary care practitioners (PCPs) who care for refugees in Australia, Canada, Ireland and the US (n = 314). We analysed qualitative data from the survey about barriers to interpreter use (n = 178). We completed an inductive thematic analysis, iteratively developed a Normalisation Process Theory (NPT)-informed coding frame and then mapped the emergent findings onto the theory's construct about enacting interpreted consultations. RESULTS: In all four countries, the use of an interpreter presented communication and interaction challenges between providers and patients, which can impede the goals of primary care consultations. Primary care practitioners did not always have confidence in interpreted consultations and described poor professional practice by some interpreters. There was variation across countries, and inconsistency within countries, in the availability of trained interpreters and funding sources. CONCLUSION: There are shared and differential barriers to implementation of interpreted consultations in a consistent and sustained way in the four countries studied. These findings can be used to inform country-specific and international level policies and interventions focusing on improving skills and resources for interpreted consultations to improve implementation of interpreted primary care consultations.

Adolescent Substance Use and Misuse: Recognition and Management.

Adolescent use of illicit substances imposes an enormous burden on individuals, families, and communities. The types of illicit substances adolescents are using have changed drastically over the past decade with decreases in alcohol use (including binge alcohol use) offset by increases in electronic cigarette, marijuana, and opioid use. Primary care physicians have the opportunity to identify adolescents who use illicit substances. The U.S. Preventive Services Task Force and the American Academy of Family Physicians found insufficient evidence to assess the balance of benefits and harms of primary care-based behavioral interventions to prevent or reduce illicit substance use or nonmedical pharmaceutical use in children or adolescents. The American Academy of Pediatrics recommends that clinicians become familiar with Screening, Brief Intervention, and Referral to Treatment initiatives. Validated screening tools that may be used in primary care include the CRAFFT, POSIT, AUDIT, and NIAAA Screening Guide. During the clinical visit, a split-visit model encourages parents to participate in the visit for a limited time but also allows adolescents to have confidential conversations with physicians. Evidence-based treatment modalities range from school- and parent-based interventions to medication-assisted treatment. Brief interventions using components of motivational interviewing may be suitable for addressing substance use, even among adolescents not seeking treatment. Prevention efforts can supplement cessation programs to maximize program effectiveness.

Strengthening effective preventive services for refugee populations: toward communities of solution.

Refugee populations have unequal access to primary care and may not receive appropriate health screening or preventive service recommendations. They encounter numerous health care disadvantages as a consequence of low-income status, race and ethnicity, lower educational achievement, varying degrees of health literacy, and limited English proficiency. Refugees may not initially embrace the concept of preventive care, as these services may have been unavailable in their countries of origin, or may not be congruent with their beliefs on health care. Effective interventions in primary care include the appropriate use of culturally and linguistically trained interpreters for health care visits and use of evidence-based guidelines. Effective approaches for the delivery of preventive health and wellness services require community engagement and collaborations between public health and primary care. In order to provide optimal preventive and longitudinal screening services for refugees, policies and practice should be guided by unimpeded access to robust primary care systems. These systems should implement evidence-based guidelines, comprehensive health coverage, and evaluation of process and preventive care outcomes.

Changing Places: Where Will We Be with Our Patients? A Perspective from the Keystone IV Conference.

Dr. Stephens knew a lot about place-his place within family medicine and the place of family medicine as a catalyst for change in our communities. In "G. Gayle Stephen's Festschrift," the evolution of our profession is mirrored by Dr. Stephen's seminal contributions to practice and service to his discipline. He describes our place as healers, teachers, scholars, builders, moral agents, professionals, and reformers. Stephen's place-changing career and ethos pave the way for our place as advocates for our patients and change agents for family medicine in this newest millennium.

Recognition and Differential Diagnosis of Psychosis in Primary Care.

Psychosis is a symptom complex that may include hallucinations, delusions, disorders of thought, and disorganized speech or behavior. Acute psychosis is primary if it is symptomatic of a psychiatric disorder, or secondary if caused by a specific medical condition. Patients with primary psychiatric disorders are likely to have auditory hallucinations, prominent cognitive disorders, and complicated delusions. If psychosis is caused by a medical condition, the patient may exhibit cognitive changes and abnormal vital signs, and may have visual hallucinations. Illicit drug use is the most common medical cause of acute psychosis. Clinicians should ask about recent head injury or trauma, seizures, cerebrovascular disease, or new or worsening headaches. A subacute onset of psychosis should raise suspicion for an oncologic cause. Collateral history from family members is helpful in establishing the presentation and course of the illness. The physical examination should include complete neurologic and mental status assessments. Tachycardia or severe hypertension may indicate drug toxicity or thyrotoxicosis; fever may suggest encephalitis or porphyria. Suggested initial laboratory tests include a complete blood count, metabolic profile, thyroid function tests, urine toxicology, and measurement of parathyroid hormone, calcium, vitamin B12, folate, and niacin. Testing for human immunodeficiency virus infection and syphilis should also be considered. Prompt recognition of the etiology of psychosis may improve treatment, consultation, and prognosis.

Engaging Immigrant and Refugee Women in Breast Health Education.

This project assessed the impact of a community-based educational program on breast cancer knowledge and screening among Buffalo (NY) immigrant and refugee females. Program participants completed language-matched pre- and post-test assessments during a single session educational program; breast cancer screening information was obtained from the mobile mammography unit to which participants were referred. Pre- and post-test knowledge scores were compared to assess changes in responses to each of the six individual knowledge items, as well as overall. Mammogram records were reviewed to identify Breast Imaging Reporting and Data System (BI-RADS) scores. The proportion of correct responses to each of the six knowledge items increased significantly on the post-program assessments; 33 % of women >40 years old completed mammograms. The findings suggest that a health education program for immigrant and refugee women, delivered in community-based settings and involving interpreters, can enhance breast cancer knowledge and lead to improvements in mammography completion.

Communities of solution: partnerships for population health.

Communities of solution (COSs) are the key principle for improving population health. The 1967 Folsom Report explains that the COS concept arose from the recognition that complex political and administrative structures often hinder problem solving by creating barriers to communication and compromise. A 2012 reexamination of the Folsom Report resurrects the idea of the COS and presents 13 grand challenges that define the critical links among community, public health, and primary care and call for ongoing demonstrations of COSs grounded in patient-centered care. In this issue, examples of COSs from around the country demonstrate core principles and propose visions of the future. Essential themes of each COS are the crossing of "jurisdictional boundaries," community-led or -oriented initiatives, measurement of outcomes, and creating durable connections with public health.

Family practice enhancements for patients with severe mental illness.

Individuals with severe mental health disorders experience difficulty maneuvering the complexity encountered in primary care (PC). This study describes the impact of three components of primary care practice enhancements on: changes in missed appointments, changes in health outcomes, number of ER visits and hospitalization days, and perceptions of integrated care. Missed PC appointments: baseline to post practice enhancement changed from 42 to 11, statistically significant (p < .01). Changes in health outcomes: SF-12 scores had no significant change nor did ER utilization and hospitalization; however, outcomes are low-base rate and assessment period was short. Integration of care: liaison was most helpful in accessing and navigating PC, educating and reconciling medication lists. Behavioral health staff voiced relief regarding access and felt better informed. Strategies focusing on increasing communication, staff education, and reducing barriers to access and receipt of PC may improve integration and continuity of care.

Bipolar disorder is common in depressed primary care patients.

OBJECTIVE: To examine the prevalence and treatment of typical and subsyndromal bipolar disorder (BD) in depressed primary care patients. METHODS: Patients with a diagnosis of a mood disorder being treated with antidepressants in 2 academic family practice clinics underwent a structured diagnostic interview (Mini International Neuropsychiatric Inventory) for manic and hypomanic symptoms. RESULTS: Of 58 patients evaluated, 19% met full criteria for bipolar I disorder and 8.6% for bipolar II disorder; 31% had subsyndromal BD (ie, persistent elation or irritability accompanied by additional symptoms of hypomania but not enough symptoms to meet full criteria for bipolar I or II disorder). Only 5 patients with BD were receiving mood stabilizers, which had not been instituted in any patient by the primary care physician. CONCLUSIONS: The high prevalence of patients meeting full criteria for BD and the low rate of identification of BD in primary care patients are consistent with estimates using self-administered questionnaires, but the interview revealed a substantial additional population that could be considered to have subsyndromal BD. Because subsyndromal forms of BD are associated with significant impairment and comorbidity as well as progression to frank BD, recognition of both full and subthreshold BD in primary care practice should be improved.

The research mentoring relationship in family medicine: findings from the grant generating project.

BACKGROUND AND OBJECTIVES: Mentoring has been acknowledged as a critical factor in the development of family medicine academicians. Specific aims were to describe the research mentoring in family medicine from the experience of both mentors and protégés and identify characteristics that mentors and protégés associated with a successful mentoring relationship. The Grant Generating Project (GGP) Fellowship, a training and mentoring program for family medicine researchers, provided a natural opportunity to study these issues and better understand what is successful in research mentoring. METHODS: Separate mentor and protégés surveys measured perceptions about the extent of mentoring assistance, perceived relationship success, costs and benefits of the relationship, and the nature and duration of the relationship. Correlations between demographic characteristics and the mentoring relationship were also examined. RESULTS: Mentors were generally professors (78%), male (82%), with a mean age of 53 years, while protégés were assistant professors (53%) and almost evenly divided between male (51%) and female (49%) with mean age of 44 years. Both mentors and protégés describe the mentoring relationship in general to be of benefit to both mentor and protégé. Nonetheless, statistically significant differences between mentor-protégé responses were found for nine of the 20 survey items. Mentors tended to give higher values in their ratings of specific mentor-protégé relationship variables. Significant positive correlations were found between benefit, quality of the relationship, and mentoring assistance and the number of hours per month of mentor-protégé interaction, the number of mentor-protégé meetings per month, and the number of months the mentor worked with the protégé. Mentor-protégé acquaintance before the GGP fellowship was significantly correlated with cost, benefit, and mentoring assistance. CONCLUSIONS: This study shows agreement between mentor and protégé regarding the mentors' ability to promote the protégés, provide important technical skills, convey respect for the protégés, and serve as a friend and role model. Protégés tend to be more connected with their colleagues and with their profession, perhaps in part because the mentoring relationship facilitates networking opportunities provided by the mentor. In particular, excellent mentors can provide protégés with opportunities to meet other influential scholars at conferences and/or through various forms of correspondence. Such relationships can be helpful to the protégé in developing a constellation of mentoring relationships that may result in more successful research careers. Future studies should examine the relationship upon various outcomes.

Issues important to the research mentoring relationship.

BACKGROUND AND OBJECTIVES: Family medicine lacks a critical mass of experienced, federally funded researchers to serve as research mentors for young investigators. The purpose of this study was to identify issues important when mentoring junior investigators. METHODS: Eight experienced primary care investigators, known for their excellence in mentorship, were recruited from the Primary Care Research Methods and Statistics Conference. After participation in a focus group exploring issues related to the quality, techniques, effectiveness, and efficiency of mentorship, subjects completed three rounds of Delphi using variables identified during the focus group to develop a comprehensive, stable list of 72 mentoring strategies. RESULTS: Five items received perfect ratings of agreement: (1) primary task to help protégé identify long-term goals and strategize to meet them, (2) difference exists between mentoring and collaboration, (3) assigning mentor is not a guarantee that the relationship will work, (4) mentor can provide expertise and encouragement but not ensure a desired outcome, and (5) mentor who does not care about the protégé is not likely to be effective. The strategies with which the mentors disagreed included mentor-protégé characteristics and differences. CONCLUSIONS: Mentors emphasized the importance of long-term goals, difference between mentorship and collaboration, and commitment from the mentor.

A randomized trial: are care navigators effective in connecting patients to primary care after psychiatric crisis?

Persons with serious mental illnesses suffer excess medical morbidity compared to the general population. This RCT aimed to determine whether navigators are effective in helping patients connect to primary care after psychiatric crisis. Adults presenting for emergency care were randomly assigned to a navigator versus usual care. Navigators facilitated access to primary care. Outcomes were connection rates to medical care and the impact of health insurance, hospitalization and mental health care on primary care attendance. After 1 year, the intervention group was statistically more likely to access care, versus controls (62.4 vs. 37.6%, P < .001). Navigators were effective in helping patients connect to primary care after a psychiatric crisis. Improved access to primary care is important given the complex chronic health problems of this vulnerable cohort.

How patients view primary care: differences by minority status after psychiatric emergency.

BACKGROUND: Patients' race or ethnic background may affect their ability to access health care due to their socioeconomic status, hereditary predispositions to illnesses, or discrimination either perceived or actual by those providing health care. For patients with mental health disorders, additional barriers are created due to poor experiences with the health care system. METHODS: This was a mixed methods randomized control study examining the effectiveness of care managers linking patients to primary care after psychiatric crisis. The aim reported in this paper was to analyze differences by minority status in patients' quantitative and qualitative responses before and after facilitation to primary care (N=85). Patients responded to a "patient enablement" and primary care index assessing their feelings of empowerment after a primary care visit; and to qualitative questions about their experiences and perceptions of care. FINDINGS: Following a primary care visit, responses by minority and non-minority individuals did not differ significantly on either the patient enablement or primary care index score. On qualitative inquiry, both non-minorities and minorities reported positive and negative views of their health, with corresponding positive and negative health experiences. DISCUSSION: In sum, there were no differences in patient enablement between the minority and non-minority subgroups over the course of the study, nor were there any changes in patient's perception of their relationship with healthcare providers. However, this cohort found primary care services less satisfactory than a general population without mental illness. Patients with psychiatric disorders experience stigmatization in their attempts to access health care. This stigma may have a greater impact than race and ethnicity, thereby leading to a similarity in perception of health care between minorities and non-minorities with mental illness.

Adolescent substance use and abuse: recognition and management.

Substance abuse in adolescents is undertreated in the United States. Family physicians are well positioned to recognize substance use in their patients and to take steps to address the issue before use escalates. Comorbid mental disorders among adolescents with substance abuse include depression, anxiety, conduct disorder, and attention-deficit/ hyperactivity disorder. Office-, home-, and school-based drug testing is not routinely recommended. Screening tools for adolescent substance abuse include the CRAFFT questionnaire. Family therapy is crucial in the management of adolescent substance use disorders. Although family physicians may be able to treat adolescents with substance use disorders in the office setting, it is often necessary and prudent to refer patients to one or more appropriate consultants who specialize specifically in substance use disorders, psychology, or psychiatry. Treatment options include anticipatory guidance, brief therapeutic counseling, school-based drug-counseling programs, outpatient substance abuse clinics, day treatment programs, and inpatient and residential programs. Working within community and family contexts, family physicians can activate and oversee the system of professionals and treatment components necessary for optimal management of substance misuse in adolescents.