Low-threshold Care Research Articles

Perspectives of Families with Seriously ill Children and Adolescents in Lower Saxony: Focus on Care and Support - An Analysis of the Current Situation and Possible Support Services

The care of children and adolescents in need of care at home is exacerbated by the shortage of skilled workers in the care sector, which leads to bottlenecks in care and presents caring families with major challenges. The implementation of new care approaches in existing structures in the healthcare system is proving to be a key development task in order to provide targeted support for affected families in the future. Qualitative explorative interview study to record the perspective of families with (seriously) ill children and adolescents on the current care situation and possible helpful support services. The sampling was criteria-driven and the analysis and evaluation was content-analytical. Respondents were given a short questionnaire to record socio-demographic characteristics. In particular, the transmission of the diagnosis, the everyday challenges and the impact on quality of life were named as stress factors by n=10 participating parents. Improved access to information, voluntary structures and central contact points as well as digital services were named as key development needs. The interviews from real life and needs-oriented perspective show that there is a need to expand low-threshold care coordination services, strengthen voluntary structures and use telemedical services. Meeting these needs should enable access to specialized treatment and helpful services, especially in rural areas.

“I want to stay here”: Patient and staff perspectives on transitioning from a low-threshold buprenorphine program to clinic-based care

BackgroundThe Project Connections At Re-Entry (PCARE) Van is a low-threshold buprenorphine program operating outside the Baltimore City Detention Center. Like other low-threshold programs, PCARE seeks to engage a vulnerable population in care, stabilize patients, then transition patients to longer-term care; however, <10% of patients transition to clinic-based buprenorphine treatment. Our goal was to better understand these low transition rates and center patient perspectives in discussion of broader low-threshold program design. MethodsFrom December 2022 to June 2023, semi-structured interviews were conducted with 20 former and current PCARE patients and 6 staff members. We used deductive and inductive coding followed by thematic content analysis to identify themes around treatment experiences and care preferences. ResultsThere were strong preferences among current and former patients for continuing buprenorphine treatment at the PCARE Van. Several themes emerged from the data that explained patient preferences, including both advantages to continuing care at the van (preference for continuity, feeling respected by the program’s structure and philosophy) and disadvantages to transitioning to a clinic (perceived harms associated with rigid or punitive care models). Staff noted limited program capacity, and patients expressed that if needed, they would transition to a clinic for altruistic reasons. Staff expressed varied perspectives on low-threshold care, emphasizing both larger systems factors, as well as beliefs about individual patient responsibility. ConclusionsWhile many low-threshold care settings are designed as transitional bridge models, this research highlights patient preference for long-term care at low-threshold programs and supports efforts to adapt low-threshold models to be sustainable as longitudinal care.

Integrating Harm Reduction into Medical Care: Lessons from Three Models.

Substance use disorders (SUDs) are at a national high, with significant morbidity and mortality. Harm reduction, a public-health strategy aimed at reducing the negative consequences of a risky behavior without necessarily eliminating the behavior, represents a useful approach to engage patients with SUDs in care. The objective of this article is to describe how 3 medical practices operationalized harm reduction as a framework toward patient care and identify the common practices undertaken across these settings to integrate harm reduction and medical care. We conducted a qualitative study using in-depth, semistructured interviews with 20 staff and providers at 3 integrated harm reduction and medical care sites across New York State from March to June 2021. Interview questions focused on how harm reduction approaches were implemented, how harm reduction philosophies were demonstrated in practice, and barriers to adoption. The interviews resulted in 8 main themes of integrated harm reduction medical care: 1) role of provider as both learner and informer; 2) pragmatic measures of success; 3) collaborative and interdisciplinary care teams; 4) developing a stigma-free culture; 5) creating a comfortable and welcoming physical space; 6) low-threshold care with flexible scheduling; and; 7) reaching beyond the clinic to disseminate harm reduction orientation; and 8) creating robust referral networks to enhance transitions of care. These themes existed at the patient-provider level (#1 to 3), the organizational level (#4 to 6), and the level extending beyond the clinic (#7 to 8). All 3 sites followed 8 common themes in delivering harm reduction-informed care, most of which are consistent with the broader movement toward patient-centered care. These practices demonstrate how medical providers may overcome some of the barriers imposed by the medical model and successfully integrate harm reduction as an orienting framework toward care delivery.

Outcome for dizzy patients in a physiotherapy practice: an observational study

Background Dizziness is a common reason for referral to physiotherapy. Additional information on clinical characteristics, treatment effect and prognostic indicators in physiotherapy practice are needed. Methods A retrospective observational study. Based on a standardised clinical evaluation patients were labelled as having Benign Paroxysmal Positioning Vertigo (BPPV) or not (no-BPPV). BPPV was treated with repositioning manoeuvres and exercises. In no-BPPV, treatment was based on additional clinical tests. Treatment was provided once per week and considered successful when the patient was free of symptoms confirmed by negative positional tests. Results From 148 referred patients, 88 were labelled as having BPPV, 60 as no-BPPV. The symptom of a short-lasting spinning sensation provoked by head movements was highly suggestive of BPPV. On average, in BPPV treatment was completed after 2.27 ± 1.68 treatments, in no-BPPV this was after 4.91 ± 3.46 treatments. The delayed outcome was related to higher ‘age’ and ‘concomitant neck pain’ in BPPV and with higher ‘age’ only in no-BPPV. Favourable outcome was related to the feature ‘dizziness provoked by movements in the horizontal plane’ in BPPV. Conclusions Clinical evaluation and treatment in physiotherapy practice can be an effective and safe option for patients with dizziness. Several clinical variables with prognostic values were identified. Key messages Clinical evaluation and treatment in physiotherapy practice can be part of low threshold care for dizzy patients. Despite prior medical screening, one-third of patients without signs of BPPV were sent back for further evaluation, illustrating the need for interdisciplinary collaboration. Based on the description of the dizziness symptom (vertigo rather than light-headedness), provocation of the dizziness by movements, and a short duration of the dizziness attack, and positive clinical vestibular tests, BPPV treatment could be initiated.

Blending Internet-based and tele group treatment: Acceptability, effects, and mechanisms of change of cognitive behavioral treatment for depression

The current COV-19 pandemic increases the need for remote treatment. Among several provision strategies, tele groups have been tested as an efficient option. Still, the number of studies is comparably low, with a clear lack of studies investigating supposed treatment mechanisms.Sixty-one mildly to moderately depressed participants from Salzburg, Bavaria, and Upper Austria were randomized to the intervention or a waiting list control group (RCT). The seven-week treatment comprised preparatory online modules, followed by personalized feedback and a subsequent tele group session.Large treatment effects were observed for depression (CES-D: d = 0.99, p < .001; PHQ-9: d = 0.87, p = .002), together with large effects for cognitive behavioral skills (cognitive style, and behavioral activation, d = 0.88–0.97). Changes in skills mediated treatment outcomes for CES-D and PHQ-9, suggesting comparable mechanisms as in face-to-face therapy. Two typical moderators, therapeutic alliance, and group cohesion, however, failed to predict outcome (p = .289), or only exhibited statistical tendencies (p = .049 to .071). Client satisfaction, system usability, and treatment adherence were high.Blending Internet-based and tele group interventions offers additional options for low-threshold care that is less dependent on population density, commuting distances, or constraints due to the current COV-19 crisis. Results indicate that the blended intervention is clinically effective by fostering core CBT skills. While findings suggest the notion that working alliance and group cohesion can be established online, their relevancy for outcomes of blended treatment needs to be further investigated.

LeiP#netz - Leipziger Psychiatrie Netzwerk - A Pilot Project to Implement the Functional Basic Model by Steinhart and Wienberg in a Defined Psychiatric Care Region

The functional basic model (Steinhart, Wienberg) offers the theoretic ground for a pilot project which emphasis on outpatient treatment in psychiatric care. The following subgoals were pursued a) networking with providers/institutions/actors located in the study region; (b) evaluation of the offered services for the purpose of mapping psychosocial care. Consequently, a project-based survey instrument was developed and applied for the survey of all care providers. Merging and networking of all actors was started successfully. All services needed for psychiatric care of severe mentally ill people are provided in the study region. While counselling and prevention tend to be well-maintained structures, there is a lack of access to low-threshold care such as crisis management, retreats alternatives to hospitals and assertive multi-professional complex treatment.

Early intervention, treatment and rehabilitation of employees with common mental disorders by using psychotherapeutic consultation at work: study protocol of a randomised controlled multicentre trial (friaa project)

BackgroundCommon mental disorders are one of the leading causes for sickness absence and early retirement due to reduced health. Furthermore, a treatment gap for common mental disorders has been described worldwide. Within this study, psychotherapeutic consultation at work defined as a tailored, module-based and work-related psychotherapeutic intervention will be applied to improve mental health care.MethodsThis study comprises a randomised controlled multicentre trial with 1:1 allocation to an intervention and control group. In total, 520 employees with common mental disorders shall be recruited from companies being located around five study centres in Germany. Besides care as usual, the intervention group will receive up to 17 sessions of psychotherapy. The first session will include basics diagnostics and medical indication of treatment and the second session will include work-related diagnostics. Then, participants of the intervention group may receive work-related psychotherapeutic consultation for up to ten sessions. Further psychotherapeutic consultation during return to work for up to five sessions will be offered where appropriate. The control group will receive care as usual and the first intervention session of basic diagnostics and medical indication of treatment. After enrolment to the study, participants will be followed up after nine (first follow-up) and fifteen (second follow-up) months. Self-reported days of sickness absence within the last 6 months at the second follow-up will be used as the primary outcome and self-efficacy at the second follow-up as the secondary outcome. Furthermore, a cost-benefit assessment related to costs of common mental disorders for social insurances and companies will be performed.DiscussionPsychotherapeutic consultation at work represents a low threshold care model aiming to overcome treatment gaps for employees with common mental disorders. If successfully implemented and evaluated, it might serve as a role model to the care of employees with common mental disorders and might be adopted in standard care in cooperation with sickness and pension insurances in Germany.Trial registrationThe friaa project was registered at the German Clinical Trial Register (DRKS) at 01.03.2021 (DRKS00023049): https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00023049.

Integrated treatment of hepatitis C virus infection among people who inject drugs: study protocol for a randomised controlled trial (INTRO-HCV)

BackgroundA large proportion of people who inject drugs (PWID) living with hepatitis C virus (HCV) infection have not been treated. It is unknown whether inclusion of HCV diagnostics and treatment into integrated substance use disorder treatment and care clinics will improve uptake and outcome of HCV treatment in PWID. The aim is to assess the efficacy of integrating HCV treatment to PWID and this paper will present the protocol for an ongoing trial.MethodsINTRO-HCV is a multicentre, randomised controlled clinical trial that will compare the efficacy of integrated treatment of HCV in PWID with the current standard treatment. Integrated treatment includes testing for HCV, assessing liver fibrosis with transient elastography, counselling, treatment delivery, follow-up and evaluation provided by integrated substance use disorder treatment and care clinics. Most of these clinics for PWID provide opioid agonist therapy while some clinics provide low-threshold care without opioid agonist therapy. Standard care involves referral to further diagnostics, treatment and treatment follow-up given in a hospital outpatient clinic with equivalent medications. The differences between the delivery platforms in the two trial arms involve use of a drop-in approach rather than specific appointment times, no need for additional travelling, less blood samples taken during treatment, and treatment given from already known clinicians. The trial will recruit approximately 200 HCV infected individuals in Bergen and Stavanger, Norway. The primary outcomes are time to treatment initiation and sustained virologic response, defined as undetectable HCV RNA 12 weeks after end of treatment. Secondary outcomes are cost-effectiveness, treatment adherence, changes in quality of life, fatigue and psychological well-being, changes in drug use, infection related risk behaviour, and risk of reinfection. The target group is PWID with HCV diagnosed receiving treatment and care within clinics for PWID.DiscussionThis study will inform on the effects of an integrated treatment program for HCV in clinics for PWID compared to standard care aiming to increase access to treatment and improving treatment adherence. If the integrated treatment model is found to be safe and efficacious, it can be considered for further scale-up.Trial registrationClinicalTrials.gov.no. NCT03155906.

297. Accessible Care Intervention for Engaging People Who Inject Illicit Drugs in Hepatitis C Virus Care: Preliminary Results from a Randomized Clinical Trial

BackgroundTo achieve hepatitis C elimination, treatment programs need to be developed to engage, treat, and cure people who are actively injecting drugs.MethodsWe present preliminary data from the first 65 participants in the Accessible Care intervention for engaging people who inject illicit drugs (PWID) in hepatitis C (HCV) care. The randomized clinical trial compares the effectiveness of Accessible Care (low-threshold care in a syringe service program located in New York City) with Usual Care (referral to existing services) in facilitating linkage, engagement, and retention in HCV care. Eligible participants were HCV RNA positive and had injected drugs in the past 90 days. We compared the percentage of participants in each arm linked to HCV care (defined as one visit with HCV treatment provider), and initiated direct-acting antiviral (DAA) treatment within 6 months of enrollment.ResultsAmong the 65 participants, the mean age is 41.2 years; 28% are females; 73% homeless; 6% black, 51% Latina/o and 39% white. 82% of participants had injected drugs in the last 30 days, with an average of 13.2 injections/month (median 10). Nearly all participants had health insurance, 88% public insurance, 6% uninsured. Thirty-two participants were randomized to the Accessible Care arm. Within 6 months of enrollment 79% of the Accessible Care arm and 25% of the Usual Care arm had linked to HCV care, and 69% and 13% had been started on DAA therapy, respectively. Of the 26 participants in the Accessible Care arm started on DAA therapy, the median time from enrollment to treatment initiation was 87.5 days [range 22–180].ConclusionAmong HCV-infected PWID enrolled at a syringe service program, higher rates of linkage to care and treatment initiation were seen in the Accessible Care arm where stigma- and shame-free treatment was located within a community-based location.Disclosures All authors: No reported disclosures.

Mental health specialist video consultations for patients with depression or anxiety disorders in primary care: protocol for a randomised controlled feasibility trial

IntroductionMost people suffering from depression and anxiety disorders are entirely treated in primary care. Due to growing challenges in ageing societies, for example, patients’ immobility and multimorbidity, the transition to...

The effectiveness of school-based skills-training programs promoting mental health in adolescents: a study protocol for a randomized controlled study

BackgroundAdolescence is a period of elevated stress sensitivity, which places adolescents at increased risk of developing mental health problems such as burnout, depression, anxiety, and externalizing problems. Early intervention of psychological needs and low-threshold care addressing such needs may prevent this dysfunctional development. Schools may provide an important environment to identify and address psychological needs. The aim of this protocol is to describe the design of a study aiming to evaluate the effectiveness of low-threshold school-based skills-training programs promoting the mental health of adolescents and to examine moderators of the effectiveness.MethodsA Randomized Controlled Trial will be conducted to examine the effectiveness of two school-based skills-training programs aiming to promote mental health by improving either skills to deal with performance anxiety or social skills. A multi-informant (i.e., students, parents, and trainers) and multi-method (i.e., questionnaires and physiological measurements) approach will be used to assess program targets (skills to deal with performance anxiety or social skills), direct program outcomes (performance or social anxiety) and mental health outcomes (i.e., stress, internalizing and externalizing problems, self-esteem and well-being), as well as specific moderators (i.e., student, parent and program characteristics, social support, perfectionism, stressful life events, perceived parental pressure, positive parenting behavior, treatment alliance and program integrity).DiscussionThe current study will provide information on the effectiveness of school-based skills-training programs. It is of crucial importance that the school environment can provide students with effective, low-threshold intervention programs to promote adolescents’ daily functioning and well-being and prevent the emergence of mental health problems that negatively affect school performance.Trial registrationDutch Trial Register number NL7438. Registered 12 December 2018.

Differences in sociodemographic, drug use and health characteristics between never, former and current injecting, problematic hard-drug users in the Netherlands

BackgroundInjecting drug users are at increased risk for harmful effects compared to non-injecting drug users. Some studies have focused on differences in characteristics between these two groups (e.g., housing, overall health). However, no study has investigated the specific Dutch situation which in the last years has seen a decrease in homelessness among problematic hard-drug users and an increasing focus on physical health in low-threshold addiction care. The purpose of this study was to determine differences in sociodemographic, drug use and health characteristics between never-injecting (NIDUs), former-injecting (FIDUs) and current-injecting drug users (IDUs) and describe injecting practices.MethodsA total of 202 problematic hard-drug users (NIDU = 64; FIDU = 76; IDU = 62) were recruited from 22 low-threshold care facilities, including drug consumption rooms, methadone maintenance treatment, heroin-assisted therapy, day shelter and/or night shelter, supported housing and day activity centres. Data were collected on-site through structured face-to-face interviews.ResultsResults indicate that IDUs represented a separate group of problematic hard-drug users, with distinct sociodemographic and drug use characteristics. Overall, IDUs appeared to be the group with least favourable characteristics (unstable housing/homelessness, illegal activities, polydrug use) and NIDUs appeared to have the most favourable characteristics (stable housing, help with debts, less polydrug use). The FIDU group lies somewhere in between. The three groups did not differ significantly in terms of health. Regarding injecting practices, results showed that majority of IDUs had injected drugs for over 10 years and IDUs injected heroin, cocaine, amphetamine and/or methadone in the past 6 months. Sharing syringes was not common. A quarter reported public injecting.ConclusionsUnstable housing and homelessness are related to (former) injecting drug use, and stable housing is related to never-injecting drug use. Our study suggests that the number of ‘new’ IDUs is low. However, public injecting among IDUs is not uncommon and is associated with unstable housing. This emphasizes the potential of housing projects as a component of harm reduction measures. Therefore, prevention of (risks associated with) injecting drug use and supported housing programmes for problematic hard-drug users deserve the continuous attention of policymakers and professionals in low-threshold addiction care.

Intervention to improve level of overall functioning and mental condition of adolescents at high risk of developing first‐episode psychosis in Finland

Being at high risk of developing psychosis has been suggested to be a result of a combination of acute life stressors and trait-like vulnerability to psychosis. Reducing levels of stress could support overall functioning and mental condition in those at risk. The Jorvi Early Psychosis Recognition and Intervention (JERI) project at Helsinki University Central Hospital, Jorvi Hospital, Finland, is an early intervention team for adolescents at risk of developing first-episode psychosis. The project is based on the idea of multiprofessional, community, home, family and network-oriented, stress-reducing, overall functioning-supporting, low-threshold care. The JERI team meets multiprofessionally with adolescents in their natural surroundings, for example, at school or at home, together with their parents, network and community co-worker, who has originally contacted the JERI team because of unclear mental health problems. Subjects were assessed with the PROD-prodromal screen to identify those at risk of developing first-episode psychosis. Statistically significant difference between baseline and follow-up measures was found in at risk subjects (n = 28) in scales of overall functioning (P = 0.000), depression (P = 0.001), anxiety (P = 0.001), quality of life (QOL) and pre-psychotic symptoms. JERI-type intervention may improve level of overall functioning and support mental condition in adolescents at risk of developing first-episode psychosis, even though further study with larger numbers of subjects, with a control group and with a longer follow-up time, is needed.

Krankenhaushygiene – Nadelstichverletzungen

Needlestick injuries (NSI) occur very frequently in the health-care field and represent a very serious risk for health-care workers. It is estimated that 500,000 NSI occur per year in Germany. They are the most frequent cause of infections with blood-borne pathogens. Thus prevention is of decisive importance. A simple reporting procedure and low-threshold care system after NSI would certainly help to reduce the risks and the number of undetected cases.