Staying Connected: Sustaining Collaborative Care Models with Limited Funding.

Providing psychiatric services in the primary care setting is challenging. The multidisciplinary, coordinated approach of collaborative care models (CCMs) addresses these challenges. The purpose of the current article is to discuss the implementation of a CCM at a free medical clinic (FMC) where volunteer staff provide the majority of services. Essential components of CCMs include (a) comprehensive screening and assessment, (b) shared development and communication of care plans among providers and the patient, and (c) care coordination and management. Challenges to implementing and sustaining a CCM at a FMC in Virginia attempting to meet the medical and psychiatric needs of the underserved are addressed. Although the CCM produced favorable outcomes, sustaining the model long-term presented many challenges. Strategies for addressing these challenges are discussed.

The Patient Protection and Affordable Care Act: impact on mental health services demand and provider availability.

The Patient Protection and Affordable Care Act (ACA) will greatly increase the demand for mental health (MH) services, as 62.5 million Americans from relatively high-need populations will be newly eligible for MH benefits. Consequently, the supply of MH care provider services is expected to proportionately decrease by 18% to 21% in 2014. ACA funding does not demonstrate the ability to increase turnout of psychiatrists sufficiently to meet the need. Available data indicate that the numbers of advanced practice psychiatric nurses (APPNs) continue to increase at a much greater rate, but information from either a clinical perspective or a market perspective is complicated by the weak distinctions that are made between nurse practitioners (NPs) and other nonphysician care professionals. The following recommendations are made: (a) some of the ACA funding for research into efficient and effective care delivery systems should be allocated to acquiring data on APPNs in leadership roles or clinical settings in which they are ultimately responsible for management of MH care, as differentiated from settings in which they provide support for psychiatrists; and (b) since the available data indicate nurse practitioners achieve good outcomes and are more economically viable than psychiatrists, placement of psychiatric-mental health nurse practitioners in community settings should be recognized as a realistic solution to the shortfall of MH services.

Evidence-based practice: a model for clinical application.

Health care reform authorized by the Affordable Care Act is based on the belief that evidence-based practice (EBP) generates cost savings due to the delivery of more effective care. Published meta-analyses and systematic reviews provide clear, unbiased evidence on the effectiveness of specific interventions. Yet translating the interventions into the practice setting requires additional clinical skills and judgments extending beyond the scientific assessment of the EBP literature. Effective use of EBP interventions requires clinicians effectively answering an additional set of questions specific to the case and clinical context. These questions focus on correctly identifying the problem and increased level of specificity for any given situation. Using a clinical application of the PICO model, the clinician and the patient should be able to achieve a higher level of clinical outcomes.

[Opening up psychiatric care]. / Vers une ouverture des soins en psychiatrie.

The post-war phase of the deinstitutionalisation of psychiatry, which led to the legal recognition of the sector, has been followed by the years of economic crisis. As in the past, such times favour the exclusion of the weakest. As resources dwindle, only the clinical meaning, the dynamism and creativity of the nursing teams can ensure the emergence of new solutions for complex care situations.

Effectiveness of psychiatric mental health nurses: can we save the core of the profession in an economically constrained world?

Mental and behavioral disorders are common, affecting more than 25% of all people at some time during their lives. Mental disorders and their burden on society have increased dramatically. This scenario can be an opportunity for psychiatric/mental health (P/MH) nurses. Some literature shows gratifying experiences of care delivered by P/MH nurses, but that can also be a threat if, in a world with an economic dominance such as ours, we are not able to clarify our identity and effectiveness. One implication of this is that we need to identify the contribution of nursing to patient outcomes through nurses' independent, dependent, and interdependent roles. The authors stressed the importance of improving our accountability and fighting against invisibility to policy makers to prioritize the nurse-client relationship and identify our effectiveness. Based on some literature, the authors argue that clinical nurse specialists are in a better position than nurse practitioners to produce nursing-sensitive outcomes.

The serious mental illness health improvement profile [HIP]: study protocol for a cluster randomised controlled trial.

BACKGROUND: The serious mental illness Health Improvement Profile [HIP] is a brief pragmatic tool, which enables mental health nurses to work together with patients to screen physical health and take evidence-based action when variables are identified to be at risk. Piloting has demonstrated clinical utility and acceptability. METHODS/DESIGN: A single blind parallel group cluster randomised controlled trial with secondary economic analysis and process observation. Unit of randomisation: mental health nurses [MHNs] working in adult community mental health teams across two NHS Trusts. SUBJECTS: Patients over 18 years with a diagnosis of schizophrenia, schizoaffective or bipolar disorder on the caseload of participating MHNs. PRIMARY OBJECTIVE: To determine the effects of the HIP programme on patients' physical wellbeing assessed by the physical component score of the Medical Outcome Study (MOS) 36 Item Short Form Health Survey version 2 [SF-36v2]. SECONDARY OBJECTIVES: To determine the effects of the HIP programme on: cost effectiveness, mental wellbeing, cardiovascular risk, physical health care attitudes and knowledge of MHNs and to determine the acceptability of the HIP Programme in the NHS. Consented nurses (and patients) will be randomised to receive the HIP Programme or treatment as usual. Outcomes will be measured at baseline and 12 months with a process observation after 12 months to include evaluation of patients' and professionals' experience and observation of any effect on care plans and primary-secondary care interface communication. Outcomes will be analysed on an intention-to-treat (ITT) basis. DISCUSSION: The results of the trial and process observation will provide information about the effectiveness of the HIP Programme in supporting MHNs to address physical comorbidity in serious mental illness. Given the current unacceptable prevalence of physical comorbidity and mortality in the serious mental illness population, it is hoped the HIP trial will provide a timely contribution to evidence on organisation and delivery of care for patients, clinicians and policy makers. ISRCTN: ISRCTN41137900.

Treatment and prevention of depression after surgery for hip fracture in older people: cost-effectiveness analysis.

OBJECTIVE: For older people who have had hip fracture surgery, to evaluate the cost-effectiveness of a nurse-led intervention in treating depression compared to treatment as usual (TAU), and to evaluate the cost-effectiveness of a psychological treatment for the prevention of depression. DESIGN: Two linked cost-effectiveness studies for the treatment and prevention of depression after hip surgery, from the perspective of health, social care, voluntary sector agencies and unpaid carers. SETTING: Orthopaedic units in Manchester, England. PARTICIPANTS: One hundred and twenty-one patients with Geriatric Depression Scale (GDS) scores greater than 6 were included in the treatment study and 172 patients with GDS scores less than or equal to 6 were enrolled in the prevention study. INTERVENTIONS: Nurse-led intervention for treating depression versus TAU; and cognitive behaviour therapy (CBT) for preventing depression following surgery for hip fracture. MAIN OUTCOME MEASURES: Outcomes were changes in HADS-depression scores at 6 weeks. Costs covered treatment and all service impacts. RESULTS: After 6 weeks, there were no significant differences in cost. However, the nurse-led intervention group had a lower mean HADS-depression score compared to TAU. In the prevention study, there were no significant differences in cost and depression score between patients treated with CBT and TAU. CONCLUSION: The results for this parallel randomized controlled study show that after hip fracture surgery a nurse-led intervention may be a cost-effective option for the treatment of depression in older people with depression. However CBT does not appear to be a cost-effective option for the prevention of depression in this population.

Decreasing the costs of constant observation.

A performance improvement project employed a bachelor's-prepared psychiatric liaison nurse (PLN) to reduce one-to-one (1:1) constant observation (CO) on all medical patient-care areas of a large, metropolitan hospital. The project succeeded in cutting the costs of CO in half. It showed that PLNs can safely facilitate large reductions in CO without associated increases in falls or restraint prevalence, yielding significant cost savings for hospitals.