Active Caseload Research Articles

Mapping the pathway and support offered to children with an intellectual disability referred to specialist mental health services in the UK.

This survey of 66 specialist mental health services aimed to provide an up-to-date description of pathways of care and interventions available to children with an intellectual disability referred for behaviours that challenge or with suspected mental health problems. Overall, 24% of services made contact with a family at referral stage, whereas 29% contacted families at least once during the waiting list phase. Only two in ten services offered any therapeutic input during the referral or waiting list stages. During the active caseload phase, services offered mostly psychoeducation (52-59%), followed by applied behaviour analytic approaches for behaviours that challenge (52%) and cognitive-behavioural therapy (41%). Thirty-six per cent of services had not offered any packaged or named intervention in the past 12 months. With increasing waiting times for specialist mental health support, services need to consider increasing the amount of contact and therapeutic input on offer throughout all stages of a child's journey with the service.

Audit of Lithium Monitoring in a Mental Health for Older Persons (Dublin North City Central) Service

Abstract Background Lithium is a psychotropic medication used for the treatment of bipolar affective disorder and augmentation for treatment resistant depression. Lithium monitoring is essential due to the narrow therapeutic range of serum lithium and the potential for toxicity. Other medications with similar risk profiles, such as warfarin, have established monitoring programmes. Older adults receiving lithium therapy are at an increased risk of adverse events, given the prevalence of medical co-morbidities and changing pharmacokinetics. The authors of this audit identified the lack of formalized lithium monitoring programme in the Mental Health Service for Older Persons (MHSOP). The aim of this audit to compare monitoring practices in the MHSOP against the current gold standard Irish Medication Safety Network (IMSN) for Prescribing and Monitoring of Lithium Therapy. Methods A survey of all community medical charts identifying patients attending the service receiving lithium therapy was completed. Data collected pertained to diagnosis, treating consultant, lithium dose, if the patient received educational material, compliance with ECG and blood monitoring. Results The MHSOP active case load was 682 patients, 14 patients were prescribed lithium therapy. Cycle 1 of the audit demonstrated poor compliance of lithium monitoring against the gold standard. A lithium pack was inserted in patient files to prompt all clinicians to follow the recommended standardized monitoring of lithium therapy as per the IMSN guidelines. In cycle 2 of the audit there was an improvement in recording blood monitoring across the patient group. Conclusion The audit demonstrated improvement in compliance with international guidelines following the intervention. It was recommended that a formalized Lithium Clinic was a needed resource for the MHSOP. The lithium monitoring pack will continue to be added to clinical files, included in Non-Hospital Consultant (NCHD) induction and multi - disciplinary teaching sessions. It is proposed that the audit be repeated in one year to longitudinally assess compliance.

Deaths from undetected COVID-19 infections as a fraction of COVID-19 deaths can be used for early detection of an upcoming epidemic wave.

With countries across the world facing repeated epidemic waves, it becomes critical to monitor, mitigate and prevent subsequent waves. Common indicators like active case numbers may not be sensitive enough in the presence of systemic inefficiencies like insufficient testing or contact tracing. Test positivity rates are sensitive to testing strategies and cannot estimate the extent of undetected cases. Reproductive numbers estimated from logarithms of new incidences are inaccurate in dynamic scenarios and not sensitive enough to capture changes in efficiencies. Systemic fatigue results in lower testing, inefficient tracing and quarantining thereby precipitating the onset of the epidemic wave. We propose a novel indicator for detecting the slippage of test-trace efficiency based on the number of deaths/hospitalizations resulting from known and hitherto unknown infections. This can also be used to forecast an epidemic wave that is advanced or exacerbated due to a drop in efficiency in situations where the testing has come down drastically and contact tracing is virtually nil as is prevalent currently. Using a modified SEIRD epidemic simulator we show that (i) Ratio of deaths/hospitalizations from an undetected infection to total deaths converges to a measure of systemic test-trace inefficiency. (ii) This index forecasts the slippage in efficiency earlier than other known metrics. (iii) Mitigation triggered by this index helps reduce peak active caseload and eventual deaths. Deaths/hospitalizations accurately track the systemic inefficiencies and detect latent cases. Based on these results we make a strong case that administrations use this metric in the ensemble of indicators. Further, hospitals may need to be mandated to distinctly register deaths/hospitalizations due to previously undetected infections. Thus the proposed metric is an ideal indicator of an epidemic wave that poses the least socio-economic cost while keeping the surveillance robust during periods of pandemic fatigue.

Borderline personality disorder in Irish Travellers: a cross-sectional study of an ultra-high-risk group

IntroductionIrish Travellers are recognised as a minority ethnic group in Ireland. While mental health services are available to Travellers, these services are often perceived as inadequate at addressing the mental health needs of this population. Studies have shown that there is a higher prevalence of mental disorders in the Traveller community in Ireland compared to the general Irish public. However, it is unclear if Travellers are at a higher risk of developing personality disorders, particularly borderline personality disorder.ObjectivesThis study will examine the prevalence of borderline personality disorder and other mental disorders in Travellers attending a community mental health service in Tuam, County Galway. This study will also investigate the biopsychosocial interventions delivered to this cohort and the clinical outcome following the interventions.MethodsThis is a cross-sectional study. Travellers who were active caseloads on the register of the community mental health service in Tuam were included in this study. Chart reviews were carried out on all samples included in this study.ResultsA total of 59 active patients were included in this study. The Traveller community formed 14.4% (59 out of 410) of the active caseloads of the Tuam mental health service. There were more male than female Travellers who attended the service. Mean age was 36 years old. The most common mental disorder in this study cohort is depressive episode (F32). This is followed by mixed anxiety and depressive disorder (F41.2). A significant minority (9, 15.3%) of the study participants were given a diagnosis of borderline personality disorder. 9 study participants await diagnostic clarification. Nearly one-fifth (18%, n=9) of the study participants with a diagnosis had been given a diagnosis of borderline personality disorder. Over 50% of the study participants were on at least 3 different medications from at least 2 different classes of psychotropics.ConclusionsThis study shows that there is a significant overrepresentation of Travellers attending the community mental health service in Tuam. The findings from this study can be used to plan future service development projects to better meet the needs of this unique population.Disclosure of InterestNone Declared

Consequences of understaffing on type of missed community care- a cross-sectional study.

Resource cuts to primary and community care in combination with a decline of those working in community settings is compromising quality of care and patient safety in the UK. It is reported that the negative consequences of understaffing and underfunding have worsened due to the COVID-19 pandemic. This is a cross-sectional study that aimed to examine short and long-term District and Community nursing working conditions. The objectives were to assess the prevalence of understaffing and missed care and the relationship between individual and organisational factors and their association with missed care outcome. We further explored the relationship between additional caseload, staffing levels and missed care. We developed a questionnaire based on the validated MISSCARE survey. Outcome measures were, number of vacancies per team, staffing levels, reported incidence of missed care, type of missed care, length of shift and overtime. Only 23% of teams reported having no vacancies. The mean staffing ratio was reported at 60%, including agency/bank staff (0.59±1.5). Prevalence of missed care was relatively high (60%≈). The distribution of types of missed care was spread evenly across all types of nursing care. A backward stepwise regression analysis showed that theProportion of Permanent staff capacity OR=7.9 (95% CI 0.09-0.65), Active Caseload Size OR= 5.5 (95% CI: 1.0 - 1.003), Number of RNs on the team (OR 4.8 (95% CI:1.003-1.058) and Amount of Overtime worked (OR= 3.9 (95% CI:0.98-1.0) variable are statistically significant predictors of missed care. The analysis showed an increase in additional allocated cases per RN as the permanent staff proportion decreased to 70%, at which point the likelihood of reported Missed Care outcome peaks. The compromised quality of care related to human resources and organisational aspects of the nursing process. Where RNs worked longer hours to make up for the backlog of cases, the prevalence of missed care was more likely. Longer working hours in the community increased the risk of compromised care and sub-optimal patient care. The aspects of the nursing process identified as 'missed' related to The World Health Organisation's three main pillars of community nursing (health promotion, patient education and screening). As such, significant components of the two first pillars are, according to these data, being undermined.

Results of a Continuous Quality Improvement Initiative of the Contemporaneous Model of Service Delivery.

The Contemporaneous Model of service delivery serves to manage behavioral expression in residents of long-term care homes with a diagnosis of advanced neurocognitive disorder. Its effectiveness is benchmarked in preventing the residents, on its active caseload, from seeking assistance in the emergency department and the dementia behavioral inpatient units for behavioral risks. The results of the three years of operation of the Contemporaneous Model of service delivery, for the years 2017–2018, 2018–2019, and 2019–2020, are presented here. These results are supportive of this model of service delivery as an effective way to reduce the burden of patients with advanced neurocognitive disorder with behavioral expressions on the emergency departments and specialized dementia behavioral services. It has the potential for becoming the gold standard model of service delivery in the Canadian health care system.

Reflections on lymphoedema deployment into community services during the pandemic.

During the second wave of the COVID-19 pandemic, district nursing teams were overwhelmed with their caseload due to the palliative care needs of their patients. This led to patients with wet legs and chronic wounds deteriorating due to staffing levels. Therefore, the Swansea Bay University Health Board and Lymphoedema Network Wales teams redeployed two working time equivalents (WTE) into the community to take over the management of these patients with chronic wounds for 4 months. The clinicians came from a variety of different backgrounds, including nursing, physiotherapy, emergency medicine and occupational therapy. Between the teams, 866 visits were carried out over the 4-month period, where patients' compression therapy was altered to promote healing and reduce oedema. At the end of the 4-month period, 21% of the patients were discharged off the district nursing caseload completely, while of the 60% who were still active caseload patients, 35% were in increased compression and 20% had reduced need for visits.

A retrospective evaluation of the value of COVID-19 screening and testing in patients with cancer: Aiming at a moving target

BackgroundDiagnosis of COVID-19 infection in cancer patients is critical to co-manage their underlying disease and infection appropriately. Our study aimed at evaluating the sensitivity and specificity of screening patients with cancer for COVID-19 infection. MethodsAll oncology patients receiving care at Department of Oncology at King Abdulaziz Medical City in Riyadh were screened using the acute respiratory infection (ARI) survey. Nasopharyngeal and throat swap for polymerase chain reaction (PCR) testing for severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) was performed on patients who have high ARI score (i.e. ≥ 4), or any patient requiring elective/emergency hospitalization, undergoing a procedure as well as screening asymptomatic patients receiving chemotherapy between April 1st and July 30, 2020. Institutional Review Board approval was obtained. Descriptive and inferential analyses were done and sensitivity, specificity, positive and negative predictive values (PPV and NPV) were calculated considering the COVID-19 PCR as the gold standard. ResultsDuring the study period, a total of 473 patients were included with a median age was 56 years (14–104), 51% were female, 73% had solid tumors, and 66% received treatment within the last 3 months. These patients underwent 688 PCR tests along with ARI survey screening. Testing was done in the outpatient, inpatient, and emergency department setting in 41%, 40% and 19% of the patients, respectively. Majority of tests were screening of asymptomatic patients and only 23% were tested for suspected infections with ARI ≥ 4. A total of 54 patients (8%) had positive PCR for COVID-19 infection. The prevalence of infection varied from month to month ranging from 1.09% in April up to 19.70% in June and correlated with the average daily and active case load at a national level. The diagnostic yield of the ARI score also correlated with infection burden nationally. The PPV and NPV of the ARI as a screening tool was 18.24% (0–31.8) and 95.6% (86.36–98.86%) with the PPN fluctuating considerably in parallel with the prevalence of COVID-19 result. Similarly, the sensitivity and specificity of the ARI were 55.77% (0–70.59) and 79.4 (69.19–92), respectively. ConclusionThe yield of screening asymptomatic patients with cancer varies based on the community burden of COVID-19 infection. As universal screening can cause delays to patient care, it should be tailored based on the individual patient risks and infection burden in the region.

A study on disease dynamics of covid-19 in different states of India: A data driven analysis of the available evidence

Backgrounds: Case Fatality Ratios (C.F.R.) in neighbouring countries recently varied widely, with highest being in Afghanistan (2.43%), followed by Pakistan (2.05%), Bangladesh (1.26%), Sri Lanka (0.54%), Maldives (0.38%), and Nepal (0.21%). This study–based on analysis of COVID-19 data from India, was undertaken to investigate into the inter-state differentials in active case rates, recovery rates & CFRs, role of selected demographic risk variables on case-load and trends in active cases in top 10 most affected States. Material & methods: COVID-19 data on confirmed cases, recovered (cured) cases, deaths and active cases from Indian States, as on 27th October 2020, were down loaded from the official website of the Government of India. Data on selected demographic risk variables of COVID-19 disease were also obtained from country’s 2011 Census. Such data were analyzed for case-loads, case- rates and weekly growth in active cases to understand the dynamics of COVID-19 pandemic. Results: Active case load was 68 per 1,00,000 population in top 10 highly affected States by COVID-19, as compared to rest of the Indian States (28 per 1,00,000 population), with C.F.R. (weighted average) being 1.71 % and 1.38 % in the two groups of States respectively. COVID-19 active cases were highest-around 301 per 1,00,000 population in Puducherry, followed by Kerala (281/1,00,000 population), Ladakh (252/1,00,000 population) and Goa (173/1,00,000 population). The best State amongst 10 highly affected States for COVID-19 was Uttar Pradesh with minimum active case load of 13 per 1,00,000 population, followed by Odisha (37/1,00,000 population), Tamil Nadu (41 per 1,00,000 population) whereas, in rest of the States of the country, best State was Dadra Nagar & Haveli and Daman & Diu (with active case load of 9/1,00,000 population), followed by Bihar (9/1,00,00 population), Madhya Pradesh (15/1,00,000) and then Punjab (15/1,00,000). Furthermore, Kerala, Delhi, Karnataka and West Bengal were worse in controlling the COVID-19 disease. Conclusion: Spread of COVID-19 disease has been steady and consistent throughout the country. Major burden of disease has been from 10 most affected States. COVID-19 case load increased almost continuously in different States but growth of the disease in them was slower-indicating better condition of the disease dynamics in our country than in many other countries of the world. It however, needs intense efforts from us to contain the disease in our country

Borderline personality disorder in Irish Travellers: a cross-sectional study of an ultra-high-risk group.

Irish Travellers are a marginalised ethnic minority with poor health outcomes, especially in mental health: the suicide rate in this population is 6-7 times that in the general population. There is a paucity of research into associated clinical risk factors including self-harm and mental illnesses. To examine the prevalence and treatments of mental disorders among Travellers attending a community mental health team (CMHT) in Galway. This is a cross-sectional study of the CMHT database, and included all Travellers who were active cases on the study day were included in this study. Travellers formed 12.4% (51 out of 410) of the active caseload of the mental health service. The mean age was 35.7 years (SD 13.1). The most common mental disorder was depressive disorder (16/51, 31.4%). Of 51 patients, 25.5% (13/51) were diagnosed with BPD: 7 had other comorbid mental disorders. Patients diagnosed with BPD are significantly more likely to be prescribed psychopharmacotherapy (t = 2.834, p = 0.007). A diagnosis of BPD was significantly associated with history of self-harm after controlling for age and gender (OR 2.3, p = 0.005). This study shows that there is a significant overrepresentation of Travellers in mental health services, suggesting significant need for accessible and acceptable interventions. Those with a BPD diagnosis have a significantly higher risk of self-harm, representing an ultra-high-risk population. These findings can be used to plan future service development projects to better meet the needs of this population: they may require specially adapted version of the mentalisation-based treatment programme.

Cannabis Use Among Aboriginal Youth in the Non-Aboriginal Child Protection Services System

The social, cultural and political contexts of vulnerability need to be considered in defining, understanding, and reducing substance abuse among maltreated youth with an Aboriginal background (MacNeil, 2008; Tatz, 1999). Aboriginal cultures tend to incorporate an ideology of collectivism that manifests in shared childrearing responsibilities within aboriginal families and communities (e.g., Dilworth-Anderson & Marshall, 1996). As such, Aboriginal children may identify with multiple and equally important attachment figures, and be more accepting of multiple caring adult guardians who can direct them away from risky behaviour (Christensen & Manson, 2001). We examined the relationship between cannabis use and reported identification with a caseworker among youth-identified Aboriginal and non-Aboriginal adolescents randomly drawn from the active caseload of a large urban non-Aboriginal Child Protection Services (CPS) system. While an Aboriginal-specific child welfare agency exists in this catchment area, youth need to be identified as Aboriginal to be involved in that system and some youth with Aboriginal heritage inevitably end up in non-Aboriginal CPS agencies. There were no significant differences in rates of maltreatment, trauma symptomatology, or overall cannabis use between Aboriginal and non-Aboriginal youth in this study. However, Aboriginal youth who reported a more negative (i.e., low) identification with their caseworker were five times more likely to use cannabis in the past 12 months compared to Aboriginal youth who reported a more positive (i.e., medium-high) identification with their caseworker. These results suggest that having a moderate-to-high positive identification with caseworker may be a protective factor in regard to abstinence from cannabis use among Aboriginal and non-Aboriginal youth in the non-Aboriginal CPS system.

Use of Electrical Stimulation for People With Spinal Cord Injury: A Survey of Occupational Therapy Practitioners.

When working with clients who have experienced spinal cord injury (SCI), occupational therapy practitioners can face challenges in achieving desired results during functional activity when using electrical stimulation (ES) interventions. In an effort to understand current practice, a survey study was conducted. For people with SCI, ES elicits positive physiological effects; however, no implementation guidelines exist for upper extremity application of ES for this population. Therefore, we surveyed occupational therapy practitioners about their use of ES with clients who have cervical-level SCI. A 33-item, 20-min online survey was used. We queried 57 occupational therapy practitioners with active caseloads in regional rehabilitation centers specializing in SCI, both outpatient and inpatient. For clients with SCI, occupational therapy practitioners used ES most often for grasp-and-release, reaching, and grip or pinch activities using a broad range of parameter settings. Among respondents, 43% did not use a specific treatment protocol; 27% used research evidence to guide selection of parameters. Findings suggest that ES treatment parameters are not uniformly applied, introducing potential unknown effects on client outcomes and undermining treatment fidelity. Our survey of occupational therapy practitioners regarding their practice and use of ES interventions with this population revealed variation in application of ES treatment parameters. Understanding different treatment approaches and justification used when applying ES to clients with SCI is an important first step in unifying and promoting best practice and maximizing patient outcomes.

Measurement training and feedback system for implementation of evidence-based treatment for adolescent externalizing problems: protocol for a randomized trial of pragmatic clinician training

BackgroundInnovations in clinical training and support that enhance fidelity to evidence-based treatment (EBT) for adolescent behavior problems are sorely needed. This study will develop an online training system to address this gap: Measurement Training and Feedback System for Implementation (MTFS-I). Using procedures intended to be practical and sustainable, MTFS-I is designed to increase two aspects of therapist behavior that are fundamental to boosting EBT fidelity: therapist self-monitoring of EBT delivery, and therapist utilization of core techniques of EBTs in treatment sessions. This version of MTFS-I focuses on two empirically supported treatment approaches for adolescent conduct and substance use problems: family therapy and cognitive behavioral therapy (CBT).Methods/designMTFS-I expands on conventional measurement feedback systems for client outcomes by adding training in observational coding to promote EBT self-monitoring and focusing on implementation of EBT treatment techniques. It has two primary components. (1) The training component, delivered weekly in two connected parts, involves self-monitored learning modules containing brief clinical descriptions of core EBT techniques and mock session coding exercises based on 5–8 min video segments that illustrate delivery of core techniques. (2) The feedback component summarizes aggregated therapist-reported data on EBT techniques used with their active caseloads. MTFS-I is hosted online and requires approximately 20 min per week to complete for each treatment approach. This randomized trial will first collect data on existing delivery of family therapy and CBT techniques for youth in outpatient behavioral health sites (Baseline phase). It will then randomize site clinicians to two study conditions (Implementation phase): Training Only versus Training + Feedback + Consultation. Therapists will choose whether to train in family therapy, CBT, or both. Study aims will compare clinician performance across study phase and between study conditions on MTFS-I uptake, reliability and accuracy in EBT self-monitoring, and utilization of EBT techniques in treatment sessions (based on observer coding of audiotapes).DiscussionStudy contributions to implementation science and considerations of MTFS-I sustainability are discussed.Trial registrationClinicalTrials.gov, NCT03722654. Registered on 29 October 2018.

MAANASI - A Sustained, Innovative, Integrated Mental Healthcare Model in South India

Studies in low and middle-income countries (LMICs) point to a significant association of common mental disorders with female gender, low education, and poverty. Depression and anxiety are frequently complicated by lack of disease awareness and non-adherence, the absence of care and provider resources, low value given to mental health by policy-makers, stigma, and discrimination towards the mentally ill. This paper aims to show that female village leaders/ community health and outreach workers (CHWs) can be used to overcome the lack of psychiatric resources for treatment of common mental disorders in rural areas. A multidisciplinary team was set up to evaluate and treat potential clients in the villages. A program of care delivery was planned, developed and implemented by: (a) targeting indigent women in the region; (b) integrating mental health care with primary care; (c) making care affordable and accessible by training local women as CHWs with ongoing continued supervision; and (d) sustaining the program long-term. Indigenous CHWs served as a link between the centre and the community. They received hands-on training, ongoing supervision, and an abridged but focused training module to identify common mental disorders, help treatment compliance, networking, illness literacy and community support by outreach workers. They used assessment tools translated into the local language, and conducted focus groups and client training programs. As a result, mental healthcare was provided to clients from as many as 150 villages in South India. Currently the services are utilized on a regular basis by about 50 villages around the central project site. The current active caseload of registered clients is 1930. Empowerment of treated clients is the final outcome, assisting them in self-employment. Rural mental healthcare must be culturally congruent, and must integrate primary care and local CHWs for success. Training, supervision, ongoing teaching of CHWs, on-site resident medical officers, research and outreach are essential to continued success over two decades.

Speech-language pathologists’ perceptions of the use of telepractice in the delivery of services to people with Parkinson’s disease: A national pilot survey

Purpose: To explore the perceptions, use and interest to use telepractice by speech-language pathologists (SLPs) to deliver services to people with Parkinson’s disease (PwPD).Method: A cross-sectional, mixed-methods online survey was conducted. Recruitment of SLPs with an active caseload of PwPD was conducted through non-probability, purposive sampling. Data were analysed using frequency distribution and thematic analysis.Result: A total of 63 SLPs responded. The majority (82.5%) were interested in telepractice, but only 23.1% provided services to PwPD online. Monitoring of motor speech function, and therapy were the primary services delivered online. Of those who did not currently offer online services to PwPD, 77.5% expressed interest to use telepractice. The development of telepractice guidelines and a comprehensive list of available software were the resources most requested to assist clinicians in offering such services. Most perceived telepractice as an appropriate delivery method for speech-language pathology services. However, views regarding the preference for face-to-face delivery were divided.Conclusion: SLPs view telepractice as a viable service delivery model for PwPD, but uptake of the model is variable. Several key barriers and resource limitations must be addressed to facilitate the implementation and sustainability of telepractice in clinical services.

“Getting Everyone on the Same Page”: Child Welfare Workers’ Collaboration Challenges on Cases Involving Intimate Partner Violence

Child welfare professionals frequently serve families experiencing intimate partner violence (IPV). As such, collaboration with other types of providers as part of a larger network of IPV responders is often necessary, though can be challenging for various reasons. The present study explores child welfare workers’ perspectives on collaboration challenges specific to child welfare cases that also involve IPV. Data were drawn from the fourth wave of the Florida Study of Professionals for Safe Families, a longitudinal study of child welfare workforce retention. Authors explored qualitative short responses of 493 child welfare workers with active caseloads who reported ever working on cases with IPV. Participants cited communication, complexity of IPV cases, participation in the collaborative process, and competence as the most challenging aspects of IPV case collaboration. Tensions between child welfare agencies and victim advocacy services were noted throughout. Findings suggest opportunities for sustained engagement to facilitate understanding of responder roles and responsibilities may alleviate some collaboration challenges corroborated by previous research. However, local needs assessments inclusive of all responder roles would better identify community-specific challenges, leading to more tailored intervention strategies to improve responder collaborations.

Making the Case for Specialized Caseloads Among Vocational Rehabilitation Counselors Working With Ex-Offenders: A Pilot Study

Purpose:This article outlines findings from a sample of 137 vocational rehabilitation counselors regarding their stigmatizing attitudes, burnout levels, work experience, caseload composition, and working alliance with clients who have a range of disabilities and a criminal history.Method:Electronic surveys were sent to vocational rehabilitation counselors in 3 states who met the following criteria: counselors with a master’s degree, counselors with diverse and active caseloads, and counselors from geographically diverse states. Data were analyzed using 2-tailed correlation analysis and subsequent regression analysis.Results:VR counselors with more ex-offenders on their caseloads did not have higher stigma or burnout but, surprisingly, did have stronger working alliance.Conclusion:Findings support further research to confirm if specialized caseloads comprised of clients with criminal histories enhance working alliances among VR counselors.

Routine multidisciplinary cerebrovascular meetings do not reduce aneurysm clipping case load: a cohort study.

Structured multidisciplinary care is an increasingly popular tool in the management of many complex disease processes; however, there is little published data regarding the effects of such a process on management of intracranial aneurysms and neurosurgical case loads. There is some resistance in the neurosurgical community to routine involvement of interventional neuroradiologists in the care of patients with intracranial aneurysms due to concerns regarding maintenance of neurosurgical case loads and training capabilities. At our tertiary Australian hospital, we have implemented a weekly multidisciplinary cerebrovascular meeting (MDCVM) facilitating routine discussion of these cases between neurosurgeons and interventional neuroradiologists. This study identified management modalities for ruptured and unruptured cerebral aneurysms diagnosed at our centre for a 2-year period before and after the implementation of MDCVM culminating in a 4-year retrospective cohort study. The pre- and post-MDCVM cohorts were well matched for demographics with 162 and 224 patients, respectively. There is no significant difference in percentage or absolute numbers of endovascular or surgical cases in the pre-MDCVM (103; 73.0% versus 38; 27.0%, respectively) or post-MDCVM cohorts (105; 79.5% versus 27; 20.5%, respectively), reflecting a maintained surgical case load after the implementation of MDCVM (P = 0.21). There were no significant differences in any confounding variables including age, sex, aneurysm size/location, Fisher or World Federation of Neurosurgical Societies (WFNS) grade. Implementation of MDCVM did not impact on active management case loads with consistent numbers and percentages for both endovascular and microsurgical management.

Implementation science: issues of fidelity to consider in community nursing.

Programme implementation is a complex process, and literature around the area of implementation science is growing, particularly with respect to programme fidelity (Dusenbury et al, 2003; Carroll et al, 2007). This paper draws on the findings from an evaluation in one area involving restructuring of the Public Health Nursing service from a generalist, geographically based service, to a team-based specialist approach. From this evaluation, it is clear that careful consideration must be given to a number of key issues that could arise in moving from a pilot project to a more mainstream or widescale implementation. These issues could relate to workforce planning; the role of the team leader; formation, maintenance, and development of teams; expertise and knowledge, including knowledge of local communities; active caseload management; continuity across a range of areas; alignment with primary care teams; co-location; and the need for support, particularly in the IT infrastructure.

A hidden face of community mental health care in Africa: specialist care from private providers in Kenya

In their systematic review of community mental health care in Africa, published in World Psychiatry, Hanlon et al 1 point out that “in the low-income countries of the Africa region, community mental health care is largely restricted to mental health care delivered by primary care workers, with specialist mental health workers (usually psychiatrists and psychiatric nurses) tending to provide care through hospital-based outpatient clinics”. An article by McDaid et al 2, also published in the journal, notices that non-governmental organizations can support primary care by “building on social capital in communities”. A hidden face of community mental health care in Africa, however, is specialist care from private providers, especially psychiatrists and psychiatric nurses. A good example is Kenya, where three quarters of doctors and two thirds of nurses work in the private sector 3. We administered a structured interview, between July and September 2012, to 11 private mental health specialists (8 psychiatrists, 3 psychiatric nurses), sampled using snow-balling. Five of them were from Nairobi and six – including all nurses – from central province. Three of them were women. Their average age was 46 years, and time in private sector 9.2 years. Respondents had a mean active case load of 128 mental health patients, and the mean number of mental health patients seen per clinic day was 5. The leading diagnosis for which 55% of people attended private clinics was common mental disorders, while 25% had severe mental disorders, 15% substance use disorders, and 5% epilepsy, child mental disorders or mental retardation. Slightly over half (56%) were women, representing a departure from psychiatric hospitals, where the majority are men affected by psychosis 4. In a context where the term “mental” is associated with psychotic behaviour, a private clinic in the community may offer a less stigmatizing option of care. Privately owned clinics are also more “private” to clients in that care can be sought with greater confidentiality. Private clinics operated on average 24 hours per week (range 12-40), and specialists saw their patients for an average of one hour on the first visit (range 50-90 minutes) and half an hour at follow-up (range 15-45 minutes). Typical wait time was 20 minutes (range 3-60 minutes). Patients were followed up on average monthly (maximum every 8 weeks). In the previous month, respondents referred a mean of 13% of clients for hospitalization. Two out of the three psychiatric nurses ran general health clinics, with only 5% of patients seen for mental health reasons. The third ran an exclusively mental health clinic. The mean fee of Int$ 13.0 (Ksh 500) charged by psychiatric nurses represents approximately 2.5 days work by an unskilled agricultural labourer 5 – a significant, but not unattainable sum. The average psychiatrist fee of Int$ 55.3 (Ksh 2,100) (higher in Nairobi than the province) represents one month's salary for the same agricultural worker, making it inaccessible to most. Nearly two thirds of respondents modulated fees, based on session length and ability to pay, judged in part by patient occupation. We found a large cross-over between private and public sectors: eight out of the eleven private specialists split their time with the public sector. Six of them said the care they offered in private practice was different – mainly with a greater choice of drugs, especially atypical antipsychotics. One respondent noted: “At government clinics, prescriptions are dictated by the available medications”. Continuity of care was also highlighted: “I am able to constantly follow the client”. In a context of under-paying public health providers, private employment may be seen as cross-subsidizing public health care.