Organizational dynamics of supported employment programs for people with severe mental illness

La présente étude qualitative visait à mieux comprendre l'influence des dynamiques organisationnelles sur l'implantation des programmes de soutien à l'emploi (SE) pour personnes atteintes de problèmes de santé mentale graves au Québec. Les résultats démontrent la présence de deux coalitions en lien avec ces programmes, soit une reliée au secteur de la santé et une reliée au secteur de l'emploi. La vision qui chapeaute les services des acteurs de la santé en est une de rétablissement et leurs services adhèrent ·généralement aux principes du modèle ±Individual Placement and Support¿. Comme ces acteurs, les acteurs de la coalition d'emploi visent aussi l'intégration de leurs clients en emplois compétitifs. Par contre, leurs valeurs et croyances différentes et la nature de leurs partenariats influencent ces derniers à organiser leurs services différemment des acteurs de la santé. Ensemble, les deux formes de SE semblent répondre aux besoins variés des utilisateurs de services vocationnels

Clinical practice guideline recommendations to improve the mental health of adult trauma patients:protocol for a systematic review

Introduction Mental disorders are common in adult patients with traumatic injuries. To limit the burden of poor psychological well-being in this population, recognised authorities have issued recommendations through clinical practice guidelines (CPGs). However, the uptake of evidence-based recommendations to improve the mental health of trauma patients has been low until recently. This may be explained by the complexity of optimising mental health practices and interpretating CGPs scope and quality. Our aim is to systematically review CPG mental health recommendations in the context of trauma care and appraise their quality. Methods and analysis We will identify CPG through a search strategy applied to Medline, Embase, CINAHL, PsycINFO and Web of Science databases, as well as guidelines repositories and websites of trauma associations. We will target CPGs on adult and acute trauma populations including at least one recommendation on any prevention, screening, assessment, intervention, patient and family engagement, referral or follow-up procedure related to mental health endorsed by recognised organisations in high-income countries. No language limitations will be applied, and we will limit the search to the last 15 years. Pairs of reviewers will independently screen titles, abstracts, full texts, and carry out data extraction and quality assessment of CPGs using the Appraisal of Guidelines Research and Evaluation (AGREE) II. We will synthesise the evidence on recommendations for CPGs rated as moderate or high quality using a matrix based on the Grading of Recommendations Assessment, Development and Evaluation quality of evidence, strength of recommendation, health and social determinants and whether recommendations were made using a population-based approach. Ethics and dissemination Ethics approval is not required, as we will conduct secondary analysis of published data. The results will be disseminated in a peer-reviewed journal, at international and national scientific meetings. Accessible summary will be distributed to interested parties through professional, healthcare quality and persons with lived experience associations.</p

Strategies and impacts of patient and family engagement in collaborative mental healthcare: protocol for a systematic and realist review

INTRODUCTION: Collaborative mental healthcare (CMHC) has garnered worldwide interest as an effective, team-based approach to managing common mental disorders in primary care. However, questions remain about how CMHC works and why it works in some circumstances but not others. In this study, we will review the evidence on one understudied but potentially critical component of CMHC, namely the engagement of patients and families in care. Our aims are to describe the strategies used to engage people with depression or anxiety disorders and their families in CMHC and understand how these strategies work, for whom and in what circumstances. METHODS AND ANALYSIS: We are conducting a review with systematic and realist review components. Review part 1 seeks to identify and describe the patient and family engagement strategies featured in CMHC interventions based on systematic searches and descriptive analysis of these interventions. We will use a 2012 Cochrane review of CMHC as a starting point and perform new searches in multiple databases and trial registers to retrieve more recent CMHC intervention studies. In review part 2, we will build and refine programme theories for each of these engagement strategies. Initial theory building will proceed iteratively through content expert consultations, electronic searches for theoretical literature and review team brainstorming sessions. Cluster searches will then retrieve additional data on contexts, mechanisms and outcomes associated with engagement strategies, and pairs of review authors will analyse and synthesise the evidence and adjust initial programme theories. ETHICS AND DISSEMINATION: Our review follows a participatory approach with multiple knowledge users and persons with lived experience of mental illness. These partners will help us develop and tailor project outputs, including publications, policy briefs, training materials and guidance on how to make CMHC more patient-centred and family-centred

The influence of primary care clinic characteristics on the quality of care for depression in patients with different comorbidity profiles

Dans les services de première ligne, la majorité des personnes atteintes de dépression souffrent également d’autres maladies chroniques comorbides. Offrir des soins de haute qualité à ces patients représente un défi important pour les intervenants en première ligne ainsi que pour le système de santé. Il y a des raisons de croire que les contextes organisationnels dans lesquels les intervenants pratiquent ont une influence importante sur les soins. Cependant, peu d’études ont examiné directement la façon dont les caractéristiques des cliniques facilitent ou entravent les soins offerts aux patients atteints de dépression et de différents types de maladies chroniques comorbides. L’objectif général de ce projet de recherche était donc de mieux comprendre comment différentes caractéristiques des cliniques de première ligne influencent la qualité des soins pour la dépression chez des patients ayant différents profils de comorbidité. La thèse comporte deux études. Tout d'abord, nous avons effectué une revue systématique examinant les relations entre la comorbidité physique chronique et la qualité des soins pour la dépression dans les services de première ligne afin de clarifier la nature de ces relations et d’identifier les facteurs qui pourraient influer sur ces relations. Ensuite, nous avons effectué une étude aux méthodes mixtes ayant deux volets : (a) un volet quantitatif examinant les relations entre la qualité des soins pour la dépression, les profils de comorbidité des patients, et les caractéristiques des cliniques de première ligne par le biais d’analyses de régression multiniveaux de données issues de deux enquêtes, et (b) un volet qualitatif basé sur une étude de cas explorant les perceptions des professionnels des services de première ligne sur les facteurs organisationnels pouvant influencer la qualité des soins offerts aux patients souffrant de dépression et d’autres maladies chroniques comorbides. Les résultats de ces études ont montré que, bien que la qualité des soins de la dépression en soins primaires soit sous-optimale, certains sous-groupes de patients dépressifs sont plus à risque que d’autres de recevoir des soins pour la dépression inadéquats, notamment des patients ayant uniquement des comorbidités chroniques physiques. Cependant, plusieurs caractéristiques des cliniques de première ligne semblent faciliter l’offre de soins de qualité aux patients atteints de dépression et de maladies chroniques comorbides : les normes et les valeurs liées au travail d'équipe et le soutien mutuel, l'accès au soutien des professionnels ayant une expertise en santé mentale, l’utilisation des algorithmes de traitement et d’autres outils d’aide à la décision pour la dépression, et l’absence d’obstacles liés aux modèles de rémunération inadéquats. Une des façons dont ces caractéristiques favorisent la qualité est en facilitant la circulation des connaissances dans les cliniques de première ligne. Nos résultats suggèrent que des interventions organisationnelles ciblées sont nécessaires pour améliorer la qualité des soins pour la dépression que reçoivent les patients ayant des maladies chroniques comorbides. Ces interventions peuvent viser différents domaines organisationnels (ex : caractéristiques structurelles/stratégiques, sociales, technologies et épistémiques) mais doivent aussi prendre en compte comment les éléments de chaque domaine interagissent et comment ils pourraient influencer les soins pour des patients ayant des profils de comorbidité différents.In primary care settings, most patients presenting with major depression also suffer from comorbid chronic mental and/or physical conditions. Delivering high quality depression care to these patients represents an important challenge for primary care providers and for health care systems. There are reasons to believe that the organizational contexts in which providers practice have an important influence on the care they provide to patients with depression and comorbid chronic conditions. However, few studies have directly examined how primary care organizational characteristics facilitate or impede care for these patients. The main objective of this thesis was to better understand how different primary care organizational characteristics influence the quality of depression care provided to patients with different profiles of comorbid chronic conditions. The thesis has two components. First, we conducted a systematic review examining relationships between chronic physical comorbidity and the quality of depression recognition and treatment in primary care in order to clarify the nature of these relationships and identify factors associated with observed differences in these relationships across studies. Next, we carried out a mixed-methods study conducted in two sequential phases: (a) a quantitative phase examining relationships between depression care quality, patients’ comorbidity profiles, and primary care clinic characteristics using multilevel regression analyses of data collected from two inter-related surveys, and (b) a qualitative phase relying on a case study approach that examines primary care professionals’ perceptions of the organizational factors that influence the quality of care they provide to patients living with depression and other comorbid chronic diseases. Results of these studies revealed that while the quality of depression care in primary care is suboptimal, some patient subgroups are more at risk of receiving low quality of care than others. Specifically, depressed patients with chronic physical comorbidity only were more at risk of receiving suboptimal care than patients presenting only with psychiatric comorbidity. However, several characteristics of primary care organizations facilitated the delivery of high quality care to patients with depression and comorbid chronic conditions. These included norms and values related to teamwork and mutual support, access to supports from professionals with expertise in mental health, use of decision support tools for depression treatment, and a lack of barriers due to inadequate payment models. One of the ways these characteristics support quality is by facilitating the flow of knowledge in primary care organizations. Our findings suggest that targeted organizational interventions are needed to improve the quality of depression care delivered to patients with depression and comorbid chronic conditions. Interventions could target multiple organizational domains (e.g. structural/strategic, social, informational and epistemic characteristics) and should consider how elements in each domain interact and how they might impact patients with different comorbidity profiles

Améliorer la santé mentale des populations par l’intégration des soins de santé mentale aux soins primaires

L’intégration des soins de santé mentale dans les soins primaires est une stratégie importante pour améliorer la santé mentale et le bien-être des populations. Dans la dernière décennie, le Québec a adopté plusieurs mesures pour renforcer les soins de santé mentale primaires, mais certains problèmes d’intégration persistent. Cette synthèse a été réalisée afin d’identifier et comparer les grandes initiatives internationales liées à l’intégration des soins de santé mentale aux soins primaires et de résumer les leçons tirées de ces initiatives qui sont pertinentes pour le Québec. Vingt initiatives ont été sélectionnées, décrites dans 153 articles et rapports. Trois initiatives portaient sur la santé mentale des jeunes, quatorze portaient principalement sur les adultes et trois autres initiatives portaient sur la santé mentale des aînés. La majorité des initiatives ont visé à implanter des modèles de soins de collaboration pour améliorer la gestion des troubles mentaux courants par les intervenants en soins primaires. Les initiatives ont été comparées sur les stratégies d’intégration adoptées, leurs effets, et les enjeux d’implantation rencontrés. Les leçons pour le Québec incluent le besoin de consolider davantage les soins en collaboration en santé mentale, de promouvoir des services informés par des processus d’amélioration continue de la qualité et de favoriser une plus grande utilisation des technologies qui soutiennent l’intégration.Objective The objectives of this review were to identify and compare major international initiatives aiming to integrate mental health services in primary care and to summarize the lessons learned for similar integration efforts in the province of Quebec, Canada.Methods We conducted a narrative review of the literature guided by a conceptual framework drawn from the literature on integrated care. We identified relevant initiatives to support primary mental health care integration through Pubmed searches and through previous systematic reviews on this topic. We then selected those initiatives that provided sufficient details on their key characteristics, outcomes, and implementation issues (e.g. barriers, facilitators). We focused our analysis on large-scale initiatives as these offered the most potential for impacts on population mental health. This process resulted in the selection of 20 initiatives that were described in 153 articles and reports. Our synthesis was guided by our conceptual framework, which distinguishes between five types of integration, namely clinical, professional, organizational, systemic and functional integration.Results Of the 20 primary mental health care integration initiatives, 3 targeted youth, 14 targeted adults or multiple age groups, and 3 were targeted towards seniors. Most initiatives aimed to implement collaborative care models for common mental disorders in primary care. Other initiatives focused on co-locating mental health professionals in primary care, supporting the emergence of a diversity of integration projects led by community-based primary care practices, or the merger of primary care and mental health organizations. Most initiatives were based on clinical, professional and functional integration strategies. Across initiatives, a range of positive outcomes were reported, notably to the accessibility and quality of services, the satisfaction of patients and providers, the costs of services, and impacts on patients’ health and quality of life. Integration initiatives encountered many common barriers to implementation. However, steps taken to properly prepare and execute the implementation process, as well as ensure the sustainability of initiatives, helped initiative leaders to overcome certain barriers. The lessons for Quebec include the need to continue to reinforce evidence-based models of collaborative mental health care in primary care and promote a culture of continuous quality improvement and a more widespread use of information technologies that can support integrated care.Conclusion This review shows that integrating mental health services into primary care is a complex process that depends on a variety of strategies occurring at multiple levels of the healthcare system. However, it is also a unifying process that holds much potential to significantly impact the mental health and well-being of populations

Améliorer la santé mentale des populations par l’intégration des soins de santé mentale aux soins primaires

L’intégration des soins de santé mentale dans les soins primaires est une stratégie importante pour améliorer la santé mentale et le bien-être des populations. Dans la dernière décennie, le Québec a adopté plusieurs mesures pour renforcer les soins de santé mentale primaires, mais certains problèmes d’intégration persistent. Cette synthèse a été réalisée afin d’identifier et comparer les grandes initiatives internationales liées à l’intégration des soins de santé mentale aux soins primaires et de résumer les leçons tirées de ces initiatives qui sont pertinentes pour le Québec. Vingt initiatives ont été sélectionnées, décrites dans 153 articles et rapports. Trois initiatives portaient sur la santé mentale des jeunes, quatorze portaient principalement sur les adultes et trois autres initiatives portaient sur la santé mentale des aînés. La majorité des initiatives ont visé à implanter des modèles de soins de collaboration pour améliorer la gestion des troubles mentaux courants par les intervenants en soins primaires. Les initiatives ont été comparées sur les stratégies d’intégration adoptées, leurs effets, et les enjeux d’implantation rencontrés. Les leçons pour le Québec incluent le besoin de consolider davantage les soins en collaboration en santé mentale, de promouvoir des services informés par des processus d’amélioration continue de la qualité et de favoriser une plus grande utilisation des technologies qui soutiennent l’intégration.Objective The objectives of this review were to identify and compare major international initiatives aiming to integrate mental health services in primary care and to summarize the lessons learned for similar integration efforts in the province of Quebec, Canada.Methods We conducted a narrative review of the literature guided by a conceptual framework drawn from the literature on integrated care. We identified relevant initiatives to support primary mental health care integration through Pubmed searches and through previous systematic reviews on this topic. We then selected those initiatives that provided sufficient details on their key characteristics, outcomes, and implementation issues (e.g. barriers, facilitators). We focused our analysis on large-scale initiatives as these offered the most potential for impacts on population mental health. This process resulted in the selection of 20 initiatives that were described in 153 articles and reports. Our synthesis was guided by our conceptual framework, which distinguishes between five types of integration, namely clinical, professional, organizational, systemic and functional integration.Results Of the 20 primary mental health care integration initiatives, 3 targeted youth, 14 targeted adults or multiple age groups, and 3 were targeted towards seniors. Most initiatives aimed to implement collaborative care models for common mental disorders in primary care. Other initiatives focused on co-locating mental health professionals in primary care, supporting the emergence of a diversity of integration projects led by community-based primary care practices, or the merger of primary care and mental health organizations. Most initiatives were based on clinical, professional and functional integration strategies. Across initiatives, a range of positive outcomes were reported, notably to the accessibility and quality of services, the satisfaction of patients and providers, the costs of services, and impacts on patients’ health and quality of life. Integration initiatives encountered many common barriers to implementation. However, steps taken to properly prepare and execute the implementation process, as well as ensure the sustainability of initiatives, helped initiative leaders to overcome certain barriers. The lessons for Quebec include the need to continue to reinforce evidence-based models of collaborative mental health care in primary care and promote a culture of continuous quality improvement and a more widespread use of information technologies that can support integrated care.Conclusion This review shows that integrating mental health services into primary care is a complex process that depends on a variety of strategies occurring at multiple levels of the healthcare system. However, it is also a unifying process that holds much potential to significantly impact the mental health and well-being of populations

Are mobile health applications useful for supporting shared decision making in diagnostic and treatment decisions?

Mobile health (mHealth) applications intended to support shared decision making in diagnostic and treatment decisions are increasingly available. In this paper, we discuss some recent studies on mHealth applications with relevance to shared decision making. We discuss the potential advantages and disadvantages of using mHealth in shared decision making in various contexts, and suggest some directions for future research in this quickly expanding field

Incentives and disincentives for treating of depression and anxiety in Ontario Family Health Teams: Protocol for a grounded theory study

From publisher: Introduction: There is strong consensus that prevention and management of common mental disorders (CMDs) should occur in primary care and evidence suggests that treatment of CMDs in these settings can be effective. New interprofessional team-based models of primary care have emerged that are intended to address problems of quality and access to mental health services, yet many people continue to struggle to access care for CMDs in these settings. Insufficient attention directed towards the incentives and disincentives that influence care for CMDs in primary care, and especially in interprofessional team-based settings, may have resulted in missed opportunities to improve care quality and control healthcare costs. Our research is driven by the hypothesis that a stronger understanding of the full range of incentives and disincentives at play and their relationships with performance and other contextual factors will help stakeholders identify the critical levers of change needed to enhance prevention and management of CMDs in interprofessional primary care contexts. Participant recruitment began in May 2016. Methods and analysis: An explanatory qualitative design, based on a constructivist grounded theory methodology, will be used. Our study will be conducted in the Canadian province of Ontario, a province that features a widely implemented interprofessional team-based model of primary care. Semistructured interviews will be conducted with a diverse range of healthcare professionals and stakeholders that can help us understand how various incentives and disincentives influence the provision of evidence-based collaborative care for CMDs. A final sample size of 100 is anticipated. The protocol was peer reviewed by experts who were nominated by the funding organisation. Ethics and dissemination: The model we generate will shed light on the incentives and disincentives that are and should be in place to support high-quality CMD care and help stimulate more targeted, coordinated stakeholder responses to improving primary mental healthcare quality.This research is supported by the Canadian Institutes of Health Research (CIHR funding referencing number: MOP-142435)