Primary Care Mental Health Workers Research Articles

Clinical effectiveness and cost effectiveness of individual mental health workers colocated within primary care practices: a systematic literature review

ObjectivesMental health disorders contribute significantly to the global burden of disease and lead to extensive strain on health systems. The integration of mental health workers into primary care has been...

Home ward Ealing: commissioners and providers working together to deliver a new integrated model of intermediate care

The London Borough of Ealing is in the centre of eight boroughs which make up North West London, and has been part of a pioneering programme of whole systems approaches to integrated care since 2011. Ealing : The borough is one of the largest, most diverse and densely populated in London, with the largest Somali population in the UK and Sikh, Hindu and Muslim populations are significantly higher than the London average. The borough has areas of affluence and deprivation and large number of patients in hard to reach groups including those who are homeless or with problematic use of alcohol or drugs. Ealing’s population is above the national upper quartile for diabetes, and with an aging population across North West London, there is a growing number of patients suffering from other long term conditions including asthma, coronary heart disease, COPD and heart failure. Due to the geography of Ealing, a high proportion of patients from the borough are admitted to acute hospitals in neighbouring areas. Integrated Intermediate Care Service : In 2015, Ealing Clinical Commissioning Group in conjunction with the Local Authority, reprocured a newly specified integrated intermediate community care service for Ealing patients, which was designed with clinicians to provide a rapid, more responsive service that maximises admission avoidance and supports early discharge through managing a wide range of patients in a sub-acute phase in which they may need more than GPs and other community services can offer, but do not need an acute hospital bed. West London Mental Health NHS Trust led a group of other local providers from primary care, community care and secondary care, and worked with social services to develop an innovative delivery partnership which was designed to offer triple integration (vertically, with social care and mental health care), to maximise relationships with services in neighbouring boroughs, and to be delivered through accessing a single electronic patient record, shared with primary care. Together, the providers launched *Home ward Ealing* on 01 October 2015, and are collaboratively working in an open-book manner with commissioners to evolve the service to meet the needs of Ealing residents. Outcomes and obstacles overcome : We present outcomes and activity data from the predecessor service and the first six months of Home ward Ealing and outline the approaches taken to working across organisational boundaries, including the sharing of information, financial and clinical risk in an innovative integrated approach. We also outline links with other Ealing integrated care initatives, including Care Coordination and Navigation, Primary Care Mental Health and Dementia Link Workers and public health (Smoke Free Ealing) as part of a population health approach.

Determination of Optimized Multidisciplinary Care Team for Maximal Antiretroviral Therapy Adherence

We seek to determine the optimized multidisciplinary care team (MDCT) composition for antiretroviral therapy (ART) adherence. We analyzed all new regimen starts (n = 10,801; 7071 ART naive, 3730 ART experienced) among HIV-positive patients in Kaiser Permanente California from 1996 to 2006. We measured 12-month adherence to ART (pharmacy refill methodology) and medical center-specific patient exposure to HIV/infectious disease specialist (reference group), non-HIV primary care provider, clinical pharmacist, nurse case manager, non-nurse care coordinator, dietician, social worker/benefits coordinator, health educator, and mental health worker. We used recursive partitioning to ascertain potential MDCT compositions associated with maximal mean ART adherence. We then employed mixed linear regression with clustering by provider and medical center (adjusting for ART experience, age, gender, race/ethnicity, HIV risk, hepatitis C virus coinfection, ART regimen class, and calendar year) to test which potential MDCT combination identified had statistically significant association with ART adherence. We found maximal increase in adherence with pharmacist plus coordinator plus primary care provider combination (8.1% ART adherence difference compared with reference; 95% confidence interval: 2.7% to 13.5%). Other MDCT teams with significantly (P < 0.05) improved adherence compared with specialist only were nurse plus social worker with primary care provider (7.5%; 5.4% to 9.7%), specialist plus mental health worker (6.5%; 2.6% to 10.4%), pharmacist plus social worker plus primary care provider (5.7%; 4.1% to 7.4%), and pharmacist plus primary care provider (3.3%; 0.8% to 5.8%). Among these MDCTs, there were no significant differences in mean adherence, odds of maximal viral control, or CD4+ changes at 12 months (except pharmacist plus primary care provider). Various MDCTs were associated with improved adherence, including ones that did not include the HIV specialist but included primary care plus other health professionals. These findings have application to the HIV care team design.

Dissemination of behavioural activation for depression to mental health nurses: training evaluation and benchmarked clinical outcomes

Depression causes significant distress, disability and cost within the UK. Behavioural activation (BA) is an effective single-strand psychological approach which may lend itself to brief training programmes for a wide range of clinical staff. No previous research has directly examined outcomes of such dissemination. A 5-day training course for 10 primary care mental health workers aiming to increase knowledge and clinical skills in BA was evaluated using the Training Acceptability Rating Scale. Depression symptom level data collected in a randomized controlled trial using trainees were then compared to results from meta-analysis of studies using experienced therapists. BA training was highly acceptable to trainees (94.4%, SD 6%). The combined effect size of BA was unchanged by the addition of the results of this evaluation to those of studies using specialist therapists. BA offers a promising psychological intervention for depression that appears suitable for delivery by mental health nurses following brief training.

Is there a role for Psychological Wellbeing Practitioners and Primary Care Mental Health Workers in the delivery of low intensity cognitive behavioural therapy for individuals who self‐harm?

Purpose – The aim of this paper is to explore how the role of low intensity cognitive behavioural therapy (CBT) could be incorporated as a treatment option for individuals who engage in non‐suicidal self‐injury. Primary Care Mental Health Workers (PCMHWs) and Psychological Wellbeing Practitioners (PWPs) are employed to assist patients experiencing common mental health problems through CBT‐based self‐help materials; this is commonly referred to as low intensity CBT.Design/methodology/approach – This article reviews the literature in order to investigate how these workers could incorporate their skills to offer support to those who self‐harm as means of coping with psychological distress.Findings – The findings from this review identify a call for research into the efficacy of low intensity CBT, to enable the dissemination of clear guidance into the treatment of non‐suicidal self‐injury, considering the role of PWPs and PCMHWs.Originality/value – At present, there is a lack of guidance into the treatment op...

Primary-care mental-health workers’ views of clinical supervision

AbstractClinical supervision is an essential component of psychological work with clients. This article presents views of a group of primary-care mental-health workers on the introduction of clinical supervision. A focus group interview was analysed. The key themes extracted were: the supervisor's approach that provided an educative, safe, boundaried space that allowed exploration, support and validation; the advantages and disadvantages of group supervision; helpful and unhelpful ingredients of supervision; the governance and facilitative functions of supervision; and the dangers inherent in not having supervision for both client and worker. Key recommendations are made encompassing: training in supervision and a psychological approach; encouraging theory–practice consolidation; balancing competency with curiosity; and reviewing supervision regularly. Limitations of the study are also discussed.

Reflective voices: primary care mental health workers’ experiences in training and practice

BackgroundThe role of the primary care mental health worker (PCMHW) in providing self-help and signposting to people referred for mild-moderate anxiety and depression is currently being complemented by low-intensity workers training under the government’s improving access to psychological therapies (IAPT) programme.AimThis study aims to explore the experiences of five PCMHWs working in the context of a newly designed primary care mental health team in London.MethodsThematic analysis of participants’ written reflective papers provides a qualitative exploration of issues and concerns raised by PCMHWs during a fortnightly reflective practice group.ResultsThemes emerging from participants’ written accounts highlight: difficulties in applying academic and skills training to the real-life world of clinical practice; difficulties in managing issues of risk and complexity; role confusion; and the need for a visible and coherent career structure.ConclusionsThe study highlights the psychological impact on PCMHWs of managing complex client referrals. This is discussed in the context of the high volume case turnover anticipated by IAPT training curricula. Implications for the training and education of IAPT low-intensity workers are briefly considered.

Training graduate primary care mental health workers to work with people with a diagnosis of personality disorder

It is recognised that training is required for staff working with people with a diagnosis of personality disorder, as it poses challenges requiring particular skills and abilities (National Institute for Mental Health in England, 2003a). The proposal to train graduate primary care mental health workers (GPCMHWs) to work with the client group met with some scepticism by senior clinicians. However, the experience of providing training and supervision to the graduate primary care mental health workers to work with clients with personality disorder in Camden and Islington has proved positive. Several characteristics of the GPCMHWs identified in the training literature might contribute to this positive experience. Those factors include cognitive ability, motivation to learn, age, and attitudes. Initial findings from the evaluation of the training shows that graduate workers respond positively to the training, showing improvements in self‐rated knowledge and skills relating to working with the client group, and an eagerness to learn more. The relevance of this to the personality disorder capabilities framework are described.

A collaborative approach to embedding graduate primary care mental health workers in the UK National Health Service

A collaborative approach to embedding graduate primary care mental health workers in the UK National Health Service

Facilitating access to voluntary and community services for patients with psychosocial problems: a before-after evaluation

BackgroundPatients with psychosocial problems may benefit from a variety of community, educational, recreational and voluntary sector resources, but GPs often under-refer to these through lack of knowledge and time. This study evaluated the acceptability and effectiveness of graduate primary care mental health workers (GPCMHWs) facilitating access to voluntary and community sector services for patients with psychosocial problems.MethodsPatients with psychosocial problems from 13 general practices in London were referred to a GPCMHW Community Link scheme providing information and support to access voluntary and community resources. Patient satisfaction, mental health and social outcomes, and use of primary care resources, were evaluated.Results108 patients consented to take part in the study. At three-month follow-up, 63 (58%) had made contact with a community service identified as suitable for their needs. Most were satisfied with the help provided by the GPCMHW in identifying and supporting access to a suitable service. There was a reduction in the number of patients with a probable mental health problem on the GHQ-12 from 83% to 52% (difference 31% (95% CI, 17% – 44%). Social adjustment improved and frequencies of primary care consultations and of prescription of psychotropic medications were reduced.ConclusionGraduates with limited training in mental health and no prior knowledge of local community resources can help patients with psychosocial problems access voluntary and community services, and patients value such a scheme. There was some evidence of effectiveness in reducing psychosocial and mental health problems.

The ABC‐E Model of Emotion: a bio‐psychosocial model for primary mental health care

This paper highlights the social context of common mental disorders in primary care and the paucity of evidence relating to effective social interventions. It introduces the ABC‐E Model of Emotion, which combines social interventions with psychological therapy, and discusses how the implementation of the new role of graduate primary care mental health worker (GPCMHW) provides an opportunity for holistic practice in helping individuals experiencing mild to moderate mental health difficulties in primary care. It provides a case example of the implementation of the ABC‐E model and makes recommendations for further research including the evaluation of the model and GPCMHW training programmes.

Translating observation into practice: how has infant observation helped a primary care mental health worker understand families’ experiences of loss?

This paper explores how psychoanalytic infant observation helped a primary care mental worker (PCMHW) work with two children and their parents, who presented with anxiety related to loss. Three areas of focus are identified from the infant observation as being useful for understanding loss, which include early defence mechanisms, parental experiences of loss, and containment. These three areas are then explored in relation to clinical work with a 5-year-old boy and a 10-year-old boy. When discussing each area of focus, the paper draws upon vignettes from infant observation to illustrate how the observation informed the PCMHW's practice. The paper concludes that a psychoanalytic infant observation is useful for a PCMHW who offers brief work to children and their parents who are experiencing anxiety related to loss.

A collaborative approach to embedding graduate primary care mental health workers in the UK National Health Service

The UK National Health Service (NHS) workforce has recently seen the arrival of the Graduate Mental Health Worker (GMHW) in primary care. We established a Quality Improvement Collaborative to assist in embedding this new workforce in one Strategic Health Authority Area of England. The intervention utilised 'collaborative' technology which involves bringing together groups of practitioners from different organizations to work in a structured way to improve the quality of their service. The process was evaluated by an action research project in which all stakeholders participated. Data collection was primarily qualitative. During the project, there was an increase in throughput of new patients seen by the GMHWs and increased workforce satisfaction with a sense that the collaborative aided the change process within the organizations. Involvement of managers and commissioners from the Primary Care Trusts where the GMHWs were employed appeared to be important in achieving change. This was not, however, sufficient to combat significant attrition of the first cohort of workers. The project identified several barriers to the successful implementation of a new workforce for mental health problems in primary care, including widespread variation in the level and quality of supervision and in payment and terms of service of workers. A collaborative approach can be used to support the development of new roles in health care; however, full engagement from management is particularly necessary for success in implementation. The problems faced by GMHWs reflect those faced by other new workers in healthcare settings, yet in some ways are even more disturbing given the lack of governance arrangements put in place to oversee these developments and the apparent use of relatively unsupported and inexperienced novices as agents of change in the NHS.

Psychometric comparison of PHQ-9 and HADS for measuring depression severity in primary care

The 2004 National Institute for Health and Clinical Excellence (NICE) guidelines highlight the importance of assessing severity of depression in primary care. To assess the psychometric properties of the Patient Health Questionnaire (PHQ-9) and the depression subscale of the Hospital Anxiety and Depression Scale (HADS-D) for measuring depression severity in primary care. Psychometric assessment. Thirty-two general practices in Grampian, Scotland. Consecutive patients referred to a primary care mental health worker completed the PHQ-9 and HADS at baseline (n = 1063) and at the end of treatment (n = 544). Data were analysed to assess reliability, robustness of factor structure, convergent/discriminant validity, convergence of severity banding, and responsiveness to change. Both scales demonstrated high internal consistency at baseline and end of treatment (PHQ-9 alpha = 0.83 and 0.92; HADS-D alpha = 0.84 and 0.89). One factor emerged each for the PHQ-9 (explaining 42% of variance) and HADS-D (explaining 52% of variance). Both scales converged more with each other than with the HADS anxiety (HADS-A) subscale at baseline (P<0.001) and at end of treatment (P = 0.01). Responsiveness to change was similar: effect size for PHQ-9 = 0.99 and for the HADS-D = 1. The HADS-D and PHQ-9 differed significantly in categorising severity of depression, with the PHQ-9 categorising a greater proportion of patients with moderate/severe depression (P<0.001). The HADS-D and PHQ-9 demonstrated reliability, convergent/discriminant validity, and responsiveness to change. However, they differed considerably in how they catergorised severity. Given that treatment decisions are made on the basis of severity, further work is needed to assess the validity of the scales' severity cut-off bands.

Evaluating training for collaborative practice for graduate primary care mental health workers

This paper focuses on a shared learning module on collaborative practice for graduate primary care mental health workers as a case study in formative evaluation that combines qualitative and quantitative methods. Evaluation data are collected across four levels in an attempt to explore issues relating to:• curriculum content• training methods and design• PCMHWs' experiences of the training• outcomes in respect of attitude change and self‐reported changes in knowledge, skills and practice.The paper draws on a review of inter‐professional education undertaken by the British Education Research Association (BERA) to explore what interactive methods of learning are employed in the delivery of the module as a means of fostering improved collaborative practice that can be transferred from the learning environment to the primary care mental health setting. According to Barr et al (2005, p31) inter‐professional education takes place on ‘occasions when two or more professions learn with, from and about each other to improve collaboration and the quality of care’.The paper concludes that although limited in its generalisability and the extent to which changes in attitudes and practice can be attributed to the training intervention, there are some useful lessons to be learned for planning and delivering training to promote collaborative working within primary care mental health.

Training graduate primary care mental health workers for collaborative practice: part 1

This paper is the first of two linked articles that explores a shared learning approach to developing a module on collaborative working for graduate primary care mental health workers (PCMHWs). The article describes how the policy context shaped the training agenda and how the requirements of the roles and responsibilities in respect of collaborative practice were mapped against the Ten Essential Capabilities of the mental health workforce. The process of constructive alignment (Biggs, 1999) that involves matching teaching and assessment methods to intended learning objectives was used alongside evidence from the research literature on systems working and interprofessional education to inform the design of the modular curriculum in more detail.The second paper will provide an in‐depth evaluation of the module as it was delivered using a framework derived from the academic literature (See Bailey &amp; Littlechild, 2001 and Barr et al, 1999a; 1999b). Included in the evaluation will be a discussion of how the context of workforce change in primary care mental health influenced the training inputs together with a reflection on the training methodologies employed to promote collaborative practice. Different levels of evaluating the training will be discussed including the impact of the module on practice outcomes such as attitudes of the workers and changes in their practice. The lessons learned from the evaluation will be discussed in relation to the models of best practice emerging from the IPE literature and the challenges of implementing a new workforce strategy in primary care mental health.

Developing the mental health workforce capacity in primary care: implementing the role of graduate primary care mental health workers in England

The scale of current demand on primary care services from people seeking help with common mental health problems places enormous pressure on the existing front line workers in general practice. The paucity of training opportunities and competing pressures to deliver improved services across a range of general practice targets remains a major challenge for primary care professionals. The impact of government policy, to improve both access to and choice of treatments, has raised public expectations.The commissioning of the graduate workforce, the graduate worker in primary care mental health (GWPCMH), commenced in 2002, in response to the publication of target numbers detailed in the Priorities and Planning Framework, (DoH, 2002). It signalled a determination to expand the workforce provision and improve the quality of care for service users with common mental health problems.This paper examines the scale of common mental health problems, the policy response and the commissioning process. Particular attention is given to examining the barriers that have been shown to affect implementation, identifying the key influencers and the resources required to train these workers.

Retention and future job intentions of graduate primary care mental health workers: A newly developed role in England

Modernization of the English National Health Service (NHS) workforce has led to the introduction of a number of new roles. One such role is the graduate primary care mental health worker (PCMHW). Although generally successful in expanding primary mental health care, several challenges were raised by the initial implementation, including retention and development of effective career pathways for these workers. The aim of this study was to examine retention and future job intentions of graduate PCMHWs at the end of their one-year training. Mail surveys of the first cohort of graduate PCMHWs recruited in 2004 were conducted at the beginning and end of their 12-month training. Satisfaction with training courses was generally low. Over half indicated they were likely to leave their graduate PCMHW post within the next few months. However, most intended to stay within the NHS. After training, problems were highlighted in relation to the quality of the training programmes and lack of development of an effective career pathway. This has serious consequences for the viability of this initiative.

Contributions of graduate mental health workers in primary care

Graduate primary care mental health workers are part of the NHS strategy for improving the mental health of the primary care population. This article describes the role and potential contribution of these health workers to patients' mental wellbeing in primary care. Readers are informed about the need for graduate worker, and some of the issues that arose on implementing this initiative in one English region.

Integrating graduate primary care mental health workers with clinical training: The Selby &amp; York PCT/Hull &amp; York Universities Scheme

This article describes the experiences of five graduate primary care mental health workers (GPCMHWs) based in York and Selby PCT, forming part of a unique graduate scheme linking the PCT and York University to the Hull Clinical Psychology Doctoral Training Course.