Prioritizing quality measure concepts at the interface of behavioral and physical healthcare.

OBJECTIVE: Integrated healthcare models can increase access to care, improve healthcare quality, and reduce cost for individuals with behavioral and general medical healthcare needs, yet there are few instruments for measuring the quality of integrated care. In this study, we identified and prioritized concepts that can represent the quality of integrated behavioral health and general medical care. DESIGN: We conducted a literature review to identify candidate measure concepts. Experts then participated in a modified Delphi process to prioritize the concepts for development into specific quality measures. SETTING: United States. PARTICIPANTS: Expert behavioral health and general medical clinicians, decision-makers (policy, regulatory and administrative professionals) and patient advocates. MAIN OUTCOME MEASURES: Panelists rated measure concepts on importance, validity and feasibility. RESULTS: The literature review identified 734 measures of behavioral or general medical care, which were then distilled into 43 measure concepts. Thirty-three measure concepts (including a segmentation strategy) reached a predetermined consensus threshold of importance, while 11 concepts did not. Two measure concepts were 'ready for further development' ('General medical screening and follow-up in behavioral health settings' and 'Mental health screening at general medical healthcare settings'). Among the 31 additional measure concepts that were rated as important, 7 were rated as valid (but not feasible), while the remaining 24 concepts were rated as neither valid nor feasible. CONCLUSIONS: This study identified quality measure concepts that capture important aspects of integrated care. Researchers can use the prioritization process described in this study to guide healthcare quality measures development work.

Acute mental health service use by patients with severe mental illness after discharge to primary care in South London.

BACKGROUND: To return the patients to primary care is arguably the desired service outcome for community mental health teams (CMHTs). AIMS: To assess acute mental health service use (hospitalisation or Home Treatment Team) by people with severe mental illness following discharge to primary care. METHOD: Retrospective cohort study comparing receipt and duration of acute care by 98 patients in the two years following discharge to primary care from CMHT, with a cohort of 92 patients transferred to another CMHT. RESULTS: The discharged group was significantly more stable on clinical measures. Fifty-seven (58.2%) patients were re-referred after median 39 weeks, with 35 (60.3%) in crisis. The difference in acute service use between discharged patients (27.9 days/patient) and transferred patients (31.7 days/patient) was not significant. Hospitalisation in the two years prior to discharge or transfer increased the odds of re-referral (OR 3.93, 95% CI 1.44-14.55), subsequent acute service use (OR 1.02, 95% CI 1.01-1.03) and duration of input (0.45 extra days/patient, 95% CI 0.22-0.68). CONCLUSIONS: The majority of the discharged patients were re-referred to mental health services. Although these were more stable, there was no difference from the transferred group on acute service use. Further support may be required in primary care to maintain stability.

Bearing the cost of the American dream: reflecting on street homelessness in America.

This paper is a British psychiatrist's personal reflection of the treatment of homeless people in American societies. Drawing upon theories of social distance, exclusion, discrimination and internalised stigma, this reflective piece suggests that homelessness is one price that certain societies pay to invest in the notion of individualised success and self-sufficiency. In reflecting on his own dissonance, the author argues that these societal processes exert a powerful influence on us as individuals, even if we as psychiatrists might think that our understanding confers on us a certain level of understanding.

Increased rates of sequelae post-encephalitis in individuals attending primary care practices in the United Kingdom: a population-based retrospective cohort study.

The true extent of sequelae in encephalitis survivors relative to rates within the general population is not known. This study aimed to quantify increased risks of epilepsy, depressive disorders, anxiety disorders, psychotic disorders, bipolar disorder, cognitive problems, dementia, headache, and alcohol abuse among encephalitis cases. 2460 exposed individuals diagnosed with incident encephalitis in the Clinical Practice Research Datalink and 47,914 unexposed individuals without a history of encephalitis were included. Multivariable Poisson regression was used to estimate adjusted rate ratios in individuals with encephalitis compared to the general population and to estimate whether the effect of these outcomes varied over time. Individuals with encephalitis had an increased risk of all investigated outcomes. The highest RR was seen for epilepsy (adjusted RR 31.9; 95 % confidence interval 25.38-40.08), whereas the lowest was seen for anxiety disorders (1.46, 1.27-1.68). The second highest RRs were for particular psychiatric illnesses, including bipolar disorder (6.34, 3.34-12.04) and psychotic disorders (3.48, 2.18-5.57). The RR was highest in the first year of follow-up for all outcomes except headache; this was particularly true for epilepsy (adjusted RR in first year of follow-up 139.6, 90.62-215.03). This study shows that sequelae are common in survivors of encephalitis. We confirm the presence of outcomes more commonly linked to encephalitis and describe those less commonly identified as being associated with encephalitis. The results of this study have important implications for the management of encephalitis patients and for the design of tertiary prevention strategies, as many of these sequelae are treatable.