No longer 'flying blind': how access has changed emergency mental health care in rural and remote emergency departments, a qualitative study.

BACKGROUND: Mental health presentations are considered to be a difficult aspect of emergency care. Although emergency department (ED) staff is qualified to provide emergency mental health care, for some, such presentations pose a challenge to their training, confidence, and time. Providing access to relevant and responsive specialist mental health care can influence care and management for these patients. The Mental Health Emergency Care-Rural Access Program (MHEC-RAP) is a telepsychiatry program that was established to improve access to specialist emergency mental health care across rural and remote western NSW, Australia. METHOD: This study uses interviews with ED providers to understand their experience of managing emergency mental health patients and their use of MHEC-RAP. The lens of access was applied to assess program impact and inform continuing program development. RESULTS: With MHEC-RAP, these ED providers are no longer 'flying blind'. They are also more confident to manage and care for emergency mental health patients locally. For these providers, access to specialists who are able to conduct assessments and provide relevant and responsive advice for emergency mental health presentations was valued. Assessing the fit between the consumer and service as a requirement for the development, evaluation, and ongoing management of the service should result in decisions about design and delivery that achieve improved access to care and meet the needs of their consumers. The experience of these providers prior to MHEC-RAP is consistent with that reported in other rural and remote populations suggesting that MHEC-RAP could address limitations in access to specialist care and change the provision of emergency mental health care elsewhere. CONCLUSION: MHEC-RAP has not only provided access to specialist mental health care for local ED providers, but it has changed their practice and perspective. MHEC-RAP could be adapted for implementation elsewhere. Provider experience confirms that the program is accessible and offers insights to those considering how to establish an emergency telepyschiatry service in other settings.

Activating patients with chronic disease for self-management: comparison of self-managing patients with those managing by frequent readmissions to hospital.

Understanding the factors that activate people to self-manage chronic disease is important in improving uptake levels. If the many frequent hospital users who present with acute exacerbations of chronic disease were to self-manage at home, some hospital admissions would be avoided. Patient interview and demographic, psychological, clinical and service utilisation data were compared for two groups of patients with chronic disease: those attending self-management services and those who managed by using hospital services. Data were analysed to see whether there were differences that might explain the two different approaches to managing their conditions. The two groups were similar in terms of comorbidity, age, sex, home services, home support and educational level. Self-managing patients were activated by their clinician, accepted their disease, changed their identity, confronted emotions and learnt the skills to self-manage and avoid hospital. Patients who frequently used hospital services to manage their chronic disease were often in denial about their chronic disease, hung on to their identity and expressed little emotional response. However, they reported a stronger sense of coherence and rated their health more highly than self-managing patients. This study shed light on the process of patient activation for self-management. A better understanding of the process of patient activation would encourage clinicians who come into contact with frequently readmitted chronic disease patients to be more proactive in supporting self-management.

What distinguishes clinicians who better support patients for chronic disease self-management?

Many frequent readmissions due to acute exacerbations of chronic disease could be prevented if patients self-managed. This study explored factors involved in patient activation for chronic disease self-management by qualitative analysis of interview data from hospital and community-based clinicians and patients. All clinicians reported that many frequently readmitted patients did not readily take up referral to chronic disease self-management services. This reluctance was compounded by system or access barriers. Clinicians who had a defined role in chronic disease management and patient-centred and behaviour change skills reported that although some patients were more resistant than others, patients could be persuaded to adopt self-management behaviours. Hospital clinicians and GPs were more inclined to attribute blame to clinical, social and personal patient factors, such as difficulty with support at home, social circumstances and reluctance to take responsibility. Investment in extending the skills and role of hospital clinicians and GPs to take a more supportive role in patient uptake of referrals to chronic disease self-management services would reduce hospital readmissions. Improvements in access to chronic disease self-management and GP services are also needed to address failure to take up chronic disease self-management.

Unplanned return visits to emergency in a regional hospital.

OBJECTIVE: The aim of this study was to determine the patient characteristics associated with unplanned return visits, using routinely collected hospital data, to assist in developing strategies to reduce their occurrence. METHODS: Emergency department data from a regional hospital were analysed using univariate and multivariate methods to determine the influence of clinical, service usage and demographic patient characteristics on unplanned return visits. RESULTS: Around 80% of the 16000 patients attending emergency presented on only one occasion in a year. Five per cent of patients presented with an unplanned return visit. Older patients, those with minor and low urgency conditions and with non-psychotic mental health conditions, those presenting during winter and after hours were significantly more likely to present as unplanned return visits. CONCLUSION: Although patient characteristics associated with unplanned return visits have been identified, the reasons underpinning the unplanned return visit rate, such as patient service preference and attitudes, need to be more fully investigated.

Frequent emergency attenders: is there a better way?

BACKGROUND: Understanding the reasons for frequent re-attendances will assist in developing solutions to hospital overcrowding. This study aimed to identify the factors associated with frequent re-attendances in a regional hospital thereby highlighting possible solutions to the problem. METHODS: A retrospective analysis was performed on emergency department data from 2008. Frequent re-attenders were defined as those with four or more presentations in a year. Clinical, service usage and demographic patient characteristics were examined for their influence on re-presentations using multivariate analysis. RESULTS; A total of 8% of the total patients presenting to emergency re-attended four or more times in the year. Frequent re-attenders were older, presented with an unplanned returned visit and had a diagnosis of neurosis, chronic obstructive pulmonary disease (COPD), convulsions, dyspnoea or repeat prescriptions, follow-up examinations or dressings and sutures and less likely to present in summer. Frequent re-attendances were unrelated to sex, time of presentation or country of birth. CONCLUSIONS: Diversion of patients with minor conditions to alternative services; referral of COPD patients to follow-up respiratory services and patients with neurosis to community mental health services would reduce emergency utilisation. Improving access to and resourcing of alternative non-hospital services should be investigated to reduce emergency overcrowding.

Patient related factors in frequent readmissions: the influence of condition, access to services and patient choice.

BACKGROUND: People use emergency department services for a wide variety of health complaints, many of which could be handled outside hospitals. Many frequent readmissions are due to problems with chronic disease and are preventable. We postulated that patient related factors such as the type of condition, demographic factors, access to alternative services outside hospitals and patient preference for hospital or non-hospital services would influence readmissions for chronic disease. This study aimed to explore the link between frequent readmissions in chronic disease and these patient related factors. METHODS: A retrospective analysis was performed on emergency department data collected from a regional hospital in NSW Australia in 2008. Frequently readmitted patients were defined as those with three or more admissions in a year. Clinical, service usage and demographic patient characteristics were examined for their influence on readmissions using multivariate analysis. RESULTS: The emergency department received about 20,000 presentations a year involving some 16,000 patients. Most patients (80%) presented only once. In 2008 one hundred and forty four patients were readmitted three or more times in a year. About 20% of all presentations resulted in an admission. Frequently readmitted patients were more likely to be older, have an urgent Triage classification, present with an unplanned returned visit and have a diagnosis of neurosis, chronic obstructive pulmonary disease, dyspnoea or chronic heart failure. The chronic ambulatory care sensitive conditions were strongly associated with frequent readmissions. Frequent readmissions were unrelated to gender, time, day or season of presentation or country of birth. CONCLUSIONS: Multivariate analysis of routinely collected hospital data identified that the factors associated with frequent readmission include the type of condition, urgency, unplanned return visit and age. Interventions to improve patient uptake of chronic disease management services and improving the availability of alternative non-hospital services should reduce the readmission rate in chronic disease patients.

"Should I and can I?" A mixed methods study of clinician beliefs and attitudes in the management of lifestyle risk factors in primary health care.

BACKGROUND: Primary health care (PHC) clinicians have an important role to play in addressing lifestyle risk factors for chronic diseases. However they intervene only rarely, despite the opportunities that arise within their routine clinical practice. Beliefs and attitudes have been shown to be associated with risk factor management practices, but little is known about this for PHC clinicians working outside general practice. The aim of this study was to explore the beliefs and attitudes of PHC clinicians about incorporating lifestyle risk factor management into their routine care and to examine whether these varied according to their self reported level of risk factor management. METHODS: A cross sectional survey was undertaken with PHC clinicians (n = 59) in three community health teams. Clinicians' beliefs and attitudes were also explored through qualitative interviews with a purposeful sample of 22 clinicians from the teams. Mixed methods analysis was used to compare beliefs and attitudes for those with high and low levels of self reported risk factor management. RESULTS: Role congruence, perceived client acceptability, beliefs about capabilities, perceived effectiveness and clinicians' own lifestyle were key themes related to risk factor management practices. Those reporting high levels of risk factor screening and intervention had different beliefs and attitudes to those PHC clinicians who reported lower levels. CONCLUSION: PHC clinicians' level of involvement in risk factor management reflects their beliefs and attitudes about it. This provides insights into ways of intervening to improve the integration of behavioural risk factor management into routine practice.