Integrated Care Clinics Research Articles

To Print or Not to Print - Sustainable Practice in Geriatric Integrated Care Clinics

Abstract Background The Comprehensive Geriatric Assessment (CGA) is a cornerstone of geriatric medicine and is frequently carried out in integrated care clinics using a paper document (1). The expansion of integrated care services occurs alongside climate change, an increasingly challenging public health crisis at a local and national level (2). Paper waste is a contributor to deforestation and carbon emissions. We aimed to assess the environmental impact of paper use within our geriatric integrated care service. Methods 12 months of Geriatric Integrated Care attendances were included between 1st January 2023 to 1st January 2024. We measured the number of CGAs performed and A4 pages used in documentation. Environmental impact was evaluated based on carbon emissions per A4 page (3). Results A CGA was completed on 780 patients in a 12-month period which included in-hospital, frailty at the front door and 2 community specialist teams' assessments. This resulted in 11,700 pages of A4 paper in documentation. Estimated carbon emissions are 70.2kg CO2 emissions for the 12-month period. Extrapolating this solely to the 32 ICPOP teams in geriatric medicine in Ireland it would result in the equivalent of 22 trees per year, emitting 1,123.2 Kg of CO2 emissions per year from these assessments alone or equivalent to driving 8028.6km (4). Conclusion The benefits for patients and staff of integrated digital healthcare records are well established. The environmental impact of how we provide healthcare is not. Paperless solutions are required for both patient safety, seamless record keeping and environmental sustainability in keeping with UN sustainable development goals.

Long-term impact of an integrated HIV/non-communicable disease care intervention on patient retention in care and clinical outcomes in East Africa.

To describe rates of retention in care and control of hypertension, diabetes and HIV among participants receiving integrated care services for a period of up to 24 months in East Africa. Between 5 October 2018 and 23 June 2019 participants enrolled into a prospective cohort study evaluating the feasibility of integrated care delivery for HIV, diabetes and hypertension from a single point of care in Tanzania and Uganda (MOCCA study). Integrated care clinics were established in 10 primary healthcare facilities and care was provided routinely according to national guidelines. Initial follow-up was 12 months. Outcomes were rates of retention in care, proportions of participants with controlled hypertension (blood pressure <140/90 mmHg), diabetes (fasting blood glucose <7.0 mmol/L) and HIV (plasma viral load <1000 copies/ml). The study coincided with the COVID-19 pandemic response. Afterwards, all participants were approached for extended follow-up by a further 12 months in the same clinics. We evaluated outcomes of the cohort at the end of long-term follow-up. The MOCCA study enrolled 2273 participants of whom 1911 (84.5%) were retained in care after a median follow-up of 8 months (Interquartile range: 6.8-10.7). Among these, 1283/1911 (67.1%) enrolled for a further year of follow-up, 458 (24.0%) were unreachable, 71 (3.7%) reverted to vertical clinics (clinics providing services dedicated to study conditions), 31 (1.6%) died and 68 (3.6%) refused participation. Among participants who enrolled for longer follow-up, mean age was 51.4 ± 11.7 years, 930 (72.5%) were female and 509 (39.7%) had multiple chronic conditions. Overall, 1236 (96.3%) [95% confidence interval 95.2%-97.3%] participants were retained in care, representing 1236/2273 (54.3%) [52.3%-56.4%] of participants ever enrolled in the study. Controlled hypertension, diabetes and HIV at the end of follow-up was, 331/618 (53.6%) [49.5%-57.5%], 112/354 (31.6%) [26.8%-36.8%] and 332/343 (96.7%) [94.3%-98.4%] respectively. Integrated care can achieve high rates of retention in care long term, but control of blood pressure and blood sugar remains low.

Benefits of expanding behavioral health screening in a pediatric diabetes clinic to include anxiety and caregiver reports in youth 12 years and younger.

Depression and anxiety among youth with Type 1 diabetes (T1D) are associated with poor diabetes management. Further guidance regarding psychosocial screening measures would benefit pediatric integrated care clinics. The purpose of this exploratory study was to examine whether screening for anxiety, assessing caregiver reports, and screening children 12 years old and younger could identify a larger percentage of youth who may benefit from behavioral health support compared to the standard approach of only screening youth 13 and older for depression. Sixty-five youth 8-17 years old with T1D (N = 65; M = 13.2 years; 55.4% females) and their caregivers (75% mothers) completed validated self-report and proxy-report depression and anxiety screeners during routine clinic visits between 2019 and 2021. Twenty-seven youth aged 13-17 also completed a measure of diabetes-related distress. The standard approach of screening youth aged 13-17 for depression via self-report identified 25.6% of participants, whereas screening youth ages 8-17 for depression and anxiety via self- and proxy-reports identified 47.7%. Screening for depression/anxiety identified unique portions of youth independent of diabetes distress. Utilizing anxiety and proxy-report measures may identify youth likely to benefit from behavioral health support who are not identified when only a self-report depression measure is used in screening. Research should evaluate whether utilizing multiple measures and screening children under 13 years old improve detection and connection to care for youth experiencing difficulty managing diabetes. Early identification and intervention could subsequently mitigate the negative impacts of social-emotional difficulties on diabetes management. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

92 ‘Greenprint’ for integrated care clinics—the hub and spoke model

Abstract Background Climate change is a major public health crisis requiring attention at an individual, local and national policy level. Transport is the largest source of energy related carbon emissions in Ireland. The development of integrated care occurs alongside climate emergency. Care previously delivered in hospital outpatients, or a central ‘hub’ is now being delivered in integrated care clinics, ‘spokes’. We aimed to assess the environmental impact of transport to integrated care clinics compared to travel to hospital clinic. Methods Geriatric Medicine Integrated Care attendances from January 2023 to March 2023 were included. Distance from the patient’s home address to the location of Integrated Care Clinic (spoke), and to the affiliated hospital (hub) were recorded in kilometres. For the primary analysis we have not considered staff travel as there was heterogeneity in number of staff per clinic and distance travelled per staff member. Where more than one route was available, the shortest distance was recorded. Carbon emissions were estimated based on kilometres travelled by a standard new passenger car. Results Among 206 clinic attendances, the mean distance to ‘spoke’ clinic was 16.06 km (15.98). The mean distance to the ‘hub’ clinic was 39.29 km (17.82). The estimated total distance travelled by patients to integrated care clinics was 3293.45 km, whereas the distance which would have been travelled to ‘hub’ clinics was 8055.85 km. Total carbon emissions for 3 month travel to ‘spoke’ clinics were estimated at 371 kg, compared to 907 kg to the ‘hub’. Conclusion The development of integrated care services, which provides necessary care to older adults, may also have an environmental advantage. Healthcare’s contribution to climate change action is another incentive to invest in integrated care services.

Implementing integrated care clinics for HIV-infection, diabetes and hypertension in Uganda (INTE-AFRICA): process evaluation of a cluster randomised controlled trial

BackgroundSub-Saharan Africa is experiencing a dual burden of chronic human immunodeficiency virus and non-communicable diseases. A pragmatic parallel arm cluster randomised trial (INTE-AFRICA) scaled up ‘one-stop’ integrated care clinics for HIV-infection, diabetes and hypertension at selected facilities in Uganda. These clinics operated integrated health education and concurrent management of HIV, hypertension and diabetes. A process evaluation (PE) aimed to explore the experiences, attitudes and practices of a wide variety of stakeholders during implementation and to develop an understanding of the impact of broader structural and contextual factors on the process of service integration.MethodsThe PE was conducted in one integrated care clinic, and consisted of 48 in-depth interviews with stakeholders (patients, healthcare providers, policy-makers, international organisation, and clinical researchers); three focus group discussions with community leaders and members (n = 15); and 8 h of clinic-based observation. An inductive analytical approach collected and analysed the data using the Empirical Phenomenological Psychological five-step method. Bronfenbrenner’s ecological framework was subsequently used to conceptualise integrated care across multiple contextual levels (macro, meso, micro).ResultsFour main themes emerged; Implementing the integrated care model within healthcare facilities enhances detection of NCDs and comprehensive co-morbid care; Challenges of NCD drug supply chains; HIV stigma reduction over time, and Health education talks as a mechanism for change. Positive aspects of integrated care centred on the avoidance of duplication of care processes; increased capacity for screening, diagnosis and treatment of previously undiagnosed comorbid conditions; and broadening of skills of health workers to manage multiple conditions. Patients were motivated to continue receiving integrated care, despite frequent NCD drug stock-outs; and development of peer initiatives to purchase NCD drugs. Initial concerns about potential disruption of HIV care were overcome, leading to staff motivation to continue delivering integrated care.ConclusionsImplementing integrated care has the potential to sustainably reduce duplication of services, improve retention in care and treatment adherence for co/multi-morbid patients, encourage knowledge-sharing between patients and providers, and reduce HIV stigma.Trial registration numberISRCTN43896688.

Women living with HIV, diabetes and/or hypertension multi-morbidity in Uganda: a qualitative exploration of experiences accessing an integrated care service

PurposeWomen experience a triple burden of ill-health spanning non-communicable diseases (NCDs), reproductive and maternal health conditions and human immunodeficiency virus (HIV) in sub-Saharan Africa. Whilst there is research on integrated service experiences of women living with HIV (WLHIV) and cancer, little is known regarding those of WLHIV, diabetes and/or hypertension when accessing integrated care. Our research responds to this gap.Design/methodology/approachThe INTE-AFRICA project conducted a pragmatic parallel arm cluster randomised trial to scale up and evaluate “one-stop” integrated care clinics for HIV-infection, diabetes and hypertension at selected primary care centres in Uganda. A qualitative process evaluation explored and documented patient experiences of integrated care for HIV, diabetes and/or hypertension. In-depth interviews were conducted using a phenomenological approach with six WLHIV with diabetes and/or hypertension accessing a “one stop” clinic. Thematic analysis of narratives revealed five themes: lay health knowledge and alternative medicine, community stigma, experiences of integrated care, navigating personal challenges and health service constraints.FindingsWLHIV described patient pathways navigating HIV and diabetes/hypertension, with caregiving responsibilities, poverty, travel time and cost and personal ill health impacting on their ability to adhere to multi-morbid integrated treatment. Health service barriers to optimal integrated care included unreliable drug supply for diabetes/hypertension and HIV linked stigma. Comprehensive integrated care is recommended to further consider gender sensitive aspects of care.Originality/valueThis study whilst small scale, provides a unique insight into the lived experience of WLHIV navigating care for HIV and diabetes and/or hypertension, and how a “one stop” integrated care clinic can support them (and their children) in their treatment journeys.

Diverting paediatric patients from hospital outpatient appointments to integrated care clinics

The International Journal of Integrated Care (IJIC) is an online, open-access, peer-reviewed scientific journal that publishes original articles in the field of integrated care on a continuous basis.IJIC has an Impact Factor of 2.913 (2021 JCR, received in June 2022)The IJIC 20th Anniversary Issue was published in 2021.

Clinician commentary on “Integrated care is associated with increased behavioral health access and utilization for youth in crisis” by Sean O’Dell.

Comments on the article "Integrated care is associated with increased behavioral health access and utilization for youth in crisis" by Sean O'Dell (see record 2022-06988-003). As a pediatrician with a practice focused exclusively on pediatric mental health, I am highly motivated to improve care by minimizing barriers to accessing care, and ensuring that the right care is delivered at the right time and in the right place. I am based in the outpatient clinic of a large mental health hospital (Waypoint Center for Mental Health Care) in rural central Ontario. As part of this program, I also have the opportunity to support integrated care clinics at four Family Health Teams (analogous to patient-centered medical homes), where I collaborate with child and youth therapists and primary care providers. In this setting, there is improved information sharing among the clinical team members, including shared documentation, which improves access and quality of care for pediatric patients and their families. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Análise dos encaminhamentos realizados pela triagem quanto ao acesso às clínicas do curso de Odontologia da Universidade Federal de Santa Maria

O objetivo deste estudo foi descrever o acesso ao tratamento e as necessidades terapêuticas dos pacientes que buscam atendimento nas clínicas do Curso de Odontologia da Universidade Federal de Santa Maria (Brasil) por meio dos encaminhamentos realizados pelo Serviço de Triagem do curso, bem como verificar quantos desses pacientes efetivamente receberam atendimento. Trata-se de um estudo observacional descritivo de caráter quantitativo, baseado em dados secundários existentes nos registros das listas de espera do Serviço de Triagem do curso e nos dados do software Gerenciador Odontológico usado para registro de procedimentos. Foram incluídos no estudo os dados dos pacientes que buscaram o serviço entre 2015 e 2017. Os dados foram analisados utilizando o programa estatístico STATA 14.0, apresentando frequências relativas e absolutas. O número total de encaminhamentos realizados no período foi de 3.945, a maioria destes para pessoas do sexo feminino e com idade média de 51,2 anos. Do total de encaminhamentos, em 60,2% (2.377) dos casos o atendimento não se concretizou. Nas situações que resultaram em atendimento, em 77,6% (1.221) dos casos, este ocorreu no mesmo ano do encaminhamento. A maioria dos encaminhamentos foram para clínicas de atendimento integrado, indicando um acúmulo de necessidades terapêuticas. Esse tipo de avaliação é fundamental para o planejamento estratégico de um serviço de saúde, pois permite fazer uma análise e mapeamento do fluxo dos pacientes, além de uma reflexão sobre as possibilidades de acesso para as pessoas que buscam o serviço.

Setting Our Sails: Counseling Psychology in the Age of Integrated Health Care

Counseling psychology has a documented ability to adapt to the winds of societal, market, and professional change. Adjusting our sails to the winds of integrated care will require realizing that (a) the value systems and approaches that define our field compel us to become more involved in the movement and (b) we have the requisite expertise to do so. This article echoes the others in this Major Contribution highlighting the importance of interprofessional training for counseling psychologists and the need for integrated care professional role models. Barriers to involvement in integrated care for counseling psychologists include time and effort without institutional support, integrated care being seen as on the fringe of the field, limited training in evidence-based practices, and hesitance to move into integrated care clinics despite their high proportion of underserved patient populations. Integrated care is an incredible opportunity for counseling psychology to draw on its historical strengths and be a flagship of this paradigm shift.

Integrated-care clinics: patient management and return to work rates

The International Journal of Integrated Care (IJIC) is an online, open-access, peer-reviewed scientific journal that publishes original articles in the field of integrated care on a continuous basis.IJIC has an Impact Factor of 5.120 (2020 JCR, received in June 2021)

A Clinical Care Monitoring and Data Collection Tool (H3 Tracker) to Assess Uptake and Engagement in Mental Health Care Services in a Community-Based Pediatric Integrated Care Model: Longitudinal Cohort Study.

BackgroundNational recommendations for pediatric integrated care models include improved capacity for care coordination and communication across primary care and specialty mental health providers using technology, yet few practical, short-term solutions are available for low-resource, community-based pediatric integrated care clinics.ObjectiveThe goal of the paper is to describe the development and features of a Web-based tool designed for program evaluation and clinician monitoring of embedded pediatric mental health care using a community-partnered approach. In addition, a longitudinal study design was used to assess the implementation of the tool in program evaluation, including clinical monitoring and data collection.MethodsBiweekly meetings of the partnered evaluation team (clinic, academic, and funding partners) were convened over the course of 12 months to specify tool features using a participatory framework, followed by usability testing and further refinement during implementation.ResultsA data collection tool was developed to collect clinic population characteristics as well as collect and display patient mental health outcomes and clinical care services from 277 eligible caregiver/child participants. Despite outreach, there was little uptake of the tool by either the behavioral health team or primary care provider.ConclusionsDevelopment of the H3 Tracker (Healthy Minds, Healthy Children, Healthy Chicago Tracker) in two community-based pediatric clinics with embedded mental health teams serving predominantly minority children is feasible and promising for on-site program evaluation data collection. Future research is needed to understand ways to improve clinic integration and examine whether promotion of primary care/mental health communication drives sustained use.Trial RegistrationClinicalTrials.gov NCT02699814; https://clinicaltrials.gov/ct2/show/NCT02699814 (Archived by WebCite at http://www.webcitation.org/772pV5rWW)

How Primary Care Pediatricians Manage Behavioral Health Problems in Integrated and Non-Integrated Clinics

Introduction: Pediatric primary care physicians (PPCPs) are often the first professionals families consult for management of child behavioral health (BH) problems but may vary in their level of training and experience with these issues. These factors, as well as patient access to BH providers, is likely to influence how PPCP’s manage presenting BH concerns. Method: This study assessed PPCP’s perceptions on identification, treatment, and referral follow-up of patients with common BH problems (i.e., issues with anxiety, depression, feeding, sleep, toileting, behavior, and ADHD). Surveys were completed by 60 PPCPs practicing in 20 clinics within two major academic medical centers. Responses were on a 7-point Likert Scale (1= Very Uncomfortable/Unlikely to 7 = Very Comfortable/Likely). Results: PPCP’s endorsed relative comfort with differential diagnosis of all types of BH concerns (range of 5.17 to 6.20) but indicated significantly less comfort providing treatment for all concerns (p The likelihood of using medication to treat BH problems was examined for various patient age groups (0 to 2; 3 to 5; 6 to 12; 13 and up). PPCP’s only endorsed greater than neutral likelihood (M> 4.00) for ADHD ages 6 and up (M= 6.15), depression ages 13 and up (M= 4.32), sleep issues ages 13 and up (M= 4.05), and toileting problems at all ages (M= 4.41). PPCPs were significantly more likely (p The likelihood of patient follow-up with on-site BH services (M= 6.03) was rated significantly higher than off-site (M= 4.05), p Conclusions: PPCPs endorsed discomfort treating all common BH problems with the exception of ADHD but felt comfortable with differential diagnosis of these issues. Use of medication was deemed unlikely for most ages and BH problems and was less supported for younger children. PPCPs were highly confident their patients with BH problems received care when referred to an on-site psychologist but not off-site. Lessons Learned: PPCP’s feel comfortable identifying BH problems but are substantially less comfortable treating the majority of these conditions, especially those presenting in young children. PPCP’s acknowledge that clinics with integrated BH providers improve patient care and enhance patient access to BH services. These findings indicate a need for integration of BH services witihin the primary care setting and provide insight on specific issues PPCP's feel most ill-equipped to manage independently. Limitations: It is unclear what accounts for PPCP’s higher comfort with treating behavioral health concerns relative to their likelihood of using medication. Future Research: It would be useful to examine whether or not integrated care clinics influence PPCP’s management of BH problems in terms of diagnoses, treatment, and referrals.

Reliability and normative data for the Behavioral Health Measure (BHM) in primary care behavioral health settings.

The Behavioral Health Measure (BHM) is a brief self-report measure of general psychological distress and functioning developed for the tracking of mental health outcomes in outpatient psychotherapy settings (Kopta & Lowry, 2002). Although the BHM is used in integrated primary care behavioral health clinics, the scale's psychometric properties have not been evaluated in these settings. The current study investigated the BHM's psychometric properties, including its factor structure and reliability, and presents normative data from 3 large integrated primary care clinics. Mean scores for each of the BHM's 4 scales were significantly lower (i.e., more distress) for women than men, with scores being stable across the 3 primary care samples. Confirmatory factor analysis demonstrated adequate fit for the 3-factor and 1-factor models, with fit improving when 3 items were omitted. Internal consistency estimates for the BHM's 4 scales ranged from adequate to very good (α range: .72-.93). The 4 scales were highly intercorrelated, suggesting they measure similar constructs. Results suggest a revised, 17-item version of the BHM has adequate structure and reliability estimates, and is appropriate for use in primary care settings.