Targeted Self-Management of Epilepsy and Mental Illness for individuals with epilepsy and psychiatric comorbidity.

OBJECTIVES: Serious mental illness is disproportionately common in people with epilepsy and contributes to complications and mortality. Few care approaches specifically target individuals who have epilepsy and severe mental illness. We used an iterative process to refine an existing intervention and tested the novel intervention, Targeted Self-Management for Epilepsy and Mental Illness (TIME) in individuals with epilepsy and comorbid mental illness (E-MI). METHODS: The TIME intervention was developed with input from a community advisory board and then tested for feasibility, acceptability, and preliminary efficacy in people with E-MI, using a 16-week prospective, randomized controlled design comparing TIME (N=22) vs. treatment as usual (TAU, N=22). Primary outcome was change in depressive symptoms, assessed by the Montgomery Asberg Depression Rating Scale (MADRS). Secondary assessments included global psychiatric symptom severity, seizure frequency, sleep patterns, quality of life, stigma, social support, and self-efficacy. RESULTS: There were 44 individuals enrolled, mean age 48.25 (SD=11.82) with 25 (56.8%) African-Americans. The majority (N=31, 70.5%) were unemployed, and most (N=41, 95.5%) had annual income

A Nursing Approach to Self-Management Education for Individuals With Mental Illness and Diabetes.

Patients with serious mental illness (SMI) and diabetes often seek care in primary care settings and have worse health outcomes than patients who have either illness alone. Individual, provider, and system-level barriers present challenges to addressing both psychiatric and medical comorbidities. This article describes the feasibility, acceptability, and implementation of Targeted Training and Illness Management (TTIM), a self-management intervention delivered by trained nurse educators and peer educators to groups of individuals with SMI and diabetes to improve self-management of both diseases. TTIM is intended to be delivered in a primary care setting. Findings are intended to support the future development of nurse-led programs within the primary care setting that teach self-management to individuals with concurrent SMI and diabetes. This approach supports both adaptability and flexibility in delivering the intervention. Interventions such as TTIM can provide self-management skills, accommodate people with both SMI and diabetes in primary care settings such as patient-centered medical homes, and address known barriers to access.

A Consult Service to Support and Promote Community-Based Research: Tracking and Evaluating a Community-based Research Consult Service.

PURPOSE: This study describes the design, operation and evaluation of a community-based research (CBR) consult service within the setting of a Clinical and Translational Science Award (CTSA) institution. To our knowledge, there are no published evaluations of a CBR consult service at a CTSA hub. METHODS: A community-based research Consult Service was created to support faculty, health care providers/research coordinators, trainees, community-based organizations and community members. A framework was developed to assess the stages of client engagement and to foster clear articulation of client needs and challenges. A developmental evaluation system was integrated with the framework to track progress, store documents, continuously improve the consult service and assess research outcomes. RESULTS: This framework provides information on client numbers, types, services used and successful outreach methods. Tracking progress reveals reasons that prevent clients from completing projects and facilitates learning outcomes relevant to clients and funding agencies. Clients benefit from the expert knowledge, community connections and project guidance provided by the Consult Service team, increasing the likelihood of study completion and achieving research outcomes. CONCLUSION: This study offers a framework by which CTSA institutions can expand their capacity to conduct and evaluate community-based research while addressing challenges that inhibit community engagement.

Clinic Appointment Attendance in Adults with Serious Mental Illness and Diabetes.

OBJECTIVES: We assessed characteristics that may predict outpatient appointment attendance in outpatient medical clinics among patients comorbid for serious mental illness (SMI) and type 2 diabetes (DM). METHODS: Baseline covariate data from 200 individuals with SMI-DM enrolled in a randomized controlled trial (RCT) were used to examine characteristics associated with electronic health record-identified clinic appointment attendance using a generalized estimating equations approach. The analyses evaluated the relationship between clinic attendance and potentially modifiable factors including disease knowledge, self-efficacy, social support, physical health, and mental health, as well as demographic information. RESULTS: Demographic and mental health characteristics were most associated with clinic attendance in adults with SMI-DM. Physical health was not associated with clinic attendance. CONCLUSIONS: Information on clinical and demographic characteristics and factors potentially modifiable by psychological interventions may be useful in improving adherence to treatment among SMI-DM patients. It is our hope that clinicians and researchers will use these results to help tailor adherence-facilitating interventions among people at particular risk for poor engagement in care.

Behavioral stage of change and dialysis decision-making.

BACKGROUND AND OBJECTIVES: Behavioral stage of change (SoC) algorithms classify patients' readiness for medical treatment decision-making. In the precontemplation stage, patients have no intention to take action within 6 months. In the contemplation stage, action is intended within 6 months. In the preparation stage, patients intend to take action within 30 days. In the action stage, the change has been made. This study examines the influence of SoC on dialysis modality decision-making. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: SoC and relevant covariates were measured, and associations with dialysis decision-making were determined. In-depth interviews were conducted with 16 patients on dialysis to elicit experiences. Qualitative interview data informed the survey design. Surveys were administered to adults with CKD (eGFR≤25 ml/min/1.73 m(2)) from August, 2012 to June, 2013. Multivariable logistic regression modeled dialysis decision-making with predictors: SoC, provider connection, and dialysis knowledge score. RESULTS: Fifty-five patients completed the survey (71% women, 39% white, and 59% black), and median annual income was $17,500. In total, 65% of patients were in the precontemplation/contemplation (thinking) and 35% of patients were in the preparation/maintenance (acting) SoC; 62% of patients had made dialysis modality decisions. Doctors explaining modality options, higher dialysis knowledge scores, and fewer lifestyle barriers were associated with acting versus thinking SoC (all P<0.02). Patients making modality decisions had doctors who explained dialysis options (76% versus 43%), were in the acting versus the thinking SoC (50% versus 10%), had higher dialysis knowledge scores (1.4 versus 0.5), and had lower eGFR (13.9 versus 16.8 ml/min/1.73 m(2); all P<0.05). In adjusted analyses, dialysis knowledge was significantly associated with decision-making (odds ratio, 4.2; 95% confidence interval, 1.4 to 12.9; P=0.01), and SoC was of borderline significance (odds ratio, 5.8; 95% confidence interval, 1.0 to 32.6; P=0.05). The model C statistic was 0.87. CONCLUSIONS: Dialysis decision-making was associated with SoC, dialysis knowledge, and physicians discussing treatment options. Future studies determining ways to assist patients with CKD in making satisfying modality decisions are warranted.

Cultural Competency Education for Researchers: A Pilot Study Using a Neighborhood Visit Approach.

BACKGROUND: Little attention has been given to the cultural competence education needs for researchers. OBJECTIVES: To describe the planning and implementation of a neighborhood visit approach to cultural competency education in the community. METHODS: A committee of community partners and academics planned, conducted and evaluated the visit. The cultural competence and confidence (CCC) model was used to engage researchers. An evaluation survey assessed participant satisfaction and experiences. RESULTS: Of the 74 attendees 64 (84%) completed the conference evaluation. Attendees expressed that the visit and conference objectives were met and that the content was relevant to their work. Nearly all (95%) responded they would incorporate what they learned into practice. CONCLUSION: A neighborhood visit approach is feasible and acceptable to researchers and community partners. Evaluation of this community based education program showed preliminary evidence of changing both the way researchers think about the community and conduct research.

Neighborhood socioeconomic status and barriers to peritoneal dialysis: a mixed methods study.

BACKGROUND AND OBJECTIVES: The objective of this study was to evaluate the association between neighborhood socioeconomic status and barriers to peritoneal dialysis eligibility and choice. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: This study was a mixed methods parallel design study using quantitative and qualitative data from a prospective clinical database of ESRD patients. The eligibility and choice cohorts were assembled from consecutive incident chronic dialysis patients entering one of five renal programs in the province of Ontario, Canada, between January 1, 2004 and December 31, 2010. Socioeconomic status was measured as median household income and percentage of residents with at least a high school education using Statistics Canada dissemination area-level data. Multivariable models described the relationship between socioeconomic status and likelihood of peritoneal dialysis eligibility and choice. Barriers to peritoneal dialysis eligibility and choice were classified into qualitative categories using the thematic constant comparative approach. RESULTS: The peritoneal dialysis eligibility and choice cohorts had 1314 and 857 patients, respectively; 65% of patients were deemed eligible for peritoneal dialysis, and 46% of eligible patients chose peritoneal dialysis. Socioeconomic status was not a significant predictor of peritoneal dialysis eligibility or choice in this study. Qualitative analyses identified 16 barriers to peritoneal dialysis choice. Patients in lower- versus higher-income Statistics Canada dissemination areas cited built environment or space barriers to peritoneal dialysis (4.6% versus 2.7%) and family or social support barriers (8.3% versus 3.5%) more frequently. CONCLUSIONS: Peritoneal dialysis eligibility and choice were not associated with socioeconomic status. However, socioeconomic status may influence specific barriers to peritoneal dialysis choice. Additional studies to determine the effect of targeting interventions to specific barriers to peritoneal dialysis choice in low socioeconomic status patients on peritoneal dialysis use are needed.

Research ethics education for community-engaged research: a review and research agenda.

Community engagement is increasingly becoming an integral part of research. "Community-engaged research" (CEnR) introduces new stakeholders as well as unique challenges to the protection of participants and the integrity of the research process. We--a group of representatives of CTSA-funded institutions and others who share expertise in research ethics and CEnR--have identified gaps in the literature regarding (1) ethical issues unique to CEnR; (2) the particular instructional needs of academic investigators, community research partners, and IRB members; and (3) best practices for teaching research ethics. This paper presents what we know, as well as what we still need to learn, in order to develop quality research ethics educational materials tailored to the full range of stakeholder groups in CEnR.