The White River model of colocated collaborative care: A platform for mental and behavioral health care in the medical home.

In the past two decades a great deal of research has demonstrated improved quality of care when mental health care is integrated into primary care. To date, most of the literature has addressed care management for specific mental illnesses. Such programs can be difficult to implement and sustain. We describe a program of "Colocated Collaborative Care," implemented in 2004 that has been sustained and grown over the 6 years since inception. The Primary Mental Health Care clinic at the White River Junction (Vermont) Veterans Affairs Medical Center offers a full spectrum of mental health care that allows 75% of referred patients to receive all of their care within the primary care clinic, thus conserving scarce specialty services for the most complex patients. The clinic is staffed by a therapist and a psychiatrist (or advanced practice nurse) and complemented by care management and health psychology. It makes use of technology to streamline assessment and track outcomes. The clinic provides a mix of care management, specialty expertise and chronic disease management. Originally developed in a capitated health care system, adherence to general principles that guided its development may be useful in any system of care.

Low dose lignocaine added to propofol does not attenuate the response to electroconvulsive therapy.

BACKGROUND: The addition of small amounts of lignocaine (50 mg) to propofol (200 mg) has been previously shown to reduce pain in injection, a common problem with this particular anaesthetic agent. The aim of this study was to investigate whether using the mixture of propofol plus lignocaine had any adverse effects on ECT seizure expression (duration, and ictal quality). METHOD: Ictal EEG records were retrospectively examined in 29 patients who underwent 80 pairs of ECT treatments, one given with propofol alone and one with propofol plus lignocaine. Ictal quality was manually rated for the transition from the polyspike phase to the slow wave phase, amplitude of the mid-ictal spike-and-wave phase, regularity of morphology of the predominant pattern of the slow wave phase, stereotypy, variability of the morphology and amplitude of the slow wave phase and post-ictal suppression. RESULTS: There was no significant difference in seizure duration between the two groups (33.4+/-13.0 s (propofol) vs. 33.6+/-11.2 s (propofol plus lignocaine). Furthermore although the addition of lignocaine delayed the onset of the slow wave phase by about 1s, it resulted in an improvement in three of four of the other measures of ictal quality. CONCLUSION: The addition of a small dose of lignocaine to propofol during ECT treatment enhanced rather than reduced the quality of the seizures produced.

Access to what? An evaluation of the key ingredients to effective advanced mental health access at a VA medical center and its affiliated community-based outreach clinics.

Initial evaluation of an advanced access clinic developed at a VA medical center (VAMC) found decreased Mental Health wait times and improved quality of care for veterans with depression. Subsequently, modified advanced access models were implemented at affiliated community-based outreach clinics (CBOCs). By comparing each site, we sought to determine whether less resource-intensive models could improve care to the same degree. We assessed contributions of the model's components to the improvement of care (i.e., wait times and depression treatment adequacy). The modified advanced access models led to significant improvements, although no such improvements were seen at 2 control sites. Six features related to rapid access, short-term treatment, and barrier-free access to mental health services accounted for most of the observed improvements. CBOCs can implement limited advanced mental health access models and derive similar improvements to those seen in more extensive models at the VAMCs to which they are affiliated.