Mark G. Embrett

Effectiveness of Health System Services and Programs for Youth to Adult Transitions in Mental Health Care: A Systematic Review of Academic Literature

Abstract Youth shifting to adult mental health services often report experiencing frustrations with accessing care that adequately replaces the youth services they had received. This systematic review assesses the peer reviewed evidence on services/programs aimed at addressing youth to adult transitions in mental health services. Findings suggest little data exists on the effectiveness of transition services/programs. While the available evidence supports meetings between youth and youth caseworkers prior to transitions occurring, it also verifies that this is not common practice. Other identified barriers to effective transitions were categorized as logistical (ineffective system communication), organizational (negative incentives), and related to clinical governance.

Lost in transition or translation? Care philosophies and transitions between child and youth and adult mental health services: a systematic review

Abstract Background: Differences in care philosophies may influence transitions from child and adolescent mental health services (CAMHS) to adult mental health services (AMHS). Aims: To review literature about CAMHS and AMHS care philosophies and their influence on transitions. Method: MEDLINE, PsycINFO, Embase and CINAHL databases were searched electronically using keywords related to transitions, youth and mental disorders. Content relating to philosophies of care was searched manually. Descriptive themes were extracted and the analysis suggested four hypotheses of how care philosophies influence transitions. Results: Of the 1897 identified articles, 12 met eligibility criteria. Findings reveal consistent differences in care philosophies between CAMHS (developmental approach, involving families and nurturing) and AMHS (clinical/diagnosis-focus, emphasis on client autonomy and individual responsibility). Conclusions: Better understanding of philosophical differences and collaborative planning and service delivery may foster shared approaches in CAMHS and AMHS to better meet the needs of transitioning youth.

Preventing Youth from Falling Through the Cracks Between Child/Adolescent and Adult Mental Health Services: A Systematic Review of Models of Care

Optimizing the transition between child and adolescent mental health services (CAMHS) and adult mental health services (AMHS) is a priority for healthcare systems. The purpose of this systematic review is to: (1) identify and compare models of care that may be used to facilitate the transition from CAMHS to AMHS; and (2) discuss trends and implications to inform future research and practice. Results identified three models of care which move beyond healthcare services and incorporate a broader range of services that better meet the dynamic needs of transition-aged youth. Joint working among providers, coupled with individualized approaches, is essential to facilitating continuity of care.

Coordination of care in the Chinese health care systems: a gap analysis of service delivery from a provider perspective

BackgroundIncreases in health care utilization and costs, resulting from the rising prevalence of chronic conditions related to the aging population, is exacerbated by a high level of fragmentation that characterizes health care systems in China. There have been several pilot studies in China, aimed at system-level care coordination and its impact on the full integration of health care system, but little is known about their practical effects. Huangzhong County is one of the pilot study sites that introduced organizational integration (a dimension of integrated care) among health care institutions as a means to improve system-level care coordination. The purposes of this study are to examine the effect of organizational integration on system-level care coordination and to identify factors influencing care coordination and hence full integration of county health care systems in rural China.MethodsWe chose Huangzhong and Hualong counties in Qinghai province as study sites, with only Huangzhong having implemented organizational integration. A mixed methods approach was used based on (1) document analysis and expert consultation to develop Best Practice intervention packages; (2) doctor questionnaires, identifying care coordination from the perspective of service provision. We measured service provision with gap index, overlap index and over-provision index, by comparing observed performance with Best Practice; (3) semi-structured interviews with Chiefs of Medicine in each institution to identify barriers to system-level care coordination.ResultsTwenty-nine institutions (11 at county-level, 6 at township-level and 12 at village-level) were selected producing surveys with a total of 19 schizophrenia doctors, 23 diabetes doctors and 29 Chiefs of Medicine. There were more care discontinuities for both diabetes and schizophrenia in Huangzhong than in Hualong. Overall, all three index scores (measuring service gaps, overlaps and over-provision) showed similar tendencies for the two conditions. The gap indices of schizophrenia (> 5.10) were bigger for diabetes (< 2.60) in both counties. The over-provision indices of schizophrenia (> 3.25) were bigger than diabetes (< 1.80) in both counties. Overlap indices for the two conditions exceeded justified overlaps, especially for diabetes. Gap index scores for schizophrenia interventions at the township-level and over-provision index scores for diabetes interventions at both village- and township-level showed big differences between the two counties. Insufficient medical staff with appropriate competencies, lack of motivation for care coordination and related supportive policies as well as unconnected information system were identified as barriers to system-level care coordination in both counties.ConclusionFindings demonstrate that organizational integration in Huangzhong has not achieved a higher level of care coordination at this stage. System-level care coordination is most problematic at village-level institutions in Hualong, but at county-level institutions in Huangzhong. These findings suggest that attention be given to other aspects of integration (e.g., clinical and service integration) to promote system-level care coordination and contribute to the full integration of health care system in the pilot county.

The transition from youth to adult mental health services and the economic impact on youth and their families

The transition from Child and Adolescent Mental Health Services (CAMHS) to Adult Mental Health Services (AMHS) can be challenging for youth, their families, and healthcare providers. The purpose of this study was to identify, summarize, and assess evidence found in scholarly literature regarding the economic impact on youth and their families during the transition from CAMHS to AMHS. Relevant studies were identified through a search of 7 electronic platforms. The search identified 829 articles; 5 of which met all inclusion criteria. Evidence from the included studies suggests that, when continuity of care is lacking, transitions from CAMHS to AMHS have substantial impacts on the financial demands of youth and their families. These demands are due to increases in the cost of care, loss of employment income and productivity, and changes in insurance coverage. However, there remains limited information in this area, which highlights the need for further research.

Physician perspectives on Choosing Wisely Canada as an approach to reduce unnecessary medical care: a qualitative study

BackgroundReducing monies spent on unnecessary medical care is one possible target to improve value in healthcare systems. Regional variation in the provision of medical care suggests physician behaviour and patient demands influence the provision of unnecessary medical care. Recently, Choosing Wisely campaigns began using ‘top 5 do-not-do’ lists to target unnecessary medical care by encouraging greater physician and patient dialogue at the point of care. The present study aims to examine the rationale for Choosing Wisely Canada’s (CWC) design and to analyse physician perceptions regarding the features of CWC aimed to reduce unnecessary medical care.MethodsThe study involved semi-structured interviews with 19 key informant physicians with CWC experience and the application of procedures of grounded theory to analyse interview transcripts and develop explanations addressing the objectives.ResultsParticipants reported that the CWC was the medical community’s response to three pressures, namely (1) demand for unnecessary medical care from patients during the clinical encounter; (2) public perception that physicians do not always prioritise patients’ needs; and (3) ‘blunt’ government tools aimed to reduce costs rather than improving patient care. Respondents stated that involving the patient in decision-making would help alleviate these pressures by promoting the clinical encounter as the paramount decision-point in achieving necessary care. However, CWC does not address several of the key reasons, from a physician perspective, for providing unnecessary medical care, including time pressures in the clinical encounter, uncertainty about the optimal care pathway and fear of litigation.ConclusionThis study contributes to our understanding of the perceptions of physicians regarding the CWC campaign. Specifically, physicians believe that CWC does little to address the clinical reasons for unnecessary medical care. Ultimately, because CWC has limited impact on physician behaviour or patient expectations, it is unlikely to have a major influence on unnecessary medical care.