Interdisciplinary Team Perspectives on Mental Health Care in VA Home-Based Primary Care: A Qualitative Study.

OBJECTIVES: This qualitative study describes the structure and processes of providing care to U.S. Department of Veterans Affairs (VA) Home-Based Primary Care (HBPC) enrollees with mental health care needs; explains the role of the HBPC psychologist; and describes how mental health treatment is integrated into care from the perspective of HBPC team members. DESIGN: HBPC programs were selected for in-person site visits based on initial surveys and low hospitalization rates. SETTING: Programs varied in setting, geographic locations, and primary care model. PARTICIPANTS: Eight site visits were completed. During visits, key informants including HBPC program directors, medical directors, team members, and other key staff involved with the HBPC program participated in semi-structured individual and group interviews. MEASUREMENTS: Recorded interviews, focus groups, and field observation notes. RESULTS: Qualitative thematic content analysis revealed four themes: 1) HBPC Veterans have not only complex physical needs but also co-occurring mental health needs; 2) the multi-faceted role of psychologists on HBPC teams, that includes providing care for Veterans and support for colleagues; 3) collaboration between medical and mental health providers as a means of caring for HBPC Veterans with mental health needs; and 4) gaps in providing mental health care on HBPC teams, primarily related to a lack of team psychiatrists and/or need for specialized medication management for psychiatric illness. CONCLUSIONS: Mental health providers are essential to HBPC teams. Given the significant mental health care needs of HBPC enrollees and the roles of HBPC mental health providers, HBPC teams should integrate both psychologists and consulting psychiatrists.

Impact of Nursing Home Palliative Care Teams on End-of-Life Outcomes: A Randomized Controlled Trial.

BACKGROUND: Deficits in end-of-life care in nursing homes (NHs) are reported, but the impact of palliative care teams (PCTeams) on resident outcomes remains largely untested. OBJECTIVE: Test the impact of PCTeams on end-of-life outcomes. RESEARCH DESIGN: Multicomponent strategy employing a randomized, 2-arm controlled trial with a difference-in-difference analysis, and a nonrandomized second control group to assess the intervention's placebo effect. SUBJECTS: In all, 25 New York State NHs completed the trial (5830 decedent residents) and 609 NHs were in the nonrandomized group (119,486 decedents). MEASURES: Four risk-adjusted outcome measures: place of death, number of hospitalizations, self-reported moderate-to-severe pain, and depressive symptoms. The Minimum Data Set, vital status files, staff surveys, and in-depth interviews were employed. For each outcome, a difference-in-difference model compared the pre-post intervention periods using logistic and Poisson regressions. RESULTS: Overall, we found no statistically significant effect of the intervention. However, independent analysis of the interview data found that only 6 of the 14 treatment facilities had continuously working PCTeams throughout the study period. Decedents in homes with working teams had significant reductions in the odds of in-hospital death compared to the other treatment [odds ratio (OR), 0.400; P<0.001), control (OR, 0.482; P<0.05), and nonrandomized control NHs (0.581; P<0.01). Decedents in these NHs had reduced rates of depressive symptoms (OR, 0.191; P≤0.01), but not pain or hospitalizations. CONCLUSIONS: The intervention was not equally effective for all outcomes and facilities. As homes vary in their ability to adopt new care practices, and in their capacity to sustain them, reforms to create the environment in which effective palliative care can become broadly implemented are needed.

Finding electronic information for health policy advocacy: a guide to improving search results.

PURPOSE: The success of advanced practice registered nurses' (APRNs') health policy advocacy depends on staying well informed about key issues. Searching for high-quality health policy information, however, can be frustrating and time consuming. Busy clinicians need strategies and tips to reduce information overload and to access synthesized research for evidence-based health policy. This article therefore offers APRNs practical guidelines and resources for searching electronic health policy information. DATA SOURCES: Scholarly databases and Internet sites. CONCLUSIONS: Electronic health policy information is generated by a wide variety of public and private organizations and disseminated in hundreds of journals and Web pages. Specialty search tools are needed to retrieve the unindexed gray literature, which includes government documents, agency reports, fact sheets, standards, and statistics not produced by commercial publishers. Further, Internet users need to examine search results with a critical eye for information quality. IMPLICATIONS FOR PRACTICE: Expertise in searching electronic health policy information is a prerequisite for developing APRNs' leadership in political arenas to influence health policy and the delivery of healthcare services.

A clinical microsystem model to evaluate the quality of primary care for homebound older adults.

The declining use of nursing homes and a growing aging population is increasing the demand for home-based primary care (HBPC) among chronically ill disabled homebound older adults and their informal caregivers. The problem this poses is that access to HBPC is limited. Typically, HBPC programs are small and available in only a few communities. Expansion of HBPC nationally has been hampered by limited awareness of this mode of care and by a dearth of research examining the quality and effectiveness of primary care delivered in the home. In this article, we address the need for stronger evidence demonstrating how well HBPC programs deliver and improve care by laying the foundation for more rigorous evaluation of HBPC services. First, an HBPC clinical microsystem model for evaluating program quality and effectiveness is described to clarify relationships among 5 elements essential for delivering high-quality primary care to homebound elders: purpose, patients, people (staff), processes, and patterns. Data for the model were identified through MEDLINE, CINAHL, and PubMed searches that produced 540 potentially relevant studies, from which 21 studies of HBPC programs and services were selected to construct the clinical microsystem. Second, in order to inform health policymaking about the design and financing of HBPC, findings from program evaluations reported in the selected studies are summarized. Finally, recommendations for future research are outlined, including epidemiological studies to estimate the proportion and characteristics of the homebound population for planning appropriate services and creating large databases for evaluating HBPC quality, costs, and outcomes. Ultimately, the scalability of HBPC to meet the demand of current and future older adults depends on incentives that value the home as a bona fide setting for delivering primary care.

Strengthening nurses' political identity through service learning partnerships in education.

The extent to which nursing students are educationally prepared to lead health policy initiatives is inextricably linked to their political identity. Knowing and showing oneself to be a politic person in interactions with others is a dynamic social process that the authors propose can be facilitated by innovative, community-based service learning partnerships. A partnership between an elected city councilman and Registered Nurses in a baccalaureate-level professional issues course demonstrates how service learning can create a context for students' political socialization. In a pilot study, systematic qualitative research techniques were used to analyze the partners' reflections about their relationship. Findings suggest that students' political identities were developed through involvement in the community. Working on issues of mutual interest also raised policy makers' and nurses' consciousness of the value both groups contribute to addressing problems in urban communities.

Ethics and managed care.

Managed care in the USA is best understood in the context of the history of health care. It is an effort to manage the soaring costs of health care while retaining quality. Many ethical concerns arise because managed care organizations (MCOs) have dual purposes: to realize profits and to provide quality care. Dilemmas are created when persons in institutions are expected to play conflicting roles or when professionals, patients, or others in MCOs lose their voices as participating persons. These and other ethical concerns can be addressed by on-going processes of involvement of persons who have a stake in these organizational arrangements.