Mechanisms underpinning effective peer support: a qualitative analysis of interactions between expert peers and patients newly-diagnosed with bipolar disorder.

BACKGROUND: The increasing burden on mental health services has led to the growing use of peer support in psychological interventions. Four theoretical mechanisms have been proposed to underpin effective peer support: advice grounded in experiential knowledge, social support, social comparison and the helper therapy principle. However, there has been a lack of studies examining whether these mechanisms are also evident in clinical populations in which interpersonal dysfunction is common, such as bipolar disorder. METHOD: This qualitative study, conducted alongside a randomized controlled trial, examined whether the four mechanisms proposed to underpin effective peer support were expressed in the email exchange between 44 individuals newly-diagnosed with bipolar disorder and their Informed Supporters (n = 4), over the course of a supported online psychoeducation program for bipolar disorder. A total of 104 text segments were extracted and coded. The data were complemented by face-to-face interviews with three of the four Informed Supporters who participated in the study. RESULTS: Qualitative analyses of the email interchange and interview transcripts revealed rich examples of all four mechanisms. The data illustrated how the involvement of Informed Supporters resulted in numerous benefits for the newly-diagnosed individuals, including the provision of practical strategies for illness management as well as emotional support throughout the intervention. The Informed Supporters encouraged the development of positive relationships with mental health services, and acted as role models for treatment adherence. The Informed Supporters themselves reported gaining a number of benefits from helping, including a greater sense of connectedness with the mental health system, as well as a broader knowledge of illness management strategies. CONCLUSIONS: Examples of the mechanisms underpinning effective peer support were found in the sample of emails from individuals with newly-diagnosed bipolar disorder and their Informed Supporters. Experiential knowledge, social support, social comparison and helper therapy were apparent, even within a clinical population for whom relationship difficulties are common. Trial registration number ACTRN12608000411347.

Multidisciplinary Team Care Arrangements in the management of patients with chronic disease in Australian general practice.

OBJECTIVE: To explore factors associated with the frequency of multidisciplinary Team Care Arrangements (TCAs) and the impact of TCAs on patient-assessed quality of care in Australian general practice. DESIGN AND SETTING: Data were collected as part of a cluster randomised controlled trial conducted in 60 general practices in New South Wales, the Australian Capital Territory and Victoria between July 2006 and June 2008. Multilevel logistic regression analysis evaluated factors associated with the frequency of TCAs recorded in the 12 months after baseline, and multilevel multivariable analysis examined the association between TCAs and patient-assessed quality of chronic illness care, adjusted for patient and practice characteristics. MAIN OUTCOME MEASURES: Frequency of TCAs; Patient Assessment of Chronic Illness Care (PACIC) scores. RESULTS: Of 1752 patients with clinical audit data available at 12-month follow-up, 398 (22.7%) had a TCA put in place since baseline. Women, patients with two or more chronic conditions, and patients from metropolitan areas had an increased probability of having a TCA. There was an association between TCAs and practices with solo general practitioners and those with greater levels of teamwork involving non-GP staff for the control group but not the intervention group. Patients who had a TCA self-assessed their quality of care (measured by PACIC scores) to be higher than those who did not. CONCLUSIONS: Findings were consistent with the purpose of TCAs--to provide multidisciplinary care for patients with longer-term complex conditions. Significant barriers to TCA use remain, especially in rural areas and for men, and these may be more challenging to overcome in larger practices.

A tool to measure whether business management capacity in general practice impacts on the quality of chronic illness care.

Our aim was to develop a tool to identify specific features of the business and financial management of practices that facilitate better quality care for chronic illness in primary care. Domains of management were identified, resulting in the development of a structured interview tool that was administered in 97 primary care practices in Australia. Interview items were screened and subjected to factor analysis, subscales identified and the overall model fit determined. The instrument's validity was assessed against another measure of quality of care. Analysis provided a four-factor solution containing 21 items, which explained 42.5% of the variance in the total scores. The factors related to administrative processes, human resources, marketing analysis and business development. All scores increased significantly with practice size. The business development subscale and total score were higher for rural practices. There was a significant correlation between the business development subscale and quality of care. The indicators of business and financial management in the final tool appear to be useful predictors of the quality of care. The instrument may help inform policy regarding the structure of general practice and implementation of a systems approach to chronic illness care. It can provide information to practices about areas for further development.

Systematic care for asthma in Australian general practice: a randomised controlled trial.

OBJECTIVE: To evaluate whether systematic asthma care involving a register-recall system, postcard prompts for review, and education for general practitioners and staff in Australian general practice improves the quality of care and health outcomes for adult patients with moderate to severe asthma. DESIGN AND SETTING: Cluster randomised controlled trial in 40 general practices in urban and rural South Australia and New South Wales over the 2 years 2004 and 2005; practices were randomly allocated to the intervention or control group. PARTICIPANTS: 565 adult patients of these randomly allocated practices who had doctor-diagnosed moderate to severe asthma and were taking inhaled corticosteroids. MAIN OUTCOME MEASURES: Clinical asthma indicators, quality of care, acceptability of the intervention to patients, quality of life, and asthma self-management skills at baseline, 6 months and 12 months. RESULTS: Although 46% of patients in the intervention group practices responded to the postcard prompts, only 32% actually attended for their asthma review. At 12 months, there was a statistically significant difference in provision of written asthma action plans (rate ratio, 1.9; 95% CI, 1.0-3.5; P = 0.04) for intervention group patients compared with control group patients; there was no significant difference in other indicators. CONCLUSION: We found little objective evidence of improvement in patient management and outcomes resulting from a systematic model of asthma care. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ACTRN12605000091606.

Medical assistants: a primary care workforce solution?

BACKGROUND: A new medical assistant training program has been developed as an innovative solution to the workforce pressures facing general practice in Australia. OBJECTIVE: This article describes the development and implementation of the Australian medical assistant role and training program, and discusses key lessons learned in the 4 years after the first medical assistants were trained. DISCUSSION: Medical assistants are trained to carry out delegated administrative and clinical assisting duties specific to the ambulatory care environment. Lessons learned thus far from the introduction of this national qualification include the need to consult widely within the health care profession in the development of new roles, the imperative to bring together health and education sector expertise, the importance of flexible course delivery and the need for clearer role and boundaries definitions. The experience from the program implementation described in this article may help inform further primary care workforce development.

Defining internet-supported therapeutic interventions.

BACKGROUND: The field of Internet-supported therapeutic interventions has suffered from a lack of clarity and consistency. The absence of professional leadership and of accepted governing approaches, terminology, professional standards, and methodologies has caused this field to be diffused and unstructured. Numerous terms have been used to label and describe the activities conducted over the Internet for mental and physical health purposes: web-based therapy, e-therapy, cybertherapy, eHealth, e-Interventions, computer-mediated interventions, and online therapy (or counseling), among others. METHODS: Following a comprehensive review, we conceptualized Internet-supported interventions, using four categories based on prime practice approaches: web-based interventions, online counseling and therapy, Internet-operated therapeutic software, and other online activities (e.g., as supplements to face-to-face therapy). We provide a working definition and detailed description of each category, accompanied by numerous examples. CONCLUSIONS: These categories may now serve as guiding definitions and related terminologies for further research and development in this emerging field.

Chronic Care Team Profile: a brief tool to measure the structure and function of chronic care teams in general practice.

AIM: At a time when workforce shortages in general practices are leading to greater role substitution and skill-mix diversification, and the demand on general practices for chronic disease care is increasing, the structure and function of the general practice team is taking on heightened importance. To assist general practices and the organizations supporting them to assess the effectiveness of their chronic care teamworking, we developed an interview tool, the Chronic Care Team Profile (CCTP), to measure the structure and function of teams in general practice. This paper describes its properties and potential use. METHOD: An initial pool of items was derived from guidelines of best-practice for chronic disease care and performance standards for general practices. The items covered staffing, skill-mix, job descriptions and roles, training, protocols and procedures within the practice. The 41-item pool was factor analysed, retained items were measured for internal consistency and the reduced instrument's face, content and construct validity were evaluated. RESULTS: A three-factor solution corresponding to non-general practitioner staff roles in chronic care, administrative functions and management structures provided the best fit to the data and explained 45% of the variance in the CCTP. Further analyses suggested that the CCTP is reliable, valid and has some utility. DISCUSSION: The CCTP measures aspects of the structure and function of general practices which are independent of team processes. It is associated with the job satisfaction of general practice staff and the quality of care provided to patients with chronic illnesses. As such, the CCTP offers a simple and useful tool for general practices to assess their teamworking in chronic disease care.

What happens after diagnosis? Understanding the experiences of patients with newly-diagnosed bipolar disorder.

UNLABELLED: Bipolar disorder is chronic condition involving episodes of both depression and elevated mood, associated with significant disability and high relapse rates. Recent estimates suggest a lifetime prevalence of 5%. Little is known about the subjective experiences of patients after receiving a diagnosis of bipolar disorder, and the impact of these experiences on patients' willingness and ability to work with their health professionals to find the most effective combination of treatments and to set up self-management plans. OBJECTIVE: This paper describes a qualitative study exploring the experiences and difficulties faced by patients after they have received a diagnosis of bipolar disorder, as expressed online to expert patients trained to provide informed support. DESIGN: Qualitative study. SETTING: Online communication within a public health service setting. PARTICIPANTS: Twenty-six participants with recently-diagnosed bipolar disorder communicated online with 'Informed Supporters', people who had been managing their bipolar disorder effectively for 2 years or more, as part of an online psycho-education programme. RESULTS: Participants cited unwanted side-effects of medication, coping with unpleasant symptoms, positive and negative reactions to the diagnosis, identifying early warning signs and triggers of the illness, the loss of a sense of self, uncertainty about their future and stigma as issues of major importance after diagnosis. CONCLUSIONS: Personal concerns and difficulties following diagnosis can undermine effective treatment, thwart self-management efforts and interfere with effective functioning. Such data are important for clinicians to take into account when they work in partnership with their patients to fine-tune treatments and help them set up self-management plans.

Multidisciplinary care plans for diabetes: how are they used?

OBJECTIVE: To understand how multidisciplinary care plans are being used in the management of patients with diabetes, and to explore the role of collaboration in care planning. DESIGN: Grounded theory interview study. SETTING: Primary care, June 2005 to October 2006. PARTICIPANTS: Thirty-eight people from three New South Wales Divisions of General Practice: 19 general practitioners, eight diabetes-related allied health providers, two endocrinologists, and nine adults with type 2 diabetes. Sampling was purposeful then theoretical. RESULTS: GPs use care plans to organise clinical care and help patients access allied health providers. Written plans are used to educate patients about their care and to motivate change. GPs rarely discuss care plans with other providers, and providers are unlikely to change their approach to patients on the basis of care plans. Patients do not expect to participate in care planning. CONCLUSIONS: Care planning may increase evidence-based multidisciplinary care for patients with diabetes, but it rarely results in genuine collaboration between providers and patients. This suggests a difference may exist between Australian policymakers' and providers' definitions of patients with complex needs. Care plans could facilitate patient self-management by including more personalized information. Further research is needed to clarify which patients would benefit from a truly collaborative approach to their care.

How people with chronic illnesses view their care in general practice: a qualitative study.

OBJECTIVES: To explore the perceptions of patients with chronic conditions about the nature and quality of their care in general practice. DESIGN: Qualitative study using focus group methods conducted 1 June to 30 November 2002. PARTICIPANTS AND SETTING: 76 consumers in 12 focus groups in New South Wales and South Australia. MAIN OUTCOME MEASURES: Recurring issues and themes on care received in general practice. RESULTS: Three groups of priorities emerged. One centred on the quality of doctors, including technical competence, interpersonal skills, time for the patient in the consultation and continuity of care. A second concerned the role of patients and consumer organisations, with patients wanting (i) recognition of their knowledge about their condition and self-management, and (ii) for GPs to develop closer links with consumer organisations and inform patients about them. The third focused on the practice team and the importance of practice nurses and receptionists. CONCLUSION: GPs should consider the amount of time they spend with chronically ill patients, and their interpersonal skills and understanding of patients' needs. They need to be better informed about the benefits of patient self-management and consumer organisations, and to incorporate them into their care. They also need to review how their practice nurses and receptionists can maximise the care of patients.

Computer-based treatment for anxiety and depression: is it feasible? Is it effective?

The rise of consumerism, escalating levels of technological change and increasing demand for better dissemination of psychological treatments signal a transformation in the treatment of mental health problems. Soon health care consumers will have a choice as to whether they wish to consult a clinician in his/her rooms in order to receive a diagnosis, treatment and support, or instead to receive these services electronically, or a combination of both. Some of the online services currently available include structured therapy programs, psychological treatment by email, real-time online counselling, professionally assisted chat rooms, self-help groups, health information and educational modules. This paper reviews the use of computer programs in mental health care and, in particular, for the treatment of anxiety and depression. Issues of feasibility, ethics, and effectiveness are discussed and the future of computer-based treatment programs in mental health is considered.