Medically vulnerable populations are constantly at risk of having poor health related outcomes, low satisfaction in the healthcare system and increased mortality. Studies have shown the increased prevalence rates of various medical comorbidities in patients with severe mental illness. These patients are obviously vulnerable because of their mental illness but they are also more likely to have severe cases of medical conditions commonly seen in the general population. Expenditures and utilization of resources is often inappropriate due to frequent visits for acute needs and low rates of preventative care and primary care appointments. My proposed model focuses on the implementation of the integrated care model which encourages collaboration between mental health professionals and primary care physicians through referral programs or integrated clinic settings. This model is initiated with education to both current clinicians as well as future clinicians through medical schools and residency programs. Once the education component has begun, the next steps are formal exploration, preparation, implementation and evaluation of the model in clinics. The aim is to improve health outcomes by increasing preventative care and using behavioral techniques to assist with adherence, increase satisfaction in the healthcare system and contain expenditures by utilizing primary care services instead of emergency services when appropriate.

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Yes / Integrated models of care intend to provide seamless and timely access to health and social care services. This study investigated the integration of musculoskeletal services across community and secondary care boundaries, including the introduction of a single point of access from which patients were triaged. Staff (n = 15) involved in service development and delivery were interviewed about how, why and to what extent integration impacted service delivery. The analysis focused on staff experiences of using an on-line patient self-referral form and co-located clinics to enhance decision-making in triage, and on the provision of educational materials and de-medicalising language in patient consultations to support self-management. Single point of access, including online self-referral, were operationalised during data collection, but co-located clinics were not. Triage staff explained that the volume of referrals and quality of information provided in online self-referrals sometimes constrained decision-making in triage. Secondary care staff discussed concerns that the single point of access might not consistently identify patients with hard to diagnose conditions that require timely surgical intervention. This concern appeared to constrain staff engagement with integration, potentially inhibiting the delivery of co-located clinics. However, triage staff accessed support to inform secondary care referral via alternate modes. Patient circumstances, for example, need for reassurance, necessitated multiple self-management strategies and innovative approaches were developed to provide patients ongoing and professionally led support. Findings emphasise that restructuring services requires engagement from diverse stakeholders. Collaborating with stakeholders to address their concerns about the impact of restructures on well-established pathways may help cultivate this engagement. / Newcastle upon Tyne Hospitals NHS Foundation Trust

Mental illness and psychological distress is associated with higher rates of medical service usage and treatment of these issues results in more appropriate medical utilization rates. Little research has been conducted in an integrated care clinic, wherein health psychologists or behavioral health specialists work together with physicians to provide patient care. The current study examines the effects of brief behavioral and mental health interventions on patient medical utilization in this setting with care delivered by medical residents and doctoral psychology trainees. Access to the health system’s electronic billing records allowed for objective measures of annual healthcare utilization in terms of inpatient, outpatient, and emergency department use. A quasi-control group was constructed using propensity score matching in order to compare patients who had received a primary care psychology intervention to those who had not. Rates of inpatient utilization decreased significantly among treated patients overall as well as among treated patients identified as frequent attenders; there was no change in inpatient utilization among patients in the control group overall nor among frequent attenders in the control group, indicating that there is likely an effect of behavioral and mental health treatment on rates of inpatient visits. Rates of emergency department use and specialty outpatient visits were comparable between treated and control group patients, suggesting the lack of a treatment effect in these areas. Strengths, limitations, possible mechanisms, and implications for future research are discussed.

This study served as an initial evaluation of integrated psychology services within a clinic designed to serve uninsured patients with complex medical concerns and high utilization histories at the Medical College of Virginia in Richmond, Virginia. The current study evaluates patient outcomes, and more specifically, it further quantifies and describes the role that psychologists play in the primary care setting and their impact on utilization of medical care and in improved health outcomes. Additionally, the study evaluates psychologists’ success at treating mental and behavioral health conditions within the primary care model. The present study demonstrates that patients with complex medical and mental health needs can be effectively managed and treated in an integrated ambulatory care clinic. Care within this clinic resulted in significant improvements in depression, anxiety, HbA1c, cholesterol, and blood pressure. The findings suggested possible improvements in behavioral health outcomes such as insomnia as well, but more structured follow-up data are needed in future research to explore this relationship. Additionally it is possible that reductions in BMI may be significant if followed over a longer period of time. Utilization outcomes were more mixed, and contrary to the expectation that integrated services and improvements in health would be related to decreased utilization. Given the shift in health outcomes over the follow-up period, it is possible that early increases in utilization at the six-month mark, may shift to reductions in utilization and cost if the window of observation is expanded.

This thesis examines the retention of best practices by clinicians after the implementation of an integrated care pathway for patients with congestive heart failure. While the literature suggests there are many reasons why the implementation of best practices is difficult, there is little information on the sustainability of best practices once implemented.<p>Using a qualitative research design guided by Rogers theory of Diffusion of Innovations the researcher interviewed seven clinicians who participated in the implementation of the pathway. A thematic analysis revealed several themes that ran throughout participants responses. <p>While the participants indicated they see value in best practices, they also identified barriers to getting that knowledge into practice and keeping it there. A spectrum of factors, including individual autonomy, time, resources, organizational support and the organization of the system all played a role.<p>In the end, participants revealed that although small pieces of the pathway remain in practice, the pathway itself is no longer used by clinicians to manage patients with congestive heart failure.