The Western Norway mental health interface study: a controlled intervention trial on referral letters between Primary Care and Specialist Mental Health Care

Background: Referral letters are the main communication means between Primary and Specialised Mental Health Care. However, studies of referral letters reveal that they lack important information, and how this lack of information affects the care for patients is unknown. This study aims to explore if and to what degree the quality of referral letters within Mental Health Care for adults can be improved and the potential improvement’s impact on defined patient, professional and organisational related outcomes. Methods and design: A controlled study with pre and post test will be prepared and accomplished to explore the correlation between the content of referral letters and outcomes of the care for the referred patients. The study is performed in accordance with the guideline of the Medical Research Council on development and evaluation of complex interventions. Using a mixed method design, a stepwise model will be conducted: Firstly, process and outcome measures will be developed and tested. Secondly, by these measures, the results from an intervention group of General Practitioners (GPs) who receive a complex quality improvement intervention will be compared with results from a control group who perform “care as usual”. Compliance to the introduced guideline will be measured as a mediator. Discussion: The Western Norway Mental Health Interface Study is among the first trials to evaluate the impact of the quality of referral letters on the organization of care. This study will provide information that will be usable for healthcare managers and clinicians in both Primary and Specialised Care settings.publishedVersio

Quality of life among patients undergoing bariatric surgery: associations with mental health- A 1 year follow-up study of bariatric surgery patients

Background: Preoperative mental health seems to have useful predictive value for Health Related Quality of Life (HRQOL) after bariatric surgery. The aim of the present study was to assess pre- and postoperative psychiatric disorders and their associations with pre- and postoperative HRQOL. Method: Data were assessed before (n = 127) and one year after surgery (n = 87). Psychiatric disorders were assessed by Mini International Neuropsychiatric Interview (M.I.N.I.) and Structured Clinical Interview (SCID-II). HRQOL was assessed by the Short Form 36 (SF-36) questionnaire. Results: Significant improvements were found in HRQOL from preoperative assessment to follow-up one year after surgery. For the total study population, the degree of improvement was statistically significant (p values < .001) for seven of the eight SF-36 subscales from preoperative assessment to follow-up one year after surgery. Patients without psychiatric disorders had no impairments in postoperative HRQOL, and patients with psychiatric disorders that resolved after surgery had small impairments on two of the eight SF-36 subscales compared to the population norm (all effect sizes < .5) at follow-up one year after surgery. Patients with psychiatric disorders that persisted after surgery had impaired HRQOL at follow-up one year after surgery compared to the population norm, with effect sizes for the differences from moderate to large (all effect sizes ≥ .6). Conclusion: This study reports the novel finding that patients without postoperative psychiatric disorders achieved a HRQOL comparable to the general population one year after bariatric surgery; while patients with postoperative psychiatric disorders did not reach the HRQOL level of the general population. Our results support monitoring patients with psychiatric disorders persisting after surgery for suboptimal improvements in quality of life after bariatric surgery

Recommended content of referral letters from general practitioners to specialised mental health care: a qualitative multi-perspective study

Background: In most Western countries, the referral letter forms the basis for establishing the priority of patients for specialised health care and for the coordination of care between the services. To be able to define the quality of referral letters, the potential impact of the quality on the organisation of care, and to improve the quality of the letters, we need a multidimensional definition of the ideal content. The study’s aim was to explore what information is seen as most important and should be included in referral letters from primary care to specialised mental health care to facilitate prioritisation and planning of treatment and follow-up of the patients. Methods: Based on purposive sampling, four mixed discussion groups, which included general practitioners, mental health nurses from primary health care, psychiatrists and psychologists from specialised mental health care, managers and patient representatives, were formed; they were asked to identify the information they considered important in a mental health referral letter. In line with the Delphi technique, the importance of the themes was later individually rated by the participants. The study was conducted within The Western Norway Regional Health Authority.Results: The four groups identified 174 information themes. After excluding themes that were assessed as duplicates, replaceable or less important, 40 themes were suggested, organised in seven units. A set of check-off points of essential information is recommended as an introduction in the referral letter. Conclusion: Compared with general guidelines and guidelines for somatic care, the results of this study suggest that the referral letter to specialised mental health care should have a larger emphasis on the overall treatment plan, on the specific role of specialised health care in the continuum of care, and on patient involvement. Further research should evaluate the validity of these findings for other patient groups in need of integrated care and investigate how the quality of referral letters affects patient-related and organisational outcomes

The impact of referral letter quality on timely access to specialised mental health care: a quantitative study of the reliability of patient triage

Background Patients referred to specialised mental health care are usually triaged based on referral information provided by general practitioners. However, knowledge about this system’s ability to ensure timely access to and equity in specialised mental health care is limited. We aimed to investigate to the degree to which patient triage, based on referral letter information, corresponds to triage based on a hospital specialist’s consultation with the patient, and whether the degree of correspondence is affected by the quality of the referral letter. Methods We gathered information from three specialised mental health centres in Norway regarding patients that were referred and offered health care (N = 264). Data consisted of triage decisions for each patient (i.e., the hospital specialist’s assessment of maximum acceptable waiting time), which were determined on the basis of a) referral information and b) meeting the patient. Referral letter quality was evaluated using the Quality of Referral information-Mental Health checklist. The reliability of priority setting and the impact of referral letter quality on this measure were investigated using descriptive analyses, binary logistic regression and Nadaraya-Watson kernel regression. Results In 143 (54%) cases, the triage decision based on referral information corresponded with the decision based on patient consultation. In 70 (27%) cases, the urgency of need for treatment was underestimated when based on referral information compared with that based on information from patient consultation. Referral letter quality could not explain the differences between the two triage decisions. However, when a cut-off value of 7 on the Quality of Referral information-Mental Health scale was used, low-quality letters were found more frequently among patients whose urgency of need was underestimated, compared with those whose need was overestimated. Conclusions Deciding the urgency of patient need for specialised mental health care based on referral information is a reliable system in many situations. However, the possibility of under- and overestimation is present, implying risks to patient safety and inappropriate use of resources. Improving the content of referral letters does not appear to reduce this risk when the letters are of acceptable quality.publishedVersio

Communication and Relational Ties in Inter-Professional Teams in Norwegian Specialized Health Care: A Multicentre Study of Relational Coordination

Introduction: The delivery of integrated care depends on the quality of communication and relationships among health-care professionals in inter-professional teams. The main aim of this study was to investigate individual and team communication and relational ties of teams in specific care processes within specialized health care. Methods: This cross-sectional multi-centre study used data from six somatic hospitals and six psychiatric units (N = 263 [response rate, 52%], 23 care processes) using a Norwegian version of the Relational Coordination Survey. We employed linear mixed-effect regression models and one-way analyses of variance. Results: The mean (standard deviation) relational coordination total score ranged from 4.5 (0.33) to 2.7 (0.50). The communication and relationship sub-scale scores were significantly higher within similar functional groups than between contrasting functional groups (P < .05). Written clinical procedures were significantly associated with higher communication scores (P < .05). The proportion of women in a team was associated with higher communication and relationship scores (P < .05). Conclusion: The Relational Coordination Survey shows a marked variation in team functions within inter-professional teams in specialized health-care settings. Further research is needed to determine the reasons for these variations.publishedVersio

Defining when specialised mental health care is needed: A focus group study

Background: Shared understanding between GPs and hospital specialists concerning when patients need specialised mental health care is important to ensure patients receive appropriate care. The large amount of rejected referrals often indicates a lack of such shared understanding. Aim: To explore how patient representatives, GPs, and mental health specialists understand ‘need for specialised mental health care’, meaning that primary care is no longer sufficient. Design & setting: This qualitative study was conducted in western Norway. The study has a service user-involved research design in which GPs and patient representatives participated in all stages of the research process. Method: Six semi-structured focus group interviews were conducted. The groups were homogenous as they included only the perspectives of either GPs, mental health specialists, or patient representatives. Data were analysed using thematic analysis. Results: The need for specialised mental health care was assessed using two continuums: (a) the patient’s level of functioning and symptoms; and (b) characteristics of the healthcare system and the patient’s informal support networks. Assessment along these continuums were often overruled by the evaluation of expected usefulness of specialised mental health care. In addition, all participants reported they often adapted their definition of need to fit other stakeholders’ interpretations of need. Conclusion: Evaluation of need for specialised mental health care is complex and depends on several factors. This may explain some of the current challenges that exist with regard to equity and timely access to appropriate healthcare interventions.publishedVersio

Nutritional risk, nutrition plan and risk of death in older health care service users with chronic diseases: A register-based cohort study

Background and aims Nutritional risk in older health care service users is a well-known challenge. Nutritional risk screening and individualised nutrition plans are common strategies for preventing and treating malnutrition. The aim of the current study was to investigate whether nutritional risk is associated with an increased risk of death and whether a nutrition plan to those at nutritional risk could reduce this potential risk of death in community health care service users over 65 years of age. Methods We conducted a register-based, prospective cohort study on older health care service users with chronic diseases. The study included persons ≥65 years of age receiving health care services from all municipalities in Norway from 2017 to 2018 (n = 45,656). Data on diagnoses, nutritional risk, nutrition plan and death were obtained from the Norwegian Registry for Primary Health Care (NRPHC) and the Norwegian Patient Registry (NPR). We used Cox regression models to estimate the associations of nutritional risk and use of a nutrition plan with the risk of death within three and six months. Analyses were performed within the following diagnostic strata: chronic obstructive pulmonary disease (COPD), dementia, type 2 diabetes, stroke, osteoporosis and heart failure. The analyses were adjusted for age, gender, living situation and comorbidity. Results Of the 45,656 health care service users, 27,160 (60%) were at nutritional risk, and 4437 (10%) and 7262 (16%) died within three and six months, respectively. Among those at nutritional risk, 82% received a nutrition plan. Health care service users at nutritional risk had an increased risk of death compared to health care service users not at nutritional risk (13% vs 5% and 20% vs 10% at three and six months). Adjusted hazard ratios (HRs) for death within six months were 2.26 (95% confidence interval (CI): 1.95, 2.61) for health care service users with COPD, 2.15 (1.93, 2.41) for those with heart failure, 2.37 (1.99, 2.84) for those with osteoporosis, 2.07 (1.80, 2.38) for those with stroke, 2.65 (2.30, 3.06) for those with type 2 diabetes and 1.94 (1.74, 2.16) for those with dementia. The adjusted HRs were larger for death within three months than death within six months for all diagnoses. Nutrition plans were not associated with the risk of death for health care service users at nutritional risk with COPD, dementia or stroke. For health care service users at nutritional risk with type 2 diabetes, osteoporosis or heart failure, nutrition plans were associated with an increased risk of death within both three and six months (adjusted HR 1.56 (95% CI: 1.10, 2.21) and 1.45 (1.11, 1.88) for type 2 diabetes; 2.20 (1.38, 3.51) and 1.71 (1.25, 2.36) for osteoporosis and 1.37 (1.05, 1.78) and 1.39 (1.13, 1.72) for heart failure). Conclusions Nutritional risk was associated with the risk of earlier death in older health care service users with common chronic diseases in the community. Nutrition plans were associated with a higher risk of death in some groups in our study. This may be because we could not control sufficiently for disease severity, the indication for providing a nutrition plan or the degree of implementation of nutrition plans in community health care.publishedVersio

The Effect of Intensive Implementation Support on Fidelity for Four Evidence‑Based Psychosis Treatments: A Cluster Randomized Trial

Abstract Purpose: Service providers need effective strategies to implement evidence-based practices (EBPs) with high fidelity. This study aimed to evaluate an intensive implementation support strategy to increase fidelity to EBP standards in treatment of patients with psychosis. Methods: The study used a cluster randomized design with pairwise assignment of practices within each of 39 Norwegian mental health clinics. Each site chose two of four practices for implementation: physical health care, antipsychotic medication management, family psychoeducation, illness management and recovery. One practice was assigned to the experimental condition (toolkits, clinical training, implementation facilitation, data-based feedback) and the other to the control condition (manual only). The outcome measure was fidelity to the EBP, measured at baseline and after 6, 12, and 18 months, analyzed using linear mixed models and effect sizes. Results: The increase in fidelity scores (within a range 1-5) from baseline to 18 months was significantly greater for experimental sites than for control sites for the combined four practices, with mean difference in change of 0.86 with 95% CI (0.21; 1.50), p = 0.009). Effect sizes for increase in group difference of mean fidelity scores were 2.24 for illness management and recovery, 0.68 for physical health care, 0.71 for antipsychotic medication management, and 0.27 for family psychoeducation. Most improvements occurred during the first 12 months. Conclusions: Intensive implementation strategies (toolkits, clinical training, implementation facilitation, data-based feedback) over 12 months can facilitate the implementation of EBPs for psychosis treatment. The approach may be more effective for some practices than for others. Keywords: Evidence-based practice; Fidelity scale; Implementation support; Mental health services; Psychoses. © 2021. The Author(s).publishedVersio

The Western Norway mental health interface study: a controlled intervention trial on referral letters between Primary Care and Specialist Mental Health Care

Background: Referral letters are the main communication means between Primary and Specialised Mental Health Care. However, studies of referral letters reveal that they lack important information, and how this lack of information affects the care for patients is unknown. This study aims to explore if and to what degree the quality of referral letters within Mental Health Care for adults can be improved and the potential improvement’s impact on defined patient, professional and organisational related outcomes. Methods and design: A controlled study with pre and post test will be prepared and accomplished to explore the correlation between the content of referral letters and outcomes of the care for the referred patients. The study is performed in accordance with the guideline of the Medical Research Council on development and evaluation of complex interventions. Using a mixed method design, a stepwise model will be conducted: Firstly, process and outcome measures will be developed and tested. Secondly, by these measures, the results from an intervention group of General Practitioners (GPs) who receive a complex quality improvement intervention will be compared with results from a control group who perform “care as usual”. Compliance to the introduced guideline will be measured as a mediator. Discussion: The Western Norway Mental Health Interface Study is among the first trials to evaluate the impact of the quality of referral letters on the organization of care. This study will provide information that will be usable for healthcare managers and clinicians in both Primary and Specialised Care settings