Service delivery and quality of care for individuals with mental illness

Mental illness and substance use illnesses are the most common cause of disease burden in the United States. Over half of individuals with mental illness do not receive appropriate care for their illnesses. This often results in poor outcomes like early mortality, more hospitalizations and increased use of emergency departments (EDs). Provider and payor systems have embarked on delivery system reforms that aim to improve quality of care and reduce health disparities for these individuals. In this dissertation we examine three aspects of health care quality – readmission, ED use and continuity of care – to explore their impact for individuals with mental illness. We show that individuals with mental illness have greater odds of thirty day readmission after acute hospitalization and this odds is increased if medications are dropped after discharge. We categorize individuals with mental illness who frequent the ED and show that high utilizers have a significantly greater rate of substance use comorbidities than occasional utilizers. We also show that high utilizers do not use outpatient services concomitant with their ED use. Finally, we examine the care coordination in physical and behavioral health specialties for seriously mentally ill individuals who have type II diabetes and its association with ED use. We show that increased care coordination in physical health settings is associated with a lower rate of ED visits. Public Health Significance We expect our study to inform health care facilities and policy makers in developing health care delivery systems and improve quality of care for individuals with mental illness

Acceptability of PrEP among MSM and transgender communities-Qualitative findings from two metropolitan cities in India.

BackgroundGlobal evidence suggests that Pre-Exposure Prophylaxis (PrEP) plays a pivotal role in reducing new HIV-infections among key populations (KP). However, the acceptability of PrEP differs across different geographical and cultural settings and among different KP typologies. Men who have sex with men (MSM) and transgender (TG) communities in India have around 15-17 times higher prevalence of human immunodeficiency virus (HIV) than the general population. The low rates of consistent condom use and poor coverage of HIV testing and treatment among the MSM and transgender communities highlight the need for alternative HIV prevention options.MethodsWe used data from 20 in-depth interviews and 24 focused group discussions involving 143 MSM and 97 transgender individuals from the two metropolitan cities (Bengaluru and Delhi) in India to qualitatively explore their acceptability of PrEP as a HIV prevention tool. We coded data in NVivo and conducted extensive thematic content analysis.ResultsAwareness and use of PrEP were minimal among the MSM and transgender communities in both cities. However, on being provided with information on PrEP, both MSM and transgender communities expressed willingness to use PrEP as an additional HIV-prevention tool, to complement inability to consistently use condoms. PrEP was also perceived as a tool that could enhance the uptake of HIV-testing and counseling services. PrEP awareness, availability, accessibility and affordability were identified as determining factors that could influence its acceptability. Challenges such as stigma and discrimination, interrupted supply of drugs and non-community-friendly drug dispensing sites were identified barriers to continuing PrEP.ConclusionsUsing qualitative data from two Indian settings, this study provides community perspectives and recommendations to stakeholders and policymakers for introduction of PrEP into programs as a prevention tool among MSM and transgender communities in India