Measurement Characteristics of the Wraparound Fidelity Index Short Form: Results from a Statewide Implementation.

Implementation fidelity has been an important issue in the service provision and associated outcomes of Wraparound, an intensive, individualized care planning process that uses a team-based approach to integrate youth into the community to minimize the need for intensive, institutional services. In response to the growing need to monitor fidelity to the Wraparound process, a variety of instruments have been created and tested. In this study, the authors present the results of several analyses designed to better understand the measurement characteristics of the Wraparound Fidelity Index Short Form (WFI-EZ), a multi-informant fidelity instrument. The results from our analysis of 1027 WFI-EZ responses indicate that the internal consistency of the instrument is very good, although the negatively worded items did not appear to function as well as positively worded items. Results from two confirmatory factor analyses were unable to validate the original domains identified by the instrument developers, but for certain outcomes the WFI-EZ demonstrated deseriable predictive validity. Preliminary evidence is also provided that WFI-EZ responses likely differ by respondent type. We conclude by discussing the implications of using the WFI-EZ in programming, policy, and practice considering the findings of our study.

Applying a Social Ecological Model to Medical Legal Partnerships Practice and Research.

The social ecological model (SEM) is a conceptual framework that recognizes individuals function within multiple interactive systems and contextual environments that influence their health. Medical Legal Partnerships (MLPs) address the social determinants of health through partnerships between health providers and civil legal services. This paper explores how the conceptual framework of SEM can be applied to the MLP model, which also uses a multidimensional approach to address an individual's social determinants of health.

Patient empowerment: Its implementation and systems within hospitals in England and Greece.

INTRODUCTION: International health policies recognise patient empowerment, resulting in diverse empowerment models and systems. Research on organisational systems for implementing patient empowerment between countries or from organisational stakeholders' perspective, however, is limited. Aims and methodology: This paper explores and compares organisational systems and structures for patient empowerment implementation in six acute public hospitals in England and Greece (three in each country), their cross-case and cross-national similarities and differences. It uses a comparative, qualitative, explanatory embedded case study design. Semi-structured interviews with a representative sample of stakeholders (n = 33) and documentary sources (n = 79) were analysed with framework. RESULTS: Two main patient empowerment themes were identified: (1) organisational leadership, systems, structures; (2) operational structures, services, mechanisms and activities. Generic organisational systems and structures for patient empowerment varied across-cases, but with common organisation of empowerment roles in England and common leadership in Greece. Operational structures, services and mechanisms supporting empowerment varied across-cases and cross-nationally, but with similarities in the main services. CONCLUSION: Implementation of patient empowerment was weaker in Greece than in England, attributable to differing approaches to strategic and operational leadership, limited development of strategies and influential organisational structures. Overall, patient empowerment is well-embedded in organisations with a highly visible patient empowerment profile; commitment to policies and strategy implementation at different levels; strategic and operational leadership investing in dedicated roles with clear authority for patient empowerment, influential empowerment structures and mechanisms.

A critical analysis of national policies, systems, and structures of patient empowerment in England and Greece.

BACKGROUND: Comparison of patient empowerment (PE) policies in European countries can provide evidence for improvement and reform across different health systems. It may also influence patient and public involvement, patient experience, preference, and adherence. OBJECTIVE: The objective of this study was to compare PE within national policies, systems, and structures in England and Greece for achieving integrated people-centered health services. METHODS: We performed a critical search and review of policy and legislation papers in English and Greek languages. This included 1) general health policy and systems papers, 2) PE, patient and/or public involvement or patients' rights policy and legislation (1990-2015), and 3) comparative or discussion papers for England and/or Greece. RESULTS: A total of 102 papers on PE policies, systems, and structures were identified initially; 80 papers were included, in which 46 were policy, legislative, and discussion papers about England, 21 were policy, legislation, and discussion papers about Greece, and 13 were comparative or discussion papers including both the countries. In England, National Health Service policies emphasized patient-centered services, involvement, and empowerment, with recent focus on patients' rights; while in Greece, they emphasized patients' rights and quality of services, with recent mentions on empowerment. The health ombudsman is a very important organization across countries; however, it may be more powerful in Greece, because of the nonexistence of local mediating bodies. Micro-structures at trusts/hospitals are comparable, but legislation gives more power to the local structures in Greece. CONCLUSION: PE policies and systems have been developed and expressed differently in these countries. However, PE similarities, comparable dimensions and mechanisms, were identified. For both the countries, comparative research and these findings could be beneficial in building connections and relationships, contributing to wider European and international developments on PE, involvement, and patients' rights and further impact on patient preferences and adherence.

Interprofessional Medical-Legal Education of Medical Students: Assessing the Benefits for Addressing Social Determinants of Health.

PROBLEM: Screening tools exist to help identify patient issues related to social determinants of health (SDH), but solutions to many of these problems remain elusive to health care providers as they require legal solutions. Interprofessional medical-legal education is essential to optimizing health care delivery. APPROACH: In 2011, the authors implemented a four-session didactic interprofessional curriculum on medical-legal practice for third-year medical students at Morehouse School of Medicine. This program, also attended by law students, focused on interprofessional collaboration to address client/patient SDH issues and health-harming legal needs. In 2011-2014, the medical students participated in pre- and postintervention surveys designed to determine their awareness of SDH's impact on health as well as their attitudes toward screening for SDH issues and incorporating resources, including a legal resource, to address them. Mean ratings were compared between pre- and postintervention respondent cohorts using independent-sample t tests. OUTCOMES: Of the 222 medical students who participated in the program, 102 (46%) completed the preintervention survey and 100 (45%) completed the postintervention survey. Postintervention survey results indicated that students self-reported an increased likelihood to screen patients for SDH issues and an increased likelihood to refer patients to a legal resource (P < .001). NEXT STEPS: Incorporating interprofessional medical-legal education into undergraduate medical education may result in an increased likelihood to screen patients for SDH and to refer patients with legal needs to a legal resource. In the future, an additional evaluation to assess the curriculum's long-term impact will be administered prior to graduation.

Do High Fidelity Wraparound Services for Youth with Serious Emotional Disturbances Save Money in the Long-Term?

BACKGROUND: Treating youth with serious emotional disturbances (SED) is expensive often requiring institutional care. A significant amount of recent federal and state funding has been dedicated to expanding home and community-based services for these youth as an alternative to institutional care. High Fidelity Wraparound (Wrap) is an evolving, evidence-informed practice to help sustain community-based placements for youth with an SED through the use of intensive, customized care coordination among parents, multiple child-serving agencies, and providers. While there is growing evidence on the benefits of Wrap, few studies have examined health care spending associated with Wrap participation and none have examined spending patterns after the completion of Wrap. Merging health care spending data from multiple agencies and programs allows for a more complete picture of the health care costs of treating these youth in a system-of-care framework. AIMS OF STUDY: (i) To compare overall health care spending for youth who transitioned from institutional care into Wrap (the treatment group) versus youth not receiving Wrap (the control group) and (ii) to compare changes in health care spending, overall and by category, for both groups before (the pre-period) and after (the post-period) Wrap participation. METHODS: The treatment group (N=161) is matched to the control group (N=324) temporally based on the month the youth entered institutional care. Both total health care spending and spending by category are compared for each group pre- and post-Wrap participation. The post-period includes the time in which the youth was receiving Wrap services and one year afterwards to capture long-term cost impacts. RESULTS: In the year before Wrap participation, the treatment group averaged USD 8,433 in monthly health care spending versus USD 4,599 for the control group. Wrap participation led to an additional reduction of USD 1,130 in monthly health care spending as compared to the control group in the post-period. For youth participating in Wrap, these spending reductions were the result of decreases in mental health inpatient spending and general outpatient spending. DISCUSSION: Youth participating in Wrap had much higher average monthly costs than youth in the control group for the year prior to entering Wrap, suggesting that the intervention targeted youth with the highest mental health utilization and likely more complex needs. While both groups experienced reductions in spending, the treatment group experienced larger absolute reductions, but smaller relative reductions associated with participation. These differences were driven mainly by reductions in mental health inpatient spending. Larger reductions in general outpatient spending for the treatment group suggest spillover benefits in terms of physical health care spending. Further analysis is needed to assess how these spending changes impacted health outcomes. IMPLICATIONS FOR HEALTH POLICIES: Wrap or similar programs may lead to reductions in health care spending. This is the first study to find evidence of longer-term spending reductions for up to a year after Wrap participation. IMPLICATIONS FOR FURTHER RESEARCH: Randomized trials or some other source of plausibly exogenous variation in Wrap participation is needed to further assess the causal impact of Wrap on health care spending, outcomes, or broader system-of-care spending.

Empowerment in nurse leader groups in middle management: a quantitative comparative investigation.

AIMS AND OBJECTIVES: The aim was to investigate structural empowerment in nurse leaders in middle management positions. Objectives were to determine levels of empowerment of nurse leaders and to compare levels of empowerment between nurse leader groups. BACKGROUND: Access to formal and informal power, opportunity, resources, information and support are determinants of structural empowerment. Empowerment of nurse leaders in middle management positions is vital given their roles in enabling nursing teams to deliver high-quality care, benefitting both patient and workforce outcomes. DESIGN: Quantitative component of a mixed methods study using survey principles. METHODS: The Conditions of Work Effectiveness Questionnaire II was distributed to the total population (n = 517) of nurse leaders in an NHS Foundation Trust in England. Nurse leader groups comprised unit leaders (sisters, matrons) and senior staff nurses. Quantitative data entered on spss v 17/18, were analysed using descriptive and inferential statistics. RESULTS: Overall, the unit response rate was 44·1% (n = 228). Levels of total and global empowerment were moderate and moderate to high respectively. Groups did not differ significantly on these parameters or on five elements of total empowerment, but significantly higher scores were found for unit leaders' access to information. Significantly higher scores were found for senior staff nurses on selected aspects of informal power and access to resources, but scores were significantly lower than unit leaders for components of support. CONCLUSIONS: A moderately empowered population of nurse leaders differed in relation to access to information, aspects of support, resources and informal power, reflecting differences in roles, spheres of responsibility, hierarchical position and the constraints on empowerment imposed on unit leaders by financial and resource pressures. RELEVANCE TO CLINICAL PRACTICE: Empowerment of nurse leaders in middle management is vital in enabling nursing teams to deliver high-quality care. Roles, spheres of responsibility, hierarchical position and constraints imposed by financial and resource pressures influence nurse leader empowerment. Administrative support is needed to sustain practice engagement.

Mind how you cross the gap! Outcomes for young people who failed to make the transition from child to adult services: the TRACK study.

Aims and method The Transitions of Care from Child and Adolescent Mental Health Services to Adult Mental Health Services (TRACK) study was a multistage, multicentre study of adolescents' transitions between child and adult mental health services undertaken in England. We conducted a secondary analysis of the TRACK study data to investigate healthcare provision for young people (n = 64) with ongoing mental health needs, who were not transferred from child and adolescent mental health services (CAMHS) to adult mental health services mental health services (AMHS). Results The most common outcomes were discharge to a general practitioner (GP; n = 29) and ongoing care with CAMHS (n = 13), with little indication of use of third-sector organisations. Most of these young people had emotional/neurotic disorders (n = 31, 48.4%) and neurodevelopmental disorders (n = 15, 23.4%). Clinical implications GPs and CAMHS are left with the responsibility for the continuing care of young people for whom no adult mental health service could be identified. GPs may not be able to offer the skilled ongoing care that these young people need. Equally, the inability to move them decreases the capacity of CAMHS to respond to new referrals and may leave some young people with only minimal support.

Defining continuity of care from the perspectives of mental health service users and professionals: an exploratory, comparative study.

BACKGROUND: Continuity of care (COC) is central to the organization and delivery of mental health services. Traditional definitions have excluded service users, and this lack of involvement has been linked to poor conceptual clarity surrounding the term. Consequently, very little is known about the differences and similarities in the conceptualization of COC by mental health service users and professionals. OBJECTIVE: To explore and compare mental health service users' and professionals' definitions of COC. METHODS: Using an exploratory, qualitative design, five focus groups with 32 service users each met twice. Data were analysed thematically to generate a service user-defined model of COC. In a cross-sectional survey, health and social care professionals (n = 184) defined COC; responses were analysed thematically. Service user and professional definitions were conceptually mapped and compared to identify similarities and differences. RESULTS: There was crossover between the service user and professional derived models of COC. Both contained temporal, quality, systemic, staff, hospital and needs-related elements of COC. Service users prioritized access, information, peer support and avoiding services; health professionals most frequently referred to staff, cross-sectional and temporal COC. Service users alone identified service avoidance, peer support and day centres as COC elements; professionals alone identified cross-sectional working. CONCLUSIONS: Important similarities and differences exist in service user and professional conceptualizations of COC. Further research is necessary to explore these differences, prior to integrating service user and professional perspectives in a validated COC framework which could enable the development and evaluation of interventions to improve COC, informing policy and practice.

An evaluation of a specialist nursing service for adult patients with congenital heart disease.

The purpose of this study was to evaluate grown-up congenital heart (GUCH) patients' experiences and satisfaction with the delivery of a nurse specialist service, including perceived priorities and recommendations for future service delivery. A service evaluation utilizing descriptive, cross-sectional survey principles was conducted over a 2 year period. Postal questionnaires were sent to three patient cohorts (general adult n = 747; pregnancy n = 202; learning disability n = 72). Quantitative data were analysed using descriptive statistics. The majority of respondents were satisfied with the nursing care provided, including information provision, time made available to discuss needs, emotional support, well-being, self-management and symptom distress. Priority areas included timely information and advice; specialist knowledge and expertise; effective care coordination, monitoring and support. Accessibility, contact and responsiveness were dominant. A majority of patients agreed that their first, second and third-rated priorities had been met. Findings identified strong commitment, support and satisfaction with the GUCH nurse specialist service.

Examining the potential of information technology to improve public insurance application processes: enrollee assessments from a concurrent mixed method analysis.

OBJECTIVE: To assess the perceived readiness of Medicaid and Children's Health Insurance Program (CHIP) enrollees to use information technologies (IT) in order to facilitate improvements in the application processes for these public insurance programs. METHODS: We conducted a concurrent mixed method study of Medicaid and CHIP enrollees in a southern state. We conducted focus groups to identify enrollee concerns regarding the current application process and their IT proficiency. Additionally, we surveyed beneficiaries via telephone about their access to and use of the Internet, and willingness to adopt IT-enabled processes. 2013 households completed the survey. We used χ(2) analysis for comparisons across different groups of respondents. RESULTS: A majority of enrollees will embrace IT-enabled enrollment, but a small yet significant group continues to lack access to facilitating technologies. Moreover, a segment of beneficiaries in the two programs continues to place a high value on personal interactions with program caseworkers. DISCUSSION: IT holds the promise of improving efficiency and reducing barriers for enrollees, but state and federal agencies managing public insurance programs need to ensure access to traditional processes and make caseworkers available to those who require and value such assistance, even after implementing IT-enabled processes. CONCLUSIONS: The use of IT-enabled processes is essential for effectively managing eligibility and enrollment determinations for public programs and private plans offered through state or federally operated exchanges. However, state and federal officials should be cognizant of the technological readiness of recipients and provide offline help to ensure broad participation in the insurance market.

The effect of organisational resources and eligibility issues on transition from child and adolescent to adult mental health services.

OBJECTIVES: To investigate the organisational factors that impede or facilitate transition of young people from child and adolescent (CAMHS) to adult mental health services (AMHS). METHODS: Thirty-four semi-structured interviews were conducted with health and social care professionals working in child and adult services in four English NHS Mental Health Trusts and voluntary organisations. Data were analysed thematically using a structured framework. RESULTS: Findings revealed a lack of clarity on service availability and the operation of different eligibility criteria between child and adult mental health services, with variable service provision for young people with attention deficit hyperactivity disorder, autism spectrum disorders and learning disabilities. High workloads and staff shortages were perceived to influence service thresholds and eligibility criteria. CONCLUSIONS: A mutual lack of understanding of services and structures together with restrictive eligibility criteria exacerbated by perceived lack of resources can impact negatively on the transition between CAMHS and AMHS, disrupting continuity of care for young people.

Development of an assessment tool for the multidisciplinary evaluation of neurological dependency: preliminary findings.

BACKGROUND: Multidisciplinary inputs are of vital importance in the comprehensive care management and rehabilitation of individuals with long-term neurological conditions. Although many ordinal measures of disability correlate with patient dependency and care, few are based on numbers of different health professionals required, or their skill-mix, for assistance associated with levels of dependency. AIM AND OBJECTIVES: To develop an instrument to assess dependency in adult patients suffering from severe and complex neurological disability for use by multidisciplinary teams. Objectives were to establish content validity, construct validity, inter-rater reliability and internal consistency, and to demonstrate preliminary clinical utility from the perspective of professional staff. DESIGN AND METHODS: A mixed methods design utilised qualitative and quantitative approaches. Stage I involved developmental fieldwork using focus groups (n = 3), questionnaires (n = 70), expert panel (n = 20) and direct observation (n = 12). In stage 2, intensive refinement through direct observation, construct validity and reliability testing (n = 100) of the instrument was completed. The research complied with the research governance and ethical standards set by the Department of Health (UK). RESULTS: In the final format, an instrument was developed which comprised two sections. Section 1: an ordinal scaled basic care section, with 15 categories of dependency and level of descriptors based on numbers, grade and time taken by staff providing assistance. Factor analysis identified one dominant and four subsidiary factors which explained 67% of the total variance. Overall inter-rater agreement was 0.87 (kappa coefficient: range 0.67-1.0), and Cronbach's coefficient alpha was 0.733. Section 2: comprised a nominally measured specialist care section for inputs from nurses and therapists. The mean time taken to complete assessments was 12 minutes. CONCLUSION: The instrument satisfied preliminary selective criteria for validity and reliability. Further research is necessary to satisfy other requirements of psychometric testing and clinical utility.

'Talking a different language': an exploration of the influence of organizational cultures and working practices on transition from child to adult mental health services.

BACKGROUND: Organizational culture is manifest in patterns of behaviour underpinned by beliefs, values, attitudes and assumptions, which can influence working practices. Cultural factors and working practices have been suggested to influence the transition of young people moving from child to adult mental health services. Failure to manage and integrate transitional care effectively can lead to young people losing contact with health and social care systems, resulting in adverse effects on health, well-being and potential. METHODS: The study aim was to identify the organisational factors which facilitate or impede transition of young people from child and adolescent mental health services (CAMHS) to adult mental health services (AMHS) from the perspective of health professionals and representatives of voluntary organisations. Specific objectives were (i) to explore organizational cultures, structures, processes and resources which influence transition from child to adult mental health services; (ii) identify factors which constitute barriers and facilitators to transition and continuity of care and (iii) make recommendations for service improvements. Within an exploratory, qualitative design thirty four semi-structured interviews were conducted with health and social care professionals working in CAMHS and AMHS in four NHS Mental Health Trusts and four voluntary organizations, in England. RESULTS: A cultural divide appears to exist between CAMHS and AMHS, characterized by different beliefs, attitudes, mutual misperceptions and a lack of understanding of different service structures. This is exacerbated by working practices relating to communication and information transfer which could impact negatively on transition, relational, informational and cross boundary continuity of care. There is also evidence of a cultural shift, with some positive approaches to collaborative working across services and agencies, involving joint posts, parallel working, shared clinics and joint meetings. CONCLUSIONS: Cultural factors embodied in mutual misperceptions, attitudes, beliefs exist between CAMHS and AMHS. Working practices can exert either positive or negative effects on transition and continuity of care. Implementation of shared education and training, standardised approaches to record keeping and information transfer, supported by compatible IT resources are recommended, alongside management strategies which evaluate the achievement of outcomes related to transition and continuity of care.

Can access to a medical-legal partnership benefit patients with asthma who live in an urban community?

Approximately one in 10 children in the U.S. has a diagnosis of asthma. African American and low-income children are more likely to be diagnosed with asthma. They are more likely to suffer the worse outcomes because of low socioeconomic status and environmental exposures. A medical-legal partnership is an interdisciplinary collaboration between a medical entity such as a hospital or clinic and a legal entity such as a lawyer, law school, or legal aid society created to address barriers to health care access and limitations to well-being. Addressing the legal concerns of these patients can improve access to medical services, reduce family stress, and address legal concerns that contribute to poor health. The Health Law Partnership (HeLP) is one such medical-legal partnership that provides a holistic, interdisciplinary approach to health care. During the seven-year study period we found both financial ($501,209) and non-financial benefits attributable to interventions by the attorneys at HeLP.

Clinical leadership for high-quality care: developing future ward leaders.

AIM: This paper reports upon the development, delivery and evaluation of a leadership programme for aspiring Ward Leaders in one National Health Service Trust in England. BACKGROUND: The ward sister role is fundamental to quality patient care and clinical leadership, however the role is increasingly difficult to recruit to. A lack of formal preparation and skills development for the role has been widely acknowledged. METHOD: An evaluation of a programme of education for leadership. Three cohorts (n = 60) completed the programme. Semi-structured questionnaires were completed by participants (n = 36: 60%) at the conclusion of the programme. Qualitative data from questionnaires was analysed using a thematic approach. RESULTS: Participants reported increased political, organizational and self-awareness, increased confidence, feelings of empowerment and the ability to empower others. Opportunities for networking with peers were valued within the action learning approach. For some participants, career intentions were clarified through reflection. CONCLUSION: The majority of participants had benefited from the leadership programme and valued this development as an empowering preparation for future careers. IMPLICATIONS FOR NURSING MANAGEMENT: Investment in leadership preparation for future ward sister roles is strongly recommended as part of a strategy designed to enhance quality improvement, career path development, workforce empowerment and retention.

Continuity of care for carers of people with severe mental illness: results of a longitudinal study.

INTRODUCTION: Continuity of care has been demonstrated to be important for service users and carer groups have voiced major concerns over disruptions of care. We aimed to assess the experienced continuity of care in carers of patients with both psychotic and non-psychotic disorders and explore its association with carer characteristics and psychological well-being. METHODS: Friends and relatives caring for two groups of service users in the care of community mental health teams (CMHTs), 69 with psychotic and 38 with non-psychotic disorders, were assessed annually at three and two time points, respectively. CONTINUES, a measure specifically designed to assess continuity of care for carers themselves, was utilized along with assessments of psychological well-being and caregiving. RESULTS: One hundred and seven carers participated. They reported moderately low continuity of care. Only 22 had had a carer's assessment and just under a third recorded psychological distress on the GHQ. For those caring for people with psychotic disorders, reported continuity was higher if the carer was male, employed, lived with the user and had had a carer's assessment; for those caring for people with non-psychotic disorders, it was higher if the carer was from the service user's immediate family, lived with them and had had a carer's assessment. CONCLUSION: The vast majority of the carers had not had a carer's assessment provided by the CMHT despite this being a clear national priority and being an intervention with obvious potential to increase carers' reported low levels of continuity of care. Improving continuity of contact with carers may have an important part to play in the overall improvement of care in this patient group and deserves greater attention.

Continuity of care for people with psychotic illness: its relationship to clinical and social functioning.

BACKGROUND: The relationship between continuity of care and user characteristics or outcomes has rarely been explored. The ECHO study operationalized and tested a multi-axial definition of continuity of care, producing a seven-factor model used here. AIMS: To assess the relationship between user characteristics and established components of continuity of care, and the impact of continuity on clinical and social functioning. METHODS: The sample comprised 180 community mental health team users with psychotic disorders who were interviewed at three annual time-points, to assess their experiences of continuity of care and clinical and social functioning. Scores on seven continuity factors were tested for association with user-level variables. RESULTS: Improvement in quality of life was associated with better Experience & Relationship continuity scores (better user-rated continuity and therapeutic relationship) and with lower Meeting Needs continuity factor scores. Higher Meeting Needs scores were associated with a decrease in symptoms. CONCLUSION: Continuity is a dynamic process, influenced significantly by care structures and organizational change.

Pan-London tuberculosis services: a service evaluation.

BACKGROUND: London has the largest proportion of tuberculosis (TB) cases of any western European capital, with almost half of new cases drug-resistant. Prevalence varies considerably between and within boroughs with research suggesting inadequate control of TB transmission in London. Economic pressures may exacerbate the already considerable challenges for service organisation and delivery within this context. This paper presents selected findings from an evaluation of London's TB services' organisation, delivery, professional workforce and skill mix, intended to support development of a strategic framework for a pan-London TB service. These may also interest health service professionals and managers in TB services in the UK, other European cities and countries and in services currently delivered by multiple providers operating independently. METHODS: Objectives were: 1) To establish how London's TB services are structured and delivered in relation to leadership, management, organisation and delivery, coordination, staffing and support; 2) To identify tools/models for calculating skill mix as a basis for identifying skill mix requirements in delivering TB services across London; 3) To inform a strategic framework for the delivery of a pan-London TB service, which may be applicable to other European cities. The multi-method service audit evaluation comprised documentary analysis, semi-structured interviews with TB service users (n = 10), lead TB health professionals and managers (n = 13) representing London's five sectors and focus groups with TB nurses (n = 8) and non-London network professionals (n = 2). RESULTS: Findings showed TB services to be mainly hospital-based, with fewer community-based services. Documentary analysis and professionals' interviews suggested difficulties with early access to services, low suspicion index amongst some GPs and restricted referral routes. Interviews indicated lack of managed accommodation for difficult to treat patients, professional workforce shortages, a need for strategic leadership, nurse-led clinics and structured career paths for TB nurses and few social care/outreach workers to support patients with complex needs. CONCLUSIONS: This paper has identified key issues relating to London's TB services' organisation, delivery, professional workforce and skill mix. The majority of these present challenges which need to be addressed as part of the future development of a strategic framework for a pan-London TB service. More consistent strategic planning/co-ordination and sharing of best practice is needed, together with a review of pan-London TB workforce development strategy, encompassing changing professional roles, skills development needs and patient pathways. These findings may be relevant with the development of TB services in other European cities.

Understanding service user-defined continuity of care and its relationship to health and social measures: a cross-sectional study.

BACKGROUND: Despite the importance of continuity of care [COC] in contemporary mental health service provision, COC lacks a clearly agreed definition. Furthermore, whilst there is broad agreement that definitions should include service users' experiences, little is known about this. This paper aims to explore a new construct of service user-defined COC and its relationship to a range of health and social outcomes. METHODS: In a cross sectional study design, 167 people who experience psychosis participated in structured interviews, including a service user-generated COC measure (CONTINU-UM) and health and social assessments. Constructs underlying CONTINU-UM were explored using factor analysis in order to understand service user-defined COC. The relationships between the total/factor CONTINU-UM scores and the health and social measures were then explored through linear regression and an examination of quartile results in order to assess whether service user-defined COC is related to outcome. RESULTS: Service user-defined COC is underpinned by three sub-constructs: preconditions, staff-related continuity and care contacts, although internal consistency of some sub-scales was low. High COC as assessed via CONTINU-UM, including preconditions and staff-related COC, was related to having needs met and better therapeutic alliances. Preconditions for COC were additionally related to symptoms and quality of life. COC was unrelated to empowerment and care contacts unrelated to outcomes. Service users who had experienced a hospital admission experienced higher levels of COC. A minority of service users with the poorest continuity of care also had high BPRS scores and poor quality of life. CONCLUSIONS: Service-user defined continuity of care is a measurable construct underpinned by three sub-constructs (preconditions, staff-related and care contacts). COC and its sub-constructs demonstrate a range of relationships with health and social measures. Clinicians have an important role to play in supporting service users to navigate the complexities of the mental health system. Having experienced a hospital admission does not necessarily disrupt the flow of care. Further research is needed to test whether increasing service user-defined COC can improve clinical outcomes. Using CONTINU-UM will allow researchers to assess service users' experiences of COC based on the elements that are important from their perspective.