Mental Health and Illness.

Circumstances forcing individuals and families to flee set the stage for disruptions in mental health and forge resilience. Individual characteristics and conditions premigration, perimigration, and postmigration influence health, mental health, care-seeking behavior, and stages of well-being and successful resettlement. Primary care providers have strategies to promote mental well-being, including focusing on resilience and social determinants of health. Integrated or collaborative care models are ideal for delivering optimum care for refugee and immigrant communities. Connecting primary and behavioral care promotes a team approach; provides comprehensive, whole-person care; and relies on participation of patients and families.

Strengthening effective preventive services for refugee populations: toward communities of solution.

Refugee populations have unequal access to primary care and may not receive appropriate health screening or preventive service recommendations. They encounter numerous health care disadvantages as a consequence of low-income status, race and ethnicity, lower educational achievement, varying degrees of health literacy, and limited English proficiency. Refugees may not initially embrace the concept of preventive care, as these services may have been unavailable in their countries of origin, or may not be congruent with their beliefs on health care. Effective interventions in primary care include the appropriate use of culturally and linguistically trained interpreters for health care visits and use of evidence-based guidelines. Effective approaches for the delivery of preventive health and wellness services require community engagement and collaborations between public health and primary care. In order to provide optimal preventive and longitudinal screening services for refugees, policies and practice should be guided by unimpeded access to robust primary care systems. These systems should implement evidence-based guidelines, comprehensive health coverage, and evaluation of process and preventive care outcomes.

Communities of solution: partnerships for population health.

Communities of solution (COSs) are the key principle for improving population health. The 1967 Folsom Report explains that the COS concept arose from the recognition that complex political and administrative structures often hinder problem solving by creating barriers to communication and compromise. A 2012 reexamination of the Folsom Report resurrects the idea of the COS and presents 13 grand challenges that define the critical links among community, public health, and primary care and call for ongoing demonstrations of COSs grounded in patient-centered care. In this issue, examples of COSs from around the country demonstrate core principles and propose visions of the future. Essential themes of each COS are the crossing of "jurisdictional boundaries," community-led or -oriented initiatives, measurement of outcomes, and creating durable connections with public health.

Family practice enhancements for patients with severe mental illness.

Individuals with severe mental health disorders experience difficulty maneuvering the complexity encountered in primary care (PC). This study describes the impact of three components of primary care practice enhancements on: changes in missed appointments, changes in health outcomes, number of ER visits and hospitalization days, and perceptions of integrated care. Missed PC appointments: baseline to post practice enhancement changed from 42 to 11, statistically significant (p < .01). Changes in health outcomes: SF-12 scores had no significant change nor did ER utilization and hospitalization; however, outcomes are low-base rate and assessment period was short. Integration of care: liaison was most helpful in accessing and navigating PC, educating and reconciling medication lists. Behavioral health staff voiced relief regarding access and felt better informed. Strategies focusing on increasing communication, staff education, and reducing barriers to access and receipt of PC may improve integration and continuity of care.

A randomized trial: are care navigators effective in connecting patients to primary care after psychiatric crisis?

Persons with serious mental illnesses suffer excess medical morbidity compared to the general population. This RCT aimed to determine whether navigators are effective in helping patients connect to primary care after psychiatric crisis. Adults presenting for emergency care were randomly assigned to a navigator versus usual care. Navigators facilitated access to primary care. Outcomes were connection rates to medical care and the impact of health insurance, hospitalization and mental health care on primary care attendance. After 1 year, the intervention group was statistically more likely to access care, versus controls (62.4 vs. 37.6%, P < .001). Navigators were effective in helping patients connect to primary care after a psychiatric crisis. Improved access to primary care is important given the complex chronic health problems of this vulnerable cohort.

How patients view primary care: differences by minority status after psychiatric emergency.

BACKGROUND: Patients' race or ethnic background may affect their ability to access health care due to their socioeconomic status, hereditary predispositions to illnesses, or discrimination either perceived or actual by those providing health care. For patients with mental health disorders, additional barriers are created due to poor experiences with the health care system. METHODS: This was a mixed methods randomized control study examining the effectiveness of care managers linking patients to primary care after psychiatric crisis. The aim reported in this paper was to analyze differences by minority status in patients' quantitative and qualitative responses before and after facilitation to primary care (N=85). Patients responded to a "patient enablement" and primary care index assessing their feelings of empowerment after a primary care visit; and to qualitative questions about their experiences and perceptions of care. FINDINGS: Following a primary care visit, responses by minority and non-minority individuals did not differ significantly on either the patient enablement or primary care index score. On qualitative inquiry, both non-minorities and minorities reported positive and negative views of their health, with corresponding positive and negative health experiences. DISCUSSION: In sum, there were no differences in patient enablement between the minority and non-minority subgroups over the course of the study, nor were there any changes in patient's perception of their relationship with healthcare providers. However, this cohort found primary care services less satisfactory than a general population without mental illness. Patients with psychiatric disorders experience stigmatization in their attempts to access health care. This stigma may have a greater impact than race and ethnicity, thereby leading to a similarity in perception of health care between minorities and non-minorities with mental illness.

Primary care after psychiatric crisis: a qualitative analysis.

PURPOSE: Patients with serious psychiatric problems experience difficulty accessing primary care. The goals of this study were to assess whether care managers improved access and to understand patients' experiences with health care after a psychiatric crisis. METHODS: A total of 175 consecutive patients seeking care in a psychiatric emergency department were randomly assigned to an intervention group with care managers or a control group. Brief, semistructured interviews about health care encounters were conducted at baseline and 1 year later. Five raters, using the content-driven, immersion-crystallization approach, analyzed 112 baseline and year-end interviews from 28 participants in each group. The main outcomes were patients' responses about their care experiences, connections with primary care, and integration of medical and mental health care. Scores for physical function and mental function were compared by analysis of variance (ANOVA). RESULTS: At baseline, most participants described negative experiences in receiving care and emphasized the importance of listening, sensitivity, and respect. Fully 71% of patients in the intervention group said that having a care manager to assist them with primary care connections was beneficial. Patients in the intervention group had significantly better physical and mental function than their counterparts in the control group at 6 months (P = .03 for each) but not at 12 months. There was also a trend toward functional improvement over the course of the study in the intervention group. CONCLUSIONS: This analysis suggests that care management is effective in helping patients access primary care after a psychiatric crisis. It provides evidence on and insight into how care may be delivered more effectively for this population. Future work should assess the sustainability of care connections and longer-term patient health outcomes.

Connections to primary medical care after psychiatric crisis.

BACKGROUND: Patients presenting with a psychiatric emergency face a unique set of challenges in connecting to primary care. OBJECTIVES: We tested the hypothesis that, in contrast to usual care, case management will result in higher rates of connection to primary care. We examined variables affecting primary care entry, including insurance status, hospital admission, and concurrent linkages to mental health care. RESEARCH DESIGN/METHODS: This article reports on a preliminary outcome of an ongoing randomized controlled trial conducted with 101 patients presenting in an urban psychiatric setting. Patients were randomized to a case management team or to usual care. The need for medical care was assessed by documenting medical comorbidity. RESULTS: Average age of the sample was 37.5; 65% were male, and 78% had low income; 37% were African American and 9% were Hispanic. Within 3 months of study enrollment, 57% of the intervention group was successfully linked to primary care compared with 16% of the usual care group, a difference that was statistically significant (P < .001). Associated positive predictors for linkage to primary care included mental health care visits and success in obtaining health insurance. Inpatient hospital stay at the time of psychiatric crisis was negatively associated with later attendance at primary care. CONCLUSIONS: Case management intervention was effective in establishing linkage to primary care within 3 months. Ongoing work will evaluate primary care retention and physical and mental health outcomes.

Seriously emotionally disturbed youth: a needs assessment.

A desire to improve outcomes for children and families led Erie County, New York to collaborate with the University at Buffalo Department of Family Medicine on a needs assessment of children with emotional disturbance. Demographic and behavioral characteristics, as well as service needs were identified through case-based interviews conducted with key informants who provided services to children with emotional disturbance. Family interviews were conducted whenever possible. Results demonstrate a need for enhanced case management, service coordination, services specific to children and families, and expanded community-based services.