Collaborative Care Network Research Articles

A sense of injustice in care networks: An intersectional exploration of the collaboration between professionals and carers with a migration background.

This study tries to understand the power of knowledge within collaborative care networks to provide insights for designing successful collaboration within care networks by combining intersectionality and epistemic (in)justice. Becoming an informal carer for someone with an acquired brain injury (ABI) causes a dramatic disruption of daily life. Collaboration between professionals and carers with a migration background may result in unjust and unfair situations within care networks. Carer experiences are shaped by aspects of diversity which are subject to power structures and processes of social (in)justice in care networks. In this study, intersectionality was used to both generate complex in-depth insights into the different active layers of carer experiences and focus on within-group differences. Intersectionality was combined with the theoretical concept of epistemic (in)justice to unravel underlying dynamics in collaborative care networks contributing to the understanding that carers with a migration background are often not seen as ‘knowers of reality.’ This qualitative study conducted in the Netherlands between 2019 and 2022 incorporated three informal group conversations (N = 32), semi-structured interviews (N = 21), and three dialogue sessions (N = 7) with carers caring for someone with an ABI. A critical friend and a community of practice, with carers, professionals, and care recipients (N = 8), contributed to the analysis. Three interrelated themes were identified as constituting different layers of the carer experience: (a) I need to keep going, focusing on carers' personal experiences and how experiences were related to carers social positioning; (b) the struggle of caring together, showing how expectations of family members towards carers added to carer burden; and (c) trust is a balancing act, centering on how support from professionals shaped carers' experiences, in which trusting professionals' support proved challenging for carers, and how this trust was influenced by contextual factors at organizational and policy levels. Overall, the need for diversity-responsive policies within care organizations is apparent. Carers with a migration background need to feel heard so they can meaningfully tailor care to meet recipients' needs.

Quality indicators for collaborative care networks in persistent somatic symptoms and functional disorders: a modified delphi study

BackgroundCare for persistent somatic symptoms and functional disorders (PSS/FD) is often fragmented. Collaborative care networks (CCNs) may improve care quality for PSS/FD. Effectiveness likely depends on their functioning, but we lack a straightforward quality evaluation system. We therefore aimed to develop quality indicators to evaluate CCNs for PSS/FD.MethodUsing an online three-round modified Delphi process, an expert panel provided, selected and ranked quality indicators for CCNs in PSS/FD. Recruited experts were diverse healthcare professionals with relevant experience in PSS/FD care in the Netherlands.ResultsThe expert panel consisted of 86 professionals representing 15 disciplines, most commonly physiotherapists, psychologists and medical specialists. 58% had more than 10 years experience in PSS/FD care. Round one resulted in 994 quotations, which resulted in 46 unique quality indicators. These were prioritised in round two and ranked in round three by the panel, resulting in a final top ten. The top three indicators were: “shared vision of care for PSS/FD”, “pathways tailored to the individual patient”, and “sufficiently-experienced caregivers for PSS/FD”.ConclusionsThe identified quality indicators to evaluate CCNs in the field of PSS/FD can be implemented in clinical practice and may be useful in improving services and when assessing effectiveness.

Perceptions of Educational Needs in an Era of Shifting Mental Health Care to Primary Care: Exploratory Pilot Study.

BackgroundThere is an unmet need for mental health care in Canada. Primary care providers such as general practitioners and family physicians are the essential part of mental health care services; however, mental health is often underestimated and underprioritized by family physicians. It is currently not known what is required to increase care providers’ willingness, comfort, and skills to adequately provide care to patients who present with mental health issues.ObjectiveThe aim of this study was to understand the need of caregivers (family members overseeing care of an individual with a mental health diagnosis) and family physicians regarding the care and medical management of individuals with mental health conditions.MethodsA needs assessment was designed to understand the educational needs of caregivers and family physicians regarding the provision of mental health care, specifically to seek advice on the format and delivery mode for an educational curriculum to be accessed by both stakeholder groups. Exploratory qualitative interviews were conducted, and data were collected and analyzed iteratively until thematic saturation was achieved.ResultsCaregivers of individuals with mental health conditions (n=24) and family physicians (n=10) were interviewed. Both the caregivers and the family physicians expressed dissatisfaction with the status quo regarding the provision of mental health care at the family physician’s office. They stated that there was a need for more educational materials as well as additional support. The caregivers expressed a general lack of confidence in family physicians to manage their son’s or daughter’s mental health condition, while family physicians sought more networking opportunities to improve and facilitate the provision of mental health care.ConclusionsRobust qualitative studies are necessary to identify the educational and medical management needs of caregivers and family physicians. Understanding each other’s perspectives is an essential first step to collaboratively designing, implementing, and subsequently evaluating community-based mental health care. Fortunately, there are initiatives underway to address these need areas (eg, websites such as the eMentalHealth, as well as the mentorship and collaborative care network), and information from this study can help inform the gaps in those existing initiatives.

Report on a new remote collaborative medical care system -construction and operation of a remote collaborative medical care network for inflammatory bowel disease using information and communication technology in Hokkaido

Inflammatory bowel disease (IBD) comprises 2 major types-ulcerative colitis (UC) and Crohn's disease (CD). A remote collaborative medical care fee has been established for patients with suspected intractable diseases since 2020. Remote collaborative medical care is a type of telemedicine wherein a hospital specialist for intractable diseases, the patient, and an attending physician at a community hospital communicate via video calls. In IBD cases, however, treating patients who have already been diagnosed with severe or intractable diseases is difficult. As a part of the Hokkaido Intractable Disease Medical Care System Development Project, we have started providing free remote collaborative medical care services for all IBD patients, including those with a confirmed diagnosis and attending regional hospitals. We set up the telemedicine system using Microsoft365, a commercial cloud, and Nextcloud, a PaaS, to ensure robust security and enable rapid and massive sharing of medical details by information and communication technology. Since April 2021, we have examined 27 patients (36 times). Among these patients, 5 patients from regional hospitals were undiagnosed (1 patient of suspected CD, 3 patients of suspected IBD unclassified (IBD-U), and 1 patient of undiagnosed enteritis). Twenty-two patients from regional hospitals had a confirmed diagnosis (17 UC and 5 CD patients). Eight patients required a second time remote collaborative medical care, and 1 patient required a third time remote collaborative medical care. There was no equipment failure such as communication failure or system trouble, and all patients could be examined smoothly. The maintenance cost of the telemedicine system was 2500yen/month per hospital. Among all cases receiving remote collaborative medical care, 86% were consultations for refractory or severe active cases with a confirmed diagnosis of IBD. At present, the remote collaborative medical care fee for diagnosed patients is not permitted. Since remote collaborative medical care has the potential to correct regional disparities in medical standards, there is an urgent need to review the criteria for remote collaborative medical care fees.

Impact of Multicenter Diagnostic Workup on Time-to-Diagnosis and Time-to-Treatment in Patients with Pancreatic Ductal Adenocarcinoma: A Nationwide Analysis

Background: Due to centralization of pancreatic surgery, patients with suspected pancreatic cancer may undergo multicenter diagnostic workup, i.e. in both a local hospital and a pancreatic expert center. The aim of this study was to assess whether this multicenter diagnostic workup is associated with repetition of diagnostics, a prolonged diagnostic phase, and treatment delay. Materials and methods: This retrospective study included all patients diagnosed with non-metastatic pancreatic ductal adenocarcinoma (PDAC) in 2015, registered in the Netherlands Cancer Registry. Multicenter diagnostic workup was defined as diagnostic investigations in both a local hospital and a pancreatic expert center. A prolonged diagnostic phase was defined as ≥3 weeks from initial hospital visit to final diagnosis. A delayed time-to-treatment was defined as ≥6 weeks from the first hospital visit to start of tumor treatment. Multivariable logistic regression analyses were performed. Results: In total, 951 patients were included. Nineteen percent (n=181) underwent multicenter diagnostic workup. Significantly more patients with a multicenter workup had a prolonged diagnostic phase (70% vs 56%, P<0.01) and a delayed time-to-treatment (76% vs 64%, P<0.01) when compared with patients with monocenter workup. In multivariate analysis, multicenter diagnostic workup was a strong risk factor for a delayed diagnostic phase (OR=2.4; 95%CI 1.64–3.52, P<0.001). Conclusion: Multicenter diagnostic workup for patients suspected of PDAC is associated with a delayed time-to-diagnosis and delayed time-to-treatment compared to patients with monocenter diagnostic workup. These preliminary results suggest that pancreatic expert centers and local hospitals may need to improve their collaborative pancreatic care network. Note: These are preliminary results, we will analyse associations between multicenter diagnostics and the repetition of diagnostic investigations, delayed time-to-treatment (adjusted for covariates) and survival. Multilevel analysis will be performed, which will reveal how much variation in the outcome can be attributed to the different pancreatic cancer networks (expert hospital+ non-expert hospitals).

Guidelines and scientifically-based spina bifida care: Guidance across the lifespan in a global health context

The COVID-19 pandemic has reminded us that, if of nothing else, we live in a globalized community. Enthusiasm for evidenced-based medical knowledge is also contagious. Just as the incidence of SARS-CoV-2, the associated coronavirus, has had a borderless impact on global public health, so too neural tube defects have widespread significance. Previously, the concept of "blue marble health" was introduced as a policy framework to illustrate trends in the geographic distribution of health disparities affecting at-risk populations that live, not only in low-income countries, but also in pockets of the populace in wealthier nations. Subsequently, the Spina Bifida Association's Collaborative Care Network, through a cooperative agreement with the Centers for Disease Control and Prevention, recently produced the "Guidelines for the Care of People with Spina Bifida." While language differences, immigration, cultural beliefs, acculturation, local resources and social determinants of health, must be taken into account when these guidelines are implemented across the globe, they could not come at a more suitable time. The current digital age, as well as open access to this special issue, will ensure their ongoing wide distribution.

Medication management needs information and communications technology-based approaches, including telehealth and artificial intelligence.

Life expectancy is rising in most parts of the world as is the prevalence of chronic diseases. Suboptimal adherence to long‐term medications is still rather the norm than the exception, although it is well known that suboptimal adherence compromises the therapeutic effectiveness. Information and communications technology provides new concepts for improving adherence to medications. These so‐called telehealth concepts or services help to implement closed‐loop healthcare paradigms and to establish collaborative care networks involving all stakeholders relevant to optimising the overall medication therapy. Together with data from Electronic Health Records and Electronic Medical Records, these networks pave the way to data‐driven decision support systems. Recent advances in machine learning, predictive analytics, and artificial intelligence allow further steps towards fully autonomous telehealth systems. This might bring advances in the future: disburden healthcare professionals from repetitive tasks, enable them to timely react to critical situations, and offer a comprehensive overview of the patients' medication status. Advanced analytics can help to assess whether patients have taken their medications as prescribed, to improve adherence via automatic reminders. Ultimately, all relevant data sources need to be collated into a basis for data‐driven methods, with the goal to assist healthcare professionals in guiding patients to obtain the best possible health status, with a reasonable resource utilisation and a risk‐adjusted safety and privacy approach. This paper summarises the state‐of‐the‐art of telehealth and artificial intelligence applications in medication management. It focuses on 3 major aspects: latest technologies, current applications, and patient related issues.

Collaborative care for child and youth mental health problems in a middle-income country: study protocol for a randomized controlled trial training general practitioners

BackgroundChild and youth mental health problems are leading causes of disability and particular problems in low- and middle-income countries where populations are young and child mental health services are in short supply. Collaborative care models that support primary care providers’ efforts to detect and treat child mental health problems offer one way to address this need. However, collaborative care for child mental health can be more complex than collaboration for adults for a number of reasons, including two-generational aspects of care, high degrees of co-morbidity, and variations in presentation across developmental stages.MethodsThe study takes advantage of an existing collaborative care network in Tehran, Iran, in which general practitioners are supported by community mental health centers to care for adult mental health problems. At present, those practitioners are asked to refer children with mental health problems to the collaborating centers rather than treating them themselves. We are conducting a cluster randomized trial in which practitioners in the network will be randomized to receive training in child/youth mental health treatment or a booster training on recognition and referral. Children/youth aged 5–15 years making visits to the practitioners will be screened using the Strengths and Difficulties Questionnaire; those found positive will be followed for six months to compare outcomes between those treated by trained or control practitioners.DiscussionIf the trial demonstrates superior outcomes among children treated by trained practitioners, it will support the feasibility of expanding collaborative care networks to include children.Trial registrationClinicalTrials.gov, NCT03144739. Registered on 8 May 2017.

Scientific methodology of the development of the Guidelines for the Care of People with Spina Bifida: An initiative of the Spina Bifida Association

BackgroundWe combined literature review and consensus-building methodologies to develop health care guidelines for people with Spina Bifida across the life span. ObjectiveThe present paper describes the methodology used to update and expand this fourth edition of the Guidelines for the Care of People with Spina Bifida (“Guidelines”). This process was a fundamental initiative within the Spina Bifida Collaborative Care Network. MethodsWorking groups were formed consisting of international, multidisciplinary teams of clinical and research experts. A systematic review of multiple databases was conducted. The consensus building methodology, One-Text Procedure, was followed to draft and revise documents. Each section of the Guidelines was presented by working group chairs at a face-to-face meeting using the Nominal Group Technique (NGT). ResultsThe Level 1 review resulted in 2449 abstracts being reviewed, and the Level 2 review resulted in 874 full text articles being archived for working groups. After working groups added and eliminated articles, a total of 803 manuscripts were included in the bibliography of the Guidelines. The final version of the Guidelines was then released in 2018. ConclusionsEvidenced based-research and consensus methodologies were used to develop the fourth edition of the Guidelines. It is hoped that this document will guide not only health care providers, but also patients and families, so that people with Spina Bifida can have the best and most scientifically-based care and treatments throughout ever-longer and higher-quality lives.

Towards Integrated Care for Chronic Patients in Belgium: The Pilot Project, an Instrument Supporting the Emergence of Collaborative Networks

In 2015, the Belgian Health Ministers launched a plan intended to evolve towards an integrated care system for chronic patients. This plan is implemented through pilot projects involving local actors. Therefore, the researcher raised the following research question: how does the use of pilot projects as implementation instruments structure the collaboration between parties involved in a pilot project? The term “pilot project” refers to a collaborative work method coupled with an experimentation purpose. This is further developed in the paper via a literature study. This qualitative research draws on interviews, focus groups, direct observation, and a documentary analysis. During the two first phases of the process, field workers had to create multidisciplinary local consortia and write an application file describing the project they would implement during the third phase, which raised challenging collaboration issues. Many people learned to work together over time, progressively overcoming the traditional fragmentation of care. They met regularly, understood their respective roles, and dealt with controversies through negotiation to reach an agreement on a common project. In conclusion, the researcher shows that, thanks to its characteristics, the pilot project instrument supports the development of collaborative care networks; in this example of community-based integrated care networks.

Children and adolescents' mental health in Iran's primary care: Perspectives of general practitioners, school staff and help seekers.

Iran has well-established networks for primary care staffed by general practitioners who provide services to patients across the lifespan. Iran recently established collaborative care networks to build general practitioners' capacity to provide adult mental health services. In an NIH-funded study, we are designing and evaluating a training program for general practitioners (GPs) to extend this collaboration to include services for children and adolescents. In the formative phase of this project, we conducted a qualitative study to obtain information relevant to the design of the training program. We conducted semi-structured individual interviews with 28 stakeholders; including 15 GPs working in a collaborative care network, 6 parents and 4 adolescents who had received child mental health care from a GP, and 3 policymakers. We also held a focus group discussion with 8 school teachers and counselors. All interviews were transcribed during the interviews' sessions and then were thematically analyzed. GPs reported seeing a range of child emotional and behavioral problems but felt the need for additional training in diagnosis and management, especially in skills for interviewing and communicating with children. GPs also expressed the need to understand legal issues involved in treating children, including cases of possible child abuse. School staff agreed that GPs could help with children's educational and emotional problems but also believed GPs would need extra training. Parents indicated a preference for GPs over psychiatrists (as did adolescents) as a source of mental health care, and for psychological over pharmacological interventions. Adolescents expressed a preference not to speak about private issues in the presence of their parents, and expressed concern that the GPs did not respect their preference. They also desired a more active role during visits. Before expanding the scope of practice of Iranian GPs to provide management of common emotional and behavioral problems in children and adolescents, the concerns and specific needs of these practitioners need to be addressed. Parents and youth in the study expressed a preference for mental health care from a GP rather than a specialist. However, they also commented on the need for restructuring the current GP visits to facilitate youth participation. These findings provide directions for expanding the scope of practice of adult collaborative care networks to meet the mental health care needs of children and adolescents more expeditiously and effectively.

Comparison of Inter-hospital Urological Transfers Between a Metropolitan and Rural Tertiary Care Institution

IntroductionUrological services are not available at all hospitals, and the transfer of patients between medical centers provides an avenue to meet medical need. In rural areas, patients often visit community medical centers with limited services and require transfer. We aimed to compare the transfer process between two tertiary care institutions, one serving a metropolitan and the other a rural population. MethodsTwo academic medical centers were selected, one which primarily services a large metropolitan city center, while the second primarily services a large rural population. Transfer logs for the urological services from September 2015 to September 2017 were compared. Records were examined for an affiliated urologist at the originating hospital, distance traveled, reason for transfer, and the need for surgical management. Variables were analyzed using descriptive statistics. ResultsOverall, 606 transfers were included, with 16% (97/606) transferred to the metropolitan center and 84% (509/606) to the rural center. Patients transferred to the rural center were younger (53.3 versus 61.9; p<0.001) and traveled further (64.2 versus 36.5 miles; p<0.001) compared to the metropolitan site. Hospitals referring patients to the rural center were less likely to have an affiliated urologist (66.7% versus 91.1%; p=0.008). 38% of patients were surgically managed which was not different between the institutions. ConclusionsDifferences exist between transfers to the rural and metropolitan center, suggesting an increased need for basic urological services in the surrounding rural community. At both centers, most patients did not require a procedure and might avoid transfer through telehealth or collaborative care networks.

Co-Designing a Collaborative Chronic Care Network (C3N) for Inflammatory Bowel Disease: Development of Methods.

BackgroundOur health care system fails to deliver necessary results, and incremental system improvements will not deliver needed change. Learning health systems (LHSs) are seen as a means to accelerate outcomes, improve care delivery, and further clinical research; yet, few such systems exist. We describe the process of codesigning, with all relevant stakeholders, an approach for creating a collaborative chronic care network (C3N), a peer-produced networked LHS.ObjectiveThe objective of this study was to report the methods used, with a diverse group of stakeholders, to translate the idea of a C3N to a set of actionable next steps.MethodsThe setting was ImproveCareNow, an improvement network for pediatric inflammatory bowel disease. In collaboration with patients and families, clinicians, researchers, social scientists, technologists, and designers, C3N leaders used a modified idealized design process to develop a design for a C3N.ResultsOver 100 people participated in the design process that resulted in (1) an overall concept design for the ImproveCareNow C3N, (2) a logic model for bringing about this system, and (3) 13 potential innovations likely to increase awareness and agency, make it easier to collect and share information, and to enhance collaboration that could be tested collectively to bring about the C3N.ConclusionsWe demonstrate methods that resulted in a design that has the potential to transform the chronic care system into an LHS.

Improving Depression Care for Adults With Serious Mental Illness in Underresourced Areas: Community Coalitions Versus Technical Support.

Community Partners in Care (CPIC) was a group-randomized study of two approaches to implementing expanded collaborative depression care: Community Engagement and Planning (CEP), a coalition approach, and Resources for Services (RS), a technical assistance approach. Collaborative care networks in both arms involved health care and other agencies in five service sectors. This study examined six- and 12-month outcomes for CPIC participants with serious mental illness. This secondary analysis focused on low-income CPIC participants from racial-ethnic minority groups with serious mental illness in underresourced Los Angeles communities (N=504). Serious mental illness was defined as self-reported severe depression (≥20 on the Patient Health Questionnaire-8) at baseline or a lifetime history of bipolar disorder or psychosis. Logistic and Poisson regression with multiple imputation and response weights, controlling for covariates, was used to model intervention effects. Among CPIC participants, 50% had serious mental illness. Among those with serious mental illness, CEP relative to RS reduced the likelihood of poor mental health-related quality of life (OR=.62, 95% CI=.41-.95) but not depression (primary outcomes); reduced the likelihood of having homelessness risk factors and behavioral health hospitalizations; increased the likelihood of mental wellness; reduced specialty mental health medication and counseling visits; and increased faith-based depression visits (each p<.05) at six months. There were no statistically significant 12-month effects. Findings suggest that a coalition approach to implementing expanded collaborative depression care, compared with technical assistance to individual programs, may reduce short-term behavioral health hospitalizations and improve mental health-related quality of life and some social outcomes for adults with serious mental illness, although no evidence was found for long-term effects in this subsample.

Are Your Patients Using ‘Digital Supplements’?

Are Your Patients Using ‘Digital Supplements’?

CMS Proposes Rule to Reimburse for Psychiatric Collaborative Care

CMS Proposes Rule to Reimburse for Psychiatric Collaborative Care

‘Curbside’ Consults With Primary Care Involve Quick Response, Education

Psychiatrists working in collaborative care networks must be readily available to primary care physicians who are seeking guidance on a patient’s treatment.

Board Takes Action on Wide Range of Issues

Board Takes Action on Wide Range of Issues

Chapter 37 - Functional (psychogenic) dizziness

Functional and psychiatric disorders that cause vestibular symptoms (i.e., vertigo, unsteadiness, and dizziness) are common. In fact, they are more common than many well-known structural vestibular disorders. Neurologists and otologists are more likely to encounter patients with vestibular symptoms due to persistent postural-perceptual dizziness or panic disorder than Ménière's disease or bilateral vestibular loss. Successful approaches to identifying functional and psychiatric causes of vestibular symptoms can be incorporated into existing practices without much difficulty. The greatest challenge is to set aside dichotomous thinking that strongly emphasizes investigations of structural diseases in favor of a three-pronged approach that assesses structural, functional, and psychiatric disorders simultaneously. The pathophysiologic mechanisms underlying functional and psychiatric causes of vestibular symptoms are better understood than many clinicians realize. Research methods such as advanced posturographic analysis and functional brain imaging will push this knowledge further in the next few years. Treatment plans that include patient education, vestibular rehabilitation, cognitive and behavioral therapies, and medications substantially reduce morbidity and offer the potential for sustained remission when applied systematically. Diagnostic and therapeutic approaches are necessarily multidisciplinary in nature, but they are well within the purview of collaborative care teams or networks of clinicians coordinated with the neurologists and otologists whom patients consult first.

Collaborative stepped care for somatoform disorders: A pre–post-intervention study in primary care

ObjectiveThe successful management of somatoform disorders in primary care is often limited due to low diagnostic accuracy, delayed referral to psychotherapy, and unstructured overuse of health care. This study aimed to investigate the feasibility of establishing a collaborative stepped health care network for somatoform disorders, and its impact on the diagnostic process and treatment recommendations in primary care. MethodThe Network for Somatoform and Functional Disorders (Sofu-Net) was established to connect 41 primary care physicians (PCP), 35 psychotherapists, and 8 mental health clinics. To evaluate Sofu-Net, primary care patients at high risk of having a somatoform disorder were identified using the Patient Health Questionnaire, and were assessed in detail at the patient and PCP level. Discussion of psychosocial distress in the consultations, diagnostic detection rates and treatment recommendations were compared before and 12months after establishing the network. ResultsOut of the pre- (n=1645) and 12-months-post Sofu-Net patient samples (n=1756), 267 (16.2%) and 269 (15.3%) high-risk patients were identified. From these, 156 and 123 patients were interviewed and information was assessed from their PCP. Twelve months after Sofu-Net establishment, high-risk patients more frequently discussed psychosocial distress with their PCP (63.3% vs. 79.2%, p<.001). PCPs prescribed more antidepressants (3.8% vs. 25.2%, p<.001) and less benzodiazepines (21.8% vs. 6.5%, p<.001). Sofu-Net did not affect PCP's diagnostic detection rates or recommendation to initiate psychotherapy. ConclusionThe study results indicate feasibility of an interdisciplinary network for somatoform disorders. Collaborative care networks for somatoform disorders have the potential to improve doctor–patient-communication and prescription behavior.