Elizabeth Siantz

Chronic disease self-management interventions for adults with serious mental illness: a systematic review of the literature

OBJECTIVE While there is strong evidence in support of chronic disease self-management programs, much less is available with regard to individuals living with serious mental illness (SMI). The objectives of this review are to identify and appraise chronic disease self-management studies tested with samples of US adults living with SMI. We include an appraisal of methodological quality of the chronic disease self-management (CDSM) studies that met our final criteria. METHODS Systematic search methods were utilized to identify intervention studies published before 2012 that describe CDSM outcomes for adults with SMI. RESULTS Eighteen unduplicated articles were identified that included outcomes of CDSM studies, while 10 met all inclusion criteria. Favorable treatment effects were observed for adults with SMI across 10 studies that took place in different types of clinical settings. CDSM studies that met all search criteria had a wide range of methodological quality, indicating that this is a nascent field of study. CONCLUSIONS Given the high chronic disease burden experienced by individuals with SMI combined with our nations health care reform, emphasis on self-management to improve population health, coupled with advancing the quality of research to evaluate CDSM programs for adults with SMI, is critically needed.

The use of inhaled antibiotic therapy in the treatment of ventilator-associated pneumonia and tracheobronchitis: a systematic review

BackgroundVentilator-associated respiratory infections (tracheobronchitis, pneumonia) contribute significant morbidity and mortality to adults receiving care in intensive care units (ICU). Administration of broad-spectrum intravenous antibiotics, the current standard of care, may have systemic adverse effects. The efficacy of aerosolized antibiotics for treatment of ventilator-associated respiratory infections remains unclear. Our objective was to conduct a systematic review of the efficacy of aerosolized antibiotics in the treatment of ventilator-associated pneumonia (VAP) and tracheobronchitis (VAT), using the Cochrane Collaboration guidelines.MethodsWe conducted a search of three databases (PubMed, Web of Knowledge and the Cochrane Collaboration) for randomized, controlled trials studying the use of nebulized antibiotics in VAP and VAT that measured clinical cure (e.g., change in Clinical Pulmonary Infection Score) as an outcome measurement. We augmented the electronic searches with hand searches of the references for any narrative review articles as well as any article included in the systematic review. Included studies were examined for risk of bias using the Cochrane Handbook’s “Risk of Bias” assessment tool.ResultsSix studies met full inclusion criteria. For the systemic review’s primary outcome (clinical cure), two studies found clinically and statistically significant improvements in measures of VAP cure while four found no statistically significant difference in measurements of cure. No studies found inferiority of aerosolized antibiotics. The included studies had various degrees of biases, particularly in the performance and detection bias domains. Given that outcome measures of clinical cure were not uniform, we were unable to conduct a meta-analysis.ConclusionsThere is insufficient evidence for the use of inhaled antibiotic therapy as primary or adjuvant treatment of VAP or VAT. Additional, better-powered randomized-controlled trials are needed to assess the efficacy of inhaled antibiotic therapy for VAP and VAT.

Contextual Factors in the Health of People With Serious Mental Illness

People living with serious mental illness (SMI) have shorter life expectancies than the general population. We examined how contextual factors influence the physical health of this population. We conducted interviews, focus groups, and participant observations with stakeholders from six behavioral health organizations. We found that consumers’ avoidance of overt disagreement during medical visits, their mistrust of medical institutions, and cultural variations in body image influenced the clinical encounter. Mental health providers’ ambivalence about intervening in consumers’ physical health, primary care providers’ misattribution of physical symptoms to mental disorders, and providers’ stigmatization of consumers shaped clinical encounters. Consumers’ diets were shaped by food environments and social norms associated with traditional diets. Internal and external factors impacted consumers’ physical activity. In this article, we illustrate the importance of considering contextual factors in the development and implementation of interventions aimed at improving the physical health of people with SMI.

Implementation of Peer Providers in Integrated Mental Health and Primary Care Settings

Objective: Peer providers are essential to the delivery of recovery-oriented mental health services, but little is known about their roles in delivering integrated mental health and primary care services. This study examines how peer-based services are implemented in newly integrated behavioral health care settings in Los Angeles County, California. Methods: During summer 2013, teams of 3 implementation monitors conducted full-day on-site program visits at 24 integrated behavioral health pilot programs. Site visits involved semistructured interviews with program staff members. Case study analysis was used to explore the implementation of peer services in newly integrated care programs. We report findings using the Consolidated Framework for Implementation Research. Results: The integrated behavioral health teams at 14 integrated programs included peer providers. Variation in the definition of peer providers, their roles, and the extent of programmatic infrastructure to support their team involvement is identified across pilot program types. We find that in many programs designed for underserved ethnic communities, a climate of stigma regarding mental illness influences the inclusion of peer providers who have experienced mental illness. Conclusion: Enhanced training of peer providers in the intersecting areas of physical and mental health from a cultural perspective is needed to enhance the effectiveness of peer providers and increase community acceptance of their services. Promoting greater awareness of the critical nature of peer support services among other members of the integrated care workforce is also needed.

Integrated Primary Care in Assertive Community Treatment

Assertive community treatment (ACT) has the potential to serve as a medical home for adults with serious mental illness, a population that experiences some of the most significant health disparities in the United States. Using site visit methodology, the authors describe partnerships that were created between five ACT programs and federally qualified health centers (FQHCs) to provide integrated behavioral health and primary care. The authors examined rates of screening for common chronic conditions. The programs used three distinct approaches: two programs colocated ACT teams at an FQHC, two programs employed primary care providers who split their time between the FQHC and the ACT program, and one program embedded a primary care provider within the ACT team. Effective communication between staffs may be more important than type of partnership in determining integration success.

Evaluation Of The Behavioral Health Integration And Complex Care Initiative In Medi-Cal

This article reports how a large Medi-Cal managed care plan addressed challenges in accessing health care for approximately 7,000 enrollees with multiple chronic conditions through a project known as the Behavioral Health Integration and Complex Care Initiative. The initiative increased staffing for care management, care coordination, and behavioral health integration. In our evaluation of the initiative, we demonstrated that participation in it was associated with improved clinical indicators for common chronic conditions, reduced inpatient costs in some sites, and improved patient experience in all sites. The initiative may be best understood as a new type of ongoing strategic partnership among the health plan, its providers, and their patients. Changes in funding to support models of value-based care are needed to sustain these efforts in the long term.

Health Care Decisions among Mental Health Services Consumers in San Diego County: Implications for Integrated Care

People living with serious mental illness are at elevated risk for chronic diseases compared with those in the general population. Whether integrated care for this population would be most accessible in primary care or mental health settings is unclear. The cross-sectional study described in this article used descriptive analyses and multinomial logistic regression to assess factors associated with using physical health services from primary or mental health providers. Data were drawn from a large-scale assessment of client-reported use of primary care services in a large and ethnically diverse public mental health system. Most people (80.4 percent) reported accessing primary care services from one or more service settings. Having chronic conditions was associated with accessing physical health care from multiple service settings, whereas having poor self-rated emotional health decreased health services use from any setting. It was concluded that mental health services consumers access health care from various service settings. Social workers can play a critical role in enhancing care coordination across the mental health and primary care systems.

Peer Support in Full-Service Partnerships: A Multiple Case Study Analysis

Peer providers are integral to Full Service Partnerships (FSPs), which are team-based mental health service models. Peer providers use principles of recovery to engage clients, but FSPs can vary in their recovery orientation. Whether and how peer recovery orientation reflects the organizational environments of FSPs is unclear. This qualitative study explored peer provider attitudes towards recovery within the organizational contexts of FSPs where they are employed. Case study analysis was conducted on eight purposively sampled FSPs using qualitative interviews with peer providers and program directors. In two cases, peer recovery attitudes diverged from those of their organizational context. In these cases, peer providers were champions for recovery, and used practice-based strategies to promote client autonomy despite working in settings with lower recovery orientation. Peer providers could be uniquely positioned to promote client autonomy in settings where organizational factors limit consumer choice.