Kim S. Griswold

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.

Cultural Awareness through Medical Student and Refugee Patient Encounters

Purpose: This paper presents findings from a qualitative investigation of cultural awareness that medical students developed in the context of providing medical care to refugees. Our evaluation question was: What kinds of cultural awareness and communication lessons do medical students derive from clinical encounters with refugee patients? Methods: Thirty-eight semi-structured interviews were conducted to debrief a sample of 27 medical students. A multidisciplinary research team analyzed the debriefing texts following an interpretive “immersion-crystallization” approach. Results: Three domains in cultural awareness training encompassed 13 key lessons or themes. Students reported enhanced awareness about the use of interpretation services and cross-cultural communication. A second set of lessons reflected awareness of the refugees’ cultural background, and a third learning component involved experiences of cultural humility. The refugee plight prompted reflection on the students’ own culture, and validated the rationale for empathetic care and patient empowerment. Conclusion: As medical school curricula incorporate more cultural diversity training, a patient-based learning approach with selected ‘hands-on’ experiences will create opportunities for students to increase their cultural sensitivity and competency. This program’s experiential model indicates that after refugee medical encounters, these beginning medical students reported greater awareness of communication issues, and sensitivity toward religious values, family patterns, gender roles and ethnomedical treatments. It will be important to test these kinds of preceptor/apprenticeship models of cultural sensitivity training at later stages of medical training; in order to assess long-term effects.

Pregnant women at risk: An evaluation of the health status of refugee women in buffalo, New York

Each year, conflicts escalate the need for women, children, and men to seek refuge outside their home countries, and the United States and Canada provide asylum for many of these refugees. However, few researchers have investigated the health status of specific populations of refugees sojourning or newly arrived in the United States. As nurses at a Buffalo, New York, refugee shelter for Canada-bound asylum seekers, we provided health assessments to this group of refugees at their on-site clinic. Pregnant women were of major concern, being potentially at risk for poor pregnancy outcomes. We found that our sample of pregnant refugees had several previously undetected health problems and suggest that further research on refugee populations is needed.

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.

Bipolar Disorder is Common in Depressed Primary Care Patients

Abstract Objective: To examine the prevalence and treatment of typical and subsyndromal bipolar disorder (BD) in depressed primary care patients. Methods: Patients with a diagnosis of a mood disorder being treated with antidepressants in 2 academic family practice clinics underwent a structured diagnostic interview (Mini International Neuropsychiatric Inventory) for manic and hypomanic symptoms. Results: Of 58 patients evaluated, 19% met full criteria for bipolar I disorder and 8.6% for bipolar II disorder; 31% had subsyndromal BD (ie, persistent elation or irritability accompanied by additional symptoms of hypomania but not enough symptoms to meet full criteria for bipolar I or II disorder). Only 5 patients with BD were receiving mood stabilizers, which had not been instituted in any patient by the primary care physician. Conclusions: The high prevalence of patients meeting full criteria for BD and the low rate of identification of BD in primary care patients are consistent with estimates using self-administered questionnaires, but the interview revealed a substantial additional population that could be considered to have subsyndromal BD. Because subsyndromal forms of BD are associated with significant impairment and comorbidity as well as progression to frank BD, recognition of both full and subthreshold BD in primary care practice should be improved.

Refugees and medical student training: results of a programme in primary care

Context  Medical schools have responded to the increasing diversity of the population of the USA by incorporating cultural competency training into their curricula. This paper presents results from pre‐ and post‐programme surveys of medical students who participated in a training programme that included evening clinical sessions for refugee patients and related educational workshops.

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.

Linkage to Primary Medical Care Following Inpatient Detoxification

It is important to address the medical problems of individuals admitted for detoxification by arranging for follow-up with primary care physicians after discharge. This was a prospective cohort study of 119 patients admitted for detoxification. Follow-up data were collected over the telephone one week following discharge. Among this group of patients, 72% had a primary care provider (PCP). Patients who intended to see their provider were statistically more likely to be abstinent on follow-up (OR = 4.5, CI = 1.24-16.58, p = 0.024). As compared to those patients without primary care follow-up, having a plan to see ones PCP was associated with lower rates of relapse following detoxification.

Changing Places: Where Will We Be with Our Patients? A Perspective from the Keystone IV Conference.

Dr. Stephens knew a lot about place—his place within family medicine and the place of family medicine as a catalyst for change in our communities. In “G. Gayle Stephens Festschrift,” the evolution of our profession is mirrored by Dr. Stephens seminal contributions to practice and service to his discipline. He describes our place as healers, teachers, scholars, builders, moral agents, professionals, and reformers. Stephens place-changing career and ethos pave the way for our place as advocates for our patients and change agents for family medicine in this newest millennium.

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.