Jennifer Boggs

Patient-Identified Factors Related to Heart Failure Readmissions

Background—Although readmission after hospitalization for heart failure has received increasing attention, little is known about its root causes. Prior investigations have relied on administrative databases, chart review, and single-question surveys. Methods and Results—We performed semistructured 30- to 60-minute interviews of patients (n=28) readmitted within 6 months of index heart failure admission. Established qualitative approaches were used to analyze and to interpret data. Interview findings were the primary focus of the study, but patient information and provider comments from chart data were also consulted. Patient median age was 61 years; 29% were nonwhite; 50% were married; 32% had preserved ejection fraction; and median time from discharge to readmission was 31 days. Reasons for readmission were multifactorial and not easily categorized into mutually exclusive reasons. Five themes emerged as reasons cited for hospital readmission: distressing symptoms, unavoidable progression of illness, influence of psychosocial factors, good but imperfect self-care adherence, and health system failures. Conclusions—Our study provides the first systematic qualitative assessment of patient perspectives concerning heart failure readmission. Contrary to prior literature and distinct from what we found documented in the medical record, patient experiences were highly heterogeneous, not easily categorized as preventable or not preventable, and not easily attributed to a single cause. These findings suggest that future interventions designed to reduce heart failure readmissions should be multifaceted, should be systemic in nature, and should integrate patient input.

Web-Based Intervention in Mindfulness Meditation for Reducing Residual Depressive Symptoms and Relapse Prophylaxis: A Qualitative Study

Background Mindful Mood Balance (MMB) is a Web-based intervention designed to treat residual depressive symptoms and prevent relapse. MMB was designed to deliver the core concepts of mindfulness-based cognitive therapy (MBCT), a group treatment, which, despite its strong evidence base, faces a number of dissemination challenges. Objective The present study is a qualitative investigation of participants’ experiences with MMB. Methods Qualitative content analysis was conducted via 38 exit interviews with MMB participants. Study inclusion required a current PHQ-9 (Patient Health Questionnaire) score ≤12 and lifetime history ≥1 major depressive episode. Feedback was obtained on specific website components, program content, and administration as well as skills learned. Results Codes were assigned to interview responses and organized into four main themes: MBCT Web content, MBCT Web-based group process, home practice, and evidence of concept comprehension. Within these four areas, participants highlighted the advantages and obstacles of translating and delivering MBCT in a Web-based format. Adding increased support was suggested for troubleshooting session content as well as managing time challenges for completing home mindfulness practice. Participants endorsed developing affect regulation skills and identified several advantages to Web-based delivery including flexibility, reduced cost, and time commitment. Conclusions These findings support the viability of providing MBCT online and are consistent with prior qualitative accounts derived from in-person MBCT groups. While there is certainly room for innovation in the domains of program support and engagement, the high levels of participant satisfaction indicated that MMB can significantly increase access to evidence-based psychological treatments for sub-threshold symptoms of unipolar affective disorder.

Facilitators and Barriers to Implementing Screening, Brief Intervention, and Referral to Treatment (SBIRT) in Primary Care in Integrated Health Care Settings.

BACKGROUND Substance abuse in the United States is a serious public health concern impacting morbidity and mortality. However, systematic screening and intervention has not been widely adopted into routine practice by health care organizations and routine screening and intervention is not currently in place for primary care at Kaiser Permanente Colorado. Therefore, a formative evaluation was conducted to explore and enhance implementation of the Substance Abuse and Mental Health Services Administration (SAMHSA) screening, brief intervention, and referral to treatment (SBIRT) approach in the organization. METHODS Key clinical stakeholders, including internal and family medicine physicians, primary care nurses, mental health therapists, chemical dependency clinicians, and clinic-based psychologists provided feedback. Two focus groups were also conducted with patient stakeholders: one in English and one in Spanish. RESULTS All clinical stakeholders promoted clinic-based psychologists to conduct brief intervention and determine referral to treatment as the optimal implementation program. Inclusion of the patient perspective also highlighted the importance of considering this perspective in implementation. Both patient groups were generally supportive of SBIRT, especially the educational value of screening questions defining healthy drinking limits; however, English-speaking patients noted privacy concerns and Spanish-speaking patients noted frequently being asked about drug or alcohol use. Organizationally, systems exist to facilitate drug and alcohol use screening, intervention, and referral to treatment. However, physician time, alignment with other priorities, and lack of consistent communication were noted potential barriers to SBIRT implementation. CONCLUSIONS Clinicians expressed concerns about competing priorities and the need for organizational leadership involvement for successful SBIRT implementation. A unique suggestion for successful implementation is to utilize existing primary care clinic-based psychologists to conduct brief intervention and facilitate referral to treatment. Patient stakeholders supported universal screening, but cultural differences in opinions and current experience were noted, indicating the importance of including this perspective when evaluating implementation potential.

Assessing Capacity for Providing Culturally Competent Services to LGBT Older Adults

This qualitative, interview-based study assessed the cultural competence of health and social service providers to meet the needs of LGBT older adults in an urban neighborhood in Denver, Colorado, known to have a large LGBT community. Only 4 of the agencies were categorized as “high competency”; 12 were felt to be “seeking improvement” and 8 were considered “not aware.” These results indicate significant gaps in cultural competency for the majority of service providers. Social workers are well-suited to lead efforts directed at improving service provision and care competencies for the older LGBT community.

A pragmatic randomized clinical trial of behavioral activation for depressed pregnant women.

Objective: Depression among pregnant women is a prevalent public health problem associated with poor maternal and offspring development. Behavioral activation (BA) is a scalable intervention aligned with pregnant women’s preference for nonpharmacological depression care. This is the first test of the effectiveness of BA for depression among pregnant women, which aimed to evaluate the effectiveness of BA as compared with treatment as usual (TAU). Method: Pregnant women (mean age = 28.75 years; SD = 5.67) with depression symptoms were randomly assigned to BA (n = 86) or TAU (n = 77). Exclusion criteria included known bipolar or psychotic disorder or immediate self-harm risk. Follow-up assessment occurred 5 and 10 weeks postrandomization and 3 months postpartum using self-report measures of primary and secondary outcomes and putative targets. Results: Compared with TAU, BA was associated with significantly lower depressive symptoms (d = 0.34, p = .04) and higher remission (56.3% vs. 30.3%, p = .003). BA also demonstrated significant advantage on anxiety and perceived stress. Participants attended most BA sessions and reported high satisfaction. Participants in BA reported significantly higher levels of activation (d = 0.69, p < .0002) and environmental reward (d = 0.54, p < .003) than those who received TAU, and early change in both of these putative targets significantly mediated subsequent depression outcomes. Conclusions: BA is effective for pregnant women, offering significant depression, anxiety, and stress benefits, with mediation analyses supporting the importance of putative targets of activation and environmental reward.

Screening for and Diagnosis of Depression Among Adolescents in a Large Health Maintenance Organization

OBJECTIVE The aim of this analysis was to determine changes in patterns of depression screening and diagnosis over three years in primary and specialty mental health care in a large health maintenance organization (HMO) as part of a project to develop quality measures for adolescent depression treatment. METHODS Two series of aggregate data (2010-2012) were gathered from the electronic health records of the HMO for 44,342 unique adolescents (ages 12 to 21) who had visits in primary and mental health care. Chi square tests assessed the significance of changes in frequency and departmental location of Patient Health Questionnaire-9 (PHQ-9) administration, incidence of depression symptoms, and depression diagnoses. RESULTS There was a significant increase in PHQ-9 use, predominantly in primary care, consistent with internally generated organizational recommendations to increase screening with the PHQ-9. The increase in PHQ-9 use led to an increase in depression diagnoses in primary care and a shift in the location of some diagnoses from specialty mental health care to primary care. The increase in PHQ-9 use was also linked to a decrease in the proportion of positive PHQ-9 results that led to formal depression diagnoses. CONCLUSIONS The rate of depression screening in primary care increased over the study period. This increase corresponded to an increase in the number of depression diagnoses made in primary care and a shift in the location in which depression diagnoses were made, from the mental health department to primary care. The frequency of positive PHQ-9 administrations not associated with depression diagnoses also increased.

Mindful mood balance: a case report of Web-based treatment of residual depressive symptoms.

Residual depressive symptoms are associated with increased risk for relapse and impaired functioning. Although there is no definitive treatment for residual depressive symptoms, Mindfulness-Based Cognitive Therapy has been shown to be effective, but access is limited. Mindful Mood Balance (MMB), a Web-based adaptation of Mindfulness-Based Cognitive Therapy, was designed to address this care gap. In this case study, we describe a composite case that is representative of the course of intervention with MMB and its implementation in a large integrated delivery system. Specifically, we describe the content of each of eight weekly sessions, and the self-management skills developed by participating in this program. MMB may be a cost-effective and scalable option in primary care for increasing access to treatments for patients with residual depressive symptoms.

Perspectives of LGBTQ Older Adults on Aging in Place: A Qualitative Investigation

ABSTRACT This qualitative study conducted by a community-research partnership used multiple types of data collection to examine variables relevant for LGBTQ older adults who wished to age in place in their urban Denver neighborhood. Focus groups, interviews, and a town hall meeting were used to identify barriers and supports to aging in place. Participants (N = 73) identified primarily as lesbian or gay, aged 50–69, and lived with a partner. Ageism, heterosexism, and cisgenderism emerged as cross-cutting themes that negatively impact access to health care, housing, social support, home assistance, and legal services. Resilience from weathering a lifetime of discrimination was identified as a strength to handle aging challenges. Recommendations for establishing an aging in place model included establishing welcoming communities and resource centers and increasing cultural competence of service providers. This study provides a unique contribution to understanding the psychosocial, medical, and legal barriers for successfully aging in place.

Lessons learned from community-based participatory research: establishing a partnership to support lesbian, gay, bisexual and transgender ageing in place

Background Due to a history of oppression and lack of culturally competent services, lesbian, gay, bisexual and transgender (LGBT) seniors experience barriers to accessing social services. Tailoring an evidence-based ageing in place intervention to address the unique needs of LGBT seniors may decrease the isolation often faced by this population. Objective To describe practices used in the formation of a community-based participatory research (CBPR), partnership involving social workers, health services providers, researchers and community members who engaged to establish a LGBT ageing in place model called Seniors Using Supports To Age In Neighborhoods (SUSTAIN). Methods A case study approach was employed to describe the partnership development process by reflecting on past meeting minutes, progress reports and interviews with SUSTAINs partners. Results Key partnering practices utilized by SUSTAIN included (i) development of a shared commitment and vision; (ii) identifying partners with intersecting spheres of influence in multiple communities of identity (ageing services, LGBT, health research); (iii) attending to power dynamics (e.g. equitable sharing of funds); and (iv) building community capacity through reciprocal learning. Although the partnership dissolved after 4 years, it served as a successful catalyst to establish community programming to support ageing in place for LGBT seniors. Conclusion Multi-sector stakeholder involvement with capacity to connect communities and use frameworks that formalize equity was key to establishing a high-trust CBPR partnership. However, lack of focus on external forces impacting each partner (e.g. individual organizational strategic planning, community funding agency perspectives) ultimately led to dissolution of the SUSTAIN partnership even though implementation of community programming was realized.

The Association of Firearm Suicide With Mental Illness, Substance Use Conditions, and Previous Suicide Attempts

Background: Firearms account for one half of all suicide deaths in the United States (1), and reducing access to firearms among at-risk patients may reduce suicide mortality (2). Attempts to reduce access to firearms have focused on persons with a mental health condition or a history of suicidal behavior. Objective: To identify the proportion of suicide deaths that could be prevented by limiting firearm access for persons with a mental health condition or a history of suicidal behavior. Methods and Findings: The TUBS (Treatment Utilization Before Suicide) study identified 2674 adults and adolescents in 8 integrated health systems who died by suicide between 2000 and 2013 and were continuously enrolled for at least 10 of the 12 months before death (3). Using medical records and claims information, we identified 1 group who had a history of any mental health or substance use condition diagnosed at any medical or mental health visit in the year preceding death and another who had previous suicide attempts. These groups were not mutually exclusive. Persons who previously attempted suicide overlapped considerably with those who had a mental health condition, because a mental health condition is usually diagnosed in patients who have attempted suicide. Among persons who died by suicide, 54.7% had a mental health or substance use condition and 42.8% of persons with 1 of these conditions used a firearm (Table). In addition, only 10.9% of persons who died by suicide had previously attempted suicide and only 37.5% of these persons used a firearm in their death. In contrast, more persons without a mental health or substance use condition used firearms in their death than did persons with those conditions (671 vs. 627). Also, more persons without a previous suicide attempt used firearms in their death than did those with a previous attempt (1189 vs. 109). In fact, among persons who died by suicide, only 4.1% had previously attempted suicide and used a firearm; 23.5% had a mental health or substance use condition and used a firearm. Table. Suicide Deaths by Firearm in Those With a Mental Health or Substance Use Condition and Those With a Previous Suicide Attempt* Discussion: Our findings show that, even if successful, current efforts to limit firearm access only for persons with a mental health condition (including substance use disorders) or those who previously attempted suicide would prevent few suicide deaths by firearm. We suggest that prevention of firearm suicide should be expanded beyond the current focus on these patients to include other persons at risk for suicide. Suicide prevention resources are available to educate primary care providers about how to identify patients at risk, evaluate firearm access, engage patients in treatment, and transition patients to specialty care (4). Our findings also highlight the importance of expanding attention beyond an exclusive focus on firearmsespecially for persons with mental health or substance use conditionsto include other common means of suicide, such as instruments used for suffocation (for example, rope for hanging) and poison (for example, medications, alcohol, and recreational drugs). Suicide prevention resources are also available to educate primary care providers about restricting access to common means of suicide and counseling at-risk patients and their families about how to implement restrictions (5).