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PubMed2004

Improving mental health services in a local area -- an exploratory study.

The change in the focus of care for people with mental illness from hospital to community has been far from uniformly successful for a variety of reasons. A review of the development of mental health services suggests that the views of doctors and the responses of administrative systems are significant forces in shaping the development of services. This study explored the attitudes of general practitioners, psychiatrists and administrators, with a view to establishing areas of congruence in order to move towards an improved model of service delivery. Recommendations are made in the areas of primary care psychiatry, access, communication and education.

Attitude of Health Personnel↗
PubMedDate not supplied

Challenges for undergraduate speech pathology students undertaking cross-cultural clinical placements.

BACKGROUND: Two Australian undergraduate speech pathology students completed a series of clinical placements working with people with complex communication needs in cross-cultural contexts. AIMS: To describe the challenges that the students faced and how best to prepare future students for such experiences. METHODS & PROCEDURES: The students completed the placements in Thailand, Nepal, Bangladesh, India and South Africa. They used personal journaling to record their experiences. The students used the journals as the basis for reflective discussion when considering the challenges they experienced in applying their knowledge and skills. OUTCOMES & RESULTS: The challenges were (1) to prepare adequately ahead of the placements; (2) to select appropriate models of service delivery; (3) to use existing service approaches, resources and infrastructure appropriately; (4) to access professional support; (5) to define their professional role; (6) to manage variable shared language proficiency; (7) to adapt personally; and (8) to work using an undergraduate level of knowledge, skills and experience. CONCLUSIONS: The students encountered challenges related to their clinical preparation and their capacity to adapt in both a professional and personal sense. Future students preparing to undertake such placements need to attain at least minimum clinical competencies before placements. They will be helped if they have some clinical experience in working with people with complex communication needs in cross-cultural contexts, information about the cultures they will visit, and if they set professional and personal learning goals for each clinical placement. This preparation will aid students in maximizing their learning experience.

Adaptation, Psychological↗
PubMed2004

Gundhu Adolescent Wing: providing adolescent beds in a rural acute mental health unit.

OBJECTIVE: To describe the evolution, structure and outcomes of Gundhu Adolescent Wing, Toowoomba, Queensland, which comprises six dedicated beds set aside during development of a new rural acute mental health unit. METHODS: All adolescents discharged from Gundhu in its first 7 months were included in the study. Data pertaining to patient characteristics, model of service delivery, length of inpatient stay and outcome at 7 months were obtained. RESULTS: Thirty-three adolescents with mental illness living in the rural area were discharged from Gundhu in the first 7 months. For the 23 adolescents who stayed on the unit <14 days, outcome at 7 months after discharge was generally favourable. Six adolescents with length of stay of >or=30 days did less well, but made similar progress to patients in tertiary units. CONCLUSIONS: From the authors' experience, designating a small number of beds as adolescent within a rural acute mental health unit is an effective intervention for short-stay patients and is valued by adolescents and their families. Keeping the adolescent unit separate is beneficial even at the expense of foregoing access to space and facilities enjoyed by adult patients. Involving families early to provide off-ward fun, exercise and socialization with peers is important. Rural services tend to have high staff turnover. Involving rural general practitioners in follow-up plans may ensure better continuity of care after discharge.

Adolescent↗
PubMed2003

The invisible dimension: abuse in palliative care families.

The family as the unit of care underpins the philosophy and practice of palliative care. Through this model of service delivery, palliative care professionals attempt to provide holistic, quality end-of-life care to terminally ill patients and their families. The research on palliative care families to date, however, constructs the family unit as functional, articulate, cohesive and, thus, able to adapt to the impact of a terminal diagnosis, albeit with professional intervention if required. This notion of the family as monolithic and unproblematic masks the existence of family issues that have the potential to impact negatively on the care that patients receive, and thus constrain the palliative health professional in facilitating quality end-of-life care. Through a review of current literature, this paper identifies such an issue--that of abusive family relationships--which has been hitherto neglected in palliative care research. It is suggested that the issue of abusive family relationships needs to be identified and responded to at some level if the goal of providing holistic care and facilitating a "good death" for all terminally ill people receiving palliative care is to be achieved. The continued invisibility of this issue does not resolve the problem of abuse and could result in the implementation or continuation of practices that may in fact be damaging.

Aged↗
PubMedDate not supplied

The impact of community rehabilitation for acquired brain injury on carer burden: an exploratory study.

OBJECTIVES: This study evaluated the relative efficacy of a community rehabilitation service and a more traditional outpatient service for carers of people with an acquired brain injury. METHODS: Seventeen carers who had received a community intervention were retrospectively compared with 24 carers who had received an outpatient service. Dependent variables were level of met family need, a measure of family dysfunction, carer psychopathology, and carer emotional acceptance. RESULTS: The community sample fared significantly better on all measures except carer psychopathology. CONCLUSIONS: These results suggest that community-based services have efficacy for the carer and family. There is a clear need for large clinical trials using standardized instruments to establish what models of service delivery benefit carers.

Adult↗
PubMed1996

Understanding the forces driving medical group practice activities: an overview.

This article provides the historical context for examining the current forces driving medical group practice organizations. Prepayment has been around for some groups since the 1930s and the dual objectives of lowering costs and improving the quality of patient care were among the original reasons for forming group practices. Some of the basic issues for group practices today are discussed in light of evolution of this model of service delivery and the intensity of today's changing environment.

Group Practice↗
PubMed1997

Over the horizon: the future and the advanced practice nurse.

The move to managed care has expanded the role and opportunities for the advanced practice nurse (APN). The focus on building the continuum of care, the movement out of institutional models of service delivery, and the need for well-developed primary health services have created a major role for APNs. The major obligation for APNs today is to ensure their presence in the places where the design and structuring of the future health care system are unfolding.

Continuity of Patient Care↗
PubMed2006

Feasibility and acceptability of providing nurse counsellor genetics clinics in primary care.

AIM: This paper reports a pilot study to test the feasibility of providing genetic nurse counsellor clinics in primary care in the United Kingdom, to develop a questionnaire to evaluate patients' satisfaction with their genetics appointments, and to establish patient and provider costs. BACKGROUND: Genetic counsellors are healthcare professionals with experience in medical genetics and counselling and often have a professional background in nursing, science, genetics, psychology, or public health and work as members of multidisciplinary teams. Professional genetic counsellor accreditation is possible in the United Kingdom, United States of America, Australia and Canada. Increasing referrals to specialist genetics services have precipitated a review of models of service delivery in the United Kingdom. METHODS: A random half of 74 general practices in three primary care trusts were selected for the study, and the patients registered with these practices and referred to the clinical genetics service, were offered an appointment in primary care with a genetic nurse counsellor. A clinic follow-up postal questionnaire was developed. RESULTS: Between July 2002 and May 2003, 64 appointments were offered to patients referred and registered with the selected general practices, 45 (79%) patients attended their appointment and 34 (77%) returned their follow-up questionnaire. Total mean satisfaction score was high and patients were most satisfied with the information and affective domains of the appointment. Those referred with a family history of cancer were more satisfied than those referred with a non-cancer diagnosis. Forty-eight per cent of patients seen by the genetic nurse counsellor did not need to attend a further appointment with a doctor in secondary care. Patients were satisfied with the travel time and distance to clinic and patient clinic costs were low. CONCLUSION: Patients do attend genetic nurse counsellor clinics in primary care, and are satisfied with the new location. A large cluster randomized controlled trial is now being conducted to obtain a controlled comparison of clinic attendance rates and patients' satisfaction with clinics in primary vs. secondary care settings.

Adolescent↗
PubMed2006

Evaluating the clinical effectiveness of neonatal nurse practitioners: an exploratory study.

AIM AND OBJECTIVES: The aim of the investigation was to establish if there was any preliminary evidence to indicate if the quality of care and clinical outcomes for premature birth babies are affected by the type of practitioner (i.e. nurse practitioner vs. medical practitioner) responsible for the initial assessment, treatment and management of neonates during the first 6-12 hours following admission to a neonatal intensive care unit. BACKGROUND: The United Kingdom (UK) has seen a proliferation in the number of nurse practitioners in the past decade. While there is a growing body of evidence to suggest that nurse practitioners in primary care settings are able to provide a high quality and effective level of clinical service comparable with many of their medical counterparts, there has been relatively little evaluation of the nurse practitioner role in acute or high dependency hospital settings. DESIGN AND METHODS: The study design used a mixed method approach combining a retrospective examination and quality assessment of nursing and medical records. A random sample of 61 sets of medical records, relating specifically to the initial management and treatment of neonates were criterion assessed by an experienced consultant neonatologist and a variety of patient outcome data collated and analysed. RESULTS: The analysis of the patient outcome data and quality assessment of nursing and medical records revealed that there was no statistical difference in the standard and quality of care provided between nurse practitioners and medical staff in the vast majority of areas evaluated. However, trends in the data suggest that Advanced Neonatal Nurse Practitioners (ANNPs) did not perform as well as their medical counterparts in terms of the overall completeness or comprehensiveness of the standard care provided in a number of areas. CONCLUSION: Neonatal nurse practitioners provide an alternative model of service delivery in the initial admission and management of premature birth babies. While the results of the study suggest that ANNPs do not perform as well as medical staff, in the majority of cases, they still performed to an acceptable standard. Nonetheless, some deficits in the standard of care provided by both groups of practitioners were identified which in turn have implications for ongoing training and skills development. Relevance to clinical practice. The findings suggest that ANNPs are capable of taking on an advanced role in the assessment and management of neonates.

Clinical Nursing Research↗
PubMed2003

Development of the ASQoL: a quality of life instrument specific to ankylosing spondylitis.

BACKGROUND: Although disease-specific health status measures are available for ankylosing spondylitis (AS), no instrument exists for assessing quality of life (QoL) in the condition. OBJECTIVE: To produce an AS-specific QoL measure that would be relevant and acceptable to respondents, valid, and reliable. METHODS: The ASQoL employs the needs-based model of QoL and was developed in parallel in the UK and the Netherlands (NL). Content was derived from interviews with patients in each country. Face and content validity were assessed through patient field test interviews (UK and NL). A postal survey in the UK produced a more efficient version of the ASQoL, which was tested for scaling properties, reliability, internal consistency, and validity in a further postal survey in each country. RESULTS: A 41 item questionnaire was derived from interview transcripts. Field testing interviews confirmed acceptability. Rasch analysis of data from the first survey (n=121) produced a 26 item questionnaire. Rasch analysis of data from the second survey (UK: n=164; NL: n=154) showed some item misfit, but showed that items formed a hierarchical order and were stable over time. Problematic items were removed giving an 18 item scale. Both language versions had excellent internal consistency (alpha=0.89-0.91), test-retest reliability (r(s)=0.92 UK and r(s)=0.91 NL), and validity. CONCLUSIONS: The ASQoL provides a valuable tool for assessing the impact of interventions for AS and for evaluating models of service delivery. It is well accepted by patients, taking about four minutes to complete, and has excellent scaling and psychometric properties.

Adult↗
PubMed1999

Clustered randomised trial of an intervention to improve the management of asthma: Greenwich asthma study.

OBJECTIVES: To evaluate the effectiveness of an asthma resource centre in improving treatment and quality of life for asthmatic patients. DESIGN: Community based randomised controlled trial. SETTING: 41 general practices in Greenwich with a practice nurse. SUBJECTS: All registered patients aged 15-50 years. INTERVENTION: Nurse specialists in asthma who educated and supported practice nurses, who in turn educated patients in the management of asthma according to the British Thoracic Society's guidelines. MAIN OUTCOME MEASURES: Quality of life of asthmatic patients, attendance at accident and emergency departments, admissions to local hospitals, and steroid prescribing by general practitioners. RESULTS: Of 24 400 patients randomly selected and surveyed in 1993, 12 238 replied; 1621 were asthmatic of whom 1291 were sent a repeat questionnaire in 1996 and 780 replied. Of 24 400 patients newly surveyed in 1996, 10 783 (1616 asthmatic) replied. No evidence was found for an improvement in asthma related quality of life among newly surveyed patients in intervention practices compared with control practices. Neither was there evidence of an improvement in other measures of the quality of asthma care. Weak evidence was found for an improvement in quality of life in intervention practices among asthmatics registered with study practices in 1993 and followed up in 1996. Neither attendances at accident and emergency departments nor admissions for asthma showed any tendency to diverge in intervention and control practices over the study period. Steroid prescribing rates rose steadily during the study period. The average annual increase in steroid prescribing was 3% per year higher in intervention than control practices (95% confidence interval -1% to 6%, P=0.10). CONCLUSIONS: This model of service delivery is not effective in improving the outcome of asthma in the community. Further development is required if cost effective management of asthma is to be introduced.

Adolescent↗
PubMed2007

"There is such a thing as asking for trouble": taking rapid HIV testing to gay venues is fraught with challenges.

OBJECTIVES: To explore the feasibility and acceptability of offering rapid HIV testing to men who have sex with men in gay social venues. METHODS: Qualitative study with in-depth interviews and focus group discussions. Interview transcripts were analysed for recurrent themes. 24 respondents participated in the study. Six gay venue owners, four gay service users and one service provider took part in in-depth interviews. Focus groups were conducted with eight members of a rapid HIV testing clinic staff and five positive gay men. RESULTS: Respondents had strong concerns about confidentiality and privacy, and many felt that HIV testing was "too serious" an event to be undertaken in social venues. Many also voiced concerns about issues relating to post-test support and behaviour, and clinical standards. Venue owners also discussed the potential negative impact of HIV testing on social venues. CONCLUSION: There are currently substantial barriers to offering rapid HIV tests to men who have sex with men in social venues. Further work to enhance acceptability must consider ways of increasing the confidentiality and professionalism of testing services, designing appropriate pre-discussion and post-discussion protocols, evaluating different models of service delivery, and considering their cost-effectiveness in relation to existing services.

Antibodies, Viral↗
PubMed1976

Mental health services and the elderly: needs and options.

The author examines mental health issues related to the elderly from the perspective of the options for immediate impact on treatment. He stresses the potential for creative collaboration between public and private mental health care systems. Myths, stereotypes, and misinformation about the aged are discussed, as are the positive. The author also describes an innovative model of service delivery in the treatment of older individuals.

Aged↗
PubMed2001

Effectiveness, transportability, and dissemination of interventions: what matters when?

The authors identify and define key aspects of the progression from research on the efficacy of a new intervention to its dissemination. They highlight the role of transportability questions that arise in that progression and illustrate key conceptual and design features that differentiate efficacy, effectiveness, and dissemination research. An ongoing study of the transportability of multisystemic therapy is used to illustrate independent and interdependent aspects of effectiveness, transportability, and dissemination studies. Variables relevant to the progression from treatment efficacy to dissemination include features of the intervention itself as well as variables pertaining to the practitioner, client, model of service delivery, organization, and service system. The authors provide examples of how some of these variables are relevant to the transportability of different types of interventions. They also discuss sample research questions, study designs, and challenges to be anticipated in the arena of transportability research.

Adolescent↗
PubMed2004

Forensic assertive community treatment: preventing incarceration of adults with severe mental illness.

OBJECTIVE: Persons with severe mental illness are overrepresented in jails and prisons in the United States. A national survey was conducted to identify assertive community treatment programs that have been modified to prevent arrest and incarceration of adults with severe mental illness who have been involved with the criminal justice system. METHODS: Members of the National Association of County Behavioral Health Directors (NACBHD) were surveyed to identify assertive community treatment programs serving persons with criminal justice histories and working closely with criminal justice agencies. Programs were identified that met three study criteria: all enrollees had a history of involvement with the criminal justice system, a criminal justice agency was the primary referral source, and a close partnership existed with a criminal justice agency to perform jail diversion. Senior representatives of each program were subsequently contacted, and a telephone survey was administered to gather information about the design and operation of the programs. RESULTS: A total of 291 of 314 NACBHD members (93 percent) responded to the survey. Sixteen programs that met the study criteria were identified in nine states. The primary referral sources for 13 of these programs (81 percent) were local jails. Eleven programs (69 percent) incorporated probation officers as members of their assertive community treatment teams. Eight programs (50 percent) had a supervised residential component, with five providing residentially based addiction treatment. Eleven of the 16 programs have begun operating since 1999. Only three programs have published outcome data on program effectiveness. CONCLUSIONS: Forensic assertive community treatment is an emerging model for preventing arrest and incarceration of adults with severe mental illness who have substantial histories of involvement with the criminal justice system. Further research is needed to establish the structure, function, and effectiveness of this developing model of service delivery.

Adult↗
PubMed1981

The private general hospital's psychiatric emergency service in a decade of transition.

The psychiatric emergency ward of the private general hospital is faced with increasing demands for services and a changing role as a result of the progression of deinstitutionalization and shifts in the relationships between public and private facilities. Ten years ago the psychiatric emergency ward operated primarily as an evaluation and referral unit, triaging patients to primary sources of care; today the public facilities that serve as the primary caregivers frequently turn referrals away. Thus the referral model of service delivery is no longer viable for a psychiatric emergency ward, but it is yet to be replaced by other programs within the ward that will enable the chaos of the current system to be bypassed and prevent further deterioration of patient care. The authors discuss the dilemmas facing the emergency ward staff in the management and treatment of involuntary, psychotic, and chronic crisis patients.

Boston↗
PubMed2005

Measuring the outcomes of word cueing technology.

BACKGROUND: Measurement of assistive technology outcomes is complex because many factors (e.g., environment and model of service delivery) influence the successful use of the technology. PURPOSE: Using the example of measuring the outcomes of word cueing technology, this paper presents an approach for measuring assistive technology outcomes. METHOD: The Canadian Occupational Performance Measure (COPM) was administered to 29 children with physical and learning disabilities, between the ages of 3.9 and 19 years. Participants were provided with WordQ, a software program designed to assist the development of writing skills. Follow-up data were collected through telephone interviews. RESULTS: The COPM findings supported the effectiveness of WordQ Version 1 to enhance written productivity, with a mean performance change score of 3.5 (SD = 1.5). The COPM was an effective tool for measuring clients' perceived outcome of word cueing technology. Telephone interview was considered a successful method for collecting outcome data. PRACTICE IMPLICATIONS: A mix of tools and methodologies should be used to gain a comprehensive understanding of the impact of assistive technology.

Adolescent↗